Integrated Care

Overview

The language of accountable care comes from the US, where accountable care organisations (ACOs) were set up under President Obama’s health reforms in an attempt to improve care and reduce growing costs.

NHS England has recently changed the name of accountable care systems to Integrated Care System. The basic idea behind Integrated care systems are that different organisations from the health and care system work together to improve the health of their local population by integrating services and tackling the causes of ill health.

Our Approach

As a Chosen Care patient, you will receive more coordinated care from our team of Social Care Managers, nurses and other professionals who develop your personalised care plan for you to achieve and maintain wellness. You are at the center of the Chosen Care Team, the personalised more coordinated approach to care allows you and your family to have an active voice in your care and decision making.

We are committed to providing you with an excellent care experience by helping guide you through all the care you need. We help you with referrals to specialists, scheduling follow-up visits, and any questions you have on your path to better health.

Investing in Staff

Staff engagement was not only central to developing the strategic vision, but has also been key to deliver Integrated Care. Chosen Care group has invested in developing its staff’s capability and skills in innovation and change management and now has a 10 social services manager for individual case management.

Rehabilitation on enablement

Our community rehabilitation enablement and support team offers community- based rehabilitation to older people. The team supports people to return home from the hospital and to avoid care home admission. It began as a supported discharge service but has since been extended and ready to take referrals directly from GPs, helping to avoid hospital admissions. Chosen Care team provides intensive, community-based support, with a focus on rehabilitation and helping people to rebuild their social networks. Multidisciplinary support is provided for up to six weeks (up to four visits a day, seven days a week), and offers nursing services; occupational therapy and physiotherapy; support with activities of daily living; home-based rehabilitation; continuing clinical assessment to recognise any deterioration; personalised care plans; education for patients, their carers and families; and liaison with general practice.

Hospital Readmission Reduction

Hospital readmissions are important to patients, families, clinicians, and policy makers throughout the world, as reducing these events can improve care and reduce costs. Our assessment and development of a personalised social needs plan for enrolled patients (e.g. transportation and community resource identification), with post-discharge follow-up calls reduce hospital readmission. “We have the potential of impacting one’s overall health if we can assist with those social determinants, such as paying bills and having access to fresh food” Patients are uncertain and vulnerable when discharged after a long hospitalisation. These patients shift from being dependent and complacent while hospitalised to having significant responsibilities, which can potentially affect their risks for readmission. Our Hospital readmission programme includes enhanced Patient education and staff training. Patients who have a clear understanding of their after-hospital care instructions, including how to take their medicines and when to make follow- up appointments, are 30 percent less likely to be readmitted or visit the emergency department than patients. Our staffs are trained to promote patient health and carry out health-care services and who acts as a link between formal health services and patients, especially those at high-risk. Our staffs perform specific, delineated tasks, like assisting during medical appointments and providing access to transportation.

Technology

Improving and developing new IT systems has been a key part of Chosen Care move towards working as an integrated system. Progress has required, partnership innovation and investment. Our key development includes “Deep Learning Cure App” DLCare which enables citizens to stay healthy long and reduce hospital admission.

Electronic shared care record view

The electronic shared care record view is a secure online summary of care record, combining of the care plan, daily notes and medication record sheet. The access to shared record has been key to the success of some of the new ways of working implemented Integrated Care system in the community.

Enhanced

out-of-hours

Our staff are available and can access all rota and relevant company information 24/7, 365 days per year through a cloud-based package ensuring maximum information access and communication and available to deliver quality care all time.

Empathy Gap

As the healthcare system continues to come under increased pressure to maximise throughput and treat patients more efficiently, there is a growing body of work in Artificial Intelligence (AI) to optimize everything from diagnosing a patient to designing treatment plans, however in the push to make healthcare increasingly efficient, it is also coming at the expense of empathy.

Compassion is great medicine, enabling patients to thrive, frontline workers to rediscover their passion for healing and health systems to prosper. Our Empathy Programs build engaged and resilient frontline staff who are prepared to provide the most compassionate and patient-centered care possible. To care for and show compassion for patients takes emotional strength and resilience, it requires staff to see the person in the patient, listen to their fears, concerns and worries, to empathies and to imagine yourself in their shoes, not least to be able to help them improve.  

We orient, train and provide ongoing support to staffs also provide a group discussion once a month at lunchtime, with lunch provided, dedicated to frontline staffs describing their experience of a patient-care scenario. The facilitator leads 45 minutes of discussion and reflection to explore issues raised by this case. Only staff members partake in the rounds and all discussion is confidential. Frontline workers who participated in multiple Empathy Rounds sessions reported:

  • Increased insight into the social and emotional aspects of patient care; increased feelings of compassion toward patients; and increased readiness to respond to patients’ and families’ needs.
  • Improved teamwork, interdisciplinary communication, and appreciation for the roles and contributions of colleagues from different disciplines.
  • Decreased feelings of stress and isolation, and more openness to giving and receiving support.
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