In 2004, the Government of San Marino began the process of integrating the health and social care system to improve care coordination and efficiency, and published the first social-health plan in 2006 to help guide change; health and social care reforms reinforced already widespread informal practices in service delivery and nurtured the existing spirit of mutual respect, collaboration and effective communication; familiarity and close professional relationships across health and social care sectors were integral to the development of the initiative; integration of management structures at the system level provided a strong platform from which to drive integration at the service delivery level; a focus on peer-led multidisciplinary education and trainings provided professionals with improved knowledge of each other’s disciplines and fostered mutual respect.
Description of practice
Over the past two decades, San Marino has seen rising levels of chronic disease and multimorbidity; trends which are expected to continue given population ageing. In this context, greater demand has been placed on health and social sectors to effectively meet population needs. Despite San Marino’s small size, separate management of health and social sectors hindered effective coordination of services, contributing to inefficiencies in care delivery.
San Marino has a long history of providing health and social protection to its population. This cultural context was important for helping to establish formal links between the health and social sectors in response to emerging demographic pressures on the health and social care system. In 2006, the government adopted the first social-health plan, outlining a strategy for the integration of health and social services under a single organization. The health and social sectors were united with a single budget and common objectives managed by the Social Security Institute. Redesign of care pathways and protocols to support integration has helped standardize services provided, drive efficiency improvements and increase accountability. This has included the development of a protected hospital discharge pathway that brings health providers, social workers and informal caregivers together to collectively design care plans. Due to San Marino’s small size – with only one hospital and three primary health centres to cover population needs – providers already worked in close proximity to one another and had close, collaborative relationships across sectors. However, a shared electronic information system has been developed to increase connections between providers and facilitate information sharing. Peer-led training sessions have also been introduced to support knowledge sharing across disciplines. At present, the Social Security Institute continues to focus on “the whole system” and collectively plan future directions in an integrated and collaborative way, seeking input from all stakeholders. Upgrades to the information system are currently underway to provide the Institute with data to support evidence-based system planning.
Implementation of practice
What stage is the practice currently in?
Who was/is responsible for the implementation of the practice?
As a result of the initiative, the Social Security Institute has been established as the single authority responsible for managing and coordinating health and social services. While the design and planning of system reforms to integrate the health and social sectors was led in a top-down approach by the Ministry of Health, changes have felt largely organic as a result of San Marino’s small size and close-knit community, which favoured collaboration with multiple stakeholders. While the Ministry of Health led the reform process, input on changes was sought from both providers and patients. All stakeholders were given a voice and were able to influence reforms. Rather than politicians dictating the system, clinical experts significantly contributed to the design process, enabling the development of practical solutions. A special office was established to manage ongoing feedback between the population and the Social Security Institute; this service is “the way by which the patient can have a dialogue”. Patient associations also play an important role in representing patients’ voices.
Impact directly attributable to the integration of the health and social sectors is difficult to determine, but it is believed that reforms have improved cost-effectiveness and encouraged greater coordination among providers.
This case was prepared as part of a larger effort by the WHO Regional Office for Europe and published (2016) in the document, "Lessons from transforming health services delivery: Compendium of initiatives in the WHO European Region".
© Copyright World Health Organization (WHO), 2016
The methodology used for the development of this case is slightly different from the templates used on the IntegratedCare4People web platform, in particular in the analysis of enabling factors and barriers to change.
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- Paolo Pasini and Marianne Alders
- Social Security Institute