ArrowArrow IconLightbulbLightbulb IconLightbulbLarge Lightbulb IconBriefcaseBriefcase IconBriefcaseLarge Briefcase IconSurveySurvey IconStroke 1ClipboardClipboard IconClipboardLarge Clipboard IconConvergeConverge IconConvergeLarge Converge IconExpandExpand IconFacebookFacebook IconFeaturesFeatures IconCountryCountry IconFlowchartFlowchart IconFlowchartLarge Flowchart IconStrategyStrategy IconStrategyLarge Strategy IconGovernmentGovernment IconGovernmentGovernment IconInfoInfo IconIntegrationIntegration IconIntegrationLarge Integration IconArrow Pagination LeftPeoplePeople IconPeoplePeople IconStatsStats IconPhonePhone IconPhoneLarge Phone IconFeaturesFeatures IconTagTag IconTagLarge Tag IconTwitterTwitter Icon

What is being done to promote delivery system integration and care coordination?

  • Australia

    Approaches to improving integration and care coordination include the Practice Incentives Program (PIP), which provides a financial incentive to providers for the development of care plans for patients with certain conditions, such as asthma, diabetes, and mental health needs. The Primary Health Networks (PHNs) were established in July 2015 with the objective of improving coordinated care, as well as the efficiency and effectiveness of care for those at risk of poor health outcomes. These networks are funded through grants from the federal government and will work directly with primary care providers, health care specialists, and LHNs. Care may also be coordinated by Aboriginal health and community health services.

  • Canada

    Provinces and territories have introduced several initiatives to improve integration and coordination of care for chronically ill patients with complex needs. These include Divisions of Family Practice (British Columbia) (Divisions of Family Practice, 2014), the Regulated Health Professions Network (Nova Scotia), and Health Links (Ontario). Also, Ontario has alternative community-based and multidisciplinary primary care models that are funded by the province and serve primarily vulnerable populations; these models include Community Health Centres and Aboriginal Health Access Centres. Also in Ontario, a pilot program that bundles payments across different providers is being expanded (from one to six communities) to improve coordination of care for patients as they transition from hospital to the community (Government of Ontario, 2015). As discussed above, some provinces have also implemented incentives to encourage physicians to provide guideline-based care for chronic disease. In Ontario, for example, Diabetes Education Programs (employing teams of diabetes education nurses and registered dieticians) support individuals and primary care physicians in providing guideline-based diabetes care.

    Each province determines its own structure for the coordination of health and social care services. In Ontario, for instance, Community Care Access Centres are also responsible for coordinating services for vulnerable populations, particularly the elderly and individuals with disabilities, including health and social care services (e.g., supportive housing and meal delivery programs). In Ontario, there is a single ministry responsible for health and long-term care, with funding devolving to the regional level.

  • China

    Medical alliances are regional hospitals groups, often including one tertiary hospital and several secondary hospitals and primary care facilities, that provide access to primary care facilities for patients with minor health issues. The aim is to reduce the need for people to visit tertiary hospitals. At the same time, patients with serious health problems can be referred to tertiary hospitals easily and moved back to primary care facilities after their condition improves. It is hoped that this type of care coordination will meet demand for chronic disease care, improve health care quality, and contain rising costs. Hospitals in the same medical alliance use the same electronic health record system, and results of labs, images, and diagnoses can be shared easily within the alliance.

    There are three main medical alliance models. Hospitals in the Zhenjiang model have only one owner (usually the local bureau of health). Those in the Wuhan model do not belong to the same owner, but administration and finances are all handled by one tertiary hospital. Hospitals in the Shanghai model share management and technical skills only; ownership and financial responsibility are separate.

  • Denmark

    Current mandatory health agreements between municipalities and regions on coordination of care address a number of topics related to admission and discharge from hospitals, rehabilitation, prevention, psychiatric care, IT support systems, and formal progress targets. Agreements are formalized for municipal and regional councils at least once per four-year election term, generally take the form of shared standards for action in different phases of the patient journey in the system, and must be approved by the Danish Health Authority. The agreements are partially supported by IT systems with information that is shared between different caregivers. The performance of regions and municipalities in reaching the goals is measured by national indicators published online (

    Regions and municipalities have implemented various measures to promote care integration. Examples include the use of outreach teams from hospitals doing follow-up home visits; training programs for nursing and care staff; establishment of municipal units located within hospitals to facilitate communication, particularly in regard to discharge; and the use of “general practitioner practice coordinators.” Many coordination initiatives have a special emphasis on citizens with chronic care needs, multi-morbidity, or frailty due to aging or mental health conditions . Municipalities are in charge of a range of services, including social care, elder care, and employment services; most are currently working on models for integrating these services better, such as through joint administration with shared budgets and formalized communication procedures.

