Expert Group on Health systems performance assessment Presentation of the report on measuring performance of the integrated care and of the future work programme of the expert group Exchange of views Endorsement of the amendment to rules of procedure of the expert group - Main contents

Document date	20-01-2017
Publication date	24-01-2017
Reference	5169/17 ADD 1
From	General Secretariat of the Council
External link	original article
Original document in PDF

Council of the

European Union PUBLIC

Brussels, 20 January 2017 (OR. en)

5169/17 ADD 1

LIMITE

SAN 11

NOTE

From: General Secretariat of the Council

To: Delegations

Subject: Expert Group on Health systems performance assessment  

· Presentation of the report on measuring performance of the 

integrated care and of the future work programme of the expert group 

· Exchange of views 

· Endorsement of the amendment to rules of procedure of the expert 

group 

In view of the meeting of the Working Party on Public Health at Senior Level on 3 February 2017,

delegations will find attached the draft final report of the HSPA Expert Group on Tools and

methodologies to assess integrated care in Europe.

________________________

ANNEX

Tools and methodologies to assess integrated care in Europe

Contents

List of abbreviations ................................................................................................................................ 3

List of tables, figures and boxes .............................................................................................................. 4

Executive Summary ................................................................................................................................. 5

Chapter 1: Introduction ........................................................................................................................... 7

Chapter 2: What do we mean by integrated care: theory, concepts and definitions .......................... 11

Chapter 3: Building blocks, design principles and system levers for integrated care ........................... 14

Chapter 4: Measuring the performance of integrated care .................................................................. 27

Chapter 5: Conclusions .......................................................................................................................... 56

Annex 1: Table A1 Success factors and transferable elements from integrated care experiences in

Europe ................................................................................................................................................... 59

Annex 2: Table A2 Mapping summary of success factors from integrated care experiences in Europe

 ............................................................................................................................................................. 107

Annex 3. Maturity Model for integrated care .................................................................................... 109

Annex 4. Results from the survey on integrated care ........................................................................ 117

Annex 5. Examples of potential measures of people-centred and integrated health services as

compiled by WHO (2015) .................................................................................................................... 121

List of abbreviations

AHA Active and Healthy Ageing

A&E Accident and Emergency (Department in UK hospitals)

EIP European Innovation Partnership

EC European Commission

EU European Union

GP General Practitioner

HSPA Health Systems Performance Assessment

ICT Information and Communications Technology

IT Information Technology

NHS National Health Service (UK)

OECD Organisation for Economic Co-operation and Development PPP Public Private Partnerships

PREMs Patient-reported experience measures

SP Specialist

WHO World Health Organization

WPPHSL Working Party on Public Health at Senior Level

List of tables, figures and boxes

Tables

Table 1 Selection criteria for quality indicators within the OECD Health Care Quality

Indicators Project

Table 2 Indicators used for assessing performance of integrated care in selected EU Member States

Table 3 Documented frameworks and indicator sets for assessing the performance of integrated care

Table 4 Generic indicators for assessing integrated care as proposed by Raleigh et al. (2014) Table 5 Proposed core suite of integration indicators, Scotland

Table A1 Success factors and transferable elements from integrated care experiences in

Europe

Table A2 Mapping summary of success factors from integrated care experiences in Europe Table A3 The 12 maturity dimensions for delivering integrated care

Figures

Fig. 1 Different levels of care integration

Fig. 2 Maturity Model for Integrated Care

Fig. 3 Proposed approach to conceptualising the measurement of the performance of integrated care

Fig. 4 Conceptualising the measurement of the performance of integrated care by different areas of enquiry

Fig. 5 Proposed model for alternate, in-depth HSPA reporting on identified priority areas

Fig. A1 Application of Maturity Model in Gesundes Kinzigtal

Fig. A2 Application of Maturity Model in Valencia Region, Spain

Fig. A3 Application of Maturity Model in Olomouc Region, Czech Republic

Fig. A 4 AHRQ Care coordination measurement framework

Boxes

Box 1 Source for cases on good practices on implementing integrated care

Box 2 Policy Focus group – sub-group Integrated Care

Box 3 Desirable attributes of quality indicators

Box 4 Considerations for selecting indicators for measuring the quality of integrated care

Executive Summary

Background and scope of the report

 The expert group on Health Systems Performance Assessment (HSPA) was activated in the autumn of 2014. It was mandated to focus each year on a particular policy area and to identify tools and methodologies to support national policy makers in developing HSPA in that specific area.

 Following its first report in April 2016 on the assessing the quality of care (So What? Strategies across Europe to assess quality of care), the expert group directed its focus on the assessment of integrated care. This area is a fundamental component of health system reforms: it is considered central to addressing challenges due to population ageing, the rising burden of chronic diseases and constraints in public resources. At the same time there is a lack of widely available information in terms of tools, methodologies and indicators to assess this area of care delivery.

 The structure of this report mirrors the dual challenge of assessing the degree of integration of a system (i.e. measuring how firmly integrated are the different layers of care delivery) and finding tailored ways to assess the performance of integrated care models in such a way that is able to capture the specific added value brought in by the integration.

Defining integrated care

 The report uses the following definition of integrated care: Integrated care includes initiatives seeking to improve outcomes of care by overcoming issues of fragmentation through linkage or co-ordination of services of providers along the continuum of care.

 Useful approaches have identified targeted areas for integration, namely functional, organisational, professional and clinical integration as well as the systemic levels at which it can occur, i.e. horizontal integration links services that are on the same level in the process of health care, (e.g. general practice and community care) while vertical integration brings together organisations at different levels of a hierarchical structure under one management umbrella (e.g. primary care and secondary care).

 The transition to integrated care is a highly complex process in all aspects: design, implementation and assessment of integrated care. So far, the evidence base for the benefits of integrated care on both patient outcomes and cost-effectiveness is based on small-scale examples, although the scale of implementation is slowly growing. Better, more comparable and longer term data collection and reporting will be crucial for building a more comprehensive evidence base.

Building blocks, design principles and system levers

 A review of experiences in implementing integrated care in Europe - carried out for this report - has identified elements of good practices deemed to be successful and which potentially could be transferable across Europe. A key lesson learned is that it matters a lot how integrated care is designed and implemented to fit local contexts and needs.

 The review was able to single out several inter-related “building blocks” or "system levers" for the effective design and implementation of integrated care frameworks. These relate to: political support and commitment; governance; stakeholder engagement; organisational change; leadership; collaboration and trust; workforce education and training; patient focus / empowerment; incentives (including contracting and reimbursement); ICT infrastructure and solutions; and the monitoring / evaluation system. It is noteworthy that each identified system lever or building block is common to several of the integrated care case studies that were examined.

Measuring the performance of integrated care systems

 Measuring the performance of integrated care is a different activity from measuring the level of integration in a system. It not only has to take into account the objectives of a health care system (eg. improving health outcomes, enhancing the patient care experience and reducing costs ) but also needs to reflect the complexity of integrated care systems which operate at different tiers of service delivery - micro (patient care), meso (organisational context) and macro-level (financing and policy context).

 Integrated care can be seen to be both a design principle and a means to achieve person-centred, efficient and safe care.

 Given that different countries are at different stages in the development of integrated care systems, approaches and frameworks to assess integrated care can be seen to lie on a continuum that stretches from selected indicators that may form part of a wider framework of system performance assessment to a specific integrated health system measurement approach.

 While the applicability of different considerations will vary by country and system context, a framework or indicator set for assessing the performance and progress in integrated care systems needs to have a good understanding of: the core aims of integrated care; the desired outcomes; the timeframe over which such outcomes can reasonably be expected to be achieved; how impact can be measured; the robustness of measures; and simplicity and ease of measurement.

 The Donabedian approach to evaluate quality of care by assessing structure, process and outcome provides a useful way to guide integrated care performance measurement. The expert group agreed with Donabedian statement that “good structure increases the likelihood of good process, and good process increases the likelihood of good outcome”.

Findings from the survey and the policy focus group

 A survey on the use of integrated care in EU countries carried out by the sub-group on Integrated Care of the in the summer of 2016 highlighted that only a small number of EU Member States have so far developed specific indicator sets to assess integrated care (United Kingdom, Italy) or that could be used for this purpose (Austria, Belgium, Estonia, Sweden, Italy). This reflects international experience, with only a few other countries (New Zealand and the US) plus the World Health Organization’s 2015 global strategy on people-centred and integrated health services releasing documented frameworks and indicator sets.

 In 2016 experts from 17 European countries took part in a structured policy focus group on Integrated Care and reflected on the international documented frameworks and indicator sets as well as their own experiences in health system performance assessment more broadly and measurement of integrated care specifically.

 Key insights of the policy focus group discussions included:

• a) 

  understanding and conceptualisation of integrated care will be key to determining what will be measured;

• b) 

  current indicator sets for integrated care tend to overlap with those currently used in ongoing HSPA exercises and there may be a need or indeed an opportunity to develop additional indicators that are specific to measuring integrated care;

• c) 

  measurement should consider indicators of structure, processes and outcomes; and

• d) 

  as countries vary with regard to HSPA frameworks more broadly and integrated care approaches more specifically, any integrated care measurement system or framework should be tailored to countries’ specific goals, values and needs, with no single ‘right’ approach that would be applicable and valid for every system.

 Another concern relates to where integrated care performance assessments sit within the wider HSPA processes and systems in a given country, given that member states differ in the ‘stage’ of their journey to more integrated care systems. One proposal is that national HSPA reporting could include a set of core measures indicative of integrated care reported on a regular (e.g. bi-annual) basis, while more in-depth thematic volumes (on primary care, mental health care etc.) might provide more detailed insights into progress on integrated care.

Chapter 1: Introduction

performance of national health

Background systems. 4. Intensify EU cooperation with

In June 2011, under the Hungarian international organisations, in presidency, the Council adopted a set of particular the OECD and the WHO. conclusions towards modern, responsive

and sustainable health systems 1 . As part In Autumn 2014, the Commission, in

of this process, the Council invited cooperation with Sweden, activated the

Member States and the Commission to expert group on health systems initiate a reflection process aiming to performance assessment (from here on: identify effective ways of investing in the Expert Group) inviting all Member health, so as to pursue modern, States to participate; the OECD, the WHO responsive and sustainable health Regional Office for Europe, and the systems. European Observatory on Health Systems

and Policies are permanent members of

Several working groups were established, the Expert Group. with participants from Member States and the Commission. Among their conclusions The Expert Group is currently jointly was the recommendation to set up an chaired by Belgium and the European expert group to deal with Health Systems Commission. So far, it has met eight times; Performance Assessment (HSPA). four meetings have taken place in Brussels

and four in other European capitals:

The Council Working Party on Public Stockholm, Berlin, Rome, and Vienna. This

Health at Senior Level (WPPHSL) solution permits a deeper insight into acknowledged the recommendations and Member States’ experience and a more agreed on the terms of reference for the effective exchange of practices.

expert group on HSPA. 2 Its mandate was defined by the following objectives: The scope of this report

According to its mission, the Expert Group

• 1. 

  Provide participating Member States focuses each year on a particular priority with a forum for exchange of area, with the goal to identify tools and experience on the use of HSPA at methodologies to support policy makers in national level. developing HSPA in that specific area.

• 2. 

  Support national policy-makers by

identifying tools and methodologies In its first year of activity, the Expert

for developing HSPA. Group has been working on the

• 3. 

  Define criteria and procedures for assessment of quality of care. It presented

selecting priority areas for HSPA at its findings in April 2016 in the report So

national level, as well as for selecting What? Strategies across Europe to assess

EU-wide in order to illustrate and better understand variations in the

During 2016, the area of interest of the aiming to identify key factors that enable Expert Group has been the assessment of good integration of care and readiness for integrated care. This area was selected integration. This analysis is done on the because of the interest many health basis of a large number of cases and systems show towards the development provides insights on how to assess the of integrated care models, and also degree of integration of a system. This because not much is available in terms of chapter was drafted by representatives of tools, methodologies and indicators to B3 Action Group on Integrated Care of the assess this area of care delivery. European Innovation Partnership on

Active and Healthy Ageing: a collaborative

It was clear from the first discussion space of partners representing around 120 among the experts in the Group that they multi-stakeholder commitments across were confronted with a double task. On the EU to promote integrated care the one hand, they had to find ways to services that are more closely oriented to assess the degree of integration of a the needs of patients. system; in other words, to measure how firmly integrated were different layers of Chapter 4 provides an overview of trends care delivery. On the other hand, the in assessing the performance of integrated experts had to find tailored ways to assess care, together with some lists of indicators the performance of integrated care already in use in some pilot experiences. models, which were able to capture the The chapter also discusses the potential specific added value brought in by the use and usefulness of existing frameworks integration. and indicators and the role of evaluating

achievements in the context of broader,

The structure of this report mirrors this system-level performance assessment double challenge: Chapter 2 presents an strategies and frameworks. The chapter overview on theory, concepts and was drafted by Dr Ellen Nolte of the definitions of integrated care; this is based European Observatory on Health Systems on the work developed during the and Policies, and builds on insights from reflection process on health systems experts from 17 European countries that mentioned above, and on the following intook part in a structured policy focus depth analysis carried out by experts in group whose main objective was to the Group. generate in-depth discussion and provide

suggestions and recommendations for a

Chapter 3 provides a broad analysis of framework for performance assessment of experiences of integrated care models, integrated care.

References

• 1. 

  Council of the European Union. Council conclusions: Towards modern, responsive and sustainable health systems. Luxembourg, June 2011. Available at:

  http://www.consilium.europa.eu/uedocs/cms_data/docs/pressdata/en/lsa/122395.pdf

• 2. 

  Council of the European Union. Document 12945/14 of the 9 th of September 2014.

• 3. 

  European Union. So What? Strategies across Europe to assess quality of care. Report by the Expert Group on Health Systems Performance Assessment. Luxembourg, 2016.

  Available at: http://ec.europa.eu/health//sites/health/files/systems_performance_assessment/docs/ sowhat_en.pdf

Chapter 2: What do we mean by integrated care: theory, concepts and definitions

For the purpose of this report, and in many cases for the rest of their lives. As especially the survey on national a consequence, a rising number of people experiences on the use of integrated care, with complex care needs require the we adopted the definition below: development of delivery systems that

bring together a range of professionals

Integrated care includes initiatives seeking and skills from the health care, long-term to improve outcomes of care by and social care sectors. The former helps overcoming issues of fragmentation them to overcome difficulties stemming through linkage or co-ordination of from their health status deterioration. The services of providers along the continuum latter continue to provide assistance when of care. they get better and their condition is not

acute but their ability to function This definition was used by the integrated independently is limited. care sub-group of the EU reflection process on modern, responsive and Failure to better integrate or coordinate

sustainable health systems. 1 It seems to services from these two sectors may result

be broad and general enough to ensure in suboptimal outcomes. It not only entails that a priori no valuable initiatives would a missed opportunity to bring together the be omitted in the discussion on integrated best possible outcomes of cure and care care in the Expert Group. activities but it also means that limited

resources may be wasted, including Naturally, this is only one of many human and financial resources. approaches to answer the question of

what integrated care is. Depending on Integrated care classifications

which aspects are seen as crucial,

scientific definitions as well as those Integration of care impacts upon many adopted for everyday use, when aspects of care systems' functioning. It integrated care projects and models are concerns their different functions and drafted, may differ. levels. It may be limited to only one sector

The rest of this chapter is based on the (health, social care) or be inter sectorial. presentation given by Dr Ellen Nolte at the All these factors make classifying seminar on integrated care measurement integrated care multidimensional and

on the 8 April 2016 in Rome. almost as complex as the needs of those to whom it is provided.

Reasons for integrating care Different approaches have attempted to

Demographic changes, among other capture the targets of integration, in things in European countries, in recent terms of both its hierarchical levels as well years mean that people live longer but as its degree (depth). Looking at the they are more often chronically ill and targets of integration Shortell et al. face their health problems for a long time,

(1994) 2 and Simoens and Scott (1999) 3 own service responsibilities,

mention four types: funding and eligibility criteria and operational rules;

• functional: integration of key • co-ordination: it involves support functions and activities, additional explicit structures and

e.g. financial management, processes, such as routinely shared strategic planning and human information, discharge planning resources management; and case managers, to co-ordinate

• organisational: e.g. creation of care across various sectors; networks, mergers, contracting; • full integration: integrated

• professional: e.g. joint working, organisation/system assumes group practices, contracting or responsibility for all services,

strategic alliances of healthcare resources and funding, which may professionals within and between be subsumed in one managed institutions and organisations; structure or through contractual

• clinical: integration of different agreements between different

components of clinical processes, organisations. 4,5,6

e.g. coordination of care services

for individual health care service A relation may be observed between the

users, care pathways; needs of patients and the degree of

integration in care systems. The more

They differentiate integration depending complex the care needs are, the more on the levels of the system it involves: appropriate it would be to move along the

integration continuum from linkage to full

• horizontal integration: links integration.

services that are on the same level

in the process of health care, e.g. In systems where risk-stratification general practice and community methods are used, mixes of services care; envisaged for different strata of the

• vertical integration: brings population differ in terms of integration

together organisations at different and completeness, depending on the level

levels of a hierarchical structure of needs for care. In the case of low-risk

under one management umbrella, healthy people only health promotion

e.g. primary care and secondary activities are proposed whereas severely

care. ill patients, especially those who have

terminal conditions, receive a vast range

The degree to which elements of a care of health and social care services. The system are connected places various design of services reflects this relation initiatives on a continuum of integration: between the level of needs and the

degree of integration.

• linkage: operating through

separate structures of existing Based on work by Leutz (1999) 4 , the

health and social services systems, following activities relate to different with organisations retaining their needs levels and degrees of integration:

Another way of describing integrated care

• low needs and linkage: is by focussing on the process of identification of "emergent need"; integration. Normative integration occurs referring and follow-up; on request when shared values are at the core of provision of information; clarifying implemented changes. The other type i.e. who pays for which services; systemic integration, takes place if rules

• moderate needs and coand policies are implemented in a ordination: identification of the coherent way. It needs to be highlighted population at risk; discharge that the process of integration typically planning; routine, bidirectional requires simultaneous action at different reporting; establishing of case levels, involves different functions, and

managers and staff linkages; develops in different phases. 7,8 Figure 1

defining payment agreements; presents integration of care on different

• high needs and integration: all levels: micro – clinical integration of care in all settings is managed by person-focused care, meso – concerning multidisciplinary teams; using professionals and organisations and the common health records as part of population- based care that they provide joint practice/management; and finally, macro level – where all the funding is pooled to purchase cure systems also providing population-based and care services. care are integrated. According to this

approach both normative and functional integration take place at the meso and macro levels.

Fig. 1: Different levels of care integration

References

• 1. 

  Council of the European Union. Document 12981/13, Annex IV.

• 2. 

  Shortell S, Gillies R, Anderson D. The new world of managed care: creating organized delivery systems. Health Affairs, 1994;13:46–64.

• 3. 

  Simoens S, Scott A. Towards a definition and taxonomy of integration in primary care.

  Health Economics Research Unit Discussion Paper 03/99. Aberdeen, University of Aderdeen, 1999.

• 4. 

  Leutz W. Five laws for integrating medical and social services: lessons from the United States and the United Kingdom. Milbank Quarterly, 1999;77:77–110.

• 5. 

  Goodwin N et al. Managing across diverse networks of care: lessons from other sectors. London, National Co-ordinating Centre for NHS Service Delivery and Organisation R&D, 2004.

• 6. 

  Ahgren B, Axelsson R. Evaluating integrated health care: a model for measurement.

  International Journal of Integrated Care, 2005;5:1–9.

• 7. 

  Fulop N, Mowlem A, Edwards N. Building integrated care: lessons from the UK and elsewhere. London, The NHS Confederation, 2005.

• 8. 

  Minkman M. A development model for integrated care. International Journal of

  Integrated Care, 2011; 11(Suppl):e099.

• 9. 

  Valentijn PP, Schepman SM, Opheij W, Bruijnzeels MA. Understanding integrated care: a comprehensive conceptual framework based on the integrative functions of primary

  care. International Journal of Integrated Care, 2013;13(1).

Chapter 3: Building blocks, design principles and

system levers for integrated care

Integrated care is considered by many matters a lot how integrated care is stakeholders as a fundamental component designed and implemented to fit the local in health system reforms to address context and needs. If not done effectively, challenges due to population ageing, the it may not bring benefits and, under such rising burden of chronic diseases and circumstances, whatever indicators are constraints in public resources. The used to measure performance will transition to integrated care is, however, a inevitably show poor or suboptimal complex process with high complexity results. Other lessons, which can be drawn being present in all aspects: design, from well-functioning integrated care implementation and assessment of programmes to date, concern elements integrated care. that make them work well - the "system

levers" - and elements that can be In most cases where integrated care has considered as "transferable". been implemented, this has been done on a small scale (although there are cases To this end, a review of experiences in where deployment is growing in scale). implementing integrated care in Europe The evidence from these earlier efforts was carried out by the secretariat of the suggests that benefits, in terms of patient Expert Group and by the "B3 Action Group outcomes, can be legitimately expected. on Integrated Care" of the European In terms of cost-effectiveness, the Innovation Partnership on Active and evidence base is less clear. This is partly Healthy Ageing (EIP on AHA). The due to the lack of available data collected objective of this review was to identify the over long-term periods (experts argue that elements of the good practices which it can take 10 years or more to see a clear were recognised by the owners of the impact in terms of cost-effectiveness at good practices as successful and system level), partly due to the potentially transferable across Europe. differences/inconsistencies in what is The rationale was to capture learning measured (leading to data which is not embedded in the good practices and make comparable or easy to aggregate) and it available to potential adopters of these partly due to evidence being reported in innovative practices. the grey literature (i.e. it is not always reported in scientific publications). The cases examined came from various

sources, with variable degree of detail in

Nevertheless, there are cases where the their description depending on the implementation of integrated care has led template for the description of good to benefits, both in terms of health practice. The sources are listed in Box 1. outcomes and cost-effectiveness. One lesson learnt from these cases is that it

Box 1: Source for cases on good practices on implementing integrated care

Compilation of Good Practices (second edition) of the B3 Action Group on Integrated Care of the EIP on AHA, available at: https://ec.europa.eu/research/innovation-union/pdf/active-healthyageing/gp_b3.pdf

The "How To" Guide of the Reference Sites of the European Innovation Partnership on Active and Healthy Ageing, available at: http://ec.europa.eu/research/innovation-union/pdf/active-healthyageing/how_to.pdf

The collection of case studies prepared by the European Commission's Joint Research Centre in the context of the project "SIMPHS 3 - Strategic Intelligence Monitor on Personal Health Systems", available at: http://is.jrc.ec.europa.eu/pages/TFS/SIMPHS3cases.html

The collection of "Value cases for integrated care" on the web site of the Local Government Association in the United Kingdom, available at: http://www.local.gov.uk/health/- /journal_content/56/10180/4060433/ARTICLE

The "EU models of care" available on the web site of the NHS European Office, available at: www.nhsconfed.org/eumodelsofcare and the web site of NHS Confederation, available at: http://www.nhsconfed.org/resources/2011/12/the-search-for-low-cost-integrated-healthcare

The King's Fund report "Integrating health and social care in Torbay", available at: https://www.kingsfund.org.uk/sites/files/kf/integrating-health-social-care-torbay-case-study-kingsfund-march-2011.pdf

The Nuffield Trust report "Putting integrated care into practice: the North West London experience" (Research summary), available at: http://www.nuffieldtrust.org.uk/sites/files/nuffield/publication/integrated-care-north-westlondon-experience_0.pdf

The compilation of good practices of the SCIROCCO project, available at: http://www.sciroccoproject.eu/

Highlights of success factors from approach was adopted with the objective

integrated care experiences in to capture the experience and lessons

Europe learned in the implementation and assessment of integrated care in the

The review focused on identifying success European regions. It has nevertheless

factors and transferable elements from a highlighted a number of principles and number of integrated care programmes in factors which the stakeholder community Europe, according to the description and in the domain of integrated recognise as analysis in the documentation available. being important, namely:

Annex 1 provides details of the findings 1. Political support and commitment for each case reviewed. 2. Governance

The review was not carried out in the 3. Stakeholder engagement context of a scientific forum or evaluation 4. Organisational change of the success factors. The bottom-up 5. Leadership

• 6. 

