Integrated Care- Models and Issues

• Introduction
  • What is "Integrated Care"?
  • Integrated Care for "System Quality"
  • Aims, Objectives and Methods of Integrated Care
  • Health Needs Come First
  • Who is the Scheme For - Target Populations?
• Five Models of Integrated Care
  • Model 1: The Practitioner / Project Model
  • Model 2: The IPA / Specialist Model
  • Model 3: The Local Purchaser Model
  • Model 4: The Community Model
  • Model 5: The Primary Care Model
  • An Evolutionary Approach
  • Purchasing is Both a Professional and a Political Function
• Issues to be Considered in Developing an ICO
• Evaluating Integrated Care
• Conclusions
• References

Introduction

After some debate about methods and organisations for managed care, the New Zealand government is encouraging experimentation and evaluation of alternative approaches. based on principles of integrated care. The purpose of this paper is to describe the aims of integrated care and outline five types of integrated care organisations (ICOs), as well as some issues in setting up these schemes and the criteria for evaluating them.

What is "Integrated Care"?
Integrated care refers to the methods and type of organisation which will provide the most cost-effective preventative and caring services to those with the greatest health needs and which will ensure continuity of care and co-ordination between different services. Many methods and organisations for integrated care originate from managed care concepts and experience in the US. Managed care in the US has developed to contain health care costs and as a result of a move to capitation-based payment systems for health care coverage (where payment is on a per-person per-month basis). This requires providers to take part in systems which organise the full range of health care, which use techniques to reduce utilisation, and which also involve health promotion interventions to reduce the need for health care and to maintain the health of the population enrolled in the managed care scheme. The term "integrated care" has been adopted by public systems to describe both managed care ideas applied within public systems and other ideas such as the creation of "chains of care" or "care pathways".  ¹  

Integrated Care for "System Quality"
Interest in integrated care has increased in health systems which have introduced public markets such as the UK, New Zealand and some Swedish counties.  ²   In these systems a public purchaser or funder contracts services from separate and often competing organisations. Contracting and competition has exacerbated the tendency for professions and services to concentrate on their own part of the care process. Providers concentrate only on providing the element of service which they are contracted for, yet patients often require a range of services from different organisations. There is no effective local responsibility for ensuring that a patient’s care is managed and co-ordinated between the different services as a complete episode of care. Neither is there a local overview of population needs and of the range of services and actions required to meet these needs. Integrated care and devolved purchasing is viewed as a way of overcoming some of these problems and of increasing "system quality".

Aims, Objectives and Methods of Integrated Care
The aims of "integrated care" are to maximise the health gain produced from a given resource by ensuring that resources are targeted, that effective interventions are used, and that the contributions of different services are linked. The intentions are, first, to focus on the most serious health needs and, secondly, to create an effective health "system" - a system of prevention and care where different interventions work together in a synergistic way so that the total effect on health is greater than the sum of the separate interventions. The objectives are, within a public market system, to:

1. Increase the access to care of those most in need and who can benefit most from care;
2. Improve the continuity of care for individual patients and the quality of the entire care episode by improving co-ordination between services (through, for example, clearer agreements about transfer of responsibilities, better communications, defined care pathways within and between services for entire care episodes, "relay team" development, shared care protocols, and case management systems);
3. Reduce costs by reducing inappropriate use of services, by influencing the choice of cost-effective interventions, by introducing cost-saving substitution (eg replacing secondary with primary care, and medical with nursing care), as well as by shifting resources from tertiary and secondary care to primary and preventative services, where these are more cost effective;
4. Overcome financial barriers to effective and appropriate interventions (often by pooling budgets) and create financial risk-sharing arrangements with providers to encourage more cost-effective actions. The main methods for achieving these aims are:

• agreements and contracts, better communication systems, guidelines and protocols;
• utilisation controls (gatekeeping, discharge planning);
• pooling finance from separate sources, creating financial incentives, and removing financial disincentives for achieving the above objectives;
• new organisation, such as formalised networks or a new formal organisation for receiving and distributing finances at a local level, and/or creating integration.

