It's time to demonstrate the value of care co-ordination

At The King’s Fund, we have long argued that care and services need to be better integrated around the needs of users. Yet the positive benefits of primary and community-based care co-ordination have yet to be universally recognised – especially in terms of cost-effectiveness and reduced hospitalisations. There is also relatively little evidence on how best to apply care co-ordination in practice. Without an understanding of ‘how to’ integrate care at a clinical or service level then even the best-laid strategic plans may come unstuck.

As part of our new Integrated Care Programme we are currently undertaking a research project on care co-ordination for people with complex chronic conditions funded by The Aetna Foundation. This work seeks to understand the key markers for success in care co-ordination and develop practical lessons for successful adoption. To support this, we are working with five demonstrator sites with a proven track-record in delivering effective care co-ordination. During the calls for application to be involved in this work, three things became clear about the state of care co-ordination in the UK.

First, there was considerable enthusiasm and interest in developing better care co-ordination for people with complex needs and in understanding how to bring the various components of care co-ordination together. However, there was a lack of understanding on how best to achieve this and a feeling that the projects were acting somewhat ‘outside the system’ and lacking legitimacy.

Second, the more established care co-ordination projects tended to be focused on implementing disease-based or clinical pathways – for example, for diabetes or arthritis – rather than taking a more holistic approach to co-ordination of care and services for people with multiple health and social care needs. Care pathways are the mode de jour, but have limitations when faced with the need to support the increasing number of people with multiple issues.

Third, despite many innovative primary care-based approaches to care co-ordination, a chronic lack of attention is paid to the value of demonstrating or measuring outcomes. So, while many projects provided compelling patient or carer stories about the difference care co-ordination made to their lives, few projects used client feedback pro-actively to help them reflect on the care services they provided. Information on care outcomes, whether on a patient or carer's ability to better manage their anxiety, on their physical functioning or chronic illness was not routinely collected. Even information on changes to the utilisation and costs of services remain rudimentary. This suggests two things about the UK care system: first, that the business of measuring and monitoring outcomes is not strongly valued (culturally or managerially) as a way of judging service performance; second, as we found in our GP Inquiry last year, health professionals are not predisposed to using such information as a means to drive improvements in quality.

There is ample evidence globally that care co-ordination has the potential to bring significant benefits to patients, carers and service users. However, there is rather less about how to develop such approaches successfully in practice. Unless we are ready and prepared to invest in this approach, and to examine the outcomes of the many innovations in care co-ordination that exist in the UK and other countries, it will continue to be on the fringes of activity rather than being the main event. It’s time to demonstrate the value of care co-ordination.

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Comments

#1274 Mike Stone

‘rather than taking a more holistic approach to co-ordination of care and services for people with multiple health and social care needs’.

‘a chronic lack of attention is paid to the value of demonstrating or measuring outcomes.’

‘few projects used client feedback pro-actively to help them reflect on the care services they provided’

I am interested in something a bit different: end-of-life patients who are at home, who wish to die at home, and who happen to die ‘suddenly’ at home prior to ‘Expected Death’ having been ‘called/recorded’ by a GP (there isn’t a nation-wide definition of ‘Expected Death’ – the easiest way to think of it, is as ‘a promise from the GP to certify future natural death, even if the GP cannot attend’). But all of the above quotes apply, because there is no joined-up and coherent behaviour for such deaths, when you happen to look at existing behaviour as a live-with relative. Especially if for some reason the 999 Services become involved and the GP doesn’t.

Good luck with your push for co-ordinated behaviour – so far as I can see, there are two very strong inhibitors arising from everyone being mainly concerned about their own role, and also because most people do not fully understand the situation when viewed through the eyes of others. Even if you could persuade everyone that joined-up behaviour would be better, you would still have those two problems to overcome, and I cannot find much willingness to address them (most people prefer to think from their own position, not from something approaching a ‘neutral’ position). The fact that different professionals rarely seem to discuss complicated scenarios with the other professions which might become involved, let alone with patients and relatives, means that many professionals simply cannot even loosely appreciate how their behaviour appears inappropriate/absurd, when viewed ‘from outside’.

#1275 Vickie Ferns

In trying to discover why my own case has gone so badly wrong with the new dream world of community care I have found an example at Middlemore Hospital in Auckland New Zealand pgnz.org.nz/assets/Uploads/VHIU-Report.pdf on case studies.
This particular case study suggests certain illness should not fall under the community care label and I think for me that is why my care has been so poor and caused so much suffering because the doctors involved in my care did not take my particular needs in to consideration. I was asked by the Minister of Health in NZ to put in a complaint which I was reluctant to do but now that I have more knowledge I will do so as it may save someone else with an unusual scenario suffering the same fate. (I have mentioned on other blogs a little of what occured over a 12 year period and still have to deal with a G.P more concerned with saving the hospital money than what is best for me ie he would rather I suffer in pain than be put in hospital for IV antibiotics to bring that pain down such is the strong brainwashing the G.P's are receiving.)
Other sites that might interest readers on community care are
cmdhb.org.nz/about_cmdhb/planning/health.../health-status.ht
ccdhb.org.nz/.../homecommunity/....
If they don't work I would suggest writing 'when did community based health care start in New Zealand? and it should bring up several sites of interest. It appears that it started in 2001 although for me I believe there has been a move to that scenario for 15 years.
At least your democratic enough to let the public know through newspapers what is happening. I read widely and never remember reading that this is was being rolled out in our country. IT has been done in a very underhand manner and while I can see the merits of it where it works , there are people who can fall through the cracks if they have a rare illness that no one understands which can lead to unnecessary suffering.
I was told by a doctor the other day that because I have accepted my illness it contributed to my accepting G.P's telling me I could not go to hospital when I was in immense pain for up to two months at a time and than finding out that other patients with intractable pain for other reasons were getting care in hospital. I have also since learnt that intractable pain can kill you , putting a strain on the heart and adrenal glands and causing calcium loss.

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