Handbook Integrated Care

Integrated care is difficult to define and understand since it represents a complex service innovation in the way health and care services should be redesigned around people’s needs. Consequently, integrated care has come to mean different things to different people and the resulting conceptual ‘soup’ has often acted as a barrier when it comes to developing commonly understood strategies to support implementation and change. This chapter attempts to outline that there are three distinct dimensions to what integrated care means in practice.

Throughout this chapter, barriers and challenges are mentioned, which still impede the radical cultural and systemic change necessary to implement integrated people-centred systems at scale. Given how long the interplay of body, mind and social environment has already been recognised as essential for the health and wellbeing of people, it is at first glance astonishing that so little has changed in our systems thus far. However, upon closer scrutiny, the shift from patho- to salutogenesis represents a profound paradigm shift, which touches at the cultural, financial and structural core of our systems.

This chapter provides an overview of available evidence supporting integrated care. It highlights that evidence of the impacts of integrated care as a whole is difficult to derive, given the complex and polymorphous nature of a concept that has been approached from different disciplinary and professional perspectives. Instead, it may be more instructive for decision-makers and practitioners to draw on evidence of impact of core elements and strategies that can help to achieve integrated care.

In this chapter we focus on the values in integrated care. As values often play a role in underlying integrated care processes and mechanisms, they may help us explain why integrated care initiatives work or do not work. However, values are not always tangible or visible and their role is often implicit. This chapter therefore presents a list of eighteen frequently appearing values underpinning integrated care, including insight into their relevance on the levels of integration. The list forms an international normative basis for the integrated care concept. Furthermore it can be used for the identification and explication of values in integrated care practice, while also enabling discussion among stakeholders that appear to prioritize or interpret values differently.

The presented studies reviewed in this chapter support efforts for increased consideration of patient benefit as an essential quality criterion in the assessment of integrated care. Especially where it is difficult to clearly differentiate between services in terms of medical and financial aspects, comprehensive information on patient benefits (and to that of communities as well) can be very useful in prioritizing approaches to care and treatment. Studies of this type can thus help to stimulate fresh discussion and lead to the formulation of increasingly person-centred care concepts in the long term.

In this chapter we examine the impact of social issues on people’s health and well-being and present the argument that integration at both population-level and in delivery of direct services are necessary to achieve better outcomes and address inequalities. Different approaches to responding to social need are taken within and between countries and regions. This is influenced by macro-economic, funding and delivery structures, and also their cultural traditions of how best to care for those with social needs. Despite such differences there are common lessons that can be shared internationally.

ICC is a resilience-oriented approach that seeks to strengthen communities by tackling the determinants of health. It assumes accountability towards a territorially defined population, creating new cross-sectoral and interdisciplinary partnerships and taking a population health approach with a focus on prevention. In ICC, a new power dynamic and relationship is forged: people and communities co-design and co-produce health and care; the role of government is that of an equalizer (ensuring resources are allocated to those most in need) and investor in public services; and the traditional boundaries between informal and formal care are blurred.

Using the theory of path dependence, this chapter increases our understanding of the hyper-stability of certain practices in health care as well as of the whole health system. Technological, institutional and organizational path dependences are based on self-reinforcing mechanisms that create such stability, making deviations from existing paths extremely difficult. If coordination and complementarity or learning and adaptive expectation effects are at work, transformation towards more integrated care will be difficult, if not impossible. Policy makers, health professionals and health care managers should be aware of these difficulties when aiming for technological, institutional or organizational change.

In this chapter, we will begin with a consideration of what is meant by ‘culture’ and ‘values’ and how they have been connected in relation to the field of integration. We will then focus on two key approaches to developing them positively—teamwork and inter-professional learning—while critically reflecting on some of the challenges. Creative-relational inquiry is then introduced as an alternative framework to exploring cultures and values. Finally, we conclude with a reflection on what this means for those leading and working in integrated settings.

