Improving Outcomes for Users and Carers through Integrated Care: The Role of Housing

1. Improving Outcomes for Users and Carers through Integrated Care: The Role of Housing Nick Goodwin & Caroline Hawkings Housing LIN, Extra Care Housing Annual Conference Park Plaza Riverbank, 8th December 2011

2. What do we mean by ‘integrated care’?

3. A new idea? The idea is not new – concern about lack of integrated care dates back to before the start of the NHS This concern has been about fractures in systems and delivery that allow individuals to ‘fall through the gaps’ in care – e.g. primary/secondary care, health/social care, mental/physical health care Approaches that seek to address fragmentation of care are common across many health systems, and the need to do so is increasing as more people live longer and with complex co-morbidities

4. Integrated care is centred around the needs of users Integrated care means different things to different people ‘The patient’s perspective is at the heart of any discussion about integrated care. Achieving integrated care requires those involved with planning and providing services to ‘impose the patient’s perspective as the organising principle of service delivery’ (Shaw et al, 2011, after Lloyd and Wait, 2005)

5. Integration and Integrated Care Integrationis the combination of processes, methods and tools that facilitate integrated care. Integrated careresults when the culmination of these processes directly benefits communities, patients or service users – it is by definition ‘patient-centred’ and ‘population-oriented’ Integrated care may be judged successful if it contributes to better care experiences; improved care outcomes; delivered more cost-effectively ‘Without integration at various levels [of health systems], all aspects of health care performance can suffer. Patients get lost, needed services fail to be delivered, or are delayed, quality and patient satisfaction decline, and the potential for cost-effectiveness diminishes.’ (Kodner and Spreeuwenburg, 2002, p2)

6. Types of Integration

7. Many approaches to integration Integration can be undertaken between organisations, or between different clinical or service departments within and between organisations Integration may can focus on joining up primary, community and hospital services (‘vertical’ integration) or involve multi-disciplinary team-work between health and social care professionals (‘horizontal’ integration) Integration may be ‘real’ (i.e. into a single new organisation) or ‘virtual’ (i.e. a network of separate providers, often linked contractually). Integration may involve providers collaborating, but it may also entail integration between commissioners, as when budgets are pooled. Integration can also bring together responsibility for commissioning and provision. When this happens, clinicians and managers are able to use budgets either to provide more services directly or to commission these services from others: so-called ‘make or buy’ decisions. (Curry and Ham, 2010)

8. 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.

9. What problems does integrated care seek to address?

10. Who is integrated care for? • 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.

11. 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.

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

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

14. Why is integrated care such a challenge?

15. Integrated care does not evolve naturally – it needs to be nurtured • Integrated care does not appear to evolve as a natural response to emerging care needs in any system of care whether this be planned or market-driven. • There is no evidence, therefore, that clinical and service integration in England is any more or any less likely to succeed than in countries without a purchaser-provider split such as Scotland or New Zealand • Achieving the benefits of integrated care requires strong system leadership, professional commitment, and good management • Systemic barriers to integrated care must be addressed if integrated care is to become a reality. (Ham et al, 2011)

16. Key organisational and management barriers • Bringing together primary medical services and community health providers around the needs of individual patients • Addressing an unsustainable acute sector • Developing capacity in primary care to take on new services • Managing demand and developing new care models • Establishing effective clinical leadership for change • Overcoming professional tribalism and turf wars • Addressing the lack of good data and IT to drive integration, e.g. in targeting the right people to receive it • Involving the public and creating a narrative about new models of care • Establishing new forms of organisation and governance (where these are needed) • Learning from elsewhere in the UK and overseas (Ham and Smith, 2010; Goodwin 2011)

17. Key challenges for health and social care integration • Scale and pace of change could undermine local achievements in integrated care • Clinical commissioners commitment to integrated care • Strength of health and wellbeing boards to promote integration and exert influence/leadership • Whether financial pressures will promote the shared planning and use of resources • Whether three separate outcomes frameworks (right) will offer sufficient incentives for aligning services around the needs of people rather than organisations (Humphries and Curry, 2011)

18. Key policy barriers • Payment policy that encourages acute providers to expand activity within hospitals (rather than across the care continuum) • Payment policy that is about episodes of care in a particular institution (rather than payment to incentivise integration, such as payments for care pathways and other forms of payment bundling) • Under-developed commissioning that often lacks real clinical engagement and leadership • Policy on choice and competition • Regulation that focuses on episodic or single-organisational care • Lack of political will to support changes to local care, including conversion or closure of hospitals (Ham and Smith 2010; Ham et al 2011)

19. The Role of Housing