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Delivering integrated care

[The] call by Mr Miliband for an integrated NHS where “services are designed around the needs of patients [with] teams of doctors, nurses, social workers and therapists all working together”, combined with “a greater focus on preventing people getting ill and more care being provided directly in people’s homes so they avoid unnecessary hospital visits” is a very welcome call indeed and one which supports an integrated, community-centric care model centred around health coaching.

With £7 out of every £10 in the NHS being spent on the management of long term conditions such as diabetes, obesity and cancer, combined with an ageing demographic, it is vital that a more sustainable way of delivering healthcare is achieved.

Placing the patient at the centre of the process and providing each individual with greater insight to and responsibility for their care choices, while enabling the management thereof to be seamlessly integrated with local care pathways is the key to improved patient outcomes and a more efficient NHS. And examples where integrated care is being delivered in this way are already being evidenced within the NHS today.

Leicester City CCG has benefited from averting 22 hospital admissions across a group of 30 COPD patients in the first seven weeks of a scheme combining telehealth with a health coaching programme for support of the long-term condition.

Specialist health coaches are registered nurses that provide support and mentor patients, in their own homes, in partnership with local health organisations. They can make a huge difference to individuals diagnosed with long-term conditions; many of whom require on-going care by addressing key concerns about their condition via two-way phone calls. This technique is emerging as a powerful platform to nurture informed patients, help them change unhelpful thinking patterns, make lifestyle choices and set goals, and proactively manage their condition.

Health coaches can talk to patients, using the correct, non-directive, terminology and suggest whether they need to report symptoms to their GP which crucially may provide the necessary spur a patient requires to help early diagnosis, prevent an unplanned hospital admission and improve health outcomes. Critically, the information patients share is clearly, securely and privately available online to be shared between health and social care professionals.

In order to improve care services and reduce the burden on the NHS, we need an integrated care system, where the key components of patient-centric services, such as electronic healthcare and telehealth, are joined together with health coaching providing a human mechanism to sit at the centre and evaluate all available, linked data, and identify areas where technology can help reduce costs, improve care pathways and get care delivered to patients in the place where they want it most – the home.

Wendy Lawrence, CEO, Totally Health

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