  Collaboration and trust establish a common understanding and
• 7. 

  Workforce education and training commitment on the future direction of
• 8. 

  Patient focus / empowerment travel [Basque Country].
• 9. 

  Incentives (including contracting

and reimbursement) Political commitment and support is

• 10. 

  ICT infrastructure and solutions required, and can be observed, at all
• 11. 

  Monitoring / evaluation system levels. At national level, policy support can

be a determinant for fostering initial

Annex 2 provides a summarised investments to facilitate system illustration of these principles/success integration [Kinzigtal] or to provide central factors and the experiences (cases) where funding in the realm of a systemic shift they are observed. It is evident from from hospital-based treatment to a Annex 2 that each identified preventive care for long-term conditions principle/success factor is common to [Scotland]. Such a shift can only be several integrated care experiences, which triggered by national political engagement

verifies the validity of the identification. and willingness to change, especially in centralist states [Région Ile-de-France]

Analysis of factors enabling while political support at the regional and

successful integration of care and local levels plays a more important role for federal states or states with strong

readiness for integration regional powers [Brescia, Catalonia,

Turning now to the identified Emilia-Romagna, Southern Denmark]. principles/success factors from the review, However, system-wide transformative each is discussed in greater detail below, change can only happen when many with case study examples provided in policy levers are aligned and activated square brackets for illustrative purposes. towards shared goals.

Political support and commitment Political commitment often results into

If the existing systems of care need to be the adoption of innovative legislation and re-designed to provide a more integrated legal frameworks to support set of services this will require change implementation of integrated care across many levels, including the creation services and to promote cross-sectoral of new roles, processes and working strategic planning [Scotland, Southern practices. This is a disruptive process - so Denmark, Italy]. In general, it has been creating a compelling vision and strategy observed that overall political mobilisation for integrated care with clearly defined elevates the issue of integrated care and objectives [as in the Basque Country, associated forms of cooperation and Scotland] that is embedded in national / agreements among all parties. regional policy constitutes significant Involvement of all stakeholders in the determinants of the success of integrated development, implementation and service delivery models. In addition, the dissemination of the new models and policy needs to be built on the outcomes ways of working, and formalisation of of stakeholder engagement and public agreements between parties proves to be consultations [Northern Ireland] to a successful factor in integration of

services [Walcheren]. This involves, for responsibility for concluding contracts example, collaborations between home with a range of care providers [Kinzigtal]. care, primary care and acute (hospital) care [Skåne], introduction of Next to such management structures, telemonitoring services following topworking partnerships among care actors down political decisions [Northern Ireland, and providers need to be established, with

Olomouc], agreements to ensure a shared responsibility for planning and continuity of care [Southern Denmark] or delivering care [Scotland]. At local level, agreements on the implementation of the care delivery organisations can benefit tools to support integrated care delivery from having lean/flat structures: these such as risk stratification tools [Scotland]. promote trust among managers and care

Governance staff and also help to save on overheads, which can enable re-investment of savings

One of the first steps to consider when into innovation and care improvements configuring an approach to integrated [Buurtzorg].

care is to establish strong governance

mechanisms at both national and local Having a supportive legal framework in level [Scotland] and among the private place, which promotes cross-sectorial service providers and the care strategic planning to meet the needs of authorities/actors involved [Kinzigtal]. This the population [Scotland] and the can take the form of "joint governance" formulation of agreements that through an Integrated Management Board strengthen cooperation among made up of representatives of all administrations and care providers alike providers [North West London, [Olomouc, Southern Denmark] can Walcheren, Olomouc]. Such a Board can ultimately ensure continuity of care. have responsibility for defining agreed Within the overall governance scheme, goals and outcomes, a shared achieving the right balance between top performance and evaluation framework down and bottom up levers and [North West London], as well as configuring the right incentives is an procedures and standards [Southern important ingredient for success [Basque Denmark, Scotland]. Country].

Joint governance can be operationalised Stakeholder engagement via a single management structure, which Integrated care includes many levels of integrates health and social care integration, such as integration between organisations and becomes responsible primary and secondary care, of all for commissioning and providing health stakeholders involved in the care process, and social care services [Torbay]. Another or across many organisations. It may be way of achieving this is through the developed simply for healthcare needs establishment of a new organisation (i.e., vertical integration) or it may include whose role is to manage the redesign of social workers, the voluntary sector and care to facilitate system integration. This informal care (i.e., horizontal integration). organisation has accountability for The broader the ambition is, the more managing the healthcare budget and numerous and diverse are the

stakeholders that should be engaged and services. Improved cooperation communicated with. [Norrbotten] and active engagement of

stakeholders is facilitated by the creation

Similarly to political commitment and of networks to promote and support support, stakeholder engagement needs knowledge transfer, dissemination of to happen at all levels and across all findings, reflections and feedback on the relevant sectors [Emilia-Romagna, implementation of integrated care

Valencia]. Strong clinician collaboration services [Emilia-Romagna, Saxony, [Catalonia, Northern Ireland], engagement Scotland]. of policy actors [Kinzigtal], participation of municipalities [Saxony], voluntary and Organisational change statutory organisations [Northern Ireland,

Emilia-Romagna], involvement and The provision of integrated care and reflection on the opinions of patients and service redesign implies changes in the citizens and commitment and cohealthcare structures, organisation of operation between health and social care workflows, workforce development and professionals [Badalona, Getafe, Puglia] resources allocation to provide more are essential for the implementation of responsive care delivery. There are a integrated care solutions. Effective number of ways in which the regions can communication strategies are required to support the expansion of integrated establish trust, confidence and good health and social care programmes and recollaboration and involvement of all organise their systems, services and care stakeholders. It is also necessary to processes. This reorganisation often overcome any communication barriers requires horizontal integration and and increase awareness among participant collaboration among General Practitioners

organisations [Kinzigtal]. (GPs) and other health and social care providers [Kinzigtal, Puglia]. Examples

All stakeholders need to be equally and include the establishment of integrated regularly engaged in policy formulation, primary care centres [Valencia] to enlarge budget spending [Torbay] design and the scope of healthcare centres; the development of solutions specifications introduction of social services [Olomouc] [Pardubice, Scotland]. This has often been or full integration of health and social care referred to as “stakeholder services [Badalona, Northern Ireland,

empowerment”. Scotland] to ensure continuity of care; and shared responsibilities [Jönköping]. An

Engagement of stakeholders in the emphasis on the patient and the need to implementation phase of projects is also re-orientate the focus of care from the critical for a successful operationalisation hospital to the patient is another critical of integrated care services and acceptance element of service redesign [Norrbotten, of organisational changes in care delivery Scotland, Skåne, Southern Denmark].

and managerial processes [Southern

Denmark]. Early involvement is a critical Other examples include building success factor in speeding up the design partnerships and cross-sectoral

and implementation of integrated care cooperation of health and social care providers to establish standards

assessments, technical and clinical examples include the establishment of protocols [North West London, Olomouc, dedicated project teams or Steering

Puglia, Scotland, Walcheren] and to Groups with dedicated local introduce integrated care pathways to implementation officers to implement the streamline the management of health change [Northern Ireland, Scotland]. This problems across prevention, acute care, has the dual purpose of maintaining rehabilitation, chronic and palliative care momentum during a period of change and and to ensure a continuum of care conflicting priorities and of providing local [Languedoc-Roussillon, Norrbotten, Puglia, and regional dedicated support, including Saxony, Trikala, Valencia]. technical support, for strategic planning

and service redesign [Northern Ireland,

The redesign of professional roles and the Scotland]. provision of new or extended roles for health and social care professionals are In general, change management is other examples of enablers of the addressed through agreeing strategic and implementation of integrated care operational objectives along with [Olomouc, Puglia]. These comprise the responsibilities; developing and inclusion of social workers in healthcare implementing an agreed operational plan; settings to promote integration between and communication strategy [Norrbotten, care levels and areas [Basque Country, Northern Ireland, Scotland].

Torbay]; introduction of new roles such as case managers [Badalona]; management Leadership and continuity nurses who apply case

management methodologies [Valencia]; or Effective national leadership and the health and social care coordinators / emergence of local leaders / champions managers [Torbay]. Other examples have proven to be important factors in include the establishment of integrated, managing the complex process of co-located health and social care teams, transformation and implementation of with a strong emphasis on multiintegrated care solutions [Jönköping, professional leadership and development Olomouc, Scotland, Walcheren]. The

[Torbay]. existence of “digital champions” is a critical enabler in implementing digital

The regions have adopted various health and care services at scale approaches to help to identify and correct [Scotland]. Other examples include the deficiencies related to the implementation establishment of improvement leaders of organisational changes. For example, and leadership fora for discussions and the use of business process notation decision-making across organisations models, flexible implementation and [Skåne]. This often requires a significant incremental pace to accommodate the investment in senior management learning processes of both health and care leadership, local leadership programmes professionals and patients appear to be and dedicated programme support [North effective strategies to deal with the West London, Torbay].

complexity of organisational changes

[Catalonia, Northern Ireland]. Other Organisational stability and continuity of leadership is another critical enabler of

integrated care, including scientific, managerial and clinical leadership Collaboration and trust among [Catalonia, Getafe, Torbay]. Strong clinical stakeholders have also been built through leadership, in particular that of GPs, plays participation in European, national and a central part in ensuring the effective regional projects that have the objective participation and engagement of other of facilitating knowledge transfer, learning clinicians [North West London]. Having and generating further evidence on engaged healthcare professionals and integrated care [Catalonia, Languedoclocal champions enables them to work Roussillon, Olomouc, Puglia, Scotland]. together to achieve positive outcomes and

facilitates a snowball effect for the large Workforce education and training

scale deployment of integrated care

solutions [Catalonia, North West London]. As the systems of care are transformed, many new roles need to be created and

Collaboration and trust new skills developed. As demands continue to change, skills, talent and

The broad set of changes needed to experience must be retained and the deliver integrated care at a regional or systems of care need to become ‘learning national level presents a significant systems’ that are constantly striving to challenge. This requires re-organisation of improve productivity and increase services [Badalona] and care processes; success. alignment of purpose across diverse organisations and professions; and the As such, the implementation of integrated willingness to collaborate and put the care solutions often requires the redesign interest of the overall care system above of health and social care professionals’ individual incentives [Emilia-Romagna, roles [Catalonia] and / or the creation of Kinzigtal, Norrbotten, Southern Denmark, new professional roles to ensure

Valencia]. The introduction of very flat continuity of care – e.g., the introduction structures, with less hierarchy, has also of roles such as telemedicine physician, proved to be an interesting approach to management nurses, nurse coaches and building an ecosystem of trust and continuity nurses [Olomouc, Puglia, collaboration among the stakeholders Valencia]. This is often supported by involved [Buurtzorg, Jönköping]. dedicated education and training

programmes on extended roles [Brescia,

The establishment of networks for Buurtzorg, Piemonte, Puglia]. The healthcare providers and other agencies incorporation of the training modules as and authorities has proven to be an part of the solution is another example of effective tool for active cooperation, workforce education and training [Puglia]. networking and building trust among the In addition, commitment to adaptive, stakeholders [Piemonte, Saxony]. continuous learning and long term Healthcare providers are also involved in education plans has proven to be the design and specification of the service successful in empowering the workforce procured and in the selection of the [Brescia, North West London, Norrbotten]. contractors to deliver this service

[Northern Ireland].

The establishment of learning networks to West London, Norrbotten, Olomouc, support sharing of good practices and Scotland]; and in engagement and knowledge appears to be another recruitment processes [Puglia]. Other common success factor [Norrbotten, examples include the involvement of Saxony, Scotland]. There are various patients in providing feedback on some resources freely available to support service specifications and on the workforce development, such as webcasts development of products [Northern with re-useable content for Ireland]. undergraduate teaching sessions

[Scotland]; conferences; dedicated Another critical element of patient newsletters; development of manuals; empowerment is the development and and personal discussions with interested implementation of training strategies parties [Saxony]. Other resources to drive [Northern Ireland]; the provision of change include the establishment of multieducation and training programmes and stakeholder education and training tools for patients to increase health steering groups for staff working in health, literacy and patients’ ability to participate social care and housing services in the collaborative decision-making

[Scotland]. The rationale is to promote processes [Northern Ireland, Norrbotten, cross-sectoral collaboration and develop a Puglia, Scotland]. The format of education Skills Framework, particularly for the and training modules has changed over healthcare professionals involved in the the years, with a current focus on delivery of digital services [Scotland]. educational games, social media,

networks and other platforms and training

Patient focus / empowerment facilities [Puglia].

Patient empowerment has to be at the

core of integrated care. This implies that Equally, patients are empowered through the patient is a member of the “care access to their healthcare data and team”; that he / she is involved in the information about health care services decision-making processes; and care plans [Puglia, Olomouc, Scotland]. Data privacy are tailored to patients’ individual needs. is a critical incentive to use these services It has been argued that the barriers to [Puglia].

patient empowerment are mainly located

at the cultural level affecting both patients Another aspect of patient empowerment

and health and social care professionals. lies in the recognition that not all services are appropriate for all patients.

Patient empowerment occurs at the Stratification of patients and identification different levels within health and care of the “right” patient is a critical element systems. There are examples of to successful patient empowerment involvement of patients at the policy level [Basque Country, Norrbotten, Olomouc, at the heart of strategic planning for Scotland].

integrated care and the vision for

improvement [Scotland, Torbay]; at an In general, truly empowered patients operational level through co-creation of prove to be the drivers of change and they

care plans and service solutions [North help to focus on the quality of provided renumeration [TK in Germany]. Another services [Valencia]. example [Valencia] shows financial

bonuses resulting in up to 40% higher

Incentives (including contracting and earnings for high performance and for the

reimbursement) compliance of healthcare professionals. In

Changing systems of care to facilitate the some cases, the incentives target private delivery of integrated care services entities to treat patients in the most requires initial investment and funding; appropriate and cost-effective setting, i.e. a degree of operational funding during which means limiting the demand on the transition to the new models of care hospital services through preventative and as well as on-going financial support and community care services [Valencia].

incentives until the new services are fully

operational and the older ones are de Another form of incentive is the long-term commissioned. This means wellcontract (10 years or more) that allows for established incentives, financing and initial investment until earnings are reimbursement schemes to allow sufficient to secure return on investment alignment of the financial interests of [Kinzigtal, Valencia]. The evidence also payers and providers in the system shows that sustainability of service

[Kinzigtal]. provision in the long-term is incentivised via investment to attract young doctors to

Several models can be observed across specific regions by offering them training

European regions. The shared-revenue positions required for their medical model promotes additional incentives for qualifications [Kinzigtal].

healthcare professionals. For example, in

the case of Kinzigtal, the regional health A bundled payment scheme where risk is management company is co-owned by the shared between payers, healthcare physicians’ network in the region; a part of providers and ICT suppliers seems to be an the generated margins / profits is readequate model to release efficiencies at invested in training of local physicians and health system level and to facilitate another part is available to physicians as investment in ICT innovation without increased income. The shared-revenue increasing total healthcare costs models leverage health improvements by [Catalonia]. Other examples include a incentivising prevention activity and shared risk model (Public-Private

efficiency savings in processes [Kinzigtal]. Partnership, PPP) established between the healthcare providers and IT providers

Another form of incentive is the [Catalonia]; a contractual model (PPP with performance-based financial bonus. For capitation) where a private entity receives instance, doctors are paid if patients are a fixed annual sum per local inhabitant fit for work after 4 weeks on a programme (capitation) from the regional government and remain that way for another 6 months [Valencia]; and pooled budgets for without any interruptions. In contrast, if integrated commissioning with a shared the patient is still not fit for work after 8 risk approach and capitation payment to weeks on the programme, the doctors are cover all patient care [North West London, financially penalised – e.g., by 7% of their Torbay].

unexpected complexity of ICT solutions

The end-to-end Managed Service model is and infrastructure [North West London]. a useful model for developing services Another critical factor is connectivity and that require innovation and flexibility. This broadband availability [Trikala]. means that the contract is for the provision of a service, including clinical The existence of common ICT triage, and not simply for the purchase of infrastructure [Brescia, Kinzigtal, patient equipment and software. It Norrbotten, North West London, Southern provides the capacity and capability to Denmark, Valencia] facilitates the flexibly manage and grow the service over transferability and deployment of ICT time [Northern Ireland]. solutions. The simplification of ICT

infrastructure enables easier use of

Another example is the reward funding interoperability standards to support model where those performing well are integration of services and information given extra funding whereas those who flows across the continuum of care have not achieved the required targets are [Badalona, Campania Catalonia, Emiliaprovided with additional intensive support Romagna, Southern Denmark, Trikala, to meet them [Scotland]. Valencia]. The definition of both clinical In some regions, the introduction of and technical standards is an important business cases is emerging [Northern enabler of information sharing [Catalonia].

Ireland], particularly in the case of the Another enabler includes analytics and delivery of remote tele-monitoring algorithms to allow exchange of services. structured and unstructured data

between healthcare providers and

ICT infrastructure and solutions suppliers or to provide feedback on

Integrated care requires, as a foundational patients’ behaviour [Catalonia, Olomouc, capacity, the sharing of health information Puglia]. The introduction of an open ICT and care plans across diverse care teams platform to support organisational and sectors to enable continuous interoperability and collaborative work, collaboration, measuring and managing with no need to replace the pre-existing outcomes, and enabling citizens to take a proprietaries, has proven to be an more active role in their care. This means important element to overcome building on existing eHealth services; resistance to ICT solutions [Badalona, connecting them in new ways to support Catalonia, Emilia-Romagna, Puglia]. integration; and augmenting them with Scalable and robust ICT systems with rich new capabilities, such as enhanced user interfaces allow the gradual security and mobility. This process is implementation of additional ICT equally supported by the introduction of components with minimum disruption information governance and privacy and [Campania, Catalonia]. security policies [Puglia, Scotland]. The Various tools to manage the health timeline of implementation of health information of enrolled patients have information systems needs to be carefully been introduced in Europe. This includes planned. There is a need to incorporate the introduction of Unique Patient considerable leeway for refinement and Identifiers and / or centralised shared

electronic health records to support quality of care, cost of care, access and cooperation between GP practices and citizen experience. This supports the other care actors across the different concept of evidence-based investment, health and social care settings [Badalona, where the impact of each change is Kinzigtal, Olomouc, Scotland, Southern monitored and evaluated.

Denmark, Valencia]. Confidentiality and security measures applied to patient The experience to date shows the records, registries and other online establishment of monitoring and services and devices for use by patients performance evaluation systems to have proven to be a critical factor in provide evidence of impact in a number of enabling information-sharing and European regions [Kinzigtal, Scotland, continuous collaboration. Skåne, Torbay, Valencia]. Continuous

evaluation of the progress of the The evidence also shows that the use of strategies for integrated care is critical to

ICT solutions is more effective if it is the scaling up process as it provides the introduced as part of the service redesign results and lessons learned during the [Scotland, Olomouc]. The use of ICT implementation process [Basque Country]. solutions in routine practice has facilitated In addition, a strong performance the work of healthcare professionals, management culture within the National improved the management of workflows Health Service (NHS) can be observed [Olomouc] and empowered citizens [Scotland].

[Getafe]. The reliability of ICT solutions is a prerequisite for confidence and trust in Benchmarking exercises are other using ICT by patients and health care examples of monitoring systems, often professionals [Norrbotten, Olomouc, facilitating the allocation of performance

Puglia]. based financial bonuses [Skåne] and providing cost analytics and what-if

A further enabler of implementation of ICT capabilities [Valencia]. The evaluation of solutions to support the integration of the performance of GP surgeries and health and social care services concerns other multi-disciplinary groups drives procurement frameworks that address the competition and encourages sharing of issue of variances in procurement best practices [North West London]. processes from area to area [Scotland].

The introduction of modular systems ensures vendor independence so that

different vendors can provide specific The Maturity Model

functionalities [Badalona].

It is noteworthy that the findings of the

Monitoring / evaluation systems review of integrated care cases in Europe bear a strong resemblance to the

As new care pathways and services are dimensions of the Maturity Model introduced to support integrated care, developed by the B3 Action Group on there is a clear need to ensure that the Integrated Care of the EIP on AHA. The changes are having the desired effect on Maturity Model was developed on the

basis of interviews with 12 European integrated care in order to guide the regions with a rationale to capture the regions on how to improve rather than local learning and experience when rank their performance in this area. The implementing integrated care. The Model provides useful insights on where

Maturity Model intends to assess the the European regions currently stand in system’s capacity to adopt integrated care terms of weakness and strengths and thus approaches. It covers a broad range of provide an opportunity to share good areas, which relate to system levers and practices in integrated care and promote essential blocks in terms of readiness and learning from each other. maturity to implement integrated care.

