What does good co-ordinated care look like?

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Later this year, Norman Lamb will announce the first cohort of health and social care integration ‘pioneers’. The organisations within these localities hope to work together to develop radically new ways of delivering integrated and co-ordinated services that benefit local people.

So what does good co-ordinated care look like? We have been undertaking a research project on care co-ordination for people with complex chronic conditions to understand the key markers for success and develop practical lessons for successful adoption. The first case studies, published this week, highlight two important components – identifying patients at an early stage and intervening to put the appropriate care in place to avoid emergency hospital admissions.

The Midhurst Macmillan Palliative Care Service in Surrey provides specialist end-of-life care in the community for patients with complex medical and social needs. Palliative care consultants and clinical nurse specialists work closely with local GPs, community teams and acute hospitals to identify patients needing specialist support. Early identification means that staff have time to develop a comprehensive package of care and support, so that patients can remain at home for as long as possible.

An external evaluation of the service found that early referrals to the service reduced hospital admissions and improved patient and carer experience. The service also appears to be cost effective compared to hospice care. Almost two-thirds of Midhurst’s patients  were referred to the service before they had a hospital admission compared to 29 per cent of hospice patients. As a result, early referral reduces overall care costs as patients are less likely to be admitted in the last 12 months of their lives.

Our second case study, the Sandwell Wellbeing Hub, is a holistic primary care mental health and wellbeing service for people in Sandwell and West Birmingham. Within the Hub, the Esteem Team focus on co-ordinating care for patients with mild or moderate mental health problems and complex social needs.

Potential clients are selected from the severe mental health (SMI) register held by GP practices. Link workers in the team also seek referrals from a wide range of secondary and community care organisations as well as social care, probation services and the voluntary sector. Once the client has been assessed, the Hub facilitates access to range of therapies and services with link workers accompanying clients to appointments if needed. The Esteem Team are ideally placed to intervene before a patient’s mental wellbeing deteriorates to the point where they require admission to secondary care services.

According to patient feedback collected by the Hub, clients are benefitting from the service, and analysis of patient wellbeing scores has shown an overall improvement in patients’ mental wellbeing and resilience.

Both examples show that good care co-ordination must be both proactive and reactive. Another key design element apparent in both sites is a focus on raising awareness and building relationships with local care providers, particularly GPs. Sandwell regularly hold events to showcase the range of services available and have developed a series of GP training sessions on primary care mental health. In Midhurst, clinical nurse specialists from the team regularly attend GP practice meetings to provide case updates on patients and to liaise with colleagues.

Stepping in with support at an early stage can prevent deterioration in patients’ physical and mental wellbeing, helping them to stay at home and out of hospital. In some cases, care co-ordination can be cost-effective, but above all it is a tool to improve the quality and experience of care. The challenge will be to take the learning from these specific case studies and make more joined-up care a reality for patients throughout the country.

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Nicola Buckley

Nursing Manager,
Consultus Care & Nursing Ltd
Comment date
08 August 2013
With the many problems being faced by the NHS at the moment I wholeheartedly agree. The future is with truly integrated care, and as an independent provider of live-in nursing services, Consultus is working with various Trusts through Continuing Care Packages to enable those suffering with chronic illnesses to remain at home.

What are your thoughts about patients remaining at home for the duration of their illness?

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