Combining Integration of Care and a Population Health Approach: A Scoping Review of Redesign Strategies and Interventions, and their Impact

To provide comprehensive, patient-centered, proactive, and preventive care, in addition to supporting all older adults within context of community care;

To prolong ability of older adults to age in place by meeting their needs by supporting self-management, detecting changes in health status early, and preventing escalation of health- related problems.

To reduce health inequalities caused by poor quality housing conditions and improve access to health and wellbeing related services;

To reduce premature deaths, primary care consultations and hospital admissions;

To drive up standards in private rental sector while also addressing wider determinants of health through housing issues and other factors from access to services to lifestyles.

To improve tenant access to healthcare services in order to improve health outcomes.

To reduce the risk of housing related health issues, such as an extension to the house, a transfer to a larger home, housing design improvements or creation of healthy environments, including insulation and ventilation.

To identify social or welfare issues and provide a link to the appropriate social service agencies.

To treat each person holistically through the coordination of medical and social services to improve health outcomes and reduce cost;

To increase use of preventive care and reduce preventable hospital admissions and emergency visits in high-risk population it serves.

To reduce chronic disease in marginalized communities by improving outcomes and opportunities in early life;

To transition Maternal and Child Health services from an individual-focused (mother–child dyads/family) home visiting model to a population-focused, place-based model.

To become a “beacon” for delivering integrated care;

To significantly improve patient experience;

To decrease emergency admissions by 30% and nursing home admissions by 10% for people with diabetes and the frail elderly through better, more proactive and coordinated care;

To reduce cost of care for these groups by 24% over next 5 years.

To offer patients in need of care the possibility to stay at home;

To improve and guarantee offer of health and social care in a district;

To help patients and their families to find suitable care for their needs;

To start and develop care programmes for relatives.

To provide older adults with primary medical, pharmaceutical and nursing care, and social and domestic assistance while they remain at their homes.

Socio-ecological model

Life-course approach

To deliver primary medical, pharmaceutical, nursing care, social and domestic assistance to eligible persons with disabilities living in community.

To respond appropriately to needs of older persons with disabilities;

To maintain and promote independence of older persons;

To optimize use of community-, hospital- and institutional-based resources

To establish integrated health and social care teams within a single organization to better meet the needs of older people.

To establish more efficient and better-organized health care in cooperation with patients, health professionals and health insurers;

To provide best practice health care to all patients.

To improve access in the whole system of care;

To deliver more care in the community;

To prevent acute exacerbations of chronic disease;

To increase value for patients by improving treatment, care, systems and processes

To provide high quality, affordable care to members

To manage population health

To build a high-performing health system;

To improve access to services;

To support relationship-based model of care;

To promote customer-owners’ pride and self-confidence;

To honour Alaska Native culture

Public health

Primary care

Hospital care

Social care

Local primary care

Regional community hospital

Tertiary care state wide hub

Referral to welfare agencies by case manager (Embrace)

Access to income support (Healthy Homes)

“Navigator” or “integrator” help members connect with community-based social services (Kaiser Permanente)

Referral pathways supported by teams of referral and health, and social care co-ordinators and information technology (Torbay)

Access to healthy foods via community kitchens (Spokane, Kaiser Permanente)

Help with financial deprivation by improving access to welfare agencies (Healthy Homes, Embrace)

Regular community meetings to identify needs and support referrals to welfare agencies (Embrace)

Addressing system-level barriers perpetuating health inequalities (Spokane)

Creating social support networks via socialisation of elderly (KAPI)

Promoting social participation and preventing social isolation (Zijloevern)

Social case management (social workers support patients with complex social problems) (Gesundes Kinzigtal)

Referral pathways supported by teams of referral and health, and social care co-ordinators and IT (Torbay)

Discharge streamlined with systematic follow up within 72 hours and “Welcome Back Home” package from social care staff (Jönköping)

Referral of diabetic patients to neighbourhood support groups (Healthy Homes)

Fostering of “working together” among networks of Alaska Native and other providers and customers-owners (Nuka)

Physical exercise through social networking – KP Walks and Every Body Walk programs (Kaiser Permanente)

Red Cross, Caritas, Volkshilfe, district hospital coordinate network of social and health care providers (Hartberg)

Family Wellness Warriors Initiative – weekly support groups and gatherings for victims of abuse and neglect (Nuka)

Group meetings (life cafés) to discuss how to improve different aspects of health and well-being (Jönköping)

Learning cafés to connect people with similar conditions and draw on expertise of “expert patients” (Jönköping)

Referral to welfare agencies via regular community meetings (Embrace)

