Ponencia a cargo del médico geriatra Marco Inzitari, director de Atención Intermedia, Investigación y Docencia del Parc Sanitari Pere Virgili, en el marco de la VI Jornada Right Care sobre Modelos avanzados en integración de servicios sociales y sanitarios, organizada por la Societat Catalana de Gestió Sanitària el 24 de mayo de 2019.

1. A movement for change
www.integratedcarefoundation.org @IFICinfo
International Trends in Integrated
Health and Social Care
Dr Toni Dedeu, Director of Programmes, International Foundation for Integrated Care
6ª Jornada anual “Right Care” | Barcelona, 24 May 2019

2. A movement for change
Outline
1. The integrated care challenge
2. Defining and understanding integrated care
3. Key approaches to integrated health and
social care with case examples
4. Conclusions

3. A movement for change
Why Integrated Health and Social
Care?

4. A movement for change
Representation of Integrated Care

5. A movement for change
Designing Better Care for
Malcolm and Barbara
Frontier Economics (2012) Enablers and barriers to integrated care and implications for Monitor

6. A movement for change
Coping with Complexity
Frontier Economics (2012) Enablers and barriers to integrated care and implications for Monitor -
ü Barbara has supported her husband,
Malcolm, to live with Alzheimer’s disease for
16 years.
ü Together, they faced daily challenges in
navigating the health system (e.g. primary,
community and hospital-based care), the
social care system (e.g. respite and day
services for the elderly, welfare benefits, at-
home care support), and a myriad of other
services from the statutory, private and
voluntary sectors.
ü At any one time, over a dozen ‘touch points’
were held with different care professionals,
ü Care and support services were not always
available and/or were poorly co-ordinated.
ü Barbara has reported increasing feelings of
isolation, depression and an inability to cope.
12‘touch points’

7. A movement for change Courtesy of Prof. Richard Antonelli, Boston Children’s Hospital, Harvard Medical School
Gabe

8. A movement for change
www.childrenshospital.org/care-coordination-curriculum/care-mapping
Gabe’s map of care

9. A movement for change
Mr Smith

10. A movement for change
Mr Smith

11. A movement for change
Designing Better Care for
people, caregivers and communities
Goodwin N, Alonso A (2014) Understanding integrated care: the role of information and communication technology
in Muller S, Meyer I, Kubitschke L (Eds) Beyond Silos: The way and how of eCare, IGI Global
Key problems of fragmented health and care systems
A lack of
ownership from
the range of
providers to
support ‘holistic
care needs’
•Driven by silo-based
working
•Separate professional
and organisational
systems for
governance and
accountability
A lack of
involvement of the
patient/carer in
supporting them to
make effective
choices
Poor
communication
between
professionals and
providers
•Inability to transfer date
•Silo-based working
•Embedded cultural
behaviours
Care and
treatment by
different care
providers for only
a part of their
needs
•Rather than seeing the
person as a whole and
managing all of the
needs

12. A movement for change
Designing Better Care for
people, caregivers and communities
Goodwin N, Alonso A (2014) Understanding integrated care: the role of information and communication technology
in Muller S, Meyer I, Kubitschke L (Eds) Beyond Silos: The way and how of eCare, IGI Global
A poor and disabling
experience for the
service user
•Information hard to get hold
of
•Differing advise and views
•Confusion is the next steps
of a course of illness
Reduced ability for
people to live and
manage the needs
effectively
Poor system outcomes
•Inability to prevent
unnecessary hospitalisation
•Inability to prevent long-term
residential home placements
Key problems of fragmented health and care systems

13. A movement for change
The hypothesis for integrated care is that
it can contribute to meeting the “Triple
Aim” goal in health and care systems
• Improving the user’s care experience
(e.g. satisfaction, confidence, trust)
• Improving the health of people and
populations (e.g. morbidity, mortality,
quality of life, reduced hospitalisations)
• Improving the cost-effectiveness of
care systems (e.g. functional and
technical efficiency)
The Promise of Integrated Care
The hypothesis for integrated care is
that it can contribute to meeting the
“Quadruple Aim” goal in health
and care systems
• Improving work-life balance of
health and care professionals

