How can care be best co-ordinated around the needs of people with complex chronic ill-health:
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How can care be best co-ordinated around the needs of people with complex chronic ill-health: reflections on Belgian’s strategic plans. Dr Nick Goodwin Co-Founder and CEO , International Foundation for Integrated Care Paper to;

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How can care be best co-ordinated around the needs of people with complex chronic ill-health: reflections on Belgian’s strategic plans

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How can care be best co-ordinated around the needs of people with complex chronic ill-health: reflections on Belgian’s strategic plans

Dr Nick Goodwin

Co-Founder and CEO, International Foundation for Integrated Care

Paper to;

RIZIV 50th Anniversary Event, Academy Palace, Brussels, 2nd April

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 -

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

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

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

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


    • 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“

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

Multiple strategies to be collectively applied

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

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

Some Reflections for Belgium – 6 Action Areas

Action: Multidisciplinary EHR

  • Yes, but ICT is a tool, not an end in itself. Give people access.

    Action: Case management

  • Yes, but learn the lessons from past successes and failure for success

    Action: Multi-disciplinary teams

  • Yes, including pro-active care co-ordination and involvement of the community

    Action: Education and training

  • Yes, inter-professional working and new roles and skill mix

    Action: Quality and assessment of care

  • Make sure that the process focuses on continuous quality improvement not performance management. Quality-based pay and incentives

    Action: Implementing, supporting, assessing

  • Yes, evaluation of outcomes to build evidence and support QI is important

  • The focus on supporting the change process is welcome


  • It is undoubtedly right to go beyond the CCM for complex patients who require a more flexible response

  • It is right to avoid organisational restructuring – simplification is key

  • Need to build narratives to create a burning platform for change

  • Focus on building common vision and strategy from bottom-up and ensure roles and responsibilities clear

  • Utilise resources differently, not shift money or threaten organisations and professionals

  • Specific measurable objectives to support Triple Aim objectives

  • Promote active care co-ordination

  • More on empowering users/community

  • Focus on holistic care in the home environment

  • Think inter-sectoral action and be prepared to challenge medical model (e.g. GPs and hospital sector)


Dr Nick Goodwin

CEO, International Foundation for Integrated Care

[email protected]

@goodwin_nick @IFICinfo

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