Co-ordinated care for people with complex chronic conditions: Key lessons and markers for success

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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.

Related content


Reeta Ram

Care Coordinator/Family and Patient Representative,
Disabled and Elderly Care Conciliation Solutions
Comment date
21 January 2014

My clients are main carers of such patients. Over the last two years, these clients report significant improvements in care and treatment plans due to the involvement of our skilled family representative services. A family representative is effective as a care coordinator because they help the family secure improvements in quality via the numerous appeals and complaints processes. This also leads in the longer term to improvements in quality, staff training, integration and shifts in adverse cultural attitudes of NHS and Social Services personnel towards patients.

Nick Goodwin

International Foundation for Integrated Care
Comment date
17 January 2014
In response to Margaret, the case sites chosen for study were selected because they were able to demonstrate that care experiences to the user (patient or carer) had reportedly improved as had care outcomes, and that this had been achieved at the same or lower costs. The literature on care co-ordination is overwhelmingly positive when it comes to improving care experiences

Margaret Chirgwin

Programme Director Primary Care Strategy,
Newham CCG
Comment date
01 November 2013
I find the above summary unhelpful as a policy maker - all the literature suggests that despite investment these integrated care/care coordination projects do not improve patient and carer staisfaction or reduce emergency admissions. Are they worth the investment? So far the literature says no. SO when you say these are the key design features of "successful" care coordination you need to say what you are using as a measure of "success"? Did you see increased patient and carer satisfaction and or improved health outcomes and or reduced emergency admissions?

Jane Robinson

Comment date
25 October 2013
I am surprised that anyone should be surprised at the findings on GPs' lack of engagement. In my long experience of the NHS GPs have always seen themselves as 'above' the interdisciplinary working demanded of this area of care. The only remedy is a root and branch change to GP education.

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