Abstract
The National Health Services (NHS) within inner Northwest London implemented a transformational change pilot program for integrated care from 2011-13. This pilot focused on two populations within the inner northwest quadrant of London: diagnosed diabetics and the elderly over 75 years of age. An information technology (IT) tool was used to pool data across primary, secondary, community, social, and mental health care sectors in order to assess an integrated approach to care coordination. The network of service providers included: 5 social care services; 3 community care services; 106 primary care practices; 2 mental health facilities; 2 hospitals; and 2 non-profit organizations. Some of the main goals of the pilot were to: improve health outcomes among diabetics and the elderly; improve patient experience; reduce service outcomes such as emergency hospital admissions; create care plans for the targeted populations; and establish multidisciplinary case reviews of high-risk patients with the most complex needs. A mixed methods evaluation was essential for assessing the care process and health outcomes of the pilot. Results of the evaluation will be presented, particularly as they relate to clinical outcomes and quality of care, as well as patient and professional experience throughout the integrated care process.