Handbook Integrated Care

Description

This handbook shares profound insights into the main principles and concepts of integrated care. It offers a multi-disciplinary perspective with a focus on patient orientation, efficiency, and quality by applying widely recognized management approaches to the field of healthcare. The handbook also highlights international best practices and shows how integrated care can work in various health systems. In the majority of health systems around the world, the delivery of healthcare and social care is characterised by fragmentation and complexity. Consequently, much of the recent international discussion in the fields of health policy and health management has focused on the topic of integrated care. “Integrated” acknowledges the complexity of patients’ needs and aims to meet them by taking into account both health and social care aspects. Changing and improving processes in a coordinated way is at the heart of this approach. The second edition offers new chapters on people-centredness, complexity theories and evaluation methods, additional management tools and a wealth of experiences from different countries and localities. It is essential reading both for health policymakers seeking inspiration for legislation and for practitioners involved in the management of public health services who want to learn from good practice. Preface Contents Foundations of Integrated Care 1 What is Integrated Care? 1.1 Introduction 1.2 The Rationale for Integrated Care 1.3 Defining Integrated Care 1.4 The Core Dimensions of Integrated Care 1.5 The Building Blocks of Integrated Care 1.6 Conclusions References 2 Refocussing Care—What Does People-Centredness Mean? 2.1 Introduction 2.2 Theoretical Underpinnings 2.3 What Does ‘People-Centred’ Mean? 2.4 Strategies and Instruments to Support People-Centred Services and Systems 2.5 Prerequisites for People-Centred Services and Systems References 3 Evidence Supporting Integrated Care 3.1 Introduction 3.2 Conceptualising Integrated Care 3.3 The Evidence Supporting Integrated Care 3.4 The Economic Impacts of Integrated Care 3.5 How to Interpret the Evidence Supporting Integrated Care 3.6 Conclusions References 4 Values in Integrated Care 4.1 Introduction 4.2 What Are Values? 4.3 Values Underpinning Integrated Care 4.4 Practice Implications 4.5 Normative and Functional Aspects 4.6 Conclusion References 5 Patients’ Preferences 5.1 Patients’ Priorities for Integrated Healthcare Delivery Systems 5.2 Stated Preference Studies: Method and Study Design 5.3 Preference for Integrated Healthcare Delivery Systems 5.4 Discussion and Outlook Acknowledgements References 6 Integrating Health- and Social Care Systems 6.1 Introduction 6.2 What Do We Mean by Social Care? 6.3 Integrating Health- and Social Care for Populations 6.3.1 Population Health Improvement Approach 6.3.2 Population Health Management Approach 6.3.3 Combined Population Health Improvement and Management 6.4 Integrating Health and Social Care for Individuals 6.5 Integrating Health and Social Care Through the Workforce 6.5.1 Inter-Professional Competence 6.5.2 Professional Accountabilities 6.5.3 Information Sharing 6.5.4 Leadership and Followership 6.6 Conclusion References 7 Integrated Community Care—A Community-Driven, Integrated Approach to Care 7.1 What is ICC? 7.1.1 A Root Definition 7.2 Advancing the ICC Agenda 7.3 Exemplars 7.3.1 Community Health Centres 7.3.2 Caring Communities 7.3.3 Healthy Place-Making 7.4 ICC and Community Resilience 7.5 Conclusion Acknowledgements References 8 Path Dependence and Integrated Care 8.1 Introduction 8.2 Understanding Path Dependence 8.3 Self-Reinforcing Mechanisms Leading to Path Dependencies in Health Care 8.4 Overcoming Path Dependencies in Order to Integrate Care 8.5 Conclusion References 9 Values and Culture for Integrated Care: Different Ways of Seeing, Being, Knowing and Doing 9.1 Introduction 9.2 What is Meant by Culture? 9.3 What is Meant by Values? 9.4 How Do We Positively Develop Values and Cultures? 9.4.1 Teamwork 9.4.2 Inter-Professional Learning 9.5 Conclusion Acknowledgements References Management of Integrated Care 10 Positioning Integrated Care Governance: Key Issues and Core Components 10.1 Introduction 10.2 Positioning Integrated Care Governance 10.2.1 Holistic Approach to Service Provision for People 10.2.2 Organizing Support with and Around People 10.2.3 Re-arranging Care at Scale Supported by Digitalization 10.2.4 Integrated Care Governance 10.3 Integrated Care Governance Components 10.3.1 Leadership 10.3.2 Accountability 10.3.3 Supervision 10.3.4 Financial Models 10.4 Values Underpinning Integrated Care Governance 10.5 To Conclude References 11 Perspectives on Governing Integrated Care Networks 11.1 Introduction 11.2 Conceptual Background 11.3 Three Perspectives on Governing Integrated Care Networks 11.4 Discussion 11.5 Conclusion References 12 Governance and Accountability 12.1 What is Governance and Accountability? 