Health Needs Come First
"Managed care" and "integrated care" are terms which cover a variety of arrangements. The complexity of the technical details can obscure the primary aim of protecting and improving health. The local needs should drive decisions about which integrated care methods and organisation to use. It is important to keep to the forefront the particular health needs to be met, the health outcomes to be achieved, and the local problems of co-operation or financing to be addressed. Consideration of these should lead to a definition of the purpose and objectives of a particular scheme. These local considerations should then decide the methods and type of ICO to be used in an area.

Who is the Scheme For - Target Populations?
Integrated care schemes are in part defined by the type and size of population to be served. There are three main types of target population relevant to integrated care schemes. The first is the full range of health needs of a registered or geographical population. The scheme is comprehensive and aims to provide the full range of prevention, primary, secondary, tertiary, rehabilitative and home care services for this population. The second is a specific care group such as children, women, people with mental health problems, or older people. The third is a specific disease or health condition such as diabetes, asthma, schizophrenia, heart disease, hypertension or cancer. If a particular integrated care scheme is for a sub-population like a care group or disease, then consideration has to be given to the effects of the scheme on services for other patients which are not targeted by the integrated care scheme (and on providers which are not part of the scheme - see the later discussion of issues).

Integrated care schemes also differ in their proactivity or reactivity to needs. Some aim for better co-ordination of existing care services which are provided once a person presents with an illness. Other schemes reach out to those who do not access services, or do so late or in emergency, and aim to provide early intervention or screening. Some schemes aim to manage the health of a defined population and to provide a range of health promotion, preventative and other services.

Five Models of Integrated Care

Five types of scheme were identified: the practitioner/project support model; the IPA-specialist model; the local purchasing model; the community model; and the primary care model, the latter being similar to the 1998 UK proposals for primary care groups or trusts.

Model 1: The Practitioner / Project Model
In this model the ICO does not hold a purchasing budget but is an "umbrella" and support organisation for projects to improve the co-ordination of patient care between practitioners and services, and to develop services to those in need but not well served. The model involves two organisational forms. First, a "Care Co-ordination Support Organisation" is created (CCSO) which oversees projects for developing co-ordination between practitioners and services. The second is one or more "Co-ordination Development Project Teams" made up of practitioners from the different services and a facilitator from the CCSO.

The projects might be, for example, to improve how primary and secondary care providers co-ordinate care for diabetic patients or for all children in an area, or to create case-management systems for specific mental health clients.  ³   Achieving these ends may involve improving communication and information technology systems, working on referral and shared-care protocols, arranging for secondary care specialists to run local clinics, for general practitioners to work in Accident & Emergency departments, agreeing on substitution arrangements such as supervised primary care treatments or nurse prescribing, or carrying out health promotion work. Projects often use patient pathway frameworks as models for practitioners to use in agreeing how to improve co-ordination, the roles of different providers, the scope for preventative work and to establish protocols for "patient relay teams" covering entire care episodes.  ³  

The CCSO does not have a purchasing budget but does have some finance for project support. Existing contract arrangements are not changed but the contents of contracts may be: the CCSO may ask the central purchaser to change contracts or to shift resources from secondary to primary care if appropriate, but changes are made within existing finance and systems. The central purchaser makes the decisions and carries the financial and other risks of contract changes. The purchaser also bears any investment costs necessary to develop preventative or primary care services before expected savings come from lower use of secondary care services (which may not occur).

In effect, this model creates a matrix organisation out of a set of organisations (rather than a matrix organisation within an organisation). This matrix allows for practitioners to agree on cross-service co-ordination mechanisms for patient care, as well as to decide how to provide care or health promotion beyond existing services where more serious needs are not being met.

Issues to consider (see also Issues to be Considered in Developing an ICO)

1. Are there sufficient incentives for providers to spend time designing better co-ordination arrangements and then to spend time ensuring that the care of individual patients is co-ordinated for entire care episodes? (Evidence from mental health is that this is not the case, even when there are case managers.)
2. Will it take too long for the purchaser to consider and make contract changes, and how many of such changes can the purchaser realistically cope with? These changes are in addition to the existing contracting work.

