The Importance of Integrated Care to the Future of
Health Systems:
National and Regional Developments in Europe and other countries
Dr Nick Goodwin & Dr Lourdes Ferrer
CEO, International Foundation for Integrated Care
www.integratedcarefoundation.org
Paper to: Health Quality and Safety Commission New Zealand
Workshop: Towards Integrated Care in New Zealand
Wellington, New Zealand, November 14th 2013
The Challenge
Ageing Society = Greater Complexity of Care
By 2034, >85s will represent c.5% of the population in Western Europe.
Care Systems in Europe are Failing to
Cope with Complexity
The complexity in the way care
systems are designed leads to:
• lack of ‘ownership’ of the
person’s problem;
• lack of involvement of users
and carers in their own care;
• poor communication between
partners in care;
• simultaneous duplication of
tasks and gaps in care;
• treating one condition without
recognising others;
• poor outcomes to person, carer
and the system
Frontier Economics (2012) Enablers and barriers to integrated care and implications for Monitor -
The Challenge: Summary
• Age-related chronic conditions absorb the largest, and
growing, share of health/social care activities
• Poor co-ordination of care for people with longterm/complex illnesses leads to poor care experiences
and adverse outcomes
• Practical solutions to tackle the socio-determinants of illhealth and pathology of the complex patient
• Strategies of care co-ordination to create more
integrated, cost effective and patient-centred services
are growing internationally
• Lack of knowledge about how best to apply care coordination in practice.
The European Response
• There are many different
examples of policies and
innovation on integrated care
around Europe
• The political agendas, however
focus on:
– Financial reform
– Cost containment
– Legislative change
– Structural reorganizations
– Personalised care
– Pilot programmes
• Not enough on change
management and the ‘how to’
of integrated care
National Strategies - Examples
•
•
•
•
•
•
•
•
Denmark & Norway: Coordination Reform
Sweden: Joint agencies link funding and
delivery (e.g. Jönköping & Nortallje)
England: The National Collaborative for
Integrated Care and Support (Pioneers)
Germany: Versorgungsstrukturgesetz (care
structure law) supports interdisciplinary
and cross-sector models of care
Netherlands: Managed care organizations
and bundled payments for certain
diseases
Health and social care integration in
Northern Ireland, Scotland and Wales
Spain: vertically and horizontally
integrated care organizations to support
better chronic care ( e.g. Basque Country,
Catalonia, Valencia)
Switzerland: physician networks / HMOs
Example 1:
The Basque System, Spain
Care transformation in the midst of a deep economic crisis
• Developing a favourable
policy environment
• Stimulating systems
thinking with new models
of care
• Aligning ‘bottom-up’ and
‘top-down’ integration
• Providing a distributed
leadership approach
Bengoa, 2013 - http://www.ijic.org/index.php/ijic/article/view/URN%3ANBN%3ANL%3AUI%3A10-1-114747/2042
Example 2:
Maccabi, Israel
• Physician group partnership providing coordinated care to 1.9m people (25%
population)
• Integrated ICT systems promote
communication , continuity of care and
supported self-care through ‘patient
portal’ and telehealthcare
• System focus on managing chronic
disease and the elderly
• Investment in leadership and interprofessional working
• Investment in research
• Positive impact on care experiences,
clinical outcomes and cost containment
Maccabi 2011 - http://www.intel.co.uk/content/dam/www/public/us/en/documents/white-papers/coordinated-healthcare-from-maccabi-and-intel-paper.pdf
Example 3:
National Collaborative for Integrated Care, England
• The ‘Narrative’
• Change to NHS Mandate
• Development of shared care outcomes
between government departments, and
quality regulator includes new targets
• Integration encouraged alongside
competition by economic regulator
• Financial reforms supports range of new
incentives to providers
• Commissioning reforms supports new
opportunities to pool budgets
• New resources to support change – and
the Integration Transformation Fund
(£3.8bn)
• Pioneers Programme
HEALTH IN EUROPE 2020
EUROPE 2020 FLAGSHIPS FOR SMART, SUSTAINABLE AND INCLUSIVE GROWTH
Digital
Agenda
New
Industrial Policy
Innovation
Union
Digital Agenda
for Europe
Youth
on the Move
New Skills
and New Jobs
Innovation
Union
Platform against
Poverty
Resource
Efficiency
• innovation for tackling societal challenges, e.g. ageing and health
• innovation for addressing the weaknesses & removing obstacles in the European
innovation system
• ICTs for tackling societal issues - ageing, health care delivery
• sustainable healthcare & ICT-based support for dignified & independent living
EUROPEAN INNOVATION PARTNERSHIP ON
ACTIVE AND HEALTHY AGEING
+2 Healthy Life Years by 2020
Triple win for Europe
Sustainable &
efficient care
systems
health &
quality of life
of European
citizens
growth &
expansion of
EU industry
Action Groups
Better management of health:
preventing falls (A2)
Preventing functional decline and frailty
(A3)
Integrated care for chronic conditions, inc.
