The West Essex primary care practices have grouped together into six networks that work together, share staff and services. One example is integrated neighbourhood teams, created from primary care clinicians, practice and community nurses, therapists such as occupational, physiotherapy, mental health, social prescribers and care co-ordinators.
These skilled staff identify patients that would benefit from multi-disciplinary care. This looks at their holistic needs and the needs of their carers, to support them to stay well and at home, give them easy access to services and connect them to social care and voluntary support. Together with the patient, they create a care plan that is visible to the team so that care is consistent and joined up.
Delivering proactive care
- Understanding the needs
- Build the plan
- Deliver the work
- Review to improve
Who are the Integrated neighbourhood teams?
- GPs
- community nurses
- hospital doctors
- social care workers
- community pharmacists
- paramedics
- social prescribers
- local councils
- the voluntary sector