How to Deliver Integrated Care

A Guidebook for Managers

Axel Kaehne, Henk Nies

• Publisher: Emerald Publishing Limited
• Year: 2021
• ISBN:
  9781838675295
• Topic: Medicina
• Subtopic: Prestazione di assistenza sanitaria

Care integration has become an important part of managing health and social care services all over the world. Bringing organisations together is thought to produce better access to care, reduce health care expenditure and improve quality of care for patients and service users.
This book helps managers to think about how to collaborate in integrated care programmes. It provides practical advice on how to implement various aspects of care integration, such as finance, digital technology and evaluation. The book also contains chapters on the social and behavioural strategies, values and leadership approaches that should underpin integration. Each chapter contains key information based on the current state of research, illustrations from practical contexts and further reading.

1

Integrated Care – An Introduction

Axel Kaehne and Henk Nies

Why Integrated Care?

Over the last decades, the health of populations has improved dramatically. As life expectancy is increasing all across the world, chronic and complex conditions are becoming a key issue for care systems everywhere. Where, previously, interventions for acute infections constituted the bulk of care related tasks, now, continuing and long-term health conditions are the norm for many people. These ongoing health conditions require the collaboration of many different staff, often across professional and organizational boundaries. However, our health systems are often ill prepared for this shift from acute to long-term care. Where single specialties used to be sufficient, now multi-professional and multi-agency interventions are often needed. This calls for flexible person-centred services that can deliver effective care to individuals, often across the life course.

As health systems developed historically in response to acute intervention models, they are not set up to cope well with patients with long terms care needs. Worse, funding, infrastructure, and organizational structures are often not geared toward the new models of care necessary to address ongoing care requirements. ‘One-size-fits-all’ is often still what is routinely offered by many health services. Yet it is not just the personalization of services that poses a problem. The interprofessional nature of today's care means that different organizations need to work together to create smooth care pathways for patients often suffering many different conditions at the same time. It makes collaboration across professions with different status, training and values essential, something for which medics, nurses and care staff have been ill prepared in their education and training. Moreover, funding systems and legislation are poorly adjusted to this new reality.

Integrated care takes up this challenge around the significant demographic change and its attendant shift in patient needs from acute to long term care. It tries to design services that provide holistic and seamless care for individuals, taking their specific needs into account. This is not a simple thing to do. As a recent study pointed out care integration is

…an emergent set of practices intrinsically shaped by contextual factors, and not as a single intervention to achieve predetermined outcomes.

(Greenhalgh, Shaw, & Hughes, 2020)

It makes integrated care an endeavour requiring and, in turn impacting on, policy, clinical practices as well as the care organizations themselves. This shift to collaborative care models demands a sea change in how we organize care for patients in the long run.

As pandemics like COVID-19 are turning health systems across the world upside down, managers and service directors may temporarily have to fight sudden health system emergencies. Yet the long term trend in health systems remains orientated towards providing person-centred, well-coordinated services to people with chronic and complex conditions.

Collaboration and adaptation have therefore become by-words for the urgent demands on health management and policy. This book will help managers identify and implement innovative integrative solutions for care services stretched by rising demand, rapid change and soaring costs.

The magnitude of change currently occurring in health systems is humbling. Our notion of health itself is being revised in the face of unprecedented challenges. Huber et al. (2011) argue that resilience and self-management will play key roles in our understanding of what health is. As resilience, asset based approaches and self-management take centre stage for all services contributing to health of individuals, the notion of quality of life, as a way for framing health as a holistic concept, becomes ever more important. Although, many health care organizations and health care workers recognize this implicitly, traditional single disease oriented approaches of health care are still being employed routinely, in particular with people with long-term, chronic and multiple conditions. It speaks to reason that the traditional ‘silos’ of specialties need to give way to collaborative, integrative, cross-sectoral approaches to care.

The debates around how to bring about person-centred care illustrate this clearly. Standardized, off-the-shelf solutions come increasingly under pressure to be replaced by specifically tailored and individual care management approaches which take into account multiple care needs of patients and service users.

What person-centred care, resilience, asset-based approaches and self-management have in common is that they require multi-professional and inter-organizational interventions and support mechanisms to achieve the best outcomes for patients and users. This is what integrated care is all about.

