Keynote address at the 2013 World Congress of the World Organization of Family Doctors.
Keynote address at the 2013 World Congress of the World Organization of Family Doctors.
The burden of chronic diseases, such as heart disease, cancer, diabetes, and mental disorders is high in low-income and middle-income countries and is predicted to increase with the ageing of populations, urbanisation, and globalisation of risk factors. Furthermore, HIV/AIDS is increasingly becoming a chronic disorder. An integrated approach to the management of chronic diseases, irrespective of cause, is needed in primary health care. Management of chronic diseases is fundamentally different from acute care, relying on several features: opportunistic case finding for assessment of risk factors, detection of early disease, and identification of high risk status; a combination of pharmacological and psychosocial interventions, often in a stepped-care fashion; and long-term follow-up with regular monitoring and promotion of adherence to treatment. To meet the challenge of chronic diseases, primary health care will have to be strengthened substantially. In the many countries with shortages of primary-care doctors, non-physician clinicians will have a ...
We are at an unprecedented moment in history in terms of the health of populations around the world. New and old problems all require both short- and long-term solutions, at the individual, community, national and global levels. Unique solutions for each challenge may not be feasible or adequately effective or cost-effective. We are confronted by health systems that are not well matched to current and future needs, both for sustained prevention and chronic care. Moving forward effectively as a field will benefit from a focus on the changing needs of global health, and on how changing conditions, globally, should define the next generation of public health leadership so as to best accomplish global health goals.
Introduction and objectives:
To achieve the level of impact necessary to reverse current trends of rising incidence and costs of multimorbidity and enabling healthy ageing will require new health care policy and practices. Notwithstanding integrated care receiving worldwide attention in improving healthcare delivery, the value of data driven and mobile technology for integration of health and care services remains unclear. Nevertheless, person-centered and data driven mobile health (mHealth) has the potential to evolve integrated care from business process re-design towards a new digital health ecosystem that is truly centered around a person facing health challenges. The objective of our study was to identify the opportunities and barriers of mHealth to do this.
MHealth applications attack the underlying causes of the multimorbidity and ageing challenge in various ways. First, mHealth lifestyle apps promise to help in the prevention of chronic disease and multimorbidity by attacking high risk conditions such as ...
Health systems in low- and middle-income countries were designed to provide episodic care for acute conditions. However, the burden of disease has shifted to be overwhelmingly dominated by chronic conditions and illnesses that require health systems to function in an integrated manner across a spectrum of disease stages from prevention to palliation. Low- and middle-income countries are also aiming to ensure health care access for all through universal health coverage. This article proposes a framework of effective universal health coverage intended to meet the challenge of chronic illnesses. It outlines strategies to strengthen health systems through a “diagonal approach.” We argue that the core challenge to health systems is chronicity of illness that requires ongoing and long-term health care. The example of breast cancer within the broader context of health system reform in Mexico is presented to illustrate effective universal health coverage along the chronic disease continuum and across health ...
Long-term diseases are today the leading cause of mortality worldwide and are estimated to be the leading cause of disability by 2020. Person-centered care (PCC) has been shown to advance concordance between care provider and patient on treatment plans, improve health outcomes and increase patient satisfaction. Yet, despite these and other documented benefits, there are a variety of significant challenges to putting PCC into clinical practice. Although care providers today broadly acknowledge PCC to be an important part of care, in our experience we must establish routines that initiate, integrate, and safeguard PCC in daily clinical practice to ensure that PCC is systematically and consistently practiced, i.e. not just when we feel we have time for it. In this paper, we propose a few simple routines to facilitate and safeguard the transition to PCC. We believe that if conscientiously and systematically applied, they will help to make PCC the ...
The 16th International Conference in Integrated Care "Building a platform for integrated care: delivering change that matters to people" will incorporate the 5th World Congress on Integrated Care as it comes to Europe for the first time. It will take place in Dublin, Ireland, from the 8-10 May 2017.
The conference themes include: Promoting the health and welfare of people, families and communities; Timely transitions: optimizing patient flow across care settings: Preventing and managing chronic disease: engaging and empowering people; Ageing health and well being; and Implementing integrated care.
For more information, please visit: http://www.integratedcarefoundation.org/icic17
In response to the growing populations of people with multiple chronic deseases, new models of care are currently being developed in European countries to better meet the needs of these people. This paper aims to describe the occurrence and characteristics of various types of ntegrated care practices in European countries that target people with multimorbidity.