12.2 Appropriate, Agile and Effective: New Directions for Governance and Accountability in Integrated Health Systems 12.3 Implementing Innovation: Next Steps for Governance and Accountability in Integrated Health Systems 12.3.1 Vanguard Integration Sites 12.4 Tools for Governance and Accountability 12.4.1 Frameworks 12.4.2 Tools 12.5 Conclusions References 13 Adaptive Approaches to Integrated Care Regulation, Assessment and Inspection 13.1 Introduction 13.2 What is Meant by Regulation, Assessment and Inspection? 13.3 Benefits and the Importance of Integrated Care Regulation, Assessment and Inspection Now? 13.4 What Role Can Regulators, Assessors and Inspectors Play? 13.5 Overview of Approaches Used in Assessment and Inspection Programs 13.5.1 Canada 13.5.2 England 13.5.3 Netherlands 13.5.4 Denmark 13.6 Value of Assessment and Inspection During System Transformation 13.6.1 Sweden 13.6.2 Malta 13.6.3 Norway 13.6.4 Scotland 13.7 Regulation as a Barrier or Facilitator to Integrated Care 13.8 Post-COVID-19 Implications 13.9 Summary Acknowledgements References 14 Leadership in Integrated Care 14.1 The Neglected Topics in Designing Integrated Care 14.2 No Coincidence: What Management Literature Tells Us About Leadership 14.2.1 Manager Versus Leader 14.2.2 Types and Styles of Leadership 14.2.2.1 Theories 14.2.2.2 Learning from the Big Bosses’ Experience 14.2.3 Leadership Learnings from Empirical Data 14.2.3.1 Fundamental Practices by Kouzes and Posner (2009) 14.3 Leadership in Networks 14.4 Leadership in Health Care: Learning from Best Practice 14.4.1 What Is Different in Health Care: The Logic of Healthcare Delivery 14.4.2 Professional Cultures in Health Care 14.4.3 Leading a Healthcare Organization: Personal Skills and Institutional Habits 14.5 Lessons to Be Learned for Leadership in Integrated Care 14.5.1 System-Related Pitfalls 14.5.2 People-Related Pitfalls 14.5.3 Organization-Related Pitfalls 14.6 Conclusion References 15 Co-leadership—A Facilitator of Health- and Social Care Integration 15.1 The Interpretation of Leadership Over Time 15.1.1 The Conceptualization of Co-leadership 15.1.2 Co-leadership in Integrated Service—Opportunities and Obstacles 15.2 What Prerequisites Are Needed to Exercise Co-leadership in Integrated Services? 15.2.1 Contextual Prerequisites 15.2.2 Personal and Interpersonal Prerequisites 15.3 How Can Co-leadership Be Operationalized in Practice? 15.3.1 Management Tasks 15.3.2 Daily Operation 15.3.3 Leadership Development 15.4 What is the Contribution of Co-leadership for Integrated Health and Social Care? 15.5 Summing Up References 16 Change Management 16.1 Introduction 16.2 A Conceptual Understanding of Change Management 16.3 The Evidence Base 16.4 Lessons from Practical Experience 16.5 The Components of a Change Management Process Towards Integrated Care 16.5.1 Needs Assessment 16.5.2 Situational Analysis 16.5.3 Value Case Development 16.5.4 Vision and Mission Statement 16.5.5 Strategic Plan 16.5.6 Ensuring Mutual Gain 16.5.7 Communications Strategy 16.5.8 Implementing and Institutionalising the Change 16.5.9 Monitoring and Evaluation: Developing Systems for Continuous Quality Improvement 16.6 Building an Enabling Environment 16.6.1 Developing a Guiding Coalition 16.6.2 Building Support for Change 16.6.3 Developing Collaborative Capacity 16.6.4 The Facilitating Role of Managers and Decision-Makers in Supporting the Process of Change 16.7 Conclusions References 17 How to Make Integrated Care Services Sustainable? An Approach to Business Model Development 17.1 Introduction 17.2 ASSIST: Socio-economic Impact Assessment Using Cost–Benefit Analysis 17.2.1 Background 17.2.2 Assessment in Four Steps 17.2.3 A Cost—Benefit Indicator Set for Integrated Care 17.3 Learning by Example: The Service Implementation Simulator 17.3.1 Integrated ECare Example Case 17.3.2 Overall Service Model 17.3.3 Elements of the Service 17.3.4 Assessment of the Example Case in Four Steps 17.3.4.1 Step 1: Stakeholders 17.3.4.2 Step 2: Impact Identification 17.3.4.3 Step 3: Data Collection 17.3.4.4 Step 4: Analysing the Value Case 17.3.5 A Set of Lessons to Be Learned 17.4 Conclusions References 18 Planning 18.1 Introduction 18.1.1 The Need for Planning 18.1.2 Planning Taxonomy 18.2 Workforce Planning Methodologies 18.2.1 Planning of Supply 18.2.2 Demand-Based Planning 18.2.3 Needs-Based Planning 18.2.4 Benchmarks 18.2.5 Limitations of Current Planning Approaches in Integrated Care Settings 18.3 New Approaches to Workforce Planning in Integrated Care 18.3.1 Team-Based Workforce Planning 18.3.2 Proactive Management of Healthcare Utilization 18.3.3 Tackling Geographic Variations Through Technology 18.4 Conclusion References 19 Towards Sustainable Change: Education and Training as a Key Enabler of Integrated Care 19.1 Introduction and Background 19.1.1 The Parallel Universes of Education and Health Systems 19.1.2 A Workforce Under Constant Pressure 19.1.3 The Workforce as a Barrier to Integrated Care 19.2 The Principles of Learning 19.2.1 Learning Is an Active Process 19.2.2 What Are Competences? 