Working across transitions of care, finding like-minded healthcare professionals willing to help people with complex chronic conditions is the first step. Helping people with complex conditions and their carers to find their " local support team" is the next one. Funding the navigators- complex care coordinators - is problematic for siloed healthcare systems and challenges usual care and funding? power? of institutionalised care. There will be a lot of barriers - people who feel their role in patient care is being challenged. The need for open communication underpins the role of care coordinators. The imperative to be diplomatic as we try to change the nature of care for our complex clients and collect "true believers" must be understood by all who take on such challenges. Measuring outcomes with our colleagues in the research arena is the final jewel in the crown, and as Nick Goodwin has highlighted deserves our earnest attention. Just like our traditional healthcare system these outcome measures are based around single disease states and are just as siloed. Finding validated tools which we can use across settings and indeed across countries will hopefully give care coordination the political grunt needed to "speak the truth to power"and fund the navigators to the level needed to change the way healthcare system function.
After many years as an NHS commissioner and now working across health and social care I am more convinced than ever that KPOOH and GPOOH are the central elements that need to be tackled in the pursuit of better integration for services and viable care particularly for the frail elderly in older old age. With an NHS budget of circa £114b and a social care budget of closer to £14b. The continuing cap and squeeze on social care funding combined with an ageing population being supported to live with significant comorbidities at home by unsustainable care packages will perpetuate the volume of people being admitted to acute hospitals putting great pressure of costs and services not to mention the wellbeing and consequences of hospital care. Solution focused risk sharing health and social care alliances with independent care providers should be encouraged and trialled using some of the £3.8b transition funds. New ideas should be looked out in an open minded way with choice and best interests of the elderly in mind. Safe and fun for older people must be central themes. 24/7 care in environments that KPOOH and GPOOH That's keeping people and getting people out of hospital of course. As I'm sure you'd already worked out. !!!