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Design the new model of care


The individual needs to be at the centre of all new models of integrated care in North West London. The following section will lay out how providers can think about the new types of models that they want to provide, as well as how they can work together with individuals and their carers to improve care and support.

The exhibit below shows four settings of care: individual care, the home, ambulatory care and inpatient care. When designing new models, people across the system should think about where care can be best provided to keep the needs of the individual front and centre. As we design new models together, we must keep in mind the question, "where is the best place for care?”.

The following section will present the interventions that can be used to design a new model of care as they map to these four settings of care. There are three sections:




We will discuss each of these in turn, moving through the interventions that directly affect the individuals’ ability to care for themselves to the interventions that can support discharge from an inpatient facility.


As set out above, changing current models of care to empower individuals through selfcare, personal control of care, community capital, collaboration with carers and embracing proven technology for health is a core and non-negotiable element of designing a new model of integrated care. This section will show how interventions directed at empowering individuals, carers, families and communities can form the foundation of integrated care models. Provider networks will need to use the interventions proposed in this section, as well as the list of case studies, to design their own initiatives around these topics.


Empowerment and self-care means enabling individuals to take better care of themselves.

The health and care system has a role to play through three routes. First, providing individuals with structured education about their conditions so they can better self-manage. Second, the routes to adopting healthier lifestyles so they can improve their overall health status. Third, connecting them with others who can provide advice and/or mutual support. Care model design must consider how each of these will be enabled and facilitated.

There is significant evidence that self-care interventions can reduce hospitalisations, improve outcomes and reduce costs for the system. For example, one study found that supported self-management had the strongest effect on clinical outcomes of all integrated care interventions, and reduced hospitalisations by 25-30 percent. 1 Tsai et al, Am J Manag Care, 2005 (August), 11(8) 478-488 (Table 4)

Helping individuals to manage their own care is an important part of keeping people healthier for longer. Not only does greater self-care mean care that is lower cost – as it is delivered by unpaid individuals rather than professionals – it has also been proven to result in a wide range of better outcomes:

  • Improved health outcomes
  • Improved feeling of well-being
  • Greater confidence and sense of control
  • Better symptom control, including pain management
  • Better mental-health and lower levels of depression
  • Improved adherence
  • Better planned and coordinated care
  • Reduced need for emergency health- and social-care
  • Reduction in hospital admissions
  • People being able to remain independent for longer.

Starting points: Embracing behaviour change

Understanding the different levels of involvement in care is vital to understanding how to design programmes that will help different types of people care for themselves. The categories below can be used as a tool for providers to assess the current abilities of a given individual to self-manage. This will help them tailor which interventions they use to the individuals that they treat.


There are a wide range of interventions that can support self-care and can empower individuals. These are described in the exhibit below:

How can we encourage behaviour change to ensure better self-care?

Changing individual behaviour is key to maintaining health, helping people who use services manage their conditions and encouraging appropriate utilisation of health services – especially as healthcare costs continue to rise and the incidence of behaviourally-induced long-term conditions continues to increase. Changing behaviour, however, is hard – individuals struggle to act even when they understand the risks of inaction. How they act is directly linked to their motivations and beliefs, including beliefs about outcomes, social norms and perceptions of their ability to change.

Supporting individual behaviour change therefore involves understanding the barriers to change for each individual and targeting our approach to meet the unique needs of each person. The approach must be personalised and focused in order to ensure that people are getting the best interventions for them.

One way to understand barriers to change is to understand the basic ideas of behavioural economics, which is the study of how innate cognitive biases can affect our ability to make rational decisions. Basically, this means that we all have preconceptions and built-in patterns of thought that influence how we make decisions. Some of these innate biases can stop people from changing their behaviours, even when it is clear that doing so would be in their best interests. In order to overcome these innate barriers to change, providers will need to understand the differences in behaviours shown by different people in the population.

One way to help effect lasting change is to understand current behaviour of an individual and to then target interventions to that behaviour. In other words, by understanding why they are currently uninterested or interested in change, we can tailor programmes to be more effective. One example of this was service user segmentation in diabetes self-management programmes, which is illustrated in the exhibit overleaf. This programme segmented people based on their behaviour, and then targeted interventions and services to the different types of people identified. This allowed providers and public health officials to make greater impact, because they understood people on a more intuitive and personal level before starting their services.


