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.
PRIME Centre Wales
Long Term Conditions Consensus Meeting
Tuesday 10th November 2015, St Mary's Priory, Abergavenny, NP7 5ND
http://www.primecentre.wales/ltc-consensus-meeting.php
PRIME Centre Wales
Long Term Conditions Consensus Meeting
Tuesday 10th November 2015, St Mary's Priory, Abergavenny, NP7 5ND
http://www.primecentre.wales/ltc-consensus-meeting.php
Dan Venables_LTC Consensus Meeting 10-Nov-2015angewatkins
PRIME Centre Wales
Long Term Conditions Consensus Meeting
Tuesday 10th November 2015, St Mary's Priory, Abergavenny, NP7 5ND
http://www.primecentre.wales/ltc-consensus-meeting.php
Richard Neal LTC _Consensus Meeting 10-Nov-2015angewatkins
PRIME Centre Wales
Long Term Conditions Consensus Meeting
Tuesday 10th November 2015, St Mary's Priory, Abergavenny, NP7 5ND
http://www.primecentre.wales/ltc-consensus-meeting.php
Jacquie White, Deputy Director of NHS England Long Term Conditions, Older People & End of Life Care and Claire Cordeaux SIMUL8 Executive Director for Health & Social Care were invited by Centers for Medicare & Medicaid Services to discuss how NHS England work in chronic disease.
PRIME Centre Wales
Long Term Conditions Consensus Meeting
Tuesday 10th November 2015, St Mary's Priory, Abergavenny, NP7 5ND
http://www.primecentre.wales/ltc-consensus-meeting.php
PRIME Centre Wales
Long Term Conditions Consensus Meeting
Tuesday 10th November 2015, St Mary's Priory, Abergavenny, NP7 5ND
http://www.primecentre.wales/ltc-consensus-meeting.php
Dan Venables_LTC Consensus Meeting 10-Nov-2015angewatkins
PRIME Centre Wales
Long Term Conditions Consensus Meeting
Tuesday 10th November 2015, St Mary's Priory, Abergavenny, NP7 5ND
http://www.primecentre.wales/ltc-consensus-meeting.php
Richard Neal LTC _Consensus Meeting 10-Nov-2015angewatkins
PRIME Centre Wales
Long Term Conditions Consensus Meeting
Tuesday 10th November 2015, St Mary's Priory, Abergavenny, NP7 5ND
http://www.primecentre.wales/ltc-consensus-meeting.php
Jacquie White, Deputy Director of NHS England Long Term Conditions, Older People & End of Life Care and Claire Cordeaux SIMUL8 Executive Director for Health & Social Care were invited by Centers for Medicare & Medicaid Services to discuss how NHS England work in chronic disease.
Healthcare in the United States has become very fragmented, expensive and disjointed. Over the course of a hospitalization, a patient may be transferred from one unit to another, sometimes spending as much as 5 different units in a 3 day stay. This has led to many hand-off reports, and increased the potential for mistakes, improper communication, and patient deaths.
Partnership in this context is defined as a relationship between individuals or groups that is characterized by mutual cooperation and responsibility, as for the achievement of a specified goal (The American Heritage Dictionary, 2006). Partnership ensures that each member is equal and brings something important to the table. The Partnership Care Delivery Model (PCDM) ensures that the patient is an integral part of the healthcare team, and their experiences, contributions, advice, and influence is needed and valued.
Judith Smith and Chris Ham: Commissioning integrated care - what role for cli...The King's Fund
Dr Judith Smith, Head of Policy at the Nuffield Trust, and Professor Chris Ham, Chief Executive of The King’s Fund, share the findings of their recent research into how NHS commissioners have been commissioning better integrated services and care for people in local areas.
Elena Reyes, PhD, Associate Professor & Director of Behavioral Medicine, Florida State University College of Medicine, Regional Director Southwest Florida
Latino Health Forum 2014
Slides from the workshop 'A modern vision of integrated care and support' led by Dr Martin McShane, Dr Damian Riley (NHS England) and David Pearson (ADASS) - NHS Medical Leaders Conference 2014. - See more at: http://www.icase.org.uk/pg/cv_content/content/view/98680#sthash.45Xs2o9r.dpuf
Chris Ham on making integrated care happen at scale and paceThe King's Fund
Chris Ham, Chief Executive at The King’s Fund, highlights the 16 lessons needed to make a reality of integrated care, drawing on work by the Fund and others to provide examples of good practice.