14. A movement for change
Perspectives
Shaping
Integrated
Care
(Shaw et al, 2011, p.13)
There are
different
viewpoints and
different
objectives
regarding
integrated care
Viewpoints regarding Integrated Care
Integrated
care for
the person
and
population
All
are
legitimate

15. A movement for change
Design Principles: What Works in
Integrated Health and Social Care?

16. A movement for change
Many Frameworks Have Been Developed to Understand
the Key Elements for Successful Integrated Care

17. A movement for change
The WHO European Framework for Action
on Integrated Health Services Delivery
Identifying health needs
Engaging patients
Empowering populations
Reorienting the model of care
Organizing providers & settings
Managing services delivery
Improving performance
Rearranging accountability
Aligning incentives
Preparing a competent workforce
Promoting rational use of medicines
Innovating health technologies
Rolling out e-health
Tackling determinants
CHANGE
Strategizing with people at the centre Implementing transformations Enabling sustainable change
The European Framework for Action on Integrated
Health Services Delivery
PEOPLE SERVICES SYSTEM
WHO Europe, The Framework for Action on Integrated Health Services
Delivery. A Concept note. WHO Europe, Copenhagen 2016

18. A movement for change
o-producing healthy
ng care services in partnership
r and contributing to
Special attention is given to
ing the voices of minorities.
and communities
a Declaration recognized
on as a core principle of
long ago as 1978 (20),
on in the extent to which
and empowerment has been
h systems. Nonetheless,
ecognized the importance
ple and communities as assets
ed to be harnessed as a way
alth outcomes and improving
co-production of care
ple
deaths in partnership
WHO Global Framework
• Seeing people and communities as assets
• Empowerment, engagement and co-production
• Self-management
• Health education
• Focusing on the most disadvantaged
er than population-oriented
and the priorities and
lopment agencies and donors
ance and accountability
uired to achieve a coherent
oach in health care policy
and accountability
cular attention over the last
ng together the range of
affecting health systems. This
that the different goals of
vertical programmes tackling
not hinder the ability of health
n community health and
d
• New regulatory frameworks
• Aligning finances and resources
• Strengthening public reporting and involvement
well as to contain health care
rvices can also promote
miliarity for patients with
ems, address an increasing
ervices (87) and promote
ment in health.
o reorienting the model
• Rebalancing health services towards primary and
community-based care
• Creating new methods of coordination and cooperation
• Defining team roles and responsibilities
ex health problems (see Box 5).
• Active care co-ordination required, especially to those
with highly intense needs
• Formal (‘real’) organizational integration not required
• Internal silos must be addressed
• Coordination at clinical and service level matters most
“I think we have made several leaps with regards
to primary care services...but we still have a long
way to go. The politicians need to understand that
primary care is the backbone of any health system
and getting it right will lead to cost–benefits,
healthier populations and public faith in the system”
Male general practitioner, WHO Region of the Americas
ñ the level and relevance of health policy research
and the engagement of various networks in
research;
ñ prevailing standards of integrity, accountability
and transparency; and
ñ leadership in government, industry, academia and
the community (97).
9. Strategic direction 5.
Creating an enabling environment

19. A movement for change
The Rainbow Model Framework
Valentijn P et al (2015) Towards an international taxonomy
of integrated primary care: a Delphi consensus approach.
BMC Fam Pract, 16(1):64-015-0278-x

20. A movement for change
The Building Blocks of Integrated Care

21. A movement for change

22. A movement for change
The Building Blocks of Integrated Care
• Creating an enabling political environment for
Health and Social Care integration
• Competences for Health and Social Care.
Workforce changing/swift
• Integration between Health and Social care:
bridging the divide, building common values.
Building social capital and collaborative
capacity
• Supporting peoples empowerment and
engagement in health and care
• Financial incentives to stimulate integrated
care
• Effective ICT systems

23. A movement for change
Building Block „Building an enabling environment“:
We need an Integrated Care in all policies approach
Adapted from WHO-HQ Global Strategy on people-centred and integrated health services 2015
HEALTH
SYSTEM
Governance,
financing and
workforce
OTHER
SECTORS
Education,
sanitation, social
assistance, labor,
housing,
environment,
others
PERSON
SERVICES
DELIVERY
CONTEXT
Epidemiology, cultural, socio-demographic and economic

