Co-ordinated care for people with complex chronic conditions

The costs of caring for people with age-related chronic and complex medical conditions are high and will continue to rise with population ageing. Yet people with multiple health and social care needs often receive a very fragmented service, resulting in less than optimal care experiences, outcomes and costs. Many countries have developed strategies to improve care co-ordination, but these have often failed to achieve their objectives. There is also a general lack of knowledge about how best to apply (and combine), in practice, the various strategies and approaches to care co-ordination.

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.

Key findings

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.

Policy implications

• 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.