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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

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 Challenge of Complexity with complex chronic ill-health:

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 Change with complex chronic ill-health: Think 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
Managing Complex Patients – What Works? with complex chronic ill-health:

  • 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 works1
Managing Complex Patients – What Works? with complex chronic ill-health:

  • 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 works2
Managing Complex Patients – What Works? with complex chronic ill-health:

  • 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
Meeting the Challenge at a, 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
Multiple strategies to be collectively applied

Meeting the challenge at a systems and organisational level
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
Meeting the Challenge of Complexity: 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
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