Challenges in commissioning research on what works in integrated care


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Challenges in commissioning research on what works in integrated care.

Tara Lamont, Scientific Adviser
NIHR Evaluation, Trials and Studies Coordinating Centre (NETSCC)

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  • Well recognised problems of silos of care which leave patients suffering fragmented, duplicated, sub-standard care. Micro – Locality based integrated health and social care teams Call for more integration and various things tried – from specialist nurses, integrated care pathways, multidisciplinary teams, personalised care and bundled payment. Let’s take a step back and just consider conceptually the model for different approaches. Macro – Health Maintenance Organisations in US with fully integrated primary and secondary providers and payments to incentivise hospital avoidance Meso – structural and service level integration, with joint planning and budgeting – for instance, diabetes or epilepsy managed networks and pathways or locality-based health and social care teams in Torbay for older people. Micro-level : coordination driven by single assessment of the patient (may be linked to personalised budgets) and with care or case manager.
  • Xoo patients at 3 sites
  • Challenges in commissioning research on what works in integrated care

    1. 1. Challenges in commissioning research onwhat works in integrated careTara Lamont, Scientific AdviserNIHR Evaluation, Trials and Studies Coordinating Centre (NETSCC) 27/11/12
    2. 2. National Institute for Health Health Services and What research do Delivery Research Research (NIHR) Programme managers need to C£16m (€19.8m) deliver good £1bn (€1.2bn)/year Focus on quality and services? effectiveness of applied health healthcare systems research system for NHS ImpactAsk the right Answer themquestions the right way
    3. 3. What do we mean by integration?
    4. 4. What mechanisms work? Call for new research in 2009 (England/Wales) – Evaluating innovations in integrating health + social care > £2m (€2.4m)
    5. 5. Problems in evaluating integratedmodels of care Systematic review of international evidence – few high quality, controlled evaluations of models of integration [Johri 2003] • Complex interplay of context, mechanism and outcome • Difficult to track real patient activity and costs across settings • Local initiatives which may be difficult to replicate • Small-scale studies often at single sites
    6. 6. How do the new studies tacklethese challenges (i)? New evidence on efficacy and cost-• Lewis and team at Nuffield Trust UK effectiveness of integration at• Virtual wards – started as experiment 10 years ago, spreading micro and meso widely Robust levels• Target patients at high risk of emergency admission and monitor economic analyses daily by involving 2008 multidisciplinary team (matron, pharmacist, social worker, GP) with coordination by ward clerk and integrated care record patients over 3 sites• Sophisticated methods on costing and activity: - difference-in-difference analysis (comparison of admissions with matched non-intervention groups) - economic analysis (person-linked data on patients services across Tracking use of across sectors health and social care) Useful practical using innovative tools for• person-level Should answer question: what do virtual wards cost and what effect managers eg `bottom-up’ calculating do they have on costs and use of hospital and other services? costing optimal casemix for virtual wards
    7. 7. How do the new studiestackle these challenges (ii)? Case study• Parker et al at York University, UK design informed by• Innovations in integrated services for people with neurological programme disorders (as exemplar longterm condition) theory• 4 organisational case studies selected purposively to test different forms of structural integration (eg comparison of joint funding agencies versus separate authorities) against micro-level initiatives• Initiatives compare and contrast models of multidisciplinary team management for brain injury – health led, social care led, joint led Evidence on how• Multi-methods tomicro-level understand interplay of context and mechanisms integrated care• Working with patients to develop user-derived outcome measures can best be against which to assess at supported models of care meso- and macro-levels.
    8. 8. 5 top tips for researchers evaluating integrated care• Describe intervention well (eg workforce – include grademix, skillmix, professions) – could it be replicated elsewhere?• Think about generaliseability of findings (eg comparator sites, controls, use of national reference data) – will findings be meaningful elsewhere?• Consider context in study design (eg sampling frame based on variables derived from evidence)• Consider new methods to capture costs and service complexity (eg person-linked data to track activity across settings) – top class health economics input essential• Position your study against existing body of knowledge – what is already known and what will your study add?
    9. 9. For more information on these and some other health services research studies, visit This presentation presents independent research funded by the National Institute for Health Research (NIHR). The views expressed are those of the author(s) and not necessarily those of the NHS, the NIHR or the Department of Health.Tara LamontScientific AdviserNIHR Health Service & Delivery Research