Healthcare systems globally are fancing multiple challenges, with ageing populations, increasing chronic disease, rising multiborbidity, and innovative treatments and technologies all leading to rising costs. With finite resources, and an increasing recognition of the potential harms to patients of overdiagnosis and overtreatment, it is essential that resources are used optimally. This article explore how the value based healthcare framework can help decisions about how to allocate resources, and the importance of good evidence not only for patient treatment but the organisation of health services.
Integrated care interventions are extremely complex as they tend to invilve multiple actors and different care levels. When evaluating such programmes indicators provide several benefits in comparison with other approaches. The Agència de Qualitat Avaluació Sanitàries de Catalunya, through a new collaborative approach, has been working on the development of indicators specially aimed at assesing integrated care. The aim of this study was to present the methodology developed and review the evolution of the prioritized indicators in three different projects aimed at assessing chronic integrated care initiatives.
The Atlantic Healthcare Collaboration for Innovation and Improvement in Chronic Disease (AHC) Quality Improvement Collaborative (QIC) in Eastern Canada provided an approach to spur system-level reform across multiple health systems for patients and families living with chronic disease. Developed and led by senior executives with a unique governance approach and involving clinical front-line teams, the AHC serves as a practical example of leadership creating and driving momentum for achieving success in collaborative health system improvements
Chronic diseases are becoming a huge threat to the Chinese health system. Although the New Round of Medical Reform aims to improve this, the chronic disease management in rural China is still worrying as it relies highly on hospital care instead of primary care. The vertical integrated care model has proven to be effective for chronic disease patients in many high-income countries, while few studies have been conducted in China. In this project, vertical integrated care will be applied to optimize the care of patients with type 2 diabetes mellitus (T2DM) and primary hypertension in rural China, and to shift the care from hospital to primary care.
EPPs hold promise for reducing hospital readmissions. Certain patient populations with chronic conditions may differentially benefit from portal use depending on their needs for communication with their providers.
However, there is little empirical research on the potential benefit that electronic patient portals (EPP) can have on the care quality and health outcomes of diverse multi-ethnic international populations. The purpose of this study is to determine the extent to which an EPP was associated with improvements in health service use.
To enable delivery of high quality patient-centered care, as well as to allow primary care health systems to allocate appropriate resources that align with patients’ identified self-management problems (SM-Problems) and priorities (SM-Priorities), a practical, systematic method for assessing self-management needs and priorities is needed. In this current report, are present the patient reported data generated from Connection to Health (CTH), to identify the frequency of patients’ reported SM-Problems and SM-Priorities; and examine the degree of alignment between patient SM-Priorities and the ultimate Patient-Healthcare team member selected Behavioral Goal.
Many health care organizations are reasonably effective in treating chronic diseases, but they are limited from doing better by fee-for-service payment, which remains the predominant payment model in the United States. The latest NEJM Catalyst Insights Council report serves as a snapshot in time, showing the intent of health care providers to be proactive in treating chronic disease, but limitations in their ability to address population health
On the International Day of the Older Person (1st October) the World Health Organization (WHO) released a package of tools to support the implementation of the Integrated Care for Older People (ICOPE) approach.
ICOPE, based on the WHO Framework on integrated people-centred health services, has been developed in the context of populations around the world ageing rapidly. It enables health and long-term care systems-and the services within them-to respond optimally to the unique, varied and often complex needs of older people.
The package of tools includes: the ICOPE Implementation Framework (guidance for policy makers and programme managers to assess and measure the capacity of services and systems to deliver integrated care at the community level); the ICOPE Handbook, which describes practical care pathways to detect declines in intrinsic capacity and develop personalised care plans; and the ICOPE handbook App, which helps implement ICOPE in community care settings.
As people grow older, their health needs are likely to become more complex and chronic. However, existing health systems are fragmented and lack coordination, which makes it difficult to effectively address these needs. The WHO Integrated Care for Older People (ICOPE) package of tools offers an approach that helps key stakeholders in health and social care to understand, design, and implement a person-centred and coordinated model of care. By providing evidence-based tools and guidance specific to every level of care, ICOPE helps health systems support Healthy Ageing and maximise older people’s intrinsic capacity and functional ability.
Every older person, everywhere, should have access to high quality and person-centred health services. That's why the World Health Organization has published guidelines on Integrated Care for Older People.