Fostering of ownership and governance from networks of Alaska Native providers and customers-owners (Nuka)

Enrolling children in early childhood education and ensuring school attendance (Healthy Homes)

Family Wellness Warriors Initiative – education on prevention of abuse and neglect (Nuka)

School interventions via Thriving Schools and the Fire Up Your Feet Program (Kaiser Permanente)

Referral to English language courses and employment training (Healthy Homes)

Family Wellness Warriors Initiative – workshops and training for providers and residents on abuse and neglect treatment and prevention (Nuka)

Need for education identified via regular community meetings and referral to welfare agencies is facilitated (Embrace)

Healthy Workplace and HealthWorks wellness programs for employees (Kaiser Permanente)

Referral to welfare agencies re: employment by case manager (Embrace)

Employment training (Healthy Homes)

Need for employment identified via regular community meetings and referral to welfare agencies is facilitated (Embrace)

Focus on socializing to help keep elderly active, fit and healthy in their social environments (KAPI)

Primary care centre used as a meeting place and community hub (Nuka)

Social case management and/or referrals to welfare agencies (social workers or case managers support patients with complex social problems) (Gesundes Kinzigtal, Embrace)

Fostering of “working together” with the Alaska Native community for governance, planning and delivery of different types of care (Nuka)

Physical exercise through social networking – KP Walks and Every Body Walk programs (Kaiser Permanente)

Integrated system of community-based care, offering front and second-line health and social services, incl. short- and long-term care in community and institutions (SIPA)

Single point of contact in each zone (health and social care co-ordinators) (Torbay)

Family Wellness Warriors Initiative – weekly support groups and gatherings for victims of abuse and neglect (Nuka)

Regular community meetings to facilitate referral to welfare agencies (Embrace)

Community engagement via locality-based advisory groups, governance, surveys, focus groups, telephone hotlines, reinforcement of “working together” attitude (Nuka)

Established regional organization, Social Care and Health District, for co-ordination and co-operation of health and social care organizations (Hartberg)

Primary care centre used as a community hub was designed and built using traditional materials and exhibiting local arts to foster pride and confidence in local communities (Nuka)

Housing options advice, home improvements (Healthy Homes, Healthy Housing)

House modifications due to disability (Healthy Housing)

Re-housing due to overcrowding (Healthy Housing)

Placement in stable housing (Hennepin)

Monitoring of protocols, control of budgets to allow utilization of home services, group homes, and additional services (SIPA)

Co-location of health and social care teams (Torbay)

Co-location and “open concept” – all providers in one open space (Nuka)

Enhancing residents’ sense of identity, security and inclusion by involving householders in home renovations (Healthy Housing)

Primary care centre used as a community hub was designed and built using traditional materials and exhibiting local arts to foster pride and confidence in local communities (Nuka)

Health promotion workshops (Healthy Homes, Healthy Housing)

Health risks education (Healthy Housing)

Safe opportunities for physical activity (Spokane, Kaiser Permanente)

“Patient university” (health education and patient counselling by medical experts) (Gesundes Kinzigtal)

“Healthy body weight” combining prevention with regular blood sugar level check ups (Gesundes Kinzigtal)

Physical activity integrated into all aspects of daily life, activated employees and health care professions, marketing of what matters, healthy foods being available throughout the community, and schools strengthened as the heart of health (Kaiser Permanente)

Referral pathways supported by teams of referral, health, and social care coordinators and IT (Torbay)

Integrated medical care complimented by dental, behavioural, after-care, youth, elders; Family Wellness Warriors; Tribal and Traditional Services; Chiro, massage, acupuncture (Nuka)

Integrated approach with physical activity integrated into all aspects of daily life, activated employees and health care professions, marketing of what matters, healthy foods being available in the community, and schools strengthened as the heart of health (Kaiser Permanente)

Self-management support and prevention for frail and complex care needs via community meetings and case manager (Embrace, Nuka)

Health and fitness promotion for elderly with focus on socialisation (KAPI)

Traditional Healing Clinic for acute or chronic pain, behavioural health and counselling (Nuka)

Family Wellness Warriors Initiative – fostering individual/community skills to cope and respond to abuse and neglect and its prevention (Nuka)

Increasing access to healthy foods via community kitchens (Spokane, Kaiser Permanente)

Patients (customer-owners) and providers are encouraged to use phone, email and text for routine monitoring and some preventative screening (Nuka)

Patient-facing online tools for managing preventive and chronic care to increase patient agency in health promotion (Kaiser Permanente)

Patient self-management and shared decision-making (Gesundes Kinzigtal, Nuka, Kaiser Permanente, Jönköping)