19.3 Competencies for Integrated Care 19.3.1 Competences on All Levels 19.3.2 Building a Continuous Learning Environment 19.3.3 Inter-professional Education and Training to Support Integrated Care 19.4 Education and Training as a Key Enabler for Integrated Care References 20 Integrated Care and the Health Workforce 20.1 Background 20.2 Staff Mix and Skill Management 20.3 Multidisciplinary Team Work 20.4 Workforce à La Carte 20.5 Conclusions References 21 Financing of and Reimbursement for Integrated Care 21.1 Introduction 21.2 Principles of Financing of and Payment for Services 21.2.1 Financing of Health and Social Care 21.2.2 Payment Mechanisms in Healthcare 21.3 Incentivizing Coordination and Integration of Service Delivery: Examples from Different Countries 21.3.1 Commitment of Additional Funding 21.3.2 Innovative Payment Schemes 21.3.2.1 Financial Incentives 21.3.2.2 Value-Based Payment Schemes 21.3.3 Changes to Financing Mechanisms 21.4 Conclusions References 22 Reimbursing Integrated Care Through Bundled Payments 22.1 Introduction 22.2 Reimbursement Instruments 22.3 Reimbursing Integrated Care 22.4 Bundled Payments in Use 22.4.1 Case Study I: Disease Management of Diabetes in the Netherlands 22.4.2 Case Study II: The Bundled Payments for Care Improvement (BPCI) Initiative by Medicare in the United States 22.5 Effects of Bundled Payments 22.6 Discussion References 23 Strategic Management and Integrated Care in a Competitive Environment 23.1 Integrated Care as a Strategic Option: Preliminary Remarks 23.2 Strategic Management: Definition and Differentiation 23.2.1 Strategy 23.2.2 Basics of Management Theory 23.3 The Strategic Planning Process 23.4 Instruments for Strategic Planning 23.4.1 SWOT Analysis 23.4.2 Analysis of Value Chains and Competitive Environments 23.5 Options for Strategic Positioning 23.5.1 Ansoff’s Product/Market Matrix 23.5.1.1 Market Penetration 23.5.1.2 Product Development 23.5.1.3 Market Development 23.5.1.4 Diversification 23.5.2 Porter’s Competitive Strategies 23.5.2.1 Cost Leadership 23.5.2.2 Differentiation 23.5.2.3 Low Cost and Differentiation Focus Strategies 23.5.2.4 “Stuck in the Middle” 23.6 Integrated Care as a Quality Improvement Strategy References Tools and Instruments 24 Disease Management 24.1 Introduction 24.2 What is Disease Management? 24.3 What are the Impacts of Disease Management? 24.4 Interpreting the Existing Evidence Base 24.5 Conclusions References 25 Case Managers and Integrated Care 25.1 The Story of Julia and John in 2025 25.2 The Definition of Case Manager 25.2.1 Complex Situations 25.2.2 All the Needs 25.2.3 Physicians’ Cooperation 25.2.4 The Life/Care Plan 25.2.5 Informal Care and the Case Manager 25.2.6 Within a Program 25.2.7 Target Population 25.2.8 Rejected Broader Definitions 25.2.9 Competencies and Skills of Case Managers 25.3 Specific Tools for Case Managers 25.3.1 Evaluating Health and Social Needs 25.3.2 Empowering Interviewing of Patients, Clients and Relatives 25.4 The Real World and the Ideal World of the Case Story 25.5 Implementation Strategies to Disseminate the Function of Case Managers References 26 Discharge and Transition Management in Integrated Care 26.1 Introduction 26.2 What Is Discharge Management? 26.3 Why Discharge Management? 26.3.1 Demographic Challenges 26.3.2 Rising Costs and Financial Pressure 26.3.3 Declining Length of Stay 26.3.4 Financing and Reimbursement Systems 26.3.5 The Need to Manage Complexity 26.4 How to Put Discharge Management into Practice 26.4.1 Professionalization of Discharge Planning 26.4.2 Integrating Various Components 26.4.3 Patient Involvement 26.4.4 Information Exchange and Technology 26.4.5 Early Initiation and Predictive Models for Discharge Management 26.5 Conclusion References 27 Polypharmacy and Integrated Care 27.1 Introduction 27.1.1 What Is Polypharmacy? 27.1.2 Why Is It Important to Address Polypharmacy? 27.2 Polypharmacy Management 27.2.1 Prevalence of Polypharmacy 27.2.2 Appropriate Polypharmacy and Integrated Care 27.2.3 How to Undertake a Polypharmacy Review 27.3 Patient-Centred Decision-Making 27.4 Which Patients Should We Prioritise for Review? 27.5 How to Implement a Polypharmacy Programme 27.6 How to Measure Effectiveness of a Programme 27.7 The WHO Challenge: Medication Safety in Polypharmacy 27.8 Case Study 27.8.1 Scotland: Changing Culture to Implement at Scale 27.8.2 Catalonia: Government Sponsored and Institutional-Based Programmes 27.8.3 Sweden: A National Legislation Model 27.8.4 Greece: Incipient Developments 27.8.5 Italy: Growing Awareness and Pilot Studies 27.8.6 Northern Ireland (UK): A Regional Model for Medicine Optimisation in Older People 27.8.7 Poland: No Policies, Other Pressing Issues 27.8.8 Portugal: No Programmes But Promising Measures References 28 Digital Health Systems in Integrated Care 28.1 Introduction 28.2 Defining Digital Health-Enabled Integrated Care 28.3 Digital Health Solutions to Three Common Problems 28.4 Moving Toward a Networked Model: Attending to Normative Integration Through Implementation 28.5 How to Know You Are on the Right Track References 29 Data Integration in Health Care 29.1 Types of Data Integration 29.1.1 Horizontal Integration 29.1.2 Vertical Integration 29.1.3 Historical Integration 29.1.4 Longitudinal Integration 29.1.5 Cross-Indexing Integration 29.1.6 Alternative Sources 29.2 The Importance of