What Is Care Integration?

In this book, we will provide directions for answers to the question of how to deliver integrated care. But first, we need to define what we mean by integrated care. Care integration is defined as ‘a coherent set of methods and models on the funding, administrative, organizational, service delivery and clinical levels designed to create connectivity, alignment and collaboration within and between the cure and care sectors’ (Kodner & Spreeuwenberg, 2002). It relates to connectivity, alignment of, and collaboration between social services, public health, citizens and communities (van Duijn, Zonneveld, Lara Montero, Minkman, & Nies, 2018). It may extend to issues of substance abuse, addictions, mental health, old age and frailty, or social exclusion of people with disabilities. At present, most integrated care research is generated by studies in acute and long-term care, but the knowledge about integration in other sectors is growing. The main purpose of integrated care is to reduce ‘fragmentations in service delivery and to foster both comprehensiveness of care and better care co-ordination around people's needs’ (González-Ortiz, Calciolari, Goodwin, & Stein, 2018).

Valentijn and colleagues have summarized the various domains of integrated care in a useful framework (Valentijn, Schepman, Opheij, & Bruijnzeels, 2013). As can be seen in Fig. 1.1, integration takes place at various levels, in a horizontal or vertical direction.

1. a personal or clinical level refers to the extent to which services are coordinated in consultation with the person.
2. a professional level refers to the extent to which professionals coordinate services across different fields of specialty.
3. an organizational level refers to the extent to which organizations coordinate services between different organizations.
4. a system level refers to the alignment of organizational structure, governance and policies in various policy domains.

Source: Valentijn et al. (2013) under the terms of the Creative Commons Attribution-NonCommercial-NoDerivs 4.0 Unported (CC BY-NC-ND 4.0).

Fig. 1.1. Framework for Integrated Care.

Moreover, integration can occur in a vertical direction too. There, the four levels are to be aligned through measures at clinical level, mirroring professional integration and collaboration. Systems ideally facilitate these coordinated and integrated actions at the various levels. Macro-level integration supports processes at meso level (organizational integration and professional integration) in order to deliver a coherent package of services and treatment to the individual. This demonstrates that care delivery is embedded in the social context of the particular individual, such as next of kin, family, household, neighbours and friends, work, or school.

What Does Integrated Care Look Like in Practice?

So far, we spoke about integrated care in an abstract way. It has become clear that integration is about making useful connections to serve the relevant needs of individuals. But what are ‘useful’ connections and what are ‘relevant needs’?

As needs of patients and service users differ there are usually several solutions to one problem. There may be care quality standards or clinical guidelines for some issues, but no standard can tell us all about the quality of care an individual requires. Therefore, there is a need to align the professional and clinical protocols with the individual needs profile. What is the ‘right’ thing to do in a specific situation? How can we achieve the best result for somebody in our care? Integrated care helps us define the balance between what is most effective in terms of health and what has most value to the patients and users in our care.

The recent COVID-19 crisis amply illustrates that in order to achieve a good person-centred solution, all clinicians and care workers need to work towards what they agree to be the most effective decision. This is to align with what the person and his or hers relatives see as the most appropriate solution. Following Pim Valentijn et al. (2013), this may be called normative integration. It takes place within the context of the professionals' standards of care quality, the norms espoused by the person involved, as well as the norms and values we bring to bear on our decisions on a daily basis. It is of considerable importance in the context of integrated care.

Besides normative consensus, functional integration of care delivery is also required. Functional integration is about the issue of ‘who does what’. Questions about what patients themselves do or want may help us to define the division of labour. What are the tasks for the professionals caring for an individual, what do informal carers do and what can be dealt with by the patient him or herself? Professionals have assessment tools and protocols to coordinate across their delivery activities. They make decisions about care inputs, skills, expertise, resources and information needed to act. Aligning this with organizational and staff roles as well as responsibilities and resources is a key task for managers. Carefully calibrated integrated care packages may provide the answer to the problems of allocation and coordination. However, they are not an answer that is easy to identify, but once found, integrated services will make for better outcomes. More recently, the issues of self-management and shared decision making have received considerable attention. What a patient can and wants to contribute to the decisions about their care is critical to make the resulting care package a success. This links with the issue of informal care which now contributes the overwhelming bulk of care activities.

