Integrated Care Network (ICN)

Patients identified by their own doctors as having complex or long term conditions, that may benefit from extra support to keep them well, remain independent and avoid unplanned hospital admissions, are referred into the service. Patients have a holistic, comprehensive assessment by a community matron at home. Cases are then discussed by a multidisciplinary team consisting of community matrons, their GP, Consultants in elderly care, mental health workers and representatives from voluntary sector organisations. Our GPs chair these meetings and help create an action plan for the team to take forward.

All referrals are seen within 5 working days wherever possible.