During the EU Project Integrate final session the findings from the work package on Policy Lessons were presented. This work package dealt with an analysis of what policy makers can do to improve the care of people with multiple chronic conditions. We have looked for both “lessons learned” and “policies on integrated” care that provided the basis to the development of a policy guide on integrated care. The building blocks of this policy guide are a mission, a vision and a strategy. We looked at health policy (what should be done) and governance (how things are done), as differences in governance explain why some countries in Europe have been more successful in pursuing effective integrated and chronic care policies than others. Key lessons learned from Project Integrate were: ‘it is about excellent care’, ‘disruptive innovation’, ‘competencies’, ‘the broader picture of well-being’, ‘effective implementation strategies’, ‘context’, and ‘outcomes’. From there, a broad range of policies were outlined directed at people and communities, care and accountability and change management.
The approach of policy makers to integrated care consists of a mission, vision and a strategy.
Mission: The Triple Aim framework serves as the foundation for organizations and communities to successfully navigate the transition from a focus on health care to optimizing health for individuals and populations.
Vision: It is important for policy makers to understand the core principles that underpin integrated care, e.g. ‘led-by whole systems thinking’, ‘evidence-informed’, ‘co-produced’, ‘empowering’, ‘engaging’, goal-oriented, and equitable care. Policy makers should also profoundly understand the context for change, and must understand the models for producing health in a population, including the medical, the public health and the social determinants of health model. Our experiences with Project Integrate have shown all three models must be pursued in balance.
Strategy: It is essential to develop a national, regional and local plan on integrated care including the appointment of a secretary of state, as part of good health system governance. Central to any strategy is the idea of value chains. What is crucial in these “chains” ideas is that each link in the chain adds up some value to the previous one.
But, most essential when defining an entry point is ‘what do people with chronic conditions value most? National Voices in the UK have clearly described the expectations of patients when it comes to goals, communication, information, decision making, care planning, transitions and emergencies.
Numerous entry points can be identified to the development of a national/regional or local plan on integrated care, but we think there are five potential entry points that can safeguard that patient’s expectations and needs become the truly organizing principle to integrated care policies.
• Entry point 1: Preventing adverse childhood experiences. There is compelling evidence that different types of trauma in early life are important risk factors for poor health in adulthood, including autoimmune and other chronic diseases of all kinds. Adverse childhood experiences (ACEs) are potentially traumatic events that can have negative, lasting effects on health and well-being. These experiences range from economic hardship, exposure to violence, and the occurrence of mental illness, physical, emotional, or sexual abuse over parental divorce. ACEs often occur together. An estimated 50% of the population in Europe has experienced at least one ACE. It would be wrong to focus only on risk factors to chronic diseases such as physical activity, smoking or diet, and not considering adverse events to be a crucial part of our strategies on integrated care. It is not an easy topic, but it offers a potentially vital new resource for working with chronic illnesses: that of addressing the trauma from the past.
• Entry point 2: A life course approach to the development of health literacy. We need a life course approach to the development of health literacy, starting at a very young age, while involving parents, schools, community health centres, primary care providers and specialists.
• Entry point 3: Regulatory frameworks for educational and professional reforms
We urgently need regulatory frameworks for educational and professional reforms. New competencies that promote integrated care are essential. This responsibility does not lie with the Minister of health, but it demonstrates the importance of intersectoral collaboration, and the collaboration with professional bodies and universities.
• Entry point 4: Regulatory frameworks for collaborative entities and teams
We need regulatory frameworks for collaborative entities and teams, coupled with financial incentives and/or changes in payment systems.
• Entry point 5: Regulatory frameworks for improved population health
At last, we need regulatory frameworks for improved population health including e.g. population needs assessment, health registries, risk stratification and pooling of budgets between health and social care.
A vivid debate started off after the presentation, including panelists Prof. Michael Rigby, Angela Cooper and Robert Johnstone. One of the key comments related to the need for disruptive innovation. While there was consensus we don’t need innovation at the margins, the way and degree ‘disruptive innovation’ will look like in practice might differ considerably within countries. On the entry points for integrated care programmes the prevention and management of childhood adverse experiences was considered essential. The development of competencies in patients was considered another vital component to the improvement of health literacy and overall empowerment of patients. Regulatory frameworks for educational and professional reforms, collaborative entities and teams and improved population health were considered to provide the basis to any integrated care strategy or programme.
Dr Liesbeth Borgermans
Professor of Chronic Care,
Vrije Universiteit Brussel