A Framework for Assessing Enablers and Risks in Health and Care System Integration

Integrated care is aimed at improving patient experience, delivering improved population health and care outcomes whilst containing cost. The hypothesis is that greater delivery integration will improve care co ordination, patient experience, patient safety and utilisation of resources; managing clinical risk in a patient centred manner. Different mechanisms have been proposed to promote greater health and care integration including accountable care networks on the provider side and outcomes based contracting on the commissioning side. This shift from current siloed operating models to greater integration and co ordination can be seen through a number of lenses. Optimity Advisors have developed an evidence based readiness assessment tool to inform the implementation of an integrated health and care system and enable rapid system wide sense making in the context of high degrees of complexity. It is designed to be applied from commencement through to post implementation stages to enable progress to be tracked. The tool is based on a review of the international evidence defining the success criteria for delivering integrated health and care. This paper sets out this evidence review and our approach to validating the framework and toolkit.  We conducted a rapid narrative review to answer the 'what do we know about the critical success factors for integration? question. We shortlisted 19 articles, case studies and reviews for in depth analysis. This literature review then informed an analytic framework which formed the basis of the readiness toolkit which was tested in a number of contexts. Much of the evidence was in the form of single case studies of integrated pathways for single diagnostic groups or health and care systems developing population based models of care. While many case studies acknowledged the importance of measuring progress against objectives, few have systematically established a baseline. The readiness toolkit Creating a sustainable integrated care system (ICS) is complex and challenging The readiness assessment tool can support the initial phase of creating an ICS and assess the readiness of individual health and care providers to become part of an ICS. This tool identifies providers' readiness by assessing them against criteria categorised into twelve domains (figure 1)  The 12 domains in the readiness assessment tool. Each domain has a set of questions to evaluate a health care provider's position from "very high risk" to "all risks actively managed" (risks of not meeting metrics) and is calibrated on a scale from 1 to 6 "all risks actively managed" The readiness assessment is done through semi structured interviews, document reviews, online surveys and facilitated workshops, all of which gauge the providers' readiness and current capabilities. Interviews conducted with key stakeholders, professionals and service users allow potential risks and barriers that need mitigating to surface early on. It also helps to identify good practice examples that can be diffused across the system. Document reviews can include vision, strategy and implementation plans and the online surveys can be used to validate information obtained in the interviews and gather new information. It is clear that the readiness of providers will differ. This readiness assessment tool, identifies where the priorities are for transformation, and by encouraging an honest self appraisal, helps to overcome the optimism bias normally associated with the initial planning stages.  The readiness assessment tool has been applied in five health and care economies in the UK. These have included a broad range of stakeholders including public health, general practice, primary and community care, secondary or hospital services, and social care. The model has been refined over 18 months of application and the number of domains has extended from 11 to 12 as findings are incorporated into the conceptual model. The tool has been validated through field work in terms of its practicality, adaptability and value. Literature also supports the early adoption of a readiness tool in the context of system wide change Using a tool like this supports the agreement of a statement of vision and intent provides a framework for gaining consensus of outcome, a critical success factor for integrated care systems Furthermore, the model is presently being embedded within organisations in London and the initial findings are that early detection of risks and barriers can alleviate failure along the integration journey by allowing identification of collective strengths and areas needed to build on.  Ultimately, the tool, enables systems to catalyse integrated health care system implementation; providing a flexible framework with which to work and illustrate priorities for operational transformation and improvement. The model has successfully enabled organisations to adapt and create sustainable health care organisations in the UK.  Testing, evaluating and learning what works. 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