Collaborative action for person-centred coordinated care (P3C): an approach to support the development of a comprehensive system-wide solution to fragmented care

Abstract

Background: Fragmented care results in poor outcomes for individuals with complexity of need. Person-centred coordinated care (P3C) is perceived to be a potential solution, but an absence of accessible evidence and the lack of a scalable 'blue print' mean that services are 'experimenting' with new models of care with little guidance and support. This paper presents an approach to the implementation of P3C using collaborative action, providing examples of early developments across this programme of work, the core aim of which is to accelerate the spread and adoption of P3C in United Kingdom primary care settings.

Methods: Two centrally funded United Kingdom organisations (South West Collaboration for Leadership in Applied Health Research and Care and South West Academic Health Science Network) are leading this initiative to narrow the gap between research and practice in this urgent area of improvement through a programme of service change, evaluation and research. Multi-stakeholder engagement and co-design are core to the approach. A whole system measurement framework combines outcomes of importance to patients, practitioners and health organisations. Iterative and multi-level feedback helps to shape service change while collecting practice-based data to generate implementation knowledge for the delivery of P3C. The role of the research team is proving vital to support informed change and challenge organisational practice. The bidirectional flow of knowledge and evidence relies on the transitional positioning of researchers and research organisations.

Results: Extensive engagement and embedded researchers have led to strong collaborations across the region. Practice is beginning to show signs of change and data flow and exchange is taking place. However, working in this way is not without its challenges; progress has been slow in the development of a linked data set to allow us to assess impact innovations from a cost perspective. Trust is vital, takes time to establish and is dependent on the exchange of services and interactions. If collaborative action can foster P3C it will require sustained commitment from both research and practice. This approach is a radical departure from how policy, research and practice traditionally work, but one that we argue is now necessary to deal with the most complex health and social problems.

Keywords: Collaborative action; Integration; Person-centred coordinated care.

Fig. 1

Collective action: an alignment of resources for promoting and supporting person-centred coordinated care (P3C). Grey vertical pillars represent the positioning and type of organisations that are partners in the Collaborative effort. The light grey box and orange box depict the ways in which we come to know of the challenges and potential solutions to service redesign for P3C, and how we use this knowledge to inform practice and our emerging theory. The dark grey boxes and the beige box represent how, through specific projects and service development innovations, we are able to develop insights about what works and how we feed this back into practical efforts to support on-going development. The yellow boxes represent the scale of change, this could be a specific service or a system wide approach and how knowledge from these initiatives flows into the development of practice, the development of theory or defining specific research projects. The blue arrows represent the flow of knowledge around the system

Fig. 2

Overarching logic model and evaluation domains for person-centred coordinated care across a system. Pink box represents the organisational changes and support that needs to take place with the arrow linking to the potential impact of this on how practitioners work with patients and how this impacts on their experiences of delivering care. The centre purple boxes represent patient and family/supporter activities and how these influence and are influenced by care interactions. The large blue arrows show how these activities have the potential to influence patient outcomes and experiences of care. The yellow box represent system outcomes and processes around cost and provision of care. These processes and outcomes are influenced by organisational processes (pink box) and, in turn, influence patient experiences of care

Fig. 3

South West United Kingdom practice-based evaluations of person-centred coordinated care. This figure depicts a map of the South West of England showing the counties and the sites with which the collaborative works

Fig. 4

Multi-perspective, multi-level measurement of change with specified measures. Purple boxes depict patient outcome domains, related questions and the measures used to gather this data. Similarly, the green boxes show the domains of interest aimed at practitioners. The red boxes depict the organisational process domains and the yellow boxes describe the cost activity outcomes to be measured. CSU clinical support unit

Fig. 5

Somerset Test and Learn: the roll out and adaption of the south Somerset Symphony model

Fig. 6

Local Implementation of Integrated Personal Commissioning (IPC) in the South West