Integrated Care Fact Sheet

Often patients with multiple health problems find themselves working with different professionals for different bits of their health and social care. The professionals often focus on just their area of expertise rather than the whole person. The Ealing Integrated Care Programme plans to change that. It aims to make sure that patients with one or more long-term condition (like diabetes, mobility issues, hearing loss, heart conditions, cancer, learning disabilities etc.) have a well-informed team of people looking after their whole health and wellbeing. This is done by assigning them a Care Coordinator.

A Care Coordinator works with all the people involved in caring for someone and helping them remain independent at home. They coordinate that team of professionals in a way that works well

Who Is The Service For?

People aged over 18, with one or more long term health condition.

This group was chosen because they rely so heavily on NHS services.

A Joint Care Team could include the patient’s GP, specialists for particular health conditions, social workers, friends, family, carers and local community services. Together with the patient they design and follow a shared care plan.

How Can A Person Access The Service?

Currently, Care Coordinators are referred to patients by the individual’s GP.

All Ealing GP's are now part of the scheme

This information will updated as the service is rolled out across Ealing

Download the Integrated Care Fact Sheet from here