Abstract
Introduction/Background: The Accessible Quality Healthcare (AQH) Project piloted an Integrated Care (IC) model in Fushe Kosova and Lipjan, focusing on integrating health and social services to address the needs of elderly patients with chronic non communicable diseases specifically T2DM. Services included geriatric assessments, individual care plans, and motivational counseling, with patients actively participating in their care. This study evaluates the IC model, identifying the benefits of multidisciplinary collaboration and gaps, particularly the limited involvement of pharmacists in patient care which has the potential to hinder optimal medication management and patient outcomes.
Methods: An integrative review methodology was employed to synthesize evidence from multiple sources related to the implementation of Integrated Care (IC). The review examined findings from the AQH Project's evaluation reports, including data on geriatric care plans, individual care plans, and health resource center (HRC) visits. Additional insights were drawn from international frameworks and evidence-based practices, such as the Scirocco maturity model, to assess the readiness of healthcare infrastructures for scaling Integrated Care. Quantitative data from 2022–2023 provided contextual evidence of the intervention's impact, highlighting over 295 geriatric plans, 323 individual care plans, and 41,417 HRC visits, which informed the review’s conclusions.
Results: The IC model demonstrated high patient satisfaction and significant health improvements. Patients benefited from motivational counseling, physical activities, and social support services, which fostered self-management and better adherence to care plans. However, while doctors, nurses, and social workers collaboratively developed individual care plans, pharmacists were notably absent from the team, leaving critical gaps in medication counseling, polypharmacy management and medication adherence. Quantitative data showed that considerable HRC visits and thousands of distributed health passports supported chronic disease management, yet medication-related challenges persisted due to pharmacist exclusion.
Discussion: Integrating pharmacists into IC teams is essential to enhance care coordination and medication management. Evidence from international models shows that pharmacist involvement reduces hospitalizations, improves medication adherence, and mitigates risks associated with polypharmacy. Patients’ involvement in care planning was highlighted as a strength, with opportunities for negotiation and agreement on individual care plans (2). Despite these strengths, better data-sharing frameworks, interdisciplinary communication and inclusion of pharmacists remain critical for holistic patient care.
Conclusion: The AQH Project's IC model exemplifies the potential for improving health outcomes through integrated, patient-centered care. Expanding the model to formally include pharmacists will strengthen multidisciplinary collaboration and address medication management gaps, ensuring more comprehensive and sustainable care delivery. This approach aligns with the 9 Pillars of Integrated Care, emphasizing inclusiveness, community involvement, and interprofessional teamwork to advance healthcare in Kosovo.
References
1.Zahorka M. Evaluation of the Integrated Care Component of the Accessible Quality Healthcare Project. Accessible Quality Healthcare Project; 2023.
2.Accessible Quality Healthcare Project. Case Study: Integrated Care in Fushe Kosova and Lipjan. AQH Project; 2023.
3.World Health Organization. Framework on integrated, people-centred health services. 69th World Health Assembly; 2016.