    Practices increasingly employ specialized nurses, and several municipalities and regions have provided financial support to set up multispecialty facilities, commonly called “health houses.” Models vary, but often include GPs, practicing specialists, and physiotherapists, among others. GPs in medical homes are encouraged to function as coordinators of care for patients and to develop a comprehensive view of their patients’ individual needs in terms of prevention and care. This principle is commonly accepted and is supported by the general national-level agreements between GPs and regions. GPs participate in various formal and informal network structures and are included in the health service agreements made between regions and municipalities to facilitate cooperation and improve patient pathways. All GPs use electronic information systems as a conduit for discharge letters, electronic referrals, and prescriptions.

  • England

    GPs increasingly work in multipartner practices that employ nurses and other clinical staff, who carry out much of the routine monitoring of patients with long-term conditions. These practices also have some of the features of a medical home—that is, they direct patients to specialists in hospitals or to community-based professionals, like dieticians and community nurses, and hold treatment records of their patients. GPs are responsible for care coordination as part of their overall contract; to improve coordination for older patients, the latest version of the contract (2014–15) requires practices to have a “named accountable GP” for all patients over age 75. GPs also have financial incentives to provide continuous monitoring of patients with the most common chronic conditions, such as diabetes and heart disease.

    The 2012 Act charged National Health Service (NHS) England, Monitor, and the Clinical Commissioning Groups (CCGs) with promoting integrated care—closer links between hospital- and community-based health services, including primary and social care. The health and well-being boards within local authorities are intended to promote integration between NHS and local authority services, particularly at the intersection of hospital and social care.

    The government announced in 2013 the selection of 14 “Pioneer” integration pilot programs, aimed at improving coordination of health and care services for patients most at risk of having to undergo unplanned or emergency treatment. The Better Care Fund provides GBP3.8 billion (USD5.4 billion), pooled from existing health and social care budgets, for integration projects by local health and social care commissioners starting in 2015–16. Health and well-being boards have submitted plans for these funds with a range of objectives, including a reduction in emergency hospital admissions by 3.5 percent.

  • France

    Various quality-related initiatives aim to improve coordination of hospital, out-of-hospital, and social care. At the regional level, telemedicine pilot programs are under way to coordinate health and social care services for target populations identified by the Regional Health Agencies, such as infants, prisoners, and persons with disabilities. Funding streams are pooled and earmarked for these pilots, and assessment is planned for 2016.

  • Germany

    Many efforts to improve care coordination have been implemented, e.g., sickness funds offer integrated-care contracts and disease management programs for chronic illnesses to improve care for chronically ill patients and to improve coordination among providers in the ambulatory sector. In December 2014, 9,917 registered disease management programs for six indications had enrolled about 6.5 million patients (more than 8% of all the statutory health insurance (SHI)-insured). There is no pooling of funding streams between the health and social care sectors.

    From 2016, the Innovation Fund will promote new forms of cross-sectoral and integrated care (also for vulnerable groups) supported by annual funding of EUR300 million, or USD381 million (including EUR75 million, or USD95 million, for evaluation and health services research). Funds will be awarded through an application process overseen by an Innovation Committee based at the Federal Joint Committee.

  • India

    No information available
  • Israel

    The health plans, which are both insurers and providers, are essentially the sole source of primary care and the main source of specialty care. This structural integration of services provides the foundation for provision of relatively seamless care for all the insured, including complex and chronically ill patients. The plans’ health information systems link primary and specialty care providers, and a new national health information exchange is linking the health plans and the hospitals. Increasingly these provide access to electronic medical information at the point of care.

    In addition, the health plans have put forth several targeted management programs that aim to provide comprehensive integrated care for complex patients with chronic conditions. These make extensive use of the plans’ sophisticated information systems, videoconferencing, and other innovative techniques (Intel, 2015).

    Generally speaking, integration is still limited among the various components of the long-term care system and between long-term care and other components of the health care system. However, this may change in the future if long-term care becomes a responsibility of the health plans.

  • Italy

    Integration of health and social care services has recently improved, with a significant shift of long-term care from institutions to the communities, with an emphasis on home care. Community home care establishes a home care network that integrates the competencies of nurses, GPs, and specialist physicians with the needs and involvement of the family. General practitioners oversee the home care network, liaise with social workers and other sectors of care, and take responsibility for patient outcomes.