The many activities that need to be

The Maturity Model functions as a selfmanaged in order to deliver integrated assessment tool that: (a) provides an care have been grouped into 12 indication of the readiness of care “dimensions”, each of which addresses a authorities to adopt integrated care and part of the overall effort (Figure 2). Annex

(b) supports them to improve their 3 provides a more detailed description of capacity to deploy integrated care the Maturity Model and Table A3 services. As such, the Maturity Model is summarises these 12 maturity dimensions not an objective measurement with an and their corresponding maturity intention to compare the regions in terms indicators. The Annex also contains of their performance in integrated care. It guidance on how to apply it in order to serves as a tool to facilitate very complex assess maturity. multi-stakeholder discussions on

Fig. 2: Maturity Model for Integrated Care

Chapter 4: Measuring the performance of integrated

care

Introduction care systems, approaches and frameworks

to assess integrated care can further be

Integrated care tends to raise high seen to lie on a continuum that stretches expectations for enhanced effectiveness from selected indicators that may form and efficiency, and the sustainability of part of a wider system performance broader service delivery. There is an assessment framework 4-7 to an integrated expectation for integrated care to support health system measurement approach. 2, 3 the achievement of the so-called ‘Triple Against this background there is a need to

Aim’ approach – a simultaneous focus on better understand the range of improving health outcomes, enhancing approaches and indicators that have been the patient care experience and reducing developed so far and how measurement

costs. 1 of integrated care performance sits within

a broader HSPA framework in a given

In order to assess the extent to which the context. This will also help to inform policy transformation to more integrated care development that is suited to individual systems meets these overarching goals, it countries’ needs and resources.

will be necessary to collect evidence

involving ongoing monitoring of progress This section of the report aims to to identify potential problems, support contribute to filling this gap by:

the further development of approaches

and inform decision making within a 1. providing an overview of trends in framework that includes specific and and indicators used for assessing the

measurable objectives. 2 performance of integrated care. This draws on a rapid review of published

Measurement of progress will have to documents; it includes a brief reflect the complexity of integrated care discussion of some of the systems. Existing approaches to, and requirements for indicator selection frameworks for, assessment have sought for assessing the performance of to capture these through considering the integrated care and a summary different tiers of service delivery at the overview of examples of existing micro (patient care), meso (organisational indicator sets and frameworks that context) and macro-level (financing and are being developed or policy context) 2 ; distinguishing structure, implemented in various countries or process and outcome dimensions 3 ; settings. focusing on different perspectives such as 2. discussing the potential use and patient/family, health care professional(s), usefulness of existing frameworks and system representative(s) 4 ; or a and indicators in countries’ efforts

combination of these. 5 to move to more integrated health services and systems, and the role of

As different countries are at different evaluating achievements in the stages in the development of integrated context of broader, system-level

performance assessment strategies previous report, the policy focus group

and frameworks. This second explicitly did not seek to benchmark

component builds, mainly, on countries’ experiences, or to evaluate

insights from experts from 17 whether a given country is performing

European countries that took part in better on integrated care than another

a structured policy focus group of one. Instead, it provided a forum for

the Expert Group (Box 2). exchange of experiences of, and views

on, assessing integrated care

The policy focus group approach builds performance and how this sits within

on a similar exercise undertaken as part wider efforts to measure health system

of the work by the Expert Group on performance, and the lessons that

quality of care (2016). 8 The main might be learned from the insights

objective of the focus group was to gathered, both in terms of informing generate in-depth discussion and policy development in the countries provide suggestions and concerned as well as cross-national recommendations for a framework for policy learning by means of exchanging performance assessment of integrated examples of good practices. care. However, and in line with the

Box 2: Policy focus group – Integrated Care

The policy focus group brought together experts with in-depth knowledge on their respective HSPA processes from 17 countries in Europe. By means of a semi-structured facilitated discussion coordinated by the European Observatory on Health Systems and Policies, experts reflected on frameworks and indicators for performance assessment of integrated care.

Focus groups are frequently used in qualitative research to explore topics that are not easy to observe or that are sensitive, to ascertain perspectives and experiences from people on a topic in a short time span, or to gather preliminary data and clarify findings from another method, among

other uses. 9

The main objective of the focus group was to generate in-depth discussion and provide suggestions and recommendations for a framework for performance assessment of integrated care. Taking existing frameworks for performance assessment of integrated care as a starting point, focus group discussions explored a set of questions around:

• - 

  Domains for measuring integrated care

• - 

  The degree to which existing domain indicators reflect integrated care as it is considered in participants’ individual country context

• - 

  The potential to distinguish between core indictors (which should be measured by all countries) and supplementary indicators (which countries may wish to monitor) in each domain

• - 

  Data availability and options for new data collection

• - 

  The role of international organisations in facilitating countries’ efforts to develop assessment frameworks and indicators and collect relevant data

Focus group participants were provided with background documentation prepared by the European

Observatory, which summarised documented trends in performance assessment of integrated care and provided examples of existing indicator sets and frameworks that are being developed or implemented in various countries or settings. This material was shared with participants in advance to the meeting of the policy focus group, held on 22 September 2016 in Brussels. Subsequent to the meeting, focus group participants were given the opportunity to consult with other experts in their countries and to provide additional comments and insights and, where appropriate and relevant, documented empirical evidence subsequent to the policy focus group meeting. Additional comments and suggestions received were incorporated into the present report to ensure that it appropriately reflects country’s experiences.

Choosing indicators to assess the care delivery and quality. 12 Therefore, if

performance of integrated care measurement is to guide further improvement, indicators should meet

Identifying indicators suitable for

assessing the performance of integrated certain criteria to allow for appropriate conclusions about cause and effect to be

care systems faces the same challenges

that have been described for choosing drawn or cause of action to be taken (Box measures capturing the quality of care 3). Or, to put it more simply, the identified more broadly. 10, 11 Fundamental to indicators need to show that taking a measurement is the notion that an particular action leads to some desired observed change in a given indicator outcome, such as lower morbidity or reflects something about the underlying mortality.

13

Box 3: Desirable attributes of quality indicators

Analysts have presented lists of desirable attributes of quality indicators, with validity (the extent to

which the measure captures the concept it is meant to measure), reliability (the extent to which

measurement with the given indicator is reproducible) and sensitivity to change considered among

the key criteria. 12 Depending on the context and purpose of measurement, the range of indicator

attributes may be broadened, however. For example Pringle et al. (2002) proposed a list of 12

attributes to guide indicator selection, arguing that, in addition to being valid and reliable, should

also be communicable, effective, objective, available, contextual, attributable, interpretable,

comparable, remediable and repeatable 12 , with others adding adaptability 14 , feasibility 15 , acceptability 16 , policy relevance 15 and actionability 17 as further criteria for quality indicators. 12

have to rely on existing data sets to enable

The applicability and relevance of comparison. Thus, feasibility and selection criteria will vary with the comparability form important criteria for purpose and context of measurement. For indicator selection, such as within the example, international quality OECD Health Care Quality Indicators

Table 1: Selection criteria for quality indicators within the OECD Health Care Quality

Indicators Project

Criterion Definition

Validity Sufficient scientific evidence exists to support a link between the value of an indicator and one or more aspects of health care quality

Reliability Repeated measurements of a stable phenomenon get similar results

Relevance An indicator measures an aspect of quality with high clinical importance, a high burden of disease or high health care use

Actionability An indicator measures an aspect of quality that is subject to control by providers and/or the health care system and is actually used at a national level for policy making, monitoring or strategy development

International feasibility An indicator can be derived for international comparisons without substantial additional resources

International Reporting countries comply with the relevant data definition and where comparability differences in the indicator values between countries reflect issues in

quality of care rather than differences in data collection methodologies, coding or other non-quality of care reasons

Source: Carinci et al. (2015) 18

In the context of identifying a set of for action and avoidance of perverse

indicators for measuring the quality of incentives. 5 Indicator selection was further

integrated care in the UK, Raleigh et al. informed by a broader set of

(2014) drew on criteria proposed by the considerations, ranging from the

UK Association of Public Health population being targeted by integrated

Observatories 19 , namely, importance and care efforts to the feasibility of data

relevance, validity, accuracy, reliability, collection (Box 4). feasibility, meaningfulness, implications

Box 4: Considerations for selecting indicators for measuring the quality of integrated care

Raleigh et al. (2014) describe a broad set of considerations that may guide the selection of indicators

for measuring the quality of integrated care. These are 5 :

• Size of the population covered

• Represents important aspects of the care system

• Is (wholly or partly) within the control of care services (i.e. attributability)

• Change is detectable within suitable time frames

• Unambiguous interpretation

• Likelihood of being meaningful to service users, carers and the public

• Likelihood of being meaningful to care professionals, managers and commissioners (i.e. purchasers of services)

• Reflective of the service user perspective and/or value for money perspective

• Timeliness

• Ability to assess the impact on inequalities between service user groups and areas as it relates to access to and outcomes of care

• Measurable from routinely collected data

and professionals and does it incite Clearly, the applicability of different perverse incentives? considerations will vary by country and • simplicity and ease of system context. However, reflecting on measurement: what data is already

the evidence for integrated care 20 and being collected and what are the

following Goodwin (2015), a small number options for novel and innovative of core requirements that a framework or ways to collect data that will align indicator set for assessing integrated care with data collection systems performance will need to meet can be already in place? identified. 21 Thus, in order to select

relevant measures through which to

evaluate the performance and progress of Indicator sets for assessing the

integrated care systems there needs to be performance of integrated care: a a good understanding of: summary overview of existing

• the core aims of integrated care: frameworks and indicators

who is involved and what does the A survey on the use of integrated care in approach or system seek to EU countries carried out by the sub-group influence on Integrated Care in the summer of 2016

• the desired outcomes: what highlighted that only a small number of EU outcomes should result from Member States have so far developed integrated care and to what extent indicator sets dedicated to the assessment are the measures aligned with the of integrated care.

range of desired outcomes

• the timeframe over which such Of the countries responding to the survey, outcomes can reasonably be two (United Kingdom) has developed a expected to be achieved: to what small set of national metrics for measuring extent have available progress in health and social care measurement categories the integration efforts locally. Italy has potential to be improved? developed a specific set of indicators to

• how impact can be measured: to explicitly measure aspects of integrated what extent can an observed care, but these are currently not change in a given outcome measured at the national level. Three measure be attributed to countries (Austria, Belgium, Spain, integrated care activities and Sweden) pointed to the existence of strategies? indicator sets that were not specifically

• the robustness of measures: to developed for assessing the performance what extent can a given measure of integrated care as such but may be inform action for further used for this purpose, at least in part improvement by decision-makers ( Table 2). In the Netherlands, experiences

with assessing integrated care are gathered in relation to selected however, may not yet have been made dimensions within regional-level pioneer publicly available. sites and in Spain, data are being collected within the National Health Barometer

(Barómetro Sanitario) that can be used for the assessment of aspects of integrated and coordinated care. Finally, in Estonia, a

2015 assessment of the state of health system integration identified a set of eight indicators that sought to measure the extent to which care is delivered in the appropriate care setting and of coordination and continuity of care across care settings for a set of acute and chronic

conditions, where applicable. 22

These observations for EU Member States reflect international experiences more broadly, with only a small number of countries and organisations having published a set of quality indicators through which to monitor performance as a means to support the move towards

more integrated health systems. 23 These

include, in addition to the UK, New

Zealand and the US, along with the WHO global strategy on people-centred and integrated health services (2015), which suggested a monitoring framework that builds, in part, on these national proposals

and initiatives. 2

Table 3 provides a summary overview of selected features of existing indicator sets and frameworks for assessing the performance of integrated care. It is important to highlight that examples presented in Table 3 capture documented frameworks and indicator sets only. As countries’ attempts to move to more integrated care systems are evolving, so are their efforts to develop systems for performance measurement, which

Table 2: Indicators used for assessing performance of integrated care in selected EU Member States

Country Comment Dimension/s Indicators

Austria Austria has not developed an explicit framework for assessing the coordination and integration of care. A specific outcomes framework has been devised in relation the 2013 health reform; the framework includes indicators that could be linked to various aspects of integrated care

Belgium A systematic approach is being Continuity of care 1. Informational continuity in general practice: Coverage of global developed as part of the integrated medical record (% of population with at least one contact with care pilot programme. their GP within three years)

• 2. 

  Usual Provider Continuity index ≥ 0.75

At present the only experience with 3. Management continuity between hospital and GP: GP encounter assessing integrated care is related to within 7 days after hospital discharge (% patients 65+) selected dimensions within the 4. Coordination in ambulatory care: Proportion of adult diabetics national HSPA process: continuity, (under insulin) with a convention/passport/care trajectory (% of effectiveness and patient centeredness patients)

• 5. 

  Coordination in hospital care: Patients with cancer discussed at the multidisciplinary team meeting (%)

Patient centredness 1. Doctor spending enough time with patients during the consultation (% of respondents, contact with GP/SP)

• 2. 

  Doctor providing easy-to-understand explanation (% of respondents, contact with GP/SP)

• 3. 

  Doctor giving opportunity to ask questions or raise concerns (% of respondents, contact with GP/SP)

• 5. 

  Doctor involving patients in decisions about care and/or treatments (% of respondents, contact with GP/SP)

Effectiveness 1. Asthma hospital admissions in adults (/100 000 population)

• 2. 

  Complication of diabetes hospital admissions in adults (/100 000 population)

Estonia Indicators identified as part of the 2015 Extent to which care is • Avoidable hospital admissions study that sought to assess the state of delivered in the • Extended hospital stays

health system integration 22 appropriate care setting

ANNEX DGB 2C EN

Country Comment Dimension/s Indicators

• Avoidable specialist visits

Extent of adequate • Under-provision of preventive services coordination and • Adequate provider continuity in primary care continuity across care • Incomplete discharges from acute inpatient care settings • Inadequate acute inpatient follow-up care

• Unnecessary preoperative diagnostic procedures

Italy A number of indicators that form part Effectiveness and Indicators that are already in use as proxies for integrated care

of wider performance assessment continuity of care • Avoidable hospitalisation for asthma, COPD, diabetes efforts are being used as proxies for • One-year mortality and MACCE after IMA discharge

integrated care. A specific set of indicators to explicitly measure aspects

of integrated care has been developed Indicators that have been developed but are not as yet measured at national level

• Adherence to evidence-based treatment • Follow-up for diabetes, COPD, heart failure, colon and breast cancer •

The Netherlands At present the only experience with • Diabetes care: A combination of process and outcome indicators,

assessing integrated care is related to Not yet specified e.g. HbA1c levels, BMI, blood pressure, foot examinations,

selected dimensions within regionalkidney function testing, cholesterol testing, etc. level pioneer sites Population management pioneer sites: A national for the assessment of • Population health (e.g. health outcomes, disease burden, integrated care has not yet been functioning, quality of life, etc.) developed • Quality of care (e.g. patient safety, effectivity, responsiveness, etc.) • Cost per capita (e.g. cost of care, volumes, productivity losses, etc.) • Implementation process

Spain Aspects of integrated care are included Care coordination, • Percentage of patients reporting that their questions about their in selected indicator sets including data patient experience treatment have been answered by the primary care centre

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Country Comment Dimension/s Indicators

collected within the National Health • Percentage of patients reporting that specialist appointments

Barometer (Barómetro Sanitario) were arranged by the primary care centre • Percentage of patients perceiving that their family doctor and the specialist they had to see communicate and coordinate well

• Percentage of patients reporting that they have been given all the information needed when having to visit a specialist or being admitted to hospital

Sweden A specific set of indicators to explicitly Integrated care • Percentage of patients that have received help to stop smoking measure aspects of integrated care has (examples of indicators after an AMI

not (yet) been developed. However, a as proxies) • Prescribing and use of inappropriate medications for persons number of indicators that form part of aged 75 and older and living in “elderly homes” compared with wider performance assessment efforts the total group of 75 + persons (reflecting coordination and may be used as proxies for integrated integration of medical expertise within social care for the elderly) care • Coordination in cancer care: Patients with cancer discussed at

the multidisciplinary team meeting (reflecting integration within specialist care among different health care professions)

• Different aspects of avoidable hospitalisations

Patient centredness • Health care providers spending enough time with patients (examples of indicators • Health care provider communicating easy-to-understand derived from patient information questionnaires) • Involvement in decisions about health care interventions

United Kingdom National metrics – currently developing • Non-elective admissions a set of standards • Delayed transfers of care • Admissions to care homes

Source: Country responses to the EC Expert Group on HSPA survey on integrated care (2016)

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Table 3: Documented frameworks and indicator sets for assessing the performance of integrated care

Country/ Context Objective Domains Indicator selection: Indicators organisation/ considerations and author criteria

ITALY

Ministry of National Plan for To implement The Ministry of health The National Outcome 1. Process indicators:

Health/National Chronic and evaluate in agreement with all program already includes adherence to clinical guidelines,

Agency for Diseases(2016)/Nation effectiveness of the regions has indicators to evaluate timeliness of interventions;

Regional al Outcome Evaluation an integrated approved in integrated care indirectly.

Services Programme (ref 30a e care plan for September 2016 a Indicator selection was 2. Outcome indicators:

30b: chronic diseases national plan to framed according to: mortality, avoidable http://www.regioni.it/ address chronic homogeneous data quality hospitalisation, disease sanita/2016/09/27/co diseases, proposing: across Regions, complications: nferenza-stato-regioni 1. a new cultural interconnecting capacity of del-15-09-2016- approach at health databases, scientific • Avoidable hospitalisation for accordo-tra-il-governosystem, service, evidence, implementation ambulatory care sensitive le-regioni-e-leprofessional, and within regional or local conditions (ACSC)

province-autonomepatient level evaluation systems. • 1 year mortality and MACCE sul-documento-piano 2. an integrated Clinical and organizational after admission for Acute nazionale-dellamodel between appropriateness were Myocardial Infarction

cronicita-478007/; hospital and considered. • Medium term complications http://95.110.213.190/ community (mortality, revascularisation PNEedizione16_p/inde 3. support for home Specific indicators to and amputation) after x.php; ) care evaluate integrated care admission for severe 4. patient-centred have also been developed artheropathy approach but not yet calculated, • Long term complication for 5. multidimensional identifying a model of diabetes

and outcome integrated care and results

evaluation of implementation to be 3. Indicators of interaction measured through HSPA process/outcome.

indicators specifically developed.

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New Zealand

Government: Integrated To “support the System-level Principal considerations: The proposed initial system

Ministry of Performance and health system in measures intended to • System-level measures are measures comprise 19 indicators;

Health Incentive Framework addressing “encourage specific and measurable these are not specific to integrated

(IPIF) (2014) 3 equity, safety, integration for service • Contributory measures are care as such

quality, access improvement” (p. 4) a balance of performance

and cost of across organisations indicators and “tin opener”

services” (p. 1) 3 within district health measures (i.e. to inform

systems; system-level discussions without measures are set specific targets or nationally and are thresholds)

aligned with the • There is a balance of input, Triple Aim: output and outcome 1. Improved health measures and equity for all • The collection and populations reporting of measures 2. Best value for should not increase the public health reporting burden on System resources providers

• 3. 

  Improved quality,

safety and Sees the process of indicator experience of care development to be a

continuing one with

Adds selected placeholders for areas for measures of capacity which readily available and capability that indicators do not currently underpin the system exist (e.g. healthy adolescent

and healthy ageing) System-level measures serve as

‘high level organising principle’ for locally determined contributory measures which reflect needs and

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priorities of local communities and health services

United Kingdom

NHS England National programme The pioneer Distinguishes 6 Indicator selection was The proposed indicator set of integrated care and programme aims principal headings: framed by explicit use of a distinguishes a generic indicator list support Pioneers to “[showcase] • Community pragmatic approach that which comprises 35 indicators and Beginning in 2013, the the benefits of wellbeing and reflects the elements of care sub-sets for specific clinical or programme involves a providing population health coordination and integration population groups, including mental

total of 25 integrated person-centred, • Organisational covered by other existing health and learning disabilities (18 pioneer sites that are integrated care” processes and frameworks, while also indicators); cardiovascular disease (5 developing and testing and to “[share] systems taking account of wider indicators) and cancer (1 indicator)

new and different evidence and • Personal outcomes system aspects. ways of bringing practical support • Resource An overview of the 35 indicators is together health and with others use/balance of care included in the generic list is social care services seeking to adapt • Service proxies for presented in document 5 (see across England. and adopt outcomes references) pioneer • User/carer experience in experience

their own health and care economies” (p.

• 7) 

  24

To support this programme, the Department of Health commissioned a scoping review to identify and provide advice on indicators of integrated care for progress monitoring using

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routine data. 5 Department of Better Care Fund (BFC) “[T]o drive the Not reported To measure progress of National metrics 2016-17 26 : Health and A pooled fund for the transformation integration through the BCF, • Non-elective admissions (also Department for NHS and local of local services the BCF Policy Framework referred to as emergency Communities government to ensure that established four national admissions); and Local (responsible for social people receive metrics which local areas are • Delayed transfers of care from

Government care) to commission better and more 26 required to report on. hospital per 100,000 population

(England) jointly health and integrated care • Long-term support needs of older social care services. and support” (p. National metrics based on a people (aged 65 and over) met by

Starting in 2015/16, 5) 25 range of criteria, in admission to residential and

the government particular, “the need for data nursing care homes, per 100,000 committed £3.8 billion to be available with population

to the BFC, which was sufficient regularity and • Proportion of older people (65 and

supplemented by an rigour” (p. 9) 27 over) who were still at home 91

additional £1.5 billion days after discharge from hospital

contribution from local

25 into reablement/rehabilitation

areas. services

The Scottish Health and social care To “ensure that The 2014 legislation Newly established The proposed core suit of integration Government integration as per 2014 those who use has defined nine Integration Authorities must indicators includes a total of 23

Public Bodies (Joint services get the National Health and report annually on how they measures. Of these, 10 are survey Working) (Scotland) right care and Wellbeing Outcomes, are improving the National based and the remaining 13 derive Act support which “provide a Health and Wellbeing from routinely collected The 2014 legislation whatever their strategic framework Outcomes, including on ‘core organisational or system data. put in place a needs, at any for the planning and suite of integration framework for point in their delivery of health and indicators’ An overview of the 23 indicators is integrating health and care journey. social care services” presented in document 7 (see

social care in 7 (p. 1): The indicators have been (or references). Scotland. 28 The Act Integration will will be) developed from requires regional mean a greater 1. People are able to national data and they are health boards, which emphasis on look after and organised into two groups, plan and commission enabling people improve their own according to the principal community health, to stay in their health and data source they derive primary and secondary homes, or wellbeing and live from: care for their another homely in good health for populations, and local setting, where longer. 1. Outcomes indicators based

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authorities, possible, sharing 2. People, including on survey feedback “to responsible for adult their lives with those with emphasise the importance social care and social their family and disabilities or long of a personal outcomes work, to establish friends, doing term conditions or approach and the key role integrated partnership the things that who are frail are of user feedback in arrangements. Coming give life meaning able to live, as far improving quality” into force in April and value.” (p. as reasonably 2. Indicators derived from 2016, 31 local 1) 29 practicable, organisational/ system

partnerships have independently and data primarily collected for been set up across at home or in a other reasons Scotland in which NHS homely setting in and local council care their community. services are jointly 3. People who use responsible for the health and social It is acknowledged that the health and care needs care services have identified indictors need to

of patients. 29 positive be tested in practice in terms

experiences of of usefulness for reporting those services, and progress and identifying have their dignity areas for improvement and respected. so inform planning. There is

• 4. 

