Handbook Integrated Care

Preface
Contents
Foundations of Integrated Care
1 What is Integrated Care?
1.1 Introduction
1.2 The Rationale for Integrated Care
1.3 Defining Integrated Care
1.4 The Core Dimensions of Integrated Care
1.5 The Building Blocks of Integrated Care
1.6 Conclusions
References
2 Refocussing Care—What Does People-Centredness Mean?
2.1 Introduction
2.2 Theoretical Underpinnings
2.3 What Does ‘People-Centred’ Mean?
2.4 Strategies and Instruments to Support People-Centred Services and Systems
2.5 Prerequisites for People-Centred Services and Systems
References
3 Evidence Supporting Integrated Care
3.1 Introduction
3.2 Conceptualising Integrated Care
3.3 The Evidence Supporting Integrated Care
3.4 The Economic Impacts of Integrated Care
3.5 How to Interpret the Evidence Supporting Integrated Care
3.6 Conclusions
References
4 Values in Integrated Care
4.1 Introduction
4.2 What Are Values?
4.3 Values Underpinning Integrated Care
4.4 Practice Implications
4.5 Normative and Functional Aspects
4.6 Conclusion
References
5 Patients’ Preferences
5.1 Patients’ Priorities for Integrated Healthcare Delivery Systems
5.2 Stated Preference Studies: Method and Study Design
5.3 Preference for Integrated Healthcare Delivery Systems
5.4 Discussion and Outlook
Acknowledgements
References
6 Integrating Health- and Social Care Systems
6.1 Introduction
6.2 What Do We Mean by Social Care?
6.3 Integrating Health- and Social Care for Populations
6.3.1 Population Health Improvement Approach
6.3.2 Population Health Management Approach
6.3.3 Combined Population Health Improvement and Management
6.4 Integrating Health and Social Care for Individuals
6.5 Integrating Health and Social Care Through the Workforce
6.5.1 Inter-Professional Competence
6.5.2 Professional Accountabilities
6.5.3 Information Sharing
6.5.4 Leadership and Followership
6.6 Conclusion
References
7 Integrated Community Care—A Community-Driven, Integrated Approach to Care
7.1 What is ICC?
7.1.1 A Root Definition
7.2 Advancing the ICC Agenda
7.3 Exemplars
7.3.1 Community Health Centres
7.3.2 Caring Communities
7.3.3 Healthy Place-Making
7.4 ICC and Community Resilience
7.5 Conclusion
Acknowledgements
References
8 Path Dependence and Integrated Care
8.1 Introduction
8.2 Understanding Path Dependence
8.3 Self-Reinforcing Mechanisms Leading to Path Dependencies in Health Care
8.4 Overcoming Path Dependencies in Order to Integrate Care
8.5 Conclusion
References
9 Values and Culture for Integrated Care: Different Ways of Seeing, Being, Knowing and Doing
9.1 Introduction
9.2 What is Meant by Culture?
9.3 What is Meant by Values?
9.4 How Do We Positively Develop Values and Cultures?
9.4.1 Teamwork
9.4.2 Inter-Professional Learning
9.5 Conclusion
Acknowledgements
References
Management of Integrated Care
10 Positioning Integrated Care Governance: Key Issues and Core Components
10.1 Introduction
10.2 Positioning Integrated Care Governance
10.2.1 Holistic Approach to Service Provision for People
10.2.2 Organizing Support with and Around People
10.2.3 Re-arranging Care at Scale Supported by Digitalization
10.2.4 Integrated Care Governance
10.3 Integrated Care Governance Components
10.3.1 Leadership
10.3.2 Accountability
10.3.3 Supervision
10.3.4 Financial Models
10.4 Values Underpinning Integrated Care Governance
10.5 To Conclude
References
11 Perspectives on Governing Integrated Care Networks
11.1 Introduction
11.2 Conceptual Background
11.3 Three Perspectives on Governing Integrated Care Networks
11.4 Discussion
11.5 Conclusion
References
12 Governance and Accountability
12.1 What is Governance and Accountability?
12.2 Appropriate, Agile and Effective: New Directions for Governance and Accountability in Integrated Health Systems
12.3 Implementing Innovation: Next Steps for Governance and Accountability in Integrated Health Systems
12.3.1 Vanguard Integration Sites
12.4 Tools for Governance and Accountability
12.4.1 Frameworks
12.4.2 Tools
12.5 Conclusions
References
13 Adaptive Approaches to Integrated Care Regulation, Assessment and Inspection
13.1 Introduction
13.2 What is Meant by Regulation, Assessment and Inspection?
13.3 Benefits and the Importance of Integrated Care Regulation, Assessment and Inspection Now?
13.4 What Role Can Regulators, Assessors and Inspectors Play?
13.5 Overview of Approaches Used in Assessment and Inspection Programs
13.5.1 Canada
13.5.2 England
13.5.3 Netherlands
13.5.4 Denmark
13.6 Value of Assessment and Inspection During System Transformation
13.6.1 Sweden
13.6.2 Malta
13.6.3 Norway
13.6.4 Scotland
13.7 Regulation as a Barrier or Facilitator to Integrated Care
13.8 Post-COVID-19 Implications
13.9 Summary
Acknowledgements
References
14 Leadership in Integrated Care
14.1 The Neglected Topics in Designing Integrated Care
14.2 No Coincidence: What Management Literature Tells Us About Leadership
14.2.1 Manager Versus Leader
14.2.2 Types and Styles of Leadership
14.2.2.1 Theories
14.2.2.2 Learning from the Big Bosses’ Experience
14.2.3 Leadership Learnings from Empirical Data
14.2.3.1 Fundamental Practices by Kouzes and Posner (2009)
14.3 Leadership in Networks
14.4 Leadership in Health Care: Learning from Best Practice
14.4.1 What Is Different in Health Care: The Logic of Healthcare Delivery
14.4.2 Professional Cultures in Health Care
14.4.3 Leading a Healthcare Organization: Personal Skills and Institutional Habits
14.5 Lessons to Be Learned for Leadership in Integrated Care
