Co-ordinating care for high-cost, high-need patients

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Last week I attended the Commonwealth Fund’s International Symposium in Washington DC. The symposium brought together health care leaders from various countries to discuss how best to care for high-cost, high-need patients. The real value for me came in the sessions that focused on the new care models that are being put in place in different systems for these patients.

Examples included work in Toronto to improve acute care for older patients; an initiative in Skaraborg in Sweden to provide health care at home for people with the most severe needs; the Dutch chain care model which targets the needs of frail older people; and the Principia project in Nottingham where general practices work closely with care homes to improve care and avoid inappropriate hospital admissions.

In her contribution to the symposium, Norway’s health minister reminded us of the importance of keeping the needs of patients to the fore in developing new care models. This was a valuable counterpoint to some of the other discussions that emphasised the technical challenges in integrating care, such as how care is paid for and how partnerships are governed. Finding out what matters to patients and how they can best be supported has never been more important.

I was also reminded that while technology has a role in supporting integrated care, the fundamental change that is needed is in the relationships between staff delivering care. This is especially the case for the high-cost, high-need patients who are often in contact with many staff. The outcomes of care for these patients depend critically on effective co-ordination and excellent communication on the part of caregivers.

One of the most helpful papers I’ve come across on this subject was written by a US physician, Matthew Press, who uses his own experience to draw an analogy between doctors who care for patients with complex needs and the quarterback in American football teams. These doctors help patients navigate the system, they advocate on their behalf, and they co-ordinate their assessment and treatment. To alter the metaphor, they are the lynchpins that hold different contributions together.

Press argues that doctors need time in their schedules to undertake these tasks and they must build relationships with other clinicians to ensure that patients receive the right care in the right place at the right time. He emphasises the importance of excellent communication skills, teamwork, and the challenge of teamwork spanning different care settings. He also notes that relationships may be undermined by doctors’ changing working practices.

Within the NHS, the quarterback role for high-cost, high-need patients is often taken on by specialists in the care of older people. I’ve observed this at first hand when I’ve shadowed David Oliver on his ward rounds at the Royal Berkshire Hospital. Co-ordination is important both within hospitals when the expertise of other specialists is needed and with services outside hospitals when patients are being discharged back home or into residential care. Co-ordination with services outside hospitals is especially challenging when patients live in areas served by different local authorities and community providers whose policies on funding and providing care and support may vary.

The heavy workload of specialists who care for older people in NHS hospitals is a barrier to effective care co-ordination, as is the lack of an electronic care record that provides easy access to the information needed to support decision making. In some cases, co-ordination can be delegated to other team members but, as Press points out, it often requires conversations between the different doctors involved in care. Giving priority to these conversations is essential if patients are to be cared for safely.

Discussions of integrated care in this country often focus on the policy barriers that inhibit progress or the governance arrangements that are needed to underpin partnership working in STPs and ICSs. Important as these issues are, they will not achieve the desired results if clinical teams lack the time and resources to join up their work around patients with complex needs. Workforce shortages are making this even more difficult just as demographic changes are making it ever more necessary. Valuing and supporting care co-ordination for patients with complex needs is the critical next step on the journey to integrated care.

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