Table 1
Comparison of main objectives and results of the care model in North West London vs. Odense.
| North West London | Odense | |
|---|---|---|
| Targeted patients | Patients with type 2 diabetes and elderly patients over 75 years of age. | Work-active patients with stress, anxiety or depression and elderly patients over 70 years of age. |
| Establish shared governance structure and align financial incentives | Involvement of a large number of organisations was achieved. Also, agreements to invest in development and share savings was made. However, the broad scale pilot had a tendency to make-decision making unclear. No savings documented and financial risk primarily carried by hospital sector. | Governance and aligned financial structures was established as intended across involved organisations. Decision-making seemed clear at the organizational level, but translation to middle management and clinical level proved very challenging. Significant increase in costs documented across patient groups as well as organisations. |
| Introduce shared care platform that facilitates electronic information sharing | Roll-out of the integrated care platform was slow, beset by complications and more costly than anticipated. | Roll-out of the integrated care platform was beset by complications and proved more costly than anticipated. Majority of involved professionals find the shared care platform time consuming and associate it with redundant double documentation. |
| Risk stratification and shared care plans as a mean to improve and focus care processes | Professionals support the idea of care planning. However, majority reports dissatisfaction with the extra time required to create plans and only 30% of the total possible plans are made. Efforts to increase number of completed plans also result in seeing the process as a ‘tick box’ exercise’. | General practitioners are sceptical and find stratification tools too imprecise and time consuming to use. As a result, less than 30% of the expected shared care plans are made. Intensive efforts to increase number of completed plans result in plans being made ‘in order to satisfy the project’. |
| Multidisciplinary groups as lifting pole for relational coordination and innovation | Multidisciplinary meetings are time consuming and dominated by general practitioners and consultants. They also tend to focus on individuals and not the configuration of care delivery as a whole. Mechanisms for holding multidisciplinary groups responsible were weak. | In the beginning, meetings are generally viewed as positive. As the project moves on, experienced outcome diminishes. Meetings are time consuming and dominated by doctor dialogue. Focus tends to be on clinical problems related to individuals rather than organizational learning and innovation of collaboration practices. |
| Reduce emergency admissions and shift treatment from hospital to primary care. | No significant changes documented. | No changes in emergency admissions documented. Elderly patients showed a significantly increased use of both ambulatory and stationary hospital services. Both patient groups showed significantly increased use of primary and social services. |
| Improve patient experience | Survey data indicate that patients like the idea of the pilot and that some feel more involved in the decisions about their care. However, response rates were less than 20%, and majority of respondents did not report any change in the delivery of care. | Survey data and interviews document that patients like the idea of the project. The majority of work-active patients feel more involved in the decisions about their treatment and experience a faster and more coherent treatment. Elderly patients generally have an unclear perception of the intervention and few report any change in the delivery of care. |
| Improve clinical outcomes | Some early evidence of improvement in diabetes care and an increase in dementia case finding was documented. No more important health outcomes were identified. | No significant changes documented for elderly patients. Duration of sick leave for work-active patients increased by an average of eight weeks. |
Figure 1
Organisation of the Odense Integrated Care project.
Table 2
Participants in multidisciplinary teams.
| Patients on sick leave (5 teams) | Elderly patients with chronic illness (4 teams) | |
|---|---|---|
| Private providers | 6–8 general practitioners 2–3 psychologists | 6–8 general practitioners |
| Municipality and community care | Community chief physician 2–3 social care workers/job coaches | District nurse Home nurse Dietitian Physiotherapist |
| Hospital and specialist care | Psychiatrist and psychologist with speciality in occupational medicine | Geriatric chief physician Clinical pharmacologist On ad hoc basis:
|
| Integrated Care project management | Meeting facilitator | Meeting facilitator |
Table 3
Summary of collected data.
| Data collection method | Number completed |
|---|---|
| Semi-structured group and individual interviews with health care professionals and managers | 20 interviews with a total of 77 participants, including 21 GPs |
| Survey among health care professionals | 134 completed in full (77,46% response rate) |
| Observation of 7 multidisciplinary team meetings | 20 hours |
| Individual interviews with participating patients | 19 |
| Survey with patients enrolled in the project | 324 completed in full (62,31% response rate) |
| Patient level data used to analyse service use and costs | Work-active patients:
Elderly patients:
|
Table 4
Overview of included and excluded patients compared to initial expectations.
| Included patients | Students that had to be excluded | Patients relevant for data analysis | Expected number of patients | Missing patients | GPs who included more than 20 patients | |
|---|---|---|---|---|---|---|
| Stress, anxiety and depression | 428 | 174 | 261 | 1.000 | –739 | 4 |
| Elderly patients | 222 | – | 222 | 780 | –558 | 2 |
| Total | 670 | 174 | 483 | 1780 | –1297 | 6 |