Co-ordinating Care to People with Long-Term and Complex Health and Social Care Needs: key lessons and markers for succe

1. Co-ordinating Care to People with Long-Term and Complex Health and Social Care Needs: key lessons and markers for success from international case studies Dr Nick Goodwin CEO, International Foundation for Integrated Care www.integratedcarefoundation.org Paper to; Paper to: Health Quality and Safety Commission New Zealand Workshop: Towards Integrated Care in New Zealand Wellington, New Zealand, November 14th 2013

2. The Challenge of Complexity 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 Frontier Economics (2012) Enablers and barriers to integrated care and implications for Monitor -

3. Meeting the Challenge

4. Care Systems Need to ChangeThink of the hospital as a cost centre, not a revenue centreHospitals 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

5. Managing Complex Patients – What Works? • Active support for self-management • Primary prevention • Secondary prevention • Managing ACS conditions • Integrating care for people with mental and physical health needs • Care co-ordination - integrated health and social care teams • Primary care management of end-of-life care • Effective medicines management • Managing elective admissions – referral quality • Managing emergency admissions – urgent care

6. 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

7. Managing Complex Patients – What Works? • Better coordination of care can save money and improve quality, especially: • Disease management programmes • Case management with multi-disciplinary teams • Where use of good data identifies people at risk of deterioration • Active outreach services and self-management support BUT • Lack of robust evaluation • Financial savings not equally shared between providers (funding problem) • Need for regulation and governance to create conducive environment as co-ordination neglected “Those who suffer most from under-coordination are the poor, vulnerable, old and those from ethnic minorities. The avoidable deterioration of their health results In high costs for public systems“

8. International Case Examples

9. http://www.kingsfund.org.uk/publications/co-ordinated-care-people-complex-chronic-conditionshttp://www.kingsfund.org.uk/publications/co-ordinated-care-people-complex-chronic-conditions

10. 99% of those wishing to die at home do so • High satisfaction amongst family, carers, staff • Significant cost reduction (c.25%) compared to ‘usual’ care in hospices/hospital settings

11. Awareness-raising and relationship-buildingGPs, community staff, hospital consultants, volunteers and local people strengthening its ability to ‘capture’ people nearing the end of life before, or very soon after, a hospital admission.  Holistic care assessment and personalised care planA single assessment process examines both the health and social care needs of the patient and their family. It also takes into account their personal choices about future care and treatment options. Multiple referrals to a single-entry pointThe service accepts referrals from any health professional and also local people. All referrals come into the service and are assigned to a clinical nurse specialist from a single-entry point. Dedicated care co-ordinationThe care co-ordinator has a number of roles: acting as the principal point of contact with the patient and their family; effectively co-ordinating care from within a  multidisciplinary team and liaising with the wider network of care providers. Rapid access to care from a multidisciplinary teamBoth professionals and volunteers can be rapidly deployed by the service to provide care or support to meet the needs of people living at home. The service operates 12 hours a day, with access to an on-call clinician out of hours.

13. Predictive risk modelling and risk stratification Utilising data from primary and secondary care, combined with the knowledge from local care professionals working in the community the programme can accurately identify and target patients ‘at risk’ of hospitalisation and who may benefit from at-home case management Locality working through ‘virtual wards’ Multi-disciplinary teams, anchored around the geographies of local GP practices, support health and social care to people at home. The neighbourhood based teams enable a good working relationship for partnership working and tie activities together through shared care accountabilities Holistic care assessment and personalised care management plan A single assessment of physical, mental , environmental, social and spiritual needs ensures a detailed understanding of the patient and family members as well as their preferences. A personalised care management plan, goals-based, ensures all members of the MDT understand the care that is required Dedicated care co-ordinationThe case manager has accountability for co-ordinating care and supporting the preferences of patients to be met. The role provides continuity of care and a single point of contact, including for out-of-hours care

14. International case studies of integrated care to older people with complex needs: a cross national review • The King’s Fund & University of Toronto funded by the Commonwealth Fund • Seven case studies: • TeWhiringaOra, Eastern Bay of Plenty, New Zealand • Geriant, Noord-Holland Province, The Netherlands • South Devon and Torbay Health and Care Trust, UK • The Norrtalje Model, Stockholm, Sweden • PRISMA, Canada • Health One, Sydney, Australia • Mass. General Hospital, Boston, USA

15. International case studies of integrated care to older people with complex needs: a cross national review

16. Integrated Community Care for People with Dementia at Home in the Netherlands Multi-disciplinary team: Clinical Case Manager Social Geriatrician Clinical Psychologist Specialised Home Psychiatrist Clients and Carers CARE AT HOME TEAM Wider Provider Network Source: Glimmerveen, 2013 - http://www.kingsfund.org.uk/audio-video/ludo-glimmerveen-integrated-care-people-dementia-netherlands

17. Impact Source: Glimmerveen, 2013 - http://www.kingsfund.org.uk/audio-video/ludo-glimmerveen-integrated-care-people-dementia-netherlands

18. Meeting the Challenge:Key Lessons

19. Meeting the Challenge at a Systems and Organisational Level • Find common cause • Develop shared narrative • Create persuasive vision • Establish shared leadership • Understand new ways of working • Targeting • Bottom-up & top-down • Pool resources • Innovate in finance and contracting • Recognise ‘no one model’ • Empower users • Shared information and ICT • Workforce and skill-mix changes • Specific measurable objectives • Be realistic, especially costs • Coherent change management strategy

20. 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- NOT carve-out DMPs or segmentation • Identification of people in need of care – inclusion criteria • Health promotion • Single point of access • Single, holistic, care assessment (including carer & 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, e.g. 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

21. Multiple strategies to be collectively applied

22. Integration Necessary at Every Level Source: Valentijn et al (2013) Understanding integrated care: a comprehensive conceptual framework based on the Integrative functions of primary care, IJIC, vol13. Jan-Mar

23. Meeting the Challenge of Complexity: Key Lessons Personal Level • Holistic focus that supports users and carers to live well and be resilient • Management in the home environment • Co-producers of care, even at end of life Clinical & Service Level • Early and multiple referral points for care co-ordination • Named care co-ordinators • Continuity of care • Multi-disciplinary teams • Flexible working practices – subsidiarity of role Community Level • Role of community integral to care-giving process • Build awareness, legitimacy and trust • Volunteers Functional Level • Effective communication • Shared electronic health records helpful • High-touch / low tech care – need for face-to-face interaction and conversations Organisational Level • Effective targeting • Localised – work in neighbourhoods • Long-term commitment from local clinical and managerial leaders • Shared vision – challenge silos • Operational autonomy System Level • Integrated purchasing • Long-term strategies • Political narrative • Aligned incentives • Focus on improving quality, not reducing cost

24. Meeting the Challenge of Complexity: Key Issues Sonola L & Thiel V (2013) - http://www.kingsfund.org.uk/sites/files/kf/sonola-thiel-care-coordination-oct13.pdf

25. Contact Dr Nick Goodwin CEO, International Foundation for Integrated Care nickgoodwin@integratedcarefoundation.org www.integratedcarefoundation.org @goodwin_nick @IFICinfo