WHO brief uses Scotland’s House of Care as an example of collaborative planning of care and shared decision-making.
The World Health Organization (WHO) has produced a practice brief on ‘continuity and coordination of care’ (this link will take you away from our website) intended to support the implementation of the WHO framework on integrated person-centred health services.
Without good continuity or coordination of care and support, many people with long term conditions, carers and families experience fragmented, poorly integrated care from many different providers. Poor communication between services can lead to duplication of investigations and avoidable hospital admissions or readmissions. This often results in poorer outcomes, undue stress and risk of harm to individuals and their families.
The WHO practice brief highlights eight key priorities for achieving greater continuity of care and care coordination:
- Continuity with a primary care professional
- Collaborative planning of care and shared decision-making
- Case management for people with complex needs
- Collocated services or a single point of access
- Transitional or intermediate care
- Comprehensive care along the entire pathway
- Technology to support continuity and care coordination
- Building workforce capability.
It draws out Scotland’s House of Care programme as a key example in the second priority: collaborative planning of care and shared decision-making. The care and support planning training devised and delivered by Year of Care (this link will take you away from our website) and the coordination of the Programme in Scotland provided by the ALLIANCE involves a generic approach attuned to the needs of people with several conditions by:
- collaborative planning of care and support;
- engaged, informed, empowered individuals and carers;
- a professional health and care team committed to working in partnership;
- harnessing informal and formal sources of support and care; and
- organisation and arrangements that enable the above.
Outcomes for people:
greater confidence, control, health and well-being; better experience of care; more self-care; increased knowledge, skills and satisfaction for professionals.
better organisation, teamwork and productivity in primary care; cost-neutral at practice level, but better biomarkers may increase health gains.
limited engagement with community partners, lack of awareness or trust in local community support; need for a cultural shift to relational and interpersonal practice at all levels.
connecting primary and secondary care professionals with a care pathway or clinical network as the entry point; asset mapping and accessible information on local support for well‑being.