Collaborative action for person-centred coordinated care (P3C): an approach to support the development of a comprehensive system-wide solution to fragmented care

Abstract

BackgroundFragmented care results in poor outcomes for individuals with complexity of need. Person-centred coordinated care (P3C) is perceived to be a potential solution, but an absence of accessible evidence and the lack of a scalable ‘blue print’ mean that services are ‘experimenting’ with new models of care with little guidance and support. This paper presents an approach to the implementation of P3C using collaborative action, providing examples of early developments across this programme of work, the core aim of which is to accelerate the spread and adoption of P3C in United Kingdom primary care settings.MethodsTwo centrally funded United Kingdom organisations (South West Collaboration for Leadership in Applied Health Research and Care and South West Academic Health Science Network) are leading this initiative to narrow the gap between research and practice in this urgent area of improvement through a programme of service change, evaluation and research. Multi-stakeholder engagement and co-design are core to the approach. A whole system measurement framework combines outcomes of importance to patients, practitioners and health organisations. Iterative and multi-level feedback helps to shape service change while collecting practice-based data to generate implementation knowledge for the delivery of P3C. The role of the research team is proving vital to support informed change and challenge organisational practice. The bidirectional flow of knowledge and evidence relies on the transitional positioning of researchers and research organisations.ResultsExtensive engagement and embedded researchers have led to strong collaborations across the region. Practice is beginning to show signs of change and data flow and exchange is taking place. However, working in this way is not without its challenges; progress has been slow in the development of a linked data set to allow us to assess impact innovations from a cost perspective. Trust is vital, takes time to establish and is dependent on the exchange of services and interactions. If collaborative action can foster P3C it will require sustained commitment from both research and practice. This approach is a radical departure from how policy, research and practice traditionally work, but one that we argue is now necessary to deal with the most complex health and social problems.

Quality after the QOF? Before dismantling it, we need a redefined measure of ‘quality’

“…Instead, locally directed learning from PREM data should be encouraged, as discussed in recent detailed guidance documents. 5 Fourth, tools measuring health outcomes such as quality of life and other patient outcomes (PROMs) could be routinely used to monitor the performance of the system in line with DOH policy for 'wider use of effective tools like PROMs, patient experience data, and real-time feedback'. 14 A number of organisational, methodological, and logistical challenges to the utilisation of PROMs/PREMs in primary care would need be addressed during testing, evaluation, and scaling.…”

“…Recent guidance for development and measurement of new models of care facilitate such efforts. 5 Fifth, current recall systems, which are burdensome, unpopular, and ill-suited for patients with multimorbidity, 9 should be replaced with a more efficient and personcentred management system (for example, one system is trialling in Dudley LTCF). 12 This would require co-design with patients, GPs, managers, information specialists, and researchers, with in-built capture of general practice contact data.…”

“…4 It can be considered a marker of a holistic approach, which is considered essential for the increasing numbers of people with multimorbidity and complex healthcare needs. 5 Yet it is currently in decline, 6 was reduced after the introduction of QOF, 7 and is not being captured by QOF.…”

Capturing the Role of Context in Complex System Change: An Application of the Canadian Context and Capabilities for Integrating Care (CCIC) Framework to an Integrated Care Organisation in the UK

“…In England, as elsewhere, care integration is seen as the key to improving services for patients and unlocking efficiencies [2,3]. The recent NHS Long-Term Plan [4] promotes new organisational forms and service delivery models, with greater levels of horizontal and vertical integration, emphasising better inter-professional working, more flexibility of roles and closer working between primary, community and secondary care services as well as with the voluntary sector to promote a 'person-centred approach' [5]. It is assumed that this strategy provides a means of addressing high levels of demand on acute care from an ageing population, often with multiple, long-term and complex conditions [4, [6][7][8].…”

Codesigning a Measure of Person-Centred Coordinated Care to Capture the Experience of the Patient

“…Our domain model was created to support services develop new models of person centred coordinated care (P3C). According to these core domains, an accompanying evaluation framework probes multiple perspectives (ie, that of patients, staff, and the organization) ( 31 ). In developing this framework, our initial aim was to identify a measure capable of probing if care received is both person-centred and coordinated, from the perspective of the patient.…”