At an Integrated Network meeting, representatives from general practice, mental health, social care, Age UK, community matrons and UCLH meet to discuss the care needs of patients and service users who have the most complex needs.

• Any member of the Integrated Network can present an eligible patient or service user for discussion.
• The patients discussed are those likely to have an unplanned attendance or admission to a health service, or people with complex care plans.
•  Similarly, any health and care practitioner in Islington can refer a patient or service user for discussion at an Integrated Network, by contacting the Integrated Network Coordination (INC) Admin Team directly.

Integrated Networks meet weekly or fortnightly to discuss the specific issues that are affecting individual patients and service users, who are registered at that group of GP surgeries. Health and social care issues are discussed systematically and the team create a coordinated plan that makes the best use of local services to ensure patients and service users benefit from the highest standard of care.

This plan may reduce the likelihood of someone having an unplanned admission to hospital; support their existing community care or create a new approach to solving a long term problem.

The progress of each plan is reviewed regularly until a resolution has been reached. GPs will always have a representative at the meeting to discuss the case, and all key actions are fed back to the patient/service user, carer or other relevant health and care practitioner.

Eligibility Criteria

Inclusions

• Patients registered with one of the GP surgeries the Network is centred around.
• Patient must be 18 years or older and be registered with an Islington GP.
• Patient must have two or more of the following at the point of referral 
  • i. Social Issues
  • ii. Physical Health
  • iii. Mental Health
• Or patients who are frequently attending hospital (inpatient or Emergency Department) 
• If the patient has been referred to MARAC they should not be discussed at INC until MARAC have closed the case. This is to avoid duplication of work. 
• After the first discussion, if only one service needs to provide intervention; the patient should be discharged.

How to Refer