The Most Effective Technologies for Supporting Integrated Community Care

Community integrated care is a way of organising care around people’s needs at the local level. It brings together clinical care, social care, prevention, wellbeing support and wider community services so people can receive more joined-up, personalised care closer to home.

In practical terms, community integrated care helps teams answer three simple questions:

• Who needs support?
• What matters to them?
• Which local services, professionals or community assets can help?

This might involve a GP referring someone to a social prescribing link worker, a community nurse sharing observations with a virtual ward team, a social care manager coordinating support with housing services, or a multidisciplinary team reviewing people at higher risk of deterioration.

NHS England’s neighbourhood health guidance describes a similar direction of travel: healthier communities, people living independently for longer, and better-connected health and care resources around local needs.

Shared care records and interoperable systems

Shared care records are one of the most important foundations for community integrated care. They help health and care professionals access relevant information about a person’s health, care and support needs, including current issues, medications, test results, care plans and social care information.

This information is essential for community teams because decisions are rarely made by one professional in isolation. A GP may need to understand social care involvement. A community nurse may need to see recent hospital activity. A mental health practitioner may need context about housing or safeguarding concerns.

Shared care records are most valuable when they provide a clear, consolidated view rather than forcing staff to search through disconnected tabs and systems. NHS England’s information governance framework highlights the importance of sharing information safely and securely, with appropriate access controls, training and audit trails.

Care coordination platforms and virtual multidisciplinary team (MDT) tools

Community integrated care relies on coordination. That means knowing who is involved, what has been agreed, what action is due next and whether support is making a difference.

Care coordination platforms and virtual multidisciplinary team tools can help by giving teams a shared space to manage referrals, record actions, track progress and reduce duplication. For neighbourhood teams, this is especially useful where care involves multiple organisations.

The best platforms support human conversations rather than replacing them. They make MDT meetings more focused, helping staff prepare with the same information but creating a clearer record of decisions. Social prescribing and care coordination platforms can be especially useful because they help teams manage the non-clinical factors that often affect health and wellbeing.

Access Elemental, for example, is designed to help GPs and frontline professionals refer people to social prescribing link workers, care coordinators and health coaches, while supporting safe referral management, reporting and integration with primary care, secondary care and social care systems.

The Life Rooms, a non-clinical service within Mersey Care NHS Foundation Trust, used Access Elemental to support more than 1,600 referrals and deliver over 2,000 social prescriptions.

Secure communication and messaging

Integrated care depends on fast, reliable communication. Secure messaging tools can reduce delays, support safer handovers and make it easier for professionals to check information with the right colleague at the right time.

However, secure communication must be governed properly. Community teams need approved channels, clear protocols and confidence that messages are captured where they need to be.

For patients, digital communication also has a growing role. NHS Digital advocates a digital-first approach to patient communications using the NHS App, text messages and email, while making clear that digital-first does not mean digital-only.

Remote monitoring and virtual wards

Remote monitoring is one of the most practical technologies for bringing community integrated care closer to the people who need it. Rather than relying only on scheduled visits, phone calls or crisis-led interventions, remote monitoring gives care teams a clearer view of a person’s condition, routine, or environment while they remain at home, in a care home or in another community setting.

Tools that support remote monitoring can include wearable devices, for symptom tracking, blood pressure or oxygen monitoring, and movement sensors for falls detection, beds and chairs - all of which alerts healthcare professionals about unusual activity or inactivity. These tools help staff spot subtle trends and changes earlier, to act before risks escalate and make more informed decisions about when someone needs additional support.

Virtual wards allow people who would otherwise be in hospital to receive care and treatment at home or in their usual place of residence. They can use apps and devices to monitor measures such as oxygen levels, blood pressure, pulse and temperature. For integrated community care, the value of virtual wards lies in how they connect acute teams, community services, primary care, carers and patients.

Remote monitoring and virtual wards only work well when escalation routes are clear, responsibilities are understood and the person using the services knows how to use the equipment or ask for help. Technology alone isn’t the answer. Human support is just as indispensable.

Telehealth and hybrid consultation models

Telehealth can make care more flexible, especially for people who find travel difficult or need regular check-ins. Video consultations, phone appointments and digital reviews can help community teams maintain contact without every interaction requiring a home visit or clinic appointment.

Hybrid models work best when they are designed around patient need however. The aim should not be to replace personal care with remote care. It should be to use the right channel for the right situation, freeing up staff time where appropriate while preserving human contact where it matters most.

