Integrated Care – Understanding Messages from Research

1. Integrated Care –Understanding Messages from Research Peter Thistlethwaite Associate, ICN and RiPfA Peter@integratedcare.org.uk 07813 890416

2. Introduction

3. Content • Summary of important findings – yes, briefly • But more importantly, how to think your way around this topic

4. Defining integration Integrated care is a “discrete set of techniques and organisational models designed to create connectivity, alignment, and collaboration between the cure and care sectors at the funding, administrative and/or provider levels” Kodner & Spreeuwenberg, 2002

5. Defining integration “In its most complete form, integration refers to a single system of needs assessment, service commissioning and/or service provision...A single system for a particular service would unite, for example, mission, culture, management, budgets, office accommodation, administration and records, and would apply at any level of integration (team, service or organisation) ICN, A practical guide to integrated working, 2007

6. Defining integration “Integration is a means to improve services in relation to access, quality, user satisfaction and efficiency...It is a means to an end, not an end in itself” WHO, 2000 [identified vertical and horizontal integration, and continuity of care as elements]

7. Are these the ends? • Easier to access help • Faster responses • Simpler to get decisions (& no buck-passing) • Better informed decisions • Fewer errors • Increased potential for flexible, innovative, tailored, safer care at home, with more scope for user control

8. Evidence

9. Evidence of obstacles The early literature in the UK exposed problems of implementation and practice, and which kept coming up, eg • Organisational...uncertain objectives and accountabilities; poor leadership, communication, IT support and training; resource difficulties, etc • Cultural and professional...language, tribalism, protectionism • Contextual...political differences; no mobitoring/evaluation Cameron et al (2000) Factors promoting and obstacles hindering joint working: a systematic review

10. Evidence of obstacles But this is helpful.... If you know the likely obstacles, you can anticipate, spot and plan to overcome them

11. Limitations of evidence base? “The evidence base is limited in the sense that, while there is a fair amount of evidence on the processes of integration that are important to understand, there is much less on outcomes...There is also little large scale evaluation, and a tendency to evaluate what have been called ‘boutique’ pilots from which it is difficult to generalise the findings” Ramsay, Fulop & Edwards The evidence base for vertical integration in health care Journal of Integrated Care, April 2009 (See also Dowling et al, 2004 Conceptualising successful partnerships)

12. Difficulties for researchers How easy to conduct a randomised controlled trial? Subjects: localities or individuals Throw of dice Integrated service Standard service Measures

13. Strong international evidence Summary of 3 well constructed studies of different models of integration, although all had limitations: SIPA, PACE, PRISMA • Positive on service access and use, costs, quality, health status, and user/carer satisfaction • Key factors: umbrella organisational approaches, m/d case management, organised provider networks, financial incentives Kodner (2006) Whole system approaches to health and social care partnerships for the frail elderly: an exploration of North American models and lessons

14. Some good UK studies • Unique Care – 2 studies of impact of social worker/DN within GP surgeries – reduced hospital admissions and length of stay, no increase in NH use [Lyon et al, 2004, The Castlefields Integrated Care model; Keating et al, 2006, Reducing unplanned hospital admissions and hospital bed days in the over-65 age group: results from a pilot study. Journal of integrated Care] • PSSRU, Manchester – 2 reports of impact of specialist geriatric input to assessments (RCT) – fewer immediate RH admissions, wider range of factors in assessments [Challis et al, 2004, Age & Ageing; Clarkson et al, 2006, Psychological Medicine]

15. Some good UK studies – Sedgefield Integrated Team Pre-SIT • Low inter-professional awareness • Slow & disjointed responses • Tight role boundaries/ rigid responses • Low-trust relationships, separate problem solving [Hudson, B. Integrated team working: you can get it if you really want it. JIC, Feb & April 2006 Post –SIT • High degree of mutual awareness • Speedy and joint responses • Flexible/responsive responses • High trust, collective problem solving

16. 2 Final Thoughts

17. Does the personalisation policyconflict with integration? Some say this, but.... • Integrated regulator just created • Integration “puts people first” • Now personal health budgets • “World class commissioning” requires PCT collaboration with community partners • The Social Care Reform Grant requires whole system working, eg to “join up services to provide easy-to-recognise access points, which coordinate or facilitate partner organisations to meet the needs of individuals”

18. Conclusions • Any decision about integration will be influenced by a range of factors, of which research evidence is only one. Evidence of what helped “early adopters” is being brought together [Nuffield Trust; ICN] • The first major UK study since 2002 is just starting – the DH’s ICO programme. • Don’t ignore the cumulative evidence from smaller studies – this is validating the “common sense” in policy • Collect your own evidence, and share it!