IPCHS. Integrated People-Centred Health Services

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Contents tagged: care coordination and continuity of care

Feb. 15, 2016 Global Publication
Engaging and empowering people and communities, Coordinating services within and across sectors

The Patient-Centered Health Record

Electronic Health Records (EHR) have become a core utility in health management in last decades. In this post, Peter Elias discusses how EHR can be changed in order to place people in the center of EHR.

According to Elias, patient-centered EHR would have the following main characteristics:

  • The basic unit would be one record per patient, and patient would have direct acces to his EHR.
  • Open source would be a core value in the development of patient-centered EHR.
  • Patient would have the control of his own EHR, being able to control who can see, change or use the information contained in his EHR.
  • Clinicians could enter the patient’s EHR in multiple ways, using their propietary owned  system or using a straightforward system to access multiple individual EHR.


Currently, we have professional-centered EHR; this proposal is a first step in the search for alternatives in order to achieve an EHR ...

access to personal records, care coordination and continuity of care, electronic medical record, patient-centered care
March 28, 2016 Europe Publication
Engaging and empowering people and communities, Coordinating services within and across sectors

Joining Up Care Where We Live

In April 2015 the charity Access Dorset published a video titled “Joining Up Care Where We Live”, in which citizens and patients are interviewed about their experiences with care coordination. Some respondents felt that care coordination still needs to improve. For example, according to a member of the Lypoedema and Lymphoedema Support Group, "the hospitals don't talk to the GPs" . According to a passer-by interviewed on the street, the “most unnerving thing” for a patient going to the hospital is to be asked: “So why are you here?”. On the other hand, one respondent who has a heart defect recalled a good example of care coordination. After an echocardiogram, the hospital informed her GP about the results and the GP called her to explain that her medication needed to be adjusted. With her consent, the GP immediately sent the prescription to the chemist. The video also focuses on two ...

care coordination and continuity of care, communication, hospitals, multidisciplinary team, primary health care
March 28, 2016 Europe Multimedia
Engaging and empowering people and communities, Coordinating services within and across sectors

Joining Up Care Where We Live

In April 2015 the charity Access Dorset published a video titled “Joining Up Care Where We Live”, in which citizens and patients are interviewed about their experiences with care coordination. Some respondents felt that care coordination still needs to improve. For example, according to a member of the Lypoedema and Lymphoedema Support Group, "the hospitals don't talk to the GPs" . According to a passer-by interviewed on the street, the “most unnerving thing” for a patient going to the hospital is to be asked: “So why are you here?”. On the other hand, one respondent who has a heart defect recalled a good example of care coordination. After an echocardiogram, the hospital informed her GP about the results and the GP called her to explain that her medication needed to be adjusted. With her consent, the GP immediately sent the prescription to the chemist. The video also focuses on two ...

care coordination and continuity of care, communication, hospitals, multidisciplinary team, primary health care
April 17, 2020 Western Pacific Publication
Engaging and empowering people and communities, Strengthening governance and accountability, Reorienting the model of care, Coordinating services within and across sectors, Creating an enabling environment

Communication and Coordination Processes Supporting Integrated Transitional Care: Australian Healthcare Practitioners’ Perspectives

Although a large body of research has identified effective models of transitional care, questions remain about the optimal translation of this knowledge into practice. In Australia, the introduction of a model of consumer-directed care uniquely challenges the practice of integrated care transitions for older adults. This study aimed to identify strengths and weaknesses in transitional care for older adults in an Australian setting by describing healthcare practitioners’ experiences of care provision.

care coordination and continuity of care, communication, integrated care, knowledge sharing, older people, transitions
June 8, 2020 Global Multimedia
Engaging and empowering people and communities, Strengthening governance and accountability, Reorienting the model of care, Coordinating services within and across sectors, Creating an enabling environment

People as Partners in Care

There is a growing imperative to place people and communities, and what matters to them, at the centre of health and care services. The World Health Organisation (WHO) emphasises the need to engage and empower people as partners in creating and maintaining their health and wellbeing. The Astana Declaration (2018) advocates for policies that embed integrated care in strong, community-oriented and community led primary care. This is particularly important for people with multiple health conditions and/ or care needs managed by different providers, often through many unconnected episodes of care. Continuity and collaborative care, through planning, monitoring and review are essential if we are to achieve what really matters to the person, their family and carers. This requires the right information, advice, and health literacy support to help people to understand their conditions and how to live well. However, the realisation of these aspirations remains elusive. Professional culture and practice ...

people, care coordination and continuity of care, community, continuity and collaborative care, covid-19, empowerment, engagement, multiple health conditions, partnership, professionals
Oct. 26, 2020 Europe Publication
Strengthening governance and accountability, Reorienting the model of care, Coordinating services within and across sectors

Integrated health and care systems in England: can they help prevent disease?

The National Health Service (NHS) in England plans for the entire country to be covered by integrated care systems (ICSs) by April 2021. The aims of these local health and care partnerships are broad and include improving disease prevention and population health while maintaining NHS financial sustainability. Yet, the evidence for more integrated care leading to better disease prevention is weak.

Although nearly all of the 2016 sustainability and transformation partnership (STP) plans included a prevention or population health strategy, the content varied widely, often lacked detail, and had little on population-level interventions affecting the social determinants of health.

The 2019 STP and ICS 5-year strategic plans, and the roll out of ICSs across England by April 2021, provide an opportunity for local health and care services to work together more effectively to prevent disease and improve population health. In light of limited evidence on the relationship between integrated care ...

care coordination and continuity of care, diseases, infectious disease surveillance, integrated health services, national health service, non-communicable diseases, opportunity, partnership, prevention, review, sustainability and transformation plans