Co-ordinated care for people with complex chronic conditions: Key lessons and markers for success

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People with multiple health and social care needs often receive a very fragmented service, resulting in less than optimal care experiences, outcomes and costs.  This report presents the findings from a two-year research project  to understand the key components of effective strategies employed by studying five UK-based programmes to deliver co-ordinated care for people with long-term and complex needs.

The project found that certain design features appear more likely to deliver successful care co-ordination:

  • At a personal level, a holistic focus that supports service users and carers to become more functional, independent and resilient, and to live well by managing their conditions in the home environment, is preferable to a purely clinical focus on managing or treating medical symptoms.
  • At a clinical and service level, it is important to encourage multiple referrals into a single entry point where care co-ordination can be supported. Named care co-ordinators are needed to support the process of care co-ordination by providing a source of personal continuity to patients and carers as well as enabling access to care through multidisciplinary teams.
  • At a community level, the role of members of the local community should be seen as integral to the care-giving process. Building community awareness and trust promoteslegitimacy and engagement, which can provide an essential resource within care co-ordination programmes.
  • At a functional level, effective communication between members of the multidisciplinary team is essential. There is a need for shared electronic health records to support the process, but a ‘high-touch, low-tech’ approach has value in promoting face-to-face communication, fostering collaboration and enabling meaningful conversations about the needs of patients with complex needs.
  • At an organisational level, effective targeting of service users is required to prioritise care provision. Programmes of care co-ordination need to be localised so that they concentrate on specific communities and neighbourhoods. Local leadership and long-term commitment from commissioners and providers is important to establish ashared vision and to challenge silo-based thinking.
  • At a system level, integrated health and social care commissioning can support longer-term strategies and provide a greater degree of stability. A political narrative that supports person-centred care co-ordination provides credibility when developing new ways of working.

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