This King’s Fund report summarises the findings from a 2-year research project (funded by Aetna and the Aetna Foundation) which involved looking at five UK-based programmes delivering coordinated care for people with long-term and complex needs.
The aim has been to draw generalisable conclusions about the essential and / or important components of effective strategies for delivering integrated care for such clients. This report proposes how the essential principles for effective care coordination might be transferred from the UK context to the US and more widely internationally.
Enablers and Facilitators
Certain design features appear to promote successful care coordination:
- A holistic focus which supports patients and carers.
- Building community awareness and trust.
- Effective communication, and multi-disciplinary teamworking.
- Localised care co-ordination programmes which address the priorities of specific communities.
- Leadership and commitment (from commissioners and providers) which promote shared vision and challenge silo-based working.
- Integrated commissioning, across health and social care, which actively supports the overall strategy.
“Facilitating factors included: a political narrative that supports a shift to person-centred care; local leadership and commitment; a clearly defined, shared vision of what better patient care looks like; being able to react flexibly to patients’ changing needs; and investment in supporting carers and ‘low-level’ community support services”.
Challenges and Barriers
Common challenges and barriers to integration include: funding issues; lack of GP engagement; inability to see innovation as “core business”; poorly integrated IT systems; and problems caring for people in remote / rural locations.
Goodwin, N. Sonola, L. Thiel, V. [and] Kodner, D.L. (2013). Co-ordinated care for people with complex chronic conditions: key lessons and markers for success. London: The King’s Fund / Aetna and the Aetna Foundation, October 2013.