Why don’t care coordination interventions work?

Trials of care coordination are often disappointing. Well, they quite often show improved quality of care and improved patient experience but they rarely seem to save money. Which is a pity because that’s often why they’re set up. Or at least the mantra is “Fragmented care is wasteful, so if we get it better coordinated, medical care will be cheaper with fewer unnecessary admissions etc”. And then everyone is disappointed when the negative evaluation findings come out.

Some interesting light was thrown on this at a recent meeting that the Nuffield Trust and Commonwealth Fund held on high cost high need patients. It all came down to timing. Tim Ferris described experience from his healthcare system in Boston where they found that care coordination does save money but only if you wait long enough. Interventions (including identifying high risk patients, case management etc) cost more in the first six months or so. But then there was a tipping point at about 18 months after patient enrollment in the schemes, after which they became cost saving. So a three year period was really needed to know if they were saving money as well as improving care.

How is this relevant to the UK? Well, when did you last see an NHS reform that was given three years to run before anyone decided whether it was working or not? By that time we’d have reorganised the NHS again. In our research we’ve shown that interventions that integrate care are slow to get going and often depend on developing personal relationships and trust between organisations not used to working with each other (1). So maybe the problem in the UK is that we’re always in such a rush to find a quick fix to the NHS’s finance problems that we just don’t wait long enough.

Tim Ferris also suggested that if you’re trying to prevent admissions, choosing the right patient group is critical. If you choose patients at very high risk of admission (e.g. the 2% at greatest risk) you don’t save money because there’s just not that much you can do with these very sick people. On the other hand, if you spread the net too wide, the intervention is going to be too costly to show any chance of being cost effective. The ‘sweet spot’ is to identify people at high risk but not very high risk of admission. That’s where you’re most likely to get a bang for your buck.

Ling T, Brereton L, Conklin A, Newbould J, Roland M. Barriers and facilitators to integrating care: experiences from the English Integrated Care Pilots. International Journal of Integrated Care 2012. July- September Vol 12.

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  • The Cambridge Centre for Health Services Research (CCHSR) is a thriving collaboration between the University of Cambridge and RAND Europe. We aim to inform health policy and practice by conducting research and evaluation studies of organisation and delivery of healthcare, including safety, effectiveness, efficiency and patient experience.