Better Care

Integrated Multidisciplinary Teams

Members of an IMT team.

The District Nurse Service is now referred to as Integrated Multi-Disciplinary Teams (IMT) and provides nursing assessment and treatment to patients who are unable to leave their home (permanently or temporarily housebound due to ill health). The IMTs deliver a wide range of nursing interventions to people in their own homes and plays a key role in supporting independence, managing long term conditions and preventing and treating acute illnesses. The services are required for many reasons, but are commonly needed by adults with a disability, older adults living with frailty and long term conditions and those who are near the end of their life.

The IMTs bring together the following services:

·         Community Nursing service

·         Clinical Case Managers

·         Community Physiotherapists

·         Community Occupational Therapists

Teams work closely with primary care, social work, geriatricians’ third sector organisations and other support services and specialists.

Services are provided to patients over the age of 17 years old and who are registered with a Birmingham Clinical Commissioning Group, including those living in residential care homes.

Where are we based?

The service covers Birmingham and currently has 36 teams which you can view by clicking here.

Each team is led by an appropriately qualified District Nurse Team Leader and consists of nurses with a broad range of skills and knowledge, health care assistants and administrators.

The teams provide 24 hour cover and are available 365 days of the year.

What do we do?

The IMTs carry out the following functions:-

·         Assessment

·         Dressings and wound care

·         Leg ulcerations and tissue viability (including aftercare of surgical wounds)

·         Continence assessment

·         Catheter care

·         Phlebotomy

·         Stoma care

·         Medication and prescribing

·         Administration of medicines

·         Central venous access devices and IV therapy

·         Safeguarding

Clinical Case Managers

Clinical case managers (CCMs) are experienced senior nurses who co-ordinate care and manage complex, high risk patients with long term conditions (LTCs) and are able to exercise independent clinical judgement. By preventing deterioration they support patients to live at home and avoid the need for acute services.

Clinical case managers provide early intervention to patients with LTCs to provide preventative and evidence based care. Case management will be available to patients with all long term conditions who meet the service criteria, including:

  • Coronary Heart Disease
  • Heart failure
  • Chronic obstructive pulmonary disease (COPD)
  • Diabetes
  • Neurological conditions including Multiple sclerosis, Epilepsy and Parkinson’s
  • Multimorbidity/frailty

Clinical case managers work with the Rapid Response Team where patients require urgent care and support to avoid an admission to hospital.


Community Physiotherapists and Occupational Therapists

The Community Physiotherapists and Occupational Therapists, work in partnership with other members of the IMTs, and are responsible for assessment, prevention, treatment and care of patients, working with patients in their own homes or place of residence. The aim is to support people to attain the maximum mobility in order to remain in their own homes, including care homes, as far as possible. Patients with a wide range of conditions will receive the service. These include the following:

·         Mobility/manual handling issues

·         Pain

·         Musculoskeletal problems

·         Patients who have fallen/at risk of falls

·         Palliative care

·         Neurological conditions

·         Respiratory conditions

·         Intermediate care

·         Appropriate referrals to social care services

Referral Route

Referrals will be made from a number of sources for a District Nursing assessment.

Patients and carers who are known to the service may at times re-refer themselves directly to the IMT.

GPs will be able to refer patients to the IMT service in one of three ways:

1) By telephone call to the Single Point of Access (SPA) on 0300 555 1919, Option 1.

2) By return of a completed form (supplied by BCHC to all practices for the purpose) as an attachment to an email sent to SPA

3) By faxing to SPA a completed copy of the form supplied by BCHC to all practices for the purpose.

Following referral, patients will be contacted to arrange an appointment.

Contact Us

Referral to the integrated multidisciplinary teams is now through the adult community services single point of access:

Option 1

0300 555 1919

Fax: 0845 303 9690

For non-urgent or complex referrals please complete the referral form. Download a copy by clicking  here.

Click here for details about the IMT Evening Service.