Integration is the foundation of most high-performing health systems. It enables them to deliver consistent, good-quality care, particularly for populations with high-cost chronic conditions.
Increasing numbers of commentators, including the King’s Fund, the Nuffield Trust and the NHS Future Forum, advocate integration – be it a formal merger of organisations or partnerships across bodies – as the key ingredient in meeting the financial and service challenges facing the NHS.
To learn from high-performing systems it is necessary to assess more than just outcomes. It is structure and process that actually generate and sustain excellent outcomes. Get these right and the best outcomes should follow.
The NHS focus on outcomes is often enabled locally by a data warehouse that spews out retrospective performance dashboards. Typically, these only enable the performance monitoring of two- to three-month-old data and the tracking of national targets.
This can actually be a costly distraction from implementation and improvement; draining scarce management and clinical attention away from getting effective delivery structures and processes in place.
It is like a sports coach, fixated on the score board, continually shouting to the team ‘We’re losing… Score!’ and ignoring the processes that would allow that to happen.
Integrating care to deliver the best health management for a defined population involves six accelerators. All are necessary; none are sufficient on their own; and they are interdependent structures and processes. Sounds like a big job? Yes, but it is manageable.
For most health economies, integration will not mean starting from scratch. Many of the accelerators will already be in place to some extent.
The key is recognising and then filling the gaps identified by careful assessment. Issues can be tackled in any order to suit local context, with one exception. Integrated clinical engagement and governance are fundamental to success and need to be addressed up front.
Engagement and governance
Clinical engagement is structural, like the foundations of a building, and requires three elements: devolved decision-making; shared accountability; and rapid collaborative feedback.
Existing governance frameworks need to be evolved towards a robust integrated clinical governance model. In creating its integrated care organisation by merging acute and community services, Southport and Ormskirk Hospital NHS Trust borrowed from Kaiser Permanente Colorado’s successful governance model.
Kaiser Colorado has the lowest bed-day use of all the Kaiser regions and was recently recognised by the National Committee for Quality Assurance as the best quality health plan for Medicare (over-65s).
Southport created integrated care teams, each with clinical champions (GP and specialist co-chairs and a nurse) and a co-ordinator to facilitate meetings and ensure progress is supported between meetings.
A committee of the trust board was also formed (a clinical senate) to provide clinically led oversight of the teams’ progress. The senate is chaired by the chief medical officer and must have a set number of doctors in attendance to be quorate, although the trust’s senior management team also plays an active part.
Tough questions are asked and real progress has been made on service redesign, ways of working and engagement. Engagement has in effect been hardwired into the governance arrangements.
Clinicians, especially doctors, are highly visible in the governance set-up and are accountable both to each other and to the board. Decisions simply don’t happen without the doctors’ involvement.
The redesign process is accomplished within the teams and involves team members learning by doing clinical redesign and deployment activities. Monthly progress reports to the clinical senate give way to reporting on key process and outcome measures over time.
Teams also have decision rights for redesign – clinical leaders take decisions with managerial input, not the other way around, and could receive devolved budget. The senate weighs up all requests and makes recommendations to the board.
Data and decision support
When using data in the NHS, we have at times taken our eyes off the ball. Clearly, Department of Health targets are important, but rather than this scoreboard mentality we need to focus on process measures, not outcome measures.
Is there a care plan for each patient? Are team members organised and working as a team? Do they know who is taking the lead and does the sequence change under specific circumstances? How is the communication among the players?
Real-time data is the important piece missing. Chances are you won’t find the data you really need in the data warehouse and if you did, it’s likely be months too old.
While information and data processing capabilities are critical to integrated care, it is also vital the data is integrated across organisational boundaries.
This shared data – effectively an electronic patient record – must be based on a single repository that allows complex decision logic to look across boundaries and identify gaps in care. It must also be about more than just clinical data. Real-time clinical and operational data needs to sit alongside real-time financial data, all in the same data model.
Imagine clinicians being able to see how much has been spent taking care of a patient, and how much the organisation is going to be paid for taking care of that patient while the patient is being treated.
This level of integration is particularly important for the proactive management of high-risk, high-cost patients by multi-disciplinary teams.
Creating a shared view of patients’ clinical journey and pathways will also allow multidisciplinary teams to deliver seamless care across organisational boundaries. These pathways can be designed and checked against resources such as the Map of Medicine and NICE guidance.
But the key to ensuring best practice is to weave this guidance into clinicians’ practice. High-performing providers are characterised by their use of systems to support the reliable delivery of care bundles through embedded clinical knowledge and real-time decision support – checklists, alerts and reminders.
Mobile technologies are ideal for this, enabling consistent, reliable treatment, and can help to cut errors. Making performance visible, especially to doctors, can also create a powerful incentive to modify behaviour.
In many ways this in-built support can be seen as an autopilot, highlighting the need for course corrections and gaps in care.
Registries can be created to monitor whole populations of patients, constantly interrogating subsets of critical data. If gaps are identified, dashboards can prompt a team member to take corrective action to reschedule the service, missing medication or uncontrolled lab value.
Moving away from the current payment by results reimbursement model to a model more supportive of integrated care will require discussions with commissioners.
