Co-ordinated care for people with complex chronic conditions

This project has been completed

This project involved an in-depth examination of approaches to care co-ordination undertaken in primary care settings in different parts of the UK.

About the project

Final report on this work

Co-ordinated care for people with complex chronic conditions

Co-ordinated care for people with complex chronic conditions front cover

Our report explores the key components of effective co-ordinated care, through a study of five UK-based programmes that deliver co-ordinated care for people with long-term and complex needs.

Case study sites

We worked with five case study sites who have developed innovative primary care-based approaches to care co-ordination for people with complex chronic conditions.

Each final case study includes an organogram showing the care planning/co-ordination process, patient stories and a video highlighting the work of the team.

Midhurst Macmillan Community Specialist Palliative Care Service

Midhurst Macmillan co-ordinated care case studyThe Midhurst Macmillan Service is a community-based, consultant-led, specialist palliative care service in a rural community in the south of England. The service seeks to provide direct care and support to patients in the last 12 months of life to prevent unnecessary hospital admissions and enable them to live at home and die in the place of their choice.

Read the Midhurst Macmillan Service case study report

Oxleas Advanced Dementia Service

Oxleas Advanced Dementia Service thumbnailOxleas Advanced Dementia Service provides care co-ordination, and specialist palliative care and support to patients with advanced dementia living at home. The current service consists of a consultant in old-age psychiatry, several specialist nurses and a dementia social worker.

Read the Oxleas Advanced Dementia Service case study report

Pembrokeshire community resource teams

Pembrokeshire co-ordinated care case study thumbnailThis case study looks at integrated teams of health and social care professionals, known as community resource teams (CRTs), who work to co-ordinate care for people living at home in the largely rural county of Pembrokeshire. This model of care is one aspect of a wider strategic programme of integrated care, called Care Closer to Home.

Read the Pembrokeshire community resource teams report

Sandwell Esteem Team

The Esteem Team case study front coverThis case study looks at the Sandwell Esteem Team, part of the Sandwell Integrated Primary Care Mental Health and Wellbeing Service (the Sandwell Wellbeing Hub) in the West Midlands. The hub is a holistic primary and community care-based approach to improving social, mental and physical health and wellbeing in the borough of Sandwell.

Read the Sandwell Esteem Team case study report

South Devon and Torbay

South Devon and Torbay co-ordinated care case studySouth Devon and Torbay clinical commissioning group uses proactive case management and community virtual wards to identify people at risk of an unnecessary hospital admission in the next 12 months. Each month, the multidisciplinary team identifies and addresses patients’ needs to put in place a case management plan to prevent crises from occurring.

Read the South Devon and Torbay case study report

About the project

We undertook an in-depth examination of approaches to care co-ordination in primary care settings in different parts of the UK. Work involved:

Who funded the project?

We are grateful to Aetna and the Aetna Foundation for funding this important piece of work.

Aims of the project

Why did we do work in this area?

Age-related chronic conditions absorb the largest, and growing, share of health care budgets. To address this, strategies of care co-ordination are being developed to promote more cost-effective care through streamlining services. However, there is a lack of knowledge about how best to apply care co-ordination in practice.

Through a UK-based comparison of successful innovative care co-ordination programmes, this project aimed to:

  • understand the key components of strategies used to deliver care co-ordination effectively
  • examine key barriers and facilitators to successful implementation
  • develop practical and generalisable lessons for the application of the tools and techniques of care co-ordination
  • identify lessons in how care co-ordination can best be supported, in terms of planning, leading, organising, and incentivising
  • promote and disseminate the lessons from the research to support the effective adoption of care co-ordination in both the UK and US contexts.

Expert panel

The expert panel

Our expert panel supported the project over the course of its work and, more specifically, selected the five case study sites that we worked with.

