Continuity and coordination of care at the heart of integrated people-centred health services (IPCHS)

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?

Integrated delivery and continuity of care in times of crisis

Ensuring continuity of care in response to the Covid-19 crisis has been a key issue for public health and social care services across Europe. Whilst the implementation of local partnerships for integrated care delivery have been identified as a success factor, in many cases the reality on the ground has been one of a fragmented market. One, where providers of home care, residential care and supported living have been under pressure due to the lack of protective equipment, the fear of infection, and a reduction in the number of professionals. Still a fragmented un-resourced system In light of the Covid-19 crisis, care services have been reaping a bitter harvest of years of failure to invest adequately in public health and social care systems. While older people’s care services have been affected across Europe, the situation has been particularly difficult in two countries: the UK and Spain. In Spain, the national government issued measures and recommendations covering all regions regarding emergency accommodation, home care, and care homes for older people. A protocol was issued to support health services with the discharge of older people; as a result, buildings were adapted to accommodate old people who were discharged from hospital and had additional needs. However, seven in 10 deaths from coronavirus happened among older people, many of whom lived in care homes. There has been a lack of coordination between hospital and social care. The "Círculo Empresarial de Atención a Personas (CEAPS)" (1),  the confederation of employers in people’s care, published a report on the situation faced by care homes during the pandemic. Their analysis highlights that the delivery of personal protection equipment (PPE), masks, gloves, gowns, disinfectant gels, and tests were prioritised for hospitals over nursing homes. This did not comply with government announcements and protocols to deliver PPE in nursing homes following the virus outbreaks in March and April. There was also a fall in the numbers of care workers in home care for three main reasons. Many fell sick, and it is estimated that there were three times more casualties amongst social care workers. Many were reluctant to work due to fear of becoming infected (exacerbated by a lack of PPE). They were sometimes told not to work and self-isolate even without being tested. Or they moved to work at hospitals where they were paid higher salaries. In the UK, adult social care providers highlighted that the cost of PPE rose very substantially. Ordering of PPE from existing suppliers became extremely challenging. Whilst the national health service (NHS) had a national system for the distribution of PPE, social care has been reliant on using existing suppliers with the consequent difficulties in accessing protective equipment. The focus on partnership revolved around discharge hubs that aimed at discharging people who do not need to be in hospital in 2 hours. However, social care settings needed to be well-resourced to treat and contain the infection when accepting hospital discharge. Instead, care homes highlighted that cases were discharged into care settings that were unprepared without the capacity to conduct tests and no PPE to prevent further transmission. Lessons learnt: reinforce home care and advance coordination Advancing the coordination of health and social care is one of the key lessons learnt during the Covid-19 crisis. This would involve resourcing social care settings to allow for the integrated provision of hospital-related care and social support in situations of public health emergency. For instance, deploying health workers in social services facilities including those for older people and adults with physical or intellectual disabilities, children’s homes, homeless shelters, and therapeutic communities. Public authorities should reinforce these facilities with robust testing, protective gear, as well as specific prevention and care guidelines for crisis situations like the ones caused by the coronavirus. In addition to deploying health care workers into other settings, giving social care and social services staff parity of esteem with health care is fundamental. This parity, by recognising them as essential workers, would ensure that national governments in partnership with regional and local authorities will then be required to ensure the supply of protective equipment to workers who provide home care and residential services. Investing in the adaptation and reinforcement of home care services would certainly contribute to a more integrated delivery of care for those who need it. This would involve at least three main actions. First, focusing on people with little family support and high dependency needs in the provision and preparation of meals, dispensing medication, assistance with postural changes or personal hygiene needs. Second, doing the shopping for older people or people with disabilities to minimise their risk of getting infected or injuring themselves. Third, ensuring the safety of older people in their own homes by intensifying contact with them through the phone and telecare. All these measures must be carried out to prevent the spread of the virus among those most vulnerable and workers themselves and ease the burden on health systems in future situations of emergency, including a potential second wave of the pandemic.   (1) Círculo Empresarial de Atención a Personas (CEAPS). Available at: http://ceaps.org/descarga-de-documentos/