Integrated Care Teams in Liverpool and Sefton Places

Background

The Integrated Care Teams (ICTs) in Liverpool Place and Sefton Place support a population of 810,000 people, including 427,000 residents living in the most deprived communities (IMD1) and over 64,000 individuals managing five or more long-term conditions (LTCs).

Since their commissioning in 2018, the ICTs have been central to delivering joined-up, person-centred care. They bring together members of the Integrated Neighbourhood Teams to meet the diverse needs of local people through holistic assessment and coordinated support.

At the heart of the neighbourhood integration agenda, the ICTs provide place-based care at a 30,000–50,000 population level. Their work is driving measurable improvements in health outcomes—helping communities thrive through collaboration, prevention, and tailored local delivery.

The programme aims to enhance the overall quality of life for patients and service users by addressing their biological, psychological, and social wellbeing. It seeks to improve the experience of care by reducing fragmentation across the system, creating a more seamless and coordinated approach. By fostering greater resilience among patients, service users, and carers, the programme also helps to ease pressure on general practice and urgent care services. Stronger partnerships and more proactive collaboration between organisations are central to this effort, helping to reduce duplication and streamline efforts. At its core, the approach is preventative and strengths-based, focusing on assessing and supporting individuals in ways that build on their existing capabilities and promote long-term wellbeing.

Local services provide better and more coordinated care when ICT care coordinators support different organisations to work together in this way. For staff, improved collaboration and integration and teamwork help to make it easier to work with colleagues from other organisations, systems can better understand data about local people’s health, allowing them to provide care tailored to individual needs. Effective ICTs (composed of members of the Integrated Neighbourhood Team) help people stay healthier for longer and avoid unplanned hospital admissions.

The Integrated Care Team Model

The ICTs offer both reactive and proactive pathways, with patients and service users referred by multiple organisations outside of the typical health and social care pathways. Referral pathways are established with Housing Associations, Children’s and Family Centres, Department of Work and Pensions, Merseyside Fire and Rescue and Citizens Advice Liverpool and Sefton CVS. The teams also undertake enhanced case finding using the Graphnet/CIPHA system to identify people at greatest risk of interaction with the urgent and emergency care system, including high intensity users of General Practice.

Benefits of the Integrated Care Team Model:

Application of a bio-psychosocial model of care to all people using the Integrated Care Team service to support identification of patient need and agencies/ services required to collaboratively meet their goals
Contribute to reducing health inequalities within and across places by providing high quality, equitable clinical input to all people in partnership with local integrated partners

Co-produce car plans based on holistic care principles, including assessment of the physical, psychological, functional, financial, social and environmental needs of the individual, as well as end of life care needs where appropriate
Ability to draw, where practicable, on existing assessments that have taken place within the previous four weeks by members of the MDT prior to referral to the ICT and where possible incorporate existing goals and plans of care
Collaboration with local partners to identify and/or engage in locally organised shared learning opportunities as appropriate and as capacity allows
Support local systems, via proactive care strategies, to reduce emergency activity including A&E attendances/admissions, non-elective admissions, bed days, ambulance calls, conveyances and emergency readmissions
Provide clinical leadership and case management for all people on the integrated Care Team caseload ensuring collaboration with the person, GP and wider Integrated Care Team
Provide clinical support and education to partners involved in supporting integrated care provision, enhancing the knowledge and skills of the local workforce. This includes raising awareness of the broader integration agenda
Development of core members of the Integrated Care Team for each neighbourhood who work collaboratively to improve outcomes through whole system working and principles agreed by all organisations involved
To ensure people receiving input from the Integrated Care Team, along with their families and/or carers are involved in service improvements, their experiences must be captured and acted upon
Provide flexible provision to support new developments and quality improvement schemes at both Place and neighbourhood level
Focus on patient identified goals and outcomes rather than organisational access standards and targets.

Benefits

The ‘Our Croxteth’ neighbourhood collaboration pilot has successfully improved local relationships between health, social care and voluntary sector partners via a participatory budgeting process. This initiative aims to enable asset-based community development for a local community with poor health outcomes. As an initial impact, the pilot supported the delivery of 24 neighbourhood level community projects, benefitting more than 5000 beneficiaries and engaging 30 new community volunteers. This has led to the formation of an ongoing, constituted community led working group, which has leveraged government and charitable funding to deliver local projects identified by the community. These projects focus on reducing social isolation, promoting healthy activities, and reducing harmful and anti-social behaviour, which are key determinants of health and wellbeing.

A pilot program aimed at supporting high intensity users of general practice successfully released 13.4 hours of practice time, equivalent to 67 GP appointments. The GP identified 9 adults with >12 unplanned contacts with the practice in the preceding 3-month period. Following an ICT assessment, the ICT coordinator completed a total of 35 onward referrals to local services. As a result, 8 service users showed a significant reduction in the number of contacts to the practice in the 3 months post discharge from the ICT. Moreover, it has now been 6 months since the pilot ended for most of these patients, and the reduction in contacts has persisted.

