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.
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.
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).
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.
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.
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.
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.
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). There is no pooling of funding streams by the health and social care sectors.
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.
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.
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 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.
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.
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.
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.
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 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.
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.
In general, financial incentives that encourage physicians to provide coordinated care are relatively limited. 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.
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.