That is why normative and functional integration are interdependent: the choices we take as professionals when planning functional integration reflect normative principles we hold dear about quality, access and equity of care. In addition, those who receive care must be part of this conversation. They are the ultimate arbiters of care quality.

The Nuts and Bolts of Integrated Care

There are different ways of making connections between the various domains of integrated care. Leutz argued (Leutz, 1999) that there are mainly three types of integration; linkage, coordination, or full integration.

Linkage is about arranging services in line with existing divisions of labour in the health system. It is a useful approach in those situations were clinical and professional roles are well defined in the care process. For instance, in the case of stroke services, the various tasks of different services are well known and distinct from each other. Linking services focuses on providing referral routes ensuring that patients are at the right place at the right time. Linkage calls for clear communication between professionals, facilitating continuity of care when people move from one service to another.

Coordination is a way of integrating services where care provision, definitions of core tasks, patients flows and eligibility criteria require mutual adjustment. The aim is to optimize service use, share clinical information, manage transitions of patients between settings and assign responsibilities, including overall network governance and leadership. Coordination entails more shared responsibilities and resources than linkage, but operates largely with organizationally distinct structures in care services. Co-ordinating the points of friction and discontinuity between services and systems is a key objective of this type of integration.

Full integration develops comprehensive care programmes or care packages for specific client groups. It usually takes place where new programmes or units are created which pool organizational resources drawing on multiple care systems. Full integration programmes tend to define new tasks and transform professional practices and delivery for everyone involved. Fully integrated services are likely to be jointly managed and controlled, based on new governance structures that cut across previously distinct organizations.

As integrated care research and practice moves into the tumultuous post-COVID period, its strengths stand out offering managers key advantages over conventional care approaches. Whilst integrating services remains an undertaking fraught with risks, its benefits, when done successfully, accrue to all stakeholders, patient, service users and professionals alike. The daily experience for many individuals of disruptive and fragmented patient journeys is a constant reminder of why integrated care is needed. Pursuing this objective appears to be more important than ever.

What the Book Contains

The book is divided into eight chapters. Chapter 2 deals with the various ways in which integrated care initiatives may be funded. In reality, care integration always needed extraneous finance to get out of the starting blocks as conventional funding is linked to routine care. Since truly integrated care solutions are innovative and novel ways of working, conventional funding is often inappropriate for integrated service delivery. This chapter details the funding options managers have and reflects on how the different ways of paying for integrated care aligns with different models of care delivery.

Chapter 3 focuses on a very topical aspect of health systems which is a key domain of interest for many managers: leadership. It outlines the different styles of leadership to be employed in governing and implementing transformational programmes in health and social services. The chapter reflects the latest research in the field arguing that much of leadership is a craft, a skill that can be acquired through observation and practice, trial and error. As the importance of leadership is increasingly recognized across the world, this chapter sets out the key requirements for leading integrated health and social care services in times of change.

Chapter 4 deals with an area of critical importance to integrated care, patient engagement. Integrated care programmes are programmes to bring about radical change. Conventionally, change in health services has been planned and implemented from above by services, without consulting patients and the local communities. Engaging patients in the process of designing and planning new services is a key prerequisite for success in integrated care programmes. The impact integration has on professionals as well as on patients is considerable. Consequently, consulting all stakeholders and involving them in decisions crucial to the delivery of their services is paramount to the success of the programme. The ch...

Table of contents

• Cover
• Series Editor
• Title
• Copyright
• Table of Contents
• List of Tables and Figures
• List of Contributors
• About the Contributors
• Foreword
• 1 Integrated Care – An Introduction
• 2 Financing Care Integration: A Conceptual Framework of Payment Models That Support Integrated Care
• 3 Leadership in Integrated Care
• 4 Engaging Patients for Integrating Care
• 5 Social Dimensions of Care Integration
• 6 Values in Integrated Care
• 7 Digital Health Enabling Integrated Care
• 8 Implementing Integrated Care
• 9 Evaluating Integrated Care
• Index