14.5.1 System-Related Pitfalls
14.5.2 People-Related Pitfalls
14.5.3 Organization-Related Pitfalls
14.6 Conclusion
References
15 Co-leadership—A Facilitator of Health- and Social Care Integration
15.1 The Interpretation of Leadership Over Time
15.1.1 The Conceptualization of Co-leadership
15.1.2 Co-leadership in Integrated Service—Opportunities and Obstacles
15.2 What Prerequisites Are Needed to Exercise Co-leadership in Integrated Services?
15.2.1 Contextual Prerequisites
15.2.2 Personal and Interpersonal Prerequisites
15.3 How Can Co-leadership Be Operationalized in Practice?
15.3.1 Management Tasks
15.3.2 Daily Operation
15.3.3 Leadership Development
15.4 What is the Contribution of Co-leadership for Integrated Health and Social Care?
15.5 Summing Up
References
16 Change Management
16.1 Introduction
16.2 A Conceptual Understanding of Change Management
16.3 The Evidence Base
16.4 Lessons from Practical Experience
16.5 The Components of a Change Management Process Towards Integrated Care
16.5.1 Needs Assessment
16.5.2 Situational Analysis
16.5.3 Value Case Development
16.5.4 Vision and Mission Statement
16.5.5 Strategic Plan
16.5.6 Ensuring Mutual Gain
16.5.7 Communications Strategy
16.5.8 Implementing and Institutionalising the Change
16.5.9 Monitoring and Evaluation: Developing Systems for Continuous Quality Improvement
16.6 Building an Enabling Environment
16.6.1 Developing a Guiding Coalition
16.6.2 Building Support for Change
16.6.3 Developing Collaborative Capacity
16.6.4 The Facilitating Role of Managers and Decision-Makers in Supporting the Process of Change
16.7 Conclusions
References
17 How to Make Integrated Care Services Sustainable? An Approach to Business Model Development
17.1 Introduction
17.2 ASSIST: Socio-economic Impact Assessment Using Cost–Benefit Analysis
17.2.1 Background
17.2.2 Assessment in Four Steps
17.2.3 A Cost—Benefit Indicator Set for Integrated Care
17.3 Learning by Example: The Service Implementation Simulator
17.3.1 Integrated ECare Example Case
17.3.2 Overall Service Model
17.3.3 Elements of the Service
17.3.4 Assessment of the Example Case in Four Steps
17.3.4.1 Step 1: Stakeholders
17.3.4.2 Step 2: Impact Identification
17.3.4.3 Step 3: Data Collection
17.3.4.4 Step 4: Analysing the Value Case
17.3.5 A Set of Lessons to Be Learned
17.4 Conclusions
References
18 Planning
18.1 Introduction
18.1.1 The Need for Planning
18.1.2 Planning Taxonomy
18.2 Workforce Planning Methodologies
18.2.1 Planning of Supply
18.2.2 Demand-Based Planning
18.2.3 Needs-Based Planning
18.2.4 Benchmarks
18.2.5 Limitations of Current Planning Approaches in Integrated Care Settings
18.3 New Approaches to Workforce Planning in Integrated Care
18.3.1 Team-Based Workforce Planning
18.3.2 Proactive Management of Healthcare Utilization
18.3.3 Tackling Geographic Variations Through Technology
18.4 Conclusion
References
19 Towards Sustainable Change: Education and Training as a Key Enabler of Integrated Care
19.1 Introduction and Background
19.1.1 The Parallel Universes of Education and Health Systems
19.1.2 A Workforce Under Constant Pressure
19.1.3 The Workforce as a Barrier to Integrated Care
19.2 The Principles of Learning
19.2.1 Learning Is an Active Process
19.2.2 What Are Competences?
19.3 Competencies for Integrated Care
19.3.1 Competences on All Levels
19.3.2 Building a Continuous Learning Environment
19.3.3 Inter-professional Education and Training to Support Integrated Care
19.4 Education and Training as a Key Enabler for Integrated Care
References
20 Integrated Care and the Health Workforce
20.1 Background
20.2 Staff Mix and Skill Management
20.3 Multidisciplinary Team Work
20.4 Workforce à La Carte
20.5 Conclusions
References
21 Financing of and Reimbursement for Integrated Care
21.1 Introduction
21.2 Principles of Financing of and Payment for Services
21.2.1 Financing of Health and Social Care
21.2.2 Payment Mechanisms in Healthcare
21.3 Incentivizing Coordination and Integration of Service Delivery: Examples from Different Countries
21.3.1 Commitment of Additional Funding
21.3.2 Innovative Payment Schemes
21.3.2.1 Financial Incentives
21.3.2.2 Value-Based Payment Schemes
21.3.3 Changes to Financing Mechanisms
21.4 Conclusions
References
22 Reimbursing Integrated Care Through Bundled Payments
22.1 Introduction
22.2 Reimbursement Instruments
22.3 Reimbursing Integrated Care
22.4 Bundled Payments in Use
22.4.1 Case Study I: Disease Management of Diabetes in the Netherlands
22.4.2 Case Study II: The Bundled Payments for Care Improvement (BPCI) Initiative by Medicare in the United States
22.5 Effects of Bundled Payments
22.6 Discussion
References
23 Strategic Management and Integrated Care in a Competitive Environment
23.1 Integrated Care as a Strategic Option: Preliminary Remarks
23.2 Strategic Management: Definition and Differentiation
23.2.1 Strategy
23.2.2 Basics of Management Theory
23.3 The Strategic Planning Process
23.4 Instruments for Strategic Planning
23.4.1 SWOT Analysis
23.4.2 Analysis of Value Chains and Competitive Environments
23.5 Options for Strategic Positioning
23.5.1 Ansoff’s Product/Market Matrix
23.5.1.1 Market Penetration
23.5.1.2 Product Development
23.5.1.3 Market Development
23.5.1.4 Diversification
23.5.2 Porter’s Competitive Strategies
23.5.2.1 Cost Leadership
23.5.2.2 Differentiation
23.5.2.3 Low Cost and Differentiation Focus Strategies
23.5.2.4 “Stuck in the Middle”
