￼People with multiple chronic conditions often have complex needs and are more likely to experience hospitalization, which may lead to further functional decline. These factors contribute to longer lengths of stay, increased risk of complications and adverse events.
The key practices that support integration include: single point of entry, “at risk” screening, comprehensive assessment, service coordination and case management, care planning including advance care planning, clear communication processes including shared health records, patient empowerment and self-management, quality use of medications and ongoing monitoring.
The healthcare system is complex and people have difficulty ...view middle of the document...
These various components of the system are not always coordinated around patient need and often work in parallel, with separate and distinct responsibilities that both overlap and leave important needs unmet. Models of integrated care attempt to overcome these issues by combining the key practices, explored in the previous section, into models of care.
Integrated care is based upon a systems approach to healthcare, and is vital to meet the needs of those clients who have complex needs and seek services from a variety of health professionals across different organisations and sectors of the healthcare system. Integrated care is client focused with the aims of improving client care, supporting carers and ultimately leading to better health outcomes and use of healthcare resources.
You can integrate all of the services for some of the people, some of the services for all of the people, but you can’t integrate all of the services for all of the people.
The ACT model to provide intensive and supportive care from a multi-disciplinary team in the community- as opposed to the hospital or to office based care-began with a two-fold goal. The model was designed to help consumers meet their multiple and complex needs as they transitioned from the hospital and to help them post-transition "become integrated into the community" by providing rehabilitation, counselling, and material support. In effect, the model was thought to be able to keep individuals from returning to the hospital by helping them to connect and feel a real sense of belonging to the world outside the hospital. With the refocus of mental health care from hospital based to community based care, substituting the goal of reducing incarceration for the goal of reducing hospitalization appears a natural extension of the ACT model.
In a study comparing outcomes among 41 patients during the year before and after enrolment in a program called Project Link, the mean number of jail days per patient dropped, and significant reductions were also noted in the number of arrests and hospitalizations, along with improved community functioning.
In a one-year follow-up study of the first 30 patients enrolled in the Thresholds Jail Project, the total number of jail days dropped from 2,741 in the previous year to 469 during the first year of enrolment. The total number of hospital days dropped from 2,153 to 321 for the group.
Total savings in jail costs during the one-year study period was $157,000, and total savings in hospital costs was $917,000.
Relies on smaller staff to consumer ratios, and plans for time sensitive transition points in the move from the criminal justice system into the mental health system. More specifically, the staff to consumer ratio was increased from 1:10 to 1:6
Aftercare was found to be particularly effective at reducing hospitalizations and days incarcerated but not as effective in reducing arrests, a finding also found in studies of intensive, office based case...