  Health and social an expectation that care services are indicators “will develop and centred on helping improve over time, and that to maintain or some of them still require

of life of people who use those services.

• 5. 

  Health and social care services

contribute to reducing health inequalities.

• 6. 

  People who provide unpaid care are

supported to look after their own

5169/17 ADD 1 LA/pm 40

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health and wellbeing, including to reduce any negative impact of their caring role on their own health and wellbeing.

• 7. 

  People using health and social care

services are safe from harm.

• 8. 

  People who work in health and social

care services feel engaged with the work they do and are supported to continuously improve the information, support, care and treatment they provide.

• 9. 

  Resources are used effectively and

efficiently in the provision of health and social care services.

United States

Agency for Increasing efforts by Research project Measures of care Included measures: The 2014 Atlas update lists around

Healthcare organisations and launched by coordination are • focus on the ambulatory 90 existing measures of care

Research and systems across the U.S. AHRQ aiming to organised along two care setting (for example, coordination that are organised

Quality (AHRQ) enhance care “develop an dimensions to transition from inpatient along the two dimensions: coordination to atlas to help facilitate selection of to outpatient care) mechanisms to achieve care strengthen patientevaluators care coordination • reflect structure (e.g. coordination; perspective

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centred, high-quality identify measures by Atlas presence of a patient

care but lack of appropriate users (see also Fig . 6 registry that can identify measures to assess the measures for 4 in Annex 5) : complex patients with extent to which care assessing care 1. Mechanisms to coordination needs), coordination is being coordination achieve care process (e.g. % patients achieved. interventions in coordination: asked to review their research studies Care coordination medications during a Recognised need to and activities primary care visit), and

identify caredemonstration • Establish intermediate outcomes coordination-specific projects, accountability or (e.g. % test results measurement results particularly negotiate communicated to patients to inform better those measures responsibility within a specific understanding of the focusing on care • Communicate timeframe) mechanisms that lead coordination in • Facilitate • have valid measurement

to better outcomes. 4 ambulatory transitions properties according to

care”. (p. 1). 4 • Assess needs and National Quality Forum

goals (NQF) standards • Create a • have been field tested

proactive care • are within the public plan domain

• Monitor, followup and respond to change

• Support selfmanagement goals

• Link to community resources

• Align resources with patient and population

needs Broad approaches • Teamwork

focused on

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coordination • Health care

home • Care

management • Medication

management • Health IT-

enabled coordination

• 2. 

  Measurement perspective:

• Patient/family • Health care professional/s • System representative/s

National Quality Care coordination Multi-phased Starting from evaluating 12 cross

Forum (NFQ) 30 considered to be a Care cutting measures potentially suitable

crucial component to Coordination for assessing coordination, the NQF help health care project launched eventually recommended a total of systems to achieve by NQF in 2011 five measures:

improved patient to “address the • Emergency transfer

outcomes and enhance lack of crosscommunication: % patients the quality and cutting transferred to another health care affordability of care. measures in the facility whose medical record NQF measure documentation indicated that Recognised need to portfolio by required information was “establish a developing a communicated to the receiving meaningful foundation path forward for facility prior to departure or within for future meaningful 30 minutes of transfer development of a set measures of • Median time from emergency of practices with care department arrival to time of demonstrated impact coordination departure from the emergency on patient outcomes” leveraging room for patients admitted to the

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around care health facility from the emergency

coordination (p. 3) 6 information department technology” (p. • Median time from emergency

3). 6 department arrival to time of

departure from the emergency room for patients discharged from the emergency department

• Median time from admit decision time to time of departure from the emergency department for

emergency department patients admitted to inpatient status

• Medication reconciliation: Number

of unintentional medication discrepancies per patient (hospitalised adults); assesses the actual quality of the medication reconciliation process by identifying errors in admission and discharge medication orders due to problems with the medication reconciliation process.

World Health Organization

Global strategy on Global strategy Informed by existing Proposed list of potential The proposed list includes a large people-centred and is considered to frameworks and measures to be used for number on potential measures of integrated health be “a call for a indicator sets, the monitoring progress to people-centred and integrated services fundamental proposed achieving the strategy builds health services examples of which paradigm shift in measurement on indicators that have been are presented in Annex 5. the way health framework developed in different services are distinguishes 6 settings to assess the impact funded, domains: of people-centred and managed and 1. System-level integrated health services. delivered […].to measures of meet the community well It specifically drew on the challenges being being and New Zealand Integrated faced by health population health Performance and Incentive

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systems around 2. Service proxies for Framework 31 , Raleigh et al. the world as improved health 5 (2014) , the AHRQ Care

populations are outcomes Coordination Measures

living longer and 3. Personal health Atlas 4 and the NQF-endorsed

the burden of outcomes for measures for care

costly long-term people and coordination 6 , alongside

chronic communities indicators proposed in

conditions and 4. Resource utilisation specific settings. 32, 33

preventable measures that illnesses that demonstrate the require multiple reorientation of complex activities towards interventions primary and over many years community care continues to 5. Organisational

grow” (p. 7) 2 processes and

characteristics that support evidence that systems to support highquality peoplecentred and integrated health services are in place

• 6. 

  User and carer experiences

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How can existing frameworks and

indicators be used in countries’ As discussions progressed, it became clear

efforts to move to more integrated that these views are not necessarily seen

health services and systems? to be sitting on opposite ends of a given

Insights from the policy focus conceptualisation of integrated care but rather that they provide a useful basis for

group how to approach measurement. Indeed,

as suggested by focus group participants,

Considering the documented frameworks integrated care can be seen as a tool to do and indicator sets presented in the things differently in order to better preceding section and reflecting on their address the challenges that health (and own experiences in health system social care) systems are facing in the light performance assessment more broadly of the changing disease burden and rising and measurement of integrated care demand vis-à-vis financial constraints.

specifically, policy focus group discussions

centred on three interlinked areas: (i) There appeared to be emergent countries’ understanding of integrated consensus that a useful way to think care, (ii) the selection and interpretation about measurement of integrated care of indicators for integrated care performance was that proposed by measurement, and (iii) the purpose of a Donabedian (1988) to evaluate the quality separate measurement framework for of health care, based on structures,

integrated care. processes and outcomes, arguing that a “good structure increases the likelihood of

good process, and good process increases

The interpretation of integrated care is the likelihood of good outcome” (p.

key to determining what will be 1743) 34 and we will explore this approach measured in more detail below.

Thus, mirroring the above discussion of

core requirements that a framework or Selecting and interpreting indicators for indicator set for assessing integrated care integrated care measurement: the same performance will need to meet 21 , a but different?

fundamental point raised by focus group

participants was the recognition that the As noted, prior to the policy focus group understanding and conceptualisation of meeting, participants were presented integrated care will be key to determining with an overview of existing frameworks what will be measured. It was also seen to and indicator sets for assessing integrated be core to defining the scope of care that had been developed in different integrated care, and the extent to which settings. These are summarised in Table 3, relevant efforts also include social care. with more detailed examples presented There was debate about whether below. These include the list of generic integrated care is seen to be a ‘design indicators for assessing the quality of principle’ for health service and system integrated care as proposed by Raleigh et organisation more widely or whether it al. (2014) to inform the monitoring of should be interpreted as a means to progress in the context of the National achieve person-centred, efficient and safe programme of integrated care and care. support Pioneers in England (Table 4).

Table 4 Generic indicators for assessing integrated care as proposed by Raleigh et al., 2014

Domain Indicator

Community 1. Excess winter deaths wellbeing and 2. Proportion of people who use (social care) services and their carers who population reported that they have had as much social contact as they would like health 3. Proportion of physically active and inactive adults

Organisational 4. Delayed transfers of care from hospital, and those which are attributable to processes and adult social care; Delayed transfers of care, days of delay, all ages, all settings, systems per 100,000 older population

• 5. 

  Access: attendance at A&E (separate for out-of-hours and between 9 am and 5pm)

• 6. 

  Potential indicators linked to changes to GP contracts from April 2014 Personal 7. Proportion of older people (65+) who were offered rehabilitation following outcomes discharge from acute or community hospital

• 8. 

  Improving access to GPs 9. Proportion of older people (65+) who were still at home 91 days after discharge from hospital into reablement/rehabilitation services 10. Social care related quality of life 11. Carer reported quality of life 12. Injuries due to falls in people aged 65+ 13. Proportion of people feeling supported to manage their (long term) condition 14. Proportion of patients with fragility fractures recovering to their previous levels of mobility/walking ability at 30/120 days

Resource use 15. Bed days for selected patient types

• / 

  balance of 16. Hospital use in the last 100 days of life

care 17. Gross residential and nursing care expenditure, per 100,000 older people

• 18. 

  Gross residential and nursing care minus NHS contribution. Per 100,000 older population

• 19. 

  Numbers receiving long-term community-based care as a proportion of total

numbers receiving long-term care services (by user group)

• 20. 

  Numbers receiving long-term social care as a proportion of the sum of numbers receiving emergency hospital care and numbers receiving long-term social care

  (by age group, or just for 65+ group) 21. Numbers of people receiving long-term community-based social care relative to

  population (by age group, or just for 65+ group) 22. Proportion of gross current social care expenditure funded through income

  from the NHS (by user group)

Service 23. Emergency admissions stratified by age (e.g. young people, over 65s); and risk proxies for group outcomes 24. Avoidable inpatient activity for people with ambulatory care sensitive (ACS)

admissions, including long term conditions, e.g. lower limb amputations in people with diabetes

• 25. 

  Patients with multiple admissions per year for specific age groups/prior conditions

• 26. 

  Readmissions for selected patient groups, e.g. falls 27. Proportion of people using social care who receive self-directed support, and those receiving direct payment 28. Persons (65+) discharged for rehabilitation from hospital, per 100,000 older population

User / carer 29. Proportion of people dying at home/place of their choosing experience 30. Improving people’s experience of integrated care

• 31. 

  Safety: the proportion of people who use services who say that those services have made them feel safe and secure

• 32. 

  GP Patient Survey: (i) % reporting having had enough support from local services or organisations to help manage their long-term health condition(s); (ii) %

reporting how confident they are that they can manage their own health; (iii) % reporting knowing how to contact out-of-hours GP service

• 33. 

  Inpatient survey questions: (i) % reporting whether hospital staff took family or home situation into account when planning discharge; (ii) % reporting whether hospital staff discussed with patient whether they would need any additional

equipment in their home or adaptations made after leaving hospital; (iii) % reporting whether hospital staff discussed with patient whether they needed any further health or social care services after leaving hospital; (iv) % reporting whether they received copies of letters sent between hospital doctors and their family doctor (GP)

• 34. 

  A&E survey questions: (i) % reporting whether hospital staff took family or home situation into account when they were leaving the A&E department; (ii) %

reporting whether their GP was given all the necessary information about the treatment or advice that they had received in the A&E department

• 35. 

  VOICES national bereavement survey questions: (i) % reporting whether the deceased person when at home in the last three months of life, received any help at home from a range of services; (ii) % reporting whether services worked well together; (iii) % reporting whether they felt that they and their family were getting as much help and support from health and social services as they needed when caring for the deceased person; (iv) % reporting whether hospital services worked well with the deceased person’s GP and other services outside of the hospital; (v) % reporting whether the deceased person had enough choice about where he/she died; (vi) % reporting whether they/their family were given

enough help and support by the health care team at the actual time of the deceased person’s death; (vii) % reporting whether they had talked to anyone from health and social services, or from a bereavement service, about their feelings about the deceased person’s illness and death

Source: Raleigh et al. (2014) 5

Similarly, as part of the health and social suite’ of 23 integration indicators, listed in care integration reform in Scotland, the Table 5.

Scottish government presented a ‘core

Table 5: Proposed core suite of integration indicators, Scotland

Outcomes indicators based on survey feedback Indicators derived from

“to emphasise the importance of a personal organisational/system data primarily outcomes approach and the key role of user collected for other reasons feedback in improving quality”

• 1. 

  Percentage of adults able to look after their 11. Premature mortality rate. health very well or quite well. 12. Rate of emergency admissions for adults.*

• 2. 

  Percentage of adults supported at home who 13. Rate of emergency bed days for adults.* agree that they are supported to live as 14. Readmissions to hospital within 28 days of independently as possible. discharge.*

• 3. 

  Percentage of adults supported at home who 15. Proportion of last 6 months of life spent at agree that they had a say in how their help, home or in community setting.

care or support was provided. 16. Falls rate per 1,000 population in over 65s.* 4. Percentage of adults supported at home who 17. Proportion of care services graded ‘good’

agree that their health and care services (4) or better in Care Inspectorate seemed to be well co-ordinated. Inspections.

• 5. 

  Percentage of adults receiving any care or 18. Percentage of adults with intensive needs support who rate it as excellent or good. receiving care at home.

• 6. 

  Percentage of people with positive experience 19. Number of days people spend in hospital of care at their GP practice. when they are ready to be discharged.

• 7. 

  Percentage of adults supported at home who 20. Percentage of total health and care spend agree that their services and support had an on hospital stays where the patient was

impact in improving or maintaining their quality admitted in an emergency. of life. 21. Percentage of people admitted from home

• 8. 

  Percentage of carers who feel supported to to hospital during the year, who are continue in their caring role. discharged to a care home.*

• 9. 

  Percentage of adults supported at home who 22. Percentage of people who are discharged agree they felt safe. from hospital within 72 hours of being

• 10. 

  Percentage of staff who say they would ready.* recommend their workplace as a good place to 23. Expenditure on end of life care.* work.*

Note: * indicator under development

Source: Scottish Government (2014) 7

Annex 5 presents an overview of Examples include indicators such as examples of potential measures of hospital admissions for conditions people-centred and integrated health considered avoidable by good quality services as compiled by WHO in the primary care. It was noted that the same context of the Global strategy on peopleindicator can be interpreted in different

centred and integrated health services. 2 ways to help explain, assess and

understand integrated care.

Reflecting on these existing indicators and indicator sets for assessing integrated Focus group participants suggested that care performance, several policy focus there may be a need, or indeed an group participants observed that the opportunity, to develop additional majority of indicators presented tended to indicators that are more specific to be used in ongoing HSPA exercises that integrated care. As indicated above, there are not specific to integrated care. appeared to be emergent consensus among discussants that measurement structures among different providers or should consider indicators of structure, across sectors. processes and outcomes (Figure 3).

Likewise, viewing integrated care as a

Thus, a number of focus group means to achieve patient-centred care participants pointed to the need for any reflects the processes in place, with measurement system to consider measurement helping to understand how indicators of structure to enable well they are suited to ensure assessment of the basic conditions, achievement of desired outcomes. There building blocks or system levers needed to was a suggestion that indictors could facilitate transformation to more specifically focus on those areas where integrated care systems (integrated care service users are most at risk of lack of as a design principle). Examples of system integrated service delivery, such as levers include the basic organisational and transition points between care levels (e.g. financial frameworks in place and the primary care and secondary care; hospital degree to which these enable or hinder discharge) and between sectors (health better integration, along with and social care), and task shifting (Figure infrastructural measures, such as 3). information and communication technology, and aspects of the workforce, Finally, although there was some among others. agreement that existing HSPA indicators

could already provide useful insights There was a perception that performance about selected aspects of integrated assessment of integrated care would service delivery, for example service benefit from the further development of proxies such as avoidable hospital thinking in this area, with potential admissions mentioned above, participants indicators to go beyond a simple binary identified the need for additional assessment (present or not present) to an outcome indicators, capturing those for evaluation of how well a given structure is people with multimorbidity in particular, suited to allow more integrated delivery as well as patient-reported experience of service - for example, compatibility and measures (PREMs). interconnectedness of different IT

Fig. 3: Proposed approach to conceptualising the measurement of the performance of integrated care

Against the background that countries different components of structure, have different starting points and process and outcomes delineated priorities relating to the transformation to according to geographical areas, different more integrated service delivery an populations or different conditions in alternative conceptualisation of the order to help inform improvement efforts. approach outlined in Figure 4 sees the

Fig. 4: Conceptualising the measurement of the performance of integrated care by different areas of enquiry

However, independent of the specific 'dig deeper' to explain observed results or approach to indicator selection, focus variation in outcomes, such as the extent group participants emphasised the need to which the processes in place have led for careful interpretation of observed to observed results or the degree to which trends. Recognising the complexity of the system levers have caused the relevant issues and the context-dependency within processes to perform the way they have which outcomes are achieved it was as illustrated in Figure 3. highlighted that indicators should not be looked at in isolation but needed to be Focus group discussions stressed that the interpreted in the given system setting. selection of indicators should be driven by

individual systems’ requirements. There seemed to be agreement among However, at the same time there was participants for a narrative to help acknowledgment for the need to identify understand the degree to which a given a set of comparable indicators that may indicator may tell us something about be considered core and that would allow integration. There was recognition that it for comparative assessment over time will be difficult to identify indicators that and between regions or countries. can be solely attributed to integration. It was thus suggested to use outcome indicators such as avoidable hospital admissions as a starting point and then

Is there a need for a separate framework indicative of integrated care that are for measuring the performance of being reported on a regular (e.g. biintegrated

care? annual) basis, while more in-depth

Several policy focus group participants thematic volumes might provide more raised questions about the purpose of a detailed insights into progress on

‘new’ framework for measuring the integrated care. Such an approach could performance of integrated care. It was see different in-depth investigations noted that such a framework, if aimed for, alternate with, for example, a focus on should be seen to provide guidance for primary care, mental health care, or other countries to help inform their own priority areas (Figure 5).

thinking rather than being prescriptive. Fig. 5: Proposed model for alternate, in

There was emergent agreement among depth HSPA reporting on identified discussants that as countries vary with priority areas

regard to HSPA frameworks more broadly and integrated care approaches more specifically, any integrated care measurement system or framework should be tailored to countries’ specific goals, values and needs. There was consensus that there was no single ‘right’ approach that would be applicable and valid for every system.

This last point is closely related to a further concern raised by a number of focus group participants. This centred on where integrated care performance assessments sit within the wider HSPA processes and systems in a given country.

It was highlighted that countries differ in the ‘stage’ of their journey to more integrated care systems, with some having established explicit legal frameworks for integrated health and

social care systems (e.g. Scotland 29 ) or are in the process of doing so (e.g. Finland 35 )

while others might set priorities differently.

Again, there appeared to be consensus that any model should be flexible and adaptable to different national or local contexts, where applicable. There was a proposal that national HSPA reporting could include a set of core measures

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Chapter 5: Conclusions

Measuring integration is different from • The identified principles and success measuring the performance of integrated factors for integrated care are intercare. In preparing this report, the Expert connected and are common across

Group was confronted with this double the integrated care experiences task. On the one hand, it had to find ways across Europe. to assess the degree of integration of a

system; the results of this reflection are • The findings of the review of presented in chapter 3. On the other integrated care cases in Europe bear a hand, the Expert Group had to find strong resemblance to the 12 tailored ways to assess the performance dimensions of the Maturity Model of integrated care models, which are able developed by the B3 Action Group on to capture the specific added value Integrated Care of the EIP on AHA.

brought in by the integration. This last part of the analysis is presented in chapter

• 4. 

  Conclusions relative to Chapter 4:

  Measuring the performance of integrated care

Conclusions relative to Chapter 3:

Building blocks, design principles • Integrated care can be seen to be

and system levers for integrated both a design principle and a means

care to achieve person-centred, efficient and safe care.

• The transition to integrated care is a • Integrated care models can be complex process with high complexity introduced with different goals in being present in all aspects: design, mind: increasing effectiveness of the

implementation and assessment of system, reducing costs, improving

integrated care. patient safety, etc. Before setting in

• Integrated care models have to be place an assessment system it is carefully designed and implemented important to explicitly define and to fit the local context and needs. agree on the goal of integrated care

Failing to do so effectively may not in a specific context, to permit a

bring benefits and, under such sound assessment of its performance.

circumstances, whatever indicators • The Donabedian approach to are used to measure performance will evaluate quality of care by assessing inevitably show poor or suboptimal structure, process and outcome results. provides a useful way to guide

• Design principles, building blocks and integrated care performance system levers should be included as measurement. The Expert Group part of the framework for assessment agreed with Donabedian statement

of integrated care. that “good structure increases the likelihood of good process, and good

process increases the likelihood of o outcomes – to capture in

good outcome”. particular those for people with

• There is a range of existing indicators multimorbidity, as well as that can be used for measuring the patient-reported experience performance of integrated care but measures (PREMs)

there is a need to develop indicators • Indicators and trends need to be

that are specific to integrated care. interpreted carefully. Given the

There is a need, or indeed an complexity of the issues and the

opportunity, to develop additional context-dependency within which

indicators that are more specific to outcomes are achieved, indicators

integrated care. They should consider should not be looked at in isolation

indicators of but need to be interpreted in the

o Structure - to enable assessment given system setting.

of the basic conditions, building

blocks or system levers needed • There is no single ‘right’ approach to facilitate transformation to that would be applicable and valid for more integrated care systems. every system. As countries vary with

o processes – focusing in particular regard to HSPA frameworks more

on those areas where service broadly and integrated care

users are most at risk of lack of approaches more specifically, any

integrated service delivery, such integrated care measurement system

as transition points between care or framework should be tailored to

levels and between sectors, and countries’ specific goals, values and

task shifting. needs.

ANNEXES

Annex 1: Table A1 Success factors and transferable elements from integrated care experiences in Europe

Index Practice Region/MS Intervention & Success factors Transferable elements

Target group

1 Integrated Belgium: 20 Target group: the • Co-creation with political commitment and Pilot projects are in the care through regions of 100 whole Belgian stakeholder involvement: a combination of conceptualisations phase, there are no pilot projects 000 to 150 000 population with a bottom-up and top-down by stimulation of implementations so far. During the 1 (pilot projects inhabitants (in focus on people with bottom up ideas and entrepreneurship with year preparation time, following in starting total: covering a chronic disease guidance from the policymakers by setting out elements were identified: phase 1/3th of the the framework for innovation and encouraging • The bottom-up /top down approach /conceptualisa Belgian Intervention: the the collaboration between partners in the • Guidance through coaching support, tion phase) population; implementation of a region. During the conceptualisation phase proximity of the government

3.672.558 national plan with regular intervision between stakeholdersinhabitants) the principles of government.

