Can True Integrated Care for Patients with Long Term Conditions be Achieved?

Many patients with a Long Term Condition (LTC) have social care as well as health care requirements.  Whilst it is fair to say that a plethora of resources have been thrown at LTCs, the main problem lies in the disorganisation with the way Primary Care Trusts and the community structure staff.  Providing an integrated service should include the provision of long term care, which meets the individual, different and changing needs of the person with a LTC.  Integrated care however, involves the working of all people involved in care of each specific LTC, regardless of their role, in a partnership where each person is fully aware of the roles and responsibilities of the other people involved. 

The new role of Community Matrons was introduced in order to proactively identify the most vulnerable people, and then work in partnership with the individual, their carers and other relevant health and social care professionals.  However they need to be supported by systems and be part of wider team that enables them to secure services when needed i.e. social care, in patient care, GPs, equipment, diagnostics and treatments and Allied Healthcare Professional services, if they are to be effective in co-ordinating and managing the care of these people.

“There is a real need to get some true integration from the grass roots up and this requires leadership and a shared vision that will allow the complexity of care to emerge in a coherent and simple way.  There is already a lot of good work being done in isolated ways that need bringing together”(Cooke & Stanners, 2005).

If care is too be truly integrated then all key organisations need to be involved right from the start with the designing and delivering of effective care pathways that truly reflect the needs of the patient and are flexible enough to allow the seamless movement of patients between different organisations. Patients should not be encumbered with bureaucratic decisions which hinder their care because of arguments over funding and resources due to different organisational terms and conditions and restraints.  These care pathways should also recognise that while some aspects of care for patients with LTCs could be generic, specialist care will also be required, as specific conditions will require very different approaches.

Building networks of services that place more emphasis on the person with chronic condition needs rather than on organisational boundaries should encompass:

·         Multidisciplinary learning and planning;

·         Improved distribution and location of services to ensure continuum of care;

·         Referral up and down the ladder of complementary expertise should be facilitated; Linkage of discharge to community and social services;

·         Managing wellness rather than treatment of disease.

Only then we will achieve a truly integrated service that best supports patients with ongoing conditions who have the most complex needs.

Janice Sherrard-Brisley

Innovation Manager

References:

Cooke C. and Stanners C. (2005).  Integrating Care for Older People. Jessica Kingsley Publishers, London.