Data Integration 29.3 Impact of Data Integration 29.3.1 Types of Waste that Can Be Reduced with Data Integration 29.3.1.1 Repeat Testing 29.3.1.2 Manual Integration of Data 29.3.1.3 Informal Reports 29.3.2 Improving Decision-Making Capacity 29.3.2.1 Individual Level 29.3.2.2 Provider Level 29.3.2.3 Policy Level 29.3.2.4 International Level 29.4 Key Challenges in Integrating Data 29.4.1 Access and Privacy 29.4.2 Security 29.4.3 Quality 29.4.3.1 Quality Assessment 29.4.3.2 Quality Control 29.4.4 Tracking Use of Integrated Data 29.4.4.1 Providers 29.4.4.2 Patients 29.4.4.3 Policy-Makers 29.4.4.4 Insurers 29.5 Summary References 30 Mobile Sensors and Wearable Technology 30.1 Commercial Mobile Sensors and Wearable Technologies 30.2 Clinical Mobile Sensors and Wearable Technologies 30.3 Using Mobile Sensors and Wearable Technologies to Change Health Behaviour 30.4 Current Limitations and Potential Impact on Health References 31 Legal Aspects of Data Protection Regarding Health and Patient Data in the European Context 31.1 Integrated Care and Data protection—A Crucial Requirement 31.2 Harmonised European Health Data Protection? 31.2.1 The European General Data Protection Regulation 31.2.2 Scope of Application 31.2.3 Definitions 31.2.4 The Distribution of Roles When Processing Personal Data 31.2.5 Personal Data in the Health Context 31.2.6 General Aspects of Processing Personal Data 31.2.6.1 Non-sensitive and Sensitive Data 31.2.6.2 Processing of Sensitive Data 31.2.7 Administrative Duties 31.2.8 Data Protection Impact Assessment 31.2.9 Data Protection Officer 31.2.9.1 Responsibilities of a Data Protection Officer 31.2.10 Data Breach Notification 31.2.10.1 What is a Personal Data Breach? 31.2.10.2 How to Prevent a Personal Data Breach 31.2.10.3 Potential Consequences of a Personal Data Breach 31.2.10.4 Notification of the Personal Data Breach 31.2.10.5 Documentation of Breaches 31.2.11 Rights of the Data Subject Under the GDPR 31.2.11.1 Right to Information 31.2.11.2 Right of Access by the Data Subject 31.2.11.3 Right to Erasure (‘Right to Be Forgotten’) 31.2.11.4 Right to Data Portability 31.2.12 Data Transfer to Third Countries 31.2.13 Sanctions References Evaluation and Health Services Research 32 Tools and Frameworks to Measure Health System Integration 32.1 Introduction 32.2 Tools Measuring Individual Dimensions of Integrated Care 32.3 Integration Frameworks and Theoretical Models 32.3.1 Models that Focus on Structure, Function, Process, and Capacity Dimensions of Integrated Care and Their Interactions 32.3.1.1 Theoretical Model of Integration Constructs (Singer et al. 2018) 32.3.1.2 Structure, Function, and Capacity Dimensions of Service Network Integration (Browne et al. 2007) 32.3.2 Models and Frameworks for Current State Assessment/Maturity of Integrated Care Systems 32.3.2.1 B3 Maturity Model (Grooten et al. 2018, 2019) 32.3.2.2 Project INTEGRATE Framework (Cash-Gibson et al. 2019) 32.3.2.3 Development Model for Integrated Care (DMIC, Minkman et al. 2016) 32.3.2.4 Rainbow Model of Integrated Care (RMIC, Valentijn et al. 2013) 32.3.3 Models and Frameworks that Focus on Integration Systems Performance and Outcomes 32.3.3.1 Context, Outcomes, and Mechanisms of Integrated Care (COMIC) Model (Busetto et al. 2016) 32.3.3.2 The Integrated Care Performance Assessment (ICPA) Framework (European Commission 2018) 32.3.4 Summary and Critical Appraisal 32.4 Conclusions References 33 Claims Data for Evaluation 33.1 Background 33.2 Claims Data 33.3 Methodological Aspects of Using Claims Data 33.4 Methods 33.5 Prerequisites for Data Usage 33.6 Examples 33.6.1 Evaluating Disease Management Programs 33.6.2 Gesundes Kinzigtal 33.7 Limitations 33.8 Perspective: Data Linkage 33.9 Conclusions References 34 Economic Evaluation of Integrated Care 34.1 Need for Economic Evaluation of Integrated Care 34.2 Current Economic Evaluation Frameworks 34.3 Challenges and Recommendations in Economic Evaluation of Integrated Care 34.3.1 Defining the Intervention 34.3.2 Comparator 34.3.3 Study Design 34.3.4 Evaluation Period 34.3.5 Outcome Measures 34.3.6 Measurement and Valuation of Costs 34.3.7 Broader Economic Evaluation 34.3.8 Determinants of Cost-Effectiveness 34.3.9 Policy Evaluation and Implementation Analysis 34.3.10 Standardized Reporting 34.4 Conclusion References 35 Integrated Care Through the Lens of a Complex Adaptive System 35.1 Introduction 35.2 Complexity and Healthcare 35.3 Complex Adaptive Systems (CAS) 35.4 Integrated Care 35.5 Organising principles of CAS applied to Integrated Care 35.6 Discussion 35.7 Conclusion Acknowledgements References 36 Evaluating Complex Interventions 36.1 Definition of Complex Intervention 36.2 The Rationale for Evaluation 36.3 Challenges in Evaluating Complex Interventions 36.4 Evaluation Frameworks 36.5 Process Evaluation 36.5.1 Fidelity and Quality of Implementation 36.5.2 Context 36.5.3 Causal Mechanisms 36.6 Formative and Summative Evaluation 36.6.1 Study Design 36.6.2 Outcomes 36.7 Reporting and Reviewing Evaluation Results References 37 Realist Research, Design and Evaluation for Integrated Care Initiatives 37.1 Introduction 37.2 