6. Care co-ordination through integrated health and social care teams

What is it?

Creating patient-centred care that is more co-ordinated across care settings and over time, particularly for patients with long-term chronic and medically complex conditions who may find it difficult to 'navigate' fragmented health care systems.

Why is it important?

• Co-ordination of care to people with complex chronic illness is a global challenge. Driven by broad shifts in demographics and disease status, long-term conditions absorb by far the largest, and growing, share of health care budgets (see Active support for self-management).
• Co-ordination of care for patients with complex needs and long-term illness is currently poor (The King's Fund 2011), and those with long-term conditions have a lower quality of life (Department of Health 2011).

What is the impact?

• Robust evidence on health outcomes is limited, but improved care co-ordination can have a significant effect on the quality of life of the frail elderly and people with multiple long-term conditions (Hofmarcher et al 2007).
• Highly integrated primary care systems that emphasise continuity and co-ordination of care are associated with better patient experience (Starfield 1998; Bodenheimer 2008).
• Impact on costs and cost-effectiveness is less easy to predict and is likely to be low in the short-term given the upfront investments required to develop infrastructure and change clinical practices. However, health systems that employ models of chronic care management – in which care co-ordination is a central component – tend to be associated with lower costs, as well as better outcomes and higher patient satisfaction (Singh and Ham 2005).

How to do it

There is no one model of care co-ordination, but evidence suggests that GP commissioners that employ a multi-component approach will achieve better results than those that rely on a single or limited set of strategies (Singh and Ham 2005; Powell Davies et al 2008; Kodner 2009). Some of the key components (The King's Fund 2011) are:

• a move to multi-professional teams, including generalists working alongside specialists
• a focus on case management and support to home-based care
• joint care planning and co-ordinated assessments of care needs
• personalised health care plans and programmes
• general practitioners acting as navigators, rather than the gatekeepers, retaining responsibility for patient care and experiences throughout the patient journey
• clinical records that are shared across the multi-professional team.

Torbay Care Trust provides a good example of the kind of change required. Torbay established five integrated health and social care teams that are organised in localities aligned with general practices. The teams target their efforts at the very highest-risk individuals who require intensive support from community matrons and integrated teams.

Northamptonshire Integrated Care Partnership is also developing new models of long-term condition management in primary care, under the leadership of Nene Commissioning. Their approach has focused on helping patients remain independent for longer and creating personalised care plans for high-risk individuals that aim to reduce admissions to hospital.

Useful resources

• NHS Institute for Innovation and Improvement 'Joined Up Care' resources – a new suite of products and tools to help create seamless care between services.
• The Department of Health's (2008) compendium of information on long-term conditions summarises the need for more effective care co-ordination and included some examples from local communities.
• A 2005 review of the evidence on the impact of care co-ordination for people with long-term conditions by Debbie Singh and Chris Ham.

For further information

• Download all ten priorities: Transforming our health care system
• You can also find all the references mentioned here in that version
• Watch Candace Imison talk through the ten priorites in our audio slideshow