Any innovative system needs to be built on a platform of good
practice. This section will lay out the four interventions that provider
networks that are implementing integrated care must adopt. These are
non-negotiable interventions, as they form the backbone of any
successful integrated programme, and they have strong and sound evidence
that sit behind them. They are: care coordination, care planning, MDTs,
and individual education and empowerment. Providers must implement
these interventions in order to create a successfully integrated
In addition, the following section will also provide a list of other
interventions that have sound evidence behind them, or that have been
used extensively in global case studies. Providers should use these
chapters to form the core foundational aspects of their models of care,
on top of which can be layered the innovations and novel ways of
providing care that were discussed in the two previous sections.
of care is the entire set of supportive interventions that make up the
care for any individual person. In this section, we will first talk
about interventions, or the specific things that providers and service
users can do together to improve care. We will then address how these
interventions can combine to form whole models around people that will
support them to achieve their individual goals.
The first step in understanding what new models of care could look
like for North West London was to understand what interventions are
essential to an integrated model. In order to do this, we went through a
two-step process of understanding the evidence for different
interventions. Interventions supported by the published evidences.
Interventions supported by the published evidences
First, we looked at a set of best-practice case studies from around
the world. We considered interventions that people could do for
themselves, and also services that could be provided. We considered the
most common interventions across these case studies to be the core of
real-life integrated systems. The next section presents three of these
case studies in depth, before showing a broader overview of the
What could a transformative model look like?
Tower Hamlets is a fully integrated system that uses a hub-and-spoke
polysystem model to provide better integrated care. The system covers
12,000 people in Tower Hamlets who have been diagnosed with diabetes.
Key design principles
Decided to focus on type 2 diabetes patients, where results in the borough were particularly poor.
Service users were seen by GPs who were part of primary-care networks and who attended MDT meetings.
The MDTs discussed the best care for complex cases and would include
practice nurses, physiotherapists, dieticians, hospital consultants,
Patients with diabetes were risk-stratified and those with higher risk scores were seen more often for longer appointments.
What could a transformative model look like?
Torbay is a fully integrated model that provides care for the elderly
and people with diabetes through a single-point-of-contact co-located
MDT system. Care professionals from different organisations sit together
in zone teams like the one illustrated below, and GPs have a single
number to call to have all the care coordinated. Sometimes the GPs are
also co-located with the zone teams.
Key design principles
- The Torbay model focused on elderly patients.
- Five zones were established each with their own co-location hub and a population of 25,000-40,000.
- MDTs in each zone included health- and social-care, and are the single point of contact for patients and GPs.
- Elderly people with long-term conditions would see their GP and be
referred to the MDT, who would help coordinate care across health- and
- Free transportation to appointments, family support, coordination,
discharge support and risk stratification were all introduced as part of
- Full access by care coordinators to electronic records
What could a transformative model look like?
ChenMed is an example of a truly innovative, whole system model that
provides care for the elderly segment of the population that has
For service users who are enrolled in the ChenMed programme, this
model of care is a significant change from normal ways of doing things.
While previously patients may have only had short, infrequent
primary-care appointments, with limited time with their primary care
providers and limited support available, the ChenMed model provides
longer appointments, support for transportation and care coordination
and a one-stop-shop model for getting care. This includes days when
specialists come into the medical centres to see patients. In addition,
patients enrolled in the ChenMed model get personalised care
coordination, and their doctors work in teams with regular case reviews
of anyone who goes into hospital.
There is significant potential for North West London to build on the
ChenMed model by fully integrating self-care and empowerment and
community capital programmes into their models. The ChenMed model has
serious limitations in that it does not include community care, social
care, or links with other parts of the care system, such as housing or
public health. By building on innovative models like ChenMed, North West
London will be able to create cutting-edge and holistic care for their
The exhibit below shows the whole collection of international case studies that we considered.
The global case studies provided insight on what interventions are
used in real-world integrated care systems. They can help us understand
the things that are currently working around the world. The exhibit
overleaf shows a summary of several of these case studies, with their
measured impact. A compendium of these case studies can be found in
Supporting Material D: Models of Care Supplement.
Interventions supported by the published evidence
Second, we turned to the published evidence. We carried out a
literature review of 55 primary publications and 34 systematic reviews
on the topics of integrated care.