24. A movement for change
Integrated Care in Europe: governing,
regulating, financing
• There are many different
examples of policies and
innovation on integrated care
around Europe
• The political agendas focus on:
– Financial reform
– Cost containment
– Legislative change
– Structural reorganizations
– Personalised care
– New funding streams
– Pilot programmes
National Strategies - Examples
• Denmark, Norway: Coordination Reform
• Sweden: Joint agencies link funding and
delivery (e.g. Jönköping & Nortallje)
• England: Five Year Forward View
(Vanguards)
• Germany: Versorgungsstrukturgesetz (care
structure law) supports interdisciplinary and
cross-sector models of care
• Netherlands: Managed care organizations
and bundled payments for certain diseases
• Health and social care integration in
Northern Ireland, Scotland and Wales
• Spain: vertically and horizontally integrated
care organizations to support better chronic
care ( e.g. Basque Country, Catalonia,
Valencia)
• Switzerland: physician networks / HMOs

25. A movement for change
Creating an enabling political environment for Health
and Social Care integration

26. A movement for change
Creating an enabling political environment for Health
and Social Care integration
Guiding principle:
“. . . effective services must be
designed with and for people and
communities – not delivered ‘top
down’ for administrative
convenience”
The Christie Commission Report
Commission on the future delivery of public services, June 2011

27. A movement for change
Creating an enabling political environment for Health
and Social Care integration
q Public Service Reform
q Public Bodies (Joint Working) (Scotland ) Act
2014
q Reshaping Care for Older People programme
q Telehealth and Telecare Delivery Plan for
Scotland 2015
q The Community Empowerment Bill
q 8 Innovation Centres
q Digital Health and Care
q Stratified Medicine
q Big Data
q Sensors
q Construction
q Aquaculture
q Bio-Technology
q Oil & Gas
National Policy Drivers

28. A movement for change
Creating an enabling political environment for Health
and Social Care integration
Before
Integration
AFTER April 2015
32 Local Authorities
responsible for social care,
education, housing, transport
32 new “Health and
Social Care
Partnerships”
jointly responsible for delivery of
social care, community health /
primary care and some hospital
services
14 NHS Boards
Acute, hospital, community, primary
care health services
NHS Boards and Local
Authorities continue to provide a
range of other health and care
services

29. A movement for change
Creating an enabling political environment for Health
and Social Care integration
q Cross party support
q NHS support
q Local authority support
q Having an agreed vision about what we are trying to
achieve
q Clear governance
q Single budget
q Bespoke strategies at each Scottish territory
What has helped integration?

30. A movement for change
Guiding principle:
q “. . . It's about the outcomes, but people often want to talk
about the process…
q It's about behaviours…
q Everyone wants change, but it's easier when other people
have to do it…
q There are some really hard-edged challenges where it has to
work quickly, but change takes time…
q It's iterative, we are making large and small gains all the
time…
Reflections

31. A movement for change
The Building Blocks of Integrated Care
• Creating an enabling political environment for
Health and Social Care integration
• Competences for Health and Social Care.
Workforce change/swift
• Integration between Health and Social care:
bridging the divide, building common values.
Building social capital and collaborative
capacity
• Supporting peoples empowerment and
engagement in health and care
• Financial incentives to stimulate integrated
care
• Effective ICT systems

32. A movement for change
http://www.cihc.ca/files/CIHC_IPCompet
enciesShort_Feb1210.pdf
National Interprofessional Competency Framework
(Cihcpis - Canadian Interprofessional Health Collaborative)

33. A movement for change
The Building Blocks of Integrated Care
• Creating an enabling political environment for
Health and Social Care integration
• Competences for Health and Social Care.
Workforce changing/swift
• Integration between Health and Social care:
bridging the divide, building common values.
Building social capital and collaborative
capacity
• Supporting peoples empowerment and
engagement in health and care
• Financial incentives to stimulate integrated
care
• Effective ICT systems

