Integrated Care Across Northamptonshire (iCAN)

What is the iCAN programme?

Integrated Care Across Northamptonshire, or iCAN, is a programme is a major new programme of transformation  work driven by Northamptonshire Health and Care Partnership (NHCP).

Our local population told us what they needed following a community engagement session held by NHCP and Healthwatch in 2019. The aim of this session was to discuss big ideas about what the future of care should look like. Following on from this, a public survey was launched where hundreds of people shared their views about health and care in our county.

We listened to what you said and what your priorities were in terms of accessing health support and health advice as well as the other services that we provide.

Our overall aim with iCAN is to meet the needs of our ageing local population and help people to Choose Well, Stay well and Live well.

The key areas that the iCAN programme will focus on are:

1. Communities
2. Person-centred care
3. Partnership – working across the system

With a growing and ageing population and more people living with increasingly complex long-term health conditions, Northamptonshire’s health and social care system faces a number of key challenges today and in the near future.

We know that the majority of our patients want to be at home, not in hospital, and we know that we can improve the long term health and wellbeing outcomes that we are supporting people to achieve. We also know that if we carry on working in exactly the same way as we do currently, within four years we will no longer be able to properly support the health and care needs of our county’s older residents.

The COVID-19 pandemic has showed us that when we really need to work together to change things quickly, we can do this by working together across organisational boundaries. So now is the time to act – and do the right thing to achieve better health, care and wellbeing for the people of Northamptonshire.

Our demand for health and care is growing, especially within our ageing population who are more likely to need services from us going forward and this is what the iCAN Programme is looking to achieve – meeting the needs of those who are over 65 years-old, the elderly and those who are frail.

Frailty can mean different things to different people. People may not see themselves as frail but that doesn’t mean support isn’t available to them. When we talk about frailty, we mean that as people get older they may feel like they’re slowing down and generally becoming a little less resilient.

The iCAN programme is about making sure that as people get older, start slowing down a little or a lot and become less resilient, the right support is in place to help keep them happy, healthy and independent.

There are 3 key areas that make up the iCAN programme:

Community Resilience:

"iCAN “be fully supported to live independently within my community as an older person.”

This is the support we give older people in our community to maintain their independence and to stay well. As people get older and slow down our priority is to support their independence and health at home and in their community. To do this we will carefully plan all the service and support which might be needed to help older people and their carers stay well, choose well and avoid their health getting worse.

This may be within the community where we will provide services based in the community which will make sure the right action is taken at the right time to help keep people healthy and independent.

If a person is in hospital, we will have a full set of support available to them in their community so they can return home from hospital swiftly and safely.

Frailty Escalation and Front Door:

“iCAN: “be assessed swiftly and treated effectively when I need to be so I can remain independent.”

We want to make sure older people can live happy, healthy and independent lives, helping them make good decisions about their health and care needs and avoiding stays in hospital unless absolutely necessary.

Frailty Escalation: This is what happens to a person if and when they arrive at hospital and the treatment they receive by the teams and people that they see. These specialist teams will support older people who need help which is beyond that which can be provided in the community and by GP surgeries. These teams will make sure people are treated swiftly and effectively so they can return to their normal life.

Front door: This is focussed on our community-based frontline teams. These teams, alongside those within the community, will be fully connected with Emergency Departments and the Ambulance Service to make sure all front-line health and care workers understand what support is available for people both within their communities and within health services.

Both of these teams make sure that people are being treated swiftly and effectively so they can return to their normal lives as soon as possible.

Flow & Grip:

"iCAN: “be fully aware of when I will leave hospital and what support will be given to me once I’m back home."

Flow & Grip is all about how people move through the hospital and how they are prepared to be safely discharged. If an older person does reach hospital, we will reduce the amount of unnecessary time they spend there by making sure they can return home safely and happily at the earliest possible opportunity.

Alongside this, we will make sure staff in hospitals are fully linked to those teams supporting people in the community and help people understand the care options available to them when they leave hospital.

We are committed to making sure people are kept fully informed and involved in all decisions which need to be taken about their care.

The iCAN Programme will be rolled out across Northamptonshire covering the areas under North Northamptonshire Council, and West Northamptonshire Council. 

You can find your council here.

The services that are working together include;

• Age UK Northamptonshire
• Healthwatch Northamptonshire
• Kettering General Hospital NHS Foundation Trust
• Northamptonshire Carers
• Northamptonshire CCG
• Northampton General Hospital
• Northamptonshire Health and Care Partnership
• Northamptonshire Healthcare NHS Foundation Trust
• Primary Care
• Voluntary Impact Northamptonshire

Each of the  Primary Care Networks (PCNs) in Northamptonshire have a frailty lead who will integrate a frailty team within all the GP practices in the area as well as other appropriate services. This will give patients quick and easy access to the services that they need.

It is important to note that Primary Care colleagues will know what their particular population need. This means that services and pathways will be tailored to suit each  locality.

We have dedicated team members across social care who are leading on the iCAN programme specifically, and we have recently introduced new “welfare support workers” into each of the Primary Care Networks who provide a direct link to GP services and are then linked back to social care teams.

Social care networks will be crucial in helping to link with community services once a person is discharged from hospital. A person’s relative(s) may also be involved with the social care team when discussing the most appropriate care and pathway for the person.

Within this team, the central idea is that ‘home first’ should always be the priority.

The experiences of service users will be our measure of success. We want to make people’s wishes and aspirations for their care to be met as much as we can.

Our Patient Advisory Group will be an important focus group that we will engage with when it comes to continually measuring success and outcomes – the voices of people across the county are crucial.

We will also be using a set of Key Experience Indicators and Key Performance Indicators to help us track progress too.

The iCAN programme will be funded in two ways:

The national Better Care Fund is a programme that supports local systems and brings all health partner contributions together to deliver integrated care, which is what the iCAN programme of work is aiming to do.

In addition, all of the different health partners involved have also contributed towards this investment that will change outcomes for good, and permanently.

All of our services will be running as normal as we gradually introduce new ways of working for our staff and new pathways for our patients.

Please continue to contact your usual health and care person or provider as normal about yourself or someone you know.  

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