Integrated Neighbourhood Teams – Active Case Management - Bury Community

As an Integrated Neighbourhood Team (INT) we bring together a range of health and social care professionals who have a variety of different skills, including doctors, district nurses, social workers, pharmacists, therapists, mental health practitioners and social prescribers.

Active Case Management is a program within the INT that offers a strength-based approach and provides co-ordinated care to individuals in the Bury community. Our team of professionals work together to create care plans which support individuals to achieve the goals that matter to them. This may be to support independence, promote health and wellbeing, manage conditions, access appropriate services, build self-confidence, gain knowledge and reduce hospital admissions.

It’s part of our aim to help individuals take control of their own health and wellbeing in their local community.

Padlet - Integrated Neighbourhood Teams - Active Case Management

Primary Target User Group

At risk of a non-elective hospital admission or admission to a care or residential home, where this admission could be prevented through active health or care support.
Excessively accessing the resources of health and social care, including – but not limited to – GP, NWAS and A+E attendances
Those with multiple long-term conditions who would benefit from a more collaborative approach to managing their health and social care and at risk of acute exacerbations including mental health
Might be reliant on others for daily activities, depending on symptoms; for example, managing personal care, meals, household tasks, finances, transportation, heavy housework and medications
Have one or more risk factors of frailty: alcohol excess, drug misuse, cognitive impairment, falls, functional impairment, hearing problems, mood problems, nutritional compromise, physical inactivity, polypharmacy, smoking, vision problems, social isolation and loneliness.

Support Offered

Collaborative multi professional input
Allocated key worker
Coordinated care
Onward referrals to specialist services
Shared utilisation of multiple IT systems to streamline processes and reduce duplication

Our approach involves discussing your individual health and wellbeing needs. Our professionals from different services will meet together and share information about you and your needs in order to plan your care in a more joined up way. While you are cared for by the INT, you will be given a named key worker who will be in regular contact with you and keep you fully updated.

They will help develop a plan that focuses on what matters to you, coordinate support and if appropriate, onward referrals will be made to services that will help to meet your needs. Your care will continue to be discussed at our meetings until your needs are being managed, at which point you will be discharged. If you have any future needs which can be met by our service, a health/social care professional can re-refer you.

We do not currently accept self-referrals into our service. Referrals must be completed by a health/social care professional and sent to acmreferral@nca.nhs.uk Our referral form can be accessed via the following link: www.buryintegratedcare.org.uk/news-resources

Exclusion Criteria