IPCHS. Integrated People-Centred Health Services


Image happy-doctor-communicating-with-senior-woman from Freepick
Jan. 16, 2023 Europe

How can skill-mix innovations support the implementation of integrated care for people with chronic conditions and multimorbidity?

  • The increasing and changing demands of complex patients (with chronic conditions and multimorbidity), combined with growing workloads and shortages of primary care providers, demand the reorganization of services for more patient-centred and more efficient care.
  • Reorganizing health and social care services to integrate care requires that the health workforce adopt “skill-mix changes” including reskilling; a different approach to sharing tasks and roles; and improved coordination.
  • Skill mix changes typically involve innovative re-allocation of tasks between professions; new supplementary roles; and/or the introduction of greater teamworking and flexibility.
  • The most promising skill-mix innovations for improving integration of care of patients with complex needs are:

(1)    Shifting tasks and roles to achieve new divisions of work with advanced practitioners (nurses and pharmacists) taking on management of aspects of care and coordinating processes in close collaboration with physicians.

(2)    Relocation of care to other settings for example to nurse-led clinics or patients’ homes.

(3)    Introduction of (an explicit) care coordination role with different professionals (case managers, patient navigators) developing shared care plans and monitoring patients’ health and well-being.

(4)    Empowering patients and caregivers through specialist staff (educators, community health workers) who provide information and training to strengthen patients’ self-management and support behavioural change.

(5)    Introduction of dedicated prevention roles in primary care with nurses, pharmacists, community health workers or patient navigators fostering health literacy, offering advice and counselling, and promoting healthy lifestyles.

(6)    Establishment of teamwork and collaboration in multi-professional teams enabling different professions (GPs, specialists, nurses, therapists, social workers, community health workers, housing staff) to work together across sectoral boundaries to organize and coordinate joint care and link health and care services


European Observatory on Health Systems and Policies