Approaches to improving integration and care coordination include the Practice Incentives Program, which provides a financial incentive to providers for the development of care plans for patients with certain conditions, such as asthma, diabetes, and mental health needs.
In addition, the Primary Health Networks were established in July 2015 with the objective of improving coordinated care, as well as the efficiency and effectiveness of care for those at risk of poor health outcomes. These networks are funded through grants from the federal government and will work directly with primary care providers, health care specialists, and Local Hospital Networks. Care also may be coordinated by Aboriginal health and community health services.
Brazil has developed organizational frameworks for health care coordination across the regionalized health system, including the following:
- Regional regulatory centers coordinate patient referrals to outpatient specialized, hospital, and emergency services.
- Guidelines for organizing health care networks have been published by the Ministry of Health.
- Financial incentives, care guidelines, and care pathways encourage the coordination of mental health care, emergency care, maternal care, and care for people with disabilities, chronic diseases, and cancer.
- The telehealth program, established by the Ministry of Health, provides remote clinical care and support, reducing costs for patients and expanding the capabilities of family health teams.
However, integrated, coordinated care remains a major challenge, especially in the private sector, resulting in fragmentation, redundancy, and major gaps in health care.
Provinces and territories have introduced several initiatives to improve the integration and coordination of care for chronically ill patients with complex needs. These include Divisions of Family Practice (British Columbia), Family Medicine Groups (Quebec), the Regulated Health Professions Network (Nova Scotia), and Health Links (Ontario).
In addition, Ontario has long-standing community-based and multidisciplinary primary care models in place, including Community Health Centres and Aboriginal Health Access Centres. Ontario also continues to expand a pilot program that bundles payments across different providers. This alternative payment approach is expected to improve care coordination for patients as they transition from hospital to the community.42
Medical alliances of regional hospital groups (often including one tertiary hospital and several secondary hospitals) and primary care facilities provide primary care for patients. The aims are to reduce unnecessary visits to tertiary hospitals, cut health care costs, and improve efficiency. At the same time, patients with serious health problems can be referred to tertiary hospitals easily and moved back to primary care facilities after their condition improves. The hospitals within a medical alliance share a common electronic health record (EHR) system, and lab results, radiology images, and diagnoses are easily available within the alliance. It is hoped that this type of care coordination will meet the demand for chronic disease care, improve health care quality, and contain rising costs, but it is rarely employed efficiently.
There are three main medical alliance models.19 Hospitals in the Zhenjiang model have only one owner (usually the local bureau of health). Those in the Wuhan model do not belong to the same owner, but administration and finances are all handled by one tertiary hospital. Hospitals in the Shanghai model share management and technical skills only; ownership and financial responsibility are separate. The Shanghai model is dominant in China.
Mandatory health agreements between the municipalities and regions related to coordination of care address a number of topics related to admission and discharge from hospitals, rehabilitation, prevention, psychiatric care, information technology (IT) support systems, and formal progress targets. Agreements are formalized for municipal and regional councils at least once per four-year election term, and generally take the form of shared standards to guide improvements in different phases of a patient’s journey; these agreements must be approved by the Danish Health Authority. The degree to which the regions and municipalities succeed in reaching agreed-on goals is measured by national indicators published online.21
The agreements are partially supported by IT systems with information that is shared among caregivers. All GPs use electronic information systems as a conduit for discharge letters, electronic referrals, and prescriptions. In addition, all health care personnel have access to a shared database of prescriptions, known as the shared medical card.
The national indicators are also important in a new (2019) national scheme for allocation of funding from the state to the regions. The scheme incentivizes further transition from hospital care to primary and home-based care and further development of digitally supported and integrated care by making part of the national funding contingent upon five general criteria:
- Fewer hospital admissions per citizen
- Less in-hospital treatment for chronic care patients
- Fewer unnecessary readmissions within 30 days
- Increased use of telemedicine
- Better integration of IT across regional and municipal sectors.
Regions and municipalities have implemented various measures to promote care integration. Examples include:
- The use of outreach teams from hospitals conducting follow-up home visits
- Training programs for nursing and care staff
- The establishment of municipal units located within hospitals to facilitate communication, particularly in regard to discharge
- Shared municipal and hospital nurses
- The use of general practitioner practice coordinators.
Many coordination initiatives place an emphasis on people with chronic care needs, multiple morbidities, or frailty resulting from aging or mental health conditions.22 The municipalities are in charge of a range of services, including social care, elder care, and employment services; most are currently working on models for better integration of these services, such as joint administration with shared budgets and formalized communication procedures.
