integration through care co-ordination belinda weir, senior consultant, the king’s fund lara...
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Integration through Care Co-ordination
Belinda Weir, Senior Consultant, The King’s FundLara Sonola, Senior Researcher, The King’s Fund
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Aims of session
› To hear some evidence about effective coordinated care for people with long-term conditions
› To explore the factors which support coordinated care and analyse our own services in relation to these factors
› To share experience and consider what, if anything, we will do differently as a result of this workshop
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Sam’s story http://www.kingsfund.org.uk/audio-video/what-key-effective-care-co-ordination
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Co-ordinated care for people with complex chronic conditions
Greenwich & Bexley
› Methods: Five demonstrator sites chosen through a competitive process based on their ability to demonstrate positive impacts in one or more of the following: patient experience, better health outcomes, more cost-effective care
› We examined how care co-ordination was organised and operated in practice at a patient level through interviews with teams, documentary and observational analysis.
Midhurst, Surrey
Sandwell, Birmingham
Pembrokeshire
South Devon & Torbay
Greenwich & Bexley
› 2 year project funded by Aetna/Aetna Foundation in the US
› Aims: To understand the key components of effective care co-ordination, examine key barriers and facilitators and develop practical lessons for the application of the tools of care co-ordination
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Sandwell Esteem Team
http://www.kingsfund.org.uk/publications/esteem-team
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Key LessonsEvaluation and measurement
Time
Local context
Community involvement
Integrated teams
Aligned goals
Engaging GPs/secondary
care
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Systemic
Organisational
Functional
Community
Clinical and service
Personal
• Holistic• Patient and
carer focused
• Flexible
• Integrated commissioning
• Supportive policy
• Effective targeting• Localisation • 1-3 key leaders • Commissioning
support• Supportive team
culture/ shared values
• High touch-low tech
• Shared electronic patient records
• Personal communication
• Voluntary sector involvement
• Community awareness
• Multiple referrals, single point of entry
• Named care co-ordinators
• No defined care packages
Design features
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Research into practice
PATIENT FOCUS
STAFF STRATEGY
VALUES
?
LEADERSHIP
› How can you use these design features to deliver more joined-up care in your own system?
› Are there any other features you would add?
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Any Questions?