23.6 Integrated Care as a Quality Improvement Strategy
References
Tools and Instruments
24 Disease Management
24.1 Introduction
24.2 What is Disease Management?
24.3 What are the Impacts of Disease Management?
24.4 Interpreting the Existing Evidence Base
24.5 Conclusions
References
25 Case Managers and Integrated Care
25.1 The Story of Julia and John in 2025
25.2 The Definition of Case Manager
25.2.1 Complex Situations
25.2.2 All the Needs
25.2.3 Physicians’ Cooperation
25.2.4 The Life/Care Plan
25.2.5 Informal Care and the Case Manager
25.2.6 Within a Program
25.2.7 Target Population
25.2.8 Rejected Broader Definitions
25.2.9 Competencies and Skills of Case Managers
25.3 Specific Tools for Case Managers
25.3.1 Evaluating Health and Social Needs
25.3.2 Empowering Interviewing of Patients, Clients and Relatives
25.4 The Real World and the Ideal World of the Case Story
25.5 Implementation Strategies to Disseminate the Function of Case Managers
References
26 Discharge and Transition Management in Integrated Care
26.1 Introduction
26.2 What Is Discharge Management?
26.3 Why Discharge Management?
26.3.1 Demographic Challenges
26.3.2 Rising Costs and Financial Pressure
26.3.3 Declining Length of Stay
26.3.4 Financing and Reimbursement Systems
26.3.5 The Need to Manage Complexity
26.4 How to Put Discharge Management into Practice
26.4.1 Professionalization of Discharge Planning
26.4.2 Integrating Various Components
26.4.3 Patient Involvement
26.4.4 Information Exchange and Technology
26.4.5 Early Initiation and Predictive Models for Discharge Management
26.5 Conclusion
References
27 Polypharmacy and Integrated Care
27.1 Introduction
27.1.1 What Is Polypharmacy?
27.1.2 Why Is It Important to Address Polypharmacy?
27.2 Polypharmacy Management
27.2.1 Prevalence of Polypharmacy
27.2.2 Appropriate Polypharmacy and Integrated Care
27.2.3 How to Undertake a Polypharmacy Review
27.3 Patient-Centred Decision-Making
27.4 Which Patients Should We Prioritise for Review?
27.5 How to Implement a Polypharmacy Programme
27.6 How to Measure Effectiveness of a Programme
27.7 The WHO Challenge: Medication Safety in Polypharmacy
27.8 Case Study
27.8.1 Scotland: Changing Culture to Implement at Scale
27.8.2 Catalonia: Government Sponsored and Institutional-Based Programmes
27.8.3 Sweden: A National Legislation Model
27.8.4 Greece: Incipient Developments
27.8.5 Italy: Growing Awareness and Pilot Studies
27.8.6 Northern Ireland (UK): A Regional Model for Medicine Optimisation in Older People
27.8.7 Poland: No Policies, Other Pressing Issues
27.8.8 Portugal: No Programmes But Promising Measures
References
28 Digital Health Systems in Integrated Care
28.1 Introduction
28.2 Defining Digital Health-Enabled Integrated Care
28.3 Digital Health Solutions to Three Common Problems
28.4 Moving Toward a Networked Model: Attending to Normative Integration Through Implementation
28.5 How to Know You Are on the Right Track
References
29 Data Integration in Health Care
29.1 Types of Data Integration
29.1.1 Horizontal Integration
29.1.2 Vertical Integration
29.1.3 Historical Integration
29.1.4 Longitudinal Integration
29.1.5 Cross-Indexing Integration
29.1.6 Alternative Sources
29.2 The Importance of Data Integration
29.3 Impact of Data Integration
29.3.1 Types of Waste that Can Be Reduced with Data Integration
29.3.1.1 Repeat Testing
29.3.1.2 Manual Integration of Data
29.3.1.3 Informal Reports
29.3.2 Improving Decision-Making Capacity
29.3.2.1 Individual Level
29.3.2.2 Provider Level
29.3.2.3 Policy Level
29.3.2.4 International Level
29.4 Key Challenges in Integrating Data
29.4.1 Access and Privacy
29.4.2 Security
29.4.3 Quality
29.4.3.1 Quality Assessment
29.4.3.2 Quality Control
29.4.4 Tracking Use of Integrated Data
29.4.4.1 Providers
29.4.4.2 Patients
29.4.4.3 Policy-Makers
29.4.4.4 Insurers
29.5 Summary
References
30 Mobile Sensors and Wearable Technology
30.1 Commercial Mobile Sensors and Wearable Technologies
30.2 Clinical Mobile Sensors and Wearable Technologies
30.3 Using Mobile Sensors and Wearable Technologies to Change Health Behaviour
30.4 Current Limitations and Potential Impact on Health
References
31 Legal Aspects of Data Protection Regarding Health and Patient Data in the European Context
31.1 Integrated Care and Data protection—A Crucial Requirement
31.2 Harmonised European Health Data Protection?
31.2.1 The European General Data Protection Regulation
31.2.2 Scope of Application
31.2.3 Definitions
31.2.4 The Distribution of Roles When Processing Personal Data
31.2.5 Personal Data in the Health Context
31.2.6 General Aspects of Processing Personal Data
31.2.6.1 Non-sensitive and Sensitive Data
31.2.6.2 Processing of Sensitive Data
31.2.7 Administrative Duties
31.2.8 Data Protection Impact Assessment
31.2.9 Data Protection Officer
31.2.9.1 Responsibilities of a Data Protection Officer
31.2.10 Data Breach Notification
31.2.10.1 What is a Personal Data Breach?
31.2.10.2 How to Prevent a Personal Data Breach
31.2.10.3 Potential Consequences of a Personal Data Breach
31.2.10.4 Notification of the Personal Data Breach
31.2.10.5 Documentation of Breaches
31.2.11 Rights of the Data Subject Under the GDPR
