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Co-ordinated care for people with complex chronic conditions

This project involved an in-depth examination of approaches to care co-ordination undertaken in primary care settings in different parts of the UK.

Project content

  • Co-ordinated care for people with complex chronic conditions

    Our report explores the key components of effective co-ordinated care through a study of five UK-based programmes that deliver co-ordinated care for people with long-term and complex nee...

  • Oxleas Advanced Dementia Service: supporting carers and building resilience

    This case study looks at how Oxleas Advanced Dementia Service provides care co-ordination, and specialist palliative care and support to patients with advanced dementia living at home.

  • Developing community resource teams in Pembrokeshire, Wales

    This case study looks at how four community-based teams in Pembrokeshire bring together professionals from health, social care and the third sector to provide care for patients at home.

  • The Esteem Team

    The Esteem Team aims to support people with mental health conditions and complex social needs in the borough of Sandwell. Find out more about their approach to co-ordinated care.

  • South Devon and Torbay

    This case study explores community virtual wards based in GP practices within South Devon and Torbay Clinical Commissioning Group.

About the project

We undertook an in-depth examination of approaches to care co-ordination in primary care settings in different parts of the UK. Work involved:

  • an expert panel selecting five case study sites that are delivering effective care co-ordination programmes

  • a showcase of the sites' care co-ordination work at a public event on achieving high-quality care for people with complex needs at The King's Fund

  • content analysis of key documents, face-to-face interviews with staff and observational analysis with the sites to establish key care co-ordination lessons and markers for success

  • setting up a learning network so that the case study sites can share experiences and examine key success factors.

Who funded the project?

We are grateful to Aetna and the Aetna Foundation for funding this important piece of work.

Aims of the project

Age-related chronic conditions absorb the largest, and growing, share of health care budgets. To address this, strategies of care co-ordination are being developed to promote more cost-effective care through streamlining services. However, there is a lack of knowledge about how best to apply care co-ordination in practice.

Through a UK-based comparison of successful innovative care co-ordination programmes, this project aimed to:

  • understand the key components of strategies used to deliver care co-ordination effectively

  • examine key barriers and facilitators to successful implementation

  • develop practical and generalisable lessons for the application of the tools and techniques of care co-ordination

  • identify lessons in how care co-ordination can best be supported, in terms of planning, leading, organising, and incentivising

  • promote and disseminate the lessons from the research to support the effective adoption of care co-ordination in both the UK and US contexts.

Expert panel

Our expert panel supported the project over the course of its work and, more specifically, selected the five case study sites that we worked with.

The expert panel members were:

  • Richard Humphries, Project Lead, Assistant Director, Policy, The King’s Fund

  • Dennis Kodner, Project Lead, International Visiting Fellow, The King's Fund

  • Gillian Barclay, Vice President, Aetna Foundation

  • Robert Berenson, Senior Fellow, The Urban Institute (Washington, DC)

  • Sandra Birnie, Service Development Manager, Cheshire and Wirral Partnership NHS Foundation Trust

  • Peter Colclough, Chief Executive, Weston Area Health NHS Trust

  • Jocelyn Cornwell, Director, The Point of Care Foundation and Senior Fellow, The King's Fund

  • Julien Forder, Research Fellow, London School of Economics

  • Nick Goodwin, Senior Associate, The King's Fund

  • David Healy, European General Manager, Aetna

  • Chris Ham, Chief Executive, The King's Fund

  • Stephen Johnson, Head of Long-tem Conditions, Department of Health

  • Leo Lewis, Senior Fellow, International Foundation for Integrated Care

  • Marina Lupari, Assistant Director of Nursing Research & Development, NHSCT

  • Guy Robertson, Joint Head of Ageing Well Programme, Local Government Group

  • Alyse Sabina, Programme Officer, Aetna Foundation

  • Samantha Sharp, Senior Policy Officer, Alzheimer's Society

  • Ruth Thorlby, Senior Fellow, Nuffield Trust

  • Patricia Volland, Senior Vice President and Director of the Social Work Leadership Institute, The New York Academy of Medicine