Steve Laitner on integrated care - innovations in the UKThe King's Fund
Dr Steve Laitner, GP and Associate Medical Director of NHS East of England, discusses integrated care innovations in the UK with a focus on pathway hubs.
Alzheimer Europe talk 2015 Dr Shibley Rahmanshibley
These are the slides for the presentation I will give this year at the Alzheimer Europe conference in Ljubljana in Slovenia. It's survey based research on the importance of clinical nursing specialists in dementia.
At its biannual meeting Oct. 18-19, the Board of Trustees of the Council for a Parliament of the World’s Religions elected as its chair Imam Abdul Malik Mujahid. The board met in Williams Bay, Wis.
Healthcare in the United States has become very fragmented, expensive and disjointed. Over the course of a hospitalization, a patient may be transferred from one unit to another, sometimes spending as much as 5 different units in a 3 day stay. This has led to many hand-off reports, and increased the potential for mistakes, improper communication, and patient deaths.
Partnership in this context is defined as a relationship between individuals or groups that is characterized by mutual cooperation and responsibility, as for the achievement of a specified goal (The American Heritage Dictionary, 2006). Partnership ensures that each member is equal and brings something important to the table. The Partnership Care Delivery Model (PCDM) ensures that the patient is an integral part of the healthcare team, and their experiences, contributions, advice, and influence is needed and valued.
Judith Smith and Chris Ham: Commissioning integrated care - what role for cli...The King's Fund
Dr Judith Smith, Head of Policy at the Nuffield Trust, and Professor Chris Ham, Chief Executive of The King’s Fund, share the findings of their recent research into how NHS commissioners have been commissioning better integrated services and care for people in local areas.
Elena Reyes, PhD, Associate Professor & Director of Behavioral Medicine, Florida State University College of Medicine, Regional Director Southwest Florida
Latino Health Forum 2014
Slides from the workshop 'A modern vision of integrated care and support' led by Dr Martin McShane, Dr Damian Riley (NHS England) and David Pearson (ADASS) - NHS Medical Leaders Conference 2014. - See more at: http://www.icase.org.uk/pg/cv_content/content/view/98680#sthash.45Xs2o9r.dpuf
Chris Ham on making integrated care happen at scale and paceThe King's Fund
Chris Ham, Chief Executive at The King’s Fund, highlights the 16 lessons needed to make a reality of integrated care, drawing on work by the Fund and others to provide examples of good practice.
Steve Laitner on integrated care - innovations in the UKThe King's Fund
Dr Steve Laitner, GP and Associate Medical Director of NHS East of England, discusses integrated care innovations in the UK with a focus on pathway hubs.
Alzheimer Europe talk 2015 Dr Shibley Rahmanshibley
These are the slides for the presentation I will give this year at the Alzheimer Europe conference in Ljubljana in Slovenia. It's survey based research on the importance of clinical nursing specialists in dementia.
At its biannual meeting Oct. 18-19, the Board of Trustees of the Council for a Parliament of the World’s Religions elected as its chair Imam Abdul Malik Mujahid. The board met in Williams Bay, Wis.
SEMINARIO 100%. LA DIFERENCIACIÓN POSITIVA, TU MARCA PERSONAL.Aje Región de Murcia
Con este taller aprenderás a valorar los aspectos necesarios para desarrollar tu marca personal, sabiendo de primera mano en qué te beneficia a la hora de captar, fidelizar clientes y relacionarte comercialmente.
Nick Goodwin - Bringing integrated care to lifeAge UK
Dr Nick Goodwin, Senior Fellow, The King's Fund - presentation from Age UK's For Later Life conference, 25th April.
For more information: www.ageuk.org.uk/forlaterlife
Apresentação realizada no I Seminário Internacional de Atenção às Condições Crônicas, pela diretora do Programa da Gestão de Doenças Crônica dos Serviços Sanitários De Alberta/Canadá, Sandra Delon.