34. A movement for change
Building block “Empowering people”: we
need involved individuals and communities
Adapted from Goodwin 2008 and 2014
Informal care
Self care
Health
system
Primary care
Family physician
Community nurse
Dentist
Pharmacist
Therapist
Mental health
worker
Walk-in centre
Palliative care
Secondary care
Hospital
Inpatient ward
Outpatient clinic
Day surgery
Treatment center
Tertiary care
Specialist unit
Inpatient ward
Outpatient clinic
Rehabilitation
service
Palliative care
service
Longterm care
service
Hours with
professional / NHS
= 3 in a year
Hours of self care =
8757 in a year
Ø Need for people
engagement
Ø Need for patient
empowerment

35. A movement for change
Integration between Health and Social care: bridging the divide, building
common values. Building social capital and collaborative capacity
2014
Millom Alliance founded in rural
community of 8500 people in
response to closure of community
hospital and crisis in GP recruitment
– assets-based approach embraced
2018
Whole of Cumbria & Morecambe
Bay (750k people) supported
through 20 community-based
alliances – fastest transforming
integrated care system in the UK
enabling 8-10% year on year
financial savings & turnaround in
population health outcomes
Integrated Care is a People-Driven Community-Based Movement
“Working as equal partners with the community
resulted in improvements for healthcare locally
highlighting the importance of co-creation”

36. A movement for change http://integration.healthiernorthwestlondon.nhs.uk/about-us
• Started as an Integrated
Care Pilot in 2011
• Has now been
transformed into a
Pioneer and established
a network of over 30
organisations from the
health and social
services, as well as
community and lay
partners
• Taking care of over 2M
people
North West London
Whole Systems Integrated Care

37. A movement for change
3 key principles
– People are empowered to direct
their care and support and
receive the care they need in
their homes or local community.
– GPs are at the centre of
organising and coordinating
people's care.
– This system enables and not
hinder the provision of
integrated care.
http://integration.healthiernorthwestlondon.nhs.uk/about-us
North West London
Whole Systems Integrated Care

38. A movement for change
Facilitating continuity of care at a health system level to
support integration
q Population 4.2 million
q Entirely public system
q 4,000 family doctors and 4,000 specialists - most paid fee-for-service
q One single delivery agency: Alberta Health Services (AHS)
q Structural integration: acute care, long-term care, home care, public
health, addictions and mental health, cancer care, emergency medical
services
q Joint-venture relationship with primary care: 86% of family doctors belong
to Primary Care Networks (PCNs), a partnership with AHS
q Most specialty services offered through Alberta Health Services
q Patients can only access specialists by referral from a family doctor
q Patients can choose or change their family doctor at will

39. A movement for change
Facilitating continuity of care at a health system level to
support integration

40. A movement for change
Facilitating continuity of care at a health system level to
support integration

41. A movement for change
Facilitating continuity of care at a health system level to
support integration
The collective strategy

42. A movement for change
Facilitating continuity of care at a health system level to
support integration

43. A movement for change
Facilitating continuity of care at a health system level to
support integration

44. A movement for change
Facilitating continuity of care at a health system level to
support integration

45. A movement for change
The Building Blocks of Integrated Care
• Creating an enabling political environment for
Health and Social Care integration
• Competences for Health and Social Care.
Workforce changing/swift
• Integration between Health and Social care:
bridging the divide, building common values.
Building social capital and collaborative
capacity
• Supporting peoples empowerment and
engagement in health and care
• Financial incentives to stimulate integrated
care
• Effective ICT systems

46. A movement for change
Training in the
Nuka Health System, Alaska
• Development Centre
with 11 Departments
of Learning
• Workshops and
training course for
interested
organisations
• RAISE programme
• Community
engagement and
patient education
programmes

47. A movement for change
Community Engagement
Nuka Health System, Alaska
Mission:
Working together with the Native
Community to achieve wellness
through integration of health and other
services
Vision:
A Native Community that enjoys
physical, mental, emotional and
spiritual wellbeing
Key approach:
Shared responsibility, commitment to
quality, family wellness
“Consumer-owners”

