About the project
Final report on this work
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 needs.
- Read the final report
- Watch our video to find out more about the key features needed for successful care co-ordination
Case study sites
We worked with five case study sites who have developed innovative primary care-based approaches to care co-ordination for people with complex chronic conditions.
Each final case study includes an organogram showing the care planning/co-ordination process, patient stories and a video highlighting the work of the team.
Midhurst Macmillan Community Specialist Palliative Care ServiceThe Midhurst Macmillan Service is a community-based, consultant-led, specialist palliative care service in a rural community in the south of England. The service seeks to provide direct care and support to patients in the last 12 months of life to prevent unnecessary hospital admissions and enable them to live at home and die in the place of their choice.
Oxleas Advanced Dementia ServiceOxleas Advanced Dementia Service provides care co-ordination, and specialist palliative care and support to patients with advanced dementia living at home. The current service consists of a consultant in old-age psychiatry, several specialist nurses and a dementia social worker.
Pembrokeshire community resource teamsThis case study looks at integrated teams of health and social care professionals, known as community resource teams (CRTs), who work to co-ordinate care for people living at home in the largely rural county of Pembrokeshire. This model of care is one aspect of a wider strategic programme of integrated care, called Care Closer to Home.
Sandwell Esteem TeamThis case study looks at the Sandwell Esteem Team, part of the Sandwell Integrated Primary Care Mental Health and Wellbeing Service (the Sandwell Wellbeing Hub) in the West Midlands. The hub is a holistic primary and community care-based approach to improving social, mental and physical health and wellbeing in the borough of Sandwell.
South Devon and TorbaySouth Devon and Torbay clinical commissioning group uses proactive case management and community virtual wards to identify people at risk of an unnecessary hospital admission in the next 12 months. Each month, the multidisciplinary team identifies and addresses patients’ needs to put in place a case management plan to prevent crises from occurring.
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
- an event to launch the findings of the final report.
Who funded the project?
Aims of the project
Why did we do work in this area?
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.
The 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
This section brings together a number of our resources on delivering care co-ordination for people with complex chronic conditions.
What is the key to effective care co-ordination?What are the key factors in delivering successful and seamless co-ordinated care? We spoke to the teams we’ve been working with during our research project to hear their views.
Case study site interviews
We inteviewed our five case study sites to find out more about their approach to co-ordinated care.