Care Close to Home: Integrated Neighbourhoods

Our South East Integrated Neighbourhoods team leads the programme to deliver integrated neighbourhood working and care closer to home across the region.  Integrated Neighbourhood Teams (INTs) support delivery of holistic care in the community, which is focused on co-ordinating care across different services for patients to best meet their care needs.

INTs generally comprise a group of professionals from across primary care, hospital care, community care, mental health services, social care and local charitable and voluntary sector organisations who come together to deliver care for a group of patients within their area. The team would look to proactively identify patients who may need additional support to prevent later ill health and hospital care, through working with general practice to support the patient to live well in the community. Early support for patients should lead to better joined up care for the patient, clear care plans to manage existing conditions and less need for hospital- based care. Depending on the patient needs a neighbourhood can have more than one INT, for instance, some areas may need an INT for their frail and elderly population and for complex mental health for example.

Already across the South East our services and teams are working across organisational boundaries and with local populations to provide integrated services but are consistently looking at new models of care to ensure patients within neighbourhoods are receiving proactive care. Our team brings together colleagues from across the region from Integrated Care Boards, NHS hospital trusts, NHS community trusts, NHS mental health trusts, NHS ambulance services, social care and the voluntary sector to share good practice and facilitate learning across the region.

Our team specifically leads on the following areas:

Integrated Neighbourhood Team development – this is a priority area supported by our regional Care Closer to Home Group, community of practice, and matrix working with other relevant regional programmes. This involves developing a more personalised, proactive, and preventative approach to delivering more integrated care in the community.

Community Services Transformation – We support the transformation of community services including a reduction in long waiting times for community services and how to support more patients being treated in urgent community response teams, where appropriate for their care.

Primary Care Transformation – Our team works alongside our primary care transformation team, to further develop Primary Care Networks (PCNs) and the Additional Roles Reimbursement Scheme (ARRS), both of which are to support increased access to primary care.

Better Care Fund – The Better Care Fund enables community integration with its two core objectives of enabling people to stay well, safe and independent for longer and providing the right care in the right place at the right time.

Personalisation – We support a regional approach to Personalisation which includes, statutory Personal Health Budgets (PHBs), support to the personalised care workforce, and facilitating new models of care including supported self-management, social prescribing, and shared decision making.

South East conference 

Case studies and resources