48. A movement for change
Key lessons: involving patients and
communities imrpoves outcomes
• Alaskan Native leadership has ownership and management of care system since
1997
• 60000 people south of Anchorage and spread across 1800km of land and islands
• Range of services including:
Ø inter-disciplinary primary care,
Ø dentistry and optometry,
Ø behavioural health,
Ø patient education and peer2peer health promotion
Ø home care – case management
Ø telehealth with self-management of chronic illness
• Focus on rights and responsibilities approach

49. A movement for change
Key lessons: involving patients and
communities imrpoves outcomes
Some results since 1996-present
• 95% enrolled in primary care, up from 35%
• Same day access for routine appointment, down from 4 weeks
• Waiting list for behavioural health consultation eliminated
• 36% reduction in hospital days
• 42% reduction in ER
• 58% reduction in specialist clinics
• High patient satisfaction with respect to culture and traditions
• Staff turnover reduced by 75%

50. A movement for change
The Building Blocks of Integrated Care
• Creating an enabling political environment for
Health and Social Care integration
• Competences for Health and Social Care.
Workforce changing/swift
• Integration between Health and Social care:
bridging the divide, building common values.
Building social capital and collaborative
capacity
• Supporting peoples empowerment and
engagement in health and care
• Financial incentives to stimulate integrated
care
• Effective ICT systems

51. A movement for change
Financial incentives to stimulate
integrated care
• Community building and securing health care for the
region
• Satisfied and healthier professionals
Participants die 1.4
years later (78.9 vs
77.5 control)
98.9 % of
enrollees who
set an objective
agreement with their
physician would
recommend becoming a member to
their friends or relatives
5.613 M€
surplus
improvement
for the two sickness
funds in the Kinzigtal

52. A movement for change
The Building Blocks of Integrated Care
• Creating an enabling political environment for
Health and Social Care integration
• Competences for Health and Social Care.
Workforce changing/swift
• Integration between Health and Social care:
bridging the divide, building common values.
Building social capital and collaborative
capacity
• Supporting peoples empowerment and
engagement in health and care
• Financial incentives to stimulate integrated
care
• Effective ICT systems

53. A movement for change
Effective ICT systems
Political Will | Inter-Ministerial Integrated Care Programme
q Shared health and social
care record
q Multimorbidity unified
data set
q Users’ platform – My
Health
q Big Data Analytics for
Research and Innovation

54. A movement for change
Integrated Care in North America:
management and organisational integration
USA
• Integrated delivery systems for
enrolees
– E.g. Kaiser Permanente
– E.g. Veterans Health
• HMOs & group practice models
– E.g. Mayo, Geisinger, Seattle
• Managed care or disease
management programmes
– E.g. PACE
• ACOs and Medical Homes
• Integrated delivery systems for
populations:
– E.g. Nuka, Alaska
– E.g. Massachusetts
Canada
• Health Canada – Health Accord,
2004
– Sets 10 plans to overcome
duplications, improve access and
promote efficiency
– Emphasis on care transitions
hospital-home to reduce ‘bed
blockers’
• Provincial application leads to
decentralisation and variation
– PRISMA, Quebec
– GP group practices, Alberta
– ICCPs in Ontario
– Community-oriented primary care
centres, Newfoundland and others
– SPOR networks

55. A movement for change
Innovations in the Western Pacific
Region: care close to home
Japan
Integrated community care
New Zealand
Healthy families and communities
Singapore
Regional Health System

56. A movement for change
Rurality
Eksote, Finland
Established integrated
care organisation in 2010
combining
primary/secondary care
with elderly/social care.
Goal is equal access to
care across a rural
municipality with a focus
on prevention and citizen
responsibility in own care
Eksote provides all health, family and social welfare and senior services for 133,000
citizens some 200km apart. Village associations have a key part to play to promote
health and wellbeing and prevent social and medical problems – e.g. themed
events for the hard of hearing and with various sports federations