Last year, as Southport and Ormskirk launched its integrated care organisation, it negotiated block contracts for both the acute and community activity.
This move away from Payment by Results was key in helping the trust focus on reducing inpatient activity without the fear of losing revenue. It required a higher level of trust between providers and commissioners.
Transparency – discussed earlier in terms of governance and performance – will help build the level of trust needed in a health economy.
The finance department has other roles too. It is the natural choice for owning the population risk adjustment and predictive modelling tool. Many trusts have developed or are using various available tools. But being able to segment a patient population by clinical and financial risk is a prerequisite to identifying patients who will consume significant resources in the near future, so targeted interventions can be initiated.
Operational excellence does not just happen – pathways need to be defined, processes implemented and then continuously improved. A simple approach is recommended.
Define what needs to be done and decide how from a process standpoint that will be delivered reliably. Identify who is responsible for doing it, where it should be delivered and when. Ideally, all this should be made transparent via mobile checklists and decision support tools.
Tools and methods to enable and support redesign efforts and continuous improvement are critical for locally integrated care.
To deliver continuous improvement, leaders need to be able to view real-time performance in a way that enables them to drill down to accountable managers, who can in turn drill down to front-line processes to help identify problems and barriers.
For example, to reduce admissions, Southport is using a transition checklist listing activities that must be completed prior to the patient leaving the hospital.
A manager can see if patients nearing discharge have received their bundle of services (green indicator). If it is red, the manager can drill down to see what is missing and who is responsible.
This is all in real-time. While a warehouse could tell you the same thing, typically it would be weeks after the patient has gone home.
High-performing systems also train staff to use some form of operational improvement model to support the redesign and implementation work. Initially an organisation may just use simple ‘plan, do, study, act’ cycles.
Other organisations, such as Seattle’s Virginia Mason Medical Centre and the Royal Bolton Hospital NHS Foundation Trust, have used Lean successfully.
Trafford Healthcare NHS Trust (now part of Central Manchester University Hospitals NHS Foundation Trust) chose a model used by InterMountain Healthcare, largely based on quality guru Deming’s approach.
Integrated care model
Once high-risk patients are identified, targeted interventions need to be delivered by various members of the patient’s virtually integrated team.
For this to work effectively and efficiently, the entire team needs to know the pathway and what individually they are responsible for delivering. For patients with chronic conditions, this clarity of plan and responsibility is often missing.
For an integrated care team to function, there needs to be clear definition of the care plan, the content of services, responsibilities and timing of delivery. In Southport patients identified at risk of readmission are enrolled in a care coordination service.
All steps are clearly defined and often scripted. So, for high-risk heart failure patients, the heart failure integrated care team has collaborated with the care co-ordination team to define a rescue plan, phone-based follow-up schedule and scripts to be used during calls.
Each member knows what should be done, how the service is to be delivered, who is responsible and where and when it is to occur. Professional judgement still has a crucial role but there’s a checklist for the key processes.
Educated and empowered patients become active participants in their care and the decisions affecting their health and healthcare.
The process of informed choice enables individual patients to understand the benefits and risks associated with treatment options and allows them to choose the option best suited to their goals, needs and circumstances.
Patients can actively contribute to their health management if they know and agree what plans are in place and the goals.
Self-care can enable patients to manage their condition better. And as a by-product, they are better placed to recognise an exacerbation early on, enabling more proactive steps to be taken. Patients effectively become an additional and critical member of their multi-disciplinary team.
Diabetic patients at Salford Royal NHS Foundation Trust, for example, have been enabled to better manage their condition via an integrated approach employing non-clinical coaches to motivate patients to follow their care plans. Kaiser Colorado uses a similar model of coaches, nurses and specialists.
Patients and care team members are kept informed of patient progress through web-based portals and mobile apps when appropriate, as well as other communication options, such as text, phone and post.
Making it happen
Accelerating the delivery of integrated care models in the NHS has tremendous potential to aid health economies in dealing with the financial pressures and increasing burden of chronic disease.
Whether the integration is structural or virtual, the six integrated care accelerators described provide a practical playbook for a management team serious about making integrated care a reality.
Organisations do not need an expensive consulting diagnostic to define their state. One health economy is not that different from most others. Instead, a practical approach involves a fairly simple assessment of where you are now with a clear view of the key accelerators in practice today and a disciplined plan to evolve them into an effective, integrated care model.
Integrated care isn’t rocket science. It is how clinicians want to work with each other and with patients. In the future, the functions needed to support a thriving health ecosystem are predictably going to be the same.
Organisations will need multi-disciplinary teams working across the continuum of care as a single team with a clear view of what needs to be done for patients and the authority to redesign services and clearly designate who is going to do what. Wrapped around this is real-time decision support to prompt reliable delivery across settings at the appropriate time. Simple!
About the author: Dr Rob Beardall began his medical career as a flight surgeon in the US military, where he led the development of its first evidence-based guidelines for preventive care. More recently he has worked as a chief medical information officer in the US and advised NHS organisations.
He is now CMIO at Net.Orange and has been supporting implementation of an integrated care organisation at Southport and Ormskirk Hospital NHS Trust. Net.Orange has partnered with the Healthcare Financial Management Association to support organisations that want to improve the coordination of care.
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