The Nature of Reality (Ontology) 37.2.1 Causal Inference 37.2.2 Mechanisms 37.3 Understanding Reality (Epistemology) 37.4 Intensive and Extensive Methodology 37.5 Critical Realist Research, Design and Evaluation Cycles 37.5.1 Realist Explanatory Research 37.5.2 Realist Design 37.5.3 Realist Explanatory Evaluation 37.6 Realist Evaluation of Complex Interventions 37.7 Conclusion References Selected Client Groups 38 Integrating Perinatal and Infant Care 38.1 Introduction 38.2 Significance of Perinatal and Infant Care 38.3 Challenges 38.4 Goals of Integrated Perinatal and Infant Care 38.5 Approaches to Integrating Perinatal and Infant Care 38.6 Conclusion References 39 Children 39.1 Challenges in Providing Care for Infants, Children and Young People 39.2 Goals of Integrated Care for Children 39.3 Value Proposition of Integrated Care for Children 39.4 From Services to Systems: Integrated Care and Population Health Management for children 39.5 The Integrated Treatment Path: Examples and Outcomes 39.6 Lessons Learned and Outlook References 40 Integrated Care for Older Patients: Geriatrics 40.1 Introduction 40.2 Challenges for Providing Care for the Geriatric Patient 40.2.1 Multimorbidity and Geriatric Syndromes 40.2.2 Fragmentation of Care 40.2.3 Place of Living: From Community to Institutions 40.3 Models of Integrated Care for Older People and Outcomes 40.3.1 Models Mentioned in the WHO Europe Report 2016 40.3.2 Literature Update on Integrated Care Geriatrics 40.3.2.1 Review 40.3.2.2 Factors Associated with Negative Outcomes 40.3.2.3 Integrated Care to Improve Care Transitions 40.3.2.4 Home Care Home-Based Primary Care Hospital-At-Home 40.3.2.5 Preventative Care for Frail Older Adults in an Integrated Way 40.3.2.6 Impact on PROMs 40.3.2.7 Qualitative Studies 40.3.2.8 Social Components of Care 40.3.2.9 European Projects About Integrated Care 40.4 Matters of Integration in Technology Design for Ageing People 40.5 Final Remarks References 41 Integrated Care for Frail Older People Suffering from Dementia and Multi-morbidity 41.1 The Challenge 41.2 Service Users’ Needs for Integrating Services 41.3 Inter-organizational Collaboration by Care Standards 41.4 Implementation 41.5 Personalization 41.6 Future Perspectives 41.7 Conclusions References 42 Integrated Palliative and End-of-Life Care 42.1 Introduction 42.2 Defining Palliative Care and End-Of-Life Care 42.3 Challenges for Providing Care to Palliative and End-Of-Life Patients 42.4 Goal of Integrated Care 42.4.1 What Needs Do End-of-Life Patients Have? 42.4.2 Health and Social Integrated Care Based on Empathy and Compassion 42.5 The Integrated Care Path 42.6 Results of Integrated Palliative Care 42.7 A New Paradigm: Compassionate Communities 42.8 Conclusion References 43 Physical and Mental Health 43.1 Challenges Involved in Integrating Physical and Mental Health Care 43.1.1 Disease Factors 43.1.2 Patient Factors 43.1.3 Professional Factors 43.1.4 Institutional and System Factors 43.2 Goals of Integrated Physical and Mental Health Care 43.3 Key Components of Integrated Physical and Mental Health Care 43.3.1 Collaborative Care 43.3.2 Multidisciplinary Case Management 43.3.3 Liaison Mental Health 43.3.4 Managing Medically Unexplained Symptoms in Primary Care 43.4 Results of Integrated Care Approaches 43.5 Lessons Learned References 44 Rare Diseases 44.1 Challenges Faced When Providing Care to People Living with a Rare Disease 44.1.1 Background on Rare Diseases 44.1.2 Unmet Needs of People Living with a Rare Disease 44.1.3 Challenges in Care Provision 44.2 Goal of Integrated Care for Rare Diseases 44.3 The Integrated Care Pathway for Rare Diseases 44.3.1 Proposals for the Provision of Integrated Care to People with Rare Diseases 44.3.1.1 Centres of Expertise 44.3.1.2 Individual Care Plans 44.3.1.3 Care Pathways and Standards of Care 44.3.1.4 Case Managers 44.3.1.5 Resource Centres for Rare Diseases 44.3.1.6 Networking and Training Programmes for Service Providers 44.3.1.7 Integration of Rare Diseases into National Functionality Assessment Systems 44.3.1.8 e-Health to Facilitate Data Sharing and Interoperability 44.3.1.9 European Reference Networks 44.4 Results of Integrated Care Approaches to Care Delivery 44.5 Lessons Learned and Outlook Acknowledgements References 45 Integrated Care for People with Intellectual Disability 45.1 Definition and Classification of Intellectual Disability (Intellectual Developmental Disorder) 45.2 General Health Issues 45.3 Mental Health Issues 45.4 Access to Care 45.5 Specialized Services for ID Associated with Other Mental Disorders 45.6 Integrated Care and Person-Centred Approaches 45.6.1 Integrating Care of Somatic Illnesses 45.6.2 Integrating Care of Psychiatric Disorders 45.6.3 Integrating Specialized or Secondary Mental Health Care 45.7 Conclusion References 46 SORCe—An Integrative Model of Collaborative Support for People in Need 46.1 Introduction 46.1.1 Results to Date 46.2 The SORCe Model 46.2.1 Evolution of SORCe 46.2.1.1 The Cross Roads Centre 46.2.1.2 The Calgary Community Court 46.3 Summary and Conclusion Acknowledgements References 47 Two Decades of Integrated