There are many descriptions of integrated care. I particularly relate to one framed by National Voices: ‘’My care is planned with people who work together to understand me and my carer(s), put me in control, coordinate and deliver services to achieve my best outcomes.” It speaks of a collaborative approach to achieve what really matters to the individual and their carer(s) and places coordination of care and support at the heart of integrated care. For without effective coordination, even the most holistic care plan still leads to fragmented care, duplication, waste and harm.
Continuity and coordination are vital, now more than ever. With increasing specialisation in healthcare, people meet many providers and frequently move between various teams at different points in the system as they experience multiple episodes of health and social care. At best, this may be well intentioned pursuit of the best quality care from the right professional in the right setting. At worst, it is chaotic poor quality care. In fact, both are a challenge, particularly for people who have complex or multiple conditions. Although mainly driven by ageing, when often associated with frailty, multimorbidity is not confined to later life. It is increasingly prevalent in mid-life, heavily influenced by socioeconomic circumstances, and often manifest as combined mental and physical health problems.
Each episode of care must be part of a continuum that is proactive, planned, coordinated, and enabled by good communication and effective collaboration. These skills and behaviours are at the heart of interdisciplinary practice, relevant at all life stages – from early years intervention for children; case management for adults with multiple chronic diseases; comprehensive geriatric assessment for an older person living with frailty; or person-centred palliative and end of life care. In each scenario, care by multiple providers can be coordinated by a link worker, care navigator or case manager so that care and support are coherent and continuous. This relational continuity is easier to achieve if all involved can access the information required to make the best possible decisions together.
As a geriatrician I understand that navigating a complex web of care is challenging for patients, carers and for professionals. As a daughter, I see the benefits when the system works well for my 91 year old father: his trusted general practitioner understands what matters to him and shares his electronic anticipatory care plan so emergency services know how to respond if chronic conditions flare up. Recently this meant out of hours providers quickly coordinated an ambulatory care response instead of a hospital admission – avoiding the risk of deconditioning and also reducing demand on the system. While this doesn’t yet happen reliably for everyone, all of time, responding to the pressures of COVID-19 has made us more aware of the need to improve collaboration, continuity and coordination of care.
For evidence and practical advice, I suggest you read the “Continuity and coordination of care: a practice brief to support implementation of the WHO Framework on integrated people-centred health services” document. This highlights examples from high, low and middle income economies of actions in eight priority areas:
- Continuity with a primary care professional
- Collaborative care planning and shared decision-making
- Case management to reduce gaps in care, anticipate crisis and plan future care.
- Collocated services or a single point of access to different providers and supports
- Transitional and intermediate care for safe, coordinated and timely transfers between settings and to enable recovery, independence and confidence as health changes.
- Comprehensive care that includes urgent response in evenings and weekends and an effective interface with acute hospital services.
- Technology to exchange information, enable adoption of good practices, and identify and target people at greatest risk who have the most to gain from interventions.
- Building capability of the workforce in all sectors so that everyone has the right skills and competences to fill their roles.
One example highlights the role of Community Health Agents in Brazil. During 2019 I was privileged to work with a team from Sao Paulo State Secretary of Health and Regional Department of Health in our Transforming Together project in Litoral Norte, Brazil. Four municipalities worked together across sectors, and with community partners, to improve continuity and coordination of people centred integrated care. Community Health Agents, empowered and supported as Integrated Care Champions in their neighbourhoods, mapped existing community resources and built partnerships with other professionals and sectors to establish local networks of coordinated care and support. Primary care services are now more resilient from support from community partners for prevention and early intervention, mental wellbeing initiatives in schools, community rehabilitation and palliative care, and neighbourhood care for 720 vulnerable families. This integrated way of working during 2019 helped the municipalities implement a coordinated regional response to COVID-19.
Inspiring work by inspirational people!
What can you do to ensure continuity and coordination of care are at the heart of integrated people-centred health services as you build back better after COVID-19?
Professor Anne Hendry
Director IFIC Scotland
Honorary Professor, University of the West of Scotland, on behalf of the Transforming Together team