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 Local Hospital Networks (LHNs). Care also may be coordinated by Aboriginal health and community health services.
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), the Regulated Health Professions Network (Nova Scotia), and Health Links (Ontario). Also, Ontario has long-standing alternative community-based and multidisciplinary primary care models including 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.
Each province determines its own structure for the coordination of health and social care services. In Ontario and Quebec, there is a single ministry responsible for health care that includes long-term and social care, with funding devolving to the regional level.
Care coordination is an issue, particularly in light of a projected lack of health professionals 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 strategy includes a comprehensive projection of the priorities of health care policy until the year 2020. The strategy 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 implementing 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 at the conceptual level and design pilot projects, aiming at the practical level to encourage different types of health professionals to work together. The National Health Report 2015 discusses the growing number of case management programs for chronically ill patients, but pooled funding streams do not yet exist. It is also worth noting the efforts in the area of e-health, which should considerably improve care coordination.
Medical alliances are regional hospital 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 the demand for chronic disease care, improve health care quality, and contain rising costs. The hospitals within a medical alliance share a common electronic health record system, and results of labs, images, and diagnoses are easily available 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.
Current mandatory health agreements between the municipalities and regions on coordination of care address a number of topics related to admission and discharge from hospitals, rehabilitation, prevention, psychiatric care, information technology (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 a patient’s journey within the system, and must be approved by the Danish Health Authority. The agreements are partially supported by IT systems with information that is shared among caregivers. The degree to which the regions and municipalities succeed 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; the 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 place an emphasis on people with chronic care needs, multimorbidity, or frailty resulting from aging or mental health conditions. The municipalities are in charge of a range of services, including social care, elder care, and employment services; most are currently working on models for better integration of these services, such as through joint administration with shared budgets and formalized communication procedures.
Practices increasingly employ specialized nurses, and several municipalities and regions have set up joint multispecialty facilities, commonly called “health houses.” Models vary, but often include general practitioners (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 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.
Many efforts to improve care coordination have been implemented; for example, sickness funds offer integrated-care contracts and disease management programs (DMPs) for chronic illnesses to improve care for chronically ill patients and to improve coordination among providers in the ambulatory sector. In December 2015, 9,966 registered DMPs for six indications had enrolled about 6.6 million patients (more than 8% of all the statutory health insurance [SHI]-insured). There is no pooling of funding streams by the health and social care sectors.
As of 2016, the Innovation Fund promotes new forms of cross-sectoral and integrated care (also for vulnerable groups) supported by annual funding of EUR300 million, or USD382 million (including EUR75 million, or USD95 million, for evaluation and health services research). Funds are awarded through an application process overseen by the Innovation Committee, based at the Federal Joint Committee.
Inadequate coordination in the health care system remains a problem. Various quality-related initiatives piloted by the health ministry or by regional agencies aim to improve the coordination of hospital, out-of-hospital, and social care (see above). They target the elderly and fragile populations and attempt to streamline the health care pathway, integrating providers of health and social care via a shared portal and case managers.
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 dietitians 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 (2014–2015) 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 Clinical Commissioning Groups (CCGs) with promoting integrated care, i.e., 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.
Practical initiatives include the Better Care Fund (GBP3.9 billion, or USD5.6 billion), pooled from existing health and social care budgets, for integration projects by local health and social care commissioners starting in 2015–2016. These funds are being used to improve the discharge process for hospital patients, reduce reliance on long-term care, and improve access to out-of-hospital care.
Patient care continues to be fragmented in India. There has been very little effort made to redesign how care is delivered or to promote patient-centered care. Likewise, health coverage models are fragmented, with patients given limited choice across packages.
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 a foundation for the 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. These systems are increasingly providing 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.
Generally speaking, there is still only limited integration among the various components of the long-term care system and between long-term care and other components of the health care system. However, integration may be expanded in the future if long-term care becomes a responsibility of the health plans.
Integration of health and social care services has recently improved, with a significant shift of long-term care from institutions to the communities and an emphasis on home care. Community home care establishes a home care network that integrates the competencies of nurses, general practitioners (GPs), and specialist physicians with the needs and involvement of the family. GPs oversee the home care network, liaise with social workers and other sectors of care, and take responsibility for patient outcomes.
The regions have chronic care management programs, dealing mainly with high-prevalence conditions such as diabetes, congestive heart failure, and respiratory conditions. All programs involve different competencies. Some regions are also trying to set up disease management programs based on the chronic care model, although the degree of organization varies across regions.
The most recent Pact for Health, signed in July 2014, is a significant step toward care integration (see below): 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, such as Tuscany and Emilia-Romagna, where there are collectively 81 medical homes currently providing multispecialty care to approximately 1.7 million people.