Stroke Services in the Netherlands 47.1 About Stroke 47.2 Integrated Patient-Centred Stroke Care 47.3 Towards Integrated Stroke Services 47.4 Dutch Knowledge Network of Stroke Services 47.5 Improvement of Dutch Integrated Stroke Care: A Never-Ending Story References 48 Pathways in Transplantation Medicine: Challenges in Overcoming Interfaces Between Cross-sectoral Care Structures 48.1 Introduction 48.2 Structures of Care 48.2.1 Outpatient and Inpatient Care 48.2.2 Living Donations 48.3 General Key Elements for the Future 48.3.1 Communication 48.3.2 Forms of Compensation 48.3.2.1 Leadership 48.4 Conclusions References Case Studies 49 Scotland 49.1 Introduction 49.2 Integrated Care in Practice 49.2.1 Problem Definition 49.2.2 Description of the Lead Agency Model 49.2.3 Governance 49.2.4 New Ways of Working 49.2.5 People Involvement/Service User Perspective (Value) 49.2.6 Impacts 49.2.7 Dissemination and Replication of the Case Study 49.2.8 Lessons Learned and Outlook References 50 Three Horizons of Integrating Health and Social Care in Scotland 50.1 Three Horizons of Integrating Health and Social Care in Scotland 50.1.1 The First Horizon, the Political and Policy Landscape in Scotland 50.1.2 Health and Social Care Arrangements 50.1.3 Making the Case for Change 50.1.4 Building Cross-Party Political Support and Commitment 50.1.5 Engagement 50.1.6 Legislation 50.1.7 New Organisational Arrangements 50.1.7.1 Financial Context 50.1.7.2 Summing Up the First Horizon 50.2 The Second Horizon: Supporting Implementation—2015–2019 50.2.1 Leadership, Collaboration, Culture and Trust 50.2.2 Empowerment and Co-production 50.2.3 Digital Health and Care 50.2.4 Integrated Information and Analysis to Inform Commissioning 50.2.5 Workforce Development and Contracts 50.2.6 Regulation and Standards 50.2.7 Service Transformation 50.2.8 Sharing Good Practice 50.2.9 Monitoring Experience, Outcomes and Impacts 50.2.9.1 Key Trends and Analysis 50.2.10 Summing up the Second Horizon 50.3 The Third Horizon 50.3.1 Self-management and Social Prescribing Partnerships 50.3.2 Anticipatory Care Planning 50.3.3 Compassionate Communities 50.3.4 Housing 50.3.5 Neighbourhood Care 50.3.6 Summing Up the Third Horizon 50.4 Lessons Learned and Reflections on Scaling up 50.4.1 Lessons Learned 50.4.2 Scaling Up the Gains—A Case Study 50.5 Reflections Acknowledgements References 51 Innovative Payment and Care Delivery Models: Accountable Care Organizations in the USA 51.1 Integrated Care in the USA 51.2 Integrated Care in Practice: Accountable Care Organizations 51.2.1 Problem Definition 51.2.2 Description of the ACO Model 51.2.3 The CMS ACO Program Pathways to Success 51.2.4 Impact 51.2.5 Preliminary Results 51.2.6 Dissemination 51.2.7 Lessons Learned and Challenges Ahead 51.2.8 General Outlook of ACOs and the Impact of the COVID-19 Pandemic References 52 Case Study—Community Capacity for Health: Foundation for a System Focused on Health 52.1 The Challenge Before Us 52.2 Healthy Communities: National and Provincial Contexts 52.3 The Journey Begins in Airdrie 52.4 Community Plan for Health 52.5 Aspirations Advanced by Blue Zones Project 52.6 Blue Zones Project Airdrie Implementation 52.7 Abrio Health Experiential Insights 52.8 Perspectives: Healthy Citizens, Sustainable and High Performing Systems—We Can Have Both WHEN…. References 53 Switzerland 53.1 Health Care in Switzerland 53.2 Swiss Integrated Care in Practice 53.2.1 Number and Types of Integrated Care Initiatives 53.2.2 People-Centeredness of the Initiatives 53.2.3 Professionals Involved & Interprofessional Practices 53.2.4 Use of Clinical Information Systems 53.2.5 Integration Between Levels of Care 53.3 Conclusion References 54 Netherlands: The Potentials of Integrating Care Via Payment Reforms 54.1 Integrated Care in the Netherlands 54.1.1 The Dutch Healthcare Reform in 2006: The Introduction of Managed Competition 54.2 Integrated Care in Practice 54.2.1 Problem Definition 54.2.2 Description of the Bundled Payment Model for Diabetes Care 54.2.3 People Involvement/Service User Perspective 54.2.4 Impact 54.2.5 Lessons Learned 54.2.6 Outlook 54.2.6.1 Bundled Payment for Pregnancy and Child Birth 54.2.6.2 Population Health Management References 55 Designing Financial Incentives for Integrated Care: A Case Study of Bundled Care 55.1 Introduction 55.1.1 Models Based on Procedures and Diagnostic-Related Groups 55.1.2 Single Condition Versus All-Inclusive Bundles 55.1.3 Event Triggering the Start of the Bundled Care 55.1.4 Short-Term Versus Longer-Term Models 55.2 Bundled Care in Ontario: A Case Study 55.2.1 he Implementation Context 55.2.2 Rationale for Integrating Acute with Home Care 55.2.3 Characteristics of CHF and COPD Bundles in Ontario 55.3 Cost-Effectiveness of Bundled Care for Chronic Conditions 55.3.1 Evidence of Cost-Effectiveness 55.4 The Economic Theories Behind Financial Incentives as They Apply to Bundled Care 55.4.1 Principal–agent Theory 55.4.2 Transactional Cost Economic Theory 55.5 Conclusion References 56 Singapore 56.1 Introduction 56.2 History and Transitions 56.3 Governance and Care Delivery 56.4 Healthcare Financing 56.5 