In this chapter we outline the importance and complexity of integrated care governance, by positioning it in the total spectrum of integrated care. Dealing with these complexities is on the one hand daily practice in many countries, on the other hand, we do need more knowledge about what approaches work in what circumstances and why. Integrated care needs suitable governance to sustain and develop further in context. To support managers, policy makers and practitioners, we illustrate in this chapter possible approaches and action points, some examples which we like to share, and we raise new questions for future research and practice.

Countries around the world adjust the way they deliver health and social care services, responding to the changing needs of an aging population and people living with one or more chronic conditions. In many cases, service provider organisations break new ground and start coordinating activities in inter-organisational networks. However, despite best intentions, progress has remained limited, not least due to the challenge of governing these networks. This chapter aims at identifying three perspectives on the governance of integrated care networks, describing network governance as structure, process and practice.

Governance may not be a top priority when debating health care transformation for the twenty-first century but it is a critical instrument to strengthen public and institutional performance (Van Kersbergen and Van Waarden 2004; Chhotray and Stoker Chhotray 2009). The first two sections of this chapter cover theoretical aspects, including how governance and accountability are conceptualized and specific considerations of governance and accountability in integrated health systems. The latter two sections focus on the practical aspects of implementing governance and accountability into integrated health systems and the tools needed to support its implementation.

This chapter aims to provide foundational knowledge of how regulation, assessment and inspection are being designed and implemented across several countries in relation to integrated care. It begins with defining each term, the benefits of each, and roles of various health and social system actors. A common theme throughout regulation, assessment and inspection is the focus on the client journey and how the client experiences and perceives care. Equally important is the value that stakeholders attribute to the regulation, assessment or inspection process. This forces governments, assessment bodies and inspectorates to be mindful to monitor outcomes that matter.

Leadership in integrated care does not differ fundamentally from leadership challenges in other network structures and needs to be addressed adequately. Besides the general underestimation of the importance of leadership in health care, several aspects have to be considered specifically. This chapter presents general recommendations which highlight the importance of the topic for integrated care.

Management of complex service innovations, such as integrated health and social care organisations, is known to be demanding. In this chapter, co-leadership will be elaborated as one approach to address the challenges that arise from organisational complexity. This is preceded by a short historical background about how the interpretation of leadership has changed over time, from focusing on the leaders’ personality to envisioning leadership as a function or activity that numerous persons in an organisation can have and share at the same time. This chapter is based on literature in the scientific field of integrated care and leadership research and the empirical findings discussed emanate from my doctoral thesis: The only constant is change—the evolvement of health and social care integration

This chapter argues that the management of change towards integrated care requires the combination of two principle sets of processes: a step-wise progression of managerial tasks that come together to represent the core components of a change management plan (‘management’) and the ability to adapt these strategies for change in the context of the complex and multi-dimensional nature of practical reality (‘environment’). Both tasks require key individuals with the managerial skills and both have a strong relationship-building component and are inherently inter-related.

A business model development process that aims to involve stakeholders is faced with the challenge of communicating a complex subject matter to a non-expert audience with the aim of empowering them to make informed design suggestions or decisions. This chapter presents an approach to these challenges. It consists of two elements, building on each other. The first element is a method and toolkit for the assessment of socio-economic impacts in health, care and ageing, called ASSIST. The second element is a simulation tool based on real-life data that allows building an integrated care service and modelling how it responds to changes in economic factors. This second element we call the ASSIST Service Implementation Simulator. Both elements will be described in the following.

Planning, especially workforce planning, has been high on the agenda of health policy makers, practitioners, and researchers for the past 40 years. Various methods have been developed and become more and more refined. Recent changes to models of care have again called into question much of the established methodologies. That applies in particular to integrated care where clearly specified tasks for single practitioners are replaced by a team-based, pro-active approach to care delivery. This chapter proposes four key lessons for planning integrated care: (a) Setting objectives and standards of care, (b) Aligning planning approaches with the specific model of care, (c) Monitor and adapt constantly, (d) Integrated care calls for integrated planning.

