Co-ordinated care: markers for success

The King’s Fund has published the first case studies from its research project on care co-ordination for people with complex chronic conditions. We talk to Lara Sonola, Senior Researcher, Health Policy, to learn more about the project and its early findings.

The case for more integrated services for people with multiple health and social care needs is now widely accepted, and there is a strong political will to make this happen. But how do these good intentions result in more joined-up care for patients, service users and their carers?

‘This project gets close to the front line to discover how people are doing this in practice,’ explains Lara. ‘This is giving us fascinating insights into what works, and how challenges have been managed, and others can learn from it.’

About the project

This is a two-year research project looking at care co-ordination in primary care in different parts of the UK. Funded by Aetna and the Aetna Foundation, the aim of the project is to identify the key markers for success and to provide practical lessons that can be used by others in developing co-ordinated care services in other settings.

‘An expert panel was established to select the five demonstrator sites that we are currently working with,’ explains Lara. ‘We then used a mix of methods to probe their approach, including qualitative interviews, observing multidisciplinary team meetings and reviewing impact data.’

Early findings

In August, the first two case studies were published: one on the work of the Midhurst Macmillan Community Specialist Palliative Care Service; the other on the Sandwell Esteem Team, part of the Sandwell Integrated Primary Care Mental Health and Wellbeing Service.

Lara explains the insights these case studies can offer to those developing co-ordinated care programmes: ‘They both highlight a number of important components, such as identifying patients at an early stage and intervening to put the appropriate care in place to avoid emergency hospital admissions.’

Another vital component is building awareness and relationships with local providers. ‘Many of the case study sites rely on frequent and face-to-face communication across the service,’ explains Lara. This is often due to the lack of an ICT infrastructure and can be described as a ‘high touch, low tech’ approach. ‘While people noted that poorly developed IT systems could be a challenge, it had unintended benefits,’ says Lara. ‘Regular, personal communication helped to build strong working relationships and to develop trust and understanding between different professionals.’

The case studies offer practical aids too – each one contains an organogram showing the care planning/co-ordination process. ‘These really help people to understand the practicalities,’ explains Lara. ‘You might hear that a programme works well because of the multidisciplinary team involved, or because it takes a holistic approach, but the diagrams map out what that means – who talks to who, how that happens, how information is shared, what happens next and so on.’

Midhurst Macmillan Service care planning/co-ordination process

Midhurst Macmillan Service care planning process

Coming up

The case studies from the remaining three demonstrator sites will be published in September and October. These will offer further insights into what facilitates good integrated care, including the work of volunteers. ‘The value of volunteers has already been shown at Midhurst Macmillan Community Specialist Palliative Care Service,’ says Lara. This will be explored further in the Pembrokeshire (Community Care Closer to Home) case study, where volunteers attend team meetings so that they can directly identify patients who could benefit from the range of services they provide, such as respite sitting for carers or help with practical tasks like shopping.

The final paper from the research project will be published at our conference in October, Care co-ordination: Key lessons and practical insights from the front line. The paper will draw together the main themes from the research, examining the enablers and barriers to successful care co-ordination. One factor that can hinder progress is the lack of resources to robustly evaluate the projects. ‘The dedicated and passionate staff who deliver these programmes often don’t have the management and analytical support to allow them to demonstrate the value of the services they offer,’ explains Lara. ‘This can be a real stumbling block, which our paper will explore in more detail.’

The conference is also an opportunity to share practical lessons from the front line. The keynote speaker is Dr Margaret MacAdam, Associate Professor, University of Toronto, Senior Fellow, Canadian Health Policy Network, and President, The Age Advantage, Inc, who will talk about lessons learnt from Canada. Lara is looking forward to the event: ‘Putting these lessons alongside those from our own research project will be a powerful combination; there will be a lot for people to take away from the day to apply in their own work.’