Integrated Care Team

“An effective, integrated team that is dedicated to improving out of hospital care is a great way to improve both the patient's experience and their health outcomes ”

Teams across Aldershot, Farnborough, Farnham, Fleet and Yateley have a multi-disciplinary Integrated Care Team of health and social care professionals working together to keep people happy, healthy and at home. By working with multiple organisations, we aim to arrange and coordinate the right support and care, particularly where there are complex needs.

The ICT can help reduce the risk of hospital admission and speed up the safe discharge of those in hospital, when ready to return home. This is achieved by:

• Conducting holistic assessments across a number of areas of need, in the patients home environment
• Giving GPs and other medical professionals access to a team of experts when making complex care decisions
• Making or supporting referrals to wide range of community based services
• Tracking progress, coordinating updates from all disciplines and review & follow up of patients until such time as all identified needs have been met
• Keeping the patients’ GP informed of progress, multidisciplinary discussions, decisions on care and patient outcomes