 

 

Model 2: The IPA / Specialist Model
In this model the ICO is jointly established by a general medical practitioner Independent Practice Association (IPA) and a Medical Specialist’s Association, for example an association of surgeons, of specialists in pulmonary medicine, or of psychiatrists. This ICO contracts with the central funding authority for integrated primary and secondary care for a defined care group or health condition (eg certain surgical procedures and pre- and post-operative care). The ICO subcontracts its own doctors as well as nursing and other services for this work. The ICO may subcontract a Crown Health Enterprise (CHE) as a service facility, or a private surgery or specialist centre, with or without nursing and therapy services.

Other variations are where an IPA forms an ICO with one or more non-medical practitioner associations such as a midwives’, therapists’ or nurses’ "independent provider association".

Issues to consider:

1. Although the ICO is a legally separate and independently accountable business, it will subcontract to its shareholders, the IPA and specialists’ association. The funder will be contracting a private company (possibly a non-profit trust) for public services.
2. What are the incentives and inclinations for the ICO to invest in longer term preventative and health promotion actions?

 

 

Model 3: The Local Purchaser Model
This model is in some respects like model 2 where the funder contracts a local ICO to manage the health of a defined population, and the ICO then subcontracts for different services. The difference is that the ICO is established and managed by a number of local health providers and also carries out a local purchasing function above and beyond managing contracts, in particular functions such as needs assessment and utilisation management.

In this model the ICO is delegated a purchasing budget for a defined population by the funder. The ICO is a local purchasing/provider agency which receives all health finance for promoting health and providing care to a population such as a geographical area, a registered population or a care or disease group. The funder contracts this local purchasing agency to provide services (or to ensure health gain/health outcomes) for the defined population and the agency is responsible for deciding who is most in need, ensuring access, contracting providers and for taking other actions to maintain the health of the target population within the resources allocated.

Issue to consider:

1. The ICO is governed wholly or largely by local health providers. They will favour contracts going to their own services, and a "professional view of health". There may not be sufficient incentives to transfer finance between services or to shift finance to health promotion.

 

 

Model 4: The Community Model
In this model the ICO functions as a community forum and "mobilisation mechanism", and may or may not have a purchasing role like model 3. The ICO "community board" includes representatives from different sectors of the community, many of whom are able to take issues back to their own groups to get action. The board receives regular reports of the health needs of the community covered by the ICO which are produced by a board secretariat of two or three officers. Using these reports and other sources, the board plans actions by community groups to address these problems.

The ICO would have a budget for community development and for facilitation for health actions. The community ICO may also advise the purchaser about any changes to contracts with formal health providers which would support the ICO community health actions. In the purchasing variation of this model, the community ICO is delegated a purchasing budget for contracting certain health services.

Issues to consider:

1. Similar problems to model 1 in that the central funder may be slow to make, or unresponsive to, proposed contract changes.
2. The community mobilisation and development-for-health function may not mix well with the purchasing model in the latter budget-holding variation of this model.

 

 

Model 5: The Primary Care Model
In this model the ICO is governed by primary care providers, who are delegated a budget for primary care and for some or all secondary care. The ICO governing body would be made up of general practitioners, community nurses and community health service managers, and the ICO may employ or subcontract primary care providers through IPAs, as well as purchasing pharmaceuticals, laboratory services and contracting secondary services.

Issues to consider:

1. Like model 3, a professional view of health predominates, albeit a multidisciplinary primary care perspective.
2. Possible differences in view and tensions within the ICO between general practitioners and nurses about primary care developments and secondary care contracts, etc.

 

 

An Evolutionary Approach
It is possible to start with model 1 and move to one of the other purchasing or community models in a later phase. Models 2, 3, 5 and possibly 4 are also likely to involve project teams of practitioners to develop co-ordination arrangements. It takes a considerable amount of time to discuss, agree on and specify the details of an integrated care scheme. Working-up even an outline proposal is a lengthy process as full consultation is necessary, and the funding authority requires many details before it can finance even a limited scheme. It may be necessary to finance a developmental phase to specify the details, especially for schemes involving devolved budgets or with many patients/large populations.