telecare (B3)
ICT solutions for independent living & active
ageing (C2)
Age-friendly cities and environments (D4)
Reference Sites
Improving prescriptions and adherence
to treatment (A1)
EIP AHA B3 Action Plan
Increase the average number of healthy life yrs by 2 in the EU by 2020
Health status and quality of life । Supporting the long term sustainability and efficiency of health and social systems । Enhancing competitiveness of EU industry
Chronic Conditions
By 2015
Chronic Conditions’ Programmes available at
least 10% of target population in at least 50
regions
Integrated Care
By 2015 - 2020
SIP
TARGETS
Integrated Care Programmes serving older people,
supported by innovative tools and services, in at least
20 regions
Action Area
Action Area
Action Area
Action Area
Action Area






Organisational
Models
Change
Management
Workforce
Development
Risk Stratification
Care Pathways
Patient / User
Empowerment
Map of partnership
models for
implementation of
Chronic and
Integrated Care
Programmes
Map of best
practice
methodologies to
support the
implementation of
Chronic and
Integrated Care
Map of
reusable learning
resources
Stratification of
the population
Mapping Best
Practices in the EU
regions
Toolkit
Toolkit
Toolkit
Toolkit
Toolkit
2013
Monitoring impact and outcomes
Map of coaching,
education and
support
patient/user
empowerment
and adherence
Toolkit
2015
Toolkit
Action Area
Toolkit
Finance/Funding

ICT Tools


Dissemination
Action Area
Action Area
Action Area
Implementation and Scale Up of Chronic Care + Integrated Care Programmes
Developing a Regional Action
Framework for
Coordinated/Integrated
Health Services Delivery
(CIHSD) in the WHO European
Region
Dr. Hans Kluge
Director, Health Systems and Public Health
European Forum for Primary Health Care Conference
Istanbul, Turkey, September 9th – 10th 2013
The Road Map to CIHSD
\\
Field
evidence
Guide for
leading &
managing
change
Concept note –
common approach
to CIHSD
MS Focal
Points
External
Advisory
Team
Internal
Review
Team
WHO
Secretariat
PARTNERS
Patients
Providers
Int’l orgs &
NGOs
The Integrated Care Response in US and Canada
USA
Canada
• Integrated delivery systems for
enrolees
• Health Canada – Health Accord,
2004
– E.g. Kaiser Permanente
– E.g. Veterans Health
• HMOs & group practice models
– E.g. Mayo, Geisinger, Seattle
• Managed care or disease
management programmes
– E.g. PACE
• Integrated delivery systems for
populations:
– E.g. Nuka, Alaska
– E.g. Massachusetts
– Sets 10 plans to overcome
duplications, improve access and
promote efficiency
– Emphasis on care transitions
hospital-home to reduce ‘bed
blockers’
• Provincial application leads to
decentralisation and variation
– PRISMA, Quebec
– GP group practices, Alberta
– Community-oriented primary care
centres, Newfoundland and others
Example 4:
PACE Programme, USA
• Fully integrated system providing
acute and long-term care services
to older people (>55)
• Grew out of On Lok, an innovative
senior centre that developed a
day hospital approach to care to
frail older people
• Based around an adult care
centre that offers:
–
–
–
–
social and respite services
primary medical care
geriatric outpatients
ongoing care and case
management
• Designed to maintain frail older
people in the community for as
long as possible, so avoiding
institutionalisation
• Voluntary enrolment, available to
those aged >55 eligible for
nursing home admissions and
covered by both Medicare and
Medicaid
• Important role of informal carers
and supportive housing often
part of care package
Example 4:
PACE Programme, USA
• Between 1987-1997 PACE
operated as a federal
demonstration programme
• Since 1997, PACE a permanent
provider under Medicare and a
state option under Medicaid
• By January 2005 36 fully
operational programmes across
18 states
• A typical participant:
– A woman who is 80 years old with
multiple (9.7) medical conditions
with limited activities for daily
living. 49% have a diagnosis of
dementia
