Integrated Domiciliary Service (IDS)

The service has improved communication between partners, leading to more collaborative working, more joint working between Central London Community Healthcare NHS Trust and GPs, meaning better advanced care planning.

Sonia Berjon Aparicio, Integrated Domiciliary Service, Central London Community Healthcare NHS Trust

About the partnership

1. IDS is a daily virtual multidisciplinary team (MDT) involving leads from primary care, Central London Community Healthcare NHS Trust (CLCH), Imperial, London Borough of Hammersmith and Fulham and Central and North West London NHS Foundation Trust. It’s a single point of access for Frail/Complex cases in H&F. The service provides integrated clinical decision making and response to referrals across partner organisations. It’s “run by the community for the community” to ensure best use of existing resources in the community by making things happen.
2. The service model has been built to utilise already funded existing roles. The clinical responsibility for patients remains as per current arrangements between GPs and District Nursing. The IDS presents a change in triage and allocation only.
3. As part of the IDS Hub, attendees take overall responsibility for ensuring the effective delivery of the IDS for patients in their caseloads. Members of the Hub take an action focused approach and shared responsibility for check and challenge.

What has gone well

1. Virtual assessments enabling the GPs to discuss the patient’s treatment with the patient, their family or carer and the District Nurse.
2. IDS has been the catalyst to significant improvement in communication between health and care providers.
3. There are currently 32 weekly IDS Hubs in operation across all PCNs, with majority of surgeries either joining the IDS Hub or running their own MDT/IDS Hubs.
4. IDS has many functions which include education, advocacy, Influence, research, audit and continuous improvement, innovation and development of a scalable model for adoption elsewhere, identification of gaps and solutions, complex case management /anticipatory planning/caseload and more.
5. The IDS continues to gather evidence as a Model for Integration of Community Services.

Results

1. The service discusses/facilitates just below 3000 cases per year across all PCNs.
2. Early analysis of IDS as effective in identifying and risk-assessing clinical cases and providing the most appropriate clinical response.
3. The minimal contact time and virtual nature of the MDT maximises clinical time.
4. The model is a continuation of initiatives proposed in the local Integrated Care Partnership’s ‘Integrated Community Teams’ workstream and has been designed to align with the Primary Care Network Directed Enhanced Service contract, including the anticipatory and personalized care domains. This makes it potentially transferable to PCNs in other geographies as well as valid beyond the life of the Covid-19 pandemic.

What made the difference

1. Continuous engagement by its partners: this ensures inclusivity and transparency in local hubs.
2. Hub structure: the hubs are staffed by small PCN teams and there is an established information governance process.
3. Dual function: combining case management with monthly Integrated Educational Sessions organised by Central London Community Healthcare NHS Trust.