*Triple Aim, • Great emphasis on population-oriented care: * improving equity The action plan of different pilot groups must * job satisfaction for be based on the needs in their region the care providers (stratification of the population). by launching pilot • Patient focus: each pilot project must projects (in regions). implement strategies to enhance patient

empowerment, also individual patients or patient organisations must be involved in the governance of the project.

• Encouraging organisational change and actions not limited to only one part of integrated care: stepwise approach, financial and coaching

support. The action plan of the pilot regions must include 14 components of integrated care (e.g. Case management, care continuity, electronic patient record, …) and has to include re-designing the organisation of health in their region.

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• Attention for evidence based practice and quality of care: A scientific team will assist the pilot projects in building a culture of quality and procedures for auto-evaluation and

monitoring. • Financial reform: the concept of a guaranteed

budget for a region, and the possibility to reinvest efficiency gains in their region.

1 Integrated Pardubice, CZ Holistic set of • Close interdisciplinary co-operation between • Structured rules of co-operation health and support, care, and all agencies and workforce involved rather within the AZASS association shared social care services (health and than small municipalities without sufficient by municipalities – participatory services in the social care) tailored expertise and finances. democracy.

Pardubice to the needs of • Availability of strategy & vision of services in • Approaches to personal co-operation

region individuals with the region. and communication between

reduced self• Creation of AZASS (Association of local / stakeholders and the 27 sufficiency due to regional municipalities) which includes municipalities. illness, disability or mayors, economist and healthcare • Workforce development - retraining frailty and to support professionals and covers all the health and & creation of new roles. their carers. social care services in 27 municipalities to

avoid instability from political cycle; introduction of legally based cooperation of municipalities.

• AZASS has single executive leadership team with each municipality having a proportioned vote to number of citizens but none can have a majority.

• Members of the public can collaborate with leadership team to create solutions for local problems.

• Clear strategic leadership. • Regular communication and engagement with all stakeholder involved; interdisciplinary working teams.

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• Individualised approach to the different needs of workforce following the introduction of

new care models (retraining & creation of new roles).

• Sharing of information about patients/clients. • Reconfiguration of health and social care services following bankruptcy of hospital was an opportunity to redesign the care model which successfully enabled the introduction of the whole set of new social services which did not exist before. • Removal of inhibitors, including both legal and financial constraints.

2 Improved Olomouc, CZ Provision of nursing • Automated uploading/integration of home • IMACHECK software. management services to patients care nursing visits and activities into the • Training of the nurses. of visits in living at home hospital information system which results in • Involvement of patients in the design Home Care facilitated by improved accuracy of information and data of electronic identification centre.

electronic evidence integrity. of visits and activities • Providing smartphones or tablets with NFC undertaken. identifier (smart card) that act as a gateway for the identification of data which reduced the need for the nurses to manually enter the data and contributed to improved user acceptance and patient safety. • Simple software and devices. • Service is part of routine homecare services in the country. • Improved management of the workflows due to electronic evidence of visits. • Training of the nurses. • Involvement of patients in the design of electronic identification system.

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• Availability of dedicated financial resources. 3 Telehealth Olomouc, CZ Telehealth service • Adaptation of clinical protocols developed in • Appropriate vital sign parameters for

service for for patients with United4Health project to specific needs of the multi-morbid patients. patients with advanced heart region. • Clinical protocols and revised work advanced failure • Patients did not have to repeat their flow. heart failure measurements for their different chronic • Roles and responsibilities of clinical

conditions as the remote monitoring CHF staff. parameters also applied to support remote • The practice has already been monitoring of patients with haemodynamic transferred to another region in Czech support (ventricular assist device -VAD) before Republic.

orthotopic heart transplantation (OTS) or in long term regimen and thus patient and care practitioner acceptance was improved.

• Minimal organisational changes required to routine hospital work flow.

• Software platform supports additional chronic diseases, therefore suitable for multi-morbid patients.

• Technical reliability of distant communication. • Creation of new jobs in relation to the establishment of the services. • Transferability of equipment to other patients. • Dedicated funding for the service. • Education & training of the workforce.

4 Telemonitorin Olomouc, CZ Anticoagulation • Minimal organisational changes required to • Clinical protocol and revised work g of patients regime remote routine hospital work flow. flow.

with AMI and monitoring for older • Devices enable bidirectional communication • Patient stratification and intervention

in people post AMI between clinicians and patient which targeting process.

anticoagulatio improved patient and care practitioner • Roles and responsibilities of clinical n regime acceptance and patient safety. staff.

• Existence of central system (portal) which was tailor made for the University Hospital

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Olomouc. • Patient empowerment – availability of

measured data to patients; patients can directly access / download data from the portal.

• Political support. • Application of experience / outcomes of U4H projects (avoid the duplication of efforts / mistakes). • Acceptance of intervention by the patients and healthcare professionals.

5 Gesundes Kinzigtal, Baden Population-oriented • Establishment of an organisation whose • The establishment of a regional health Kinzigtal Württemberg, DE integrated care and pivotal role was the redesign of primary care, management company: this is

service integration population health management and financial transferable to any other part of encompassing: management to facilitate system integration. Germany and also to countries with preventive care Gesundes Kinzigtal GmbH holds ‘virtual similar insurance-based health care management, life accountability’ for the healthcare budget for systems such as the Netherlands, style changes and the population group, and has negotiated Austria and Switzerland (Bismarck disease prevention, cooperation contracts with a range of local health care systems). chronic disease providers that have agreed to adhere to a set • In the case of Beveridge health management. of guiding principles, standards and systems, the increasing presence of procedures. private health insurance companies in • Strong governance mechanisms among the public systems could facilitate the private service provider and the health actors implementation of the Gesundes involved, especially the association of GPs of Kinzigtal model in the private sector. Kinzigtal region (the regional health • Available elements to support management company is co-owned (tworeplication: quality indicators, thirds) by the physicians’ network in the evaluation protocols, program region). outlines, incentive systems, • Strong engagement of health and policy guidebook, data warehouse, reporting actors, in particular, the primary care system. providers. • A strong patient focus driven by preventive

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care services. • In-depth reorganisation of services and

logistical re-engineering of care processes. This reorganisation implies horizontal integration and collaboration among GPs and the other healthcare and social care operators through service contracts established with Gesundes Kinzigtal, to share patients’ information and services.

• Establish trust, confidence and good collaboration among health providers to overcome the communication barriers. Strong public relations and frequent contact to citizens.

• Well-established incentives and financing and reimbursement schemes - alignment of the

financial interests of payers and providers in the system.

o Strong relationship between the

integrated management company and local statutory health insurers (sickness funds). The contracts are based on a shared health gain approach, with the resulting benefits being shared between the sickness funds and Gesundes Kinzigtal GmbH.

o The shared-revenue model promotes

additional incentives for health professionals, since the regional health management company is co-owned by the physicians’ network in the region: part of the generated margins/profits is re-invested in training local physicians,

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OptiMedis personnel and for innovative programmes – see pages 19-20, 24-26). The overall incentives for GPs bring 15% increase of their personal income.

o The shared-revenue model leverages

health improvements by incentivising prevention activity and efficiency savings in processes.

• Long-term contract (10-years): an incentive for sustainable health investments and

prerequisite for a meaningful evaluation. Allows for initial investment until earnings are big enough for ROI.

• A common ICT infrastructure and Centralised Electronic Health Record to support

cooperation across GPs’ practices and other care actors, to manage the health information of the enrolled patients and to share it among all care actors.

• Policy commitment which led to the adoption of innovative legislation in support of

integrated care services. The initial investment was facilitated by national policy (Statutory Health Insurance Modernisation Act in Germany).

• Establishment of a monitoring and evaluation system, to provide evidence of the impacts

(with cost-benefit analysis). • Sustain service provision in the long-term, via

investing a significant amount of money to attract young doctors to the region by offering training positions, for the type of training required for their medical qualifications.

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6 Geriatric Saxony, DE Target group: • Active cooperation of the health care • Special screening tools. Concept geriatric patients providers in the networks, including GPs. • Living environment strategies. with chronic Establishing standards and treatment • Guidelines and counselling and care diseases. pathways agreed on by all net partners. frameworks.

• Participation of the municipalities as key Integrated care stakeholders. model for cross• The implementation process is accompanied sector cooperation by conferences, workshops and training of the courses for formal and informal carers. E.g. health care special training meetings for geriatrics providers, network stakeholders (“GeriNeTrainer”) every establishing standard 6 to 8 weeks on the care of patients suffering assessments, from dementia turned out to be very introducing successful.

treatment pathways and supporting formal and informal carers.

7 TK Integrated various locations, Integrated care • Re-numeration comprises of financial • The process of patient selection and Care Contract DE model (linking incentives to achieve sustainable treatment. the implementation methodology is for Back Pain doctors, hospitals o If patients are fit for work after four weeks available and could be implemented and outpatient care and remain like this for six months without by other insurance funds in Germany facilities) to improve any interruptions, their doctor receives a or in Europe.

the treatment of financial bonus. If a patient is still not fit back pain. for work after eight weeks on the Focus on secondary programme doctors are penalised 7% of and tertiary their re-numeration. prevention.

8 SAM:BO Southern Cooperation on care • Supportive legal framework: the Danish Health • The principles for electronic Cooperation Denmark, DK pathways between Legislation, which obliged the regional communication between the health on care GPs, local authorities councils and the municipalities to sign an sectors in the region (have already pathways in and hospitals. agreement on issues related to health and been transferred to the other 4 the Region of Backed up by a psychiatry - to strengthen cooperation regions in Denmark).

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Southern Shared Care Portal between hospitals, municipalities and the • The procedures and standards

Denmark as a tool in the general practices, and ultimately ensure developed (these do not require

treatment of the continuity of care. significant investments).

complex chronically • Political commitment and consensus: Strong • Transferability is feasible in the Danish

ill patients. commitment of the regional government. context, as the legal framework is the

Currently available SAMBO was agreed upon and signed at same and there is a common ICT that

for patients suffering political level, both by the Regional Council could support the practical

from CVD, but will be and by the 22 city councils. deployment of the case in other

rolled out to include • Well-established and continuous health regional or local contexts within the

COPD, diabetes, and innovation processes involving all the regional country.

cancer. stakeholders. Such innovation ecosystem

helps anticipate organisational and • Favourable conditions for

technological issues before defining transferability of SAM:BO initiative

operational standards and procedures. are national, regional or local contexts

• The existence of an electronic information and where:

communication network infrastructure, which o There is a unique patient identifier.

integrated all the health care actors in the o There is an existing health care

region using shared interoperability standards, infrastructure which supports shared care records, together with an already information sharing between the wide diffusion of eHealth applications. healthcare and social care actors.

• Strong participation of the stakeholders in the o A healthcare system implementation. This was critical for the transformation is already operationalisation of the SAM:BO initiative in underway, so that health and local contexts as the latter requires full social care actors are more willing acceptance of organisational changes in care to accept such organisational and delivery and managerial processes. It helped cultural changes.

speed up the design and implementation of o A legal framework for integrated services and to apply common standards. care is already well-established.

• A dedicated team followed the entire process, ready to support the implementation of the

new organisational structures, but also to assist in the roll-out of the new electronic communication.

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• Strong governance in terms of definition of procedures and standards.

• Cross-sector organisational implementation is most successful when the procedures and

instructions are a result of cooperation across all sectors and new practices are taught in a cross-sector set-up where both municipal staff and hospital staff are trained together.

• The organisational implementation works best when clear agreements and instructions on

the individual’s tasks and use of IT are formulated.

• The technical implementation is strengthened by developing IT as tools to support the work process that relates to the agreements and

instructions. IT is best developed through active user involvement in the development phase.

• Re-organisation of the care service with an emphasis on the patient, to re-orientate the focus of care from the hospital to the patient.

9 Basque Basque Country, Target group: • Making the transformation of the healthcare • The knowledge acquired during the Strategy for ES chronic patients model a priority health policy, with a clear implementation process of the

tackling the Population vision and defined objectives. projects. challenge of Intervention Plans in • Create a “narrative” beyond “cost • Implementation methodology of the chronicity the clinical field to containment”, provide a vision and structure innovative projects. provide healthcare in which needs to be attractive, as well as a a coordinated and cohesive common understanding on where efficient manner the main problems are, what are the key among all players issues to tackle and how to do it. involved for each • A very relevant aspect to consider is that one target population. can pull off advances in a non-aligned context

but system-wide transformative change will

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only happen when many policy levers are aligned and activated in the same direction.

• A right balance between top down and bottom up levers and the inclusion of right incentives as well as common objectives in health outcomes.

• Continuous evaluations of the advances of the strategy are critical to the scaling up process, because they provide the results and lessons learned during the implementation process.

• Research projects, thereby generating a network of improved scientific evidence concerning the treatment and care for chronicity are also important.

10 Population Basque Country, Target group: • The methodology used. Stratification ES chronic patients. • Lessons learned (key aspects to take Construction of into account, barriers and facilitators).

prospective statistical models which will provide an estimation of the health resources likely to be needed per each individual throughout the following year. The entire Basque population has been stratified, based on demographic, medical and social variables as well as the previous use of

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resources.

11 PROMIC Basque Country, Target population: • The potentiation of the roles of nurses and

ES heart failure patients the inclusion of social workers in the health older than 40 and setting promotes integration between care showing stage II to IV levels and areas, without the necessity of

(NYHA) heart failure costly investments. conditions. Assessment of the effectiveness of a Heart Failure Care Management Program Patients.

12 BSA Badalona, Target population: • Reorganisational process and the governance • The technology developed at BSA Catalonia, ES patients with mechanism established have been the main could be relatively easy to transfer to complex chronic drivers of integrated care. other health care organisations. This conditions. • Engagement and co-operation of health and technological innovation, however, Care Model for social care professionals. would not have an impact without the Patients with • Existence of interoperable information necessary organisational and

Complex Chronic systems. institutional innovation.

Conditions (MAMCC) • Resistance to technology on the part of health • BSA is an integrated care organisation is used. and social care professionals and patients has which was created in a region with Stratification of not been perceived as a barrier which NHS model. Transferability to health population. hampers integrated care deployment. insurance environment would be Integration of health • The absence of major conflicts between the more difficult. and social care. distribution of resources and the alignment of

incentives among different levels of health care and social care.

13 NEXES - Barcelona, ICT-enabled • Political support and commitment from the • Professional role redesign: case Supporting Catalonia, ES integrated care local government. manager as the lead for the different

Healthier and services: • Sustained leadership was crucial; first, from a programmes. Train participants in the Independent  well-being and more scientific/clinical perspective; later from adequate skills. Living for rehabilitation, a managerial one. • Flexible pace of adoption is a sensible

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Chronic  enhanced care • Having engaged healthcare professionals and strategy to overcome contextual Patients and for frail patients, champions in most locations facilitated a factors. Older People  home snowball effect for the larger deployment of • An open ICT platform supporting hospitalisation services in these locations. organisational interoperability and and early • Specific logistics in place to support the tasks collaborative work, with no need to discharge, involved in the program. The use of business replace pre-existing proprietary  remote support process notation models was of help to Electronic Health Record / HIS. This for diagnostic identify and correct deficiencies. requires a rather medium level of

and/or • Incremental pace to accommodate the customisation. The ICT platform can therapeutic learning process of both professionals and mediate between external

procedures. patients. Flexible pace of adoption is a applications and its core module, and sensible strategy to overcome contextual act as the common frontend showing

The focus is on factors. only the relevant information and highly prevalent • Deployment of care pathways by motivated interfaces to the relevant end-user. chronic conditions and engaged inter-professional teams o Integration with external Hospital (COPD, chronic heart facilitated the re-organisation of the services Information Systems and other failure and diabetes). to ensure cooperation between tiers of care legacy systems is achieved by and between health and social care. implementing web services for

• Simple and robust ICT solutions, with interoperable machine-toparticular attention on interoperability at machine interaction.

health system level, in order to enhance o Organisational interoperability communication and information flows across between professionals the continuum of care, are effective in participating in integrated care ensuring extensive adoption. programmes is enabled by means

• An open ICT platform supporting of a common frontend. organisational interoperability and o Modular system which ensures collaborative work was an important enabler vendor independence so that of the implementation (no need to replace different vendors can provide pre-existing proprietary Electronic Health specific functionalities.

Record / HIS, which helped overcome resistance).

• Focus on efficiencies of novel integrated healthcare services rather than on

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implementation of ICT into traditional approaches.

• A bundle payment scheme where risk is shared between payers, healthcare providers and ICT suppliers seems to be adequate to release the efficiencies at health system level, facilitating investment on ICT innovation without increasing total healthcare costs.

14 MECASS – Barcelona, Integrated, patient• A shared risk model (PPP) established • Common intervention plan, shared Collaborative Catalonia, ES centred, care model, between the healthcare provider and the IT among all the health and social care model between health and provider. Both organisations facilitated human professionals.

between social care, for resources to develop the platform that • Definition of both clinical and health and chronic diseases allowed the objectives. technical standards, to share relevant social care patients. • Organisational processes, both clinical and information among all the players. administrative, clearly defined and shared • The developed platform, based on an among stakeholders. open architecture, that allows the • Strong clinician collaboration, a bottom-up holistic vision on patients. The approach. technical solution allows escalating

• System interoperability and Standardisation. the integrated care management to

Definition of both clinical and technical different healthcare programs and standards, to share relevant information different regions. among all the players. o Connectivity and interoperability

with patient-centred management, and analytics technology that allows two-way exchange of structured and unstructured data between the healthcare provider and other suppliers.

o Scalable and robust system with

a rich user interface. It provides for the gradual implementation of additional components.

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15 Getafe Getafe, Madrid, Target population: • Computerisation – the use of Health • The core component is a “way to do ES older in- and out Information Systems in routine practice has the things” instead of instruments

patients. facilitated the work of the physicians who or devices. It allows to expand the visit patients at their homes or nursing model to different settings.

Continuous, homes. • It is possible to select the progressive and • Commitment of the professionals. components best fitted to specific coordinated • Public funds as the main source of financing. needs or budgets. attention to patients • Although the whole system at high risk of embraces several parts, it is functional decline, possible to decide to implement a institutionalisation, few of them. and hospitalisation, • It is also possible to introduce some at home or in functional changes according to the residential care characteristics of specific settings. organisation.

16 Alzira model Valencia, ES Vertical integration • High clinical, managerial and cultural • The contractual model (PPP with across primary and integration. capitated payment): first applied to secondary care to o The inclusion and clinical integration of the Hospital de La Ribera, replicated provide universal primary care into the wider system, is to over 20% of the Valencia region, access to a range of important. and also used in an area of Madrid.

primary, acute and o Integrated primary care centres specialist health established to enlarge the scope of services to the local some of the health centres, with onsite population. x-ray services, accident and emergency departments, and medical specialist outpatient clinics.

o A consultant physician is attached to

each health centre, working with the same patients as the GP, to implement clinical guidelines with the local GPs and reduce the number of inappropriate hospital referrals.

o Integrated medical care pathways, to

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streamline the management of health problems across prevention, acute care, rehabilitation, chronic care and palliative care.

o Population health management culture. o Health objectives alignment across the

whole organisation. • Reimbursement model: the provider (a private

entity) receives a fixed annual sum per local inhabitant (capitation) from the regional government.

o Long-term contract - long-term business

perspective; no short-term profit. • Private operators have an incentive to treat

people in the most appropriate and costeffective setting, which means limiting the demand on hospital services through preventative and community care.

o Patients, who are free to go elsewhere

for care and hence cost the provider money in that case, also drive the model to focus on its quality and customer service.

• A unified IT system across all services, with a shared patient record between GPs and

specialists. Comprehensive and up-to-date information drawn from a shared database.

• Rigorous management culture requiring accountability and compliance with a set of procedures and guidelines.

• Incentives for staff to ensure compliance. Performance of staff is monitored and staff receive bonuses as a result of high

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performance; can earn up to 40% more than in other hospitals in Valencia.

• Benchmarking - cost analytics and what-if capabilities.

17 Holistic health Valencia, ES Target group: older • Strong emphasis in the standardisation of its • Standardised and validated and social patients and their processes and in the maintenance of high processes.

services at caregivers. quality services. • Usage of IT technologies specifically

home • Having experience in using IT solutions supporting the unit work, including

programme Providing patients supporting work of care unit. a specific healthcare record.

and informal care • Engagement at political level.

givers with • Co-operation with primary, secondary and

comprehensive care tertiary care providers.

at home, favouring • Agreement with patients' association transition from • Scientific and technical support from experts hospitalisation to in these fields.

home care. 18 Integrated Valencia, ES Target population: • Cooperation between different actors and

care through chronic patients over sectors, as such regional and local case 65 years, who administration, private companies, management require social and professionals, patients and caregivers in the health care at home. • Creating two new professional positions: Valencian ‘management nurses’ and ‘continuity Region Setting up a pilot nurses’ who apply the case management case management methodology from a primary health care unit in two primary centre and in hospitals to better connect care centres to both spheres between themselves and with assess the effect of a social resources. case management programme applied in primary care.

19 eTrikala Trikala, EL Integrated Care • Inter-professional teams across the • Using interoperable ICT standards. based on an ICT continuum of care

infrastructure • Policy leaders facilitating the participation of

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managed by a all stakeholders and fostering innovation in telecare centre that the health system constitutes a single • Broadband internet, which covers most of entry point to health the municipality’s geographical area and social services provision.

20 HTLA: Health Région Ile-de Target population: • Political will Territory Local France, FR people of 75+ years • Performing the diagnosis and analysis of the Agreement old and extended to maturity of care through special toolkit 60+ when prepared for this purpose.

concerning • Identification of the partners to be involved. prevention. • Availability of finances and resources to

perform new tasks connected with

Better coordination management of the Agreement within the between local health relevant organisations has to be validated and social before the signature of the Agreement.

stakeholders

21 Multimorbid Languedoc Target population: • Combination of best practices in integrated • Transferability using the expertise

clinic for Roussillon, FR patients with major care instead of definitely seeking the new of the chronic disease programme chronic chronic diseases ones. which has been translated into 52

diseases • Chronic disease clinic based on languages and transferred

(MACVIA-LR) Integrated care comorbidities and/or falls integrated with all successfully to 64 countries.

pathways for chronic components of health and social care to

diseases provide an integrated cost-effective solution

22 Campania nel Campania, IT Integrated care for • The ICT is scalable and there are interactions • The ICT is easily transferable. It is

Cuore hypertensive with other clinics and departments to possible to make acquisitions of

patients, facilitated integrate their electronic records with modules separately, according to

by use of ICT. Campania Salute. resources and opportunities.

