Integrated care in response to healthcare challenges
Worldwide, public health challenges are posing constant pressure on hospital sites and service delivery systems. These include ageing populations, coexistence of multiple health conditions, increasing incidence of chronic conditions, and the emergence of new communicable diseases. Alongside this the provision of healthcare has seen a rapid increase in focus on wellness, disease prevention, and personalised medicine and surgery brought about by big data and technology advancement.
In response to these challenges, many healthcare systems are experimenting with new models to better integrate care, with the aim of improving patient satisfaction, make more effective and efficient use of resources, and deliver safe and high quality care. Yet innovative care models are often implemented as time-limited, geographically-specific, or disease specific pilot projects with limited impact on how service delivery is approached across a whole system. Work is ongoing in multiple systems in developing IC approaches, either with initiatives conducted at pilot level or with national or regional policies rolling out structured processes, however there seems to be little in the way of any overall systematic evaluation
Defining integrated care
There is no unique definition of integrated care (IC) – different connotations are linked to the term depending on the context in which it is used, the audience that is directed to, and the knowledge and background of the speaker. Integration can be achieved at different levels and in multiple ways; as such it is possible to delineate between three broad categories of model;
- Individual models – These are mostly focused on individual coordination of care for high-risk patients and/or multiple conditions and their carers. The aim is to facilitate the appropriate delivery of care services and overcome fragmentation between providers along the patient pathway. Among individual models of IC there are case-management models, individual care plans, patient-centred medical homes, and personal health budgets.
- Group – and disease-specific models – These are focused on target groups of population who may have specific diseases and/or conditions and are based on “segmentation” of the population. The aim is to meet the needs of specific population groups and/or populations with specific diseases. Among group and disease-specific IC models there are chronic-care models, IC models for elderly and frail, and disease-specific IC models.
- Population-based models – These are focused on the entire population and are based on “stratification” of the population. The aim is to supply a specific system response to meet the needs of individuals of the population, matching that response to their specific disease risk profile. Good examples of population-based IC models include the Kaiser Permanente model and the Veterans Health Administration model in the USA.
Evaluating different IC approaches
Earlier this year MJ Medical undertook a research project to investigate emerging integrated healthcare systems in several different countries, focusing on the role of acute hospitals within them, and the role of technology in enabling and supporting service delivery. The research has gathered a balanced perspective on individual, group/disease specific, and population-based models. Thirteen international and UK best practice exemplars were identified and analysed, providing knowledge and reference points of innovative practices in order to inform the identification of potential new ways of working for other care providers.
Overall, the research showed many examples of integration at an organisational and functional level being successful regardless of the model of care. Effective service and clinical integration however, appears more difficult to achieve. Other key findings include:
- Approaches to integration are extremely variable, but the most successful take into account cultural and local idiosyncrasies. This becomes particularly relevant when trying to transform a best-practice approach into a wider collective habit, enabling the outcomes of successful small scale or pilot integrated actions to be realised at a wider systems or population level
- A crucial component of successful integrated healthcare systems is mutual and systemic accountability for patients’ outcomes and a positive patient experience. Moreover, a single source of system wide funding is emerging as a key enabler for a fully integrated process of care delivery, so that health, social, community, mental, specialist, and long-term care are all seamlessly interlinked and available to the population. The role of a care manager, case manager or even a full multi-professional care team led by a physician has emerged as a consistent element in delivering integration across all levels of care
- Data recording and sharing information across the care system can face technological gaps, often due to infrastructure, training, and barriers created by organisational culture. However, technology can resolve information asymmetry and fragmentation between providers through a single integrated Electronic Patient Record (EPR) for patients. The minimum EPR standard required to deliver integrated care to a patient population requires records to be accessible to the all health, social, and community care providers responsible for an individual’s care
- The physical environment in which care is provided plays a crucial role in facilitating the evolving clinical procedures and the technological innovations adopted. There is a key role for patients and citizens in creating successful and innovative healthcare services by contributing to the pathway and environment design process. The physical environment should focus on easing care pathways and limiting transfer time across the settings where care is provided. Different parts of the patient pathway should be matched to the most appropriate delivery setting and location, ensuring that only high-acuity care is delivered in high-acuity environments and lower acuity care is delivered in community settings or even at home.
IC and trends in healthcare estates
Many healthcare systems are seeing a renewed focus on integrated health and care delivery, and in many instances these should be a catalyst for healthcare buildings and estates to respond in a similarly integrated way. Secondary care facilities must not be considered in isolation of their interconnected community, primary and tertiary counter-parts. We see evidence of a re-merging trend of one central “complex tertiary care hub” and multiple satellite “primary, secondary and community spokes”, or the development of an integrated health campus that can support the creation of a health and social care ecosystem. When centrally funded and centrally managed, these approaches can enable and empower individual self-care through a technological network and facilitate world class examples of integrated care. The challenge for many is to overcome the culture of silo development of the estate, where almost every new building is bespoke and a prototype. The time for a truly integrated, flexible and adaptable health campus, focused on a unified health and care vision is now.
Principal Consultant and Director – MJ Medical
Copies of our research and a further research paper which presents six international case studies of integrated hospital campus are available from: enquiries@MJMedical.com