This document discusses innovative approaches to healthcare design for patients with complex needs. It argues that integrated care models are needed to address the growing challenges posed by aging populations with multiple chronic conditions. Successful integrated care models coordinate services around patient needs, rather than individual diseases. They feature elements like population-based approaches, multidisciplinary teams, and flexibility in funding and regulations. While lean thinking aims to streamline care, complex patients require systems that can adapt dynamically to changing needs through features like case management and care coordination between specialized and community-based providers.

1. Innovative Healthcare Design
From lean thinking to complex adaptive system
Developing new service models to integrate care around
patients with complex care needs
Dr Nick Goodwin, Senior Fellow, The King’s Fund, UK
Paper to MIHealth Forum, Fira Barcelona, 24 May 2012

2. The Need to Focus on Complexity
• People with long-
term and chronic
illnesses are the main
challenge facing
health care systems
worldwide
• Numbers are
predicted to increase
as populations age
and lifestyle choices
lead to earlier onset
of chronic conditions
• Yet, health systems
are largely configured
for individual diseases

3. INTEGRATED CARE
• Integrated care is an approach for any individuals where gaps
in care, or poor care co-ordination, leads to an adverse impact
on care experiences and care outcomes.
• Integrated care is best suited to frail older people, to those
living with long-term chronic and mental health illnesses, and to
those with medically complex needs or requiring urgent care.
• Integrated care is most effective when it is population-based
and takes into account the holistic needs of patients. Disease-
based approaches ultimately lead to new silos of care.

4. The Mrs Smith test...
Many people with mental, physical and/or medical
conditions are at risk of long hospital stays and/or
commitment to long-term care in a nursing home.
Mrs. Smith is a fictitious women in her 80s with a
range of long-term health and social care problems for
which she needs care and support.
Mrs. Smith encounters daily difficulties and
frustrations in navigating the health and social care
system.
Problems include her many separate assessments,
having to repeat her story to many people, delays in
care due to the poor transmission of information, and
bewilderment at the sheer complexity of the system.

5. From a
fragmented set of health
Social Worker
and social care services …
G.P.
Practice
Nurse
Domiciliary Care
District Nurse
O.T.
O.T.
Diabetologist
Family &
Friends Home Cardiologist

6. … to a co-ordinated service that
meets her needs
Integrated Team
SAP
Home
Family and Specialist Services
Friends

7. Examples of Successful
Integrated Care

8. Integrated care for frail older people in Torbay, UK
Torbay Care Trust
Integrated health and social care teams,
using pooled budgets and serving
localities of c.30,000 people, work
alongside GPs to provide a range of
intermediate care services. By supporting
hospital discharge, older people have
been helped to live independently in the
community. Health and social care co-
ordinators help to harness the joint
contributions of team members.
The results include reduced use of
hospital beds, low rates of emergency
admissions for those over 65, and
minimal delayed transfers of care.
(Thistlethwaite, 2011)

9. The ESTHER Project, Sweden
Jönköping County Council
Team of physicians, nurses, and other
providers who joined together to
improve patient flow and coordination of
care for elderly patients within a six-
municipality region in Sweden.
The Esther Project team consisted of
physicians, nurses, social workers, and
other providers representing the
Höglandet Hospital and physician
practices in each of the six municipalities.
Closer cooperation among specialists and
other providers meant that PCPs and
homecare nurses were able to do for
patients some of the things specialists
had been doing. Additionally, patient
education was recognized as critical.

10. The PACE Programme, USA
Promoting All-Inclusive Care
for the Elderly
Fully integrated system providing acute
and long-term care services to older
people (>55) based around an adult care
centre that offers: social and respite
services, primary medical care, geriatric
outpatients, ongoing care and case
management, informal carers.
Since 1997, PACE a permanent provider
under Medicare - 36 fully operational "Without PACE, I would not be able
programmes across 18 states. A typical to keep working and care for my
participant: woman who is 80 years old
mother. Without the day program, I
with multiple (9.7) medical conditions
with limited activities for daily living. 49%
don't think I would have a life. It's
have a diagnosis of dementia. wonderful.”
Successful in managing care out of
hospital cost-effectively. High client
satisfaction.

11. Tackling Complexity
Key System Design Factors

12. Systemic Characteristics
• Universal coverage, care free at point of use
– Use of prepaid capitation-based budgets
• Primary/community care driven
– Developing new services that wrap around primary care practices to support people in
local communities has a record of success
• Emphasis on chronic and long-term physical and mental health care
• Emphasis on population health management and public health
• Alignment of regulatory frameworks with goals of integrated care
• Funding/payment flexibilities to promote integrated care
– Seeing the hospital as a cost-centre, not a revenue centre
• Workforce educated and skilled in chronic care, teamwork (joint working)
and care co-ordination

13. Organisational Characteristics
• Strong administrative and clinical leadership
• Shared mission, values and culture
• Common organizational and governance structure
• Shared organizational/financial accountabilities
• Aligned financial incentives and use of funding flexibilities (e.g.
pooled/capitated budgets)
• Organized provider network embedded in system
• Integrated IT & single electronic health record
• Responsibility for defined population and/or service area (e.g. registered
list)
• Continuous quality measurement and improvement

14. Delivery Characteristics
There are many different ways in which professionals and providers can work directly with
communities, patients/clients to support integrated care. These ‘tools’ focus on the ‘how’ of
clinical and service integration
Examples of tools for clinical or professional Examples of tools for service integration:
integration: • Assisted living/care support in home
• Case finding and use of risk-stratification • Single point of entry
• Standardised diagnostic and eligibility criteria • Care co-ordination
• Comprehensive joint assessments • Case management
• Joint care planning • Disease management
• Single or shared clinical records • Centralised information, referral and intake
• Decision support tools such as care • Multi-disciplinary teamwork
guidelines and protocols • Inter-professional networks
• Technologies that support continuous and • Shared accountability for care
remote patient monitoring
• Co-location of services
• Peer review
• Discharge/transfer agreements
• Personal health budgets

15. From ‘Lean Thinking’ …
to Complex Adaptive Systems
Address workplace organisation, Because complex adaptive
standardisation, elimination of non- systems self-organize,
value added steps to improve flow, no one can impose an
eliminate waste organizational design.