What is integrated care? (0)

An overview of integrated care in the NHS
What is integrated care? Research report Sara Shaw , Rebecca Rosen and Benedict Rumbold
June 2011 Nuffield Trust work on integrated care This report is part of the Nuffield Trust's extensive programme of work on integrated care, which is examining the potential of new forms of care that are intended to benefit patients and taxpayers. Other related projects include : ·Integration in action : four international case studies . A study of four international organisations that have attempted to improve integration between health and care services . Interviews, documentary analysis and literature review are used to identify the main stimuli for integration and the issues that help or hinder progress; drawing out lessons for the NHS. ·Towards integrated care in Trafford. A project that looks at the process of change and lessons learned to date in Trafford, where NHS organisations have been working on the development of an integrated care system across the whole health economy .
Further details of our integrated care work can be found at: www.nuffieldtrust.org.uk/integratedcare
Acknowledgements Our thanks go to Richard Gleave, Diane Gray, George Kissen, Dennis Kodner, Judith Smith and Sarah Smyth for their comments, all of which have helped to shape both the structure and content of this report. 3 What is integrated care?
`Integrated care' is a term that reflects a concern to improve patient experience and achieve greater efficiency and value from health delivery systems. The aim is to address fragmentation in patient services, and enable better coordinated and more continuous care, frequently for an ageing population which has increasing incidence of chronic disease . The search for ways to integrate care more effectively is a pressing policy concern. But what do we actually mean by `integrated care'? This research report examines what is meant by `integrated care'. It explores integrated care from an NHS perspective, identifies the concepts that underpin integrated care, suggests how these can be used to inform practical integration efforts both within and beyond the NHS, and sets out how integration might be measured.
Key points ·Under current Government proposals , new GP commissioning consortia will take over responsibility for £60 billion of the NHS budget . International experience suggests that the integration of primary and secondary care is vital to the delivery of efficient and effective care. ·Current reforms emphasise the need to integrate care more effectively. This emphasis reflects the long-standing concern in the NHS with how to address the division of care ­ across primary and secondary care in particular . ·Integrated care is an organising principle for care delivery that aims to improve patient care and experience through improved coordination. Integration is the combined set of methods, processes and models that seek to bring this about. ·Achieving integrated care requires that those involved with planning , financing and providing services have a shared vision , employ a combination of processes and mechanisms, and ensure that the patient's perspective remains a central organising principle throughout . · There is an urgent need for more robust and high- quality evidence to inform decisions about how to develop integrated care. There is no single model of integrated care that is suited to all contexts, settings and circumstances. Researchers and policy- makers need to work together with practitioners to develop, evaluate and implement effective approaches.
Find out more online at: www.nuffieldtrust.org.uk/integratedcare 4 What is integrated care?
An overview of integration in the NHS The current focus on integrated care reflects a long-standing concern in the NHS with the organisation of care across three sectors of the health service (primary, secondary and tertiary). This can be thought of as ` internal ' integration and is the main focus of this report. Furthermore , the organisational separation of health and adult social care services (with the exception of Northern Ireland ) has been a further cause of service fragmentation for many users ; representing a concern for ` external ' integration. Concern about fragmentation typically focuses on a lack of service coordination for individual patients and, particularly , the structural and cultural isolation of generalist from specialist medicine , or adult social care from health care, which often results in patients experiencing discontinuity of care when they are transferred from home to hospital , or vice versa.
Table 1: Trends in integration initiatives
1980s 1990s 2000s · coordinated working · inter - agency working · inter-professional working · shared planning · intermediate care · whole systems working · coordinated care · shared protocols · integrated delivery · care programmes · managed care networks · case/care management · disease management · patient-centred care · shared decision - making · integrated care pathways
The desire for better integration of care has been expressed in different ways. For example, multidisciplinary care was a particular concern in the 1960s ; partnership working in the 1970s; and shared care and disease management in the 1980s and 1990s (see Table 1). What we now refer to as `integrated care' is an umbrella term, encompassing diverse initiatives that seek to address fragmentation, but that differ in underlying scope and values ( Stein and Reider, 2009). From 1997 to 2010, the Labour Government emphasised a need for greater integration as part of the drive for improved quality, efficiency and patient outcomes. Initiatives such as `integrated care pathways', `patient-centred care' and `shared decision-making' are examples of attempts to align clinical , managerial and service user interests, and to improve coordination of care for patients, in particular those with long-term conditions . New forms of health care organisation such as care trusts (Glasby and Peck , 2005), managed clinical networks ( Woods , 2001), accountable care organisations in the US (Rittenhouse and others , 2009) and local clinical partnerships (Smith and others, 2009) are all examples of different attempts to reshape the way in which combinations of primary, secondary, community and adult social care services are organised and delivered . 5 What is integrated care?
