This report presents the findings from a two-year research project funded by Aetna and the Aetna Foundation, which aimed to understand the key components of effective strategies employed by studying five UK-based programmes to deliver co-ordinated care for people with long-term and complex needs. It elicits some key lessons and markers for success to help identify how care co-ordination might be transferred from the UK to the US context.
Certain design features appear more likely to deliver successful care co-ordination.
- A holistic focus that supports patients and carers to become more functional, independent and resilient is preferable to a purely clinical focus on managing or treating symptoms.
- Building community awareness of and trust in care co-ordination programmes promotes legitimacy and engagement.
- Effective communication based on good working relationships between members of the multidisciplinary team is essential. Shared electronic health records can support the process, but a ‘high-touch, low-tech’ approach can also be very effective.
- Care co-ordination programmes should be localised so that they address the priorities of specific communities. Leadership and commitment (from commissioners and providers alike) is vital to establish a shared vision and challenge silo-based working.
- Integrated health and social care commissioning can support longer-term strategies and provide greater stability.
Across the five sites common challenges included: funding; lack of GP engagement; inability of the wider health systems to see innovation as ‘core business’; a lack of integrated IT systems; and problems caring for people in remote and rural locations.
Facilitating factors included: a political narrative that supports a shift to person-centred care; local leadership and commitment; a clearly defined, shared vision of what better patient care looks like; being able to react flexibly to patients’ changing needs; and investment in supporting carers and ‘low-level’ community support services.
- Greater efforts must be made to measure, evaluate, compare and reflect on the performance of care co-ordination programmes.
- Care co-ordination innovations can take some years to mature and to build legitimacy and acceptance.
- Successful approaches are very context-specific; care models cannot be transported ‘en bloc’ from one setting to another.
- Care co-ordination should primarily be a quality improvement strategy rather than one aimed at reducing costs.
- Models of care co-ordination are likely to be more effective when operating as ‘fully -integrated’ provider teams with some operational autonomy.
See more of our work on co-ordinated care
- Read Veronika Thiel's blog: IT systems – an overlooked cog in the integration machine?
- Watch our video to find out more about the key features needed for successful care co-ordination
- See our press release on this report: Lack of GP engagement limiting progress on care co-ordination
- Find out more about the project: Co-ordinated care for people with complex chronic conditions