Integrated care services offer benefits for patients and for Europe’s health and social security systems, which are facing the challenges of an aging population and increased chronic conditions. However, analysing integrated care practices is not an easy task. Main reasons for such difficulties are the polymorphous nature of integrated care, the multiplicity of interpretations and formats, and the variety of professionals involved and the interactions among them. This difficulty confronts the interpretation of the results observed and complicates the extraction of useful lessons.
The general aim of the Project Integrate (Benchmarking Integrated Care for better Management of Chronic and Age-related Conditions in Europe) is to tackle this challenge. This abstract describes the work done in the work package 6 (WP6) of the Project Integrate focusing on care process design. The objective of WP6 is to gain valuable insights into integrated care practices and turn this insight into policy and managerial lessons. Furthermore, this WP aims to develop a framework to analyse the impact of care process innovation.
WP6 of the project INTEGRATE is one of the transversal work packages that are part of phase 2 of project Integrate. The aims of WP6 “Care Process Design” are: identify successful organisational models of integrated care processes; describe their effectiveness, and inform about key characteristics and elements enabling integrated care processes that facilitate positive patient experiences and care outcomes.
During the project´s first phase, we conducted in-depth studies of four European established practices on integrated care (COPD, Diabetes, Geriatrics and Mental Health). Four European established integrated care practices are known as good examples of integrated care models.
A subsequent stepped analysis took place, moving from a more general to a more specific level of detail:
In the first level of analysis, we allocated individual process components to five general blocks describing the process. In the second level, a common methodological framework was applied to all to analyse and identify which key components were seen as main contributors for integrated care success. We described the individual process components for the success of integrated care in terms of the value of distance (physical movement from one place to another) and the value of transaction (volume of information/data exchange). Furthermore, these novel processes were evaluated for their added value in comparison to standard care practices.
Moreover, the process components were analysed with respect to their pertinence and relevance to the following areas: care process design, human resources management, financial flows, patient involvement and use of ICT. These analyses differentiated central aspects from those that have context dependencies.
During the project´s second phase, we conducted a systematic review in order to obtain an overview of knowledge on care process design, followed by a Delphi consensus process study. Within the framework of the Delphi study twenty experts from 13 European countries discussed questions and statements covering the IC relevant areas, such as the integrated Care provision process and resources for integrated care provision. Further areas included for instance the leadership and governance, as well as the outcome evaluation of integrated care programs.
The main outcome of this work package was the development and the piloting of a managerial framework providing policy recommendations for good quality integrated care provision. This development of an integrated care framework was a first attempt to obtain a less conceptual and rather practical tool supporting daily IC operations in the assessment of current IC practices. In contrast to existing tools it aims for a higher operationality and applicability to individual specific work contexts and environments.
WP6 findings support health care providers in organising health care processes towards an integrated approach under consideration of specific context dependencies. The in-depth studies of four integrated care practices revealed process components for the success of integrated care.
This study showed that there is a high degree of heterogeneity of IC programs in place, including a large variety of components found in IC programs. The processes of care were very different among the cases, which were not surprising due to different context dependencies such as health conditions and health systems. However, the study of the different care processes revealed five segments that were common to all of them, albeit with diversity in their expression: The case identification, assessment, work (care) plan definition and execution, re-assessment of the care plan and transition to subsequent care.
Across the four case studies, the following points were identified as adding value to the integrated care process with respect to usual care: 1) better access to indicated health services, 2) multidisciplinary care approach, 3) holistic assessment (health and social needs), 4) better orientation to patient and carers, 5) improved involvement / empowerment of patients and carers, 6) improved formal and informal communication among health professionals and patients; 7) clearer process and care objectives and indicators for evaluation; 8) central coordination through case manager/case coordinator.
A systematic review of the current literature identified a total of fourteen types of systems-based collaborative implementation strategies in integrated care programmes, such as for instance the electronic data exchange, multidisciplinary care plans, or shared-care protocols. The study also showed that most programmes cover comprehensive services across the care continuum or standardization of care through inter-professional teams.
Within the framework of a Delphi study, conducted with 20 experts from 13 European countries, questions and statements covering the IC relevant areas were explored. The study showed that the personal communication between the patient and the health professionals, efficient organisational structure and governance of the service provider were seen as key component for IC. Other components facilitating IC implementation were for instance funding mechanisms and financial resource allocation, but also education and training of the involved health professionals, followed by the use of information and communication technologies. The study also showed that there is a lack of a common understanding of IC, and that the specifics about the kind of technology and its scope that is actually helpful for the user still needs further exploration. Similarly, the driving role of dedicated funding has been confirmed but mechanisms remain to be established.
The managerial framework contains items related to strategy, governance, stakeholders, resources, processes, products and services, and performance and quality indicators. It has been designed around existing quality management tools such as the European Foundation for Quality Management (EFQM) Excellence Model and under the use of available resources from the “InnPACT” study, which has been previously conducted by IESE Business school-CRHIM Health Innovation. The consideration of experts’ suggestions and the consideration of preceding findings from this study refined and validated the framework.
The use of the managerial framework, which will be further refined and validated in Phase III of project INTEGRATE, will permit to elaborate practical recommendations and to explain how innovations and integrated care experiences impact on stakeholders (professionals, patients, institutions, community, healthcare payers, authorities), in the following aspects: adding values, and/or representing costs; impacting the channel of access and communication; changing the relationship towards new, or different ones; making them participate in processes; demanding changes in capabilities and changed strategies; and assesses the context towards which elements make the innovation more or less attractive for the stakeholder.