Forum: Accountable care
To address the challenges of fragmentation and lack of care co-ordination between providers, a clinical transformation pilot was launched in 2011 in North West London (NWL). It focused on two particular populations− the elderly and patients with diabetes – who comprise only 10 percent of NWL inhabitants, but account for 28 percent of healthcare spend in the area.
The local providers devised a formal agreement to co-ordinate patient care for those people needing assistance across multiple providers. They created a patient registry, segmented the patient population according to risk, and developed best practice clinical protocols and care packages. Through regular meetings of multidisciplinary groups (MDGs) of healthcare and social workers (from hospitals, general practice, community care, social care and mental health), providers managed care for the most complex patients, who previously had frequent and uncoordinated interactions with many organizations.
The result was a dramatic increase in trust, co-ordination, and collaboration; the demystification of roles; and the sharing of best-practice care. Seventy five percent of healthcare professionals participating in the pilot reported a boost to their professional knowledge and to their understanding of the broader services on offer. The MDGs helped each provider play a more appropriate role for each case at a given time. Results showed patients with individualized care plans participating in the pilot had better and more convenient access to NHS services (e.g. saving time in appointment booking and eliminating the need to repeat their medical history). Following the success of the pilot, policy-makers are expanding the program to surrounding areas.
The improved co-ordination of care in NWL has been accelerated through ongoing training aimed at promoting a common language between provider organizations. Programs for frontline staff are focusing on explaining the big picture of the Integrated Care Pilot, simulating MDG case conferences (where attendees can experience playing roles other than their own), and conducting sequential simulations that follow the patient through the journey of care.