Integrated Framework of
Care Toolkit
Presentation Overview
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Drivers for change
What is integration?
Toolkit objectives
Leutz Integrated framework
Forms and types of service integration
Lessons from the literature
Leutz five laws
Quality measures
Summary
Where to from here?
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Drivers for Change
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The Ministers expectations
Demographic changes - ageing
A range of providers supporting older
adults with multiple long-term conditions
The need to improve the experience of
our service users through well planned
community services preventing avoidable
hospital and residential care admissions
Regionalisation of services - increased
movement of service users & clinicians
Requirement for the most productive use
of our health and social support
workforces
“Although my
inpatient care was
very good, I had an
overall bad
experience because
I was sent home
without any
knowledge of how
to access the
support services I
needed”
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The Toolkit
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Proposes a framework
specifying the different
degrees of integration
intensity required to meet
different levels of client
need
Provides information on
the different forms and
types of service
integration
Offers a guide to planning
integrated services
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What is Integrated Care?
An organising principle for service delivery aiming to
achieve improved patient care through better
coordination of services provided.
Integration is the combined set of methods,
processes and models that seek to bring about this
improved coordination. Done well, integration
should lead to the outcome of integrated care.
Nuffield Trust: 2011
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All Integration is Local
The design of integrated services will vary depending
upon;
- The particular issue creating difficulties for clients &
service providers
- The constraints and possibilities within the local
environment
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Leutz: First Law of Integration
‘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’
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Levels of Integration Intensity
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full integration resources are pooled
to create new services to meet the
complex health/social needs of a
targeted population group
coordination bridges largely separate
acute, long-term care, social support
systems using case managers and
agreed processes to help higher
need clients manage transitions in
and across care settings
linkage people with mild to
moderate health needs are cared for
by systems which serve the whole
population. No new services or care
management required
Full
Integration
Coordination
Linkage
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Operational Domains Matrix
• Design of integrated services varies depending upon the need
of the client group/degree of integration intensity
• The ODI proposes operational domains which should be
considered in service development demonstrating differences
between the linkage, coordination and full integration levels
• Useful for development of new services or as an
environmental scan on an existing suite of services to
understand the intensity of integration across the services
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Operational Linkage
Dimension
Coordination
Full Integration
Enablers in the Central Region
context
Screening
Screen flow at key points
(e.g. ED and hospital
discharge, primary care
providers) to find those
who need special
attention
Targeted selection of
older adults for specific
services designed to meet
priority needs of service
users and providers
Agreement between primary and
secondary health care as to
screening priorities
Screen population to
identify emergent needs
Individualised needs
assessment triggered by
screening tool
Referral protocols to
ensure that individuals
who are screened and
referred get to the service
Agreement on common screening
tools across Region, and access by
service users, caregivers and
professionals to those tools
Screening processes for high risk
within integrated healthcare
networks, accident and medical
centres and Emergency Departments
Referral protocols and pathways
locally and regionally
Identifying poor use of primary care
Reliable and common data extracts
Agreed stratification criteria for
targeted services
Information regarding eligibility for
services is easily locatable and
contingencies to fund service gaps
are available
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Matching Client Need to Integration Levels
Need Dimensions
Linkage
Coordination
Full Integration
Illness Severity
Mild/moderate
Moderate/severe
Moderate/severe
Illness Stability
Stable
Stable
Unstable
Illness Duration
Short to long-term
Short to long-term
Urgency of care
Routine/non-urgent
Mostly routine
Long-term or
terminal
Frequent urgency
Scope of services
needed
Narrow/moderate
Moderate/broad
Broad
Self-direction of
client
Self-directed or
strong
informal care
Varied levels of self
direction
and informal
care
May accommodate
weak self-direction
and informal care
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Forms of Service Integration
Forms of integration which should be considered
when an integrated service is being designed.
• Horizontal integration
• Vertical integration
• Virtual integration
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Types of Service Integration
Organisational
Integration
Systemic Integration
Organisational
Integration
Functional
Integration
Service Integration
Functional
Integration
Integrated
Care to the
Patient
Service
Integration
Clinical Integration
Normative
Integration
Systemic Integration
Clinical
Integration
Normative Integration
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Leutz Five Laws of Integration
1. You can’t integrate all the services for all the
people
2. Integration costs before it pays
3. Your integration is my fragmentation
4. You can’t integrate a square peg into a round
hole
5. The one who integrates calls the tune.
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Quality Measures
• Evidence on the impact of integration is limited
• Measures for improvement should always be linked
to the programme objectives and aims, and be able
to demonstrate that a change is an improvement
(and not just a change)
• The IHI model for improvement questions can help
define measures
• Structural, process, patient outcome measures can
all be utilised.
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Summary
1. Integrated services are a means to an end
2. Service design can be highly variable
3. Leutz levels of integration intensity provide a global view of how much integration
is required for people at different levels of need
4. The operational domains suggest activities that could be undertaken by
services/providers at various levels in order to meet client need and support
service provision at other levels
5. Service planners should review the activities proposed at each level and apply
them or not or in a variety of different ways
6. The need dimension table can be used to plan care for individual clients or to
broadly analyse the numbers of people with needs which could be met by a linked,
coordinated or 'fully' integrated service
7. Quality measures should be based upon the objectives of the service
development - organisational, process and client health outcomes.
8. Great integrated service development requires a well informed and collaborative
planning process
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• Provides a brief
understanding of the
Integrated
Framework of Care
• References to the
Framework
document
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• International literature identifies
that planning integrated care is a
complex task
• To assist the Central Region DHBs
to plan integrated care, a
Planning Integrated Care Guide
has been developed
• The guide provides a high level
list of considerations for those
involved in planning integrated
services
• The questions posed are designed
to promote a shared
understanding of what the
integration project expects to
achieve and assist in a robust
planning process
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• Case studies following
Maria and Franz as they
experience health
changes and require
different types of
assistance
• Three case studies with
emphasis on clinical /
service integration
1. Linked
2. Coordinated
3. Integrated care
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Where To From Here?
• You can access the tool kit by going to:
www.centraltas.co.nz/RegionalGroupsNetworks/
Central Region Health of Older People Network
• Application in DHB planning processes
• As a framework it is applicable to other areas such as
mental health
• Follow up in April / May 2013 with DHBs
• Report to the National Health Board in June 2013
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