Integrated care has come into its own in many countries around the world, but sustainable change is still elusive. One of the key problems remains the fact that education and training have not yet caught up with the multi-faceted changes in the provision of services. This chapter will explore how education and training must change in order to foster the development of a continuous learning environment which will, in turn, support sustainable change.

As is the case for integrated care in general, workforce interventions need to be well planned, implemented, and evaluated. The journey to improved health outcomes by means of integrated care is a relatively recent one, but it has demonstrated that workforce changes form an area of attention that is essential for the understanding and success of integrated strategies as a whole. Even if integrated care should be surpassed by a superior approach in the future, workforce changes as part of complex improvement strategies will necessarily remain on the radar of every health care system working towards improved population health.

Differences in financing sources and mechanisms, and in the allocation and flows of financial resources can pose a critical challenge for efforts to better coordinate and integrate across functions, professions and sectors. This chapter provides an overview of ways in which countries have sought to overcome these challenges. While numerous innovative approaches have been implemented, the evidence of what works best in what contexts, and their impacts on outcomes remain elusive.

An essential element of making integrated care successful is an appropriate reimbursement instrument, such as bundled payments. They may differ in the scope of bundling (target population, time, sectors), as well as in how the price is set (negotiation, fixed). Yet, they always go along with a specific mind set of taking responsibility for the delivered health care and transparency on the own performance

This chapter emphasizes that integrated care is a means to an end, not an end in itself. It serves merely as a strategy aimed at providing better services for patients and populations. The aim of integrated care is to improve quality, not to reduce costs. As illustrated throughout this book, an integrated care strategy may be implemented on different levels, but in order to be sustainable and effective, it must permeate all tiers of the healthcare value chain—from the system level to the individual level.

This chapter reviews the evidence base on the effectiveness of disease management strategies and programmes. We show that, overall, disease management holds promise to improve processes and outcomes of care but evidence that is available tends to be limited to a small set of conditions only.

This chapter on case management starts with a case story about Julia, a person with dementia, and her case manager, John. It introduces a definition of the concept of case management and discusses important terms in it. Two specific competences of case managers are discussed: (1) the assessments of care and social needs and (2) empowering interviewing of clients. The chapter emphasises that case managers are not only for clients with dementia but are relevant as an approach to support other people with health, educational and financial problems; clients with developmental disorders; patients with severe mental illness; patients with cancer and metastases; and persons with more than one chronic condition.

Discharge management is an essential—if not the essential—part of providing integrated care in all health systems. However, there is still a long journey towards guaranteeing adequate transitions for patients in most (if not all) health systems. This chapter focus on discharge management as one of the traditional managed care approaches which potentially leads to both—higher quality and reduced costs. The major challenge for its success is the existence of conflicting interests within the different sectors of the health care provision which come together in this process.

Safe and effective pharmacological treatment remains one of the greatest challenges in medicine, where models of healthcare delivery lag behind the enormous growth in single disease focused treatment with medicines. The implications for safe, efficient and effective deployment of healthcare resources and sustainability are significant from both healthcare and societal perspectives. This chapter will highlight the importance of addressing the public health issue of polypharmacy as part of an integrated approach to patient care and its impact on patient safety. It will describe a 7 step process for systematic review of appropriateness of patient’s medication with multiple morbidities, that is patient centered and encourages the patient to be part of the decision making.

Digital health systems have an important role to play in the delivery of integrated health and social care services. Despite their utility, the adoption of these tools has lagged for many organizations, leading to missed opportunities for advancing integrated care. This chapter describes how digital health innovations, in particular information and communication technologies, can address three common integrated care “problems” to demonstrate how these tools can be put into practice. Practical recommendations and strategies to enable implementation are offered at the end of the chapter.

Health data integration is considered a key component and, in some cases, a pre-requisite in nearly every systematic attempt to achieve integrated care. In the context of health care, data integration is a complex process of combining multiple types of data from different sources into a single infrastructure, allowing multiple levels of users to access, edit, and contribute to an electronic record of health services (EHRs). In the following chapter we describe six basic types of data integration, the pathways by which data integration facilitates integrated care, the main players of health care data integration, and key challenges to integrating data.