Integrated Care in Practice 56.6 People Involvement 56.7 Impact 56.8 Areas for Improvement 56.9 Learnings from the COVID-19 Pandemic 56.10 Outlook Acknowledgements References 57 Integrated Care in Norway 57.1 Introduction 57.2 Norwegian Health and Social Care Services 57.3 The Coordination Reform (2008–2009) 57.4 The White Paper on Public Health (2014–2015) 57.4.1 Care Plan 2020 57.4.2 National Health and Hospital Plan, 2020–2023 57.5 Reaching the Quadruple Aim in Norway 57.6 Patient-Centred Healthcare Team in Tromsø 57.7 Outlook for the Future References 58 Wales 58.1 Introduction 58.2 Problem Definition 58.3 Integrated Care Policy in Wales 58.4 Integrated Care in Practice in Wales 58.4.1 Integrated Care Case Study One: A Healthier West Wales: Proactive Technology-Enabled Care 58.4.2 Integrated Care Case Study Two: Providing Palliative Care for Heart Failure Patients at Home 58.5 Impact, Dissemination and Replication 58.6 Lessons Learned and Outlook 58.7 Concluding Remarks References 59 Integrated Community Care―A Last Mile Approach: Case Studies from Eastern Europe and the Balkans 59.1 Introduction 59.1.1 Organisation Redesign 59.2 Local Authorities Driving Service Integration 59.2.1 The Romanian Experience 59.2.2 The Intervention 59.2.3 General Findings 59.2.4 User Benefits/Satisfaction 59.2.5 Service Provider Benefits 59.2.6 Population Benefit 59.2.7 Cost Benefit 59.3 Social Services Developing Integrated Case Management Strategies for Elderly and Multi-Morbidity Patients in Rural Communities 59.3.1 The Moldova Experience 59.3.1.1 Health Information Systems 59.3.1.2 Sectoral Divide Between Medical and Social Services 59.3.1.3 Leadership and Priorities 59.3.2 The Intervention 59.3.3 General Findings 59.3.4 User Benefits/Satisfaction 59.3.5 Service Provider Benefits 59.3.6 Population Benefit 59.3.7 Cost Benefit 59.4 Family Medicine Centres Drive the Development of Integrated People-Centred Health Services (IPCHS) at Municipality Levels 59.4.1 The Kosovo Experience 59.4.2 The Intervention 59.4.3 General Findings 59.4.4 User Benefits/Satisfaction 59.4.5 Service Provider Benefits 59.4.6 Population Benefit 59.4.7 Cost Benefit 59.5 Conclusions and Lessons Learnt References 60 Developing Integrated Care in Portugal Through Local Health Units 60.1 Introduction 60.2 Integrated Care—Case Management 60.3 Integrated Care in Mental Health 60.4 Conclusion References 61 Primary Healthcare Integration Practices in Turkey 61.1 Introduction 61.2 Problem Definition and Motivation 61.2.1 Demographic Transition 61.2.2 Rapid Urbanization and Changing/deteriorating Lifestyles 61.2.3 Changing Disease Patterns from Communicable to Noncommunicable Diseases 61.2.4 The Need to Change Care Delivery Structures 61.2.5 High Burden of Ambulatory Care in Hospitals 61.3 Description of the Model 61.3.1 Integrated Care at High Policy Level 61.3.2 Elements of the Care Integration in Turkey 61.4 Dissemination and Replication 61.5 Implementation and Impact 61.5.1 Implementation 61.5.2 Initial Impact of Care Integration Efforts 61.6 Lessons Learned and What’s Ahead 61.6.1 Next Steps in Care Integration 61.6.2 Lessons Learned 61.7 Conclusion References 62 Israel: Structural and Functional Integration at the Israeli Healthcare System 62.1 Integrated Care in Israel 62.1.1 A National Perspective: How Integration in Practice Can Improve Quality of Outpatient Care 62.2 Integrated Care in Practice: Clalit Health Services 62.2.1 Problem Definition: Unplanned Readmissions 62.2.1.1 The Strategy: Vertical Integration 62.2.1.2 Predictive Modelling 62.2.1.3 Transitional Care Interventions 62.2.1.4 Quality Monitoring 62.2.2 Impact 62.2.3 Dissemination and Replication 62.2.4 Lessons Learned and Outlook References 63 Integrated Care Concerning Mass Casualty Incidents/Disasters: Lessons Learned from Implementation in Israel 63.1 Introduction 63.2 Basic Assumptions 63.3 Main Components of Integrated Care 63.3.1 The Preparatory Phase 63.3.1.1 Development of Integrated Guidelines and SOPs 63.3.1.2 Training and Exercise Programmes 63.3.1.3 Ongoing Monitoring Systems 63.3.1.4 Information Systems 63.3.1.5 Equipment and Infrastructure 63.3.2 The Response Phase 63.3.2.1 Implementation of an Automatic Response 63.3.2.2 Central Control and Coordination 63.3.2.3 Connectivity Between Response Agencies 63.3.2.4 Collaboration Between Military and Civilian Entities 63.3.2.5 Coordinated Risk Communication 63.3.3 The Post-response Phase (Return to Normalcy) 63.4 Conclusions References 64 Canada: Application of a Coordinated-Type Integration Model for Vulnerable Older People in Québec: The PRISMA Project 64.1 Integrated Care in Québec and Canada 64.2 Integrated Care in Practice 64.2.1 Problem Definition 64.2.2 Description of the PRISMA Model 64.3 Experimental Implementation and Impact 64.3.1 Dissemination and Replication 64.3.2 Lessons Learned and What is Ahead References 65 New Zealand: Canterbury Tales Integrated Care in New Zealand 65.1 Integrated Care in New Zealand 65.2 Integrated Care in Practice 65.2.1 Problem Definition. 