31.2.11.1 Right to Information
31.2.11.2 Right of Access by the Data Subject
31.2.11.3 Right to Erasure (‘Right to Be Forgotten’)
31.2.11.4 Right to Data Portability
31.2.12 Data Transfer to Third Countries
31.2.13 Sanctions
References
Evaluation and Health Services Research
32 Tools and Frameworks to Measure Health System Integration
32.1 Introduction
32.2 Tools Measuring Individual Dimensions of Integrated Care
32.3 Integration Frameworks and Theoretical Models
32.3.1 Models that Focus on Structure, Function, Process, and Capacity Dimensions of Integrated Care and Their Interactions
32.3.1.1 Theoretical Model of Integration Constructs (Singer et al. 2018)
32.3.1.2 Structure, Function, and Capacity Dimensions of Service Network Integration (Browne et al. 2007)
32.3.2 Models and Frameworks for Current State Assessment/Maturity of Integrated Care Systems
32.3.2.1 B3 Maturity Model (Grooten et al. 2018, 2019)
32.3.2.2 Project INTEGRATE Framework (Cash-Gibson et al. 2019)
32.3.2.3 Development Model for Integrated Care (DMIC, Minkman et al. 2016)
32.3.2.4 Rainbow Model of Integrated Care (RMIC, Valentijn et al. 2013)
32.3.3 Models and Frameworks that Focus on Integration Systems Performance and Outcomes
32.3.3.1 Context, Outcomes, and Mechanisms of Integrated Care (COMIC) Model (Busetto et al. 2016)
32.3.3.2 The Integrated Care Performance Assessment (ICPA) Framework (European Commission 2018)
32.3.4 Summary and Critical Appraisal
32.4 Conclusions
References
33 Claims Data for Evaluation
33.1 Background
33.2 Claims Data
33.3 Methodological Aspects of Using Claims Data
33.4 Methods
33.5 Prerequisites for Data Usage
33.6 Examples
33.6.1 Evaluating Disease Management Programs
33.6.2 Gesundes Kinzigtal
33.7 Limitations
33.8 Perspective: Data Linkage
33.9 Conclusions
References
34 Economic Evaluation of Integrated Care
34.1 Need for Economic Evaluation of Integrated Care
34.2 Current Economic Evaluation Frameworks
34.3 Challenges and Recommendations in Economic Evaluation of Integrated Care
34.3.1 Defining the Intervention
34.3.2 Comparator
34.3.3 Study Design
34.3.4 Evaluation Period
34.3.5 Outcome Measures
34.3.6 Measurement and Valuation of Costs
34.3.7 Broader Economic Evaluation
34.3.8 Determinants of Cost-Effectiveness
34.3.9 Policy Evaluation and Implementation Analysis
34.3.10 Standardized Reporting
34.4 Conclusion
References
35 Integrated Care Through the Lens of a Complex Adaptive System
35.1 Introduction
35.2 Complexity and Healthcare
35.3 Complex Adaptive Systems (CAS)
35.4 Integrated Care
35.5 Organising principles of CAS applied to Integrated Care
35.6 Discussion
35.7 Conclusion
Acknowledgements
References
36 Evaluating Complex Interventions
36.1 Definition of Complex Intervention
36.2 The Rationale for Evaluation
36.3 Challenges in Evaluating Complex Interventions
36.4 Evaluation Frameworks
36.5 Process Evaluation
36.5.1 Fidelity and Quality of Implementation
36.5.2 Context
36.5.3 Causal Mechanisms
36.6 Formative and Summative Evaluation
36.6.1 Study Design
36.6.2 Outcomes
36.7 Reporting and Reviewing Evaluation Results
References
37 Realist Research, Design and Evaluation for Integrated Care Initiatives
37.1 Introduction
37.2 The Nature of Reality (Ontology)
37.2.1 Causal Inference
37.2.2 Mechanisms
37.3 Understanding Reality (Epistemology)
37.4 Intensive and Extensive Methodology
37.5 Critical Realist Research, Design and Evaluation Cycles
37.5.1 Realist Explanatory Research
37.5.2 Realist Design
37.5.3 Realist Explanatory Evaluation
37.6 Realist Evaluation of Complex Interventions
37.7 Conclusion
References
Selected Client Groups
38 Integrating Perinatal and Infant Care
38.1 Introduction
38.2 Significance of Perinatal and Infant Care
38.3 Challenges
38.4 Goals of Integrated Perinatal and Infant Care
38.5 Approaches to Integrating Perinatal and Infant Care
38.6 Conclusion
References
39 Children
39.1 Challenges in Providing Care for Infants, Children and Young People
39.2 Goals of Integrated Care for Children
39.3 Value Proposition of Integrated Care for Children
39.4 From Services to Systems: Integrated Care and Population Health Management for children
39.5 The Integrated Treatment Path: Examples and Outcomes
39.6 Lessons Learned and Outlook
References
40 Integrated Care for Older Patients: Geriatrics
40.1 Introduction
40.2 Challenges for Providing Care for the Geriatric Patient
40.2.1 Multimorbidity and Geriatric Syndromes
40.2.2 Fragmentation of Care
40.2.3 Place of Living: From Community to Institutions
40.3 Models of Integrated Care for Older People and Outcomes
40.3.1 Models Mentioned in the WHO Europe Report 2016
40.3.2 Literature Update on Integrated Care Geriatrics
40.3.2.1 Review
40.3.2.2 Factors Associated with Negative Outcomes
40.3.2.3 Integrated Care to Improve Care Transitions
40.3.2.4 Home Care
Home-Based Primary Care
Hospital-At-Home
40.3.2.5 Preventative Care for Frail Older Adults in an Integrated Way
40.3.2.6 Impact on PROMs
40.3.2.7 Qualitative Studies
40.3.2.8 Social Components of Care
40.3.2.9 European Projects About Integrated Care
40.4 Matters of Integration in Technology Design for Ageing People
40.5 Final Remarks