• A strong interaction with the hospital

management and with its ICT services is at

the core of the interoperability, to ensure

maximum impact.

• Dedicated personnel are key to a fast

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forwarding of scale-up implementation.

23 ARIA Emilia-Romagna, Home follow-up • Tele-medicine and home-tele-monitoring • The model can be applied to

IT program combining services are innovative and powerful tools patients with Amyotrophic Lateral tele-monitoring and that can contribute to deliver benefit both Sclerosis, Quadriplegia and Gold

chest physiotherapy to patients/caregivers and health system in stage IV COPD. in preventing and the whole; early treating acute • Collaboration among different Wards respiratory episodes. medical specialists, GPs, patients/caregivers; • Active involvement of local/regional home Patients affected by: based service providers.

neurological, neuromuscular, rib cage diseases causing chronic respiratory failure.

24 SOLE/FSE Emilia-Romagna, Patient-centred • Strong commitment of the regional • From a technological perspective, IT integrated care government to reinforce quality of care and the SOLE/FSE infrastructure was services. efficiency, reducing at the same time built up in accordance with the

operating costs of clinical services; interoperability specifications

SOLE is the • Involvement of relevant agreed among the regional and integrated network partners/stakeholders; national organisations of a majority of local health Units, • Adoption of ICT platforms/ of the EU28 member states during hospitals, GPs and infrastructures/networks to make possible the development of the EU project paediatricians of the the sharing of data/information. EPSOS. The software code could be

Emilia-Romagna easily transferred to local contexts in

region in Italy. Italy and in Europe.

• The investment that could hinder

FSE is a software the transferability of the SOLE/FSE

application that initiative is related to ICT

helps organise, infrastructure. The SOLE/FSE

retrieve and manage initiative could only be transferred

the clinical history of in areas where there is broadband.

every citizen of the • The most critical success factors for

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region. transferability to other regions/countries are favourable institutional and cultural contexts and the local presence of a common strategic and operational management of the local health and socio-sanitary systems to guarantee:

o Strong commitment by the local

government.

o The deployment of integrated

care initiatives that make use of the SOEL/FSE infrastructure.

o The cultural and organisational

changes that allow information sharing across different tiers of care and between health care professionals in the same tier.

25 eCare Emilia-Romagna, Coordinated • Very close interaction with the voluntary • The network of citizens, Network in IT municipal social and sector, associations and public associations, public authorities, Bologna healthcare services administration professionals is the base for an to support frail old • Gathering of key resources in a given area in upcoming evolution of the service people of age 75+. order to offer opportunities and services to and its experimentation in other the older population, making them easily regional cities and regions (namely

Tele-monitoring, visible and accessible even by those who, like Lombardia, Piemonte, Puglia). tele-assistance and many older people, usually do not have a tele-company high knowledge of what can be enjoyed in services for support of their condition of loneliness and preventing the frailty.

aggravation of social and healthcare frailty and for early detection of possible worsening signals to

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avoid unnecessary hospitalisation.

Diabetes Emilia-Romagna Target population: • Health Homes: collaboration between • Clinical pathway methodology mellitus Region, IT type II Diabetes general practitioners and specialists transferable to other chronic integrated patients without (diabetologists, cardiologists, conditions such as heart failure, care complications pulmonologists, oculists, nephrologists and COPD, renal failure, dementia management Development of others) evidence based • Health Homes: integration between health recommendations and social services for integrated care • Evidence based clinical pathways

addressed to • Adoption of ICT platforms (SOLE network) to General Practitioners share data between healthcare (GP) and Center for professionals and services

Diabetes • Commitment of the regional Identification of the government to reinforce quality and population affected continuity of care

by diabetes using

information derived • Involvement of relevant from local and partners/stakeholders

regional administrative databases and clinical databases. Health Homes (Case della Salute): multidisciplinary care teams, nursing case management, ICT platform, point of care testing, social services.

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Breast and Emilia-Romagna Development of • Commitment of the regional government to • Clinical pathway methodology

colorectal Region, IT evidence based reinforce quality and continuity of care transferable to other neoplastic

cancer clinical recommendations by • Evidence based clinical pathways conditions pathways the Regional • Multidisciplinary teams Oncologic • Breast and colorectal cancer performance Commission indicators definition and monitoring

Involvement of relevant partners/ stakeholders

Proactive care Emilia-Romagna Target on patients • Multidisciplinary teams • The model of patient selection is in Health Region, IT with chronic disease • Integration between health and social transferable to other homes (Case Development of a services areas/conditions della Salute) predictive model to • Commitment of the regional government to identify patients at reinforce quality of care high risk of Involvement of relevant partners/ hospitalization or stakeholders

death Profile of patients’ risk for hospitalization or death provided periodically to primary care departments Proactive case management and personalised care

26 PDTA Brescia, Focus on “home care • Integrated care has been on the Brescia • The transferability of the PDTA case

Lombardy, IT management” and Local Health Unit agenda for the past 15 to other Italian regions does not health and social years. This local policy commitment has require significant investment in

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services integration, been the main facilitator of the PDTA case. terms of organisational effort or mostly addressed to • Continuous training actions targeted at GPs, technological infrastructure. dementia/Alzheimer the network of service providers, non• Transferring the PDTA approach to patients. professional caregivers and patients’ other EU28 contexts would probably families. be far more difficult, given the

Integrated care • Single and continuously updated IT system different health care organisation approach based on a that contains data from both patients and systems. standardised service providers. diagnosis of disease and personalised therapeutic and pharmacological pathways continuously monitored by GPs.

Integrated Lombardy 3.5 million residents • Strong commitment of the regional • Methodological approach to define Care Model in Region, IT with chronic government CReG classes scalable and Lombardy conditions • Identification of care managers transferable to other regions

(CReG-based) Expenditure for • Prospective and flexible Personalized Care • Personalised Care Plan (PCP)

chronic diseases Plan (PCP) for each patient scalable and transferable accounts for about • Care Management Service (CMS) to ensure 75% of the region’s PCP accomplishment overall health care • IT supported integrated clinical pathway expenditure • Integrated Model tested and validated at

Lombardy “Regional primary care level Plan for Chronicity • Cooperatives of GPs established to manage and frailty 2016- integrated care 2018” implements • reduced risk of hospital admissions for any organisational cause innovation in the • reduced risk of emergency department health system admission among enrolled patients targeted to patients • improved clinical outcomes in identified

patient groups (diabetes, hypertension)

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with chronic illnesses (28,4 million euro).

Strategic Plan based on a Population Health Management approach

Health-based clinical risk adjustment model to identify, classify and stratify chronic patients into “CReG classes” (CReG: Chronic Related Groups) - homogeneous both in terms of diagnosis and costs

Services targeted to CReG class related patients’ needs, with focus on monitoring, outcomes evaluation and quality improvement

Integrated care management calibrated on CReG

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class applying innovative tools at different care settings (primary care, specialised ambulatory care, hospital care)

CreG Tariff: riskadjusted capitated Prospective Payment System at primary care level to cover costs of 1- year service for each class

27 Family and Piemonte, IT, Citizens aged over 65 • (see EIP-AHA Good Practices • (see EIP-AHA Good Practices Community Liguria, IT, followed by Family documentation) documentation)

Nursing role Primorska and Community implementatio (Slovenia) Nurse (including n Karnten (Austria) prevention strategies and care pathways adherence and other levels of care)

Home Piemonte, IT Citizens/patients • Involvement of all needed stakeholders • The operational framework of the radiology (especially older and • good communication with GPs and medical home radiology service in Piedmont is service frail) needing specialists working since 2007 and it has been radiological • good collaboration with local health services extended to the whole regional area. diagnostics follow up (home care basic services and administrative living in remote services)

areas have the

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possibility to avoid stressful and dangerous transportation to hospital

Home video Piemonte, IT Video-dialysis allows • Collaboration between health and social • After overcoming initial barriers, dialysis the patient or the service staff and a small enterprise that coordination and collaboration has partner/caregiver in patented a new technology together with improved and the model can be the management of clinicians exported. peritoneal dialysis • Self management and patient • The technology employed for the who are not able to empowerment home video dialysis service can be provide • Collaboration among healthcare staff at adapted and transferred to other independently different levels of care (hospital-primary settings and environments (http://www.aslcn2.i care facilities-GPs)

t/lospedale-alba• very good results at low costs

bra/specialitamediche/nefrologia- dialisi-e-nutrizioneclinica/video- dialysis/)

The hospital Piemonte, IT The hospital-at• Trust established between caregivers, Elements that could be transferred to at-home home service (HHS) patients and hospital at home staff other settings should be evaluated for

service (HHS) is an alternative to • Communication amongst the various each single context the traditional wards healthcare providers involved, especially

for elderly patients. between GPs and hospital staff. The team operates 7 • Patient satisfaction days a week and • HHS demonstrated to be as efficacious as a looks after 25 traditional ward for elderly and functionally patients a day, on compromised patients

average. Every year, a mean of 450 patients are treated

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at home. The most common causes of admission are cardiopulmonary, cerebrovascular, metabolic, and neoplastic diseases.

HHS can be directly activated by GPs as an alternative to hospital admission, or by hospital wards to allow early and protected discharge from hospital

Medication Piemonte, IT Integrated path • Active involvement of patients The developed communication Reconciliation among professionals • Better communication between patients matrix between stakeholders can be and safety belonging to and healthcare staff replicated and exported to other different levels of • correct prescription and adherence to areas and settings care organisations therapy (hospital • Pocket list of prescribed drugs given to each pharmacists, local patient to be checked at each transition to a care pharmacists, different care setting

GPs, risk • In 2017, a web portal will be implemented management where hospital staff in charge, GPs and experts, together patients can access drugs plans prescribed, with university for an increased safety of drugs combination

researchers) aimed at checking the correct prescription of drugs at

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transitions in care (hospital admission, transfer from one unit to another during hospitalization, or discharge from the hospital to home or another facility), aiming to prevent ADE’s (adverse drug events) Medication reconciliation refers to the process of avoiding inadvertent inconsistencies across transitions in care by reviewing the patient's complete medication regimen at the time of admission, transfer, and discharge and comparing it with the regimen being considered for the new setting of care

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Oncology Piemonte, IT- Oncology Pathways, pathways Regional within the Regional Oncological Network of Piedmont and Valle d’Aosta. Oncological patients are taken care of, from diagnosis to follow-up, by each level of healthcare organisations involved

Integrated Piemonte, IT Patients affected by Pathways for heart failure, HCV, Heart failure dyslipidaemia, low care, HCV back pain patients, dyslipidaemia, low back pain

28 Telehomecare, Puglia, IT Telemonitoring • Existence of technology system / platform • H&H Hospital at Home Technology Remote aimed at patients (H&H Hospital at Home) to enable the system.

Monitoring for with Heart Failure, detection of clinical and instrumental • Stakeholder engagement.

patients Heart COPD & Diabetes parameters. • Clinical & Technical protocols.

Failure, and Remote monitoring • Introduction of integrated management of • Clinical training package.

Diamonds for people living with hospital and territory. • Telemedicine platform.

Congestive Heart • Provision of real-time Self-Monitoring Blood • Clinical triage and management

Failure Glucose (SMBG) monitoring. protocol.

• Availability of smartphone-connected • Algorithm integrated into the Decision

glucometer modified for USB cable connection Support System.

to smartphone reduces error as blood glucose • Extended role of clinicians' education readings are not manually entered into the and training package.

App.

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• Automated adjustment of insulin dosage through DSS algorithm which improves patient safety.

• Provision of immediate feedback on patient uploaded glucose readings Increases

acceptance of tele-monitoring by patients and care practitioners.

• Existence of tool to allow verification of the appropriateness of SMBG in relation to the diabetes status, accessible by the payers as well.

• Patient empowerment through the direct access to data on their diabetes status.

• Update of existing clinical and technical

protocols.

• Workforce training.

• Regular evaluation of the satisfaction of

healthcare professionals, patients and

caregivers.

• Improved communication between GPs &

Specialist.

• Early involvement and engagement of all

stakeholders involved, including the patients,

caregivers, health and social care partnerships.

• Using evidence-base for implantable

cardioverter-defibrillator (ICD) from EU project

(More-Care).

• Introduction of system based on primary care

nursing.

• Creation of new telemedicine physician and

nurse dedicated roles; including the provision

of training for these roles.

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• The central control room which receives the tele-monitoring data minimises risk of a staff member not having access to the full historical data and enables appropriate staff member to respond to any alerts as necessary.

• Providing intervention safety reassurance to patients.

29 CKD Puglia, IT Integrated • ICT regional structure, with privacy and • Diagnostic and therapeutic protocols. Integrated telemedicine securing systems. • Telemedicine integrated CKD clinical care platform for • Provision of a home-based renal dialysis pathway.

predictive medicine, platform which enabled two-way dialog • Centralised Control Room to support telemonitoring and between patient and remote renal specialist regional roll-out and beyond of CKD patient increased acceptance by patients and care multiple telemedicine applications. empowerment practitioners of telemedicine solution and

service redesign. • Dedicated telemedicine clinical specialists. • Accurate information on telecommunications

infrastructure capability of patient’s home which reduced unnecessary staff resources spent on resolution of technical problems as well as increasing acceptance by patients of telemedicine solution.

• Clinician led telemedicine integrated CKD pathway development.

• Patient empowerment through the introduction of edu-games & social networks that are part of the platform.

• Training of care and case managers, nurses and physicians – new professionals

responsible for the virtuous paths between hospital and territory, including the availability of training facility.

30 Smartaging Puglia, IT Primary and • Existence of telecom platform and inclusion of • Telemedicine algorithm that analyses

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Mindbrain secondary the interventions in the existing platform. biomarkers that meet international prevention and early • Automated feedback report to patients on guidelines for early diagnosis and

diagnosis of their lifestyle and physiological measurements monitoring of Alzheimer’s Disease. cognitive decline and rather than clinicians' time being used. • Automated algorithms for feedback Alzheimer’s disease • Dedicated telemedicine clinical specialists on patient’s behaviour and based on • Adequate training and support for older physiological parameters. computerised patients, including training facilities. analysis of • Providing data privacy policies for patient biomarkers in 50-64 reassurance.

year olds. • Patient empowerment through the

instructions on healthy lifestyle. • Building on the success / outcomes of previous

FP 7 European projects.

Diagnostic and Lazio Region, IT Identification of the • Focus on chronic diseases with high impact The model is care pathways population affected on diagnostic and therapeutic case(PDTA)/

by diabetes and management • transferrable to other areas

COPD using • Evidence based diagnostics and treatments • expandable to other chronic Houses-ofinformation of • Patient-friendly care delivery (spatial conditions (heart failure and health health information proximity of different disease related anticoagulant therapy are currently

systems services being developed Definition of • Multidisciplinary teams evidence based • Integration between health and social recommendations services for most efficient • Commitment of the regional and patient-friendly government to reinforce quality of care and

standardised case

management for efficiency, reducing at the same time

diabetes and COPD operating costs of primary-care services

Re-organisation of • Involvement of relevant chronic care in the partners/stakeholders

Lazio region Integration of care for chronic disease

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management in primary care facilities which integrate the essential levels of health and social services

Integrated Autonomous Patients: self• Implementation as a coordinated effort of • High scalability and replicability of Care Model Province of management of local policy makers, the regional healthcare the TreC platform for Patients’ Trento, IT health information trust and the research perspectives in the (transfer already ongoing at

Empowerment and access to Trentino Region, with the common mission regional, national and international

in the Trentino medical reports of improving health and wellbeing services

Region Healthcare provided to the population in a systematic, level)

through the providers: facilitates coordinated and sustainable way • easily adaptable to different social, TreC Personal delivery of quality • TreC has been developed following a Living organizational and institutional Health Record health applications Lab approach, informed by the direct contexts and services to the involvement of groups of citizens, clinical • assessment of short and long term

population stakeholders and public-private entities for effects on deployment of innovative integrated care of the implementation and validation of its technologies for health

chronic patients innovative services through an advanced • 67K citizens using the platform PHR ecosystem • over 65K healthcare service reservations in Disease specific 2016 cross-institutions • 1475 payments of medical services per year experimentation • 1077 changes of primary care physicians per (currently on year

Diabetes and oncology with other municipalities such as Forli, Bergamo) Currently over 65K citizens using the platform as regular

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target users.

Telemonitorin Veneto Region, Target on population • Access to health facilities only when needed • Results can be applied at national or

g for IT affected by

Congestive • Faster turnover of patients

regional level Congestive Heart

Heart Failure Failure (CHF) • Clinical benefits in terms of decrease in • Transferable to a larger population

(CHF) hospitalizations (most patents managed at

with the same clinical

Randomised home) characteristics with a substantial Controlled Trial: 315 • Service proves to be cost effective (savings savings estimates

patients recruited per patient> 600 €) • Expandable to other Italian regions

and randomized • Reengineering of the organisation of • Already transferred to other

(2:1) for intervention telemonitoring services for individual case countries through a European group (followed with management project (U4H)

telemonitoring • Privacy policy guaranteed • Implementation of the service at

services) and control

group (usual care) • Involvement of caregivers

regional level in Veneto, with a potential coverage of about 70.000

Patients equipped • Patient empowerment and training patients per year

with a Personal • Patient self-management

Health System (wristband device, digital weight scale for clinical data collection, personal alarms device for 24/7 real time emergency detection)

Data automatically transmitted to the Regional eHealth center (management through contacts with ER department, the Social Services,

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Physicians or family)

31 Walcheren Walcheren, NL Target population: • Involvement of all parties in the • Possibility for care-providers to Integrated frail older people development, implementation and become acquainted with the model. Care Model living independently dissemination of the model & formalisation They can make use of the

(WICM) of agreements between parties. instruments and protocols and they

A comprehensive o Broad involvement and experiences of can attend studies in order to work integrated model for health professionals. according to the model. the detection and o The GPs in this project are also involved • Various strategies can be used in assessment off with developing the dementia careorder to transfer of knowledge and needs and the chain. Their personal involvement in implementation: assignment and both projects will guarantee o a manual with a description of evaluation of care harmonisation. the WICM, the conditions for for independently o Knowledge obtained in the region putting the model into practice, living frail older regarding instruments and collaboration the instruments used, protocols people. that includes older people. A pilot and function descriptions for involving older people aged 85+ years the new functions (in Dutch); and consultations with older patients o conferences and presentations aged 65+ years. on the model and evaluation of • Laying down the basis for collaboration in the model; the formalisation of agreements on the o national and international

regional policy. publications;

• A Joint Governing Board that provides the o newsletters to care-providers, necessary provider network. organizations for the older

• Central steering from a steering group in people and interested parties which all parties are represented, ensuring (in Dutch);

coherence between various projects. o presentation of the results on • A project group to guide and monitor the the web-site;

implementation. o personal discussions with • Strong project leader. interested parties;

• Finances to implement and work according o each year the executive GPs will

to the model. provide a course for their

colleagues, with input from a

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nursing home doctor and a clinical geriatrist;

o training of geriatric nurse

practitioners. 32 Buurtzorg various locations, Nurse-led • A back office to deal with admin and

model NL community care in bureaucracy, freeing nurses to get on with collaboration with their jobs.

primary care. • Very flat structure with benefits in: Integrating nursing, o Trust (no hierarchy – no managers) medical and social o saving overheads (only 8% compared care services. with an average of 25% elsewhere), with Target group: older cost-savings re-invested into care and people with multiple innovation. pathologies, may • IT systems to share information, problems have symptoms of and ideas among nurses from across the dementia, may have country – nurses can easily network with the been discharged back office.

from hospital • Training programmes with dedicated budget recently and may be and nurse coaches who offer professional chronically or support.

terminally ill. 33 Esther Jönköping, SE Patient-centred care • Leadership and a new working culture • The model has been replicated in

Network for chronic disease leading the health system transformation. Singapore and San Francisco. patients with • Person-centred approach. • Kent (in England) is currently in the complex health • Making improvements together with process of adopting elements of this needs. partners. model.

Coordination of • Communicating systems and use of primary, hospital, transparent data to create overall home and social understanding and possibility to learn and care. The system react. brings together • Shared responsibility. doctors, nurses, • Openness and learning; “coach training pharmacists, social courses”.

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workers and • Trust and less hierarchy - letting go of the

occupational need to control, an ecosystem of trust.

therapists.

34 My Plan Norrbotten, SE Patient • Development of new workflows. • Staff new ways of working training

empowerment in the • Education & training for workforce. programme.

hospital discharge • Introduction of new supportive technology.

planning process and home care planning

35 Care process Norrbotten, SE Early intervention • Collaboration & improved coordination of all • Education & Training Programmes. for and treatment for stakeholders involved. • Organisation of care pathways for the schizophrenia patients with • Education and training for patients and patients with schizophrenia or

and schizophrenia or relatives. schizophrenia-like states.

schizophreniaschizophrenia-like • Holistic understanding of the patient and their like state states health and wellbeing. • Co-creation of care plan and its regular evaluation.

36 Distance Norrbotten, SE Remote care for • Identifying the organisational change • Knowledge of infrastructure required

spanning patients in rural elements – new ways of working & new at baseline together with maturity healthcare areas opportunities for both planned visits and and readiness of workforce to adopt acute assessments. technical solutions. • Long-term workforce education plan in place. • Workforce digital literacy competency • Meeting the strategic objective of providing requirements. equity of access to services. • Digital literacy requirements of • Carrying out a cost-analysis to establish the patients. economic case which considers the costs • Information campaigns & marketing incurred by patients and their families in about the services. having to travel to receive care and treatment as well as costs incurred by the system if clinicians have to travel to the patient’s home. • Provision of secure VPN video solution assisted by nurse rather than just telephone. • Reliability of technology solutions.

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• User and patient-participation. • Public awareness and communication activities to promote the service (money & time to conduct information campaigns). • Readiness of the environment / system for the implementation of such a practice.

37 Patient Norrbotten, SE Rapid access to • Person-centred, multidisciplinary, • Clinical protocols. journey emergency medical collaborative decision making. • Redesigned care pathways and new through care for older people • Model which recognises and builds on the ways of working. emergency competencies and capabilities of the patient. • Roles, responsibilities and medical care • Identification of care transitions and ensuring competencies of paramedics.

information flows between them. • Education and training programme. • Availability of patient folder. • Improvement work.