Learn more here: https://www.who.int/ageing/health-systems/icope/en/ and here: https://www.who.int/ageing/publications/guidelines-icope/en/
Populations around the world are rapidly ageing. It will increase demand for primary health care and long-term care, require a larger and better trained health workforce and intensify the need for age-friendly environments. These investments can enable the many contributions of older people – whether it be within their family, to their local community or to society more broadly. Universal health coverage for older people means quality health services that are integrated and person-centered.
Societies that adapt to this changing demographic and invest in Healthy Ageing can enable individuals to live both longer and healthier lives and for societies to ...
The management of people with multiple chronic diseases challenges health care systems designed around single disease. Patients with multimorbidity often receive highly fragmented care that may lead to inefficient, ineffective and potentially harmful treatments and neglect of essential health needs. A more comprehensive, person-centered approach is advocated for persons with multiple morbidities. However, examples on how to provide more person-centered care and evidence of its impact are scarce.
The aim of this study was to develop a proactive person-centered care approach for persons with (multiple) chronic diseases in general practice, and to explore the impact on ‘Quadruple aims’: experiences of patients and professionals, patient outcomes and costs of resources use.
Increasing prevalence of chronic conditions and multimorbidity challenges health care systems and calls for patient-centered coordination of care. Implementation and evaluation of health policies focusing on the development of patient-centered coordination of care needs valid instruments measuring this dimension of care. The aim of this validation study was to assess the psychometric properties of the French version of the 14-item Patient-Centered Coordination by a Care Team (PCCCT) questionnaire in a primary care setting.
The aim of this study was to describe the implementation of a model of integrated care for chronic disease in Western Sydney. This model was established on the basis of a partnership between the Local Health District and the Primary Health Network.
Globally, chronic noncommunicable diseases are the leading cause of death and accounted for 6 million deaths in India in 2016. However, the extent to which variation in chronic disease can be attributed to different population levels in India is unknown, as is whether variation in individual-level factors explains outcome variation at different population levels.
Digital health tools comprise a wide range of technologies to support health processes. The potential of these technologies to effectively support health care transformation is widely accepted. However, wide scale implementation is uneven among countries and regions. Identification of common factors facilitating and hampering the implementation process may be useful for future policy recommendations.
The aim of this study was to analyze the implementation of digital health tools to support health care and social care services, as well as to facilitate the longitudinal assessment of these services, in 17 selected integrated chronic care (ICC) programs from 8 European countries.
Comprehensive assessment of integrated care deployment constitutes a major challenge to ensure quality, sustainability and transferability of both healthcare policies and services in the transition toward a coordinated service delivery scenario. To this end, the manuscript articulates four different protocols aiming at assessing large-scale implementation of integrated care, which are being developed within the umbrella of the regional project Nextcare (2016-2019), undertaken to foster innovation in technologically-supported services for chronic multimorbid patients in Catalonia (ES) (7.5 M inhabitants). Whereas one of the assessment protocols is designed to evaluate population-based deployment of care coordination at regional level during the period 2011-2017, the other three are service-based protocols addressing: i) Home hospitalization; ii) Prehabilitation for major surgery; and, iii) Community-based interventions for frail elderly chronic patients. All three services have demonstrated efficacy and potential for health value generation.
Health policy-makers are faced with a demand for health care that exceeds supply, driven in part by an ageing population and an increased prevalence of chronic disease. An integrated ‘people-centred’ model of care across primary, secondary and tertiary health care can strengthen the health system by streamlining services to improve the patient journey and outcomes.
In Flanders, the prevalence of chronic diseases is high and still increasing partially due to aging of the population and partially due to other reasons like surviving acute diseases or cancer. The aim of the Zorgzaam Leuven project is to test the impact of the implementation of a complex intervention based on the principles of integrated care for a well defined population of approximately 100.000 inhabitants in Belgium.
The number of children with medical complexity (CMC) residing in regional Australia is growing, challenging the health system to provide equitable care. Families of CMC experience problems in accessing appropriate care locally and they have high out-of-pocket costs and family disruptions because of long travel distances to access care in metropolitan paediatric hospitals. The Murrumbidgee Local Health District (MLHD) in collaboration with the Sydney Children’s Hospitals Network (SCHN) partnered with families and local services to co-design a Model of Care (MoC) which better reflects the needs of CMC, their families and local services. The MoC was co-designed with families, local healthcare providers and the tertiary paediatric network.
Chronic disease management and maintaining healthy behaviors to prevent disease are important lifelong considerations. Adherence to prescribed management and behaviors often falls short of physician recommendations, which can result in negative health outcomes. Information communication technologies (ICTs) offer an approach to combat this issue. However, uptake and sustainability of ICTs have mixed results. One reason could be that technologies are often created without an understanding of the complexities of patient needs. Therefore, the intent of this study is to explore the current landscape of patient-centered design and development of health ICTs through a systematic review.
