Effective Interventions Unit Integrated Care Pathway Guide 1:
Definitions and Concepts
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WHAT IS THE PURPOSE OF THIS GUIDE?
This is the first in a series of guides on developing and implementing Integrated Care Pathways (ICPs). While ICPs have been developed within health settings, there is a growing interest in their development across a range of treatment and social care settings to ensure that a co-ordinated, quality service is provided over the full continuum of care. Care pathways are designed to minimise delays, make best use of resources, and maximise quality of care. They offer a way to improve Accessibility, Assessment and the Planning & Delivery of Care through effective monitoring, evaluation and information sharing processes.
In this guide we examine when and how Integrated Care Pathways can be used to provide better care for people with drug problems. We briefly outline the definitions, purposes and principles of ICPs and provide initial guidance in getting started.
WHO SHOULD READ IT?
Anyone involved in commissioning, planning, developing, delivering and evaluating services for drug users.
The Effective Interventions Unit (EIU) launched Integrated Care for Drug Users - Principles and Practice in October 2002. As part of this work, the EIU consulted service providers and service users on the key principles of planning and delivery of care in the drugs field in Scotland. The findings from these consultations are used throughout the document. In response to the interest from the field in developing evidence-based care systems the EIU undertook to produce this guide. For more information on integrated care for drug users please see www.drugmisuse.isdscotland.org/eiu/intcare/intcare.htm
WHAT ARE INTEGRATED CARE PATHWAYS?
An Integrated Care Pathway determines locally-agreed, multi-disciplinary practice based on guidelines and evidence, where available, for a specific client group. It forms all or part of the clinical record, documents care given and facilitates the evaluation of outcomes for continuous quality improvement. (Sue Overill, Journal of Integrated Care (1998) 2, 93-98).
Integrated care pathways (ICPs) use the current best evidence gained from systematic reviews, as well as input from multidisciplinary teams, to outline the optimal course of care for all clients who have a specific condition or who are undergoing a specific procedure. Other common names for these tools include clinical pathways, clinical care pathways, and Care Maps.
ICPs plot out for a particular presenting problem or procedure the optimal sequence and timing of interventions by physicians, nurses, and other professionals. Because pathways prescribe treatment and care across different care settings and even between different localities, they help ensure that a co-ordinated, quality service is provided over the full continuum of care.
Service providers attending the EIU consultation seminars concluded that there was a need for a national framework or template for the planning and delivery of integrated care that could be adapted for local use.
WHY ARE THEY IMPORTANT?
Pathways can ensure the care process is better monitored and streamlined for the majority of people in a given client population. Pathways provide clients with more consistent care/service, by minimising variations in practice. Because pathways are based in part on previous cases, providers are better equipped to predict all aspects of the care process (including milestones, complications and outcomes), and improve the quality of care provided to the next patient/client with the same condition.
Care pathways can help ensure a high degree of efficiently delivered care for a defined population. Once a pathway has been put in place, key indicators are regularly monitored (e.g. quarterly) to assess the effectiveness of care provided. This information is not used for judging individual performance, but rather for learning, monitoring quality (i.e. benchmarking comparisons, trends over time, amending the care pathway, etc.) and targeting areas in need of improvement.
An ICP aims to have . . .
Care given should reflect the client's needs and experiences and must be measured against the planned care.
Evaluation processes are built into pathways when they are developed. Pathway indicators can be tied into an agency's existing quality or performance indicator programme and can reflect qualitative as well as quantitative information. Indicators might include clients' satisfaction with specific aspects of service provision (qualitative) or waiting times for specific interventions (quantitative).
Because care pathways include information on individual outcomes, they enable service providers to monitor the appropriateness of interventions. As each client's needs change, the pathway would indicate the most appropriate interventions, their accessibility and any specific issues which would assist the client and worker to identify the most desirable next step.
Care pathways provide all care providers with information on a client's progress and status. Care pathways that are stored and updated electronically provide the most effective way of ensuring that all information pertinent to the individual's care is up-to-date and accessible to care providers.
The client's version of pathways enables people to play an informed, active role in their own care. It allows the client to see the nature and direction of their care provision and contribute to the planning and delivery of their own health and social care.
Care pathways are an excellent tool for educating students and new staff. They provide a visual representation of the care plan and the expected course of care. Pathways serve as a useful orientation tool in teaching environments where students and newly-qualified staff frequently rotate through different services. 1
WHAT IS THE DIFFERENCE BETWEEN AN ICP AND A PACKAGE OF CARE?
Confusion often arises over the differences between ICPs and Packages of Care. This may have arisen because there has been, and still is, a tendency to call ICPs by the client group they serve rather than by the service that they provide to that group.