65.2.2 People Involvement/Service User Perspectives 65.2.3 Impact 65.2.3.1 Building a Social Movement 65.2.4 The 2010–2011 Earthquakes 65.2.5 Vision 2020 Becomes Vision 2011 65.2.6 Dissemination and Replication 65.2.7 Lessons Learned and Outlook. 65.2.8 The Canterbury Health System Response to the Christchurch Mosques Terror Attacks 65.2.9 Was Vision 2020 Achieved? 65.3 Integrated Health Systems in a time of Coronavirus 65.4 Conclusion References 66 Building an Integrated Health Ecosystem During the Great Recession: The Case of the Basque Strategy to Tackle the Challenge of Chronicity 66.1 Introduction 66.2 The Role of Basque Health Care Within a Decentralised Health System 66.3 Demographic and Epidemiological Changes in the Basque Country 66.4 Organisational Transformation of the Basque Health System to Tackle the Challenge of Chronicity (2009–2019) 66.4.1 Health Policies in the Context of the Great Recession 66.4.2 The Need for New Healthcare Models: A Systemic Transformation Towards Integrated, Person-Centred Care 66.4.2.1 Phase 1. The Strategy to Tackle the Chronicity Challenge in the Basque Country 66.4.2.2 Phase 2. The Deployment of the ICO Model 66.4.2.3 Phase 3. Progress Towards a Value-Based Integrated Care Model 66.5 Conclusions References 67 The Journey from a Chronic Care Program as a Model of Vertical Integration to a National Integrated Health and Care Strategy in Catalonia 67.1 Introduction 67.2 Integrated Care in Practice 67.2.1 Problem Definition 67.2.2 Description of the Model 67.2.2.1 The Beginning of the Integrated Care Model in Catalonia—The Chronic Care Program 67.2.2.2 The evolution of the concept—From Vertical Integration to an Integrated Health and Care Strategy in Catalonia—PAISS 67.3 Experimental Implementation and Impact 67.3.1 Dissemination and Replication 67.3.2 Lessons Learned and Challenges Ahead 67.3.3 Applying Lessons Learned to a COVID Crisis Scenario 67.4 New Proposals to Reinforce Integrated Care as a Prioritized Policy in Catalonia References 68 Integrated Care in the Autonomous Community of Madrid 68.1 The Spanish National Healthcare System 68.2 Madrid Region 68.3 Strategy of Care for People with Chronic Diseases in Madrid Region 68.3.1 Stratification of the Population 68.3.2 Protocols for Patients with Chronic Diseases Adapted to Their Needs 68.3.3 Integrated Care Pathways for Patients with Complex Needs 68.3.4 Shared Electronic Health Record 68.4 The End of Life Care (Palliative Care) 68.5 Implementation in Specific Territories and Bottom-Up Initiatives 68.5.1 The Case of Rey Juan Carlos Hospital 68.5.2 “Mapeando Carabanchel Alto” (Mapping Upper Carabanchel) 68.5.3 “Vallecas Activa” (Vallecas Active) 68.6 Conclusions References 69 Integrated Care in Germany: Evolution and Scaling up of the Population-Based Integrated Healthcare System “Healthy Kinzigtal” 69.1 Integrated Care in Germany 69.2 Case Study: Healthy Kinzigtal (HK) 69.2.1 Governance and Participation 69.2.2 The Business Model of Healthy Kinzigtal 69.2.3 Coverage and Programmes 69.2.4 A Cross-Cutting Theme: People Involvement / Service User Perspective 69.3 Impact 69.4 Dissemination and Replication References 70 Case Study Finland, South Karelia Social and Healthcare District, EKSOTE 70.1 Background 70.1.1 Population 70.1.2 Social and Healthcare Reform in Finland 70.2 South Karelia Social and Healthcare District EKSOTE 70.2.1 EKSOTE’s Organization Chart 70.3 Examples of Integrated Service 70.3.1 Low-Threshold Services 70.3.2 Rehabilitative Home Care 70.3.3 Mobile Services by Car (Mallu and Malla) 70.3.4 Emergency Services (ER) in Your Living Room, Stand-by Urgent Care at Home 70.3.5 Coordination 70.3.6 Measurement of Health Outcomes and Social Services 70.3.7 Reimbursement System 70.3.8 Digitalization 70.4 Examples 70.4.1 The Smart Assessment of Service Need 70.4.2 Smart Home 70.4.3 Speech and Voice Recognition 70.5 Conclusion References 71 Ireland Case Study 71.1 Introduction 71.2 Integrated Care in Ireland 71.2.1 Health of the Nation 71.2.2 The HSE National Clinical Programmes 71.2.3 The National Integrated Care Programmes 71.2.3.1 Key Features of Establishing the Integrated Care Programmes 71.2.3.2 Governance 71.3 The Patient Voice in Integrated Care 71.3.1 Patient Narrative Project 71.4 The National Integrated Care Programme for Older People (ICP OP) 71.4.1 Insights into Implementation 71.4.2 Impact of ICP OP 71.4.3 Summary of Findings 71.4.4 Dissemination 71.5 Lessons Learned and Outlook 71.5.1 We Have Learned that Integrated Care Is a Journey and not a Destination Acknowledgements References 72 Disease Management Programs in The Netherlands; Do They Really Work? 72.1 Using the Chronic Care Model to Evaluate the Long-Term Effects of Disease Management Programs in The Netherlands 72.2 Question 1: Which Interventions Mapped to the Chronic Care Model Were Actually Implemented Within the Dutch DMPs? 72.3 Question 2: Did the Quality of Chronic Care Delivery Measured with the CCM Dimensions Improve Over Time? 72.4 Question 3: Did Quality of Chronic Care Delivery Result in Productive Interactions Between Patients and Healthcare Professionals? 72.5 Question 4: Did DMP Implementation Lead to Better Patient Outcomes? 72.6 Conclusion References