INTEGRATED, COORDINATED STEPPED CARE
Making Partnerships Work For Communities
WHAT IS INDIVIDUALIZED STEPPED COORDINATED CARE?
Stepped coordinated care provides a framework for the care of patients with chronic illnesses that uses limited resources to their greatest effect on a population basis. Stepped coordinated care is based on three assumptions: different people require different levels of care; finding the right level of care often depends on monitoring outcomes; and moving from lower to higher levels of care based on patient outcomes often increases effectiveness and lowers costs overall.
The use of stepped coordinated care has been advocated for many chronic conditions, including but not limited to Hypertension, Obesity, Cancer, Circulatory Disease Including CVD, Respiratory Disease Including COPD, Diabetes and Pre-Diabetes, Mellitus, Nicotine Dependence, High Cholesterol levels, Asthma, Bulimia, Gastroesophageal Reflux, Back Pain, Musculoskeletal Conditions and Injury, Alcohol and Drug Dependence, Mental Illness including Depression and Anxiety. The Stepped-Care processes is defined as “the least costly, least intensive, and least restrictive (that is, requiring the least total life-style change for the individual). Treatment judged as sufficient to meet the person’s needs and goals should be attempted initially before more costly and restrictive treatments are attempted.” Although stepped coordinated care is guided by the response to treatment, tailoring the care based on severity, clinical status, and patient preferences is appropriate so first-line treatment is not always the least intensive, least restrictive, or least expensive regimen. Initial and subsequent treatments are selected according to evidence-based guidelines in line with patient goals, treatment preferences, and clinical status. Patient adherence, treatment response, and outcomes are actively monitored and treatments modified as needed to achieve the best possible outcome for each patient.
ORGANIZING STEPPED COORDINATED CARE
In stepped coordinated care, the intensity of professional care is augmented for patients who do not achieve an acceptable outcome with lower levels of care. A stepped-care model defines five levels of professional support for managing chronic disease. In this scheme, a well population, at risk population and individuals experiencing mild, acute and chronic conditions receive care using evidence-based guidelines, and all use collaborative management. The level or intensity of care is guided by observed outcomes. Active follow-up is used to determine the level of care each patient or population requires over time.
Individualized stepped coordinated care is an approach in which simpler, less restrictive, less intensive, or less expensive interventions, or a combination, are used initially, followed by care based on guidelines for patients who have an inadequate response. Care is guided by the patient’s response to treatment and by a schedule for preventive maintenance, not by diagnosis alone. Stepped-care principles provide a framework for organizing and allocating the limited professional resources available for decision support, self-management support, and active follow-up in the care of chronic illnesses. Stepped coordinated care may allow primary health care physicians to transcend the gatekeeper role. However, this broader responsibility for coordinating care needs to draw on different members of a treatment team (the patient, the care coordinator, and the specialist-consultant) as the needs of patients emerge. The primary care team provides continuity and support for patients adapting to the changing demands of chronic illness. The care manager and specialist-consultant provide targeted services to ensure that patients achieve the best possible outcomes. At all levels of coordinated stepped coordinated care, supporting the patient’s role in self-management is essential: the patient is an integral part of the team.
Stepped coordinated care draws on the strengths of primary health care to care for patients with chronic illnesses without compromising the primary health care physician’s core responsibilities in both acute and chronic illness care. It emphasizes general capabilities in chronic illness care, such as treatment planning, patient education, active follow up, and outcomes monitoring. As primary care becomes better organized to provide these general care services for patients with chronic illness, the strengths of primary health care for managing chronic illness may come to the fore.
Care Coordination Team
Patient-Centered Team-Based Care
Of all of the changes envisioned as part of the transformation to provide an improved health service and provide a more patient-centered rural primary health care service, perhaps none is more promising than the transition to Rural Health Tasmania’s team-based delivery of care. Rural Health Tasmania’s Coordinated stepped model of care is designed with the following principles at its core:
1.It is a patient/client centered team based care approach,
2.it is evidence based and outcomes focused,
3.It improves the comprehensiveness, coordination, efficiency, effectiveness, cost effectiveness and value of care, as well as the satisfaction of patients and providers.
4.It is at the cultural core of our organization of care, in the nature of interactions among colleagues and with patients, in education and training, and in the ways in which rural primary health care personnel and patients understand their roles and responsibilities.
5.There is clear clinical governance that identifies and effectively manages the roles,process, organisational structure, continuous quality improvement, risk management, recruitment and attainment of quality key personnel.
6.It clearly demonstrates and measures effectiveness in chronic disease management through well-defined patient reported outcome measures (PROMS) and patient experience outcome measures (PREMS).
Rural Health Tasmania Inc. Identifies that the health needs of the community are becoming more complex. With ageing populations, the growing rates of substance abuse, mental illness and other chronic disease, health systems are becoming increasingly complicated and fragmented. It has become increasingly important to us as an organisation to ensure that services, clinicians and systems in the rural primary health care setting work collaboratively as a team to ensure the best outcomes for the patient. Rural Health Tasmania Inc.’s Coordinated stepped model of care was developed with this in mind. The Coordinated stepped care model was developed in recognition that instead of the primary care clinician trying to do everything in a 20-minute appointment, a whole team of health care providers is responsible for the patient’s care – from nurses to doctors to community health workers to mental health specialists to pharmacists.
Under the coordinated stepped model of care, the team works together to anticipate the patient’s needs, communicate their findings with each other, and make sure no aspect of the patient’s health slips through the cracks. From the patient’s perspective, the coordinated stepped model of care is a one-stop shopping experience: In a single visit, a patient could receive treatment from his or her primary care clinician, do a preventative screening with a nurse and visit with a mental health specialist. In this approach, more is more – but it actually costs less and makes better use of the clinicians and patients time.