References
41 Integrated Care for Frail Older People Suffering from Dementia and Multi-morbidity
41.1 The Challenge
41.2 Service Users’ Needs for Integrating Services
41.3 Inter-organizational Collaboration by Care Standards
41.4 Implementation
41.5 Personalization
41.6 Future Perspectives
41.7 Conclusions
References
42 Integrated Palliative and End-of-Life Care
42.1 Introduction
42.2 Defining Palliative Care and End-Of-Life Care
42.3 Challenges for Providing Care to Palliative and End-Of-Life Patients
42.4 Goal of Integrated Care
42.4.1 What Needs Do End-of-Life Patients Have?
42.4.2 Health and Social Integrated Care Based on Empathy and Compassion
42.5 The Integrated Care Path
42.6 Results of Integrated Palliative Care
42.7 A New Paradigm: Compassionate Communities
42.8 Conclusion
References
43 Physical and Mental Health
43.1 Challenges Involved in Integrating Physical and Mental Health Care
43.1.1 Disease Factors
43.1.2 Patient Factors
43.1.3 Professional Factors
43.1.4 Institutional and System Factors
43.2 Goals of Integrated Physical and Mental Health Care
43.3 Key Components of Integrated Physical and Mental Health Care
43.3.1 Collaborative Care
43.3.2 Multidisciplinary Case Management
43.3.3 Liaison Mental Health
43.3.4 Managing Medically Unexplained Symptoms in Primary Care
43.4 Results of Integrated Care Approaches
43.5 Lessons Learned
References
44 Rare Diseases
44.1 Challenges Faced When Providing Care to People Living with a Rare Disease
44.1.1 Background on Rare Diseases
44.1.2 Unmet Needs of People Living with a Rare Disease
44.1.3 Challenges in Care Provision
44.2 Goal of Integrated Care for Rare Diseases
44.3 The Integrated Care Pathway for Rare Diseases
44.3.1 Proposals for the Provision of Integrated Care to People with Rare Diseases
44.3.1.1 Centres of Expertise
44.3.1.2 Individual Care Plans
44.3.1.3 Care Pathways and Standards of Care
44.3.1.4 Case Managers
44.3.1.5 Resource Centres for Rare Diseases
44.3.1.6 Networking and Training Programmes for Service Providers
44.3.1.7 Integration of Rare Diseases into National Functionality Assessment Systems
44.3.1.8 e-Health to Facilitate Data Sharing and Interoperability
44.3.1.9 European Reference Networks
44.4 Results of Integrated Care Approaches to Care Delivery
44.5 Lessons Learned and Outlook
Acknowledgements
References
45 Integrated Care for People with Intellectual Disability
45.1 Definition and Classification of Intellectual Disability (Intellectual Developmental Disorder)
45.2 General Health Issues
45.3 Mental Health Issues
45.4 Access to Care
45.5 Specialized Services for ID Associated with Other Mental Disorders
45.6 Integrated Care and Person-Centred Approaches
45.6.1 Integrating Care of Somatic Illnesses
45.6.2 Integrating Care of Psychiatric Disorders
45.6.3 Integrating Specialized or Secondary Mental Health Care
45.7 Conclusion
References
46 SORCe—An Integrative Model of Collaborative Support for People in Need
46.1 Introduction
46.1.1 Results to Date
46.2 The SORCe Model
46.2.1 Evolution of SORCe
46.2.1.1 The Cross Roads Centre
46.2.1.2 The Calgary Community Court
46.3 Summary and Conclusion
Acknowledgements
References
47 Two Decades of Integrated Stroke Services in the Netherlands
47.1 About Stroke
47.2 Integrated Patient-Centred Stroke Care
47.3 Towards Integrated Stroke Services
47.4 Dutch Knowledge Network of Stroke Services
47.5 Improvement of Dutch Integrated Stroke Care: A Never-Ending Story
References
48 Pathways in Transplantation Medicine: Challenges in Overcoming Interfaces Between Cross-sectoral Care Structures
48.1 Introduction
48.2 Structures of Care
48.2.1 Outpatient and Inpatient Care
48.2.2 Living Donations
48.3 General Key Elements for the Future
48.3.1 Communication
48.3.2 Forms of Compensation
48.3.2.1 Leadership
48.4 Conclusions
References
Case Studies
49 Scotland
49.1 Introduction
49.2 Integrated Care in Practice
49.2.1 Problem Definition
49.2.2 Description of the Lead Agency Model
49.2.3 Governance
49.2.4 New Ways of Working
49.2.5 People Involvement/Service User Perspective (Value)
49.2.6 Impacts
49.2.7 Dissemination and Replication of the Case Study
49.2.8 Lessons Learned and Outlook
References
50 Three Horizons of Integrating Health and Social Care in Scotland
50.1 Three Horizons of Integrating Health and Social Care in Scotland
50.1.1 The First Horizon, the Political and Policy Landscape in Scotland
50.1.2 Health and Social Care Arrangements
50.1.3 Making the Case for Change
50.1.4 Building Cross-Party Political Support and Commitment
50.1.5 Engagement
50.1.6 Legislation
50.1.7 New Organisational Arrangements
50.1.7.1 Financial Context
50.1.7.2 Summing Up the First Horizon
50.2 The Second Horizon: Supporting Implementation—2015–2019
50.2.1 Leadership, Collaboration, Culture and Trust
50.2.2 Empowerment and Co-production
50.2.3 Digital Health and Care
50.2.4 Integrated Information and Analysis to Inform Commissioning
50.2.5 Workforce Development and Contracts
50.2.6 Regulation and Standards
50.2.7 Service Transformation
50.2.8 Sharing Good Practice
50.2.9 Monitoring Experience, Outcomes and Impacts
50.2.9.1 Key Trends and Analysis
