Integrated care referral pathway and support tools

Referral to Lincolnshire Community Health Services NHS Trust (LCHS) integrated care and specialist teams is via NHS net, telephone call or letter.

Short-term interventions carried out in community setting

Short-term interventions are defined as being a package of care that may last up to four weeks and may range from a single visit to a number of visits over a four week duration. If the patient requires a longer package of care then the assessment process will identify ongoing health care needs which will utilise the phase of Illness as a proactive guide to planning care in partnership.

Examples of short – term interventions
  • Daily injections
  • Suture removal
  • Simple dressings
  • Assessment
  • Blood test (house bound or on specialist caseload for admission avoidance)
  • Specialist assessment, for example, continence
  • IV infusions – long term vision, requires commissioning
  • Therapy – admission avoidance including equipment provision
  • Rehabilitation and short term care packages to enable patient to remain safely in their own homes
  • Moving and handling assessments
  • Transitional care bed placements
When Seven days a week
Who Registered nurse, allied health professional, assistant practitioner, health care support worker
Referrals in
  • Referrals from health and social care professionals
  • Self-referral in some circumstances
  • Transfer between ICT teams
  • Neighbourhood Team referral – defining who should take the lead, nurse, therapy, adult care, community psychiatric nurse
Referral onwards/discharge Self-management plan with trigger points for accessing support
  • Episode of care is complete
  • Movement into other pathways, end of life, long term conditions
  • Third sector/ voluntary
  • Independent sector
  • Transitional care pathway
  • Urgent care – home visiting service / review by a senior practitioner
  • Operations centre
  • Onward heath referral, for example, community psychiatric nurse
  • Community hospital
  • Information and resources: for example Lincs2Advice, NHS websites, Patient UK, disease specific charities

  • Holistic assessment
  • Agreed care plans including self-care strategies by visit three
  • Referrals to other clinicians and services as indicated
  • Identify stage of illness and outcome goals

Specialist services referral criteria and information required 2017

Diabetes Required Information: 2 x HbA1C results
  • Insulin initiation/GLP 1
  • Recurrent Hypoglycaemia on insulin
  • Poor glycaemic control on insulin
  • High steroid with hyperglycaemia
  • Terminal illness and blood glucose levels unstable
Diabetes Spotlight:
  • Newly diagnosed diabetes
Continence Level 3 Continence Care:
  • Refer for advice or support of complex or high risk patients as required following generic continence assessment, working diagnosis and appropriate care planning in place for Levels 1 & 2 interventions.
Tissue Viability Tissue Viability Specialist:
  • Complex wound management/advice required
Parkinson’s Disease Parkinson’s Disease Specialist Nurse:
  • Individuals aged 16years and over with a confirmed diagnosis of Parkinson Disease by a Consultant with a special interest or Consultant Neurologist.
  • Variants of the disease - Multi system Atrophy , Vascular Parkinson , Progressive Supranuclear Palsy, Corticobasal degeneration and Lewy body Dementia who are taking Parkinson Medication
Heart Failure Heart Failure:
  • Worsening signs / symptoms of heart failure
  • Objective evidence to support diagnosis – echocardiography / angiography/ MRI Scan results
Copy of echocardiogram, angiogram or MRI scan results required.
Macmillan/ Palliative Care Services Macmillan/ Palliative Care Services: Referral to Palliative Care Specialist for one of the following reasons
  • Assessment and advice on complex physical symptoms not responding to first line management
  • Advanced psychological, emotional and spiritual support for patients/ carers
  • Provision and clarification of specialist information on disease treatment and palliative care.
Cardiac Rehabilitation
  • Acute Myocardial Infarction
  • Percutaneous Cardiac Intervention
  • Recent cardiac surgery including bypass graft (CABG) , valves, ventricular assist device or heart transplant
  • Implantation of cardiac defibrillator
  • Implantation of device for cardiac resynchronisation therapy not related to acute coronary syndrome or heart failure
  • Stable Angina patients who have had two condition-related emergency admissions to hospital within a six month period.
  • Heart Failure (stable 6/52 with reduced functional ability due to hf symptoms)
Respiratory Response Services Acute Respiratory Assessment Service
  • Confirmed diagnosis of COPD (please enclose most recent spirometry)
  • Able to cope at home
  • Suitable social circumstances
Significant co-morbidities stable

Early Assisted Discharge
  • Via established pathway –inreach, outreach and RAPA
Complex Case Management
  • Confirmed diagnosis of chronic obstructive pulmonary disease with a spirometric FEV1 measurement of <50% of predicted.
AND at least three of the following criteria:
  • Two or more hospital admissions in the last 12 months with the primary diagnosis being exacerbation of COPD.
  • Two or more A & E attendances in the last 12 months with the primary diagnosis being exacerbation of COPD.
  • A hospital admission in the last 12 months of 4 weeks or more with the primary diagnosis being exacerbation of COPD.
  • Four or more visits to their GP practice in the last 12 months with needs relating to COPD.
  • An MRC dyspnoea score of 4 or 5
  • Are functionally disabled by their condition.
  • Receiving oxygen therapy.
  • 3 or more co-morbidities
Oxygen Assessment
  • Have a confirmed diagnosis of COPD (hard copy of spirometry must be attached to the referral).
  • Optimal medical management and a period of stability for a recommended 8 weeks prior to the assessment.
  • A resting SpO2 of ≤ 92% breathing air or a fall in SpO2 of 4% to below 90% on exertion or a resting SpO2 of ≤ 94% with evidence of peripheral oedema, polycythaemia (haematocrit ≥55%) or pulmonary hypertension.
  • Be in receipt of oxygen therapy without ever having been formally assessed or currently receive oxygen therapy but do not require follow up in Secondary Care.
Pulmonary Rehabilitation
  • Have a confirmed diagnosis of COPD (Chronic Bronchitis / Emphysema / Chronic Asthma) and self-reported exercise / functional limitation (MRC Dyspnoea Score 3-5)
  • Have functional limitation due to other chronic respiratory disease or condition such as Bronchiectasis, Interstitial Lung Disease, Asthma, Chest Wall Disease, Pre and Post Thoracic Surgery, e.g. LVRS, Lung transplant, Lung resection for cancer
  • Patients with an MRC Dyspnoea Score of 2 who are symptomatic and consider themselves disabled by their condition, and who require a health care professional assessment and supervision of exercise training, rather than simple advice on lifestyle changes
  • Have had all Pharmacotherapy evaluated and optimised, particularly Respiratory, Cardiac and Pain Medication / Management.
  • Be willing to be an active participant and motivated to attend
  • Be able to provide own transport (unless logistically this is impossible)
Respiratory Physiotherapy:
Confirmed Diagnosis of COPD

  • Difficulty with clearing secretions / excessive coughing / extreme sputum production
  • Poor management of breathlessness with COPD as primary cause

Self-Management Plan with triggers for when to seek advice / support

Table phase

Care Plan:
  • MDT care provision – team around patient
  • Self-management strategy
  • When and how to seek advice/support
  • Supporting Information
  • Reassessment /Case Review Date

Deteriorating phase


Care Plan:

  • MDT care provision – team around patient
  • Self-management strategy
  • When and how to seek advice/support
  • Supporting Information
  • Reassessment /Case Review Date
Unstable phase


  • Five Priorities of Care Met
  • Care Plan: EPPACS template
  • MDT care provision
  • When and how to seek advice/support
  • Supporting Information
  • Visits scheduled

Dying phase

Bereavement Support

  • Distress Thermometer
  • Information
  • Referral

Bereavement support after death

Back to Integrated Community Teams Date page modified 03/08/2021