57. A movement for change
Ruralily
Eksote, Finland
Home-based rehabilitation services, with
significant use of remote monitoring and
health coaching including an ER “in your
living room” rapid response service
Nurse-led mobile health units across rural
villages. Services include:
– Nurse consultation
– Health counselling
– Regular health checks
– Treating wounds
– Capillary blood work analysis (e.g. glucose)
– Vaccinations and medicines
– Dental care
– Physiotherapy
Impact includes an 88% reduction in need
for hospital care; 56% reduction in the
need for home-based visits; and a 30%
cost reduction to the care system

58. A movement for change
Co-ordinated Care
Organizations in Oregon
q Since 2012, Oregon Health sought to rebuild its Medicaid
programme around community health rather than individual fee-
for-service treatments for its 600,000 Medicaid beneficiaries
q They created 16 ‘co-ordinated care organisations’, different to
ACOs as they took responsibility for community health – e.g.
prevention agenda and socio-determinants
q Oregon Health Authority’s performance programme held back 3%
of payments into a ‘quality pool’ that CCOs could access if they
met 12+ of 17 quality measures and have 60% of their members
enroled in a patient-centred medical home

59. A movement for change
Co-ordinated Care
Organizations in Oregon
http://www.oregon.gov/OHA/OHPB/meetings/2012/2012-0124-hma-report.pdf

60. A movement for change
Co-ordinated Care Organizations in
Oregon
How it works
Ø Network of all types of health care providers in 15 geographic
communities across Oregon with a single capitated budget
Ø Shared accountability - governance to local community and payer
Ø Development of new model of care based on PCMH-model
ü Inter-disciplinary teams – health care homes
ü Care transitions (hospital to home)
ü Intensive transitions (mental health)
ü ICT investment
Impact in 2015 based on 2011 baseline
Ø Reduced hospitalisations due to diabetes (26.9%) and COPD (60%)
Ø Increased enrolment in health care homes by 56%
Ø Oregon CCO experiment results, however, uneven – has faced
significant implementation challenges

61. A movement for change
Prof. John Howarth’s
Integrated Care Equation
Integrated health and social care teams
(building real teams around place and
pathways)
+
Activated Individuals, carers and families
(activated individuals use services less and
have better outcomes)
+
Communities mobilised at scale for health
and well being
(the community as part of the local
leadership and delivery team)
+
Changed drivers in the health system
(system leadership, system architecture,
system culture, changed drivers, impacting
on commissioning and provision)
=
A population health and wellbeing system
IHCS – the platform,
leadership, architecture,
culture and the right set of
system rules and
behaviours
Clinical Networks – teams
without walls spanning
acute and community
Integrated Care
Communities – our
neighbourhood based
population health building
blocks

62. A movement for change
Concluding Remarks:
An Ongoing Journey

63. A movement for change
Concluding Remarks
Care systems that have effectively created a population
health-based approach with the integration of multiple
health and social care providers into new forms of collective
governance arrangements and risk-sharing frameworks with
and alongside local communities appear to have the greatest
potential for transformational change to improve care
experiences, care outcomes and promote system sustainability
ü The development of such systems is, to-date, rare.
ü They are faced with continual and significant challenges,
require committed and sustained leadership, and take
considerable time to develop and mature.
ü There are few short cuts or ‘magic bullets’ as the journey
itself builds alliances and supports the right models of care
to emerge in different country and regional contexts

64. A movement for change
Dr Toni Dedeu
Director of Programmes IFIC
tonidedeu@integratedcarefoundation.org
International Foundation for Integrated Care
www.integratedcarefoundation.org

65. A movement for change
IFIC’s Core Work & Growth
#IntegratedCare #IFICCanada #NACIC2020
Advancement
of science
Promotion &
sharing of
knowledge
Supporting
implementation
and adoption of
Integrated Care
Ø International Journal of Integrated Care
(www.ijic.org)
Ø International Conference and Event
series – e.g. APIC2 in Melbourne on 11-13
November
Ø Research and Development Faculty,
majoring in supporting multi-partner
programmes in Europe
Ø Education and Training through our
Integrated Care Academy ©
Ø Integrated Care Solutions © providing
technical advice and support to
integrated care programmes worldwide
Ø IFIC Hubs and Collaborative Centres
Ø Knowledge Exchange – e.g. Webinars,
Special Interest Groups, ERIC,
Integrated Care Search © and
Observatory