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Barriers to Integrated Care and How to Overcome Them

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Around 75% of healthcare spending in Europe is directed towards managing and treating chronic diseases. Looking at different patient groups, around 10% of patients account for almost two-thirds of healthcare expenditure.[1] These patients are to a large extent elderly people with multiple chronic conditions. The figures show clearly why increased effectiveness in preventing, managing and treating chronic diseases is a matter of the highest priority for most health policy makers – and finance ministers.

The management of chronic diseases poses specific challenges to healthcare systems. More often than not, several healthcare providers are involved in the care of the patient, from general practitioners and nurse practitioners to various specialists (for example eye specialists or podiatrists for managing diabetes complications), hospitals, home care services and, of course, pharmacies. For the patient it can be difficult to navigate this plethora of providers and to know whom to contact at what time or who is taking overall decisions about his or her treatment plan – if there is even a treatment plan, that is. Patients with several chronic conditions face even greater difficulties if there is no coordination of the different care plans, sometimes even with direct harm as a consequence – for example if medication is prescribed by different doctors without due consideration of potential side effects and interactions.

Generally, chronic diseases have much more complex “care pathways” than the treatment of other diseases, which can lead to a variety of models being used, both within and across countries, at times leading to variations in the actual health status of the patient. Clinical guidelines are often established for major chronic diseases, but the guidelines can vary between regions and countries, and they are not always implemented in the same way (or at all).

As a way to overcome these difficulties, the concept of “integrated care” has become more and more important over the last few years. Although there is no agreed definition of the concept, basically integrated care means the coordination of all healthcare activities, from primary care to rehabilitation, putting the patient and their needs at the centre. The end goal is to provide higher quality care, resulting in better health outcomes for the patient, and a better patient experience of the care journey, often at the same or even lower cost.

It sounds self-evident, but several complicating factors can make integrated care difficult to implement in practice.

  • Different healthcare professionals have different roles, responsibilities and ways of working, and are not always easy to coordinate
  • Different parts of the healthcare system sometimes fall under different organisational and political management, which also means different budgets. This problem becomes even more significant if you also include social care services
  • Payment models in healthcare often do not encourage coordinated efforts, since most healthcare professionals are reimbursed separately for the service they provide, not for the final result in terms of health for the patient
  • Health IT systems are often fragmented, making it difficult to follow the patient’s journey between different healthcare providers, and to collect all the necessary health data in one place

In care organisations all over Europe, and the world, great work is being done in experimenting with new, innovative models that can solve these issues. One such example is the implementation of integrated care for Type 2 Diabetes in the Netherlands, a model that was recently subject to a case study under the EU-funded Project INTEGRATE.[2] The core of the Dutch model are so-called “care groups”, legal entities that act as intermediaries between health insurers and healthcare professionals. The care groups negotiate the content and price of a comprehensive package of diabetes care, which makes it possible for the health insurer to buy care as one, single service, even though it will be delivered by different groups of healthcare professionals in different settings.

The case study concluded that although major progress had been made, there were still barriers to a fully-functioning, integrated care system. Some were of a political and economic nature, particularly issues in the relationship between the health insurers and the care groups. Another major barrier was that the electronic databases used by GPs, practice nurses, care chain partners and hospitals were still not integrated with each other. Task-shifting between different categories of health professionals, for instance between general practitioners and nurse practitioners, could also cause friction.

But there were also positive signs, such as good cooperation between GPs and specialists – a key relationship in any integrated care model. It was believed that one important factor behind this was that the specialists were not reimbursed on a fee-for-service model, and therefore didn’t resist when the care of patients started to shift from specialist care to primary care. Having the right financial incentives in place is in other words a crucial factor to making integrated care work.

So has diabetes care for Dutch patients improved?

Our instincts tell us that integrated care, if functioning well, should provide better quality care for patients more efficiently. But is there proof of this, and which model works best, given that there are so many different pilots in operation? The authors of the study make the point that integrated care models are difficult to evaluate due to the “lack of comparable outcome measures as well as in-depth, qualitative data”. This is indeed a problem not just for evaluating integrated care, but also for assessing the real impact of all care pathways and healthcare interventions. We are usually good at measuring if the right process has been implemented – how many healthcare professionals follow clinical guidelines, for example – but not as good when it comes to measuring what actually matters in the end: the health of the patient. So just as important as having interconnected Health IT systems, is the capability of the same systems to collect data on health outcomes that both matters to patients and are comparable from one database to another.

Agreed sets of standardised outcomes measures implemented across integrated health IT systems would enable almost real-time analysis of how different organisational changes and the introduction of new methods and technology affect the health outcomes of patients, thereby enabling comparisons between hospitals, care organisations and even countries. This would have a huge potential for increasing the quality of care given to patients, and for making substantial efficiency gains in health expenditure – a healthy investment, by any standard.

To find out more about outcomes-focused approaches to healthcare you can access the Case for outcomes here

 

[1] U.S. Figures. https://meps.ahrq.gov/data_files/publications/st448/stat448.shtml

[2] http://bmcfampract.biomedcentral.com/articles/10.1186/s12875-015-0320-z

 

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