• Making improvements to the whole care pathway rather than just parts of it and this has involved gaining commitment from many stakeholders from different care sectors.

• Ongoing achievement-led approach to meetings and sharing good practices and improvement work.

38 Shoulder Norrbotten, SE Remote • Existence of IT infrastructure (distance • The possibility to introduce the rehabilitation rehabilitation care equipment) to allow distance rehabilitation at service as complimentary to the via distance patients’ homes. existing services.

technology • Safety of the communication programme. • Incentives and motivations for the patients to use the service.

• Stratification of the patients (identification of the “right” patients for the service.

• IT professionals are directly connected while the service is delivered to ensure the reliability of technology.

5169/17 ADD 1 LA/pm LIMITE 96

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Better life for most ill older people. from a patients’ point of view. through performance-based bonuses the most sick • Political mobilisation. could be transferred to other older people Cooperation • Demonstrating positive outcomes of the countries in Europe especially to between home care, project to convince all counterparts to those, where municipalities have a primary care and introduced changes. role in the health and social care hospital care to • Quality registers allowing comparison systems. better coordinate between units facilitated continuous learning, • The establishment of improvement care of the most ill quality improvement and management of leaders and leadership forums as an older people. services. “informal” intervention could be • Benchmarking exercise facilitating allocation easily transferred to other contexts, of performance-based financial bonuses. where the organisational culture has

• Establishment of improvement leaders and the absorptive capacity to embed this leadership forums. innovative way of engaging health

professionals. • Starting at the local leadership level

by arranging forums for discussions and decision-making across the organisations.

40 North West London, England, Integrated care for • Joint governance through an integrated London UK the highest risk, management board made up of

most vulnerable representatives of all providers. patients. o Shared performance and evaluation Involving framework. professionals from o Agreed goals and outcomes. community health, o Engagement of the local authority. mental health, • Pooled budgets for integrated primary care, commissioning, with shared risk approach secondary care, and capitation payment to cover all patient social care, care. community • Service providers collaborate with lay pharmacy and partners (patients, users and carers) to specialist nursing. develop the care model. o Patient, user and carer engagement in

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co-design through reference groups, workshops and surveys.

• Track and evaluate the performance of GP surgeries and Multi-disciplinary groups to drive competition and share best practice.

• Teaching and training provided; commitment to adaptive learning.

• Significant investment in senior management leadership and dedicated programme

support, along with the active involvement of patients.

• Leaders successfully engaging with the workforce and enabling them to work together towards achieving positive

programme outcomes.

o Strong clinical leadership, in particular

that of the GP, played a central part in ensuring effective participation and engagement of other clinicians.

• Multi-disciplinary groups meet monthly as case conferences with the aim of improving the care of most complex cases.

• Clinical protocols and care packages developed for each patient group, ensuring standardisation of best practice.

• Single IT platform for information sharing across organisations.

• IT system implementation timelines must accommodate considerable leeway for

refinement and unexpected complexity. 41 Torbay Torbay, England, Patients with • Governance: Aspects that can facilitate transferability

UK complex mix of o Formal agreement between Torbay of this approach: health and social Council and Torbay Primary Care Trust • A clear vision on making a positive

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care needs, typically to establish joint governance through a difference for service users. the most complex single management structure (Torbay • Start from the bottom up by and vulnerable older Care Trust, a fully integrated NHS bringing together frontline teams people. organisation) responsible for and align these teams with general Integrated multicommissioning and providing practices and their registered disciplinary teams, community health and social care populations. which work closely services. • Consider how simple and with primary care, o NHS funding was used for (new) social inexpensive innovations like the and specialist health worker posts, at a point when no appointment of health and social services to manage funding was available from the local care co-ordinators can make a major the care of the council - assuaging some concerns from impact. populations they council staff about integration • Examine evidence from elsewhere, serve. threatening investment in social care. appraise own performance, build • Establishment of integrated, co-located communication and teamwork health and social care teams, with a strong between stakeholders, manage emphasis on multi-professional leadership risks. and development. • Integrate support services (including also intermediate care) from the bottom up around GP registration (rather than home address) to simplify access and facilitate team working and co-ordination. • Prioritise continuity of care at home, with intermediate care provision and hospital discharge processes tied in to support it. • Health and social care coordinator role introduced, with a single point of contact in each area/locality, co-ordinating health and social care. • Investment in local leadership programmes, with committed leadership team. Change relied on leadership across health and social care providers.

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• A large degree of continuity among senior leaders and organisational stability.

• Stakeholder engagement and empowerment:

o Staff engagement in all work streams of

the integration process.

o Empowering users & carers using focus

groups, journey mapping & interviews.

o Increasing use of personal budgets &

direct payments.

o Keeping patients and service users at

the centre of the vision for improvement.

• Local teams manage integrated budgets – financial risk sharing. Capitated budget for health services, and an annual agreement with Torbay Council for Social care spend.

• Systematic review of the literature highlighting the organisational, cultural and professional, and contextual issues that created barriers to joint working - this awareness enabled effective action to avoid them.

42 Integrated Northern Ireland, Integrated Citizen • Political support: a governmental initiative for • Both service users and their carers Citizen UK Centred Health and a citizen-centred approach through a care were heavily involved in the

Centred Social Care for Older reform strategy. development of the NISAT.

Health and People o The policy is built around stakeholders' • Project structure – the NISAT project

Social Care for engagement and based on consultations. office was based in and reported Older People Based on the use of The government worked together with through health and social care the Northern the voluntary sector, which engaged structures. This ensured that the Ireland Single directly community, statutory and focus was on service user and carer Assessment Tool voluntary organisations as well as older needs with direct input from health (NISAT) people. and social care professionals.

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• The government allocated funding for the development of the NISAT as well as a

significant proportion of the funding for its implementation.

• Direct care payments were introduced to enable people to "buy their own care" and make decisions for themselves.

• Clear objectives and close working relationships between key stakeholders.

• Both service users and their carers were heavily involved in the development of the NISAT.

• User groups were established, training needs identified and a regional training strategy

developed and implemented. • A dedicated, representative project team

responsible for implementation, with dedicated local implementation officers to support the central implementation teams.

o This has the dual purpose of maintaining

momentum during a period of change and conflicting priorities and providing local and regional support through knowledgeable ‘hands-on’ project management.

o Local support officers were funded in

each of the Trusts with responsibility of ensuring that the system and associated processes were integrated into daily practice by local training, working alongside staff and providing frontline support.

• Change management was addressed through:

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o agreeing strategic and operational

objectives along with responsibilities;

o developing and implementing an agreed

operational plan;

o developing and executing a

communications strategy and a regional training strategy.

43 Integrated Northern Ireland, Integrated health • Political decision to procure an end-to-end • The end-to-end Managed Service Long Term UK and social care to managed system for remote telemonitoring. model is a useful model for

Conditions support people with • Involvement of a range of key stakeholders, developing services which require Management long term conditions including political representatives, across a innovation and flexibility (end-to-end for Older across all care range of participatory meetings and events. means that the contract is for the Citizens settings. • A business case was developed outlining: provision of a service, including Management of definition of the service to be delivered; the clinical triage, and not simply a patients with chronic strategy for delivery of the remote purchase of patient equipment and conditions through telemonitoring service; roll out plans; software). more emphasis on resources required. o It provides for a collaborative prevention and • For the telemonitoring contract, five Health approach with the provider. It management in the and Social Care Trusts were closely involved in also provides the capacity and community, the specification and design of the service capability to flexibly manage and patient education, procured and in the selection of the grow the service be it during ad GP screening, contractor to deliver this service. hoc periods of increased demand monitoring, • Patients and carers opinions were also sought or as growth develops over time. use of supportive throughout the process and they were technology and risk involved in assessing the patient equipment assessment and being offered by various bidders for the stratification. contract.

• Telehealth Service Managers were appointed in each Trust to engage with stakeholders,

develop and lead the service; frequently meeting with clinicians to deploy and share knowledge.

• Dedicated resource to manage and develop

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the service – the Trust Telehealth Service Managers have been instrumental in engaging with staff as well as looking at opportunities to embed learning for the service.

• Senior management sponsorship – Trusts that have benefitted from the service have been

those who have a clear view of how they wish the service to be deployed.

• Sharing of best practice and knowledge across

the different Trusts.

• Partnership and collaborative working

between the Trusts and the provider.

• Flexibility within the service to support

innovative use by healthcare professionals as

well as suit the needs of the different profile

of patients with long term conditions who may

be at different stages of their disease.

44 Integration of Scotland, UK People with multiple • Legislation which promotes cross-sectorial • The type of analysis (which allows to

health and complex needs strategic planning to meet the needs of see the amount of resources that is

social care in population/care groups, placing the spent on the population, the

Scotland patient/service user at the centre of care balance between hospital and

planning and provision. community settings, with data also

• Existence of Integrated resource framework. analysed at various geographic

• Dedicated funding to support the “change” levels, including GP practice) is easily

(Change Fund) & a wider integration agenda. transferable to other regions and

o an accelerant in changing attitudes, countries.

cultures and behaviours;

o an important element in helping

partnerships develop joint working and implement strategic joint commissioning.

45 SPARRA/ACP Scotland, UK National Risk • Government support and political consensus • The challenge of predicting the risk of

Patient Prediction among the parties committed to health and emergency admission is applicable to Centric Tool to identify social care issues. all chronic care systems. The SPARRA

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Integrated patients at risk of • Combined responsibility for planning and tool uses national datasets to provide Care approach future emergency delivery of acute, primary and community information at a local level to support

hospital admission services within the Community Health targeting of services on a geographic and readmission. Partnerships. and an individual basis. The • Strong governance mechanisms established at anticipatory interventions can be Anticipatory Care both national and local level. locally contextualised. Planning (ACP) • A strong performance management culture • The most favourable contexts where approach that within the NHS. the SPARRA/ACP case could more

designs, implements • Adoption driven by a range of multimedia easily be transferred are those where and monitors the learning resources and good practice a well-established Community Health most suitable examples. Support for adoption levered Partnership exists. intervention through the Change Fund (national • Transferability to other EU countries according to the investment) and the GP quality contract. may be compromised by the degree of hospital • Initial prototype continually refined from specificity of the approach and the admission risk of the learning by early adopters. need for the calibration of a risk targeted patient. • Strong leadership, engagement of care stratification tool that supports the

professionals and a network of champions for identification of target patients.

Focus on preventive implementation across the country.

care management, • Development of ICT solutions to exchange and in particular, on information across care settings (Key chronic disease Information Summary).

management to avoid the risk of unplanned hospital admission.

46 Technology Scotland, UK A patient-centred • Political commitment and central funding: • Creating a Learning Network (or Enabled Care Integrated Care o A change in policy context, which something similar) to support areas in Programme management required a shift from a system oriented their implementation. Learning and process targeting the towards hospital-based treatment to a sharing of both what works and what 65+ population in system based on preventive care to doesn’t work.

the country. manage long-term conditions. • A resource library of freely available It particularly o Policy initiative from the national webcasts. addresses vulnerable government, with the provision of a o Re-useable content: several

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subgroups of development fund and associated webcasts have been reused in patients and patients programme management. undergraduate teaching

with complex o Support of local politicians achieved sessions, hosted on professional

illnesses, with the through a series of engagement events skills websites and used at use of ICT (telecare). and training sessions held by each local learning events for public sector partnership. staff.

o Existence of “digital champions”. o Short duration makes viewing o Strong commitment of both the local webcasts more convenient. authorities and the local health and • Using technology as a delivery social care actors. mechanism (to overcome the o Recognition of the need for change; challenge of accessing learning, from pilots & trials to a national especially from remote and rural approach of scaling-up. areas).

• Well-established local health and social care • Ring-fenced financing that is partnerships, capable of combining primary reportable to ensure full

and community services with a shared accountability and commitment is responsibility for planning and delivery of recommended. personalised home care assistance. • Robust performance monitoring and

• Dedicated support at national & local levels, evaluation should be embedded from consisting of technical support, strategic the start.

planning support, service redesign support • Approach to large-scale mainstream and other expertise drawn when required. adoption.

• Knowledge exchange and learning & sharing of good practice. A Telecare Learning Network

was established bringing together all the leads from each local area on a regular basis to highlight any common issues, challenges and successes.

• Targeted communication strategy with a strong emphasis on embedding Technology Enabled Care into existing service redesign.

• Dedicated programme management at a local level.

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• Standardisation of procurement linked to interoperability, creating the framework for choice to at least ensure that there was not too much variance from area to area.

• Strong performance evaluation culture. • Reward funding model: those doing well were given extra funding, whereas those who had not advanced as much as expected were provided with additional intensive support. • Application of learning from the EU projects and other European / international initiatives. • Information governance in place.

47 Building Scotland, UK • Establishment of a multi-stakeholder • The approach to supporting

Capacity and Telehealthcare Education and Training knowledge transfer (examples of good

Competency Steering Group, which has driven change and practice via the Learning Networks)

for Staff Using produced resources for staff working in across organisational and professional

Technology health, social care and housing services. The boundaries.

Telehealthcare Group also oversees staff who use telehealth

Education and and telecare.

Training • A credible platform from which to influence

Strategy relevant national policy and organisational

strategies impacting on the health and social care workforce.

• National Telehealth and Telecare Learning Network – to promote and support knowledge transfer of good practice, service

developments and innovation. • Collaboration with country-wide colleagues to

develop a Skills Frameworks for staff using assistive technology to deliver services.

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Annex 2: Table A2 Mapping summary of success factors from integrated care experiences in Europe

Success factor Location of integrated care experience

Governance (new entity for management/coordination, Autonomous Province of Trento, joint management, joint governing board, legal Badalona, Basque Country, Belgium, framework, top-down & bottom-up combination, Buurtzorg, Kinzigtal, Lombardy, management structure) London, NW Torbay, Olomouc,

Pardubice, Puglia, Scotland, Southern Denmark, Walcheren.

Stakeholder engagement (regular engagement: in Belgium, Kinzigtal, Saxony, Southern policy formulation; solution specifications, design, Denmark, Basque Country, Badalona, development, implementation and dissemination; Catalonia, N. Ireland, Scotland, NW opinions from patients and clinicians; commitments; London, Torbay, Puglia, Olomouc, feedback; communications strategy) Pardubice, Norrbotten Getafe, Trikala,

Ile-de-France, Walcheren, Emilia Romagna, Valencia, Lazio, Autonomous Province of Trento, Lombardy, Veneto

Patient focus/empowerment (incl. population health, Belgium, Kinzigtal, Southern Denmark, stratification, healthy lifestyle literacy, personal N. Ireland, Scotland, Valencia, budgets, incentives to use the services, co-creation of Jönköping, Torbay, Puglia, Olomouc, care plans, access to data/results, training facilities, Norrbotten, NW London, Basque educational games, social networks) Country, Autonomous Province of

Trento, Lombardy, Emilia-Romagna, Veneto

Organisational change (re-organisation/re-engineering, Belgium, Kinzigtal, Saxony, Southern new structures, dedicated team to implement the Denmark, Badalona, Catalonia, N. change, dedicated support (technical support, for Ireland, Scotland, , Jönköping, NW strategic planning, for service redesign), partnerships, London, Torbay, Puglia, Olomouc, integrated primary care centres, co-located care teams, Norrbotten, Valencia, Trikala, shared responsibilities, objectives and plan setting, Languedoc-Roussillon, Walcheren, standards, pathways, workflows, clinical and technical Campania, Basque Country, Badalona, protocols, new roles/extended roles (e.g., case Skåne, Lazio, Autonomous Province of manager, care coordinators, continuity nurses), Trento, Lombardy, Emilia-Romagna, business process notation, flexible implementation, Veneto incremental pace)

Collaboration and Trust (in design and specifications, Belgium, Kinzigtal, Saxony, Southern among stakeholders [incl. care professionals, patients Denmark, Badalona, Catalonia, N. and voluntary sector], among agencies/authorities, Ireland, Scotland, Jönköping, Puglia, using evidence and learning from other practices and Olomouc, Pardubice, Norrbotten,

EU projects) Valencia, Languedoc-Roussillon,

Campania, Emilia-Romagna, Piemonte, Buurtzorg, Lazio, Autonomous Province of Trento, Lombardy, Veneto

Incentives/Reimbursement/Contracting options Belgium, Kinzigtal, TK, Basque Country, (business case, reward schemes (e.g., performance Badalona, Catalonia, N. Ireland, based financial bonuses), pooled budget, shared risk Scotland, Valencia, NW London, and revenue/profits, bundled payment, capitated Torbay, Olomouc, Skåne, Southern payment, long-term contract, end-end Managed Denmark, Lombardy, Emilia-Romagna,

Service) Veneto

ICT infrastructure and solutions (unique patient ID, Belgium, Kinzigtal, Southern Denmark, broadband availability, health information systems, Badalona, Catalonia, N. Ireland, quality registers, software platforms, data sharing, Scotland, , Buurtzorg, Jönköping, NW

[shared] Electronic Health Records, algorithms, devices London, Puglia, Olomouc, Norrbotten, for use by patients, data from patients, Getafe, Valencia, Trikala, Skåne, telemedicine/telehealth/home telemonitoring, Campania, Emilia-Romagna, Brescia, interoperability, standards, procurement, modular and Lazio, Autonomous Province of Trento, scalable system, information governance – privacy and Lombardy, Veneto security policies, reliability of IT solutions)

Political support and commitment (national/regional Belgium, Kinzigtal, Southern Denmark, policy, legislation, agreements, funding, strategy, vision) Basque Country, Catalonia, N. Ireland,

Scotland, Olomouc, Pardubice, Getafe, Valencia, Trikala, Ile-de-France, Walcheren, Skåne, Emilia-Romagna, Brescia, Lazio, Autonomous Province of Trento, Lombardy, Veneto

Monitoring/Evaluation system (performance Belgium, Kinzigtal, Basque Country, management, performance evaluation, benchmarking) Scotland, Valencia, NW London,

Torbay, Skåne, Lazio, Autonomous Province of Trento, Lombardy, Emilia Romagna, Veneto

Workforce education and training (learning networks, Belgium, Kinzigtal, Saxony, Southern user groups, training strategy – long term education Denmark, N. Ireland, Scotland, plans, skills framework, training on new/extended roles, Buurtzorg, Jönköping, NW London, sharing good practices and knowledge, webcasts, Puglia, Olomouc, Pardubice, prototype refinement, nurse coaches) Norrbotten, Skåne, Brescia, Catalonia,

Valencia, Piemonte, Autonomous Province of Trento, Lombardy, Emilia Romagna

Leadership (senior management leadership, clinical Catalonia, N. Ireland, Scotland, leadership, local leaders/champions, digital champions, Jönköping, NW London, Torbay, leadership programmes, improvement leaders) Olomouc, Pardubice, Walcheren,

Skåne, Getafe, Autonomous Province of Trento, Lombardy

Annex 3. Maturity Model for integrated care

This Annex provides a simple description of the Maturity Model and its dimensions, along with guidance on how to measure maturity, so that an assessment can be quickly carried out.

The Maturity Model has been derived from interviews with stakeholders from 12 European countries, or regions within a country, responsible for healthcare delivery. The many activities that need to be managed in order to deliver integrated care have been grouped into 12 “dimensions”, each of which addresses a part of the overall effort (Table A3)

Table A3 The 12 maturity dimensions for delivering integrated care

Dimension Indicators for assessment of maturity to adopt integrated care

• 1. 

  Readiness to Change Evidence of recognition of compelling need to change.

  Evidence of public consultation and stakeholder engagement. Evidence of vision or strategic plan embedded in policy. Evidence of leaders and champions of change. Evidence of broad political and public support.

• 2. 

  Structure and Evidence of effective planning and management of change, including stakeholder involvement.

Governance Evidence of collective decision-making.

Evidence of regular communication of progress and successes. Evidence of multi-year transformation / integrated programmes with funding and a clear mandate. Evidence of eHealth competence centres or other organisations to select, develop and deliver eHealth services.

• 3. 

  Information and eHealth Evidence of policy to enable digital services.

Services Evidence of infrastructure to enable information-sharing and eHealth / eServices.

Evidence of effective sharing of information and care plans. Evidence of universal, at-scale regional / national information and eHealth services used by all integrated care stakeholders.

• 4. 

  Standardisation and Evidence of clear strategy for regional /national procurement.

Simplification Evidence of unified and mandated set of agreed standards to be used for system implementations.

Evidence of consolidation of data centres. Evidence of simplification of infrastructure. Evidence of ability to view and exchange medical data from different systems across diverse care settings.

• 5. 

  Finance and Funding Evidence of investment and stimulus funds to support the move towards integrated care.

  Evidence of regional / national funding for scaling-up and on-going operations. Evidence of innovative procurement approaches (e.g., PPP, risk-sharing, multi-year contracts for IT service provision). Evidence of sustainability of finance and funding for integrated care.

• 6. 

  Removal of Inhibitors Evidence of awareness of the effects of inhibitors on integrated care.

  Evidence of strategy to remove inhibitors in integrated care. Evidence of actions to remove barriers: legal, organisational, financial and skills. Evidence of existence of the laws to enable data-sharing. Evidence of creation of new organisations or collaborations to encourage cross-boundary working. Evidence of changes to reimbursement to support behavioural and process change. Evidence of education and training programmes to speed up solution delivery.

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Evidence of high completion rate of projects and programmes in integrated care. 7. Population Approach Evidence of use of risk stratification tools to predict future demands.

Evidence of using existing data on public health, health risks and service utilisation. Evidence of a range of care pathways available for different groups of citizens.

• 8. 

  Citizen Empowerment Evidence of policy to support citizen empowerment.

  Evidence of co-creation and co-production of integrated care services. Evidence of incentives and tools to motivate and support citizens to co-create integrated care. Evidence of participation of citizens in decision-making processes. Evidence of citizens’ access to information and healthcare data.

• 9. 

  Evaluation Methods Evidence of establishing baselines (on cost, quality, access, etc.) in advance of new service introduction.

  Evidence of systematic measuring of the impact of new services and pathways using appropriate methods. Evidence of generating evidence. Evidence of a systematic approach to evaluation, responsiveness to the evaluation outcomes and evaluation of the desired impact on service redesign.

• 10. 

  Breadth of Ambition Evidence of integration within the same level of care (e.g. primary care).

  Evidence of integration between care levels (e.g. between primary and secondary care). Evidence of fully integrated health and social care services.

• 11. 

  Innovation Evidence of plan / strategy to encourage innovation.

Management Evidence of mechanisms / governance to capture innovations.