In the future, we want people across North West London to have maximum choice, control and power over the care and support they receive. Individuals should feel empowered to take more personal control of their care and to decide how they can best be supported to meet their own personal outcomes. This can happen through more explicit collaboration between individuals and care professionals, through the use of a personalised care plan or through targeted interventions that take a person’s holistic circumstances into consideration.

By ensuring that there are processes in place through which care professionals and volunteers can support the personalisation of any individual’s care, local areas will be able to ensure that each person feels that they are receiving the support they need to feel empowered, and to take ownership of their own care journey.

One vital way to increase individual engagement with people’s own care is to provide personal budgets for health- and social-care. A personal budget is an amount of money allocated directly to individuals for their own care, that can be used on whatever they think will most improve their quality of life.

This person-centred approach represents a fundamental cultural and systemic shift away from the approaches to allocating and directing resources that have characterised the health and care system to date. Government has made it clear in the Care Bill that personal budgets will become a legal requirement for all people eligible for social-care. Work is also underway to support local areas deliver personal health budgets for NHS care and people who are already receiving NHS Continuing Healthcare will have a right to ask for a personal health budget from April 2014.

One example of a personal budget allocation can be found in Supporting Material D: Models of Care Supplement. When linked to the wider personalisation agenda, including access to universal preventive services, information and advice, co-production and the growth of social capital and support to carers, personal budgets can transform the way in which people engage with and direct their support. However, for personal budgets to be a meaningful and transformational component of new models of care, people need to be supported to use them most effectively through staff training and improved awareness, provision of information and advice and understanding of the different needs of particular population groups.


Developing the role of the community in the new care model can enable a more personal approach to care wrapped around the individual. The community has a key role in supporting independence, promoting choice and control for individuals and encouraging a greater focus on prevention. Empowering individuals to develop their community support networks will create stronger and more resilient communities and promote positive health and well-being.

The community is currently an underused resource and needs to be an integral part of a new model of care. They are often better placed to build resilience for individuals and carers through supporting their psychosocial needs than traditional health and care services than higher cost ambulatory and residential and inpatient services.

Empowering individuals to develop their contribution to their community improves the health and wellbeing of the individual as well as the people who access this community support network. An empowered community also benefits commissioners and providers by allowing them to work together to discuss how to support the health and care needs of local people. A greater understanding of the local community allows the development of tailored services to meet local needs.

How do commissioners ensure that they successfully develop community resources to effectively support individuals?

Commissioners need to establish an approach to community development. Things to consider are:

  • Do you understand what support individuals want within their community?
  • Do you know what services are available in the local community to meet these needs?
  • Do you know what individuals would like to see within their communities to feel better supported and how these could be developed?
  • Are you ensuring individuals have access to support within their communities and empowering them to have more control over the health and well-being of themselves and others within their community?

Development of networks across local areas will allow a more collaborative approach to community development. This approach focuses on leaders within the health and care system creating sustainable networks that encourage collaboration between organisations which encourages a more dynamic approach. Health and Well-being Boards are important here as a route to creating effective networks across the system. The strength of these networks can be seen through existing collaborations between health and care providers.


There are many services currently offered for carers, either through voluntary initiatives or social-care funding, including respite programmes and extra support; however, the new models of care will need to take this further and push providers to collaborate with carers on every level of care. Practically, this means:

  • Carers should be involved in planning and delivery of care. With the service user’s consent, carers should be involved at every level of the care planning conversation. This means that they should be in the room when the care plan is made, that they should be included in appointments when possible and that they should jointly own the care plan along with the person for whom they care.
  • Data on carers should be collected. Information about carers should be collected during regular data gathering and should be recorded by the GP or other care professionals in the individual’s record. In addition, care professionals who provide care for the carer should be informed of the progress of the person for whom they care and should be alerted if anything happens or in case of emergency.
  • Carer rights should be explicitly defined. Increasingly in the UK, carer rights are being articulated and defined. The new models of care in North West London will need to continue this trend and clearly lay out the rights of carers.
  • Carers should sit on MDT’s. The nature of being a carer often means that that person is the closest to the individual receiving services and spends the most time with them of anyone in the system. Because of this, when possible, carers should be included in the MDT meetings, and should be actively involved at every stage of the care process.

