Care co-ordination and continuity of care for people with complex needs: Emerging lessons from models in the UK

1. Care co-ordination and continuity of care for people with complex needs: Emerging lessons from models in the UK Lara Sonola, Researcher, The King’s Fund Veronika Thiel, Researcher, The King’s Fund Funding for this project was provided by Aetna and the Aetna Foundation

2. The problem Why are we doing work in this area? • Age-related chronic conditions absorb the largest, and growing, share of health care budgets. • Poor co-ordination of care for people with long-term/complex illnesses leads to poor care experiences and adverse outcomes • Strategies of care co-ordination to create more integrated, cost effective and patient-centredservices are growing internationally • However, there is a lack of knowledge about how best to apply care co-ordination in practice.

3. Project aims • Understand the key components of strategies used to deliver effective care co-ordination • Examine key barriers and facilitators • Develop practical and generalisable lessons for the application of the tools of care co-ordination • Identify how care co-ordination can best be supported • To promote and disseminate the lessons from the research to support the effective adoption of care coordination in both the UK and US contexts

4. Our approach • Five in-depth case studies in the UK of care co-ordination delivered in primary care settings to people with chronic and medically complex illnesses. • We will examine how: • Care co-ordination is organised • Operates in practice at a patient level • Main focus on the service delivery model • Methods • Face-to-face interviews, documentary and observational analysis, focus groups and an online survey • Learning and development programme for the sites • Supported by an international Expert Panel

5. Demonstrator sites • Five sites were chosen through a competitive process based on their ability to demonstrate positive impacts in one or more of the following: • improved patient experience; • better health outcomes; • more cost-effective care. • The sites are: • Midhurst MacMillan Specialist Palliative Care Service (Guildford, Surrey) • Greenwich & Bexley Advanced Dementia Services - Care@Home (London and Kent) • Sandwell Integrated Primary Care Mental Health & Wellbeing Service (Birmingham) • South Devon and Torbay - Pro-Active Case Management for at-risk patients • Pembrokeshire - Community Care Closer to Home (Pembrokeshire, Wales)

6. Findings…so far Key Lessons • Flexible, reactive patient and carer-centered services • No defined care package; ad hoc contact when required by patient/family • Named care co-ordinators • Responsibility for organising care, making appropriate referrals • Provides support and confidence – “envelope of care”. • Multi-professional team • Flat structure; autonomous team members • Frequent communication; information sharing/joint visits with colleagues/other providers

8. Findings…so far Key Lessons • Single point of entry • Ease of referral; ease of access for patients • Dedication of staff • Self-selecting staff – attracts “like-minded” people • Not restricted by working hours/job description • GP and social care involvement • Key factor; Varies; level of involvement based on relationships not systems • Voluntary sector • Vital component; fills the gaps that NHS services cannot provide

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10. Outcomes The good news • Qualitative evidence indicates increase in patient and carer satisfaction at all sites • Quantitative evidence from Greenwich indicates savings to NHS and Local Authorities • Findings from Midhurst external evaluation also promising, but not yet in the public realm • Preliminary viewing of evidence for Sandwell shows promising figures

11. Outcomes The not so good news • Quantitative evidence lacks robustness – hard to verify or replicate (work in progress...) • Mostly small projects => difficulty in data gathering and analysis • Attribution problems: who’s responsible for improvements?

12. Outcomes – Greenwich • Conservative estimates of cost reduction/avoidance to NHS and local authorities (LA) in 2009: £304,000* • Cost of service per year is £25,000 => Savings ratio of 12:1 *Reservations: some inconsistencies in data, need to be double-checked • The Fine Print: assumptions for cost savings: • Avoidance of £2800 per prevented A&E admission in last year of life • Avoidance of nursing home cost to NHS of £108 per week = £5616 per year • Avoidance of dementia care cost to LA of £200 pw = £10,400 per year • (cost of nursing home £800 per week, 50% funding by LAs=£400; cost of home care =£200pw => savings to LA = £200) • 2009 costs: Estimate of 14 hospital home admissions avoided = £2800*14 = £39,200; 884 weeks of care in dementia home avoided= £200*884 = £176,800; 884 weeks of nursing home cost avoided = £100*884= £88400) • Cost of service: £25,000 for 0.1 consultant, 0.25 nurse => Savings ratio of 12:1

13. Outcomes – Bexley (Caveats: small scale 1 year pilot, 12 patients => limited validity) • Seven patients died during the study period, 2 in hospital, 5 at home; 3 hospital admissions for three patients • Improvement on QUALID scale (quality of life in late stage dementia) for 5 patients, same for 1 patients and 2 deteriorated • Relatives stress scale showed improvement for 5, and stagnation for 3 55

14. Challenges – creation of service

15. Facilitators – Creation of service

16. Sustainability issues

17. Sustainability issues NHS REFORM

18. Timeline & next steps • Fieldwork continues until June 2013, includes a learning and development programme for the sites • Individual case studies and films published on the website from May onwards: www.kingsfund.org.uk/carecoordination • Annual Integrated Care Summit in London at The King’s Fund on the 8th May 2013. Details available at: http://www.kingsfund.org.uk/events/integrated-care-summit-2013 • Dissemination event and publication of final report on 26th September 2013 at The King’s Fund in London

19. Questions? Project page: www.kingsfund.org.uk/carecoordination