    Regions have chronic patient management programs, dealing mainly with high-prevalence conditions such as diabetes, congestive heart failure, and respiratory conditions. All programs involve different competencies although the degree of evolution is varied across regions. Some regions are also trying to set up disease management programs based on the chronic care model.

    The most recent Pact for Health, signed in July 2014, is a significant step toward care integration: all regions must establish “primary care complex units” (Unità Complesse di Cure Primarie) involving GPs, specialists, nurses, and social workers.

    Given that, traditionally, Italian GPs work in solo practice, shifting to this new organizational arrangement will require considerable effort. To further promote integration and adoption of multidisciplinary teams, medical homes are being encouraged in some regions. (Tuscany and Emilia-Romagna have invested considerable resources in activating and promoting medical homes. In Emilia-Romagna, for example, there are currently 62 medical homes providing multispecialty care to approximately 1 million people.)

  • Japan

    The national government prioritizes the general coordination of care, including coordination in mental health care, and has introduced financial incentives for hospitals and clinics, particularly in cancer, stroke, cardiac, and palliative care. Hospitals admitting stroke victims or patients with hip fractures can receive additional fees if they use post-discharge protocols and have contracts with clinic physicians to provide effective follow-up after discharge, for which those physicians also receive additional fees. The government also provides subsidies to leading providers in the community to facilitate care coordination.

    There are more than 4,000 “community comprehensive support centers” to coordinate services, particularly for those with long-term conditions. Funded by LTCI, they employ care managers, social workers, and long-term care support specialists. No pooled funding of the public health insurance system (PHIS) and long-term care insurance (LTCI) exists.

    Regional and large-city governments are required to establish councils to promote integration of care and support for patients with 306 designated long-term diseases.

  • The Netherlands

    A bundled-payment approach to integrated chronic care is applied nationwide for diabetes, COPD, and cardiovascular risk management. Under this system, insurers pay a single fee to a principal contracting entity—the care group (see above)—to cover a full range of chronic disease services for a fixed period. The bundled-payment approach supersedes traditional health care purchasing for the condition and divides the market into two segments—one in which health insurers contract care from care groups, the other in which care groups contract services from individual providers, each with freely negotiable fees (Struijs & Baan, 2011). To head off potential additional coordination problems and better reach vulnerable populations, the role of district nurses is currently being strengthened.

  • New Zealand

    Larger Integrated Family Health Centers (IFHCs) are developed in line with the “Better, Sooner, More Convenient” government policy, which aims to improve access to integrated care provided by district health boards (DHBs) and primary health organizations (PHOs) by establishing more convenient locations for patients (outside of hospital settings) and by emphasizing chronic disease management. These centers provide comprehensive primary care and care coordination, after-hours services, and some minor elective procedures for an enrolled population. New facilities will see services and providers colocated, or coordination of services improved, with funding from both primary care budgets and DHBs.

    Patients enrolled in PHOs have a medical home, but PHOs vary widely in size, performance, and activities. The highest-performing among them provide a model that, if nationally emulated, would result in all enrollees having a fully functional, multidisciplinary medical home, although institutional barriers to integrating primary and hospital care would remain.

    The New Zealand government is accelerating the drive for clinical integration to create a more patient-centered health system. It is also ensuring that all DHBs’ annual plans include proposals for integration. These directions have been propelled by a new PHO contract in place since mid-2013 that requires PHO–DHB alliances modeled after Integrated Family Health Center pilot programs. There is considerable scope for these alliances to integrate health and social services (see below), and there is a gradual move toward pooled funding streams. Some specialized providers contracted by the government that focus on vulnerable populations, such as Maori and Pacific people, work to coordinate health and social services.

  • Norway

    Care coordination has been pointed out as a weakness in the health care system. The coordination reform of 2012 put more emphasis on municipalities’ responsibility for 24-hour and post-discharge care, including individual treatment plans for patients with chronic diseases, but not for hospital treatment. Hospitals and municipalities must establish formal agreements on the care of patients with complex needs (Ministry of Health and Care Services 2009 and 2011). The number of integrated primary care practices is experiencing moderate growth, with GPs establishing common practices with physiotherapists and specialists in orthopedics, gynecology, ophthalmology, dentistry, and pediatrics.

    For hospitals, incentives for care coordination are provided by mandatory agreements with municipalities. Financing is still fragmented between the hospitals (state-funded) and primary care (municipality-funded), but the municipalities pay substantial fines per day to hospitals if they are not able to accommodate patients ready for discharge.

