Integrated Care

A recent BMJ paper [1] from Stephen Shortell and collaborators from the King’s Fund discusses the design of models of care to improve integration between hospital and community, and between health and social care – an old chestnut. They have a taxonomy of integrated care models that I represent like this:

DC - Integrated care Fig1

Model 1 seems to locate responsibility for integration mostly with community providers, while model 2a evokes a structural solution in which hospital and community providers work in an organisation straddling hospital and community. The article comes down in favour of model 2b and gives successful examples from America (where quality has improved at reduced cost).[2][3][4][5] The article emphasises the importance of integrated computer care records, almost saying this is a necessary ingredient.

On this latter point, the CLAHRC WM Director begs to differ – as argued in a previous post, a patient-held paper record has considerable advantages over ‘all singing and all dancing’ IT systems. He does agree, however, with the idea of an integrated record (not necessarily computer-based), the authors’ emphasis on ‘clinical integration’, and the need to win the hearts and minds of service providers.[6] CLAHRC WM is involved with two grant applications to help develop the tacit skills needed to care for patients with multiple morbidities, and different needs and preferences, across multiple types of care provider in different locations.

— Richard Lilford, CLAHRC WM Director

References:

  1. Shortell SM, Addicott R, Walsh N, Ham C. The NHS five year forward view: lessons from the United States in developing new care models. BMJ. 2015; 350: h2005.
  2. Centers for Medicare and Medicaid Services. Factsheet: Medicare ACOs continue to succeed in improving care, lowering cost growth. 2014.
  3. McWilliams JM, Chernew ME, Landon BE, Schwartz AL. Performance differences in year 1 of pioneer accountable care organizations. N Engl J Med. 2015. [ePub].
  4. Song Z, Rose S, Safran DG, Landon BE, Day MP, Chernew ME. Changes in healthcare spending and quality four years into global payment. N Engl J Med. 2014; 37: 1704-32.
  5. Markovich P. A global budget pilot project among provider partners and Blue Shield of California led to savings in first two years. Health Aff. 2012; 31: 1969-76.
  6. Curry N, Ham C. Clinical and service integration. The route to improved outcomes. London: King’s Fund, 2010.
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2 thoughts on “Integrated Care”

  1. In countries with insurance based systems, patient-held paper medical records are almost universal. And the need for such paper records will, in time, eventually be recognised throughout the UK as also being the best option to facilitate genuinely inter-operative care.

    But we do not yet seem ready to accept this simple fact.

    The Wisdam initiative has therefore moved it’s primary focus away from printing and marketing it’s comprehensive paper record, towards encouraging every person in Britain, especially the elderly housebound, to complete (or have completed on their behalf) their own “It’s Simple WISDAM” document. This encourages each of us to document, in a standard format, the kind of health and social care information which every one of us should probably already know.

    This approach has a host of advantages among which

    a) “It’s Simple WISDAM” is freely downloadable, in it’s latest version, at http://www.wisdam.info

    b) Under the ‘creative commons’ arrangement the dataset cannot be altered but can, unlike a copyright document, be downloaded and used by anyone cost free without any need for specific permission.

    c) By starting with the public ‘bottom up’ it avoids the problems with trying to get ‘top-down’ agreements from scores of conflicting government departments and competing commercial organisations

    d) Enabling people to have access to their electronic record is a valuable concept but is not likely to be helpful to the vast majority of the elderly infirm. “It’s Simple WISDAM“ has the great advantage that it is written in lay language; with nothing that most people don’t already know about themselves.

    e) It cost nothing to the tax-payer

    f) In time, if each PHC system can print out for their patients, the same information in the same order, then each person, starting with the oldest, could let the PHCs know what information is wrong and what is missing, not only improving individual medical care but also providing a unique opportunity to improve the quality of “Big Data”

    g) Each page is designed to be printed as a QR code, printable by any printer and readable as a CSV file by any computer, tablet or smart phone, thus providing a mechanism to ensure that essential Wisdam dataset can, in future, be uploaded into scores of currently incompatible computer systems.

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