Belo Horizonte, 11 de novembro de 2014
Day 1: Challenges and opportunities for better detection, diagnosis and clini...KTN
The focus of this session is to explore how the UK health system is currently responding to the increasing number of patients with multiple long-term conditions and the impacts of healthcare inequalities on patient outcomes. We will also explore opportunities for businesses to bring about much needed innovations in the prevention, early diagnosis and management of multi-morbidity.
Integrated health & social care: service transformation supported by technolo...flanderscare
Wat is de toekomst van zorg op afstand in Vlaanderen? Dat was de centrale vraag van het event van 17 juni. 100 deelnemers dachten hier samen over na. Studiebezoeken aan andere Europese regio's toonden dat daar reeds op grote schaal met telecare en telehealth gewerkt en geëxperimenteerd wordt.
La voz de los pacientes en los proyectos de integracion de servicios del nhs ...Societat Gestió Sanitària
Ponencia a cargo del director de politicas y colaboraciones del National Voices en el National Health Service inglés, en el marco de la VI Jornada Right Care sobre Modelos avanzados en integración de servicios sociales y sanitarios, organizada por la Societat Catalana de Gestió Sanitària el 24 de mayo de 2019.
Working better together: community health and primary careNHS Confederation
This slide pack captures the main points from a workshop on integrated working between primary care and community health services. The workshop was organised by the NHS Confederation Community Health Services Forum in partnership with the National Association of Primary Care, in September 2014
Understanding NHS financial pressures: visual resourcesThe King's Fund
This slideset contains key visual elements from our report, Understanding NHS financial pressures: how are they affecting patient care? Please feel free to share and re-use these graphics with credit to The King's Fund.
Nine characteristics of good-quality care in district nursing taken from interviews with patients, carers and staff.
We hope this framework and these slides will be a useful resource for you – please feel free to use them in your work, in documents and presentations.
As part of a joint learning network on integrated housing, care and health, The King's Fund and the National Housing Federation have produced a set of slides illustrating the connections between housing, social care, health and wellbeing.
We hope they will be a useful resource for you – please feel free to use them in your office, in documents or presentations.
District councils’ contribution to public healthThe King's Fund
Our health is primarily determined by factors beyond just
health care. These slides illustrate the ways in which district
councils influence the health of local people through their key
functions and in their wider role supporting communities and
influencing other bodies.
The King’s Fund Events organise more than 20 health and social care events each year. Our highly-regarded conferences attract leading speakers from the government, the NHS, local authorities and the independent and voluntary sectors.
Jos de Blok set up Buurtzorg – which means ‘neighbourhood care’ in Dutch – with a team of four nurses. Today there are nearly 8,000 Buurtzorg nurses in 630 independent teams, caring for 60,000 patients a year. Nurses in Sweden, Norway, Japan and the United States are adopting the Buurtzorg model.
Our infographics highlight some key facts and figures around leadership vacancies in the NHS and some of the difficulties NHS organisations face in recruiting and retaining people for executive positions.
Sharing leadership with patients and users: a roundtable discussionThe King's Fund
‘What more is possible when patients, service users and those delivering services share the leadership task in health and social care?’
We held a roundtable discussion with patient leaders and organisational leads to discuss this question. Our slidepack summaries the conversations, including the opportunities and challenges for patient leaders, and where and how to start shared leadership working.
Making the case for public health interventionsThe King's Fund
In partnership with the Local Government Association, we have produced a set of infographics that describe key facts about the public health system and the return on investment for some public health interventions.
We hope they will be a useful resource for you – please feel free to use them in your office, in documents or presentations.
micro teaching on communication m.sc nursing.pdfAnurag Sharma
Microteaching is a unique model of practice teaching. It is a viable instrument for the. desired change in the teaching behavior or the behavior potential which, in specified types of real. classroom situations, tends to facilitate the achievement of specified types of objectives.
Title: Sense of Taste
Presenter: Dr. Faiza, Assistant Professor of Physiology
Qualifications:
MBBS (Best Graduate, AIMC Lahore)
FCPS Physiology
ICMT, CHPE, DHPE (STMU)
MPH (GC University, Faisalabad)
MBA (Virtual University of Pakistan)
Learning Objectives:
Describe the structure and function of taste buds.
Describe the relationship between the taste threshold and taste index of common substances.
