We understand the barriers to effective care co-ordination, and how to overcome them. In our experience, these barriers stem from:
- The complexity and fragmentation of the health and care system
- The lack of an integrated electronic health record system to inform referrals, track patients as they move between providers, and capture health outcomes
- The difficulty of capturing a comprehensive real-time view of demand and capacity at patient and system-wide level
- The scale and complexity of acute settings
- Limited understanding of the range, volume and speed of provision required in alternative settings for timely transition to lower levels of care.
These barriers, whilst significant, are not insurmountable. With our strategic suppliers, we are addressing them with the tools and processes we have developed for:
- Providing live or near real-time data on demand and capacity across the system
- Accurately predicting the clinical/non-clinical support required to meet seasonal fluctuations in need
- Facilitating capacity management to monitor and direct patient flow
- Improving the management of patient flow within acute settings so that resources for care co-ordination are better directed.
We are working with primary and acute care providers, local authorities and CCGs in our operating region to introduce an integrated approach to health and social care. This work involves strategic insight, organisational development, and analytical and operational services to support the effective implementation of ICS/STPs.
In the absence of a single electronic health record, we are incorporating existing care records, patient information and performance data from a range of sources into the following resources, tools and processes, which we use to co-ordinate care and minimise transfer delays:
- Our regional capacity management team provides an urgent care operational planning function that engages the whole health economy to manage demand and flow, including surge and support for seasonal plans
- Our Urgent Care Intelligence Centre (UCIC) constantly monitors live or near real-time intelligence on regional demand and capacity to provide timely alerts to the health system which help to maintain patient flow through the whole urgent and emergency care pathway
- Online ‘what if’ analysis tools, and our expertise in scenario planning, clinical impact assessment and assessment of workforce needs
- Intelligence sources to support high-quality decision-making, building the clinical case for change based on ‘assess to admit’ rather than ‘admit to assess’
- EMSPlus, an urgent care system tracker that captures information on which ambulances are heading to which hospitals, how many are on site awaiting handover and how many have completed handover. It also captures real-time A&E, bed state and delayed discharge information.
