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.

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

4. The challenge:
Dealing with the complexity

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

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.

10. Meeting the challenge

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