Support We Provide ICAN Integrated Care Across Northamptonshire ICAN ICAN is the local interpretation of a scheme in development across the country called Integrated Care Systems. Northamptonshire became an ICS on 1st July 2022. The aim of integrated care is to give people the support they need, joined up across social services, NHS and the voluntary sector. It aims to remove the divisions between the NHS and council services and between different aspects of health – hospitals, GPs, mental and physical health. These divisions have led in the past to people experiencing disjointed care. There are partnerships developing across the country between organizations that meet health and care needs across an area, to coordinate services and to plan to improve population health and reduce social inequalities. An important part of this is that decisions about how services are arranged are made locally, in the area in which they live. The overall aim is to keep people healthy and out of hospital, enjoying their lives for as long as possible and building resilience. ICAN aims to support those living with long term health conditions such as diabetes, dementia and heart related illness. ICAN, or Integrated Care Across Northamptonshire, is our local interpretation of the ICS project. The overall aim is to meet the needs of our ageing local population and to help people to “Choose Well, Stay Well and Live Well”. Age/Ageing Well Ageing Well is a small but very significant cog in the wider iCAN service machine. The aim is to give more proactive support to those at high risk of health deterioration / hospital admission. It is a collaborative multi-disciplinary approach with Primary Care Networks (PCNs) as the lead organisation, alongside health services, social care and the voluntary sector all working as part of a ‘Ageing Well Team’ within each PCN. It is funded via the Northamptonshire Health Care Partnership. Ageing Well is a true example of Multi-Disciplinary Team (MDT) support. A PCN is a group of GP surgeries who work together, covering a geographical area. Each PCN has been allowed freedom to develop delivery models and processes to suit the needs of their PCN patient populations, so they all work in a slightly different way. Ageing Well is a project which aims to bring about the ideological and working practice change necessary to properly join health / social / wellbeing services. The multi-disciplinary approach emphasises to both patients and professionals that health is more than treating health concerns and also looks at social issues, including housing, social isolation, equipment and access. Meetings take place at the patient’s home, facilitated by a support worker placing the patient and their carers at the centre of the consultation. Support workers take basic observations e.g blood pressure, respiration, oxygen saturation, temperature, pulse. This prevents difficult and untimely trips to the GP surgery for the patient/Carer or costly home visits for clinicians. The other is being able to prescribe low level equipment, negating a waiting list of up to twenty weeks in some cases and immediately reducing risk of falls etc. feedback so far tells us this service is valuable and key to building patient resilience. Community Asset Groups The aim of these groups is to offer peer support, education and access to health intervention with ease. We currently have groups for those living with diabetes (type 1 and type 2), heart conditions and dementia. The sessions are informal but have a programme in place. As an example, we have a cardiologist present at the Pumped Up group (heart) and a diabetes expert at the diabetes group. The focus is on wellbeing as well as managing your condition with easy access to speak to the clinician – people tell us this is a positive to the groups as it avoids having to make appointments and often, they can discuss things such as medication and general changes at the group. As well as looking after our mental health, there is a physical inclusion, too. overall, a lot of fun is had as well as making friends and being informed. Referral for these groups is via a health care professional. For those living with memory problems or dementia – those groups are less structured but will include the same holistic needs. People can come along to the dementia groups without a formal referral (mindful of a current waiting list). In line with the iCAN message, we aim to provide a way to best manage these conditions so that people can live well for longer and avoid unnecessary visits to their GP or hospital. Memory Hubs Referral to the Memory Hubs is via the memory assessment service only as there is a criteria for these groups. Based on a Dutch model of a Meeting Centre, the aim of the Hubs is to provide a structured programme for those living with dementia and their loved one. Activity is based on cognitive stimulation therapy and works with the person’s ability, engaging the brain. Again, there is an element of physical as well as wellbeing activity with some outside community input such as local art gallery, adult learning and local floristry sessions. Under the ‘Hub’ umbrella is the Club where these activities happen but also the Advice Centre and the memory assessment clinic programmes. The Advice Centre is still a work in progress but its aim is to provide a wide range of education and information to families around the condition as well as practical information such as advance planning, scams, keeping safe and benefits. Working alongside the memory assessment service, this is a coproduced programme. We are currently providing this in most pockets of the county with more to come. The main aim of the Hubs is to keep people happy and well for as long as possible and we do this via education, information, crisis prevention and general wellbeing.