Practices increasingly employ specialized nurses, and several municipalities and regions have set up joint multispecialty facilities, commonly called health houses. Models vary, but often include GPs, practicing specialists, and physiotherapists, among others. The system of enlistment with a particular GP serves to develop long-standing relationships and to strengthen the role of GPs as coordinators of care for patients based on a comprehensive view of their patients’ individual needs regarding prevention and care.
GPs are responsible for care coordination as part of their overall contract with the NHS. For instance, the 2018–2019 GP contract aims to improve care coordination for older patients by requiring practices to have a “named accountable GP” for all patients over age 75. GPs also have financial incentives to provide continuous monitoring of patients with the most common chronic conditions, such as diabetes and heart disease.
GPs work increasingly in multipartner practices that employ nurses and other clinical staff to carry out much of the routine monitoring of patients with long-term conditions. These practices also have some features of a medical home. For instance, they direct patients to specialists in hospitals or to community-based professionals, like dietitians and community nurses, and maintain treatment records of their patients.
The 2012 Health and Social Care Act charged NHS England and CCGs with promoting integrated care, which is defined as closer links between hospital- and community-based health services, including primary and social care.
In 2016, NHS organizations and local authorities were brought together in 44 sustainability and transformation partnerships with the aim of planning services together. Fourteen of these partnerships have become integrated care systems (ICSs), in which local authorities, GP networks, and local hospitals assume joint responsibility for sharing resources across their populations (1 million people on average).39 The formation of integrated care systems, which are modeled on accountable care organizations in the United States, is currently voluntary. The individual organizations in the systems are still legally accountable for their own budgets.
Knowledge on care integration was gained from 50 vanguard sites, smaller pilots of collaborative working groups, launched in 2014. These 50 sites delivered integrated services for older people or those with long-term conditions via scaled-up general practices and collaborations between hospitals and care homes. Evaluation of these vanguard programs has shown the potential to reduce hospital use among vulnerable populations through better community-based care. For example, a project to improve health care in care homes led to 23 percent fewer emergency admissions and 29 percent fewer accident and emergency department attendances than in other parts of the country.40
Inadequate coordination in the health care system remains a problem. In addition to financial incentives provided to GPs (EUR 40 per patient with a chronic condition), various quality-related initiatives aim to improve the coordination of hospital, out-of-hospital, and social care. They target the elderly and fragile populations and attempt to streamline the health care pathway, integrating providers of health and social care through the use of case managers and a shared portal for both communication and data sharing. The Health Pathway of Seniors for Preserved Autonomy was launched five years ago to improve the coordination of care for the elderly. It did not improve health outcomes as expected, but will nevertheless be continued until the end of 2019.20
Many efforts to improve care coordination have been implemented; for example, sickness funds offer integrated care contracts and disease management programs for chronic illnesses to improve care for chronically ill patients and to improve coordination among providers in the ambulatory sector. In December 2017, 9,173 registered disease management programs for six indications had enrolled about 6.8 million patients (more than 9% of all the SHI-insured).16 There is no pooling of funding streams by the health and social care sectors.
Since 2016, the Innovation Fund has been promoting new forms of cross-sectoral and integrated care (also for vulnerable groups) with an annual funding of EUR300 million, or USD382 million (including EUR75 million, or USD95 million, for evaluation and health services research). Funds are awarded through an application process overseen by the Federal Joint Committee.17 So far, the fund has sponsored care models in structurally weak and rural regions and care models using telehealth.
Patient care continues to be fragmented in India. Although there is a patient referral (gatekeeping) mechanism, it is severely underused because of overcrowding, lack of health care resources, deficient infrastructure, poor regulation of the referral system, and patients’ ability to bypass primary entry points to the health system.60
The four NHI health plans are essentially the main source of primary, specialty, and mental health care. This structural integration provides a foundation for providing relatively seamless care, including care for complex and chronically ill patients. The plans’ health information systems link primary and specialty care providers, and a new national health information exchange is adding hospital data to this system. These systems are increasingly providing access to electronic patient information at the point of care.
In addition, the health plans have established several targeted care management programs that aim to provide comprehensive integrated care for complex patients with chronic conditions. These make extensive use of the plans’ sophisticated information systems, videoconferencing, and other innovative techniques.24
Integration of health and social care services has recently improved, with a shift of long-term care from institutions to communities and an emphasis on home care.
The regions have chronic-care management programs that deal mainly with high-prevalence conditions, such as diabetes, congestive heart failure, and respiratory conditions. Each program involves different competencies. Some regions are also trying to set up disease management programs based on the chronic-care model, although the degree of organization varies across regions.