The literature review found that there is strong general evidence
that integrated care programmes are effective. 34 systematic reviews
measured the effect of integrated care interventions for service users
with LTCs, and of these, 79% concluded that integrated care had a
positive effect. 88% of individual trials that were included in these
reviews showed a positive effect.
In addition, 14 of the systematic reviews measured the impact of
integrated care on hospital admissions or mortality. Overall, the
average pooled effect size for all-cause mortality was 15-25 percent,
while for hospital admissions it was 20-30 percent. The evidence showed
consistent positive evidence for only four interventions.
These interventions were also heavily used in the international case
studies described above. These are detailed in the next section, and
form the four essential elements of an integrated system.
Four essential interventions
Using these two sources of insight, we created a list of four core
interventions that are essential parts of successful integrated systems.
The interventions that we identified are below and detailed in the
accompanying exhibit. These interventions are non-negotiable: every
provider network that wants to implement integrated care will need to
implement these four interventions in their area.
- Self empowerment and education
- Multi-disciplinary teams
- Care coordination
- Individualised care plans
These interventions will vastly change care when combined. They are
applicable to all of the population groups in varying degrees, and will
positively affect the quality of care outcomes that we want to measure:
prevention, safety and quality, experience of care and personal and
social goals. For example, individualised care plans should include a
section where the individual is able to fill in their personal
ambitions, which will help clinicians and care professionals to
understand and meet their personal goals. For more on this, see Chapter 5: What are the outcomes to be delivered?
In addition, local areas will need to think about how these four
interventions will impact on different population groups and meet their
individual needs. This is an analysis that needs to be done at a local
level; however, there is a tool available that will help providers think
about which interventions are appropriate for their populations, and it
can be found in Supporting Material D: Models of Care Supplement.
The following section will detail three of these four, as
self-management and education have already been discussed at length in
the previous section.
MDTs will form the core of new models of care. These teams should
bring together all of the relevant care professionals, volunteers, and
other partners who provide care for a given individual. The
professionals included should be able to effectively look after the
physical, mental and social-care and support needs of the individuals it
covers. The vital part of an MDT is to facilitate conversations and
referrals amongst care professionals and their partners. Effective
discussion should result in a balanced care plan and care process that
is supportive of an individual’s holistic needs.
Essential members of an MDT
The MDT must include people who can look after the needs of a given
individual in a holistic way. The North West London ICP has started
doing this by including specialists, mental-health professionals, and
social-care workers. As we shift to a Whole Systems Programme, this
definition needs to be expanded. Depending on the needs of the
individual, the essential people who will need to sit on the MDTs are:
- Individuals who are receiving care
- Primary-care providers
- Mental-health specialists
- Social-care workers
- Volunteers who provide services
- Specialists from other condition areas (e.g., diabetes specialists for MDTs caring for people with diabetes)
At appropriate points, MDTs may also want to draw on the expertise of
other local public agencies such as housing representatives for
socially excluded groups and sever and enduring mental illness or
children’s and family liaison services. Other people who could be
included are dieticians, personal trainers, occupational therapists, and
The innovative elements of the MDT described above are that the
individuals and their carers are involved as much as possible with the
MDT. The involvement could be every few sessions or every session. In
addition, the involvement could be in person, by phone or by video chat
to encourage the most convenient involvement possible.
Essential operational model of an MDT
- Meet as a whole team at least once every week. A good MDT should
convene at least once every week to discuss complex cases, review
hospital admissions, and facilitate discussions of changes in care
plans. Individuals receiving services and their carers should be invited
to these discussions when their cases are being reviewed either every
session or every few sessions, and should be involved in any changes to
the care plan.
- Set up an integrated informatics system. MDTs must have a
functioning information system that works to connect individuals with
their care professionals as a group. The care plan and health and care
data should be stored in this system.
- Have a co-located core team. Each MDT should have a core team of
professionals who are full-time employed by the MDT to provide services
for the population in question. They should work as a single team whose
performance is managed individually and that has a line management
system in place. Non-core members of the team, such as specialists or
volunteers, should engage weekly with the core team.
