Co-ordinated care for people with complex chronic conditions
This project involves an in-depth examination of approaches to care co-ordination undertaken in primary care settings in different parts of the UK.
About the project
Why are we doing 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 aims 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.
Who is funding the project?
We are grateful to Aetna and the Aetna Foundation for funding this important piece of work.
What are we planning to do?
We will undertake an in-depth examination of approaches to care co-ordination in primary care settings in different parts of the UK. Work will involve:
- an expert panel (see the tab above) selecting five case study sites that are currently delivering effective care co-ordination programmes
- a showcase of the sites' care co-ordination work at a public event on achieving high-quality care for people with complex needs at The King's Fund
- interviews, focus groups, online questionnaires and observational analysis with the sites to establish key care co-ordination lessons and markers for success.
The final report on this work will be published in late 2013.
Demonstrator sites
We are working with five demonstrator sites who have developed innovative primary care-based approaches to care co-ordination for people with complex chronic conditions (see the tab above).
Expert panel
The expert panel
Our expert panel will support the project over the course of its work and, more specifically, select five case study sites that are currently delivering effective care co-ordination programmes.
The expert panel members are:
- Nick Goodwin, Project Lead, Senior Fellow, 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 King's Fund Point of Care Programme
- Julien Forder, Research Fellow, London School of Economics
- Richard Humphries, Senior Fellow in Social Care, The King's Fund
- Chris Ham, Chief Executive, The King's Fund
- Matthew Hunt, Managing Director, Health Services, Aetna International
- Stephen Johnson, Head of Long-tem Conditions, Department of Health
- Samantha Sharp, Senior Policy Officer, Alzheimer's Society
- Leo Lewis, Project Director, CCM Demonstrator, Hywel Dda Health Board
- 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
- 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
Demonstrator sites
Our five demonstrator sites
The King’s Fund is working with five organisations or partnerships that have developed innovative primary care-based approaches to care co-ordination for people with complex chronic conditions.
How were the sites selected?
The five demonstrator sites were chosen following a competitive selection process. A general call for applicants was held between 7 February and 30 April 2012, when interested parties could submit their care co-ordination project for consideration.
Overall, 23 high-quality applications were received, from which five were eventually selected following review by an expert panel. Selection of the final five sites reflected their ability to meet the core criteria for inclusion in the study including: a focus on co-ordinating the care of people with complex chronic conditions requiring a multi-disciplinary response within primary care settings; the ability to demonstrate a positive impact in improving patient experiences, influencing health outcomes, and/or securing more cost-effective care; and an approach to care with the potential to be replicated in other contexts and settings.
Who are we working with?
We announced which five demonstrator sites we were going to be working with at our Achieving high-quality care for people with complex needs conference.
Find out more about the sites and watch short presentations about their care co-ordination projects through the following links:
- Greenwich and Bexley Advanced Dementia Services - Care@Home
- Midhurst Macmillan Specialist Palliative Care Service
- Pembrokeshire – Community Care Closer to Home
- Sandwell Integrated Primary Care Mental Health and Wellbeing Service
- South Devon and Torbay – Pro-active case management for at-risk patients
How will the research be conducted?
The aim of the research is to derive practical lessons and key markers for success to the adoption of models of care co-ordination to people with chronic and medically complex illnesses in primary and community-care settings.
To achieve this, in-depth case studies are being undertaken with the five demonstrator sites to understand how care co-ordination is organised and how it operates in practice at a patient-level. A number of data collection methods will be used including:
- content analysis of key documents
- face-to-face interviews with key staff
- focus groups with care co-ordination teams and observational analysis of how these operate.
The five demonstrator sites will also be enroled in a learning network to share experiences and examine key success factors during facilitated 'organisational raids'.