Integrated Care Pathways can be used to define and describe parts of the care process which involve a number of activities, tasks, procedures or choices. They apply equally to care delivered by one person, one agency or a number of agencies working simultaneously with an individual.
The whole care process from start to finish (Package of Care) can be divided up into 'bite-sized chunks' of service or care. Each 'bite-sized chunk of service' is developed into an ICP, setting out detailed processes, i.e. a collection of activities that use one or more kinds of input, often in an order, and which provide the individual with the treatment and care that they need.
A Package of Care (often called the 'Patient Pathway' or 'Pathway of Care') may contain one or more ICPs selected for a particular client or target client group. It describes the whole range of care given to that client or client group, usually for one episode of care. A Package of Care is also sometimes represented in the form of a flow chart, process map or decision tree. In this case, each item (or small group of items) in the map could represent a discrete ICP.
It is essential during the ICP project planning stage to define the scope of each ICP so that it has a clear start and finish point. Moving from chunk to chunk can be clarified by identifying specific criteria which would give entry to a specific next step. Well-scoped ICPs will facilitate the building up of these 'bite-sized chunks of service' into seamless Packages of Care for each target client group. Keeping the ICPs discrete also makes it possible to tailor care more closely to an individual client by adding or removing ICPs from the client's anticipated Package of Care in response to their particular or changing needs. It also provides opportunities for including distinct Client/Carer ICPs as part of the Package of Care. 2
Guide 1: Definitions and Concepts
Harry was introduced in Integrated Care for Drug Users - Principles and Practice to illustrate how the design and delivery of integrated drug services might affect the individual. Harry appears below, and in subsequent guides, to maintain the person-centred focus on the way in which services are designed and delivered.
Define goals of ICP
The interventions recommended in the ICP is, wherever possible, based on evidence of effective practice rather than on "the way we've always done it".
Use a multi-disciplinary team approach. Steering group and working groups should comprise of frontline workers, clients and additional individuals who have an enhanced knowledge or expertise in this area.
Developing the team (Steering committee/ Working group)
Recognise importance of reaching a common understanding of the function of the groups and the parameters within which it will operate. Agree on timescales and communication processes at the outset.
Choosing a client population
ICPs are most suited to those (diagnoses or) procedures with 4 or more of the following criteria:
Significant variability in practice
High public profile (media or political interest)
Reliance on multidisciplinary team
Demonstrated interest of caregivers to participate and assist in the process
Including key stakeholders
The Steering group/Working group must determine
How stakeholders will be kept involved
Who will be responsible for communicating with stakeholders
How to ensure stakeholders' concerns are addressed.
Borrow or build?
Two main options are: adapt an existing pathway developed elsewhere or create your own from scratch. The National Electronic Health Library hosts a large database of existing ICPs. www.nelh.shef.ac.uk/nelh/kit/cps/paths.nsf/FO1?open
This is the first in a series of 4 guides on developing and implementing Integrated Care Pathways: Definitions and Concepts (Guide 1); Developing Integrated Care Pathways (Guide 2); Implementing Integrated Care Pathways (Guide 3); Analysis and Review (Guide 4). Although each phase represents a distinct stage on a timeline, it is not uncommon to move back and forth between phases in the process of developing a pathway. Your timeline will be highly dependent on the availability of resources (information, human, and financial) and the complexity of your pathway. Guide 2 will illustrate what a hypothetical pathway might look like.
Later guides will apply these processes to developing outline ICPs for specific interventions. These may include guides for:
Drug misuse in pregnancy
Drug Treatment and Testing Orders
Care of people with drug problems in acute psychiatric settings
Care of people with drug problems in acute medical and surgical settings
SUPPORT FOR FAMILIES
Harry's partner plays an active role in supporting Harry throughout his treatment and care. It is recognised that there is a need to provide support to families and other carers of people with drug problems. In November 2002 the EIU published Supporting Families and Carers of Drug Users - A Review. This is available on the EIU website or by contacting us at the address below.
Effective Interventions Unit
Substance Misuse Division
Scottish Executive Health Department
Room 3 East Rear
St Andrew's House
EDINBURGH EH1 3DG
E-mail Address: EIU@scotland.gsi.gov.uk
Integrated Care Pathways Users Scotland www.icpus.ukprofessionals.com
National Electronic Library for Health www.nelh.nhs.uk/carepathways/icp_about.asp
Health Service Utilization and Research Commission www.hsurc.sk.ca./resource_centre/care/GettingStarted.pdfFootnotes
1 Getting started with Integrated Care Pathways (2001) Health Service Utilisation and Research Commission.