The Unique Care approach is aimed at helping patients with complex long-term conditions within a primary care setting.

It involves setting up a coordinated approach between health, social care and other services, and is particularly aimed at patients over 65.

A personal care plan is agreed in advance of any crisis so the patient is able to remain at home, and not be admitted to hospital.

The key benefits are:

• Better quality of life and improved health outcomes for patients
• Greater choice and control for individuals over how their needs should be met
• Reduction in emergency admissions and emergency bed days in hospital
• More appropriate use of resources and a reduction in duplication of services across the system as care is better organised.

It is based upon the socio-medical model of case management developed at the Castlefields Health Centre in Runcorn and was developed through working with PCTs, acute trusts, practices and local authorities.

It is a system of coordinating health and social care to respond to referrals more efficiently and more effectively, to involve community staff in developing discharge plans for inpatients and to identify high risk individuals for preventative interventions.

The model brings together primary and community services, secondary care, social services, housing, the voluntary sector, allied health professionals and others. With the focus on patient-centred care, intermediate care and the promotion of healthy living and self-care, the model is adaptable and transferable to many different client groups.

The national policy and guidance on helping patients with long-term conditions is set out in the long-term conditions section of the Department of Health's website.

Integrated Care Pilots: Unique Care Approach

The Department of Health has recently published a prospectus inviting applications from prospective integrated care pilot sites. The Improvement Foundation can help potential pilot sites in developing their approach based on our experience with the Unique Care model which has already delivered the outcomes identified in the prospectus. Click here to read more.

If you are interested in working with the Improvement Foundation please go to How we can help or click here to contact us.

Who is involved

There are 35 active Unique Care sites across England. These are all at different stages of implementation. Sites range from a whole PCT and local authority working together, to GP consortia with their local social services team, through to single practices working with one social worker.

What we are doing

Key principles

The approach is underpinned by five key principles, however it is not a one-size fits all universal solution to anticipatory care and how the principles are addressed is down to local circumstances.

The five key principles of Unique Care are:

• Ensure local health and social services work side-by-side to effectively coordinate care
• Establish excellent communications between GPs, community nurses and social workers
• Establish proactive, practice-based systems to identify people at risk of falling into crisis
• Establish 'in-reach' systems in hospitals to ensure patients return home as soon as they possibly can
• Constantly adapt and respond to the individual needs of patients and support people to live at home.

These principles differentiate it from other case management approaches and, in order to establish effective implementation, all five key principles need to be addressed.

Other important elements of the approach include:

• Social care requirements are central to the process
• Patients can discharge their team once they are confident in managing their own care
• Patients come out of hospital quickly and easily through close working with the hospital discharge team from the point of admission
• Patients are able to take responsibility for their own health and social care, with support as and when required.

Support

The Improvement Foundation offers a tailored support framework to Unique Care teams, which usually involve senior managers, frontline staff and service users, to help them to develop local solutions to local problems.

Local activities include:

• Workshops
• Conflict resolution
• Site visits and problem-solving
• Facilitation of joint meetings
• On-line and telephone support
• Creating networks and sharing good practice
• Advice on health and social care policy and the key levers for change
• Delivering quality improvement skills training
• Mentoring
• Involving elected members and non-executives
• Developing a shared strategy
• Creating opportunities for more face-to-face contacts between organisations
• Bringing together the statutory and third sectors to identify local solutions.

Key results