Evidence of enabling an atmosphere of innovation from top to bottom, with collection and diffusion of best practice. Evidence of learning from inside the system, as well as from other regions, to expand thinking and speed up change. Evidence of involving universities and private sector companies in the innovation process. Evidence of using innovative procurement approaches (Personal Contract Purchase, Public Private Partnership, , etc.) Evidence of using European projects.

• 12. 

  Capacity Building Evidence of systematic approaches to capacity building for integrated care.

  Evidence of tools, processes and platforms to allow organisations to build their own capacity. Evidence of continuous evaluation of service improvements. Evidence of systematic learning about integrated care, ICT, change management and others. Evidence of cooperation on capacity building. Evidence of knowledge sharing. Evidence of skills being retained.

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By considering each dimension, assessing the current situation, and allocating a measure of

maturity within that domain (on a 0-5 scale), it is possible for a national or regional care

authority to develop a “radar diagram” which reveals areas of strength, and also gaps, in

capability that require attention.

• 1. 

  Readiness to Change

Assessment scale:

0 – No acknowledgement of compelling need to change

1 – Compelling need is recognised, but no clear vision or strategic plan

2 – Dialogue and consensus-building underway; plan being developed

3 – Vision or plan embedded in policy; leaders and champions emerging

4 – Leadership, vision and plan clear to the general public; pressure for change

5 – Political consensus; public support; visible stakeholder engagement.

• 2. 

  Structure & Governance

Assessment scale:

0 – Fragmented structure and governance in place

1 – Recognition of the need for structural and governance change

2 – Formation of task forces, alliances and other informal ways of collaborating

3 – Governance established at a regional or national level

4 – Roadmap for a change programme defined and broadly accepted

5 – Full, integrated programme established, with funding and a clear mandate.

• 3. 

  Information & eHealth Services

Assessment scale:

0 – Information systems are not designed to support integrated care

1 – Information and eHealth services to support integrated care are being piloted

2 – Information and eHealth services to support integrated care are deployed but there is not yet region wide coverage

3 – Information and eHealth services to support integrated care are available via a regionwide service but use of these services is not mandated

4 – Mandated or funded use of regional/national eHealth infrastructure across the healthcare system

5 – Universal, at-scale regional/national eHealth services used by all integrated care stakeholders.

• 4. 

  Standardisation & Simplification

Assessment scale:

0 – No standards in place or planned that support integrated care services

1 – Discussion of the necessity of ICT to support integrated care and of any standards associated with that ICT

2 – An ICT infrastructure to support integrated care has been agreed together with a recommended set of information standards – there may still be local variations

3 – A recommended set of agreed information standards at regional/national level; some shared procurements of new systems at regional/national level; some large-scale consolidations of ICT underway

4 – A unified set of agreed standards to be used for system implementations specified in procurement documents; many shared procurements of new systems; consolidated data centres and shared services widely deployed

5 – A unified and mandated set of agreed standards to be used for system implementations fully incorporated into procurement processes; clear strategy for regional/national procurement of new systems; consolidated datacentres and shared services (including the cloud) is normal practice.

• 5. 

  Finance & Funding

Assessment scale:

0 – No additional funding is available to support the move towards integrated care

1 – Funding is available but mainly for the pilot projects and small scale implementation

2 – Consolidated innovation funding available through competitions/grants for individual care providers

3 – Regional/national (or European) funding or PPP for testing and for scaling-up

4 – Regional/national funding for scaling-up and on-going operations

5 – Secure multi-year budget, accessible to all stakeholders, to enable further service development.

• 6. 

  Removal of Inhibitors

Assessment scale:

0 – No awareness of the effects of inhibitors on integrated care

1 – Awareness of inhibitors but no systematic approach to their management is in place

2 – Strategy for tackling inhibitors is agreed at a high level

3 – Strategy for removing inhibitors agreed at a high level

4 – Solutions for removal of inhibitors developed and commonly used

5 – High completion rate of projects & programmes; inhibitors no longer an issue for service development

• 7. 

  Population Approach

Assessment scale:

0 – Population health approach is not applied to the provision of integrated care services

1 – A population risk approach is applied to integrated care services but not yet systematically or to the full population

2 – Risk stratification is used systematically for certain parts of the population (e.g. high-use categories)

3 – Group risk stratification for those who are at risk of becoming frequent service users

4 –Population-wide risk stratification started but not fully acted on

5 – Whole population stratification deployed and fully implemented.

• 8. 

  Citizen Empowerment

Assessment scale:

0 – Citizen empowerment is not considered as part of integrated care provision

1 –Citizens are consulted on integrated care services but are not involved in cocreation and coproduction of services

empowerment are still in development

3 –Incentives and tools to motivate and support citizens to co-create health and participate in decision-making processes

4 – Citizens are supported and involved in decision-making processes, and have access to information and health data

5 – Citizens are involved in decision-making processes, and their needs are frequently monitored and reflected in service delivery and policy-making.

• 9. 

  Evaluation Methods

Assessment scale:

0 – No evaluation of integrated care services is in place or in development.

1 – Integrated care services evaluation is not seen as distinct from standard evaluation approaches.

2 – Evaluation established as part of a systematic approach

3 – Some initiatives and services are evaluated as part of a systematic approach

4 – Most initiatives are subject to a systematic approach to evaluation; published results

5 – A systematic approach to evaluation, responsiveness to the evaluation outcomes, and evaluation of the desired impact on service redesign (i.e., a closed loop process).

• 10. 

  Breadth of Ambition

Assessment scale:

0 – Integrated services arise but not as a result of planning or the implementation of a strategy

1 – The citizen or their family may need to act as the integrator of service in an unpredictable way

2 – Integration within the same level of care (e.g., primary care)

3 – Integration between care levels (e.g., between primary and secondary care)

4 – Integration includes both social care service and health care service needs

5 – Fully integrated health & social care services.

• 11. 

  Innovation Management

Assessment scale:

0 – No innovation management in place

1 – Innovation is encouraged but there is no overall plan

2 – Innovations are captured and there are some mechanisms in place to encourage knowledge transfer

3 – Innovation is governed and encouraged at a region/country level

4 – Formalised innovation management process in place

5 – Extensive open innovation combined with supporting procurement & the diffusion of good practice.

• 12. 

  Capacity Building

Assessment scale:

0 – Integrated care services are not included in capacity building

1 – Some systematic approaches to capacity building for integrated care services are in place

2 – Cooperation on capacity building for integrated care is growing across the region

4 – Knowledge shared, skills retained and lower turnover of experienced staff

5 – A ‘learning healthcare system’ involving reflection and continuous improvement.

Fig. A1: Application of Maturity Model in Gesundes Kinzigtal

Readiness to change

Structure and 5

Governance Capacity building 4

Information and 3 Innovation

eHealth service 2 management

1 Standardisation and

simplification 0 Breadth of ambiton

Finance and

funding Evaluation methods

Removal of Citizen inhibitors empowerment Poulation approach

Source: SmartCare project http://pilotsmartcare.eu/home.html

Using these insights, and comparing the radar diagram with those of other regions/countries that have conducted the same exercise, it should be possible for a care authority to seek expertise from elsewhere to fill the gaps in its capability, but also to offer to others its own knowledge and experience from its areas of strength. As such, the Maturity Model can provide opportunities for sharing good practices and mutual learning.

Fig. A2: Application of Maturity Model in Valencia Region, Spain

Readiness to change

Structure and 5

Governance Capacity building 4

Information and 3 Innovation

eHealth service 2 management

1 Standardisation and

simplification 0 Breadth of ambiton

Finance and

funding Evaluation methods

Removal of Citizen inhibitors empowerment Poulation approach

Fig. A3: Application of Maturity Model in Olomouc Region, Czech Republic

Readiness to change

Structure and 5

Governance Capacity building 4

Information and 3 Innovation

eHealth service 2 management

1 Standardisation

and simplification 0 Breadth of ambiton

Finance and Evaluation funding methods

Removal of Citizen inhibitors empowerment Population

approach

Source: SmartCare project http://pilotsmartcare.eu/home.html

Annex 4. Results from the survey on integrated care

In the Summer of 2016 a survey was circulated to the members of the Expert Group to obtain general information on experiences on integrated care across Europe. In the questionnaire, integrated care was defined to include initiatives seeking to improve outcomes of care by overcoming issues of fragmentation through linkage or co-ordination of services of providers along the continuum of care.

The survey was composed of 11 questions (see Appendix of this report) addressing aspects of present challenges and recent initiatives and strategies used to assess integration of care. 22 Member States responded to the survey.

In brief

Despite large variation in health systems design, countries participating in the survey reported a number of similar dimensions and challenges related to integrated care. These include primarily coordination and integration of primary and specialist care, and the coordination of health care and social care.

Reported barriers to achieve more integrated and coordinated care included lack of effective information structures, organisational differences and resistance from health professionals.

Several countries reported that they have no formally designated systematic approach for assessing different aspects of integration of care. However, many reported that systematic approaches are currently being developed or planned for. Four countries responding to the survey provided concrete examples of indicators used for assessing aspects of integrated care.

Survey responses confirmed that integrated care is a complex concept that includes a number of organisational tasks and different organisational levels. The concept touches on issues such as lack of fragmentation within contemporary healthcare systems and of patient (person) centeredness.

Countries outlined the challenges involved with regard to the development of simple and understandable measures at national and regional level in order to measure the range of complex processes involved in integrated care systems. The survey responses suggest that these processes should primarily be addressed and continuously developed at the micro level, i.e. the patient-health care professional interface, with the national and regional levels providing different ways to support this development.

Aspects of integrated care discussed in countries

The most often discussed areas related to integrated care were:

• Co-ordination between primary and specialist care (secondary and tertiary care) (12 countries)

• Co-ordination between health care and social care (11 countries) Other dimensions of integrated care mentioned were:

• Co-ordination between ambulatory and inpatient health care • Co-ordination between providers of different forms of specialist care • Co-ordination between somatic and mental health care • Co-ordination among private and public health care providers

Through enhancing the integration of care, countries hope to more successfully achieve a number of health system aims, including:

• Improve the quality of health care (mentioned by 14 countries) • Improve the efficiency of health care and reduce costs (mentioned by 13 countries) • Improve access to health care services (mentioned by 10 countries)

Croatia, Czech Republic and Malta also mentioned improved patient safety.

Other, more overriding aims mentioned by some countries were:

• Improving the health status of the population (through e.g. increasing health promotion)

• Improving professionals' and providers' satisfaction • Improvement of the long-term efficiency of the health system

Challenges related to implementing integrated care

Countries reported several challenges related to implementing more integrated and coordinated care for patients:

• Limitations of ICT and information structures (mentioned by 12 countries) • Lack of financial mechanisms supporting such systems (mentioned by 10 countries) • Organisational structures (related to the division of roles between departments and between health care professional) (mentioned by 10 countries)

Some countries also mentioned organisational, political and communicative challenges related to the different political levels in the countries. For instance, the Czech Republic reported that the most important challenge was to convince the representatives of regional governments that change was necessary. Greece reported that the main challenge was posed by a lack of a "gate keeping culture" in its health system.

Regarding other aspects of patient-centred care, the most common challenges mentioned were:

• ICT and information structures • Resistance from health professionals to change work practices and to cooperate • Health literacy and patient participation

There appeared to be a general call for compatible ICT solutions and enhanced possibilities (also legally) to link patient data in order to set up effective integrated care systems. Several countries also considered change of management schemes, introducing new clinical guidelines and new patient’s pathways as conditions needed to set up effective integrated care systems. Belgium and Croatia further mentioned education and training of health professionals in integrated care and multidisciplinary collaboration.

National or regional initiatives addressing integration of care

Most countries reported working continuously with several initiatives in parallel to strengthen integration and coordination of care. Many countries have taken initiatives on legislation, reorganisation and reimbursement systems. Several countries reported having carried out pilot-projects, implemented targeted programmes and strategies and adopted methods for cooperation.

Some examples include:

• Austria aims to strengthen primary care through the establishment of primary care networks and centres. These newly established health care structures are intended to enhance the integration and coordination of care. A similar initiative has been taken in Malta, where polyclinics in the public primary health care system and a number of specialised clinics that serve to interface directly with hospital services while providing care in the extramural setting, have been developed.

• Belgium has concluded “Conventions” (agreement) for functional rehabilitation to finance the holistic care of patients with chronic diseases that has an impact on their psychological health, social or work (or school) functioning.

• France introduced a regional intervention fund that made possible the gathering of financing from different sources. It also introduced a pilot bundled-payment project for chronic kidney disease, whose results are expected in 2017.

• Finland prepared a health and social care legislative reform that includes a framework for initiatives to strengthen the integration of care.

• Germany has implemented disease management programmes, i.e. structured care programmes for chronically ill persons.

• Italy has approved a national plan on chronic diseases identifying the different steps from risk stratification of the population to active medical enrolment within specific pathways of care.

• Luxembourg has introduced a “médecin referent”, a primary care doctor whose role is to coordinate care for their patients.

• Malta highlighted its diabetes shared-care programme to be among the most advanced initiatives; the programme involves training general practitioners and delivering diabetes clinics in line with a shared care protocol developed with the diabetes department of a hospital.

• The Netherlands reported the development of new health care standards (i.e. on diabetes, dementia, obesity, COPD, etc.), and of the programme of national care for elderly. It is also implementing bundled payment models for chronic diseases (e.g. diabetes, COPD) and for pregnancy and childbirth.

• Portugal has implemented a national hotline supported by nurses.

To strengthen other aspects of patient-centred care countries reported various initiatives, for example:

• Reorganisation and reimbursement systems (Bulgaria) • Implementation of territorial local support platform (France) • Different pilot projects (Germany) • Introduction of an electronic health card (Germany) • Decentralisation of health, LTC and support services to local authorities (The Netherlands) • Introduction of law on Patient´s Rights (Luxembourg) and a Patient law (Sweden) • Workshops and conferences (Poland)

Approaches to assessing performance of care integration

Most countries reported that they do not have, at present, a systematic approach in place that is explicitly designed to assess and evaluate the development of coordination and integration of care. However, many reported that such systematic approaches are currently being developed or planned for. Examples of existing approaches that were reported to be of potential applicability in the context of assessing the performance of integration of care:

• An outcomes framework related to a specific health care reform which includes certain indicators (Austria)

• A cancer registry (in relation to integrated cancer care) (Luxembourg) • Indicators developed in the context of the innovation fund (Germany) • Organisation developing integrated information systems to allow monitoring integrated care: EKSOTE in the South Karelia Social and Health Care District in Finland.

Four countries that responded to the survey (Austria, Belgium, Sweden and the United Kingdom) provided concrete examples of indicators that can be seen to reflect aspects of integration. Reported indicators are typically currently included in countries’ general frameworks for HSPA rather than forming part of an explicit assessment framework for integrated care (e.g. Belgium, Sweden, Italy).

A number of countries reported that they currently are planning to develop relevant indicators.

More examples of experiences at national and local level are provided in the countries’ replies presented in the Appendix.

Annex 5. Examples of potential measures of people-centred and integrated

health services as compiled by WHO (2015)

Domain Examples of potential indicators

• 1. 

  System-level measures of community well-being and population health

  Amenable mortality Deaths considered avoidable through health care [1]; excess winter deaths [2]; excess mortality for people with severe mental illness and schizophrenia [3]

  Healthy lifestyles smoking rates [1]; levels of obesity [1]; % population experiencing positive mental health/engaged in responsible sexual behaviour/engaged in substance

  misuse/engaged in healthy behaviours/experience injuries (incl. self-harm) [1] Population health Mortality from chronic disease; low birthweight births [1]; vaccination coverage

  (influenza older people [1,3]; measles and pertussis in children [3])

• 2. 

  Service proxies for population health outcomes

  Hospital admissions # emergency admissions (by age and risk group) [2]; avoidable admissions/ambulatory care sensitive admissions (ACS) [2] in children and older people (asthma, COPD, heart failure, angina, diabetes, bacterial pneumonia, urinary tract infection) [1, 3]]; risk-adjusted acute care hospitalisation rates [4] (incl. for ACS [5]); average length of stay [1]; occupied bed days [1]

  Hospital readmissions People with multiple admissions per year by age and prior condition [2]; readmissions for selected groups [2] (diabetes, heart failure, mental health) [1]; unplanned readmission [1]; overall # readmissions [3]

  Community-based care Persons discharged from hospital for rehabilitation [2]; death after discharge from suicide among people with severe mental disorders [3]; quality of family planning services (e.g. contraceptive methods mix offered in care facilities) [5]

  Patient safety Reduction in adverse events [1]; unintended harm from medications in people aged >65 dispensed with 5+ long-term medications [1]; NSAID use in older

  people [1]

• 3. 

  Personal health outcomes

  Quality of life Self-reported quality of life [2]; carer reported quality of life [2]; improved mental health status and mood

  Independent living % older people (>65) who remain in own home after 91 days of discharge from hospital into rehabilitation [2]; injuries due to falls in older people (>65) [2]; %

  people with fragility fractures recovering to their previous levels of mobility [2]; improved mobility and independence (EQ5D)

  Self-management % people feeling supported to manage their (long-term) condition [2]; people aged >65 with >8 long-term conditions [1]; management of risk factors in chronic disease (e.g. blood glucose and cholesterol in people with diabetes; blood

  pressure control in people with stroke, TIA, heart disease, chronic kidney disease, hypertension; diet, nutrition and weight management in under/overweight) [QOF]

• 4. 

  Resource utilisation

  Hospital utilisation Bed days for selected patient types [2]; hospital use in last 6 months/100 days of life [1,2]

  Residential and long-term care Gross residential and nursing care expenditure per # older population [2]; # utilisation receiving long-term community-based care as % of all people receiving long-term care [2]; # receiving social care as % of (# receiving emergency hospital care + # receiving long-term social care) [2]; # receiving long-term community-based social care/population [2] Primary care utilisation Enrolment in general practice/primary care practice (incl. for infants in first 4 weeks of life) [1]

  Health care costs Per capita health care costs [1]; rational use of finite resources/value for money and effectiveness [1]; GP referred pharmaceutical expenditure [1]; alignment of resources to population needs [3]

  Balance of care Ratio of primary care professionals (e.g. GPs) to specialists; relative spend on primary, community, secondary and tertiary care

• 5. 

  Organisational process and system characteristics

  Access to care Improved access to primary care services/GPs [2]; access to health care [1] (incl. % in general practice, screening, time to access GP or community services,

  timely initiation of care [4], waiting times for urgent treatment esp. cancer, severe mental health access, waiting time for elective treatment)

  Hospital use Attendances in accident and emergency [2], attendances at A&E without hospitalisation [4], acute care hospitalisations [4]

  Care transitions Delayed transfers of care from hospital [2], transition record with specified element received (hospital to home or other site of care) [4], timelines of transition (hospital to home or other site of care) [4]

Domain Examples of potential indicators

Care planning Holistic needs assessment; personalised care plans; advanced care plan [4] Medications management Medication review in older adults [4]; medications reconciliation [4]; medications conciliation post-discharge [4]

Care coordination Primary health care organisations currently coordinating patient care with other health care organisations using protocols [5]; quality of care processes based on best practice guidelines (incl. integration of care across settings as assessed

through chart reviews, medical records) [3, 7]; quality of clinical integration or coordination in multi-professional teams as assessed by surveys [7]; administrative communication (incl. % patients transferred to other health care facility whose medical documentation indicated communication of administrative information prior to transfer) [4]; presence of coordination activities [3] (e.g. clarity of responsibilities, facilitate transfers across settings, assess needs and goals, proactive care plans, support for self-management, monitor & follow-up, home care support, multidisciplinary teams in primary and community care, case management, disease management, ICT enabled communication)

• 6. 

  User and carer experience

  Experiences Improved people’s experiences of car [1,2]; patient-reported satisfaction with coordination/integrated care [2,3]; % service users who said that services

  received made them feel safe and secure [2]

  Continuity of care % service users which report that they have as much social contact as they would like [2]; person/family report confusion or hassle [4]

  Supporting holistic goals and % people dying at home/their place of choosing [2]; % people with long-term outcomes conditions reporting they had enough support to manage their conditions [2]; % people who feel confident in managing their own health [2]; people reporting that all their needs were taken into account [8]; people reporting that they were supported to achieve their own goals [8]; people reporting that the care they received helped them to live their life to the best of their ability [8]; carers and family members needs taken into account [8] Communication and Ability and knowledge on who to contact for care (esp. out of hours) [7]; doctor information spending enough time with patient [6]; doctor giving easy to understand explanations [6]; doctor giving time to raise concerns [6]; people reporting that they were always kept informed about next steps in their care [8]/the professionals involved talked to each other and worked as a team [8]/knew who was the main person in charge of their care [8]/had one first point of contact [8] who understood the person and their conditions [8]/could go to the care professional with questions at any time [8]/had the information and support needed to remain as independent as possible [7,8]/access personal health and care records at any time (incl. ability to decide who to share with and correct mistakes in information) [8]/information given at the right time and appropriate to person’s condition and needs and easy to understand and up to date [8]/told about their services available (incl. support organisations) [8]/not left alone to make sense of information [8]/ability to meet (phone/email) professional when needed to ask more questions or discuss options [8]

  Shared decision making Doctor/nurse involving patients in decisions about care and treatment [6]; people reporting they could choose kind of care and support needed and how to receive it [8]

  Care planning Family or home situation taken into account when planning discharge [2]; participation in care planning [6,7] incl. knowing what is in the care plan [8], care plan entered onto patient record [8], regular reviews of care plan [8],

  comprehensive reviews of medicine [8], care plan known in advance by professionals when using a new service and respected [8]

  Care delivery and transitions Patients’ reports of unnecessary care (e.g. tests, procedures, emergency room visits, hospitalisations) [3]; patient-reported gaps in scheduled care (e.g. missed consultations, medical test or prescribed medications) [6]; clear plan when

  moving from one service to another [8]; transitions undertaken without delays [8#; advance knowledge of care transitions and next steps in care [8]; new service providers knowing details of person and their preferences and circumstances [8]; protection of entitlements to care when moving from one jurisdiction to another [8]

  Emergencies People reporting that they could plan ahead and could stay in control in emergencies [8]; people reporting they had systems in place so they could get help at an early stage to avoid a crisis (or crisis escalation) [8]

Note: [1] New Zealand Integrated Performance and Incentive Framework; [2] Raleigh et al. (2014); [3]

McDonald et al. (2014); [4] NQF (2014); [5]WHO (2014); [6] OECD (2015); [7] Strandberg-Larsen and Krasnik

(2009) 33 ; [8] National Voices (2013) 32

Fig. A4 AHRQ Care coordination measurement framework

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