ABSTRACT
Community-oriented integrated care challenges the common expectation that long-term conditions should be treated in hospitals by specialists. This chapter describes how the three-tier model, coupled with shared records, care plans and packages of care, can build teams throughout care pathways. Practitioners in the three-tier model of care for long-term conditions need shared records. Patients, specialist and generalist practitioners all need to be able to update them. Shared records have long been used for pregnant women and people with diabetes. The patient has a hand-held record that they take to different practitioners. A care plan summarises a patient's illnesses and plans for the year. People who have a long-term condition of any kind benefit from a care plan that reminds everyone what needs to be done and when. Care plans are especially important for those who are at high risk of admission to hospital.
