How will providers deliver care?
The new models of care will require professionals delivering care to behave in different ways. This includes working with service users and carers so they are more empowered to set their own care goals and manage their own well-being, being part of a multi-disciplinary team and delivering more responsive and proactive care. They will need information systems to achieve this to help communicate with service users, carers and colleagues in their team, coordinate with colleagues about the care individuals are receiving and understand how individuals and their team are performing.
The expectation is that there will be different care models for different population groups. However, the working group has identified the core principles of care delivery that will apply regardless of care model choices and analysed the information needs, data and tools they imply.
What tools are needed for care delivery?
Care delivery will require the following tools that analyse and then display information collected in the data warehouse and provider systems:
Service user registry. To support an effective and truly integrated delivery of care, providers will need to have access to an accurate summary of information for each individual in their care, with input from all providers, the care coordinator and the service user.
Population analytics. Similar to commissioners and to the provider network organisation, individual providers and care teams should have the ability to define and measure indicators on their population’s needs, activity, outcomes and costs.
Service user identification capability. Care teams will have to care for a specific population group and therefore the segmentation capability is not necessary. However, providers will need to employ a more granular approach (e.g., risk stratification) to identify specific service users that they will need to focus more attention on.
Care planning capability. The care coordinator will need to have the ability to create a care plan and review progress and results. The care plan will be the road map for the integrated care that the individual will receive, ensuring its appropriateness and timeliness. As part of the care planning process, access to a library of care protocols should also be available, to support decision-making and ensure that the care plan being created is in line with relevant guidelines and best practices.
Intervention management capability. To ensure that they can respond to the specific needs of individuals in a timely fashion, care teams should be alerted to relevant events. This could include alerts issued when an individual requires an intervention (e.g., vaccination reminders), based on recent events (e.g., discharge from hospital) or on a "care gap analysis”.
Delivery analytics. A core principle of care delivery in Whole Systems Integrated Care is that the progress and impact of the care delivered to specific individuals and groups will have to be carefully monitored. Care teams should review the care they are delivering multiple times a week. Similarly, the individual and the care coordinator should have a review interaction at least annually to discuss the impact of the care the individual has received. These types of reviews will need to be informed by adhoc analytics that track metrics tied to specific care plans and models and are therefore different from the higher level outcome and service standard indicators determined by commissioners or the provider organisation.
Remote monitoring capability. Whole Systems Integrated Care has the objective of supporting user empowerment and the ability of individuals to receive appropriate care in their home and, where appropriate, to self-manage. To enable this, providers should have the ability to monitor certain service users remotely.