Integration in action

Our ICS is about more than strategies and plans; it is about building on existing collaboration and making services better for patients. Below are examples of how, by working more closely together, partners across Leicester, Leicestershire and Rutland are making a real difference to the health and wellbeing of our population.


Working together to keep care home residents safe

 Primary care, community care, secondary care, ambulance service and social care personnel are all working together in new ways to promote a community response and reduce the need for care home residents to be admitted to hospital as a result of falls, delirium, pressure injuries and Covid-19 as part of the Pre-Transfer Clinical Discussion and Assessment (PTCDA) scheme. 

Led by geriatricians and GPs, a discussion takes place between all relevant parties when a care home resident is deemed at risk of hospitalisation to explore safer alternatives. If staying in the care home the patient is visited by either a GP or geriatrician with a special interest in care home medicine to put an appropriate package of care and support in place. During the initial period the initiative has led to the appropriate avoidance of 577 hospital admissions and 2,885 bed days, the saving of 730 ambulance journeys, and financial savings of at least £395,245. Most importantly, it has kept many frail people in a supportive and safe environment rather than in a hospital unnecessarily


Harnessing the use of technology on virtual wards 

Across LLR, the Covid-19 pandemic has helped to drive forward a rapid expansion of remote monitoring schemes, allowing clinical teams to keep track of patients with chronic conditions safely and in the comfort of their own home. 

The scheme is a partnership between University Hospitals of Leicester, Leicestershire Partnership Trust, the CCGs and Spirit Healthcare. Inspired by efforts to establish ‘virtual wards’ for heart and lung patients after the pandemic began, work has been taking place to extending the use of technology across more care pathways including heart failure and COPD. 

The technology is set up to help patients self-manage their condition at home while giving them support and reassurance that the monitoring equipment will ensure their clinical teams can act swiftly if their health deteriorates. In the first year more than 900 patients were supported, including 700-plus with heart failure and COPD. Fifty patients with heart failure and respiratory conditions were supported in the first six months through the digital rehabilitation pathway, while 172 Covid-19 patients have been discharged after a hospital admission with remote monitoring at home during an initial five-month period.


Rapid response service supports fallers 

An innovative partnership between health and social care partners is helping to dramatically reduce the level of unscheduled hospital admissions amongst frail and older people, many of whom have suffered a fall at home. Initially launched in Leicester, the Integrated Crisis Response Service (ICRS) has been so successful it has now also been rolled out across Leicestershire and Rutland. 

The ICRS is a 24/7, 365-day solution that responds to patients within two hours of a call from a home or referral by a GP. It brings together health services, mental health services for older people and therapy services. The model offers up to 72 hours of support, which includes care, assessment, risk management and wraparound services such as equipment, assistive technologies and handyperson to make necessary changes to the patient’s home to reduce the risk of further falls. In many cases that is preventing the patient from going to hospital when they don’t need to. Data from Leicester suggests that before Covid-19 more than 1,750 fallers were being supported each year, with only 8% needing to go to hospital after intervention.