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Community-Oriented Integrated Care

Community-Oriented Integrated Care (COIC) provides a vision for society where people of all backgrounds contribute to the health of whole populations. We think of it as whole system integration for health and care where everything comes together through geographic areas of about 50,000 population – in the UK, this is primary care networks.

COIC concepts promote cycles of collaborative learning and coordinated change within and between areas, to facilitate organic emergence of innovation, social cohesion and systems-thinking. Across the community, policy ensures that different stories and cultures are valued; and positive, trusted relationships are built through deep listening, shared vision and broad participation in improvement projects. This is different to traditional hierarchical approaches to policy.

Policy for COIC is different from the usual stereotype of ‘top-down’ implementation of evidence-based solutions – that ‘tells people what to do’. Policy for COIC ‘helps people to think for themselves’. It facilitates creative interaction between people from different backgrounds that helps them to better see how individual and collective actions can affect ‘bigger pictures’. It establishes infrastructure that facilitates the emergence of innovation. It requires ‘village-size’ localities that are small enough to feel you belong and large enough to have political impact. It empowers more than controls people. It is a form of local participatory democracy.
Between 2007 and 2013 Ealing piloted and implemented policy for COIC, drawing on theories of organisational learning, generalists as sense-makers and fourth generation evaluation. Outcomes were good, as evaluated by routinely gathered data for diabetes care.

The work in Ealing shows that cycles of learning and change within geographic areas can bond and bridge. The 2011 video of the Southall Initiative for Integrated Care shows one of a sequence of meetings at which people of different backgrounds reviewed progress of four service improvement projects. You can see it at: https://www.youtube.com/watch?v=-u40x7-76iU&feature=player_detailpage. The video shows participation of lay people, primary, secondary and community care practitioners, policy makers and public health practitioners.

The acceptability of the approach is revealed in the comment by a voluntary sector participant:

“It’s not revolutionary; Yet it is revolutionary… If it is institutionalised, that would be incredible for our healthcare services”

The ability of the approach to energise people and help them to interact creatively across disciplinary boundaries is revealed in the comment by the dementia project lead:

“I’ve never had so much access and opportunity to talk across primary care and secondary care about mental health services…. and I find that the most exciting thing I have experienced in my professional life”

In 2012 learning was applied from this Initiative throughout Ealing. We:

  • developed localities within which stakeholders (generalist & specialist clinicians, public health & social care practitioners, and others) met monthly to develop care plans for frail patients, to learn, and to co-create innovations
  • aligned hospital-led diabetes clinics to these localities
  • targeted resources to reverse inequalities
  • supported a multidisciplinary team to co-design a new system for diabetes, including primary & community care practitioners, ‘expert patients’ and diabetes specialists
  • provided education courses for GPs to lead diabetes clinics within their practices
  • provided structured education for patients to contribute to their diabetes care

The COIC concept proposes policy in five areas to develop this approach:

  • Build structures to support whole system learning and change
  • Facilitate local engagement in local developments
  • Develop case studies
  • Teach theory and practice of integration
  • Support multidisciplinary leadership teams.

The approach can be used, at scale, in different contexts and at different speeds. Primary Care Networks (PCNs) could use this approach and so move towards community-oriented integrated care.

This is an extract from an article by:

Paul Thomas, FRCGP, MD. General Practitioner. Honorary Senior Lecturer in the Department of Primary Care and Public Health, within the Faculty of Medicine, Imperial College. Visiting Professor, College of Nursing, Midwifery and Healthcare, University of West London. COIN Co-Chair (Communities of Integration Network).

Raj Chandok. FRCGP FRSA MSc. GP Principal, Dr G Singh & Partners.

Dr David Colin-Thomé OBE, MBBS, FRCGP, FRCP, FFPH, FFGDP (Honorary), FQNI, is an independent healthcare consultant and formerly a GP in Castlefields, Runcorn for 36 years, chair of PCC, the National Clinical Director of Primary, Dept of Health England 2001-10, and visiting Professor Manchester and Durham Universities.

Laura Calamos, PhD, MSN, APRN-BC, FHEA. Family Nurse Practitioner. Three Chelsea Docs, 300 N. Main Street, Chelsea, Michigan USA. COIN Co-Chair (Communities of Integration Network).

The full article is available here.