Integrating Care to Prevent and Manage Chronic Diseases

Executive summary

People today are living longer with chronic health conditions. Stronger healthcare systems and better socio-economic conditions mean people today live longer: between 1970 and 2019, life expectancy at birth increased by over 11 years across OECD countries. As people age, they are at greater risk of disease, disability, and dementia. For example, recent estimates indicate nearly two‑thirds of people in OECD countries aged 65 years and over live with one or more chronic conditions.

Care fragmentation is a key issue for people with complex health needs. People with complex health needs, such as patients with a chronic condition, require care from different providers across multiple healthcare settings. Without proper care integration, people may try to address their unmet needs using excessive services in an uncoordinated manner. Not only does this worsen their experience, it is also dangerous and costly, with estimates showing fragmented care increases costs by over EUR 4 000 per patient.

Countries are experimenting with integrated models of care in response to the growing number of people living with complex health needs who are at risk of receiving fragmented care. Such models of care provide continuous, co‑ordinated, high-quality care over a person’s life. At a high level, these models aim to prevent and manage chronic conditions thereby enhancing population health, improving patient experiences, reducing per capita costs of healthcare, creating a better work/life balance for health professionals, and advancing health equity.

This report examines 13 integrated care models implemented in OECD and EU27 countries using a validated performance assessment framework. Selected case studies cover a wide range of integrated care models ranging from small pilots operating at the city level to nationwide programmes covering entire populations. Further, many case studies operate at a specific level of care, such as primary care, while others cover the whole spectrum of healthcare services. The majority of OECD and EU27 countries have implemented at least one of the selected case studies. Case studies were selected in consultation with the European Commission and were assessed using OECD’s Best Practice Identification Framework in Public Health, which was co-created with OECD member countries.

Key findings and policy recommendations outlined in this report will help countries deliver integrated care to patients with complex health needs. Findings and recommendations cover the key dimensions of integrated care, namely governance, financing, the workforce, and digital tools and health information systems. In addition, the report covers monitoring and evaluation, health equality, and scaling-up and transferability. Findings and recommendations are based on a review of the 13 selected case studies; therefore, this report does not comprehensively address all issues related to integrated care in all contexts, but rather offers interesting insights and highlights the value of applying a common assessment methodology.

Governance

Many case studies pursued care integration at a specific level of care, such as primary care, and often for a specific disease. Only a small number of case studies operate across the entire spectrum of healthcare services for whole populations. The limited number of integrated care models covering entire populations and all healthcare services is in large part due to fragmented governance structures across health and social care sectors. Findings from case studies highlight the importance of strengthening governance structures by breaking down silos across administrative systems in health and social care with the support of key stakeholders. Such governance structures encourage sustainable integration of care. For example, in Badalona, Spain, health and social care services were merged into one integrated care organisation (ICO), which is owned by the city council. The ICO’s governance model involves all stakeholders, crucially policy leaders, which ensures organisational support for, and commitment to, the ICO. The governance model has also created a cohesive culture that supports integrated care. Based on modelling work by the OECD, governance structures that support care integration are a good investment with estimates showing they reduce annual health expenditure by up to 4% (as a proportion of total health expenditure), as in the case of the OptiMedis population-based integrated care case study.

Financing (payment models)

Traditional payment models, such as fee‑for-service, do not encourage care co‑ordination and may contribute to excessive expenditure. Innovative payment models that incentivise providers to deliver co‑ordinated care have been implemented in several settings. These include add-on payments, for instance, to employ a case manager; episode‑based bundled payments, whereby providers receive one payment per patient along a clinical care pathway; or comprehensive capitation payment models that cover a set of providers for a specific population. The OptiMedis integrated care model operating in certain regions of Germany, for example, utilises a comprehensive capitation payment model with a shared savings contract. This payment model incentivises provider networks to deliver high-quality care given they receive a proportion of the difference between expected and actual healthcare costs.

Workforce

Patients with complex health needs benefit from multidisciplinary care. However, several barriers prevent this type of care provision such as a culture of professional silos. Actions to embed multidisciplinary care into everyday practice include investing in training programmes to teach health professionals new hard and soft skills (e.g. collaboration and relationship building), and promoting new professional roles that support care integration. For example, as part of Poland’s strategy to improve its primary healthcare sector (Primary Healthcare PLUS), the country introduced care co‑ordinators responsible for improving co‑ordination between health providers as well as well between providers and the patient.

Digital tools and health information systems

Digital tools play a key role in supporting care integration as highlighted by selected case studies including telehealth services for patients with chronic diseases in Italy, the Czech Republic and Denmark. Despite the benefit of deploying digital tools, they are not widely used for reasons such as low levels of digital health literacy among patients and professionals. Policies to promote the use of digital tools include digital inclusion activities targeting vulnerable populations, involving health professionals in the design of digital tools, undertaking robust evaluations of digital tools to build trust, and implementing digital health competency frameworks. On a broader level, countries can improve their health information systems by creating an overarching digital strategy, strengthening governance of health data, and building institutional and operational capacity.

Monitoring and evaluation

Evaluations of selected case studies focused on changes in patient experiences and healthcare utilisation, and to a much lesser extent, health outcomes. Economic evaluations were also scarce making it difficult to comment on the efficiency of integrated care models. To build the evidence base supporting integrated care, there should be a focus on measuring structural, process and outcome indicators specific to integrated care that are comparable across countries. Example indicators include hospital readmissions, mortality after hospital discharge, prescription of appropriate medication for secondary care prevention, and the use of digital tools. In addition, researchers should focus on undertaking economic evaluations that use robust methodologies to measure outcomes in relation to costs.

Health equality

Vulnerable populations, such as people with low socio-economic status, are at greater risk of experiencing care fragmentation. To reduce health inequalities, case studies such as the Finnish City of Oulu’s patient provider portal will offer its services in languages spoken by minority groups. Nevertheless, tangible actions to meet the needs of vulnerable populations were limited among case studies. To reduce existing health inequalities, future studies should aim to stratify data according to vulnerable populations with findings used to adapt care to better meet the needs of these patients. More broadly, investing in health literacy programmes with a focus on vulnerable populations will help narrow existing health inequalities.

Scaling-up and transferability

Only half of all selected case studies were explicitly scaled-up or transferred, however, nearly all were based on a pre‑existing model of care. Utilising existing frameworks to measure a region’s readiness to implement best practice integrated care models will facilitate their expansion. Example frameworks include the SCIROCCO (Scaling Integrated Care in Context) Maturity Model for Integrated Care as well as OECD’s Transferability Framework for public health interventions. Promoting close ties between owners and adopters of best practice models is also important for ensuring “lessons learnt” from past transfers are considered in the future.