Integrated Locality Team

About us

The integrated locality teams are an integral part of a bigger scheme that provides personalised and integrated community, mental health and social care services.

We provide patients, GPs and acute services with one quick and simple route to well joined-up, multi-disciplinary locality-based care which aims to:

• enable patients to stay independent at home or in their usual place of residence as much as possible
• safely support patients though periods of illness regardless of how many different community-based health and social care specialists are involved in providing that care
• support self-management – our patients are ‘partners’ in their care, and we personalise health and social care to patients’ unique needs as much as possible.

What we do

• Manage worsening of chronic obstructive respiratory diseases (COPD) and asthma to prevent acute hospital admission where possible, and provide support for the person to enable them to remain in their own home
• Improve quality of life
• Provide initial support after discharge from hospital or other acute service
• Ensure that the right professional is responsible for long-term care
• Identify patients goals and work with them and their carer so that they can achieve their goals.

What we offer

• Holistic assessment of complex needs, and patients whose condition might be getting worse
• Crisis management
• Care coordination
• Improving health outcomes for patients with long-term conditions, including education
• Facilitating hospital discharge
• Integration back into the community
• End of life care and support at home
• Preventing social isolation.

Useful information