The aim of the Integrated Care Operations is to support the development of patient centred co-ordinated care for UCLH patients through collaborative working across the organisation and with the community, social and primary care.
The team (based on 4th Floor East, 250 Euston Rd or the Patient Lounge, 235 Euston Rd) continues its work to join up UCLH healthcare for the benefit of patients. Alongside other providers, GPs and Commissioners, we aim to reduce fragmentation and duplication of care provision, and maximise the efficiency of our healthcare systems.
Service management
Other contact information
Debra Glastonbury – Head of Integrated Care Operations
Melanie Justiniani - Clinical Operations Lead
For all queries please contact uclh.icoadmin@nhs.net.
The Inclusion Health Service provides support to Inclusion Health patients across UCLH.
The team is made up of a consultant (the only acute based Inclusion Health Consultant in the country), clinical nurse specialists (CNS), and a support worker.
They provide a thorough assessment of referred patients through a Holistic Inclusion Health Patient Assessment (HIPA). The assessment is focused on determining unidentified and unmet health and social care needs and taking advantage of a patient’s hospitalisation to address those needs definitively.
The team also offer the 987 review which is a route for patients to attend Ambulatory Emergency Care Unit (AECU) for assessment by the Inclusion Health Team. The assessment is a planned attendance organised by the Inclusion Health Service who have specialist expertise in inclusion health patients, who often struggle when referred to standard services.
The Alcohol and Drug Service team is made up of Clinical Nurse Specialists (CNSs) experienced in the management of drug and alcohol dependence.
The CNSs will assess patients and offer guidance on prescribing for opiate or alcohol dependence as well as more general management. Once the patient is stabilised and or medically fit, the team can refer to community services that support on going sobriety.
The Camden Adult Pathway Partnership (CAPP) provides outreach nurse-led physical health interventions to vulnerable single homeless people living across 16 supported housing services in Camden.
The CAPP team consists of a project manager, administrator, and 3 nurses. The nurses provide health services to residents, including health needs assessments, vital signs, blood tests, referrals to other providers, and support with navigating the health sector.
The rough sleeper nurse forms part of a small, specialist outreach team working with people who are rough sleeping in Camden & Islington and experiencing complex health and social needs.
The team’s primary focus is to improve access to mental health, physical health, and substance use support through a flexible, trauma-informed, and assertive outreach approach. HOP is co-located with Routes off the Street (RTS), Camden’s commissioned rough sleeping outreach service.
The teams work together closely, often engaging clients jointly to provide direct psychological and nursing interventions to people who may not otherwise access support. This work often takes place at sleep sites, on the street, or through drop-ins — wherever clients are most comfortable and most likely to engage. The service is built on trust, consistency, and responsiveness.
The Homeless Intermediate Care Team’s (HICT) overarching aim is to improve the health and social care outcomes of people experiencing homelessness upon discharge.
They provide a safe, high quality, accessible, flexible, and innovative service for adults who are homeless, rough sleepers and those at risk of rough sleeping including those with no recourse to public funds (NRPF), who are in hospital through their transition between accommodations, aligned with NCL Discharge to Assess (D2A) model of care.
HICT work across the North Central London acute hospitals and provide support to patients for up to 6 weeks post discharge.
The Tobacco Dependency Service provides support to acutely admitted patients across the trust.
Our team of qualified and experienced advisors offer evidence-based tobacco dependency treatment to inpatients. Our innovative tobacco dependency treatment programme includes a combination therapy – Nicotine Replacement Therapy (NRT) and behavioural support. After discharge, we ensure patients receive continued support and treatment by referring them to their local stop smoking service.
We collaborate closely with the Smoke-Free Midwife Champion and other members of the maternity team to deliver the Smoke-Free Pregnancy project. Additionally, we offer support to hospital staff interested in quitting smoking.
The UCLH Hospital@Home service is designed to reduce acute hospital stays for patients and to prevent admissions for clinically stable individuals. Instead of remaining in hospital, these patients receive hospital-level care at home or in their current place of residence, before transitioning to the care of their General Practitioner (GP).
Patients with a range of clinical conditions may be referred to the UCLH Hospital@Home service. Once accepted, they are transferred to the care of the UCLH Hospital@Home team, which delivers the service in the community.
Current UCLH Hospital@Home pathways:
- Respiratory pathway
- OPAT services/elastomerics
- Hyperemesis gravidarum
- Orthopaedic day surgery elective joint arthroplasty
- Sickle cell pathway (step-down and step-up)
- Remote monitoring
- Bariatric surgery
- Heart failure
- Blood transfusion at Home (stand-alone pathway)
The Integrated Discharge Service (IDS) is a dedicated team of experienced nurses and healthcare workers who make sure patients leave hospital safely, with the right care in place.
What We Do
- Plan for ongoing care: Our team begins discharge planning early, working with ward staff to understand what each patient will need after leaving hospital.
- Coordinate care and services: We liaise with doctors, therapists, social workers, and community teams to make sure everything is ready—whether that’s care at home, equipment, transport, or a move to another care setting.
- Lead on complex cases: For patients with multiple needs, our nurses take the lead, acting as case managers to ensure nothing is missed and that care is tailored and safe.
- Work in partnership: We connect with community health services, adult social care, voluntary organisations, and commissioning teams to put a full support plan in place.
The Patient Lounge is a welcoming and comfortable space designed to accommodate patients who are medically fit for discharge. The Lounge plays a vital role in supporting efficient patient flow throughout the hospital, helping to free up inpatient beds for new admissions.
Patients who are suitable for transfer to the Lounge will be moved from their ward while they await final discharge arrangements such as medication preparation and transport.