Explain the chemical basis and signal transduction of taste perception for each type of primary taste sensation.
Recognize different abnormalities of taste perception and their causes.
Key Topics:
Significance of Taste Sensation:
Differentiation between pleasant and harmful food
Influence on behavior
Selection of food based on metabolic needs
Receptors of Taste:
Taste buds on the tongue
Influence of sense of smell, texture of food, and pain stimulation (e.g., by pepper)
Primary and Secondary Taste Sensations:
Primary taste sensations: Sweet, Sour, Salty, Bitter, Umami
Chemical basis and signal transduction mechanisms for each taste
Taste Threshold and Index:
Taste threshold values for Sweet (sucrose), Salty (NaCl), Sour (HCl), and Bitter (Quinine)
Taste index relationship: Inversely proportional to taste threshold
Taste Blindness:
Inability to taste certain substances, particularly thiourea compounds
Example: Phenylthiocarbamide
Structure and Function of Taste Buds:
Composition: Epithelial cells, Sustentacular/Supporting cells, Taste cells, Basal cells
Features: Taste pores, Taste hairs/microvilli, and Taste nerve fibers
Location of Taste Buds:
Found in papillae of the tongue (Fungiform, Circumvallate, Foliate)
Also present on the palate, tonsillar pillars, epiglottis, and proximal esophagus
Mechanism of Taste Stimulation:
Interaction of taste substances with receptors on microvilli
Signal transduction pathways for Umami, Sweet, Bitter, Sour, and Salty tastes
Taste Sensitivity and Adaptation:
Decrease in sensitivity with age
Rapid adaptation of taste sensation
Role of Saliva in Taste:
Dissolution of tastants to reach receptors
Washing away the stimulus
Taste Preferences and Aversions:
Mechanisms behind taste preference and aversion
Influence of receptors and neural pathways
Impact of Sensory Nerve Damage:
Degeneration of taste buds if the sensory nerve fiber is cut
Abnormalities of Taste Detection:
Conditions: Ageusia, Hypogeusia, Dysgeusia (parageusia)
Causes: Nerve damage, neurological disorders, infections, poor oral hygiene, adverse drug effects, deficiencies, aging, tobacco use, altered neurotransmitter levels
Neurotransmitters and Taste Threshold:
Effects of serotonin (5-HT) and norepinephrine (NE) on taste sensitivity
Supertasters:
25% of the population with heightened sensitivity to taste, especially bitterness
Increased number of fungiform papillae
Ozempic: Preoperative Management of Patients on GLP-1 Receptor Agonists Saeid Safari
Preoperative Management of Patients on GLP-1 Receptor Agonists like Ozempic and Semiglutide
ASA GUIDELINE
NYSORA Guideline
2 Case Reports of Gastric Ultrasound
- Video recording of this lecture in English language: https://youtu.be/kqbnxVAZs-0
- Video recording of this lecture in Arabic language: https://youtu.be/SINlygW1Mpc
- Link to download the book free: https://nephrotube.blogspot.com/p/nephrotube-nephrology-books.html
- Link to NephroTube website: www.NephroTube.com
- Link to NephroTube social media accounts: https://nephrotube.blogspot.com/p/join-nephrotube-on-social-media.html
Rasamanikya is a excellent preparation in the field of Rasashastra, it is used in various Kushtha Roga, Shwasa, Vicharchika, Bhagandara, Vatarakta, and Phiranga Roga. In this article Preparation& Comparative analytical profile for both Formulationon i.e Rasamanikya prepared by Kushmanda swarasa & Churnodhaka Shodita Haratala. The study aims to provide insights into the comparative efficacy and analytical aspects of these formulations for enhanced therapeutic outcomes.
Title: Sense of Smell
Presenter: Dr. Faiza, Assistant Professor of Physiology
Qualifications:
MBBS (Best Graduate, AIMC Lahore)
FCPS Physiology
ICMT, CHPE, DHPE (STMU)
MPH (GC University, Faisalabad)
MBA (Virtual University of Pakistan)
Learning Objectives:
Describe the primary categories of smells and the concept of odor blindness.
Explain the structure and location of the olfactory membrane and mucosa, including the types and roles of cells involved in olfaction.
