Comment: Paving the way towards integrated care

Dr Joel Ratnasothy, medical director EMEA at Caradigm, examines how population health data could help drive step change towards integrated care

Dr Joel Ratnasothy

With familiar challenges such as funding pressures, organisational silos, and evolving information governance, the sheer scale of delivering an integrated care model can appear daunting to many within health and social care

It’s widely accepted that the development of integrated care models will provide the best opportunity for more-equitable and effective healthcare for the UK population. Yet, with familiar challenges such as funding pressures, organisational silos, and evolving information governance, the sheer scale of delivering an integrated care model can appear daunting to many within health and social care.

To progress, local stakeholders should consider adopting an iterative approach that divides the journey into small, manageable sprints. Certainly, with the right tools, greater collaboration, and access to meaningful information, NHS organisations could slowly but surely take some major steps forward.

That journey begins with securing a thorough understanding of the local environment, giving commissioners the best chance to plan services that respond to identifiable health needs of designated populations. The ability to access, analyse, and act upon population health data will, therefore, be critical. But the question remains: how do you do it?

Predictive analytics

Success will be about working together, achieving small goals, sharing access to the insight learned, and then building on that success

Let’s start with the obvious: doing nothing is not an option. As healthcare resources are squeezed, a greater percentage of our health budget is being consumed by a much smaller percentage of the population. It’s a monumental problem. But what can be done locally to create more-efficient models of care?

The long-term answer is to focus on prevention, with better insight into population health data, helping clinicians develop a 360° view of individual patients. The fundamental driver of integrated care is the need to move away from reactive treatment cycles of episodic care to a world where stakeholders are able to analyse, predict and ultimately prevent avoidable disease. Prevention is, after all, better and cheaper than cure. The challenge is to build a system that gets to the ‘person’ before they become the ‘patient’ – and the downstream benefits of efficiency and outcome gains will naturally follow. It’s a futuristic vision – but in the here and now, commissioners are already being asked to commission services across the whole care continuum. Unequivocally, they need tools to help them do it.

Meaningful insights

One of the biggest challenges is co-ordinating care across organisational clinical boundaries. In many cases, organisations are blind to activity that occurs elsewhere – slowing down pathways and, at times, potentially compromising continuity of care. The importance of sharing information across boundaries is well understood, yet the inconvenient truth for healthcare leaders is that few healthcare providers currently have the tools in place that can help them achieve this goal.

Data, and access to it, is fundamental. Without the complete picture of an individual patient, it can be difficult for clinicians to deliver optimal care. Without the complete picture of all their patients – from demographics, to care pathways and prevalent long-term conditions or comorbidities, for example - a commissioner may not be able to conduct meaningful retrospective or predictive analysis to ensure that resources are appropriately aligned.

Yet there are no technological barriers to making progress. Innovative technologies that can help not only exist, but the Government believes organisations have a responsibility to leverage them across the NHS. In fact, in small pockets of the UK, information systems that can support integrated care are slowly being introduced.

It’s a long road - but it starts with securing access to meaningful population health data, and then using it to ensure clinical teams deliver the appropriate care to patients through effective co-ordination

A potential first step could be for NHS organisations to introduce solutions that allow them to capture and optimise critical population data. With the right tools, stakeholders can be better supported to co-ordinate care and transform service delivery more effectively.

The optimal use of informatics and analytics tools can empower stakeholders with cross-boundary intelligence on population health. Who are the high-risk patients that generate the majority of healthcare costs, for example? Or, indeed, who might the low-risk patients of today be that may become high-risk patients tomorrow? With this type of insight, organisations could better understand patient demographics and establish areas where integrating care can help to improve outcomes and drive disease prevention. In the process, stakeholders could use such insights to improve clinical outcomes, maintain population health and drive down utilisation costs.

Moreover, such tools provide management information that can help align the workforce and optimise resources. By enabling organisations to identify, assess and stratify patient cohorts, smart informatics could support workforce planning and give senior management crucial operational data and performance metrics to measure effectiveness. Predictive analytics may mean that future resourcing models are proactively aligned to identifiable population health needs.

The catalyst

In countries where integrated models are more mature, data aggregation, informatics and analytical tools play a crucial role to lay the foundation for the strategic development of integrated care. For example, in the US, pro-active accountable care organisations (ACO) are developing integrated models that place a care manager at the centre to monitor, guide and manage individual patients as they move across the care continuum. Likewise, in Sweden, new models of care co-ordination permit acute patients to be treated at home – breaking down the walls of traditional care settings. These models did not happen overnight but, in both examples, informatics platforms that empower stakeholders with robust patient and operational information sit at the core of the innovation.

The importance of sharing information across boundaries is well understood, yet the inconvenient truth for healthcare leaders is that few healthcare providers currently have the tools in place that can help them achieve this goal

These data aggregation and analytical tools could be implemented in the UK right now – and they could provide a significant foundation from which NHS stakeholders can move towards integrated care. With these tools, the next logical step is to develop relevant integrated care pilots that address the patient needs identified through population health analytics. The landscape for pilots, buoyed by introduction of ‘integration pioneers,’ is already taking shape. The informatics that these tools then enable can ensure these pilots are targeted and effective. Moreover, when underpinned by comprehensive data, they can provide a catalyst for the more strategic introduction of innovative initiatives like care manager programmes or clinical homecare.

But for individual organisations to take these steps in siloes is not enough. To make sure they work, transparent partnership is critical. Clinicians, IT and operational executives from across local health economies must collaborate to drive progress. Success will be about working together, achieving small goals, sharing access to the insight learned, and then building on that success. By understanding the demographics, patient population and challenges, it’s much easier to identify the areas where integrated care can improve outcomes and drive prevention.

It’s a long road - but it starts with securing access to meaningful population health data, and then using it to ensure clinical teams deliver the appropriate care to patients through effective co-ordination. It is an approach that really could help the NHS meet its current objectives of high-quality, efficient healthcare – and pave the way towards integrated care.

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