50.2.10 Summing up the Second Horizon
50.3 The Third Horizon
50.3.1 Self-management and Social Prescribing Partnerships
50.3.2 Anticipatory Care Planning
50.3.3 Compassionate Communities
50.3.4 Housing
50.3.5 Neighbourhood Care
50.3.6 Summing Up the Third Horizon
50.4 Lessons Learned and Reflections on Scaling up
50.4.1 Lessons Learned
50.4.2 Scaling Up the Gains—A Case Study
50.5 Reflections
Acknowledgements
References
51 Innovative Payment and Care Delivery Models: Accountable Care Organizations in the USA
51.1 Integrated Care in the USA
51.2 Integrated Care in Practice: Accountable Care Organizations
51.2.1 Problem Definition
51.2.2 Description of the ACO Model
51.2.3 The CMS ACO Program Pathways to Success
51.2.4 Impact
51.2.5 Preliminary Results
51.2.6 Dissemination
51.2.7 Lessons Learned and Challenges Ahead
51.2.8 General Outlook of ACOs and the Impact of the COVID-19 Pandemic
References
52 Case Study—Community Capacity for Health: Foundation for a System Focused on Health
52.1 The Challenge Before Us
52.2 Healthy Communities: National and Provincial Contexts
52.3 The Journey Begins in Airdrie
52.4 Community Plan for Health
52.5 Aspirations Advanced by Blue Zones Project
52.6 Blue Zones Project Airdrie Implementation
52.7 Abrio Health Experiential Insights
52.8 Perspectives: Healthy Citizens, Sustainable and High Performing Systems—We Can Have Both WHEN….
References
53 Switzerland
53.1 Health Care in Switzerland
53.2 Swiss Integrated Care in Practice
53.2.1 Number and Types of Integrated Care Initiatives
53.2.2 People-Centeredness of the Initiatives
53.2.3 Professionals Involved & Interprofessional Practices
53.2.4 Use of Clinical Information Systems
53.2.5 Integration Between Levels of Care
53.3 Conclusion
References
54 Netherlands: The Potentials of Integrating Care Via Payment Reforms
54.1 Integrated Care in the Netherlands
54.1.1 The Dutch Healthcare Reform in 2006: The Introduction of Managed Competition
54.2 Integrated Care in Practice
54.2.1 Problem Definition
54.2.2 Description of the Bundled Payment Model for Diabetes Care
54.2.3 People Involvement/Service User Perspective
54.2.4 Impact
54.2.5 Lessons Learned
54.2.6 Outlook
54.2.6.1 Bundled Payment for Pregnancy and Child Birth
54.2.6.2 Population Health Management
References
55 Designing Financial Incentives for Integrated Care: A Case Study of Bundled Care
55.1 Introduction
55.1.1 Models Based on Procedures and Diagnostic-Related Groups
55.1.2 Single Condition Versus All-Inclusive Bundles
55.1.3 Event Triggering the Start of the Bundled Care
55.1.4 Short-Term Versus Longer-Term Models
55.2 Bundled Care in Ontario: A Case Study
55.2.1 he Implementation Context
55.2.2 Rationale for Integrating Acute with Home Care
55.2.3 Characteristics of CHF and COPD Bundles in Ontario
55.3 Cost-Effectiveness of Bundled Care for Chronic Conditions
55.3.1 Evidence of Cost-Effectiveness
55.4 The Economic Theories Behind Financial Incentives as They Apply to Bundled Care
55.4.1 Principal–agent Theory
55.4.2 Transactional Cost Economic Theory
55.5 Conclusion
References
56 Singapore
56.1 Introduction
56.2 History and Transitions
56.3 Governance and Care Delivery
56.4 Healthcare Financing
56.5 Integrated Care in Practice
56.6 People Involvement
56.7 Impact
56.8 Areas for Improvement
56.9 Learnings from the COVID-19 Pandemic
56.10 Outlook
Acknowledgements
References
57 Integrated Care in Norway
57.1 Introduction
57.2 Norwegian Health and Social Care Services
57.3 The Coordination Reform (2008–2009)
57.4 The White Paper on Public Health (2014–2015)
57.4.1 Care Plan 2020
57.4.2 National Health and Hospital Plan, 2020–2023
57.5 Reaching the Quadruple Aim in Norway
57.6 Patient-Centred Healthcare Team in Tromsø
57.7 Outlook for the Future
References
58 Wales
58.1 Introduction
58.2 Problem Definition
58.3 Integrated Care Policy in Wales
58.4 Integrated Care in Practice in Wales
58.4.1 Integrated Care Case Study One: A Healthier West Wales: Proactive Technology-Enabled Care
58.4.2 Integrated Care Case Study Two: Providing Palliative Care for Heart Failure Patients at Home
58.5 Impact, Dissemination and Replication
58.6 Lessons Learned and Outlook
58.7 Concluding Remarks
References
59 Integrated Community Care―A Last Mile Approach: Case Studies from Eastern Europe and the Balkans
59.1 Introduction
59.1.1 Organisation Redesign
59.2 Local Authorities Driving Service Integration
59.2.1 The Romanian Experience
59.2.2 The Intervention
59.2.3 General Findings
59.2.4 User Benefits/Satisfaction
59.2.5 Service Provider Benefits
59.2.6 Population Benefit
59.2.7 Cost Benefit
59.3 Social Services Developing Integrated Case Management Strategies for Elderly and Multi-Morbidity Patients in Rural Communities
59.3.1 The Moldova Experience
59.3.1.1 Health Information Systems
59.3.1.2 Sectoral Divide Between Medical and Social Services
59.3.1.3 Leadership and Priorities
59.3.2 The Intervention
59.3.3 General Findings
59.3.4 User Benefits/Satisfaction
59.3.5 Service Provider Benefits
59.3.6 Population Benefit
59.3.7 Cost Benefit
59.4 Family Medicine Centres Drive the Development of Integrated People-Centred Health Services (IPCHS) at Municipality Levels