Child immunisations (Healthy Housing, Nuka)

Reducing child abuse and neglect (play and learn groups) (Spokane)

Pre- and post-natal care, including advising on birthing options and carrying out six-weekly check-ups as part of primary care services (Nuka)

Increasing access to first trimester prenatal care for marginalized women (Spokane)

Individual treatment plans and goal-setting agreements between doctor and patient (Gesundes Kinzigtal, Nuka, Kaiser Permanente)

Follow-up care and case management (Gesundes Kinzigtal, Nuka, Kaiser Permanente)

System-wide electronic patient records (Gesundes Kinzigtal, Nuka, Kaiser Permanente)

Intervention programme for patients with chronic heart failure (Gesundes Kinzigtal)

‘Healthy body weight’ combining prevention with regular blood sugar level check ups (Gesundes Kinzigtal, Kaiser Permanente)

Referrals to paediatric and women’s clinics with coordination from primary care team (Nuka)

Healthy Homes on Prescription in primary care (Healthy Homes)

Healthy housing surgeries in primary care (Healthy Homes)

Multidisciplinary team working with all family members to enable behavioural change (Nuka)

General practitioner and nurse-led case management aim to address the emotional, psychological and social determinants of health (Nuka)

Health and self-management education for patients and families/caregivers (Jönköping, Kaiser Permanente)

Supplementing medical records with data from the corrections department, foster care system, housing providers, and other local agencies to identify those whose health may be at risk because of nonmedical issues (Hennepin Health)

Stratification into (A) no complex care needs and with low frailty level; (B) frail at risk of complex care needs; and (C) complex care needs (Embrace)

Stratification into 1) children and young people, 2) people with mental health conditions, 3) people with drug and alcohol addiction, 4) older people (Jönköping)

Population risk stratification based on Kaiser’s Know your population model (Torbay) or simple assessment scales (NWL; Hennepin)

Patient panel from registered list of patients (Nuka, Kaiser Permanente)

“Esther model” and “Mrs Smith” provided basis for designing care pathways for all older people (Jönköping, Torbay)

Informal/formal multidisciplinary teams coordinate & provide care (Torbay, Embrace)

Community-based multidisciplinary teams responsible for health and social services and coordinating hospital and nursing home care (SIPA, Hartberg)

Inter- and multi-disciplinary group meetings to develop unified view of patients’ care and system navigation (NWL, Embrace, Nuka, Kaiser Permanente, Jönköping)

Case managers for medical and social issues, liaising with physicians, and following patients throughout care trajectory, assuring continuity and easing transitions between hospital and community (SIPA, Nuka)

Integrated system of community-based care, offering front and second-line health and social services, incl. short- and long-term care in community (SIPA)

Whole-system approach, with hospitals, primary health care and other community services in partnership with zones (Torbay)

Mental health services integrated using a ‘hub and spoke’ model (Torbay)

Integrated medical services (primary care, women’s health, paediatrics, optometry, urgent care) complimented by dental, behavioural health, family wellness, tribal and traditional services, chiro, massage, acupuncture

“The Esther model” –network of health and social care organizations; redesign of intake and care transfer process across the continuum of care; team-based telephone consultation (Jönköping)

Increasing access to first trimester prenatal care for marginalized women (Spokane)

“Esther model” provided basis for designing care pathways for all older people (Jönköping)

Monitoring of interdisciplinary protocols (nutrition, falls, congestive heart failure, dementia, depression, medication, vaccination) (SIPA)

Outreach conducted centrally at region and at medical centers via telephone, secure messaging, mail (Kaiser Permanente)

Social worker goes on rounds with a local nonprofit’s street outreach team to find homeless members (Hennepin Health)

Established regional organization, Social Care and Health District, for co-ordination and co-operation of health and social care organizations (Hartberg)

Established primary care trust to commission community health and social care services (Torbay)

Developed integrated management structure for primary care trust and adult social services (Torbay)

Established single management system (Torbay)

Established IT tool to bring together medical and social care records from different provider organizations in one location (NWL)

Making and sustaining large-scale changes to create an integrated care system capable of improvement (Jönköping)

Complete care with panel management and regional safety nets to identify and respond to the needs of patients (Kaiser Permanente)

Providers acknowledge and incorporate importance of culture to well-being (Healthy Housing)

Engagement of tribal elders and the Alaska Native community in design and delivery of care (Nuka)

Traditional healing provided by tribal doctors whose skills are culturally relevant (Nuka)

Governance from Alaska Native community (Nuka)

Organizational

Functional

Service

Clinical

System

Contract between Torbay Care Trust (now Torbay and Southern Devon Health and Care NHS Trust) and alliance of parties who deliver integrated care and services.

