The Care Co-ordination Service was piloted as part of the London Older People's Service Development Programme that started in October 2001. Following a period of service mapping, a gap in proactive preventative care for older people was identified alongside a need to better co-ordinate care across organisational and professional boundaries.

High level buy-in from key stakeholders was secured and an interagency advisory group established to address any issues as they arose and provide multidisciplinary mentorship to the pilot team.

Drawing on key principles from the Castlefields model, the approach was initially piloted for six months and was demonstrated to successfully facilitate effective joint working and cohesive patient care for patients from the two pilot practices. Reductions in service use were seen alongside a significant improvement in people's perception of the services they received and quality of life.

Results included:

In addition to the direct patient benefits, the approach influenced whole systems working. Improvements include joint training events, joint visits, better information sharing reductions in the length of time it takes for discharge information to reach practices from the community hospital from nine days to same day,.

The service was mainstreamed across Brent in April 2004 and consists of five clinical care co-ordinators (one per locality), a team leader and an administrator.

Unique Care in Brent report [Link to PDF]