Describe the pathway and mechanisms of olfactory signal transmission from the olfactory receptors to the brain.
Illustrate the biochemical cascade triggered by odorant binding to olfactory receptors, including the role of G-proteins and second messengers in generating an action potential.
Identify different types of olfactory disorders such as anosmia, hyposmia, hyperosmia, and dysosmia, including their potential causes.
Key Topics:
Olfactory Genes:
3% of the human genome accounts for olfactory genes.
400 genes for odorant receptors.
Olfactory Membrane:
Located in the superior part of the nasal cavity.
Medially: Folds downward along the superior septum.
Laterally: Folds over the superior turbinate and upper surface of the middle turbinate.
Total surface area: 5-10 square centimeters.
Olfactory Mucosa:
Olfactory Cells: Bipolar nerve cells derived from the CNS (100 million), with 4-25 olfactory cilia per cell.
Sustentacular Cells: Produce mucus and maintain ionic and molecular environment.
Basal Cells: Replace worn-out olfactory cells with an average lifespan of 1-2 months.
Bowman’s Gland: Secretes mucus.
Stimulation of Olfactory Cells:
Odorant dissolves in mucus and attaches to receptors on olfactory cilia.
Involves a cascade effect through G-proteins and second messengers, leading to depolarization and action potential generation in the olfactory nerve.
Quality of a Good Odorant:
Small (3-20 Carbon atoms), volatile, water-soluble, and lipid-soluble.
Facilitated by odorant-binding proteins in mucus.
Membrane Potential and Action Potential:
Resting membrane potential: -55mV.
Action potential frequency in the olfactory nerve increases with odorant strength.
Adaptation Towards the Sense of Smell:
Rapid adaptation within the first second, with further slow adaptation.
Psychological adaptation greater than receptor adaptation, involving feedback inhibition from the central nervous system.
Primary Sensations of Smell:
Camphoraceous, Musky, Floral, Pepperminty, Ethereal, Pungent, Putrid.
Odor Detection Threshold:
Examples: Hydrogen sulfide (0.0005 ppm), Methyl-mercaptan (0.002 ppm).
Some toxic substances are odorless at lethal concentrations.
Characteristics of Smell:
Odor blindness for single substances due to lack of appropriate receptor protein.
Behavioral and emotional influences of smell.
Transmission of Olfactory Signals:
From olfactory cells to glomeruli in the olfactory bulb, involving lateral inhibition.
Primitive, less old, and new olfactory systems with different path
Best Ayurvedic medicine for Gas and IndigestionSwastikAyurveda
Here is the updated list of Top Best Ayurvedic medicine for Gas and Indigestion and those are Gas-O-Go Syp for Dyspepsia | Lavizyme Syrup for Acidity | Yumzyme Hepatoprotective Capsules etc
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Integrating Ayurveda into Parkinson’s Management: A Holistic ApproachAyurveda ForAll
Explore the benefits of combining Ayurveda with conventional Parkinson's treatments. Learn how a holistic approach can manage symptoms, enhance well-being, and balance body energies. Discover the steps to safely integrate Ayurvedic practices into your Parkinson’s care plan, including expert guidance on diet, herbal remedies, and lifestyle modifications.
Muktapishti is a traditional Ayurvedic preparation made from Shoditha Mukta (Purified Pearl), is believed to help regulate thyroid function and reduce symptoms of hyperthyroidism due to its cooling and balancing properties. Clinical evidence on its efficacy remains limited, necessitating further research to validate its therapeutic benefits.
Nick Goodwin: making a success of care co-ordination
1. 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
2. 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.
3. 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
5. 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
6. Ageing societies is a major factor
By 2034, >85s will represent c.5% of the population in Western Europe.
7. 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
8.
9. 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.
11. 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
12. 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
13. 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
14. 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
15. 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
16. 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
17. Key lessons (under review):
Integration necessary at every level
• System
• Organisation
• Functional
• Professional
• Service
• Personal
18. 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
19. 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
20. Contact
Dr Nick Goodwin
CEO, International Foundation for Integrated Care
nickgoodwin@integratedcarefoundation.org
www.integratedcarefoundation.org
Editor's Notes
1:11
3:30
5:44
6:08
8:40
9:34
10:22
12:32
13:04
13:24
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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.