Case study
Integrated mental health services in Milton Keynes Milton Keynes is a new town with a strong history of partnership working and a community identity that is characterised by wanting to ensure the best for residents. Combined with support from local politicians, this has provided a strong foundation for joint working. In 2001 the primary care trust (PCT) and local council in Milton Keynes launched their first integrated service for mental health. Since this time, joint services have developed across mental health, learning disability and intermediate care; employing some 500 staff , ranging from consultant psychiatrists to social workers , nurses and equipment services.
Health and social care agencies in Milton Keynes have developed a structured approach to integrated care, maintaining their own organisational structures and systems and, where appropriate, pooling resources. The emphasis has been on joint administrative systems. Those involved have described themselves as `dancing partners ', working within and across existing organisations in order to better coordinate different services, share information and manage the transition of patients through elements of their care. For an area such as intermediate care, this has meant starting with the concept of rapid access , developing coordinated teams comprising nurses and social workers, and then, together, addressing problems of delayed discharge.
Across the local care economy, the focus on coordinating services is now seen as a mutual responsibility driven by a common belief that, together, health and social care agencies and professionals can make the best use of limited funding, promote wellbeing and address health inequalities. However , the policy drive for organisational integration of community services means that Milton Keynes may be required to more closely integrate with hospitals and/or general practices ; health services that have not previously been involved in integrated care within Milton Keynes. 6 What is integrated care?
There is some emerging evidence of the benefits of integration within the NHS, for example in improving access to care, managing demand and reducing delayed transfers (Ham and de Silva , 2009). However, empirical research on the impact of integrated health systems in respect of clinical outcomes and value for money remains scarce (Armitage and others, 2009), with integration that is largely focused on bringing organisations together unlikely to bring about improvements in care for patients (Alakeson, forthcoming). Although there is some limited evidence that service integration improves clinical outcomes, the impact on costs is more mixed (Ham and de Silva, 2009; Ovretveit and others, 2010). Current policy provides opportunities to extend integrated care, working towards an NHS that is `less insular and fragmented' and facilitating working across health and social care boundaries, as well as between hospitals and practices ( Department of Health, 2010). Some integrated care initiatives tend to focus on integration which brings together various providers of health care within the NHS. For example, the introduction of National Service Frameworks (NSFs) in order to try and bring about more consistency and coordination of care for specific conditions, and across different sectors. Other initiatives tend to be concerned with integration between health and other services. Recent examples in the NHS in England have included merging regulators to facilitate joint inspection of health and social care providers; extending incentive payments to providers to encourage and reward joint working; and developing integrated mental health services across health and social care (see case study on page 5). To date, discussions about improving service integration have typically focused on breaking down barriers across service providers. Integration can also involve coordination across commissioners and providers ( Lewis and others, 2010). Current policy has rejected this approach (Department of Health, 2010), however, the development of GP commissioning consortia provides an opportunity to develop new forms of care and encourage increased integration via the involvement of secondary care clinicians alongside primary care teams (Ham and Smith, 2010). 7 What is integrated care?
What do we mean by integration and integrated care? A recent review of the literature on integrated care revealed some 175 definitions and concepts (Armitage and others, 2009). Such diversity reflects what one commentator refers to as `the imprecise hodgepodge of integrated care' (Kodner, 2009). When considering integrated care, it is important at the outset to distinguish between integration and integrated care (see Table 2). Integrated care is an organising principle for care delivery with the aim of achieving improved patient care through better coordination of services provided. Integration is the combined set of methods, processes and models that seek to bring about this improved coordination of care. Accordingly, where the result of efforts to improve integration is beneficial for patient groups, so the outcome can be called integrated care (Kodner and Spreeuwenberg, 2002).
Table 2: Perspectives on integration and integrated care What is integrated care? What is integration? Description Description The patient's perspective is at the heart of any discussion It is the processes, methods and tools of integration that about integrated care. Achieving integrated care requires facilitate integrated care. Integration involves connecting those involved with planning and providing services the health care system (acute, community and primary to `impose the patient perspective as the organising medical ) with other service systems (such as long-term care, principle of service delivery' (Lloyd and Wait , 2005: p7). education or housing services) (Leutz, 1999: p77­78).
Example Example Take the example of Torbay, an area with a high In Torbay, the concern to deliver better and more proportion of over-65s. Discussions driving integrated coordinated outcomes for patients led to the establishment care have been characterised by "Mrs Smith", a fictitious of a care trust in 2005. The development of five integrated 85- year -old with a range of care needs and requiring health and social care teams aligned to general practice, coordinated support across health and social care. single assessment processes, and shared health and Mrs Smith has come to represent vulnerable local social care electronic records are processes that have residents at risk of falling between gaps in the service. facilitated integration. The focus is on improving clinical, By focusing on Mrs Smith, care has been reorganised satisfaction and efficiency outcomes (Leutz, 1999). ­ and better integrated ­ around needs such as hers. The result of integration includes a reduction in delayed