The Integrated Care Framework
Local resources, experience, people and geography differ from area to area and no one solution fits all. However, some key elements need to be in place to facilitate integration of care. This framework describes the 10 key essential steps that are needed to enable integrated care for older people to be implemented, evaluated and sustained in all locations.
The key deliverables included establishing local and national governance and recruiting clinical posts to become a catalyst for integration locally. A core component of the ICPOP approach is to leverage existing community resources in the local health ecosystem. These include acting as a conduit to coordination of care locally in tandem with social care providers (public and private), community intervention teams, day hospital, day care, community intervention teams etc.
Step 1: Establish Governance Structures
a. Set up a local integrated care governance group focused on the needs of older people within a given area.
b. Ensure membership reflects key stakeholders and ensures opportunities for meaningful engagement with older people using the services as part of the core function of this group.
Step 2: Undertake Population Planning for Older Persons
a. Identify Health and Social Care Network(s) in which there will be a focus on developing integrated care for older people. Ensure existing networks continue to be supported in service delivery / implementation.
b. Identify population trends for older people within those areas to inform service planning and development. Specific trends in older population subsets should be identified (e.g. >75’s).
c. Identify target populations who may have high complexity needs such as:
Older People with Frailty
Older People with high levels of acute hospital use
Older People with Falls
Older People with a history of cognitive vulnerability
Step 3: Map Local Care Resources
Identify, map and develop a directory of all healthcare resources, agencies and groups in the area, that are central to the development of sustainable integrated care for older persons.
The function of mapping resources in a local area is to:
1. Ensure all services for older persons are identified within a given area and collated into a local service directory.
2. Ensure appropriate targeting of future service provision builds on the population planning approach.
3. Provide opportunities for signposting to ensure effective utilisation of services. In order to ensure the development of a local resource map for older persons the local Governance group should ensure:
• Consultation with the third sector, local authority, age friendly alliance, older persons council
• Regular updating and management of the directory developed.
Mapping of local resources, together with the population profile created through Step 2 will inform the next stage in the process, Developing Services and Care Pathways.
Step 4: Develop Services and Care Pathways
Develop Services and Care Pathways “Comprehensive Geriatric Assessment (CGA) is the organised approach to assessment designed to determine an older persons medical conditions, mental health, functional capacity and social circumstances. Its purpose is to coordinate and develop an integrated plan for treatment and rehabilitation, support and long term follow up.” NCPOP, 2016.
• Conduct care pathway mapping exercise which ensures potential for access to CGA is maximised.
• Prioritise key pathways and services to be developed for older persons in areas including frailty, falls and dementia.
Step 5: Develop New Ways of Working
Develop a case management approach to manage the care needs of older people with the highest level of complexity.
Step 6: Develop MDT Teamwork and Create Clinical Network Hub
a. Develop a multidisciplinary teams approach to co-ordinate older persons health and social care needs.
b. Establish a clinical network hub to manage current and emerging needs of older people with frailty and complex care needs.
Step 7: Person Centred Care Planning and Service Delivery
a. Develop an approach to care planning that is person centred, longer term and coordinated to include user and carer input.
b. Engage with older people as equal partners in planning, developing and monitoring care to meet their needs.
c. Engage with local older people through structures such as the Older Person’s Council facilitating a co-production approach to service improvement/service design.
Step 8: Supports to Live Well
Local service leaders to work with voluntary agencies in developing a range of community supports that enable older persons to live well in their community.
Step 9: Enablers
a. Exploit existing and new technologies in hospitals and community services to enable clinical information sharing across settings, coordination of care and support of older persons to live well at home.
b. Work with local Information and Communication Technology (ICT) departments to identify tools that can be implemented
• InrerRAI Assessment Tool (CGA)
• Healthlink (e-referrals e-discharge etc.)
• Link to Hospital Patient Administrative Systems (PAS)
• Local innovations in Telehealth and assistive technologies
c. Have a local workforce plan that reflects the needs of older persons.
Step 10: Monitor and Evaluate
a. Measure the scale of integration with ICPOP Structural measures (10 Steps framework)
b. Measure care process using ICPOP Clinical management indicators
c. Measure outcomes using ICPOP Patient recorded outcome and experience measures (PROMS & PREMS)
d. Measure clinical outcomes
e. Measure staff experience