How to enable patients to be healthier in the comfort of their own homes

For UK healthcare providers, the shift from hospital to home is an opportunity to address capacity concerns while building cohesion across local authority commissioned social care, the third sector, GPs, and hospitals. To do this successfully, healthcare providers need to collaborate across the ecosystem, drawing on the expertise of pharma and medtech companies, and local health and care stakeholders. In the UK, Integrated Care Systems (ICSs) are accelerating the shift by focusing on improving collaboration and joining up health and care services to help people remain healthier at home.

Encouraging collaboration

By embedding the right formal structures and collaborative working processes, health and social care providers can share meaningful insights, understand priorities, and deliver higher quality interventions. However, our research shows that over half of global respondents are sceptical about ecosystem collaboration. To enable the adoption of solutions that move care from hospital to home, healthcare ecosystem stakeholders need to collaborate in the design, mapping, investment, and delivery and all key stages of the patient journey. This is especially critical when health and social care responsibilities intersect.

ICSs aid collaboration by bringing together relevant partners in the complex healthcare ecosystem, facilitating the co-design and co-delivery of health and social care services that meet local needs. The pivotal role that ICSs play in leading collaboration is highlighted in the NHS workforce plan. We know from experience that effective collaboration between health and social care can reduce admissions and expedite hospital discharge – in April 2023 our Argenti technology service in Hampshire received 17,000 calls, but due to Argenti’s effective triage just 727 of these calls were forwarded to the ambulance service. Get the approach to admissions right, and the pressure is relieved.

Solving complexity

The UK is home to over 200 NHS provider organisations and thousands of GP practices, all governed differently. Added to this are almost 11,000 CQC-registered domiciliary care providers. As a result, patient experiences can be disjointed and different, which doesn’t feel right or fair. Coordination across local care services, the third sector, and clinicians will help to standardise high quality care, smooth out the patient journey, and enable care delivery in the most appropriate, cost-effective location – often the home.

ICSs aim to meet increasingly complex health and social care needs by enabling partners to co-design patient-centric solutions. The only way to do this is to combine the expertise, resources, and knowledge of all ecosystem stakeholders. This includes sharing data and real-world insights about how solutions are used in practice, and the outcomes they achieve. By ensuring data is securely captured and analysed, health system stakeholders can uncover meaningful insights that support proactive care planning within a Population Health Management (PHP) approach. This approach helps to shift care from hospital to home by using data to anticipate and manage undesirable events such as emergency hospital admission and falls, proactively preventing admissions while improving resource planning and capacity when admissions are necessary.

Changing communication

Every stakeholder in the health and care ecosystem wants to achieve better patient outcomes. But despite the potential benefits of moving care to the home, our research shows that barely a third (28 percent) of healthcare professionals believe clinicians are enthusiastic about the transition. This isn’t surprising – clinicians naturally want to ensure patient safety while minimising risk and liability. They also need an evidence base to feel confident in adopting a new model of care. The new model of connected, technology-enabled care looks and feels very different to the current way of doing things. Clear communication, focusing on patient outcomes rather than the technology itself, is the only way to bring clinicians and other health and social care professionals on board.

Effective communication helps to align and focus multiple partners, enabling higher quality care in the most appropriate location. The question is how to communicate in the best way – with who, through which channels, and when? The first step in developing an effective communication strategy is working out who should be brought to the table and what their priorities are. This is where ICSs come in. By providing a formal framework for connected ecosystems, ICSs make it easier to identify communication channels and the information that can and needs to be shared. This evidences positive outcomes, motivating stakeholders – including clinicians – by easing concerns around safety and risk. Take, for example, virtual consultations. Companies such as Babylon Health have paved the way for remote assessment, diagnosis, and treatment of patients through both paid and state funded service models.

Securely sharing the real-world data that connected solutions collect, such as patient usage habits and solution efficacy, can inform future developments. When communicated effectively with the right ICS partners, this information provides a sound basis for wider adoption and improvements over time.

ICSs provide fertile ground for the growth of home-based care solutions. Equally, transitioning care from hospital to home strengthens the collaborative, community-focused fabric of ICSs. By embracing the approach, objectives, and purpose of ICSs, health and social care providers can support the delivery of personalised, preventative care solutions and create strong foundations for ongoing collaboration. When partners come together to build solutions that answer unique requirements, people can remain healthier at home for the longest possible time. Everybody wins.

This article was first published in Health Business.