  • Singapore

    Singapore’s Agency for Integrated Care was created in 2009 to bring about a patient-focused integration of primary and intermediate- and long-term care. The agency, which operates at the patient, provider, and system levels, works to encourage health care providers to coordinate their efforts on behalf of the patient. The agency also advises patients and families about appropriate health care services and helps them navigate the system. A primary example of the issues it addresses is follow-up treatment for chronic-disease patients discharged from the hospital. Another major initiative seeks to expand and improve health care capabilities at the community level. To achieve better integration of all care services, all six public hospital clusters in Singapore are undergoing a systemwide transformation to a regional health care system model. Hospitals will work in close partnership with other providers in their region, such as community hospitals, nursing homes, general practitioners, and home care providers.

    Another significant role for the agency is to ensure integration of health and social care services for elderly and disabled populations. The agency coordinates and facilitates the placement of sick elderly people with nursing homes, community providers, day rehabilitation centers, and long-term care facilities, and manages referrals to home care services. The agency also actively helps the elderly and people with disability apply for available financial assistance.

  • Sweden

    The division of responsibilities between county councils (for medical treatment) and municipalities (for nursing and rehabilitation) requires coordination. Efforts to improve collaboration and develop more integrated services include the development of national action plans supported by targeted government grants. In 2005, Sweden introduced a “guarantee” to improve access to care and to ensure the equality of that access across the country. The guarantee is based on the “0–7–90–90 rule”: instant contact (zero delay) with the health system for advice; seeing a general practitioner within seven days; seeing a specialist within 90 days; and waiting no more than 90 days to receive treatment after being diagnosed. For county councils to be eligible for the grant targeted at accessibility, 70 percent of all patients must receive care within the stipulated time frames. At the county council level, providers are eligible for grants linked partly to the fulfillment of goals related to coordination and collaboration in care provided to the elderly with multiple diagnoses.

  • Switzerland

    Care coordination is an issue, particularly in light of a projected lack of providers in the future and the need to improve efficiency to increase capacity. The task force Dialogue on National Health Policy discusses existing and new approaches to care. The national Health2020 agenda includes a comprehensive projection of the priorities of health care policy until the year 2020. The agenda also addresses care coordination, stating that integrated health care models need to be supported in all areas. The Federal Office of Public Health (FOPH) works on concrete measures to confront these challenges.

    Strategies and networks tackling emerging areas of importance, like palliative care, dementia, and mental health, have been created to improve coordination. They start on a conceptual level, aiming at the practical level to encourage different types of health professionals to work together. A growing number of such programs are in the works, as shown in the National Health Report, but pooled funding streams do not exist yet. It is also worth noting the efforts in the area of e-health, which should considerably improve coordination as well.

  • United States

    Both the government and private insurance companies are leading efforts to move away from the currently specialist-focused health system to a system founded on primary care. In particular, the “patient-centered medical home” model, with its emphasis on care continuity and coordination, has aroused interest among U.S. experts and policymakers as a means of strengthening primary care and linking medical services more closely to community services and supports.

    Another trend is the proliferation of accountable care organizations (ACOs), networks of providers that assume contractual responsibility for providing a defined population with care that meets quality targets. Providers in ACOs share in the savings that constitute the difference between forecasted and actual health care spending. More than 700 ACOs have been launched by public programs and private insurers, and more than 23.5 million Americans are enrolled in one. Two Medicare-driven ACO programs have been rolled out—the Medicare Shared-Savings Program (MSSP) and the Pioneer ACO Program, which together encompass more than 420 ACOs servicing 14 percent of the Medicare population, or 7.8 million Americans. Patients have reported better care experiences, quality measures have generally improved for the tracked indicators, and modest savings have been achieved.

    Medicare, Medicaid, and private purchasers, including employer groups, are also experimenting with new payment incentives that reward higher-quality, more efficient care. One strategy is “bundled payments,” where a single payment is made for all the services delivered by multiple providers for a single episode of care. About 7,000 hospitals, physician organizations, and postacute care providers participate in bundled payment initiatives.

    In addition, the Centers for Medicare and Medicaid Services (CMS) has supported the development of local programs that aim to better integrate health and social services. Among these is Massachusetts General Hospital’s Care Management Program, where nurse case managers work closely with Medicare patients who have serious chronic conditions to help coordinate their medical and social care. Medicaid ACOs are also implementing programs to integrate primary care and behavioral health services. Some ACOs are not only trying to integrate clinical and social services but also exploring innovative financing models, such as cross-sectoral shared-savings models.