The most recent Pact for Health, signed in July 2014, is a significant step toward care integration: all regions must establish Primary Care Complex Units involving GPs, specialists, nurses, and social workers. To further promote the integration and adoption of multidisciplinary teams, medical homes are being encouraged in some regions, such as Tuscany and Emilia-Romagna, where there are collectively 113 medical homes currently providing multispecialty care to approximately 2.7 million people.
The national government prioritizes care coordination and develops financial incentives to encourage providers to coordinate care across care settings, particularly in cancer, stroke, cardiac care, and palliative care. For example, hospitals admitting stroke victims or patients with hip fractures can receive additional fees if they use post-discharge protocols and have contracts with clinic physicians to provide effective follow-up care after discharge. The clinic physicians also receive additional fees.
The government also provides subsidies to leading providers in the community to facilitate care coordination. Highly specialized, large-scale hospitals with 500 beds or more have an obligation to promote care coordination among providers in the community; meanwhile, they are obliged to charge additional fees to patients who have no referral for outpatient consultations.
There are more than 4,000 community comprehensive support centers that coordinate services, particularly for those with long-term conditions.30 Funded by LTCI, they employ care managers, social workers, and long-term care support specialists. Currently, there is no pooled funding between the SHIS and LTCI.
Regional and large-city governments are required to establish councils to promote integration of care and support for patients with 306 designated long-term diseases.
In addition, the national government has been promoting the idea of selecting preferred physicians. The Continuous Care Fees program pays physicians monthly payments for providing continuous care (including referrals to other providers, if necessary) to outpatients with chronic disease. The 2018 revision of the SHIS fee schedule ensures that physicians in this program receive a generous additional initial fee for their first consultation with a new patient.31
A bundled-payment approach to integrated chronic care is applied nationwide for diabetes, COPD, and cardiovascular risk management (see “Primary care” above). Under this system, insurers pay a single fee to a principal contracting entity, known as the care group, to cover a full range of chronic disease services for a fixed period.
The bundled-payment approach supersedes traditional health care purchasing for the applicable condition and divides the market into two segments: one in which health insurers contract care from care groups, and another in which care groups contract services from individual providers, each with freely negotiable fees.36
Over the last years, a number of pilot studies across the Netherlands have been initiated to improve care integration and coordination, focusing primarily on health and lifestyle improvement, population management, and administrative simplification. For instance, the role of district nurses is currently being strengthened to better coordinate care and help reach vulnerable populations. These initiatives have had varying degrees of success.
District-level alliances (partnerships between district health boards and primary health organizations) are driving stronger health system integration, although performance varies across regions. The alliances have multiple cross-sector members including, but not limited to, primary care, pharmacies, ambulance services, district nursing, allied health, local government, and Maori providers. District alliances are developing services based on locality-specific needs. Some alliances have begun to form partnerships with local social agencies.10
The primary care sector is exploring how to best improve and enhance primary care to meet future demand. The “health care home” model is being implemented in several districts, with support and resourcing shared between district health boards and primary health organizations.
While district health boards are held accountable for driving integration through their annual plans, variability still exists. There is an ongoing effort to drive improvement by other means, including new funding models and contracting for outcomes. For instance, four system-level performance measures were implemented in 2016. The success of these measures is dependent on the contributions of individual providers or organizations.
The 2012 care coordination reform emphasized the municipalities’ responsibility for 24-hour care and postdischarge care. In addition, the reform stipulated individual treatment plans for patients with chronic diseases. Hospitals and municipalities must establish formal agreements on the care of patients with complex needs.19
In 2018, the Ministry of Health established three integrated clusters organized by geographic regions and made up of public-sector institutions ranging from acute hospitals to polyclinics. Each cluster is expected to develop and strengthen partnerships with GPs and other community partners across care settings to enable seamless care transitions and also to anchor care more firmly in primary and community settings.
The clusters have embarked on several programs, ranging from preventive health and chronic disease to caring for frail patients. The clusters also work with social and other related agencies to support residents who have varying combinations of health and social needs as well as to address social determinants of health. While the elderly remain a key area of focus, the clusters have adopted a life-course approach and are progressively addressing other age groups as well.
In addition to ensuring better system integration, the reorganization of providers seeks to derive greater economies of scale, to facilitate scaling up of programs and services, and to tap into a larger pool of manpower resources and talents.