Integrated care programmes are increasingly being put in place to provide care to older people living at home. However, knowledge about further improving integrated care is limited. In fourteen integrated care sites in Europe, plans to improve existing ways of working were designed, implemented and evaluated to enlarge the understanding of what works and with what outcomes when improving integrated care. This paper provides insight into the existing ways that the sites were working with respect to integrated care, their perceived difficulties and their plans for working towards improvement.
Non-communicable diseases (NCDs) cause a large and growing burden of morbidity and mortality in sub-Saharan Africa. Prospective cohort studies are key to study multiple risk factors and chronic diseases and are crucial to our understanding of the burden, aetiology and prognosis of NCDs in SSA. The aim of this study was to identify the level of research output on NCDs and their risk factors collected by cohorts in SSA.
This cross-sectional study evaluated the adequacy of the Family Health Strategy for the primary care model for chronic noncommunicable diseases and the changes that occurred between the two cycles of external evaluations of the National Program for Improving Access and Quality of Primary Care, which took place in 2012 and 2014, in the higher coverage context of the Family Health Strategy of Brazil, in the state of Tocantins, Brazil.
“Integrated care” is often used to describe concepts such as coordinated and seamless care instead of the often fragmented and episode care that patients receive. Integrated care reflects the aspirations of modern health care systems and receives significant academic attention.
This review is about what extent integration is an intervention in need of evaluation or simply a key health system outcome, as has been proposed for the medical home.
With aging populations, a growing prevalence of chronic illnesses, higher expectations for quality care and rising costs within limited health budgets, integration of healthcare is seen as a solution to these challenges. Integrated healthcare aims to overcome barriers between primary and secondary care and other disconnected patient services to improve access, continuity and quality of care. Many people in Australia are admitted to hospital for chronic illnesses that could be prevented or managed in the community. Western Sydney has high rates of diabetes, heart and respiratory diseases and the NSW State Ministry of Health has implemented key strategies through the Western Sydney Integrated Care Program (WSICP) to enhance primary care and the outcomes and experiences of patients with these illnesses.
The National Clinical Programme for Epilepsy (NCPE) in Ireland aims to deliver a holistic model of integrated person-centered care (PCC) that addresses the full spectrum of biomedical and psychosocial needs of people with epilepsy (PwE). However, like all strategic plans, the model encompasses an inherent set of assumptions about the readiness of the environment to implement and sustain the actions required to realize its goals. In this study, through the lens of PwE, the Irish epilepsy care setting was explored to understand its capacity to adopt a new paradigm of integrated PCC.
Chronic conditions are associated with over one-third of potentially avoidable hospitalisations. Integrated care programmes aim to help people with chronic conditions to self-manage their health, thus avoiding hospital admissions. While founded on principles of person-centred care, the experiences of people with multiple chronic conditions in integrated care programmes are not widely known. This study explores how person-centred care is incorporated into an integrated care programme for people with multiple chronic conditions.
In aging populations, multimorbidity (two or more chronic diseases in the same person) is very common. Patients with multimorbidity have complex health and social needs, are at risk of being admitted to the hospital or residential care home and require a wide range of interventions.
To satisfy the needs of these patients and their families, new innovative integrated care models are needed. To be effective, they should have primary care as the cornerstone of care, effective integration between care levels, empower patient and carers/families, and should be patient-centered. The use of information and communication technology (ICT) platforms could facilitate and improve communication promoting patient empowerment and home support. This innovative interoperability should increase effectiveness, efficiency, and equity.
The aim of the CareWell project was to implement and to assess the effectiveness of an integrated care program based on the coordination between health providers, home-based care, and patient empowerment, supported ...
Self-management of chronic conditions is an approach to engaging people in their own health care. It places increased responsibility on the patient for monitoring their condition and their adherence to treatment. Wherever health systems are under resource strain, self-management is promoted as a means to increase patient investment in their treatment plan, thus improving treatment adherence and reducing use of costly services. Initiatives to support self-management have included text messaging reminders to monitor blood pressure or blood glucose, and community peer groups to support adherence to medications and lifestyle advice. More recently, the COVID-19 pandemic has further focused attention on self-management of chronic conditions, for example for vulnerable patients who are self-isolating.
