IFIC 9 Pillars of Integrated Care
Integrated teamwork for person- and community-centred care
Integrated care teamwork is the point at which most people experience integration, coordination and continuity. It is about how people and professionals collaborate, formally and informally, to plan and deliver care around what matters most to people.In this context, a “team” can mean many things: a formal multi or interdisciplinary team, an alliance across different organisations and sectors, or a care partnership between providers and the person receiving care.
What matters is that all the people involved in supporting someone’s care, including health and care professionals, community care, carers, and the person themselves, are connected, coordinated, and working together.
Professionals and non-professionals paid and unpaid carers, from different backgrounds and with different competencies, roles and responsibilities work together in inter-disciplinary and inter-organisational teams that include people who need care.
New inter-disciplinary ways of working are developed and new inter-disciplinary knowledge created to promote integrated care.The relationship between care providers and people and communities shifts to a more equal basis.
For people and communities
People and family carers are provided with the opportunity to be equal members of the interdisciplinary team. They experience the support and are given the tools they need to take ownership of their own care based on their life goals, and the decision to do so is made with them. They have access to understand the existing evidence which has been shared with them in an accessible way to make informed shared decisions and manage their care to ensure a positive experience. Information is shared as appropriate, including with the individual and any nominated family carers, at the centre of care.
For care providers
Care providers from different disciplines and sectors work together in an interdisciplinary way. Teams are led with this as an operating principle; roles, responsibilities, and professional accountabilities are clear. Information is shared as appropriate, including with the individual at the centre of care. The team collaborate to enable individuals to make informed decisions and address their care needs, ensuring continuous and coordinated care. Ongoing education and training foster interdisciplinary collaboration and develop their ability to work within integrated care teams.
For system-level decision-makers
System-level decision-makers recognise that integrated inter-disciplinary teams are vital for delivering integrated care. They pool resources to invest in the development of an effective, capable, flexible, and adaptable workforce.
Policy and decision-makers also play a key role in creating policies, guidance, and regulations that promote collaboration across disciplines and sectors, and they prioritise investment in education and interdisciplinary training to equip the workforce with the skills needed for collaborative practice and ensure resources are provided for measurement, evaluation and learning.