Integrated Pathway Team Procedures

1. The Role of the Integrated Pathway Team

The Integrated Pathway Team is part of the Integrated Services Complex Care Hub.

The Integrated Services Complex Care Hub comprises of Swindon Borough Council (SBC) Integrated Pathway Team and Swindon Integrated Care Board Continuing Healthcare (CHC) Team with diverse registered professionals who work jointly to ensure SBC and Swindon ICB support plans are cost efficient by using the most appropriate health and social care funding streams, to meet assessed needs and adhere to local authority and NHS statutory obligations by:

  • Identifying complex packages of care and working with allocated case managers/care co-ordinators when evaluating support plans, using a 'cost benefit analysis' approach;
  • Completing and quality assurance of NHS Continuing Health Care Checklists;
  • Representing SBC and Swindon ICB at NHS Continuing Health Care (CHC) Multi-disciplinary team (MDT) meetings for Decision Support Tool (DST) completion and Joint Funding Matrix completion as well as participate in making recommendations on eligibility and joint funding splits;
  • Reviewing individual support plans and care plans during MDT meetings and checklist completion, to ensure the assessed needs of service users and carers are being met; to monitor the quality of service delivery; and confirm that outcomes and objectives are being met and whether the level of service provision or direct payment is in line with the requirements of eligibility criteria and represent value for money;
  • Case Management of complex care packages in liaison with SBC Adult Social care teams, care co-ordinators, advocates and service providers e.g. Avon and Wiltshire Partnership Mental Health Trust care co-ordinators across all teams, Swindon Advocacy Movement advocates, Prospect Hospice and Swindon Carers' Centre;
  • Streamlining and constant review of CHC, Funded Nursing Care (FNC) and Joint Funding processes to ensure efficiency in liaison with all Adult Social Care Teams, Integrated Care Boards, Great Western Hospital and service providers.
  • Promoting multi-professional inter-agency working and communication between and across SBC, ICBs, AWP, GWH and service providers;
  • Sharing of information regarding service quality and gaps in provision with colleagues in commissioning, to support effective service delivery and responsive service developments;
  • Providing information to service users/relatives and representatives on health and social care pathways.
Integrated Services Complex Care Hub consists of an Integrated Service Lead, an Integrated Pathway Lead and a CHC Team Leader working alongside registered nurses, care managers who are registered professionals (Social Workers and Nurses), Business Support Advisors and can be contacted on ComplexCare@swindon.gov.uk.

2. Local Resources

A range of documents can be found in the Local Resources area, including;

  1. CHC/FNC/CHC Fast Track and Joint Funding Processes
  2. CHC Checklist
  3. CHC Consent Form

Click here to access them.

3. Procedures

Integrated Pathway Team practitioners can use the links below to access some key procedures from this page:

When managing cases on behalf of an adult social care team practitioners should refer to the relevant area of this procedures site for that team to access procedures relating to assessment, Care and Support Planning and review.