Integration through Care Co-ordination

Belinda Weir, Senior Consultant, The King’s FundLara Sonola, Senior Researcher, The King’s Fund

Aims of session

› To hear some evidence about effective coordinated care for people with long-term conditions

› To explore the factors which support coordinated care and analyse our own services in relation to these factors

› To share experience and consider what, if anything, we will do differently as a result of this workshop

Sam’s story http://www.kingsfund.org.uk/audio-video/what-key-effective-care-co-ordination

Co-ordinated care for people with complex chronic conditions

Greenwich & Bexley

› Methods: Five demonstrator sites chosen through a competitive process based on their ability to demonstrate positive impacts in one or more of the following: patient experience, better health outcomes, more cost-effective care

› We examined how care co-ordination was organised and operated in practice at a patient level through interviews with teams, documentary and observational analysis.

Midhurst, Surrey

Sandwell, Birmingham

Pembrokeshire

South Devon & Torbay

Greenwich & Bexley

› 2 year project funded by Aetna/Aetna Foundation in the US

› Aims: To understand the key components of effective care co-ordination, examine key barriers and facilitators and develop practical lessons for the application of the tools of care co-ordination

Sandwell Esteem Team

http://www.kingsfund.org.uk/publications/esteem-team

Key LessonsEvaluation and measurement

Time

Local context

Community involvement

Integrated teams

Aligned goals

Engaging GPs/secondary

care

Systemic

Organisational

Functional

Community

Clinical and service

Personal

• Holistic• Patient and

carer focused

• Flexible

• Integrated commissioning

• Supportive policy

• Effective targeting• Localisation • 1-3 key leaders • Commissioning

support• Supportive team

culture/ shared values

• High touch-low tech

• Shared electronic patient records

• Personal communication

• Voluntary sector involvement

• Community awareness

• Multiple referrals, single point of entry

• Named care co-ordinators

• No defined care packages

Design features

Research into practice

PATIENT FOCUS

STAFF STRATEGY

VALUES

?

LEADERSHIP

› How can you use these design features to deliver more joined-up care in your own system?

› Are there any other features you would add?

Any Questions?