The Internet of Medical Things and the integration of wearables and sensors to support optimization of health through self-management and remote monitoring have dramatically accelerated over the past decade. With this gaining momentum, wearable devices to measure individuals’ physiology such as heart rate and activity levels have become highly popular, increasingly pervasive, and creating a cultural shift to help people to collect, quantify, and observe their own data relating to their behaviours in day-to-day life. With the potential to change health behaviour through these platforms, the general public has the ability to be more engaged and participatory in their own health. For healthcare providers, these devices are improving patient care through continuous objective reporting, remote monitoring and precision medicine.

The implementation of integrated care and essentially every progress in the medical field depends above all on data, i.e. health and patient data. Thus, harmonised and high standards of data protection regulations are crucial. The following chapter therefore focuses on the European data protection regime, in particular on health and patient data while also providing insights into the different kinds of data, the lawfulness of processing data, the main data subject rights as well as the measures that controllers and processors of personal data have to comply with.

In this chapter, we propose that stronger international cooperation needs to occur in the development of integrated care frameworks to promote a coalesced international approach to measurement. Continued progress towards integrated care will depend much on our ability to contrast and compare the impact of strategies across different levels and contexts, using consistent measurement tools.

This chapter examines if claims data generated in standard medical care is suitable for evaluating integrated care. To do so, we describe the structure and contents of relevant data and explain its advantages as well as the methodological challenges of using such data for evaluation research. Selected short examples will illustrate how to use the data and the conclusions drawn from the results for practical application. This paper ends with a description of the potential of the data in addition to approaches pursued in clinical research. In order to do so we will examine to what extent the conclusions drawn for Germany can be applied to other countries based on a number of examples.

The complexity of integrated care and the substantial resources needed to collect reliable data appears to have challenged health economists to evaluate the cost- effectiveness of integrated care to date. On the health services research side, health economists were not involved in many evaluation studies so far, which presumably resulted in low quality evidence on cost-effectiveness. Economic evaluations are frequently piggy back tailed in the effectiveness evaluation of integrated care but this needs to be changed because there is a clear need for better understanding and communication between health economists, researchers from other disciplines, clinicians, payers and decision-makers during the set-up of an evaluation study.

Complexity theory has the potential to be an inspiring and invigorating contribution to the study of integrated care. In this chapter, I propose that using Preiser’s 6 organising principles of a CAS provides a general typology around which we can design, evaluate and research integrated care interventions to develop a deeper, richer understanding of integrated care systems and interventions. We have already acknowledged that integrated care is complex and surely that behoves us to embrace complexity theory like many other disciplines have to unpack the black box of integrated care.

There is an increasing interest in evaluating complex interventions as epidemiological changes increasingly call for composite interventions to address patients’ needs and preferences. It is also because such interventions increasingly require explicit reimbursement decisions. That was not the case in the past, when these interventions often entered the benefit package automatically, once they were considered standard medical practice. Nowadays, payers as well as care providers are intrigued to know not just if a health care intervention works but also when, for whom, how, and under which circumstances. In addition, there is broad recognition in the research community that evaluating complex interventions is a challenging task that requires adequate methods and scientific approaches.

Realist research and evaluation methods are increasingly being used in health and social care research settings, including integrated care endeavours. The realist view of how the world is, and how we can explain it, seeks to look 'beneath the hood' and to ask the questions how and why. Health and social policy and service settings, within which integrated care strives to make a difference, are complex 'open' systems that can only partially be understood using empirical methods alone. Abductive and retroductive modes of reasoning, as used by realist researchers, are commonly used by physicians, detectives and lawyers to postulate hidden explanations based on available experienced evidence. The approach is, therefore, not foreign to many readers of this chapter, and realist scientific methodology gives validity to this common but scientifically neglected mode of analysis.

This chapter draws attention to the importance of creating a nurturing start to a child’s life and the role that families, neighbourhoods and society as a whole play in creating a “nest”. Often the care that is provided is focused solely on the physical health (medical) domain with neglect of the psychological, material and social needs. We have sought, therefore, to stress the importance of focusing on the whole family as partners in the care of mothers and their infants. We have also drawn attention to the benefits of an integrated multi-disciplinary and multi-agency approach to perinatal and infant health and wellbeing.