The expert panel members were:

  • Richard Humphries, Project Lead, Assistant Director, Policy, The King’s Fund
  • Dennis Kodner, Project Lead, International Visiting Fellow, The King's Fund
  • Gillian Barclay, Vice President, Aetna Foundation 
  • Robert Berenson, Senior Fellow, The Urban Institute (Washington, DC) 
  • Sandra Birnie, Service Development Manager, Cheshire and Wirral Partnership NHS Foundation Trust
  • Peter Colclough, Chief Executive, Weston Area Health NHS Trust
  • Jocelyn Cornwell, Director, The Point of Care Foundation and Senior Fellow, The King's Fund
  • Julien Forder, Research Fellow, London School of Economics
  • Nick Goodwin, Senior Associate, The King's Fund 
  • David Healy, European General Manager, Aetna
  • Chris Ham, Chief Executive, The King's Fund
  • Stephen Johnson, Head of Long-tem Conditions, Department of Health
  • Leo Lewis, Senior Fellow, International Foundation for Integrated Care
  • Marina Lupari, Assistant Director of Nursing Research & Development, NHSCT 
  • Guy Robertson, Joint Head of Ageing Well Programme, Local Government Group 
  • Alyse Sabina, Programme Officer, Aetna Foundation
  • Samantha Sharp, Senior Policy Officer, Alzheimer's Society
  • Ruth Thorlby, Senior Fellow, Nuffield Trust
  • Patricia Volland, Senior Vice President and Director of the Social Work Leadership Institute, The New York Academy of Medicine


This section brings together a number of our resources on delivering care co-ordination for people with complex chronic conditions.

What is the key to effective care co-ordination?

Sandwell Esteem Team memberWhat are the key factors in delivering successful and seamless co-ordinated care? We spoke to the teams we’ve been working with during our research project to hear their views.

Watch the interviews

Case study site interviews

We inteviewed our five case study sites to find out more about their approach to co-ordinated care.

Midhurst Macmillan Community Specialist Palliative Care Service

Jo StuttafordThe Midhurst Macmillan Service provides palliative care in the community via a consultant-led multi disciplinary team. The service provides 24/7 care and advice for patients in their homes or other preferred place of residence.

Watch our interview with the team at Midhurst Macmillan Service

Oxleas Advanced Dementia Service

Estelle Frost, Service Director, Oxleas NHS Foundation TrustCovering Greenwich and Bexley, a core team of old-age psychiatrists, mental health and community staff work with GPs, secondary care and social services to support family and/or carers in providing ongoing and palliative care.

Watch our interview with the team at Oxleas Advanced Dementia Service

Pembrokeshire community resource teams

The Community Care Closer to Home project in Pembrokeshire seeks to identify and manage people in the community who are most vulnerable to an unplanned emergency admission or exacerbation of their chronic illness.

Watch our interview with the team at Pembrokeshire

Sandwell Esteem Team

Lisa HillThis service uses care co-ordinators who work with individuals with a range of complex needs, such as those with severe mental illness, to help them navigate and access a wide variety of primary care-based mental health and wellbeing services that support their needs.

Watch our interview with the team at Sandwell

South Devon and Torbay

Solveig SansomSouth Devon and Torbay CCG uses proactive case management and community virtual wards to identify people at risk of an unnecessary hospital admission in the next 12 months.

Watch our interview with the team at South Devon and Torbay

Event presentations

Margaret MacAdam: Achieving real care co-ordination - lessons from Canada

Margaret MacAdamMargaret MacAdam, Associate Professor at the University of Toronto, gives a background to integrated care in Canada, and explains how the PRISMA integrated service delivery model has helped to improve the health, empowerment, and satisfaction of frail older people in the community.

Watch Margaret MacAdam's presentation

Jeremy Hughes: The value of engaging the third sector

Jeremy Hughes, Chief Executive at the Alzheimer's Society, gives six reasons for why engaging with the third sector is important in delivering co-ordinated care.

Listen to Jeremy Hughes's presentation

Nick Goodwin: making a success of care co-ordination

Nick Goodwin, Chief Executive at the International Foundation for Integrated Care, looks at how care could be better co-ordinated around people with complex needs.

Watch Nick Goodwin's presentation

Leo Lewis: co-ordinating care from the information perspective

Leo LewisLeo Lewis, Senior Fellow at the International Foundation for Integrated Care, draws on experience from the Carmarthenshire Chronic Conditions Demonstrator programme in Wales, to look at the key elements necessary to deliver effective services for people living with, or at risk of developing, chronic conditions.

Watch Leo Lewis's presentation