Health and care services in north Cumbria are working closer together through the development of Integrated Care Communities (ICCs) to improve the health and wellbeing of local people and treat more people closer to home.

The first phase of ICCs began earlier this year with the introduction of coordination hubs and rapid response services to quickly put care in place to support people in their own homes.

ICC hubs play a key role in coordinating care from different organisations and ensuring people receive care in the best place for their needs. The hubs are run by teams of trained administration staff who work closely with health, care and voluntary organisations and a lead practitioner of the day who is responsible for decision making.

The teams proactively monitor where people are in the health and care system to help people stay in their own homes and get home from hospital quicker, and identify those in need of preventative care. They are also working closer with voluntary organisations and local communities to support this and as the ICCs develop so will role that these groups play in developing future services and helping people to stay well.

Deborah Docherty, Senior hub coordinator for Carlisle Healthcare ICC, explains the role of coordination hubs and how they are helping people to stay well.

How would you describe the main role of the hubs?

It’s a bit like air traffic control – there’s lots going on which we coordinate to help keep people out of hospital or get them home safely and in a timely manner.

We take calls from health and care teams, coordinate referrals and make sure the ICC has all of the information they need to plan their workload. We liaise directly with staff at the acute hospital and community hospitals to see if we can actively support any patients to return home with appropriate care in place.

A can do attitude is really important – we always try to deal with whoever gets in touch as best we can and try not to pass them to another department if it is something we can sort.

How does the hub help patients?

We provide joined up thinking to support patients to get home or avoid a hospital say where ever possible. We provide a single point of access for all community teams so patients receive more seamless, joined up care.

How do you help other health and care professionals?

The hubs act as a single point of access for any health or care professional referring into ICC services – so they no longer have to call several different teams to find the right person. We either deal directly with requests from professionals or put them in contact with the correct team if needed.

How have you helped patients stay in their own homes?

We help coordinate emergency care when a patient is in crisis and may otherwise end up in hospital. For example, a patient who was independent had a fall and had no medical need to be admitted to the hospital; however, the fall had shaken their confidence and they could not manage on their own without support. An assessment was done by an occupational therapist and someone was identified to help them at home for a few days until they were back to full health.

Another example is an elderly patient who is looked after by their partner. The partner was due to have planned surgery which meant they could not provide care and were also likely to need extra help. A short term care package was set up in advanced to avoid it becoming a crisis.

How have you helped patients to get home from hospital sooner?

We proactively monitor the list of patients in the hospital who are medically well enough to leave but need some extra care in place as well as lists of those who have just been admitted. This enables us to highlight patients we feel may be able to get home sooner with extra support from the ICC until the patient is back on their feet or a long term care package can be sourced.