Proactive care is a partnership in Sussex that utilises MDTs to great effect. There are currently 9 MDTs made up of clinicians from the CCG, community nurses and matrons, occupational therapists and physiotherapists from Sussex Community NHS Trust, mental-health professionals from Sussex Partnership NHS FT, social workers and prevention assessment teams from West Sussex County Council, pharmacists and supported by the voluntary sector and wider community services. As far as possible, all team members are based in the same location.
What should happen in a MDT meeting?
The weekly MDT meetings should involve discussions of individual
cases. These meetings provide an opportunity for providers and their
- Discuss complex cases. Any case that is complex, or that given
professionals feel they need input on, should be discussed during the
weekly MDT meeting.
- Refer individuals to relevant services. Providers should discuss
where the best care can be provided for the cases brought to the MDT,
and they should ensure that direct referrals are made between services.
- Review acute admissions. One of the most successful parts of other
MDTs internationally is the use of regular reviews of any non-elective
hospital admissions. These discussions should include a consideration of
the plan for discharge and support afterwards as well as any
rehabilitation or reablement programmes.
- Coaching and trainings. MDT members will comprise a mix of more and
less experienced care professionals, which provides an excellent
opportunity for coaching and mentorship within the context of the team.
They also provide the possibility of group trainings and team building
activities to facilitate working across different disciplines.
Individualised care plans
"I can plan my care with people who work together to understand me
and my carer(s), allow me control and bring together services to achieve
outcomes important to me.” – National Voices.
A care plan is a document owned by individuals who are receiving
services that will help them plan their care. It should be created with
the individuals’ GP’s, their carers, and any other relevant care
professionals. For long-term conditions or for people whose conditions
need regular management, having a proactive care plan is vital. The care
plan should be wellness focused and should cover a comprehensive and
up-to-date understanding of the persons’ needs and circumstances.
Essential elements of a care plan: Principles of an individualised care plan
As part of the Whole Systems programme, clinicians and lay partners
came together to draw up a set of principles of what makes a good and
comprehensive care should be. These are below.
- To improve the quality of health- and social-care for individual
patients, carers and families. The current (2013/14) North West London
priorities for care plans are people most at risk of hospital admission
and chronic or long-term health conditions.
- Patients and carers own an agreed individual care plan that they understand and can use to achieve their goals.
- To create a single electronic record (where required) under the NHS
number with up to date information inputted by agreed health- and
social-care professionals so patients do not tell their story or remind
professionals about important information more than once.
- To share up to date and real time information between agreed
health- and social-care professionals and providers to make joined up
health- and social-care run more smoothly for patients and carers in
order to eliminate duplication.
- To enable patients to have their say about their own care and support in their homes or local community to achieve their goals.
- For GPs to be responsible for conversations with patients and
carers about organising health- and social-care services that meet their
- To provide essential clinical and social information about the
patient for providers delivering health- and social-care services to
patients and carers.
- To deliver parity of esteem for those with mental and / or physical health conditions
The South West Dementia Partnership uses individualised care plans that are filled in and owned by the patients themselves. They record their personal goals, their likes, dislikes and the things that make them uncomfortable. This is then combined with their clinical care plan to create a more holistic view of their journey in the future.
Core care planning process
The core process of care planning needs to be undertaken by all
individuals who are creating a care plan in partnership with their care
professionals and carers. This includes:
- Screening, tests, assessments for physical health, mental-health and social needs in advance of the care plan conversation.
- Inputting and sharing information with agreed health and care professionals and providers.
- Sharing timely results of screening or tests etc. with
patients/carers in a form and manner that makes the most sense to them
is crucial to ensure a constructive conversation between GP and patient.
- Sending out a person’s annual review results (i.e., blood and urine
tests, blood pressure, weight and foot and eye tests) before they
attend for the care planning conversation (has been hugely successful
and well received both by patients and care professionals).
- Giving patients time to understand their test results, discuss with
anyone they would like to and prepare any questions before the care
- Both patient/carer and GP to prepare thoroughly for one or more conversations that can lead to the agreed individual care plan.
- Pooling budgets for agreed health and care services for patient or carer.
- Health and care professionals working across care and professional boundaries.
