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Integrated Community Support Teams. Pilot Evaluation June 2013. Don Berwick - 2008. Address at 60th Anniversary of NHS Celebrations

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Integrated Community Support Teams

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Integrated community support teams

Integrated Community Support Teams

Pilot Evaluation

June 2013

Don berwick 2008

Don Berwick - 2008

Address at 60th Anniversary of NHS Celebrations

“These, not hospital are the soul of proper community orientated, health preserving care system. General Practice, not the hospital, is the jewel in the crown of the NHS”

Icst principles

ICST Principles

  • To provide safe, effective, person centred support to enable people to remain safely at home for as long as possible

  • When someone admitted to hospital support the person to return home as soon as possible

  • To support older people with complex health and social care needs to have their community care assessments carried out in their own home if possible

Consultation told us

Consultation told us…

  • We needed to join people up into one team

  • That we should not create a bolt on team

  • Needs to be a neighbourhood model

  • To enhance existing knowledge, skills and practice, building confidence and resilience of the local workforce

  • To make the model sustainable

  • GP’s wanted to remain responsible medical officer for patients

Integrated community support teams


Social work resources inc. Community Occupational therapists

Physiotherapists and occupational therapists

Home care and Supporting your Independence staff

District nurses 24 hr service

Other services or support from the wider community e.g. family, 3rd sector, specialist teams and independent providers



  • Existing LTC Community Nursing Teams

  • CARS physios and OTs who provided support to older people from EK & Strathaven who are discharged from hospital

  • Existing social work staff

  • Existing homecarers and homecare coordinators

  • PLUS some additional resources from change fund

  • Role of Generic Support Workers

Icst operational arrangements

ICST Operational arrangements

  • Locality Coordination Group

  • Resource Allocation Group

  • Local Practitioner Forums

  • Lead Professional Role

    ICST Operational arrangements aim to:

  • Ensure effective delivery of care and support to older people and their carers.

  • They provide an initial operational framework for Health and Social Work staff working in the community.

  • They will be subject to regular update and review in the light of experience and developments in other work streams

The future the next steps in the journey

The Future; The next steps in the Journey

  • I.T. & Performance management information

  • Continued development of structure and systems to support practice

  • Local management arrangements

  • Co-location of Staff/Teams

  • Resource management

  • Community Capacity Building

  • Role out of ICST – Hamilton Locality




Hunter Base


Greenhills Base











791>75 yr

199>85 yr



Referrals from hospital 452

Referrals from Hospital- 452

Hospital discharges 30 day outcome 30 days from referral to icst

Hospital discharges -30 day outcome, 30 days from referral to ICST

Icst support disciplines to be involved at time of triage

ICST support- disciplines to be involved at time of triage





Key elements of success

Key elements of success

  • Face-to-face primary care collaboration

  • Open criteria – “at risk of admission”

  • Single point of contact

  • Early access to advice and alternatives

  • Proactive identification and early targeted CGA

  • Strong relationships with community services

At admission and discharge!

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