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Coordinated care

For patients with continuity of care needs we want to move away from a reactive system that treats people when they become ill to one which co-ordinates care and supports people to stay well. Many Londoners will be receiving care from several different services and that can become confusing and frustrating if the services don’t work in close collaboration.

The coordinated care element of the specification focus on those patients who would benefit from an enhanced level of service which provides the continuity of care and support that these patients need to remain healthy and independent in their communities. Especially;

  • People with complex health and social care needs – coordinated care is essential in providing a service which supports their health and wellbeing.
  • Others who go through periods of severe, complicated, health problems which may last months or years before they resolve.

Current service

The current service model of general practice revolves around 10 minute GP face to face consultations which is designed to deliver a “meet, treat and cure” intervention. It is less able to deliver the team based continuity which patients increasingly require.

Some of the issues are as follows:

  • Patients have increasingly complex care needs and so longer time is needed for consultations
  • Continuity of care is more difficult to achieve as patients receive services from multi-disciplinary teams and multiple agencies
  • Practice team frustrated by limits of care they are able to provide
  • Services not sufficiently patient centred or responsive to diverse needs

What is the impact?

  • Fragmented care and a system which is less than the sum of its parts
  • Episodic relapses that result in A&E attendances and unplanned emergency admissions
  • Patients who are not able to self manage and make lifestyle changes necessary to stay healthy

What does the specification say?

There are five elements to coordinated care:

  • Case finding and review – identify the patients who would benefit from this approach. Many will be elderly and suffer from multiple chronic conditions while others may suffer from mental health issues or have a set of social circumstances and lifestyle issues which are best addressed though coordinated care.
  • Named clinician – a named clinician will routinely provide the patient’s care or act as an advocate and guide and entry point into the extended practice team and to the wider multidisciplinary team in line with their particular needs.
  • Care planning – all such patients to have a personalised care plan and to have played an active role in determining its aims and content – agreeing goals and the support they need to achieve them.
  • Patients supported to manage their health – create an environment in which patients can maximize the potential of their own self-care, lifestyle changes and knowledge to contribute to their own health and wellbeing.
  • Multidisciplinary working – patients who require coordinated care will need frequent reviews and input from a range of members of a wider team ranging from a micro-team of practice staff, pharmacy and community nursing to a macro-team of health and social care providers. Their provider network needs to be well-connected and their services seamless.

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