National government prioritizes care coordination and develops financial incentives for providers, particularly in cancer, stroke, cardiac, and palliative care. For example, 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 care after discharge (the clinic physicians also receive additional fees). The government also provides subsidies to leading providers in the community to facilitate care coordination. Highly specialized large-scale hospitals with 500 beds or more have an obligation to promote care coordination between providers in the community, as well as to charge additional fees to patients who have no referral for outpatient consultations.
There are more than 4,000 “community comprehensive support centers” to coordinate services, particularly for those with long-term conditions. Funded by the long-term care insurance (LTCI), they employ care managers, social workers, and long-term care support specialists. Currently, there is no pooled funding between the Statutory Health Insurance System (SHIS) and the LTCI.
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.
A bundled-payment approach to integrated chronic care is applied nationwide for diabetes, chronic obstructive pulmonary disease (COPD), and cardiovascular risk management. Under this system, insurers pay a single fee to a principal contracting entity—the care group—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, and another in which care groups contract services from individual providers, each with freely negotiable fees. To head off potential additional coordination problems and better reach vulnerable populations, the role of district nurses is currently being strengthened.
The care 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. Hospitals and municipalities must establish formal agreements on the care of patients with complex needs.
For hospitals, incentives for care coordination are provided by mandatory agreements with municipalities. Financing remains poorly aligned between the hospitals, which are state-funded, and primary care, which is municipality-funded. The municipalities are fined per day for patients who stay in hospitals after they are ready for discharge.
District-level alliances (partnerships between district health boards (DHBs) and primary health organizations (PHOs)) are driving stronger system integration by changing service models. While alliance performance varies, the leaders have multiple members, including, but not limited to, DHB, PHO, pharmacy, ambulance, district nursing, allied health, local government, and Maori providers. District alliances are developing services based on locality-specific needs. Some alliances have begun to form partnerships with local social agencies.
The primary care sector has begun exploring for the most appropriate model of general practice and enhanced primary care that will meet future demand. The “health care home” model is being implemented in several districts, with support and resourcing shared between DHBs and PHOs.
While DHBs are held accountable for driving integration through their annual plans, variability still exists. There is an ongoing effort to drive improvement by other means, including new funding models and contracting for outcomes.
Four system-level performance measures were implemented in 2016. These assess performance at the system level, and success is dependent on the contributions of individual providers or organizations. This reliance on multiple contributions drives the integration of services and providers and requires an effective alliance.
Singapore’s Agency for Integrated Care was created in 2009 to bring about a patient-focused integration of primary care with intermediate- and long-term care. The agency, which operates at the patient, provider, and system levels, advises patients and families on appropriate health care services and helps them navigate the health system. A primary focus is follow-up treatment for chronic-disease patients after discharge from the hospital. Another is the expansion and improvement of health care capabilities at the community level. Currently, all six public hospital clusters in Singapore are undergoing a systemwide transformation to a regional health care system model to better integrate all care services. Hospitals will work closely with other providers in their region, such as community hospitals, nursing homes, general practitioners, and home care providers.
Another significant role for the Agency for Integrated Care is that of ensuring integration of health and social services for elderly and disabled populations. The agency coordinates and facilitates placement of individuals with nursing homes, community providers, day rehabilitation centers, and long-term care facilities; facilitates treatment at home by managing referral of patients to home care services; and assists people with applying for available financial assistance.
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 and accessible services are supported by targeted government grants. In 2005, the “0–7–90–90 rule” was introduced to improve and ensure the equality of access across the country, namely: 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. Between 2008 and 2014, county councils where 70 percent of all patients received care within the stipulated times were eligible for the grant targeted at accessibility.
Since 2015, the targeted grants have focused more on care coordination; they support action plans for improving coordination and collaboration at the county council level. At the provider level, performance-related payment is commonly linked to quality targets related to care coordination and compliance with evidence-based clinical guidelines, particularly for care provided to elderly patients with multiple diagnoses.
Improved delivery system integration and care coordination have been on the National Health Insurance Administration’s (NHIA) agenda for many years. Many such initiatives are discussed earlier in this profile.
Government agencies and private insurance companies are leading efforts to move away from the current 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 800 ACOs have been launched by public programs and private insurers, and more than 28 million Americans are enrolled in one. Two Medicare-driven ACO programs have been rolled out—the Medicare Shared Savings Program and the Pioneer ACO Program, which together encompass more than 470 ACOs servicing 17 percent of the Medicare population, or 8.9 million Americans. Patients have reported better care experiences, quality measures have generally improved for the tracked indicators, and there have been modest cost savings. The Centers for Medicare and Medicaid Services (CMS) has unveiled the new Next Generation ACO program for experienced, high-performing ACOs.
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,” whereby 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, CMS has supported the development of local programs that aim to better integrate health and social services. 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 are exploring innovative financing models, such as cross-sectoral shared-savings models.