Integrated care for children is in early stages in most countries, but there are promising signs that children’s distinctive health needs are beginning to be recognised. Policy translation is the next goal in realising integrated care for children, and it is helpful to look again at the ultimate goals.

Older people are more than the sum of their conditions, and their complex needs frequently consist of health and social needs, as well as the need for both physical and mental health care. We believe that integrated care for older people should address more than their health conditions, that they rely a lot on social and leisure resources, services providers, commerce, home and public environment, and that networking and communication between the several stakeholders are crucial to deliver a coherent intervention. This leads us to reason that the ultimate form of integrated care is the concept of integrated governance.

The challenges of care for frail older people with dementia and multi-morbidity are increasing, partly due to our improved health care services and increased life expectancy. This challenge is not an easy one. It requires innovative approaches in order to face these challenges and to reduce current and future burden of service users, their families and society. It is a challenge that requires new care paradigms and new organizational paradigms. Working towards the principles of a new concept of health, working towards personalized and person-centred care in networks, based on shared normative and functional frameworks needs full attention of policy makers and care providing organisations.

The integrated palliative care model proposed in this chapter involves a set of professional health and social care services, which envelop the support and assistance of family and volunteers from an empowered community capable of caring for their families and neighbours. In the context of the growing chronic care challenge to contemporary health systems, palliative care provides better quality, more cost-efficient ways of treating people at the later stages of their chronic diseases and end-of-life than treating them in acute hospitals. Thus, as a key element in any chronic care strategy, palliative care shows the way forward in the design of a service delivery model truly embedded in the emerging integrated care paradigm.

This chapter emphasizes that innovation has often been driven by individual clinical champions working, at least initially, in relative isolation from the rest of the system. To be sustainable, the work of these clinical innovators needs to receive support from senior leaders within local organisations, and must be reinforced by consistent messages from this leadership. A powerful catalyst for cultural change is direct contact between professionals working in different parts of the system—specifically, those traditionally responsible for physical health and those specialising in mental health. Given this, the service models which have the greatest potential may be those which combine direct clinical work with joint supervision and educational functions, creating opportunities for skills transfer between mental and physical health care professionals.

Rare diseases (RDs) are serious, often chronic, progressive, degenerative and associated with comorbidities, substantially affecting quality of life.Integrated care is essential to ensure the transfer of scarce expertise on RDs, the needed coordination between care providers, and to ultimately improve care pathways, guaranteeing the continuous and holistic care delivery that people with RDs need.Studies and pilots conducted so far have shown that integrated and holistic care provision leads to important quality of life improvements for those living with RDs and their families, while being cost-effective and improving the coordination among care providers.Despite this growing evidence, much remains to be done to achieve integrated care for people living with RDs in Europe. In 2016, the Commission Expert Group on Rare Diseases recommended that European Member States should implement measures to facilitate multidisciplinary, holistic, continuous and person-centred care to people living with RDs.In 2019, EURORDIS-Rare Diseases Europe, published an important set of recommendations to support the implementation of integrated care for RDs in Europe. These refer measures to create a supporting environment at national level, specific mechanisms to ensure integrated care and concrete actions to support the dissemination of essential knowledge and good practices.Various methods can and should be used simultaneously to promote integrated care for RDs, including: Centres of Expertise and resource centres for RDs; case managers; care pathways and standards of care; individual care plans; networking and training programmes for service providers; eHealth; European Reference Networks; and the integration of RDs into national functionality/disability assessment systems.

Intellectual disability is a very interesting area to explore and to understand the design and implementation of person-centred integrated care due to its complexity in the classification and assessment, interventions, care delivery and policy planning. There is a significant ambiguity in the conceptualisation and classification of this health condition and disparities emerge between the health sector and the social and education sectors on this condition and these disparities have significant implications for service planning and delivery. The early development of strategies of both person-centred care and integrated care in this field may contribute to a better knowledge of the challenges of developing integrated care both in the interaction between primary care and secondary care and in the integration of health and social care.