Patient portals, apps and self-management tools

Patient portals and apps can support community integrated care by giving people more access to information, reminders, appointments and care plans. They can also help people manage long-term conditions, complete questionnaires and receive timely prompts for prevention or follow-up. Patients and carers gain more visibility and agency when it comes to managing their care. Professionals can communicate more effectively with patients and make routine interactions more efficient.

However, digital inclusion must be built into a community integrated care system from the start in order to have the most positive impact. NHS England’s framework on inclusive digital healthcare stresses that digital approaches should be designed inclusively and complemented by non-digital support.

This is particularly important in community care, where people may face barriers related to age, disability, language, confidence, connectivity, affordability or literacy. Digital access should widen support, not create another doorway that some people cannot get through.

Population health analytics and risk stratification

Integrated community care should not only respond to crisis. It should help teams identify risk earlier and act sooner.

Population health management uses data to understand the needs of a defined population, improve outcomes and reduce inequalities. It is a core strategic aim for integrated care systems, supporting proactive, personalised and preventative care across communities. This data-led approach to person-centred care is a key function of integrated care systems.

Risk stratification modelling tools use data to identify people who may be at higher risk of hospital admission, deterioration, isolation or unmet need, helping teams prioritise support before a situation becomes urgent. It can help teams focus limited resources where they are most needed.

Dashboards for integrated care systems, place and neighbourhood teams

Dashboards can help leaders and frontline teams see what is happening across services. They can bring together information on referral volumes, waiting times, demand patterns, unmet need, outcomes and gaps in local provision, giving them a more practical view of how community integrated care is working. This is particularly valuable because integrated care happens at several levels.

At system level, covering populations of around 500,000 to 3 million people, health and care partners come together at scale to drive strategic improvements in areas such as workforce planning, digital infrastructure and estates.

At place level, covering populations of around 250,000 to 500,000 people, partnerships need to coordinate health, social care, local authority and voluntary sector resources around the needs of their local population.

At neighbourhood level, covering populations of around 30,000 to 50,000 people, multidisciplinary teams need timely, usable insight into the people and communities they support day to day.

Effective dashboards can help connect these levels. For example, a neighbourhood team may use local data to identify rising demand for social prescribing, falls prevention or mental health support. A place partnership may use the same insight to understand whether community services are distributed fairly across towns, suburbs and rural areas. System leaders can then look across places to spot wider patterns, compare outcomes and support more informed planning.

Technology works best when it is designed with the people who will use it. That means involving staff, patients, carers and community partners early, not simply handing them a finished system and expecting adoption.

Co-design helps reveal what really happens in community care: where referrals stall, where information is duplicated, where staff lose time, and where patients feel confused. It also helps ensure that workflows reflect local realities rather than an idealised version of how services should operate.

Digital inclusion and accessibility must be built into community integrated care from the start. Patient portals, apps, remote monitoring tools and online services should be simple, accessible and supported by non-digital routes, so people are not excluded because of age, disability, language, confidence or connectivity. The aim is to give people more ways to access joined-up support, not to make digital confidence a condition of receiving care.

Governance is especially important because integrated care involves sensitive information moving across organisational boundaries. People need to know who can access what, why they can access it and how their information is protected. Professionals need clear standards, role-based access and training.

Culture matters too. Teams need to feel that shared data is there to improve care, not to expose or blame individual services. Leaders have a responsibility to create the conditions for openness, shared accountability and learning.

Integrated care needs trust. Without trust, organisations will not share information confidently. Without information sharing, teams cannot coordinate care effectively. And without coordination, community integrated care risks becoming a slogan rather than a service model.

The most effective technologies for supporting community integrated care are those that help people work together more easily. 

• Shared care records provide a fuller picture.
• Care coordination platforms support joined-up action.
• Secure messaging improves communication.
• Remote monitoring and virtual wards bring care closer to home.
• Patient portals and apps give people more access and control.
• Analytics and dashboards help systems plan around real population need.

But technology should always be an enabler of human care, not a substitute for it. The goal is not to digitise fragmentation. The goal is to create clearer pathways, stronger relationships and more personalised support across every community.

Whether you’re an ICS, ICB, PCN, community provider or neighbourhood team, Access Elemental offers a practical way to support this shift. As a cloud-based social prescribing platform, it integrates with primary care, secondary care and social care systems so users can safely and securely make, manage and report on referrals. By helping professionals connect people with local services that address social, emotional and practical needs, Access Elemental can support the joined-up, community-based model that integrated care depends on.