Next Steps: Journey to Integrated Neighbourhood Teams

The long-term sustainability of the system relies on reducing dependence on costly hospital care. To achieve this, we need to strengthen primary and community care by further integrating them with social care, local authority services and the VCFSE sector. This integration will help create Integrated Neighbourhood Teams (INTs) that leverage digital technology.

With a more neighbourhood approach, i.e. Team 100, there are opportunities to impact on local population health and well-being priorities supported by enhanced case-finding and using Data in Action, to deliver collaborative working and asset-based solutions to those who need it most. This is where asset-based community development, supported by relationships between providers, data-sharing and joined up objectives deliver on the requirements for more prevention than treatment.

Currently, the Integrated Care Team conduct joint holistic assessments with fellow professionals such as mental health practitioners, housing tenant officers, community matrons and social prescribers. This approach builds upon existing relationships with patient and service users, fostering trust throughout the assessment process. Fellow professionals and services contribute to the multi-disciplinary team meetings, bringing their expertise and clinical/ specialist input to support achievement of those goals established with the service user and/or their carers / families.

The transition from Integrated Care Teams to dedicated Integrated Neighbourhood Teams, equipped with the knowledge and skills to address the needs of neighbourhood populations of 30,000 – 50,000, represents a natural evolution for the local system and supported by recently issued national Neighbourhood Health Guidelines. The transition will require innovative and collaborative solutions to engender trust between partners with collective responsibility for local population health, drive proactive care and early intervention, share relevant information digitally and support patients closer to home.

Neighbourhood Collaboration

Community priorities: Identifying what matters to the range of residents in this community through their lens, listening to a range of voices. Survey community groups.

Mapping assets for ABCD: What is cherished by the community and is already available, and what gaps in services does that leave? Asset mapping those places at the heart of communities.

Anchor organisations: Larger trusted providers / services with local presence and can be drawn upon to bring in support where gaps in service provision exist.

Foster collaborative culture: Develop new or enhance existing community action groups to enable local volunteers to work together for the betterment of their local area / community.

Understanding impact: How do we measure success in the short and longer term know whether we have made a difference locally. Evaluation.

Enabling resources: What resources can we pull in to empower local people, groups and services to work together. Participatory budget scheme / community fund.

ICT EQ5D Analysis – Liverpool Place

Liverpool ICT use EQ5D to score the overall health, as reported by the service user, pre and post intervention to value their health.

EQ5D in use in Mersey Care NHS Trust is the EuroQol 5 dimensional 5 levels. Patients score themselves between 1-5 in the areas of mobility, self-care, usual activities, pain and anxiety / depression. These scores added together create an overall score that can be used to measure the health value of improvement.

Health Value Index

811 patients had a full EQ5D profile following referral and ICT intervention. Of these 565 patients had a full EQ5D profile on discharge. As such full analysis over overall health value index is on 565 patients post discharge.

A proportion of data collected did not contain completed scores across all domains, included incorrect scores, outside the parameters for EQ5D, or service users remained active on the ICT caseloads, and as are excluded from analysis.

Initial scores on admission to ICT caseloads are displayed in chart 1 and post ICT intervention (discharge) displayed within chart 2.

Figure 1: EQ5D pre ICT Intervention

Figure 2: EQ5D post ICT Intervention

The higher the value to 1 the better the overall self-reported health of a patient. The average health value of self-reported scores was 0.33 on admission to the ICT caseload, post discharge this improved to 0.40. Overall, this showed a slight improvement across those patients discharged. In total:

196 service users reported improved scores on discharge from the ICT (34.7%)
345 service users health value index score remained unchanged at discharge from the ICT (61%)
19 service users health value index score decreased on discharge (3.4%).

Individual elements of EQ5D are as follows:

Mobility

There was a reduction in patients dropping from the higher reported levels of mobility (3, 4 and 5) from pre intervention to post intervention. This helps demonstrate that in terms patients perceived an improvement in mobility following ICT intervention.

Self-Care

There was a reduction in patients dropping from the higher reported levels of self-care (3 and 4) from pre intervention to post intervention. This helps demonstrate that in terms of patients’ perception of their ability to self-care has increased following ICT intervention. The total patients who reported a score of 5 remains the same however.

Usual Activities

There was a reduction in patients dropping from the higher reported levels of usual activities (3, 4 and 5) from pre intervention to post intervention. This helps demonstrate that in terms of patients’ perception of their overall usual activities has increased during intervention by the ICT.

Pain

There was a reduction in patient reported levels of pain post ICT intervention (3, 4 and 5). This helps demonstrate that in terms of patients’ perception of their overall pain had reduced at the point of discharge from the ICT.

Anxiety

There was a reduction in patients dropping from the higher reported levels of anxiety (3, 4 and 5) post ICT intervention. This helps demonstrate that in terms of patients’ perception, their overall anxiety has decreased following intervention by the ICT.

Conclusion

Analysis of EQ5D scores over this 6-month period, excluding service users remaining active on the ICT caseloads, suggests that, although improvement was noted across domains, the greatest patient reported improvements were reported in usual activities and anxiety. This suggests that in terms of interventions these appear to be the most successful improvements at present.