Figure 1
The Global Syndemic of Cardiovascular Disease and Multiple Long-Term Conditions.
Patients with CVD lives with MLTC (left). Integrated care models are necessary to manage this complexity effectively, improve outcomes, and reduce the strain on health systems (right). CVD: cardiovascular disease; MLTC:multiple long-term conditions; HTN: hypertension; T2DM: type 2 diabetes mellitus; DLP: dyslipidemia; COPD: chronic obstructive pulmonary disease; CKD: chronic kidney disease; SELFIE: Sustainable intEgrated care modeLs for multi-morbidity: delivery, FInancing and performancE.
Table 1
Roadblocks to integrated care.
| DOMAIN | ROADBLOCK | DESCRIPTION | MITIGATION STRATEGIES |
|---|---|---|---|
| Administration/regulation | Regulatory & legal constraints | Data-sharing restrictions, authorisation process, liability issues, administrative burden. |
|
| Legacy institutional structures, Lack of political priorisation | Long-standing fragmentation between health and social care, primary and secondary care, etc. |
| |
| Funding | Fragmented or inadequate funding | Siloed budgets: incentives that reward activity rather than outcomes or collaboration. |
|
| Lack of funding for coordination/case management | Non-clinical but essential tasks (navigation, social support) undervalued or unfunded. |
| |
| Inter-organisational domain | Poor digital interoperability | Multiple incompatible IT systems; no shared EHR; difficult information exchange. |
|
| Lack of shared goals, vision, trust | Organisations prioritise internal goals; competition; absence of shared leadership. |
| |
| Organisational domain | Cultural, professional & hierarchical differences | Differing training, values, norms, power |
|
[i] Based on the findings of Barriers to the Integration of Care in Inter-Organisational Settings: A Literature Review (Auschra 2018) and complementary literature.
Figure 2
Treatment burden and reduced patient capacity.
Patient capacity is shaped by access to quality health services, knowledge, social support, resilience, and assistance with self-management. In contrast, accumulated physical and mental health conditions, limited information, weak support networks, and cyclical socioeconomic precarity reduce capacity. When treatment burden exceeds capacity, patients experience increased risk of poor adherence, complications, and adverse outcomes.
| Metric | Pre-intervention | Post-intervention |
| Medication adherence | ~60% | ~85% |
| LDL cholesterol (mmol/L) | 2.4 | 1.4 |
| Blood pressure (mmHg) | 148/90 | 136/82 |
| HbA1c (%) | 8.2 | 7.5 |
Table 2
Impact of integrated care on patient and system outcomes.
| DOMAIN | OUTCOME | IMPACT OF INTEGRATED CARE | EXAMPLES |
|---|---|---|---|
| Patient experience & quality of care | Care coordination | Improved | Single care plan, shared records, reduced duplication and contradictions. |
| Patient satisfaction | Higher satisfaction | Better communication, clearer responsibilities, smoother transitions between services. | |
| Person-centred care | Enhanced | Care aligned with patient goals, values, and capacity; stronger involvement in decisions. | |
| Clinical outcomes | Disease control | Improved | Better BP control, glycaemic control, lipid management through coordinated follow-up. |
| Complication rates | Reduced | Earlier detection and prevention across conditions (e.g., diabetes–CVD interactions). | |
| Mortality / hospital mortality | Lower or stabilised | Particularly when multidisciplinary teams manage high-risk patients. | |
| Treatment burden & patient capacity | Burden of treatment | Reduced | Streamlined appointments, unified advice, fewer conflicting lifestyle or medication instructions |
| Medication burden | Optimised | improved deprescribing practices and reduced polypharmacy in MLTC populations. | |
| Ability to cope | Increased | Better continuity, coaching, and support from care coordinators and nurses | |
| Healthcare use | Unplannedhospitalisations | Reduced | Coordinated follow-up and early interventions reduce avoidable admissions. |
| Emergency department use | Reduced | Better symptom recognition and access to appropriate alternatives. | |
| Length of stay | Reduced | Earlier discharge planning and better community care. | |
| System efficiency & costs | Duplication of tests & consultations | Reduced | Shared records and multidisciplinary reviews. |
| Overall healthcare costs | Costs may decrease or stabilise | Savings from fewer admissions and complications; upfront investment often required. | |
| Workforce efficiency | Improved | Role optimisation across care teams; reduced fragmentation and task repetition. | |
| Equity & access | Access toappropriate services | Improved | Navigation support for vulnerable groups; more consistent pathways. |
| Health disparities | Potentially reduced | Coordinated models can address gaps affecting underserved populations. |
Figure 3
Fragmented vs. Integrated Care Pathways for a Patient.
The left panel illustrates siloed, disease-centred services delivered independently across the health system. The right panel demonstrates an integrated, person-centred model in which services are coordinated around the individual, improving continuity, efficiency, and health outcomes.
Figure 4
The SELFIE framework for integrated care for multi-morbidity.
The SELFIE framework places the individual with multimorbidity at the centre and organises integrated care across micro, meso, and macro levels within six health system domains: service delivery, governance, workforce, financing, technologies, and information systems. It emphasises coordinated, person-centred care supported by aligned policies, resources, and continuous monitoring. The SELFIE framework for integrated care for multimorbidity. Reproduced from Leijten et al. (2018) under the terms of the Creative Commons Attribution 4.0 International License (CC BY 4.0).
Figure 5
The Key Components of Integrated Care.
Integrated care for people living with CVD and MLTCs requires coordinated action across nine interconnected system domains. At the centre is the person, whose needs and capacity should shape care design and delivery.
Figure 6
Implementation Strategies and Design Components.
Core implementation strategies, associated structural and functional design components, and practical examples to support effective, equitable, and sustainable delivery of integrated care.
Figure 7
From Design to Impact: Why Integrated Care Succeeds or Fails.
The framework demonstrates how foundational system components translate into implementation strategies, which are either facilitated or hindered by contextual accelerators and barriers, ultimately determining patient-level and health system-level outcomes.
Figure 8
Outcomes Framework for Integrated Care in CVD and MLTC.
Framework for evaluating integrated care across implementation, health system, and patient-level outcomes.
Adapted from Proctor et al 2011.
| Category | Example KPI |
| Implementation | % of clinics using new integrated care pathway |
| Service | 30-day readmission rate for people with CVD |
| Patient | % of patients reporting reduced treatment burden |
