6. Care co-ordination through integrated health and social care teams

What is it?

Creating patient-centred care that is more co-ordinated across care settings and over time, particularly for patients with long-term chronic and medically complex conditions who may find it difficult to 'navigate' fragmented health care systems.

Why is it important?

  • Co-ordination of care for people with complex chronic illness is a global challenge. Driven by broad shifts in demographics and disease status, long-term conditions absorb by far the largest, and growing, share of health care budgets (see Active support for self-management).
  • Co-ordination of care for patients with complex needs and long-term illness is currently poor (The King's Fund 2011), and those with long-term conditions have a lower quality of life (Department of Health 2011).

What is the impact?

  • Robust evidence on health outcomes is limited, but improved care co-ordination can have a significant effect on the quality of life of older frail people and people with multiple long-term conditions (Hofmarcher et al 2007).
  • Highly integrated primary care systems that emphasise continuity and co-ordination of care are associated with better patient experience (Starfield 1998; Bodenheimer 2008).
  • Impact on costs and cost-effectiveness is less easy to predict and is likely to be low in the short term given the upfront investments required. However, health systems that employ models of chronic care management tend to be associated with lower costs, as well as better outcomes and higher patient satisfaction (Singh and Ham 2005).

How to do it

There is no one model of care co-ordination, but evidence suggests that joint commissioning between health and social care that results in a multi-component approach is likely to achieve better results than those that rely on a single or limited set of strategies (Singh and Ham 2005; Powell Davies et al 2008; Kodner 2009). Some of the key components (The King's Fund 2011) are:

  • a move to community-based multi-professional teams based around general practices that include generalists working alongside specialists
  • a focus on intermediate care, case management and support to home-based care
  • joint care planning and co-ordinated assessments of care needs
  • personalised health care plans and programmes
  • named care co-ordinators who act as navigators and who retain responsibility for patient care and experiences throughout the patient journey
  • clinical records that are shared across the multi-professional team.

Care for Older People in Torbay provides a good example of the kind of change required. Torbay established five integrated health and social care teams organised in localities aligned with general practices. Care co-ordinators support older people following an emergency hospitalisation, helping them to receive the intensive support required to enable them to live at home.

Northamptonshire Integrated Care Partnership focused on helping patients remain independent for longer and creating personalised care plans for high-risk individuals that aimed to reduce admissions to hospital. It developed a new community-based service for patients at the end of life and a multidisciplinary care service for older people to support independent living in the community.

Useful resources

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