How to deliver integrated care alongside effective staff engagement

Integration is being pushed hard. The King’s Fund report Integrated Care for Patients and Populations asserts that it should have the same priority over the next decade as waiting time initiatives have had in the last. However, there is still no definitive definition of exactly what constitutes integrated care.

As someone who believes they have achieved and experienced integrated care, I am in no doubt that it is definable. I suggest: “Care that is drawn together by a cohesive unit to collaboratively manage complex care needs to the mutual benefit of all parties, with the ultimate goal of efficiently improving personalisation, choice and care outcomes for individuals.”

Ultimately, integrated care enables operational performance objectives – such as speed, responsiveness, dependability, quality and cost – to be defined collectively, with a mutual appreciation of trade-offs and the streamlining of processes to reduce variation.

Local collaboration has the potential to not only reduce risks to patient care pathways that result from changes in the competitive market, but also to collectively enhance the business position of each individual organisation as well as the integrative whole.

Competitive advantage is enhanced by maximising performance via effective people management. Performance that assures value and the best experience for service users and patients is the key to competitive advantage. Managing and supporting staff across organisations and systems is challenging, but it is possible. And when it works this is a powerful motivator and catalyst for further developments.

Finding the best fit

In Greenwich, this style of people management is working well in several areas of integration across various pathways, including end of life care, long term conditions, virtual admission avoidance and intermediate care. Our integration project won the overall prize and the staff engagement category at the 2011 HSJ Awards.

Many elements of best practice have contributed to this, including clinical leadership, partnership working, collaboration, information sharing, recruitment, training and development. However, in integrated working, there are also bespoke “best fit” approaches that have enabled creative and lateral thinking to liberate opportunities to enhance performance outcomes through people management. In Greenwich these include engagement, job enrichment, talent management, development of depth and breadth of skills, ownership of change programmes, commitment to improvement and participation.

The best fit approach recognised the best practices available but built on key elements to create an organisational culture of innovation and success. The most important elements are the need to develop encouragement, good management practices, leadership, respect and trust across organisations. Ultimately this achieved employee commitment, flexibility, discretionary behaviour and job satisfaction which, in turn, improved efficiency, productivity and achieved organisational performance objectives.

The integrated community teams and a parallel integration of intermediate and adult social care have produced significant improvements in organisational performance. Although not empirically evaluated, there does seem to be a tangible link between performance development and performance achievement; while the former comprises leadership, recognising values, a focus on communication and visibility, and building culture and coaching to drive motivation, the latter employs discretionary effort and a willingness to think in an integrated manner. It is essential that this link is captured in demonstrable outcome measures that show the overall driver for organisational performance, focusing on how measuring effectiveness delivers strategic goals in order to understand what makes integrated working work well.

Empowered line managers are the key to delivery as well as building a trusting relationship between team members and
the organisation. We have observed success when clear communication and meaningful appraisals have been undertaken and when managers provide a supportive and coaching style through change.

We have evidence showing staff success is a motivator for continuous improvement and performance, be it in achieving overall performance improvements or being engaged in, and recognised for, contributions to successful new working models. The collective work of the integrated health and social care teams in Greenwich has enabled more older people to live independently following the interventions of those teams.

Measuring success

We have traditionally measured our performance using health related key performance indicators such as bed occupancy and length of stay in intermediate care, admission and accident and emergency avoidance, waiting times, referral rates and patient satisfaction. However, we must develop more patient related outcome measures to show exactly how interventions support the management of long term conditions and self care.

Integration enables joint key performance indicators that health and social care staff feel are important and in which they have a sense of pride. Moreover, the collective impact on social care performance provides useful proxy indicators for self care. For example, since April 2011 there has been a significant monthly saving in people not needing care packages after re-ablement. If all these people continued not to need a care package, that is an annual saving of over £300,000.

Re-ablement allows people – mainly frail, older people – to regain their independence in their own homes after a period of ill health. The result of not having care packages means that, for December 2011 alone, 973 hours have been saved and reinvested. In total, 61 per cent of service users completing re-ablement in December required no further support. There has been an overall reduction in intensive packages by 19 per cent and in overall care packages by 3 per cent. This dispelled our fears that we may have more people living at home with more complex care packages and needs.

In addition, early indications suggest admissions to care homes in Greenwich have substantially reduced in 2011-12. It is acknowledged that this draws heavily on social care data but this has only been achieved through integrated working and a joint goal. It helps make sense of the bigger picture and how we can work together to manage the complexities of an aging population with a combination of long term conditions and differing social needs.

In conjunction with risk stratification through a “finding the vulnerable” collaboration across primary, community, acute and social care, proactive work is further supporting self care opportunities at home. Integrated care will continue to provide better outcomes for people and new ways of working for staff. It is mutually beneficial for all involved – and most importantly the service user.