The Swedish health system is highly integrated. The dividing of regional responsibility (for medical treatment) and municipal responsibility (for nursing and rehabilitation) requires coordination. Efforts to improve collaboration and develop more integrated and accessible services are supported by targeted government grants. Since 2015, the targeted grants have focused on care coordination; they support action plans for improving coordination and collaboration at the regional level.
At the provider level, performance-related payment is commonly linked to quality targets related to care coordination and compliance with evidence-based clinical guidelines, particularly for care provided to elderly patients with multiple diagnoses.
In addition, since the 1990s, policies have focused on shifting inpatient care to outpatient and primary care settings and on concentrating highly specialized care in academic medical centers.
Care coordination is an issue, particularly in light of a projected future shortage of health professionals and the need to improve efficiency to increase capacity. The national Health2020 strategy states that integrated health care models need to be supported, especially for patient groups that use many different and complex health care services.
To improve coordination, networks of experts are addressing important challenges such as palliative care, dementia, noncommunicable diseases, and mental health. They are designing pilot projects aimed at encouraging different types of health professionals to work together. In addition, the Forum for Managed Care awards a prize every year to promote innovative cross-sector networking projects in the Swiss health care sector.
The Federal Office of Public Health is also working on improving the framework for coordinated care, mainly in the areas of finance, education, and electronic health records (EHRs). The National Health Report 2015 discusses a growing number of case management programs for chronically ill patients, but pooled funding streams do not yet exist.25
In general, financial incentives that encourage physicians to provide coordinated care are relatively limited.30 In addition, programs integrating health and social care services for vulnerable populations are currently a work in progress. Three departments within the MoHW currently provide social care services, but full integration with health care services has not yet occurred. Funding for social care services comes from budget allocations to municipal governments.
However, improving delivery system integration and care coordination has been on the NHIA’s agenda for many years. Efforts to date include:
The Integrated Delivery System. Taiwanese living in remote and mountainous areas and on offshore islands (approximately 400,000 people, or 1.7% of the population) can access medical services through the Integrated Delivery System, a government program that began in 1999. The program provides access to outpatient care (including overnight and on holidays), 24-hour emergency care, and specialty care through integrated village clinics, local hospitals, and mobile health services. Telemedicine and helicopter services are used to provide needed care to patients on remote offshore islands, for example, and to bring pregnant women to hospitals for delivery.
As part of the program, providers receive bonuses for serving these remote patients.
The Family Doctor Integrated Care Program. Since 2003, the NHIA has been promoting this community-based program. Community networks, made up of five or more primary care physicians and one community hospital, provide patient-centered primary care, including disease management, patient health education, and preventive care. Telephone consultations with family doctors are also available 24 hours a day for people enrolled in the program.
In 2017, the Family Doctor Integrated Care Program was strengthened with an increased emphasis on service capacity and quality improvement in community-based medical networks.
As of June 2017, 4,063 primary care clinics and 183 hospitals have joined to form 526 primary care networks, covering 4.1 million residents, or 17.4 percent of NHI enrollees in Taiwan.31 Primary care networks are paid small fees for registering patients in their network.
The Hospital Patient-Centered Integrated Care Program. This initiative is aimed at outpatients aged 65 and older with two or more chronic conditions.
The ACA introduced several levers to improve the coordination of care among medical/clinical providers in the largely specialist-driven health care system. For example, the law supported adoption of the “patient-centered medical home” model, which emphasizes care continuity and coordination via primary care, as well as evidence-based care, expanded access, and prevention and chronic care management.
The ACA also expanded the Centers for Medicare and Medicaid Services’ ability to test alternative payment models that reward quality, reduce costs, and aim to improve care coordination. This trend has since been continued by public and private payers.
One of these alternative payment models is “bundled payments,” whereby a single payment is made for all the services delivered by multiple providers for a single episode of care. Another trend is the proliferation of accountable care organizations (ACOs). These networks of providers assume contractual responsibility for providing a defined population with care that meets quality targets. Providers in ACOs share in the savings that constitute the difference between forecasted and actual health care spending.
As of 2019, there were more than 1,000 ACOs in the public and private markets, covering 32.7 million people. Of these ACOs, 558 are Medicare ACOs, serving 12.3 million beneficiaries who are free to seek services from any Medicare provider, including those outside their designated ACO.38,39,40 There are many variants of the Medicare ACO: The most popular is a permanent program written into the ACA, the Medicare Shared Savings Program, which serves nearly one-third of all Medicare beneficiaries. To improve coordination, ACOs are implementing programs that include medication management, prevention of emergency department visits and hospital readmissions, and management of high-need, high-cost patients.