Integrated Care Services (iCares)
What is iCares?
iCares is a service and an approach to managing adults with long term conditions irrespective of their diagnosis, location or age.
It includes a whole range of staff including nurses and therapists providing specialist community interventions which will
- avoid unnecessary admissions to hospital
- help maintain health and well being through care management
- improve independence and function with community rehabilitation
It is open 8am – 8pm, 7 days a week.
Who can receive iCares?
Anyone 16+ years of age with a long term condition who has a Sandwell GP or lives in Sandwell (could have a different GP)
How do I refer?
There is open access to iCares – anyone can refer at any time
You can ring 0121 507 2664 (option 5) / 07817 397 533 or email sandwell.icares@nhs.net
What happens when I make a referral?
The referral will be triaged by a clinician who will ring the patient and work with them to find out what their issues are at this point in time.
A clinical decision will then be made with the patient, as to when a response will be provided. This will be based on the conversation and other information gathered from case notes and the referral.
- Urgent referrals, where we can avoid an admission, will be seen within 3 hours
- Patients who are highly complex and at risk of becoming urgent will be seen within 72 hours
- Those requiring rehabilitation will be seen within 15 days
We aim to match the patients clinical needs to the clinician with the most appropriate skills for their need at this time.
For more information about disabled access for this service, please click here.
Team
iCares is delivered by:
Community Matrons, Home Accident Prevention Officers, Rehab Support Workers, Occupational Therapists, Physiotherapists, Speech & Language Therapists, Admin & Clerical staff, and Clinical Leaders.
For a little more information about the roles in iCares then have a look at the table below:
| Case Managers / Community Matrons | Community matrons are nurses who work intensively with patients with complex health needs, with the aim to improve the quality of care, while preventing unnecessary hospital admissions.
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| Occupational therapist | Occupational therapists assess, rehabilitate and treat people using purposeful activity and occupation to prevent disability and promote health and independent function.
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| Physiotherapist | Physiotherapists assess and treat people with physical problems caused by accident, ageing, disease or disability, using physical approaches in the alleviation of all aspects of the person’s condition.
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| Specialist nurses | These are nurses specialising in a particular condition or care group such as Parkinson’s disease, MS, neurology and osteoporosis. They work within a multidisciplinary team with responsibility for planning, advising, assessing, delivering specific interventions, offering follow-ups, prescribing and referring on for further investigations or to another professional.
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| Speech and language therapist | Speech and language therapists work with people who have communication and/or swallowing difficulties caused by accident, ageing, disease or disability.
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What exactly does iCares provide?
A whole range of treatments in the community for a whole range of conditions:
Admission Avoidance, Virtual Ward, Rehabilitation, Reablement, Elderly Frail, Head Injury, Stroke, Falls & Bone Health, Progressive Neurology, Care Management, Community Bed Management, Therapy & Case Management into Intermediate Care, Therapy & Case Management into End of Life Care, and a Wheelchair Service.
NICE, (2017), “Integrated Care Services (iCares). Transforming and Integrating Community Services within admission avoidance, care management and community rehabilitation services.”: Click here to access the information.
The iCares system has received national media attention around how it has saved the NHS millions of pounds.
The story has featured on ITV.com and in the Express and Star, Birmingham Mail, and the Evening Express newspapers, as well as being covered by Free Radio and Heart FM.
Read the story below:
An innovative idea to treat people earlier for illnesses like flu and chest infections has led to patients in Sandwell and west Birmingham avoiding 17,000 nights in hospital and the NHS saving £7 million to be reinvested back into patient care.
The iCares system, developed at Sandwell and West Birmingham NHS Trust, flags people with long-term conditions who are at high risk of hospital admission to a team of 100 staff who make sure they are seen as early as possible.
Previously, patients were coping at home until in many cases they needed to be admitted to hospital. But now patients or their carers can simply call a number if they need help and are assessed and then seen in as little as three hours by a team dedicated to hospital avoidance.
So far the scheme has reduced hospital admissions by 2,478 a year and 93 per cent of patients who access the service stay in the community.
The move has also contributed to reduced lengths of stays in A&E, reduced lengths of stays in hospital from 10 days to seven days, and reduced readmission rates.
The team is made up of physios, occupational therapists, advanced clinical practitioners (ACPs), community matrons, nurses, speech and language therapists and many more.
The ACPs can dish out prescriptions to clear up infections and the team can organise extra equipment to help people manage safely at home.
The majority of people living in Sandwell have multiple long-term conditions, are likely to live their final 20 years in ill health and are likely to die younger, according to NHS England.
If patients develop urine infections, chest infections, flu, coughs, colds or cellulitis, it can lead to frailty and falls, resulting in less independence, swallowing problems, not eating and drinking enough and feeling unable to cope at home, as well as an increase in stress for both the patient and carers.
Ruth Williams, Clinical Directorate Lead at Sandwell and West Birmingham Hospitals, set up the iCares scheme five years ago after realising how difficult it was for patients to navigate the system and the waste created by multiple teams.
She brought people from three teams under one roof and consolidated 16 different points of access to care and staff now work in neighbourhood teams, based on the patients’ locations.
“iCares is based on need and not diagnosis,” she said.
“If a patient has a long-term condition and develops an infection, for example it could stop them swallowing or walking and that would make them housebound and unable to cope at home.
“Previously, the small team of three people saw urgent cases as well as possible at home but the patients they couldn’t see were admitted to hospital.
“What we’ve done is make the system simpler: one phone number, everyone can ring and one team which works together and navigates the system for the patient, keeping 93 per cent of urgent cases out of hospital.
“Most importantly of all, people only have to tell their story once.”
NHS England National Clinical Adviser for Primary Care, Dr Karen Kirkham, said: “As we develop a 10-year plan for the NHS it is innovative schemes like this that are showing how practical new ways of working can help patients live better lives and also deliver efficiencies for health organisations to reinvest.”