59.4.1 The Kosovo Experience
59.4.2 The Intervention
59.4.3 General Findings
59.4.4 User Benefits/Satisfaction
59.4.5 Service Provider Benefits
59.4.6 Population Benefit
59.4.7 Cost Benefit
59.5 Conclusions and Lessons Learnt
References
60 Developing Integrated Care in Portugal Through Local Health Units
60.1 Introduction
60.2 Integrated Care—Case Management
60.3 Integrated Care in Mental Health
60.4 Conclusion
References
61 Primary Healthcare Integration Practices in Turkey
61.1 Introduction
61.2 Problem Definition and Motivation
61.2.1 Demographic Transition
61.2.2 Rapid Urbanization and Changing/deteriorating Lifestyles
61.2.3 Changing Disease Patterns from Communicable to Noncommunicable Diseases
61.2.4 The Need to Change Care Delivery Structures
61.2.5 High Burden of Ambulatory Care in Hospitals
61.3 Description of the Model
61.3.1 Integrated Care at High Policy Level
61.3.2 Elements of the Care Integration in Turkey
61.4 Dissemination and Replication
61.5 Implementation and Impact
61.5.1 Implementation
61.5.2 Initial Impact of Care Integration Efforts
61.6 Lessons Learned and What’s Ahead
61.6.1 Next Steps in Care Integration
61.6.2 Lessons Learned
61.7 Conclusion
References
62 Israel: Structural and Functional Integration at the Israeli Healthcare System
62.1 Integrated Care in Israel
62.1.1 A National Perspective: How Integration in Practice Can Improve Quality of Outpatient Care
62.2 Integrated Care in Practice: Clalit Health Services
62.2.1 Problem Definition: Unplanned Readmissions
62.2.1.1 The Strategy: Vertical Integration
62.2.1.2 Predictive Modelling
62.2.1.3 Transitional Care Interventions
62.2.1.4 Quality Monitoring
62.2.2 Impact
62.2.3 Dissemination and Replication
62.2.4 Lessons Learned and Outlook
References
63 Integrated Care Concerning Mass Casualty Incidents/Disasters: Lessons Learned from Implementation in Israel
63.1 Introduction
63.2 Basic Assumptions
63.3 Main Components of Integrated Care
63.3.1 The Preparatory Phase
63.3.1.1 Development of Integrated Guidelines and SOPs
63.3.1.2 Training and Exercise Programmes
63.3.1.3 Ongoing Monitoring Systems
63.3.1.4 Information Systems
63.3.1.5 Equipment and Infrastructure
63.3.2 The Response Phase
63.3.2.1 Implementation of an Automatic Response
63.3.2.2 Central Control and Coordination
63.3.2.3 Connectivity Between Response Agencies
63.3.2.4 Collaboration Between Military and Civilian Entities
63.3.2.5 Coordinated Risk Communication
63.3.3 The Post-response Phase (Return to Normalcy)
63.4 Conclusions
References
64 Canada: Application of a Coordinated-Type Integration Model for Vulnerable Older People in Québec: The PRISMA Project
64.1 Integrated Care in Québec and Canada
64.2 Integrated Care in Practice
64.2.1 Problem Definition
64.2.2 Description of the PRISMA Model
64.3 Experimental Implementation and Impact
64.3.1 Dissemination and Replication
64.3.2 Lessons Learned and What is Ahead
References
65 New Zealand: Canterbury Tales Integrated Care in New Zealand
65.1 Integrated Care in New Zealand
65.2 Integrated Care in Practice
65.2.1 Problem Definition.
65.2.2 People Involvement/Service User Perspectives
65.2.3 Impact
65.2.3.1 Building a Social Movement
65.2.4 The 2010–2011 Earthquakes
65.2.5 Vision 2020 Becomes Vision 2011
65.2.6 Dissemination and Replication
65.2.7 Lessons Learned and Outlook.
65.2.8 The Canterbury Health System Response to the Christchurch Mosques Terror Attacks
65.2.9 Was Vision 2020 Achieved?
65.3 Integrated Health Systems in a time of Coronavirus
65.4 Conclusion
References
66 Building an Integrated Health Ecosystem During the Great Recession: The Case of the Basque Strategy to Tackle the Challenge of Chronicity
66.1 Introduction
66.2 The Role of Basque Health Care Within a Decentralised Health System
66.3 Demographic and Epidemiological Changes in the Basque Country
66.4 Organisational Transformation of the Basque Health System to Tackle the Challenge of Chronicity (2009–2019)
66.4.1 Health Policies in the Context of the Great Recession
66.4.2 The Need for New Healthcare Models: A Systemic Transformation Towards Integrated, Person-Centred Care
66.4.2.1 Phase 1. The Strategy to Tackle the Chronicity Challenge in the Basque Country