The Safe Communities Opportunity and Resource Centre (SORCe) is an innovative, multi-agency collaborative designed to address the complex health and social needs of homeless citizens in Calgary, Canada. The model is driven by a “Housing First” and inclusivity philosophy. The Calgary Police Service historically has been the backbone agency that supports SORCe. Complemented by 13 health care, justice and social service agencies, SORCe offers a wide range of integrated services to Calgary’s most vulnerable population. In operation since 2013, the centre sees increasing numbers of client visits per year. Positive outcomes for the homeless population as well as the justice and health systems have emerged. The model continues to evolve and grow, with the Cross Roads Centre as a recent example of connected initiatives. Collectively, these initiatives create an opportunity for real impact and successful reintegration of homeless people into the community.

Stroke remains a leading cause of death and disability. Effective treatment and management require seamless integration across the healthcare and social care interface. Cooperation and collaboration between professionals, patients and caregivers is needed. This chapter elaborates on the Dutch Knowledge network of stroke services (KNCN). The network supports the stroke services through several activities focused on quality measurement and quality improvement of integrated stroke care. i.e. benchmark of quality indicators, healthcare standard stroke care, knowledge broker network, self-evaluation tool, audit instrument, screening for impairment at home and shared decision making.

The structures of care in the field of transplantation present a variety of complicated paths and hurdles for the patient. Besides challenges concerning the involvement of different sectors of care and multiple institutions, there is no so-called owner of the process for the patients. Since the treatment path includes contacts with a variety of specialists from various fields, it is important that GPs assist in organization and help patients get their bearings. Though it all, the patients need to consolidate all information and organize their own treatment process along with the different physicians. As local physicians generally do not have much experience in handling specific issues of transplantation, the patient is kind of left to deal with it alone.

This case study provides a brief overview of the NHS in Scotland and in particular NHS Highland, including the relevant health and integration policy context. NHS Highland is responsible for the largest health board area in the UK and includes some of the most remote and rural parts of the country. In March 2012 NHS Highland was the first health board in Scotland to integrate health and social care when they signed a formal partnership agreement with the local authority (The Highland Council). Under the new arrangements—known as the lead agency model—in April 2012 all adult social care services were transferred to NHS Highland from the Highland Council. This brought together for the first time within one organisation, community, primary, social care and acute services. The legal, financial and management implications of the lead agency model are explained. Benefits of new ways of working are considered and some of the lessons learned explored. The potential pit-falls in demonstrating direct impacts in such a new complex operating environment, especially in the short-term, are also considered.

This chapter elaborates on integrated care in Scotland. The opening section outlines the first horizon—the political and policy landscape, financial and demographic context, stakeholder engagement and introduction of new organisational arrangements. The second section covers important enablers for implementing integrated care. It signposts to local examples of change and considers the challenge of measuring impacts and outcomes. The journey to improve population health and reduce inequalities is the subject of the third section. The chapter concludes with some lessons learned and briefly touches on the implications of the global Covid-19 pandemic, describing one case study which is overcoming what previously seemed unsurmountable barriers to implement new ways of working. It is illustrative of other examples of rapid change throughout the UK linked to Covid-19.

The US healthcare system has a history of continuous organizational change. The result is by no means a perfect healthcare system. However, a by-product of this history is a large number of experiments, making the USA probably the largest laboratory for healthcare delivery reform in the world. Both quality and costs are pressing issues for US healthcare reform. Efforts to address these issues by means of integrated care delivery and innovative payment models are mostly driven by the Centers for Medicare and Medicaid Services (CMS) and specifically the Center for Medicare and Medicaid Innovation (CMMI). Many of CMS’s reform efforts can be linked to goals now known as the Quadruple Aim: improving the experience of care and the health of populations, providers attaining joy in work, while reducing per-capita costs. These aims conflict with traditional, fragmented delivery structures and fee-for-service (FFS) payments, which are still the underlying structures or circumstances for reimbursing providers and delivering care for patients. One of the most discussed alternative payment models is the accountable care organization (ACO). This chapter illustrates the concept of ACOs and discusses some preliminary findings on the impact of this mode of integrated care delivery.