How PACE achieves integrated care:
• Pooled financing (Medicare &
Medicaid) and authority to
control how capitated funding is
spent
• Integrated services by range of
staff employed at adult care
centre – outside contracts for
medical services, acute
hospitalisations & nursing home
care
• Case management by
multidisciplinary teams including
comprehensive assessments,
service provision and care coordination
• Prevention and rehabilitation
focus
Example 4:
PACE Programme, USA
Evaluations of PACE conclude:
• Large decreases in hospital use
(admissions and lengths of stay)
for enrolled patients
• Increased use of outpatient
medical care and therapies, and
care in home environment
• Positive impact on Medicare costs
in comparison to non-enrolee
groups
• Client health status and
satisfaction with care
arrangements good
• Results in terms of physical
functioning inconsistent
Conclusions:
• PACE successful in managing frail
older patients and in offsetting
costs against more expensive
outpatient care
• Capital and start up costs were
substantial, so PACE needed
pump-priming from federal and
state governments in initial
phases
• Some patients not comfortable
with adult day health care
settings and/or giving up contact
with a personal physician
• Centres run at a small scale (c.300
enrolees) so issues of economies
of scale if more widely adopted
Example 5:
PRISMA Programme, Quebec, Canada
• Unlike PACE, PRISMA is a coordinated model of care
• The goal is to integrate service
delivery to older people to
improve functional autonomy
• Admission is to persons >65 who
have moderate to severe
disabilities, but show good
potential for staying at home –
they need two or more health
and social care services from the
area in which they live
How PRISMA achieves integrated
care:
• Inter- and intra-organisational coordination by joint governing
board and a service co-ordination
committee
• A single point of entry to care
services
• Case management who work with
clients’ family physician and other
providers
• Common assessment process and
care plan
• Joint budget
• Integrated information system to
track patients and support
continuity of care
The PRISMA Model
PRISMA (Canada)
Evaluations of PRISMA conclude:
•
•
•
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Declining trend in institutionalisation
Lower client preference to be institutionalised
Greater functional autonomy of clients
No reduced or significantly changed pattern in the use of
health and social care services
• Positive impact on carer burden
• No impact on mortality (survival)
• No reduction in costs
Improved system outcomes at no additional cost
PRISMA and PACE compared
Towards Integrated Health Service Delivery in
Latin America
Essential attributes of
IHSDNs (PAHO, 2011)
WHO (Geneva) - Integrated care as a strategy to
support universal health coverage

WHO (Geneva)
Strategy for High Quality and People Centred Integrated Care
(HQPCIC) to support Universal Health Coverage
Conclusions:
Strategies and Progress
• Integrated care is a global buzzword and strategy for system reform
• Integrated care takes on multiple forms, and the purpose to which
it has been adopted varies
• Cost-containment / creating sustainable care systems is a central
driver, yet evidence suggests that integrated care is primarily a tool
for quality improvement
• Evidence remains varied and limited, especially on costs
• However, there is enough to suggest what the important
components of integrated care must be, and that the approach can
support the ‘Triple Aim’ goals of care systems
• Yet, the failure rate amongst integrated care initiatives is high –
more is needed in understanding how to develop, sustain and
spread initiatives successfully and for the long-term
• There are few alternative options …
Contact
Dr Nick Goodwin
CEO, International Foundation for Integrated Care
nickgoodwin@integratedcarefoundation.org
www.integratedcarefoundation.org
@goodwin_nick
@IFICinfo