Despite increased attention and resources devoted to self-management for chronic conditions, evidence of the effectiveness of self-management limited. This is particularly true in low- and middle-income countries, where self-management is proposed as one response to the challenges that ...
The twelve Integrated Care Program pilot projects (ICPs) created by the government plan 'Integrated Care for Better Health' aim to achieve four outcome types (the Quadruple Aim) for people with chronic diseases in Belgium: improved population health, improved patient and provider experiences and improved cost efficiency. The aim of this article is to present the development of a mixed methods realist evaluation of this large-scale, whole system change programme.
This article reviews research on leadership in integrated care networks. It is timely as scholars and policy makers regard integrated care as a key part in reforming healthcare systems to cope with demographic aging, the rising prevalence of chronic diseases and the growing demand for long-term care.
In many countries, elderly patients with chronic conditions require a web of services delivered by several providers collaborating in inter-organisational networks. In view of their global importance, it is surprising how little we know how these networks are led. Like traditional organisations, networks require leadership to function effectively. This paper reviews central characteristics of leadership in integrated care networks and proposes opportunities for future research.
In this article, 73 studies published in the main academic journals are analyzed. This article consolidates the research on means, practices, activities and results of leadership, covering the levels of analysis of networks, policies and organizations.
Globally, hospital-based healthcare models targeting acute care, are not effective in addressing chronic conditions. Integrated care programmes for chronic diseases have been widely developed and implemented in Europe and North America and to a much lesser extent in the Asia-Pacific region to meet such challenges.
This scoping review aims to examine the elements of programmes identified in the literature from select study countries in the Asia-Pacific, and discuss important facilitators and barriers for design and implementation.
In Ireland, as in many healthcare systems, health policy has committed to delivering an integrated model of care to address the increasing burden of chronic disease.
Integrated care is an approach to healthcare systems delivery that aims to minimise fragmentation of patient services and improve care continuity. To this end, how best to integrate primary and secondary care is a challenge.
This paper aims to undertake a scoping review of empirical work on the integration of primary and secondary care in relation to chronic disease management.
COVID-19 affects individuals in different ways. Most infected patients develop a mild to moderate form of the disease and recover without hospitalization but adults of any age living with chronic conditions have an increased risk of serious symptoms and severe form of illness. Based on current evidence, conditions that increase risk include asthma, hypertension or high blood pressure, overweight or type 1 diabetes mellitus (ECDC, 2020). The threat to these patients is twofold, forcing them to avoid infection at the same time as their care routines are affected by the health protection measures put in place by governments. A better understanding of those impacts helps health systems to prepare adequately to provide patient-centered care during the pandemic.
A new study conducted by our team of the “School of Patients” researchers, has systematically explored these insights throught the stories of 34 chronically ill persons from the Andalusian region, at the South ...
The population of older adults is increasing globally and is projected to increase to over 1.5 billion by 2050. A similar demographic transition is occurring in Nepal. While we celebrate longevity, health and quality of life are two crucial agendas for the older population. Older adults have a higher prevalence of non-communicable chronic conditions, and with longevity, the likelihood of experiencing more than one non-communicable chronic condition also increases.
This study’s objectives were to estimate the prevalence of major non-communicable conditions and multimorbidity among older adults in rural Nepal and examine the associated socioeconomic and behavioural risk factors.
In the context of the advancement of person-centered care models, the promotion of the participation of patients with chronic illness and complex care needs in the management of their care (self-management) is increasingly seen as a responsibility of primary care nurses. It is emphasized that nurses should consider the psychosocial dimensions of chronic illness and the client’s lifeworld. Little is known about how nurses shape this task in practice. The aim of this analysis is to examine how primary care nurses understand and shape the participation of patients with chronic illness and complex care needs regarding the promotion of self-management. Guided interviews were conducted with nurses practicing in primary care and key informants in Germany, Spain, and Brazil with a subsequent cross-case evaluation.
Caring for patients with multimorbidity in general practice is increasing in amount and complexity. To integrate care for patients with multimorbidity and to support general practitioners (GPs), the Clinic for Multimorbidity (CM) was established in 2012 at Silkeborg Regional Hospital, Denmark. This case study aims to describe the CM and the patients seen in it.
Alzheimer disease (AD) and Parkinson disease (PD) are the 2 most common neurodegenerative diseases affecting millions of people worldwide. The Personalized Integrated Care Promoting Quality of Life for Older People (PC4L) project proposes an integrated, scalable, and interactive care ecosystem that can be easily adapted to the needs of several neurodegenerative and chronic diseases, care institutions, and end user requirements.