The Esteem Team Co-ordinated care in the Sandwell Integrated Primary Care Mental Health and Wellbeing Service

The Esteem Team Co-ordinated care in the Sandwell Integrated Primary Care Mental Health and Wellbeing ServiceAge-related chronic and complex medical conditions account for the largest and growing share of health care budgets in all industrialised nations. However, people living with multiple health and social care needs often experience a highly fragmented service leading to sub-optimal care experiences, outcomes and costs. To address this, strategies of care co-ordination have been developed to promote more cost-effective care through integrated services.

For older people in need of both health and social care support, the divisions in the organisation, funding and delivery of care in the United Kingdom (UK) can result in poor user experiences and outcomes. There have been many innovative projects to promote better care co-ordination for older people, but these have often not met their objectives and the failure rate has been high because of poorly designed interventions, difficulties in targeting those most likely to benefit from care co-ordination and the unmet patient needs that improved follow-up can uncover. There is a lack of knowledge about how best to apply care co-ordination tools in practice.

This case study is part of a research project undertaken by The King’s Fund and funded by Aetna and the Aetna Foundation in the USA to compare five successful UK-based models of care co-ordination (see Appendix 1 for methods used to collect the study data).

The aim of each case study has been to

  • understand the strategies used to deliver care co-ordination effectively
  • examine barriers and facilitators to successful care co-ordination
  • isolate key markers for success for the practical application of the tools and techniques of care co-ordination, and
  • to identify lessons in how care co-ordination canbest be supported in terms of planning, organisation and leadership.

In the video below the team at Sandwell Integrated Primary Care Mental Health and Wellbeing Service explain their approach to co-ordinated care. The service uses care co-ordinators who work with individuals with a range of complex needs, such as those with severe mental illness, to help them navigate and access a wide variety of primary care-based mental health and wellbeing services that support their needs.

The organogram below illustrates the care planning/co-ordination process.

The Esteem Team care planning/co-ordination process

Further details about this project can be found at