Who would most benefit from improved integrated care? Implementing an analytical strategy in South Somerset

Abstract

AimsThe Symphony Project is designed to identify which groups of the South Somerset population in England would most benefit from greater integration across primary, community, acute and social care settings.MethodsWe analysed linked health and social care data for the entire South Somerset population for the financial year 2012/2013. The data captured acute, primary, community, mental health and social care utilisation and costs; demographic characteristics; and indicators of morbidity for each individual. We employed generalized linear models to analyse variation in annual health and social care costs for all 114,874 members of the South Somerset population and for 1458 individuals with three or more selected chronic conditions.ResultsWe found that multi-morbidity, not age, was the key driver of health and social care costs. Moreover, the number of chronic conditions is as useful as information about specific conditions at predicting costs. We are able to explain 7% of the variation in total annual costs for population as a whole, and 14% of the variation for those with three or more conditions. We are best able to explain primary care costs, but explanatory power is poor for mental health and social care costs.ConclusionsThe linked dataset makes it possible to understand existing patterns of health and social care utilisation and to analyse variation in annual costs, for the whole population and for sub-groups, in total and by setting. This has made it possible to identify who would most benefit from improved integrated care and to calculate capitated budgets to support financial integration.

Clinical care in the home and population health management: improving the care of patients with long-term health conditions

“…A linked dataset is likely to significantly improve the predictive value of any mathematical model. For example, the addition of social care data has improved the predictive value of the combined predictive tool in determining who is most at risk of acute hospital admission [20].…”

The international knowledge base for new care models relevant to primary care-led integrated models: a realist synthesis

“…Integrated governance frameworks have been used to clarify roles, responsibilities and reporting arrangements, 345 and the principle of MDTs seems to be valued by professionals. 338 However, dissatisfaction and frustration can 319 Kasteridis et al, 320 Powers et al, 321 Ruikes et al, 322 Thistlethwaite, 323 Archer et al, 324 Bearne et al, 325 Chung et al, 326 Coventry et al, 327 Fortuna et al, 328 Glogowska et al, 329 Green et al, 330 Bonney et al, 331 Smith et al, 332 Tricco et al, 333 Hernández et al, 334 Huang et al, 335 Maneze et al 336 and Raine et al 337 Population-based approaches to primary and community care Kasteridis et al, 320 Powers et al, 321 Ruikes et al, 322 Thistlethwaite, 323 Huang et al, 335 Kruis et al, 338 Loewenson and Simpson, 339 Ouwens et al, 340 Stranges et al, 341 Kruis et al, 342 Nandram and Koster 343 and Martínez-González et al 344 Integrated and collaborative care Goodwin et al, 239 , Archer et al, 324 Bearne et al, 325 Chung et al, 326 Coventry et al, 327 Fortuna et al, 328 Glogowska et al, 329 Green et al, 330 Hernández et al,…”

“…327,333 Risk stratification and predictive modelling are often used to support case-finding, 361 and several recent studies present alternative methods to predict future utilisation. 319,320 Sharing and access to patient records is critical in MDTs working across organisational boundaries to support clinical decisions and more holistic support. 323,343,345 The use of technology is variable, 337 challenging informationsharing within current systems.…”

Antall kroniske sykdommer og persontilpasning bør ligge tilgrunn for prioriteringer i kommunale helse- og omsorgstjenester

“…Basert på kartlegging i våre naboland utgjør innbyggere med multisykdom en halv million i Norge (Nilsson, 2016), og de utgjør den største brukergruppen i helsetjenesten. 2/3 av helsebudsjettet går med til denne gruppen.…”