Integrated Care Pathways and CIPs - what it means in 2012...
Posted On 2011-11-21 12:59:25 By Richard Jones
Feedback from Trusts continues to show that simpler, well-bounded Service and Cost Improvement Projects continue to be 'used up'. We see that the next generation of projects are likely to involve two things - care integration and pathway reform - within and across organisations.
These are lovely concepts – they cover planning, consensus, co-operative working, and safe, formal, deployment of care. What’s not to like? Used well, probably nothing. How do they work? Lots of ways. What’s happening? A great deal. What do we mean when we talk about them? Well, quite a few different things. The word ‘Integration’ is used in the vertical or horizontal sense, and Pathways can be simple, complex, condition-specific, diagnostic... it goes on. So our workstream in Medical Mosaic felt a blog coming on…
The terms 'Vertical' and 'Horizontal' for organisational integration are well-established. Vertical Integration merges organisations across care settings, enabling acute and community care to be managed by one organisation. Horizontal integration merges similar organisations, seeking critical masses, safety, sustainability and efficiencies in premises and administration. In both contexts, pathway reform, with clinical, patient flow and resource analysis, provides the basis for planning, improved care, contracting and targetted benefits realisation including cost. .
The term 'Integrated Care’ is most commonly used to in the sense of vertical integration, with or without organisational mergers. Activity is around the acute/community/mental/social care split, with current progress usually coming from the merging of acute and community Trusts and community-wide projects. In the absence of merging organisations there is increasingly a forum led by commissioners. This is leading to redeployment of services, and a resolution of whether commisioners set up direct contracts or one provider becomes the ‘Prime’ with one provider leading to another.
Pathway improvement in the horizontal direction seeks to improve the journey for well-identified pathways within a provider, usually in terms of patient flow, communication, information, waiting times, best practice and cost. These are usually well-identified in terms of the condition, diagnosis and treatment options, and lend themselves to challenge and improvement
Pathway reform in both contexts can be addressed in an efficient consultancy exercise, with tools such as our checklist of pathway challenges, clinical flowcharts, resource profiles and cost analysis – all, naturally, integrated together. These quickly present the realities and benefits, and can be used to provide a breakdown of income, tasks and resource needs across organisations. Commissioners look to be gravitating to pathway-based commissioning in the next two years, with an intended complete care process replacing 'baked in’ historic costs. The whole picture demands a shared understanding and of the pathways, good communications and effective use of resources across care settings.
Integrated pathways emerge from both directions of integration. Multiple conditions are more difficult to manage, define and commission. Again, analysis and modelling helps to clarify and communicate reforms. If it's difficult, it's even more important to work out the details. Benefits can be gained from new ‘enabling’ projects particularly around the sharing of clinical information and care. (From recent papers and presentations, the DoH’s wish to develop patient-centred records will be significant in this.. over the next five years).
Pathways for diagnostics and urgent care embrace all the above. Their best aims and benefits are to deal with the decision-making processes and direct care in a more ordered and economic way. They naturally cross organisational boundaries, involve multiple services and commonly feed out into long-term care. Projects tend to be large in scale, and tend to follow extensive 'capture' events with significant projects and investments to drive change. The common outcome is an improved service but with problems in identifying specific benefits such as cost savings. To build a successful and accountable programme, we promote good engagement, clear project definition and enough detail to show the clinical owners how it’s actually expected to work for them. And, for this category and the others, that detail has to show where any cost savings actually come from.
Which is probably one of the main points - the NHS is littered with projects which made positive changes but where the expected result or saving somehow failed to emerge. The potential for this in integrated care is greater than ever. Let's avoid baffled looks across meeting tables. We can help.