Population Health Management in Diabetes Care: Combining Clinical Audit, Risk Stratification, and Multidisciplinary Virtual Clinics in a Community Setting to Improve Diabetes Care in a Geographically Defined Population. An Integrated Diabetes Care Pilot in the North East Locality, Oxfordshire, UK

Disparities in diabetes care are prevalent, with significant inequalities observed in access to, and outcomes of, healthcare. A population health approach offers a solution to improve the quality of care for all with systematic ways of assessing whole population requirements and treating and monitoring sub-groups in need of additional attention.

Collaborative working between primary, secondary and community care was introduced in seven primary care practices in one locality in England, UK, caring for 3560 patients with diabetes and sharing the same community and secondary specialist diabetes care providers. Three elements of the intervention included 1) clinical audit, 2) risk stratification ...

Primary care networks explained

The National Health Service (NHS) is the umbrella term for the publicly-funded healthcare systems of the United Kingdom (UK). Since 1948 they have been funded out of general taxation. There are four systems, one for each of the four countries of the UK: The NHS in England, NHS Scotland, NHS Wales and Health and Social Care in Northern Ireland. They were established together in 1948 as one of the major social reforms following the Second World War. The founding principles were that services should be comprehensive, universal and free at the point of delivery a health service based on clinical ...

Indicators of an Integrated Home Care Model Shaped by the Needs of Patients Discharged from the Emergency Department

Developing community care models aims to satisfy the needs of patients’ in-home care comprehensively. This is crucial to decrease adverse events and prevent rehospitalization.

The growing burden of chronic diseases, patients experiencing fragmented care, and increasing demand for coordination across providers in the health and social sector correlates with the need for the integration of care. The starting point in developing an integrated care strategy should be identifying and assessing population needs.

Models of integrated care may enhance patient satisfaction, increase the perceived quality of care, and enable access to services. The term ‘new models of care’ refers to a ...

Finding the Person in Electronic Health Records. A Mixed-methods Analysis of Person-centered Content and Language

The co-creation and sharing of documentation of person-centered care is important, but challenging in clinical practice. Online access to health records is considered essential to increase patient participation and empowerment in person-centered care provision.

The aims of this study were (1) to identify the extent of person-centered content in medical inpatient records and discharge letters; (2) to describe the characteristics of the language and rhetoric used in discharge letters.

Established norms for documentation in healthcare are a barrier to person-centered documentation. Patients’ needs and preferences about documentation should be explored to increase understanding of how person-centered documentation can be achieved ...

The long-term impacts of new care models on hospital use: An evaluation of the Integrated Care Transformation Programme in Mid-Nottinghamshire

In this briefing, the Improvement Analytics Unit – a partnership between the Health Foundation and NHS England and NHS Improvement – has found evidence that integrated care programmes have the potential to reduce hospital utilisation and that the best results are delivered when new ways of working start to become embedded.   

It is important that the analysis was?able to?look?at the impact of the programme?over such a long time. Integrated care programmes usually aim to reduce hospital admissions, however previous?evaluations?were not able to demonstrate?whether reductions in hospital use might begin to materialise over a longer period ...

“It’s Difficult, There’s No Formula”: Qualitative Study of Stroke Related Communication Between Primary and Secondary Healthcare Professionals

The proportion of people living with stroke is growing. In England, National Institute for Health and Care Excellence (NICE) Guidelines for stroke recommend that a person with suspected or confirmed stroke event is admitted to a specialist stroke unit, in order to receive required treatment promptly. Stroke rehabilitation follows, which involves providing stroke survivors with support and treatment from a multidisciplinary rehabilitation team. Stroke survivors’ transition from acute settings to rehabilitation can take place either in hospital, at home or the community.

One model of care is Early Supported Discharge (ESD), which offers community-based health and social care as an ...

F@ce: a team-based, person-centred intervention for rehabilitation after stroke supported by information and communication technology – a feasibility study

Despite encouraging data about declining stroke incidence, on a global level the aging population and accumulating risk factors contribute to an increasing lifetime risk of stroke. Per the Global Burden of Disease 2016 Lifetime Risk of Stroke Collaborators, the mean global lifetime risk of stroke increased from 22.8% in 1990 to 24.9% in 2016, a relative increase of 8.9% (95% CI, 6.2%–11.5%) after accounting for the competing risk of death of any cause other than stroke.

Globally, there is a growing use of Information and Communication Technology (ICT), including mobile phones, tablets and computers ...

Goal-Oriented Care: A Catalyst for Person-Centred System Integration

Person-centred integrated care is often at odds with how current health care systems are structured, resulting in slower than expected uptake of the model worldwide. Adopting goal-oriented care, an approach which uses patient priorities, or goals, to drive what kinds of care are appropriate and how care is delivered, may offer a way to improve implementation.

(Dis)Integrated Care? Lessons from East London

This paper examines one of the NHS England Pioneers programmes of Integrated Care, which was implemented in three localities in East London, covering the area served by one of the largest hospital groups in the UK and bringing together commissioners, providers and local authorities. The partners agreed to build a model of integrated care that focused on the whole person.

This qualitative and participatory evaluation looked at how an ambitious vision translated into the delivery of integrated care on the ground. The study explored the micro-mechanisms of integrated care relationships based on the experience of health and social care professionals ...

Integrated health and care systems in England: can they help prevent disease?

The National Health Service (NHS) in England plans for the entire country to be covered by integrated care systems (ICSs) by April 2021. The aims of these local health and care partnerships are broad and include improving disease prevention and population health while maintaining NHS financial sustainability. Yet, the evidence for more integrated care leading to better disease prevention is weak.

Although nearly all of the 2016 sustainability and transformation partnership (STP) plans included a prevention or population health strategy, the content varied widely, often lacked detail, and had little on population-level interventions affecting the social determinants of health.

The ...