Making a success of care co-ordination to people with complex needs

Lessons from the literature and international experience

Dr Nick GoodwinCEO, International Foundation for Integrated Care

www.integratedcarefoundation.org

Paper to development day, The King’s Fund, Aetna Foundation Study, Co-ordinated care to people with complex chronic conditions,

The King’s Fund, 29 May, 2013

What is care co-ordination?

• No ‘standard’ definition• Interchangeable usage with terms

such as – integrated care; case

management; disease management and multi-disciplinary teamwork

• Difference in perception– It’s the process of caring – ie,

with people through a person or team

– It’s the system of caring – ie, an overall strategy to improve care delivery

“ Care co-ordination is a person-centred, assessment-based,

interdisciplinary approach to integrating health care services in a cost-effective manner in which an individual’s needs and preferences

are assessed, a comprehensive care plan developed, and services

managed and monitored by an evidence-based process usually

involving named care coordinators.” 1

1. The National Coalition on Care Coordination (N3C) (no date) , Policy Brief. Implementing Care Coordination in the Patient Protection and Affordable Care Act. Available at: http://www.nyam.org/social-work-leadership-institute/docs/publications/N3C-Implementing-Care-Coordination.pdf Accessed 5th August 2011.

Integration without care co-ordination cannot lead to integrated care

Effective care co-ordination can be achieved without the need for the formal (‘real’) integration of organisations. Within single providers, integrated care can often be weak unless internal silos have been addressed. Clinical and service integration matters most.

Curry N, Ham C (2010) Clinical and service integration. The route to improved outcomes. London: The King’s Fund. Available at: http://www.kingsfund.org.uk/publications/clinical_and_service.html

The challenge:Dealing with the complexity

Care systems are failing to cope with complexity

Frontier Economics (2012) Enablers and barriers to integrated care and implications for Monitor -

The complexity in the way care systems are designed leads to:

• lack of ‘ownership’ of the person’s problem;

• lack of involvement of users and carers in their own care;

• poor communication between partners in care;

• simultaneous duplication of tasks and gaps in care;

• treating one condition without recognising others;

• poor outcomes to person, carer and the system

Ageing societies is a major factor

By 2034, >85s will represent c.5% of the population in Western Europe.

The rising challenge of co-morbidity

In the UK, the additional cost to the health and social care system is likely to be £5 billion by 2018 compared to 2011, rising from 1.9 million to 2.9 million patients

The challenge

• Poor co-ordination of care for people with long-term/complex illnesses leads to poor care experiences and adverse outcomes

• Age-related chronic conditions absorb the largest, and growing, share of health/social care activities

• Practical solutions to tackle the socio-determinants of ill-health and pathology of the complex patient

• Strategies of care co-ordination to create more integrated, cost effective and patient-centred services are growing internationally

• However, there is a lack of knowledge about how best to apply care co-ordination in practice.

Meeting the challenge

Care systems need to changeThink of the hospital as a cost centre, not a revenue centre

Hospitals can sustain revenue as aspects of care are shifted to communities

Imison et al (2012) Older people and emergency bed use. The King’s Fund, London

Managing complex patients – what works?• More effective approaches:

– Population management– Holistic, not disease-based– Organisational interventions targeted

at the management of specific risk factors

– Interventions focused on people with functional disabilities

– Management of medicines

• Less effective approaches:– Poorly targeted or broader

programmes of community based care, for example case management

– Patient education and support programmes not focused on managing risk factors

Targeting, Targeting, Targeting

Meeting the challenge at a clinical, service and personal level

No ‘best approach’, but several key lessons and marker for success that include all the following:

• Community awareness, participation and trust

• Population health planning

• Identification of people in need of care – inclusion criteria

• Health promotion

• Single point of access

• Single, holistic, care assessment (including carer and family)

• Care planning driven by needs and choices of service user/carer

• Dedicated care co-ordinator and/or case manager• Supported self-care• Responsive provider network available 24/7• Focus on care transitions, eg, hospital to home• Communication between care professionals, and between care professionals and users• Access to shared care records• Commitment to measuring and responding to people’s experiences and outcomes• Quality improvement process

Guided Care, USA• Trained nurses integrated into

primary care practice• Predictive modelling techniques to

identify at-risk patients• Nurse assessment of patient and

carer needs• Co-designed care plan• Case-loads of 50-60 individuals per

nurse• Multi-disciplinary teams based in

primary care• Self-management support• Web-based electronic health records

support real-time decision-making

Peer-Reviewed Impact Includes

• High levels of satisfaction with patients and carers

• Improvements in measures related to quality of life

• Reductions in total costs to health care budgets through reduced hospitalisations and lengths of stay (up to 11%)See: http://www.guidedcare.org/index.asp

International case studies of integrated care to older people with complex needs: a cross national review

• The King’s Fund and University of Toronto funded by the Commonwealth Fund – under review!

• Seven case studies:– Te Whiringa Ora, Eastern Bay of Plenty, New Zealand– Geriant, Noord-Holland Province, The Netherlands– Torbay and South Devon Health and Care Trust, UK– The Norrtalje Model, Stockholm, Sweden– PRISMA, Canada– Health One, Sydney, Canada– Mass. General Hospital, Boston, USA

How was integrated care built?• Australia, HealthOne

– Better care planning and case management links people to the right care providers.

• PRISMA– Co-ordination of care between providers enables earlier, faster delivery of care.

• Geriant– Intensive multi-disciplinary care allows users to remain at home

• Te Whiringa Ora – Education and supported self-care enables people manage their own conditions

• Norrtalje – Intensive home-based service allows users to remain at home for longer. Responsive

care providers enable earlier, faster and more effective delivery of services.

• Torbay – Multi-disciplinary care reduces acute episodes and allows users to remain at home

• Mass. General– Case management of high-cost patients reduces acute episodes of care

Key lessons (under review):Integration necessary at every level

• System• Organisation• Functional• Professional• Service• Personal

Meeting the challenge at a clinical, service and personal level

No ‘best approach’, but several key lessons and marker for success that include all the following:

• Community awareness, participation and trust

• Population health planning

• Identification of people in need of care – inclusion criteria

• Health promotion • Single point of access

• Single, holistic, care assessment (including carer and family)

• Care planning driven by needs and choices of service user/carer

• Dedicated care co-ordinator and/or case manager• Supported self-care• Responsive provider network available 24/7• Focus on care transitions, eg, hospital to home• Communication between care professionals, and between care professionals and users• Access to shared care records• Commitment to measuring and responding to people’s experiences and outcomes• Quality improvement process

Multiple strategies to be collectively applied

Theme Problems if overlooked …

Population-based planning

Lack of understanding of local priorities and awareness of care needs leads to poorly targeted and/or late/missed opportunities to support interventions

Health promotion and self-care

Inability to support and/or engage people to live healthier and more fulfilling lives fails to have any meaningful impact on the rising demand for institutional care

Care process Failure to plan and co-ordinate services with and around people’s needs leads to fragmentations in care and sub-optimal outcomes

Wider Network of Providers

Inability of wider provider networks to respond to real-time needs of people means co-ordination efforts undermined and under-valued

Monitoring and Quality Improvement

Inability to judge or benchmark impact and lack of evidence leads to loss of funding and professional trust, inability to influence professional behaviour, and limits ability to improve and adapt

Contact

Dr Nick GoodwinCEO, International Foundation for Integrated Care

nickgoodwin@integratedcarefoundation.orgwww.integratedcarefoundation.org