66.4.2.2 Phase 2. The Deployment of the ICO Model
66.4.2.3 Phase 3. Progress Towards a Value-Based Integrated Care Model
66.5 Conclusions
References
67 The Journey from a Chronic Care Program as a Model of Vertical Integration to a National Integrated Health and Care Strategy in Catalonia
67.1 Introduction
67.2 Integrated Care in Practice
67.2.1 Problem Definition
67.2.2 Description of the Model
67.2.2.1 The Beginning of the Integrated Care Model in Catalonia—The Chronic Care Program
67.2.2.2 The evolution of the concept—From Vertical Integration to an Integrated Health and Care Strategy in Catalonia—PAISS
67.3 Experimental Implementation and Impact
67.3.1 Dissemination and Replication
67.3.2 Lessons Learned and Challenges Ahead
67.3.3 Applying Lessons Learned to a COVID Crisis Scenario
67.4 New Proposals to Reinforce Integrated Care as a Prioritized Policy in Catalonia
References
68 Integrated Care in the Autonomous Community of Madrid
68.1 The Spanish National Healthcare System
68.2 Madrid Region
68.3 Strategy of Care for People with Chronic Diseases in Madrid Region
68.3.1 Stratification of the Population
68.3.2 Protocols for Patients with Chronic Diseases Adapted to Their Needs
68.3.3 Integrated Care Pathways for Patients with Complex Needs
68.3.4 Shared Electronic Health Record
68.4 The End of Life Care (Palliative Care)
68.5 Implementation in Specific Territories and Bottom-Up Initiatives
68.5.1 The Case of Rey Juan Carlos Hospital
68.5.2 “Mapeando Carabanchel Alto” (Mapping Upper Carabanchel)
68.5.3 “Vallecas Activa” (Vallecas Active)
68.6 Conclusions
References
69 Integrated Care in Germany: Evolution and Scaling up of the Population-Based Integrated Healthcare System “Healthy Kinzigtal”
69.1 Integrated Care in Germany
69.2 Case Study: Healthy Kinzigtal (HK)
69.2.1 Governance and Participation
69.2.2 The Business Model of Healthy Kinzigtal
69.2.3 Coverage and Programmes
69.2.4 A Cross-Cutting Theme: People Involvement / Service User Perspective
69.3 Impact
69.4 Dissemination and Replication
References
70 Case Study Finland, South Karelia Social and Healthcare District, EKSOTE
70.1 Background
70.1.1 Population
70.1.2 Social and Healthcare Reform in Finland
70.2 South Karelia Social and Healthcare District EKSOTE
70.2.1 EKSOTE’s Organization Chart
70.3 Examples of Integrated Service
70.3.1 Low-Threshold Services
70.3.2 Rehabilitative Home Care
70.3.3 Mobile Services by Car (Mallu and Malla)
70.3.4 Emergency Services (ER) in Your Living Room, Stand-by Urgent Care at Home
70.3.5 Coordination
70.3.6 Measurement of Health Outcomes and Social Services
70.3.7 Reimbursement System
70.3.8 Digitalization
70.4 Examples
70.4.1 The Smart Assessment of Service Need
70.4.2 Smart Home
70.4.3 Speech and Voice Recognition
70.5 Conclusion
References
71 Ireland Case Study
71.1 Introduction
71.2 Integrated Care in Ireland
71.2.1 Health of the Nation
71.2.2 The HSE National Clinical Programmes
71.2.3 The National Integrated Care Programmes
71.2.3.1 Key Features of Establishing the Integrated Care Programmes
71.2.3.2 Governance
71.3 The Patient Voice in Integrated Care
71.3.1 Patient Narrative Project
71.4 The National Integrated Care Programme for Older People (ICP OP)
71.4.1 Insights into Implementation
71.4.2 Impact of ICP OP
71.4.3 Summary of Findings
71.4.4 Dissemination
71.5 Lessons Learned and Outlook
71.5.1 We Have Learned that Integrated Care Is a Journey and not a Destination
Acknowledgements
References
72 Disease Management Programs in The Netherlands; Do They Really Work?
72.1 Using the Chronic Care Model to Evaluate the Long-Term Effects of Disease Management Programs in The Netherlands
72.2 Question 1: Which Interventions Mapped to the Chronic Care Model Were Actually Implemented Within the Dutch DMPs?
72.3 Question 2: Did the Quality of Chronic Care Delivery Measured with the CCM Dimensions Improve Over Time?
72.4 Question 3: Did Quality of Chronic Care Delivery Result in Productive Interactions Between Patients and Healthcare Professionals?
72.5 Question 4: Did DMP Implementation Lead to Better Patient Outcomes?
72.6 Conclusion
References