Integrated Care

Two interrelated factors – the growing prevalence of chronic diseases and population aging – are placing a heavy burden on health systems.

International experience demonstrates that, through coordinating management for elderly populations and patients with long-term conditions, integrated care across the full patient pathway can improve value of care – better outcomes for patients per pound spent.

Different approaches have been used to date, but they share one core characteristic: they design all stages of care delivery around what is best for patients and populations. Three core principles define UCLP’s approach:

• Organising care around meaningful groups of patients and populations – for individuals comprehensive needs rather than by disease
• Defining and measuring those outcomes that matter most to patients alongside costs incurred – with whole pathway measures across the continuum of care
• Developing a funding mechanism that incentivises providers to work together to meet individuals needs and preferences, and putting in place commissioning arrangements to support it

Success factors common to all include integrated care approaches include:

• Clinical leadership – with clinicians playing a prominent role in leading the change effort and demonstrating by example why and how integrated care is the appropriate way forward for patients and populations
• Promoting self-care – patients taking responsibility and actively managing their own care, with specific tools and approaches to support them to do so
• Incentives – financial systems that align providers to commit to delivering care in the agreed way, and non financial incentives that reinforce required behaviours
• Information – high quality, efficient care and information-sharing across all providers, with easy access to up-to-date patient records; and opportunities for accurate risk profiling and predictive modeling to identify which patients are likely to require the most attention
• Collective responsibility and single accountability – clarity on who is responsible for what across the pathway. Where possible, a single person is ultimately accountable for each patient, helping ensure that all appropriate services are delivered with no duplication or unnecessary utilisation of services

UCLPartners is supporting North Central London’s Integrated Care work. A draft document outlining the approach is available here.

For more information, please contact Jenny Shand, Director of Integrated Care at UCLPartners.

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