A Policy Guide on Integrated Care (PGIC): Lessons Learned from EU Project INTEGRATE and Beyond

Services difficult to navigate, disempowering, burdensome

Poor geographical access to care

Poor patient-doctor communication

Poor co-production (of services)

Poor health literacy (knowledge on health & insufficient competencies on self-management)

Poor peer support and the number of peer support programmes

Poor patient education

Insufficient compliance

Insufficient use of information technologies

Insufficient patient-reported outcome measures

Insufficient support of carers

Lack of centrality of client needs

Disease-focused approaches

Episodic medical orientation

Wrong/inadequate services at the wrong time

Fragmented chains of command

Duplicated supervision

Lack of bio-psycho-social integration of care at the individual level

Lack on integration between health and social care

Lack of co-ordination

Medication errors

Physician patient communication failure

Poor doctor-patient communication

Burnout in providers

Avoidable hospitalisation

Insufficient integration within primary care

Insufficient integration between primary care and hospital care

Insufficient integration between primary care and long-term care/palliative care

Insufficient integration between medical and mental care

Insufficient integration between health and social care

Insufficient focus on prevention

Fragmented and inadequate funding mechanisms

Inadequate payment and rewarding systems

Inadequate life-course approaches to care

Inadequate Health in All Policies approaches

Inadequate payment and rewarding systems

No agreement on quality measures for integrated care

Inadequate Information system systems

Multiple transaction costs

Integrated Care Certification (ICC) programmes

• Contracting with collaborative entities for services with explicit agreements about quality and equity

• Integrated Delivery Networks in primary care (community-based multidisciplinary teams) [1940]

• Accountable Care Organizations (ACOs) [41]

• Integration of mental health and social services [4243]

• Integration of mental and physical health care [19]

• Medical homes [28]

Co-location policies in primary care

Use of multidisciplinary guidelines, care plans and protocols [1944]

Handover strategies from hospital to primary care [45]

Value-based financing/incentives targeting collaborative efforts & quality of care [4647]

Define patient cohorts and prioritize them based on their relative importance to the health of the overall population to be managed [49]

Population needs assessment [50]

Multidimensional frailty assessment [51]

Health registries [52]

Risk stratification [53]

Predictive analytics to model medical conditions to identify high-risk patients [54]

Pooling of budgets between health care and social care [55]

Standardizing core competencies for coordinated/integrated health services delivery [62]

Regulatory frameworks for professional accreditation (e.g. clinical licensing; certifications and periodic re-certification examinations for health professionals) [63]

Strengthening regulators of education and services to ensure that services are up to a pre-determined standard [20]

Legal changes (e.g. shift of competences of providers) [64]

Promoting of particular medical specialities (e.g. family medicine, geriatrics and gerontology)

Providing financial support for medical schools and residency programmes that adopt appropriate educational innovations (e.g. simulation methods, learning in the community, inter-professional education, admission procedures, faculty development) practices [65]

Regulatory frameworks for human resources management [42]

Increasing efforts at planning and forecasting [20]

Registration of health professionals (e.g. ensuring that licences are up to date) [66]

Enhancing mechanisms to voice patient needs (patient associations provide feedback on the health workforce performance, support the development of health professional curricula, set benchmarks and indicators of services) [67]

Use of mass media campaigns on healthy lifestyles and certified health websites [71]

Targeted educational packages and life style programmes

Supported self-management (e.g. diabetes, obesity, cancer, asthma and heart failure) [727374]

Personalised care planning [75]

Integrating and financing (nurse) educators, patient navigators [7677], community health workers and case managers [7879] in primary and secondary care practices and hospitals [80]

Patient expert programmes facilitated by lay volunteers

Community participation in planning and goal-setting (e.g. community consultations through committees and participatory groups) [81]

Patient and service user groups (e.g. in the development of patient charters)

Strategies that encourage lay, parental and family-led advice and support in local communities

Shared decision making between people and health care professionals [828384]

Giving people access to personal health records [85]

(Financial) incentives related to mutually defined health goals [86]

Strengthening (group-based) parenting skills to yield benefits in relation to physical and mental health (e.g. alleviating aspects of family adversity which may negatively affect parenting and delivery of parenting interventions) [96]

Service design that recognizes the role and importance of schools in relation to children

Preventive health services in public education [97]

Use of prediction models for child maltreatment recurrence [98]

Documentation of social determinants of health in child health services health records