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Nick Goodwin: making a success of care co-ordination
 

Nick Goodwin: making a success of care co-ordination

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Nick Goodwin, Chief Executive at the International Foundation for Integrated Care, looks at how care could be better co-ordinated around people with complex needs, and the challenges around delivering ...

Nick Goodwin, Chief Executive at the International Foundation for Integrated Care, looks at how care could be better co-ordinated around people with complex needs, and the challenges around delivering joined-up care.

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  • 22:23The Guided Care model for chronic disease care was developed in the United Statesin 2001. A specially trained registered nurse is recruited, trained in chronic diseasecare, and integrated into a primary care practice participating in managed careprogrammes, including Kaiser Permanente. The nurse works collaboratively withup to five primary care physicians and others in the practice team to deliverintegrated care.Predictive modelling techniques use claims data to identify patients over 65 yearswith multiple co-morbidities who are at risk of ‘heavy’ health service use in thecoming year. Those at highest risk are targeted for the intervention and a caseload ofapproximately 50–60 patients is allocated to each Guided Care nurse.The Guided Care nurse carries out a geriatric assessment of the patient and theircarer at home. The nurse, a primary care physician, patient and carer design acomprehensive, evidence-based and patient-friendly ‘action plan’ based on bestpractice primary care interventions for this patient group. The nurse monitors thepatient monthly and promotes the principle of self-management through educationand support. The nurse co-ordinates the various parts of health care that are providedin different settings (eg, hospitals, social service agencies, hospices and rehabilitationclinics) and helps the patient make the transition between these care settings. Accessto community resources is also facilitated.A secure, web-based electronic health record is used to provide the nurse with alertsabout drug interaction, best practice evidence and appointments/encounters withhealth care professionals.Positive outcomes associated with the Guided Care approach include high levels ofsatisfaction with chronic disease care on the part of patients, carers and physicians.Compared with those receiving ‘usual care’, the perceived quality of care amongpatients and physicians is better (Boyd et al 2010; Marsteller et al 2010) while thereported strain on family care-givers was reduced (Wolff et al 2010). On average,total health care costs to the insurer were 11 per cent less (Leffet al 2009), linked tosignificant reductions in the provision of home health care and reduced admissionsto skilled nursing care facilities (Boultet al 2011).References: Boyd et al 2007; Aliotta et al 2008; Leff et al 2009; Boyd et al 2010; Marstelleret al 2010; Wolff et al 2010; Boult et al 2011. See also Guided Care, ‘Care for the wholeperson, for those who need it most’, available at: www.guidedcare.org/index.asp.
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  • 27:48System levelImportance of developing a narrative at a political level.Most systems have significant fragmentation - the process has to be led, managed and nurtured over time.Organisational levelNo single organisational model - starting point is a clinical/service model NOT an organisational model with a pre-determined design.It takes time for approaches to integrated care to develop and mature, with most programmes constantly evolving. Fully-integrated organisations are not the (end) point.Functional level – high touch/low techSuccess appears to be related to good communication and relationships between people, professionals and managers. The use of ICT is potentially an important enabler but does not appear to be a necessary condition.Building relationships to support integrated care requires time to build social capital and foster trust.Professional levelProfessionals need to work together in multi-disciplinary teams or provider networks - generalists and specialists, health and social care. Within teams, professionals need to have well defined roles, and work in partnership with colleagues in a shared care approach.In most cases, care coordination was being delivered alongside rather than by primary care physicians. This suggests that complex patients whose needs span health and social care may require an intensity of care not able to be delivered by primary care physicians  Service levelA number of common elements in the design of the care process at a service-level appear to be important. These include: - holistic care assessments; - care planning; - a single point of entry; - care co-ordination; and - the availability of a well-connected provider network where facilitated access to the necessary support is available. Personal levelAll case studies had a specific focus on working with users and informal carers to support self-management and, to some extent, shared decision-making.Continuity of care and care co-ordination to meet the specific needs of users is important and highly valued.The effectiveness of the role of the care co-ordinator and/or case manager is highly significant.
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Nick Goodwin: making a success of care co-ordination Nick Goodwin: making a success of care co-ordination Presentation Transcript

  • Making a success of care co-ordination to people with complex needs Lessons from the literature and international experience Dr Nick Goodwin CEO, 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 change Think 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 Goodwin CEO, International Foundation for Integrated Care nickgoodwin@integratedcarefoundation.org www.integratedcarefoundation.org