What is an ILR?

  • Multi-disciplinary team meetings held weekly via Microsoft Teams
  • Platform to discuss complex patients with a range of partnership agencies
  • Formulate a plan of care shared by all partnerships

Who attends?

  • GP with special interest in Frailty
  • Consultant Geriatrician, Medway Foundation Trust
  • Community Pharmacist, Medway CCG
  • Advanced Community Practitioner, MCH
  • Social Worker, Medway Council
  • Mental Health Nurse, Kent and Medway Partnership Trust
  • Care Navigators/Team Lead, Imago
  • Other representatives from SECAmb, Kent Fire and Rescue Service, GP Practices, MEGAN CIC… joining when requested by ILR Coordinators

Referrals to the ILR

  • Over 18 years old; who are complex, frail, cross boundary, and/or with multiple long-term conditions can be referred.
  • Referral to ILR must be discussed with patient and consent obtained.  If the referral is made in the patient’s best interest this must be documented on the SBAR.
  • Completed SBAR referral form can be emailed to MEDCH.ilr@nhs.net.  Key information to be included on the SBAR is as follows:
  • Situation: current concerns and reason for referral
  • Background: Past Medical / Social History: acute and chronic PMH and comorbidities; patient’s living situation (i.e. living alone, POC in place…)
  • Medications: medications patient’s taking currently (if known) 
  • Risks: risks around this patient
  • Actions: actions you have taken so far (i.e. assessed by your team, referred to a specialist service…)
  • Recommendations:  outcomes you want ILR to achieve and goals (if any) that the patient has themselves
At ILRs
  • Once referral has been accepted, the patient’s GP is notified. Both referrer and the GP are invited to join the ILR meeting.  Patient’s details are added to the meeting agenda and are distributed to the ILR core members.
  • Patient is discussed.
  • Actions taken/assigned.
  • Joint care plan and information is shared with relevant professionals.
  • Patient is reviewed at appropriate intervals or safely discharged.

If you have a patient you think would benefit from a referral, fill in the referral form >