Co-ordinated care for people with complex chronic conditions: Key lessons and markers for success

Co-ordinated care for people with complex chronic conditions: Key lessons and markers for successThis report, published by The King’s Fund, explores the key components of effective co-ordinated care through a study of five UK-based programmes that deliver co-ordinated care for people with long-term and complex needs.

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Key requirements for successful care co-ordination

  • A holistic focus that supports patients and carers to become more functional, independent and resilient is preferable to a purely clinical focus on managing or treating symptoms.
  • Building community awareness of and trust in care co-ordination programmes promotes legitimacy and engagement.
  • Effective communication based on good working relationships between members of the multidisciplinary team is essential. Shared electronic health records can support the process, but a ‘high-touch, low-tech’ approach can also be very effective.
  • Care co-ordination programmes should be localised so that they address the priorities of specific communities. Leadership and commitment (from commissioners and providers alike) is vital to establish a shared vision and challenge silo-based working.
  • Integrated health and social care commissioning can support longer-term strategies and provide greater stability.