Integrated Care: Adoption, Case Studies, Barriers And Guidelines

Tuesday, December 18, 2018

Why integrated care?

Today, integrated care focuses on reducing fragmentation in healthcare by reducing silos and providing patient-centred care. There is a greater need for care coordination, particularly due to trends such as: the ageing population, the increasing number of patients with co-morbidities, the growing number of medical specialties, the need for changes in the financing mechanisms of hospitals and health and care institutions, technological advancement, and increased healthcare costs and expenditure. The integration of care is one of the solutions that will enable care systems to address this new landscape, by increasing communication between care providers, reducing the unnecessary costs of duplication of tests and services, and enhancing continuity of care for patients moving from one care setting to another.

People-centred and integrated services

Integrated care is needed to address challenges such as lack of communication between care providers, the potential for duplication of tests and services, the breakdown of continuity of care as patients move from one care setting to another, and the possible interference between concurrent treatment plans prescribed by different providers for patients with multi-morbidities. According to the WHO, people-centred and integrated services should offer greater value for money through minimising duplication, reducing waste through improved coordination across care providers in the longer term. Further efficiencies are to be gained through changes in the healthcare structures, organisation of workflows, workforce development and in resource allocation in order to provide more responsive and integrated care delivery. Thus, integrated care should improve organisational behaviour and encourage bottom-up approaches to work, ownership, and teamwork.
Integrated care should improve organisational behavior
The World Health Organization (WHO) European Office outlined 11 key working areas for integrated care:
  • Primary healthcare;
  • Hospital management;
  • Emergency medical services;
  • Health promoting hospitals;
  • Home healthcare;
  • Financing healthcare services;
  • Developing family medicine, the family physician and family nurse;
  • Medical education;
  • Towards unity for health (multi-professional approaches);
  • Telemedicine;
  • Linking levels of care.
The WHO has also outlined six key dimensions to healthcare integration, namely:
  • Integration between preventive and curative health interventions to group appropriate and related interventions in a single patient visit;
  • Integration across service delivery locations with multiple services available so a patient can receive multiple services during one health centre visit;
  • Integration over time or continuity of care in terms of medical treatments, chronic conditions, and human life-cycle;
  • Integration between levels of care: hospitals, residential treatment centres, urgent care, primary care clinics, etc;
  • Integration between policy-making and management to ensure that health organisations meet a standard set of policies;
  • Integration across sectors, such as health and social services (e.g. long-term care for the elderly, health promotion campaigns in schools).
Moreover, different countries have implemented different integrated care models, which differ in their focus and population scope. For example, while some integrated care initiatives focus on the creation of multidisciplinary teams, others focus on integrating primary, secondary and tertiary care. Some key population groups for integrated care initiatives include: the elderly frail population, patients with long-term conditions, and patients with mental health problems. When studying these models, it is important to consider context because some models can be successful at integrating care in one government context, but may not be successful in another. Additionally, health and social organisations can enable ‘multiple degrees of integration to coexist within a single system’.

Functional, organizational, professional and clinical integration

Care integration can be categorised into four types:
  • functional: where key support back-office and non-clinical support functions and activities are integrated, e.g. financial management, strategic planning and human resources management;
  • organisational: where organisations are brought together by formal mechanisms, e.g. creation of networks, mergers, contracting;
  • professional: where different services are integrated at an organisational level, e.g. joint working, group practices, contracting or strategic alliances of healthcare professionals within and between institutions and organisations;
  • clinical: where care by providers and professionals to patients is integrated into a coherent clinical process or set of processes within and / or across professions, e.g. coordination of care services for individual healthcare service users.
Despite the utility of using the above classification to represent and subdivide different models of integrated care, it should be noted that integrated care models currently feature a much higher degree of complexity and variability, and cannot always be categorised in this manner, especially when being implemented across different health systems.

The study

To inform the design of such a framework, the study began by analysing the level of penetration and adoption of integrated care across the 28 Member States, Norway and Iceland, as well as its intrinsic variability. This was done through a literature review and a mapping exercise of integrated care initiatives, which are presented in the next section. This was followed by an analysis of the level of maturity of integrated care implementation across 12 health systems. The data and knowledge gained from of these activities informed the selection of 14 integrated care sites to co-design the performance assessment framework.


Healthcare systems across Europe have acknowledged the need for integration of care to improve health outcomes and patient experiences, and to make systems more efficient. While some countries have already developed integrated care systems, others have only recently started to adopt integrated care. The main findings in the execution of the different phases of the study that led to the development of the framework for assessing the performance of integrated care are as follows: Integrated care is present in all 30 countries included in the study. The literature describing the adoption and penetration of integrated care in Europe tends to focus on a limited number of countries (e.g. the UK, Spain, Germany, Sweden or the Netherlands). The mapping of integrated care initiatives undertaken for this study confirms the significant variability across Europe. This variability across the 28 Member States, Norway and Iceland affects models of integrated care, depth and breadth of integration, within countries and regions. The heterogeneity and variability in the implementation and adoption of integrated care was confirmed by assessing the maturity of health systems (at national, regional and local levels) with the application of the SCIROCCO Maturity Model tool. While the Maturity Model tool provided insights into the implementation of integrated care in different health systems, the assessments provided by stakeholders are context-sensitive and do not allow for in-depth comparison of health systems. Engagement with stakeholders identified that o a) there is interest from professionals engaged in the implementation of integrated care in using evidence-based tools to support them in their transformation processes; and b) co-design with potential users of these tools enhances the likelihood that they will be widely adopted for use in practice. The proposed set of 18 core indicators, together with the accompanying tool, will provide a flexible and coherent framework to support the implementation of integrated care, adapted to the local context, and allow users to assess the performance of integrated care, monitor the allocation of funds, and understand how resource allocation is linked to performance. Download the full report here.   Source: “Health system performance assessment – Integrated Care Assessment”