Healthy/healthier people and accessible, quality and sustainable health care: We need both, but how? This case study takes place in Airdrie, Alberta, a Canadian province with Alberta Health Services as the largest single health authority. The community began its journey with the typical request—“we need a hospital”—but later realized what they wanted was to “own their own health, becoming Canada’s healthiest community.” Unique to their journey was the decision to partner with Blue Zones Project®. Airdrie would have been the first demonstration community outside the USA of this integrated methodology to transform community environments and make the healthy choices the easy choices, and in so doing, reduce need for, and cost of, public healthcare services.

This chapter elaborates on the Swiss Survey of Integrated Care (SSIC), which highlights the existence of a number of integrated care initiatives. These results are encouraging and consistent with those obtained by other similar European projects.

This chapter provides insight in the potential of integrating care through payment reform in the Netherlands. We begin by briefly outlining the main characteristics of the Dutch health care system, which has been transformed into a system of managed competition in the past decade. We focus on health care, because our case study is situated in this setting. We then describe the implementation of the bundled payment for diabetes care as one main example of stimulating nationwide implementation of integrated diabetes care in the Netherlands.

Significant heterogeneity exists in the implementation of bundled care. This chapter outlines the different typologies of bundled care programs, and as a case study, highlights the implementation of bundled care in Ontario. There are several lessons for those considering adopting bundled care in their local context. In particular, great consideration should be given to the duration of treatment, the type of condition, the event triggering the beginning of the bundle and the care context and providers included in the bundle. More particularly, physician payment should be included in a bundle, as physicians make most of the decisions about care provided to patients. Finally, for health systems considering the implementation of bundled care programs, there must be widespread commitment and adoption from both payers and providers.

Singapore’s healthcare system has evolved over the years, from its initial taxation-based governmental provision, to a community of restructured public providers, to a gradually morphing network of services, to the current somewhat complex ecology of organisations that includes public, private and “people” sectors providing different levels of health and social services.

Norway has one of the highest per capita health expenditures in the world. As life expectancy increases and more people lives with long-term conditions, recent health policy development seeks to improve care coordination between primary and specialist care, shift healthcare towards more preventive and person-centred interventions and enhance user involvement in clinical decisions.

Wales has come a long way in its journey towards a more integrated health and care system for its people. It has integrated health boards with a one to one or one to many relationships with local authorities, and together, they have responsibility for population health, established legislation, developed policy and provided funding mechanisms to support such change. Yet what has become clear is that change will not necessarily happen by top down directives, but is dependent upon people making change happen, or not. Integrated care in Wales will happen when people can see it as the right thing to do and because they are encouraged, motivated and supported to do so.

This chapter shows typical entry points and a toolbox for the introduction of IPCHS at district and community levels, which can be used by other LMIC countries. It needs to be kept in mind, however, that there is no “one-size-fits-all” for these types of services. The same tools may be used in different settings, but tool selection must be guided by the local needs as well as priorities and resources, which may differ considerably between communities. In the light of the quadruple aim in health care, integrated community services are a living instrument, which can and should develop alongside people’s changing needs, building new tools and people-centred services, considering the proven possibility of creating positive change despite the various challenges.

Both case studies presented in this chapter show positive results, with benefits for patients, families and healthcare professionals and system, thereby emphasizing the importance of an integrated care system to address the real health necessities of patients, improving the quality of care and contributing to the system sustainability.

From the central policy making and the local implementation perspectives, Turkish health system has strong aspects including a robust and flexible IT system, local efforts on care coordination and multidisciplinary work. These aspects will help take the care integration efforts forward effectively. Good and increasing coverage of primary care structures together with increasing utilization figures imply public awareness and acceptance for the primary level services. These initial results present a good indication of success in the efforts to shift ambulatory care load towards the primary care.