Technology will help support and enable new models of care. There are vast technological resources available for individuals, their carers, their communities and care professionals that should be used to enhance the care and support that we provide. Professionals should take advantage of technology that already exists in order to ensure that they are making the best use of their resources. The box below shows some examples of practical technological tools that providers can use to enhance care.


Many of the ideas shared in previous sections rely on technology. Specifically they use things like Internet communities, online trading posts, blogs, video repositories and iPad and other tablet apps to facilitate self-care, empowerment and the use of community capital. This box will give a few suggestions for online tools that providers can use to implement these ideas.

Tools specifically for the medical community

  1. Tyze. Tyze is a personal network site that connects care professionals, their patients and their carers in an online community. It is available on mobile devices as well, and can be used to encourage individuals and their carers to remain independent.
  2. Know Your Own Health. KYOH is a digital healthcare provider that enables people to better manage their care through the use of a patient platform. It connects patients and carers with their care professionals.
  3. Ginger.io. Ginger.io is a smartphone app that helps people track their care, including tracking mood, their symptoms and their adherence. Ginger.io also uses big data analysis to provide insights for the people who use it.

Tools for Web development

  1. Wix. Wix is a free web-development site, to help providers create their own online communities, blogs, and trading posts. It is easy to use, and it is free to develop a site.
  2. BOnline. A similar tool to Wix with free domain hosting, can help providers set up a blog, a website or a trading post with little outside input.


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 programme.

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.

A model 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.


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 international studies.


Tower Hamlets

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, pharmacists etc.

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 social-care.
  • Free transportation to appointments, family support, coordination, discharge support and risk stratification were all introduced as part of the programme.
  • 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 long-term conditions.

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 service users.

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.


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.


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 district nurses.

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.

Source: http://www.sussexcommunity.nhs.uk/Download/services/proactive_care/proactive_coastal_leaflet.pdf 

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 partners to:

  • 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.

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.

  1. 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.
  2. Patients and carers own an agreed individual care plan that they understand and can use to achieve their goals.
  3. 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.
  4. 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.
  5. To enable patients to have their say about their own care and support in their homes or local community to achieve their goals.
  6. For GPs to be responsible for conversations with patients and carers about organising health- and social-care services that meet their goals.
  7. To provide essential clinical and social information about the patient for providers delivering health- and social-care services to patients and carers.
  8. 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.

Source: www.southwestdementiapartnership.org.uk


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 plan conversation.
  • 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: financial concerns
  • Identifying areas of self-care, patient education or support to achieve goals so patient has greater ownership of their individual care plan.

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 falls… etc.).
  • 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 necessary.

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.

  1. 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.
  2. 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.
  3. 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 as required.

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 emotional well-being.
  • 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:

  • Volunteers.
  • Nurse practitioners.
  • GPs.
  • 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 example.

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.


  • Next we need to consider the acute setting, which also includes residential and inpatient care. A significant proportion of the current healthcare budget goes to acute care, yet it is often the least desirable setting of care for individuals who receive services. Across North West London, pioneer partners have signed up to a vision which advocates moving activity out of inpatient settings into the community and the home wherever possible, and shortening stays when admission is unavoidable.

    There are three major elements of care in the residential and inpatient settings that need to be considered and addressed in an integrated model. These are outlined below.

  • Specialist input into integrated teams. Specialists generally sit in the acute settings. As such, it can often be difficult for individuals who receive services to gain access to the relevant specialists, especially if their mobility is impaired. Part of incorporating the acute settings into an integrated model is ensuring that specialist input is part of the MDT, and that specialists go out into the communities to work with other care professionals.
  • Communication lines with integrated teams. Another vital part of the collaboration with residential and inpatient care is to ensure that there are direct lines of communication to alert MDTs to a hospital admission. This will require coordination between the hospitals and the MDTs.
  • Early supported discharge and planning. Discharge planning is extremely important to ensure that the transition from hospital to home goes smoothly, and should be started either the same day as the person goes into hospital or well in advance of discharge. In fact, many individualised care plans for high-risk individuals should already have a rough plan for discharge included in them. Re-ablement and rehabilitation services should be a core component of discharge planning to help people regain and sustain independence and to reduce the risk of readmission. Some current models have care managers located in hospitals to ensure timely assessment and prevent delayed discharges. MDT members should work together, led by the care coordinators, to ensure that discharge planning happens smoothly.