- Conversations that address what is important to, and for
patients/carers; what is working and not working; and what they hope to
achieve. This may include issues beyond the clinical, for example:
- Identifying areas of self-care, patient education or support to
achieve goals so patient has greater ownership of their individual care
What should the care plan include?
The purpose of having an individualised health- and social-care plan
is to record a long-term and holistic approach to meeting care and
support needs agreed between individuals who receive services and their
care professionals. The care plan should include information about:
- The patient.
- Their health and lifestyle.
- Barriers to good health and independent living.
- Feedback on the patient’s most recent tests, assessments, medication and services already provided.
- Their goals and what they want to achieve next.
- Health- and social-care needs to achieve these goals.
- Providers who will provide agreed health- and social-care services e.g., secondary, community, primary or third sector.
- Who to contact in an emergency/ crisis or if things go wrong, and
any specific contingency plans (for example what to do if their carer
- Who to contact if agreed service / intervention is not delivered or provided inappropriately.
- The patient’s wishes for end-of-life care.
- Amount available for personal health budgets, direct payments etc.
The individual care plan is the final stage in the care planning
process. Both the patient and GP will sign and date the care plan as a
record of conversation. The patient and GP will also have conversations
at regular intervals to review the care plan and agree amendments as
Key design decisions for delivering the care plan
There are several key design decisions that will need to be made to
effectively create and use a care plan. These are outlined below.
- Governance model. Providers will need to work with individuals who
receive services to decide how the governance will work for care plans.
This includes who will have access to it, who will be able to make
changes, what processes they will need to go through to change things,
and who will review it.
- Technology. The technology that will be used to deliver the care
plan and track it over time will need to be decided together with all
the people involved in the care planning process. Two things are vital
to the technology decision: A) the technology must be accessible and
easy to use for everyone, and B) the technology must allow for real-time
updates and for the data to be stored over time.
- Scope. The list presented above of the essential elements of a care
plan is non-negotiable. Without these elements, it is not a care plan.
However, there is also a question of whether other things are added to
the scope on top of this. For example, should the care plan include the
care plan(s) of the carer, a contingency plan for discharge that is
personalised to the individuals’ preferences or other elements?
Care coordination is aimed at helping individuals who are receiving
services, and their carers navigate an often complex and overwhelming
set of services and different providers. Care coordination goes hand in
hand with establishing a MDT, as the care coordinator will be the point
person – both for the providers on the MDT and the individual – for
navigating care. The care coordinator should be the single point of
contact for people receiving services. The care coordinator should use
the person’s agreed care plan as the starting point for delivery of
support, instigating discussions to review and make changes to the plan
What are the benefits to the individual of having a care coordinator?
There are numerous benefits of having a single point of contact for co-ordinating care across providers. These are listed below.
- The individuals and their carers understand who to call in a
crisis, and have a single, simple point of contact. Knowing there is
someone to contact can significantly improve levels of confidence and
- The service user is clear about who is ultimately responsible for coordinating their care.
- There is continuity in the provision of care services, so that individuals can build relationships with their care coordinators.
- Successful coordination can help avoid duplication in care, as care is managed by a single person rather than a system.
Who can act as the care coordinator?
Care coordination means many different things in different places,
and there are different levels of care coordination that will be
appropriate for different types of individuals. For example, individuals
with less complex cases may have a care coordinator who is a volunteer,
and whom they only see once a month, while individuals who have very
complex needs may have a coordinator who is a nurse or nurse
practitioner, and whom they see once a week or once every two weeks.
Thus, different models will be appropriate for different people. The
list below shows the types of people who could act as care coordinators:
- Nurse practitioners.
- Administrative staff.
- Specially employed care coordinators who have a mix of clinical and administrative training.
Essential operational model for care coordination.
The care coordinator will need a set of specific skills in order to
provide the best care coordination services. A sample overview of a care
coordinator role, including the key tasks, is shown below as an
In addition to the list of four essential interventions, the module
working group also created a list of 15 interventions that were often
used in the international case studies (e.g., more than five times).
These are shown below. This list can be used by providers as a
tool to think about what interventions might work locally.
Finally, we have also created two reference tools that can be used by
providers as a starting point to consider other interventions and
models of care. These are a global case study compendium and an
intervention picker tool. These can be found in Supporting Material D:
Models of Care Supplement.