A new report from the Kings Fund, Delivering better services for people with long-term conditions:  building the house of care, shares learning from the “house of care” model which was developed through the Year of Care programme and discussed in a recent workshop and series of interviews.  The “house of care” metaphor is used to describe the critical elements which need to be in place and working together to deliver better care for patients with long term conditions (LTCs).

The model

Imagine a house:

• personalised care planning is in the centre – a decision coaching process is described which involves clinicians and patients working together to decide priorities and actions;
• engaged and informed patients are represented as the left wall – it is recognised that some patients will find this easier than others and support mechanisms need to be in place to help;
• committed and connected health professionals are represented as the right wall – this requires professionals to adopt a consulting style which enables shared decision making and self management;
• organisational systems and processes are represented as the roof – this includes systems for identifying and communicating with patients, sharing data, monitoring outcomes as well as tools for patients and their carers/families;
• and responsive commissioning is the foundations – this involves identifying services across health and social care which can meet needs and improve outcomes – for example, weight management and smoking cessation – and identifying a range of potential providers.

Context

Commissioners will be acutely aware of the need to improve outcomes for patients with LTCs and will be interested in innovative ways to achieve better value.    Figures quoted in the report highlight the need for a coordinated approach to tackle a growing health need:

• over 15 million people in England have a LTC;
• recent figures from Scotland show 42% of the population have at least 1 LTC and 23% have 2 or more;
• in England the number of people with multiple conditions is expected to rise from 1.9 million in 2008 to 2.9 million in 2018.

Implications

The key principles of the house of care model include:

• a strategy for all patients with LTCs not just those deemed as higher risk patients
• an active role for patients in decision making, focused around collaborative care planning and self management
• 

  The house of care model places the patient at the centre of decision making

  effective and meaningful partnership and integration between services across health and social care, including involvement of the Health and Wellbeing Board

• linking care planning for individuals with commissioning at a population level
• addressing health inequalities through provision of extra support for those most in need
• quality assurance to ensure evidence-based and knowledge-driven decision making
• strong leadership to bring together the various elements of the house of care
• a systematic process to capture and evaluate patient feedback, including the use of instruments (such as Patient Activation Measure or Self Management Ability Scale) to monitor impact

Commentary

The report acknowledges that the philosophy and components of the model will not be easy to achieve and in fact, note that no organisation has yet implemented the model fully.  However, given the slow progress in improving outcomes for LTCs and the pressure to deliver better value, the authors recommend that commissioners use this model as a framework to work towards.  26 communities within England are now engaging with this model and the report recommends that a coalition is formed to drive this forward and act as a peer network.

Specifically, commissioners will need to consider:

• are the current systems effective in identifying all patients with LTCs?
• how can primary care services best be organised to facilitate this model?
• how can the market be developed to ensure a range of health, social and community services to support patients to make decisions and manage their condition(s)?
• how can budgets be pooled to commission services outside of traditional health services, for example, cookery classes to encourage  healthier eating?
• what outcome measures need to be agreed and monitored to measure impact?
• how can data and learning be shared across organisations  to avoid fragmentation?
• how should patients be continuously supported to take a more active role in planning and decision making, including awareness of services available?
• how should health professionals be continuously supported to work differently?
• what are the implications for patients’ access to their records?
• what needs to be in place to anticipate need and reduce unplanned service use?

Link

Coulter A, Roberts S and Dixon A (2013).  Delivering better services for people with long-term conditions: building the house of care, Kings Fund.  http://www.kingsfund.org.uk/publications/delivering-better-services-people-long-term-conditions

Related Commissioning Elf posts

de Brun C, Decision-makers need to think differently about how to commission long-term condition services, The Commissioning Elf, 16 September 2013.  http://www.thecommissioningelf.net/the-work-of-commissioning-a-multisite-case-study-of-healthcare-commissioning-in-englands-nhs/

Turner A, Challenges in implementing personal health budgets: lessons for commissioners, The Commissioning Elf, 2 September 2013.  http://www.thecommissioningelf.net/challenges-in-implementing-personal-health-budgets-lessons-for-commissioners/