Good and increasing coverage of primary care structures together with increasing utilization figures imply public awareness and acceptance for the primary level services. These initial results present a good indication of success in the efforts to shift ambulatory care load towards the primary care.

Concerning vertical care integration, the prioritized disease approach will give the Turkish health system the chance to take it as pilot and reflect the implementation lessons to upcoming steps.

The PRISMA model presented in this chapter shows that it is feasible and efficacious to improve integration functionally without—or in spite of—structural integration and merging of organizations. Implementation of the innovation should be closely monitored and adequate resources should be allocated to support the implementation and training for professionals and managers. Funding is a key issue in integration, and budget incentives and mechanisms should be adapted to the integration model. The most difficult challenge is to institutionalize the innovation, given the complexity of health care systems.

Canterbury Health System, considered to be among to the most integrated in the world, places significant emphasis on valuing patients’ time, trusting clinicians, fostering curiosity among its staff, and applying improvement science to further enhance organisational performance. While no system can be transferred wholesale elsewhere, there are numerous lessons that can be applied for others’ learning to ‘Make it Better’ for their citizens.

This chapter provides an overview and a broad, forward-looking reflection on the evolution of integrated care in the Basque health system. It discusses how the existing challenges resulting from changes in the demographic, social and epidemiological profiles have been addressed so far.

This chapter elaborates on the Chronic Care Program in Catalonia. Implementation of a successful chronic and integrate public policy requires perseverance, time, having a humble attitude and continuing learning efforts. Based on the authors experience, they highlight the key lessons learned from the journey of integrated care in Catalonia.

In Spain, the more advanced Autonomous Communities have been pursuing integrated care, chronic care management, and promoting an overall culture of healthcare for their population, but with different strategies and a different package of policies, tools, and innovations in each region. In this subchapter we describe some of the innovative strategies and projects that have been implemented in the Autonomous Community of Madrid describing their main elements and results that have been achieved.

´Gesundes Kinzigtal´ is the flagship model of an Integrated Health Care System and the only fully population-based system in Germany that has been subject to rigorous external evaluation. It is based on the IHI Triple-Aim model, simultaneously pursuing to improve patient experience of care, population health and reducing per capita cost of health care. At its core is a value-oriented population-based shared savings contract. Two central evaluation studies demonstrate the success of ´Gesundes Kinzigtal´, (i) a survey amongst the insured regarding their perceived health, satisfaction, and health behaviour and (ii) an analysis of the over-, under- and misutilisation of health services, based on an analysis of routinely available health claims data from the Social Health Insurance.

Integration itself is not enough. To achieve real results from integrated settings in Finland, big changes inside the integration are needed. The examples in this article are only the first short steps to move towards real benefits of integration.

As with many other health and care systems, healthcare in Ireland is a complex adaptive system and mechanistic linear reductionist thinking is insufficient for systemic change. Creating the conditions for change, an adaptive space and some simple rules or enabling constraints has been successful in our experience. At the end of the day, all Integration is local and attending to relationships and history is important to be successful. You ignore history at your peril. Creating rich connections especially locally is vital for success. Improvement is iterative, dynamic, and organic. It takes time to build trust and confidence and patience by policy makers and funders is required. The relentless restructuring within the Irish healthcare system has made implementation challenging but the Sláintecare policy is perhaps an opportunity for full implementation.

This chapter describes the long-term benefits of Disease Management Programmes (DMPs) in The Netherlands. We used the Chronic Care Model to thoroughly evaluate their long-term effects. Results clearly show that DMPs based on the chronic care model in the Netherlands resulted in (i) the successful improvement of quality of chronic care as perceived by chronically ill patients and professionals, (ii) more productive interaction between chronically ill patients and their health care professionals (iii) and improvements in chronically ill patients’ health behaviors (they smoke less and are more physically active) and physical quality of life. The findings highlight the need to broaden the scope of DMPs not aimed at functional health and self-management of a chronic disease only but also at broader self-management abilities and overall well-being which calls for person-centred care.