All parties share risk and collectively own opportunities and responsibilities to deliver care and services

Organizational

Service

Clinical

Two community-based multidisciplinary teams in two areas in Montreal took full clinical responsibility for delivering integrated care through provision of community health and social services and coordination of hospital and long term care

Organizational

Service

Clinical

Normative

System

Co-ownership and co-management agreement between Southcentral Foundation and the Alaska Native Tribal Health Consortium (ANTHC);

Provision of care is based on integration among the providers and types of care/services and inter-provider and -agency referrals.

Financial risk and benefits from efficiencies, better coordination or better population management are shared across the system.

Organizational

Functional

Service

Clinical

Alliance partnership of commissioners (clinical groups and local authorities), voluntary sector and providers from social care and other sectors governed b the Integrated Management Board.

Funding surplus from efficiencies is shared across the partnership and a flexible resource envelope is made available to each multidisciplinary group for care planning, case conferences, and performance reviews.

Organizational

Service

University of Groningen in partnership with health insurance company Menzis and health care organization Meander initiated Embrace (public-private partnership);

Formal cooperation agreement was struck between community organisations (welfare organizations and municipalities) and health care organisations (general practitioner practices), home health care organisations, homes for the elderly, nursing homes and hospitals, and elderly associations to leverage the unique skills and expertise of each organization

Organizational

Service

Joint initiative between Housing New Zealand Corporation (provider of government- funded housing) and District Health Boards that includes other tiers of care (primary care, hospitals) and social service agencies

Alliance agreements are used to share responsibility between partners and Healthy Housing program

Organizational

Functional

Service

Clinical

Four partner affiliates of the Hennepin County government (Hennepin County Medical Center, North-Point Health and Wellness Center, Hennepin County Human Services and Public Health Department) created Hennepin Health ACO by signing a business agreement to share full financial risk for newly enrolled Medicaid beneficiaries.

Organizational

Service

Clinical

Normative

Initially established as a network of social care and health organizations, including Red Cross, Caritas and Volkshilfe; district hospital added later to assure a full continuum of care for patients within the network.

Principal task is to coordinate the network between the different social and health care providers in a district.

Organizational

Service

Clinical

Ministry of Health and Welfare and Association of Volunteer Workers set up a pilot KAPI;

Since their institutionalisation, state transferred the responsibility of their management and operation to local municipalities and KAPI have been operating with the contribution of volunteer organisations, the Greek Red Cross and the Christian Youth Organisation.

There is a cross-country network of KAPI, each KAPI is a legal entity with a board of directors and a network of local partners to support provision of health care and social assistance.

KAPI are also part of the National Social Care System cooperating with Day Protection Centres for the Aged and Health Units.

Organizational

Service

Clinical

Based on co-operation between health care (general practitioners and hospitals), care (home care, institutions for psychiatric patients, the handicapped and the elderly) and prevention.

Operates as care-friendly district characterized by the provision of residential care outside an institution, small-scale community-based care and services, co-location of all providers, and incorporation of welfare facilities.

Organizational

Functional

Service

Clinical

Normative

System

A joint venture between a network of physicians in Kinzigtal and a care management company, OptiMedis AG;

An outcome-based contract is set up and through this contract clinical and financial incentives are aligned in the management of integrated care;

Holds contracts with statutory health insurers (“sickness funds”) to integrate health and care services for their insured populations, covering all age groups and care settings.

Collaborates with community groups including gyms, sports clubs, education centres, self-help groups and local government agencies.

Organizational

Service

Clinical

Normative

System

Governed by the county council, Esther organizing committee and small networks of Esther coaches in each municipality

Provision of care is based on integration among the providers and types of care/services and inter-provider and -agency referrals.

Cost savings are reinvested across the continuum of care.

Organizational

Functional Service

Clinical

Normative

Formal contractual agreements among Kaiser Foundation Health Plan (insurance company), Kaiser Foundation Hospitals (KFH), and Southern California Permanente Medical Group.

Organizational

Service

Clinical

Two local health departments, Spokane Regional Health District and Clark County Public Health initiated transition to place-based integrated care and maintained funding.

Stakeholders included local boards of health, school partners, advisory boards, and non-profit agency leaders.

Organizational

Service

Alliance between Liverpool City Council and

Partners in public health, primary care, community-level care that includes a range of services, e.g., social care agencies, specialized care (mental health), hospitals, etc.;

Provision of care is based on inert-agency referrals.