1. Integration through Care Co-ordination Belinda Weir, Senior Consultant, The King’s Fund Lara Sonola, Senior Researcher, The King’s Fund

2. Aims of session ›To hear some evidence about effective coordinated care for people with long-term conditions ›To explore the factors which support coordinated care and analyse our own services in relation to these factors ›To share experience and consider what, if anything, we will do differently as a result of this workshop

3. Sam’s story http://www.kingsfund.org.uk/audio- video/what-key-effective-care-co-ordination

4. Co-ordinated care for people with complex chronic conditions Greenwich & Bexley ›Methods: Five demonstrator sites chosen through a competitive process based on their ability to demonstrate positive impacts in one or more of the following: patient experience, better health outcomes, more cost-effective care ›We examined how care co-ordination was organised and operated in practice at a patient level through interviews with teams, documentary and observational analysis. Midhurst, Surrey Sandwell, Birmingham Pembrokeshire South Devon & Torbay Greenwich & Bexley ›2 year project funded by Aetna/Aetna Foundation in the US ›Aims: To understand the key components of effective care co- ordination, examine key barriers and facilitators and develop practical lessons for the application of the tools of care co-ordination

5. Sandwell Esteem Team http://www.kingsfund.org.uk/publications/esteem-team

6. Key Lessons Evaluation and measurement Time Local context Community involvement Integrated teams Aligned goals Engaging GPs/secondary care

7. Systemic Organisational Functional Community Clinical and service Personal Holistic Patient and carer focused Flexible Integrated commissioning Supportive policy Effective targeting Localisation 1-3 key leaders Commissioning support Supportive team culture/ shared values High touch-low tech Shared electronic patient records Personal communication Voluntary sector involvement Community awareness Multiple referrals, single point of entry Named care co- ordinators No defined care packages Design features

8. Research into practice LEADERSHIP ›How can you use these design features to deliver more joined-up care in your own system? ›Are there any other features you would add?

9. Any Questions?