Purchasing is Both a Professional and a Political Function
Models 2, 3 and 4 are types of local purchasing where the central funding authority delegates some or all purchasing to a local body. The main accountability is through a contract with performance controls on finance rather than on health outcomes which are more difficult to measure. A capitation contract allows considerable latitude to the local purchaser. Whilst there is a technical component to needs assessment, resource allocation and contracting, purchasing is also a political task as some different social groups benefit from the resource allocation decisions and some do not. Which type of ICO is most suited to the political aspect of purchasing and subject to challenge by and accountability to groups in society who feel they are disadvantaged by a purchasing decision at the expense of another group?

Issues to be Considered in Developing an ICO

1. Needs responsiveness: those most in need often make the lowest use of health services and are little affected by traditional health promotion and illness prevention programmes. Which type of ICO is better for changing current services to be more effective or for providing new services to those most in need? Which performance criteria should be used to judge the ICO’s responsiveness to those most in need (eg availability, access and utilisation by target groups)?
   
    
2. Health gain potential of integration: there are some health problems or populations which require a special integrated approach, or where the health gain for the resources is greatest with an integrated approach. Does the proposal focus on those problems or populations which show the greatest health gain potential from an integrated approach?
   
   
3. Community mobilisation: which model is most capable of mobilising existing community networks rather than being confined to managing/contracting formal health services?
   
   
4. Medical dominance: the concern of non-medical community practitioners that they will be "put under the control" of medical IPAs or a medically dominated ICO.
   
   
5. Vulnerability of health promotion to short-term crises: which model protects health promotion against short-term financial crises and a rise in demand for acute care? Which model can create and maintain a better distribution of resources between specialist acute care and those primary care and health promotion activities which have been proven to be more cost-effective?
   
   
6. "Carve-out" consequences: if an integrated care model is chosen for a sub-population like a care group or disease, then what are the consequences for other patients who are not targeted by the integrated care scheme? What are the "knock-on" or "trickle-across" effects? Will the integrated care arrangements and benefits be spread over time to other care groups/services? Resources and time will be diverted from other groups; are the losses justifiable and politically sustainable, even if other groups gain some benefit over time?
   
   
7. Choice for citizens, patients and providers: what choice will citizens, patients and providers have about taking part in a particular scheme? It is probably not feasible to have two competing ICOs, and the choice is likely to be between taking part in the ICO or the normal arrangement - what are the implications of imposing an ICO on a population and on providers, and the consequences of opt-out, or failure to opt-in by patients, providers or citizens?
   
   
8. Investment finance: it will take time for better primary health care and preventative services to result in lower demand for specialist secondary care and, in practice, this may never happen. Which model gives the greatest and quickest chance for savings in secondary care, and allows investment in primary and preventative services whilst demand continues in secondary care or increases ("bridging-" or "kick-start" finance). (Although there is no guarantee that savings will occur, resource transfer is more likely when it is carefully planned and managed and there are financial incentives and strong gatekeeping).
   
   
9. Weakening of the central purchaser’s strategic role and powers: how might the scheme affect the central purchaser’s powers to influence long-term changes such as the size and siting of hospital developments, hospital closures or rationalisations, etc. Purchasing finance is an important "lever" for change, and if purchasing budgets are devolved the central purchaser may have less powers to implement plans for more rational or equitable services.
   
   
10. Accountability: how can a local ICO rather than government be held accountable for health services? (This is especially a concern for Maori.) This concerns financial accountability, controls against fraud or misuse of public finance, accountability for the level and quality of services and clinical accountability.
    
    
11. Government withdrawal: how will fears be addressed that the ICO is a way for government to escape accountability, to "off-load" responsibility for rationing, and take the system a step further towards privatisation? Is an ICO a privatisation of purchasing, and does it create a local private monopoly purchaser?
    
    
12. ICO finance-raising powers: will the ICO have powers to raise private capital or revenue, for example to require co-payments or other charges?
    
    
13. ICO and private services: opportunities for private work are necessary to attract some specialists (and general practitioners) to an area and to work for a CHE. How will the ICO affect these opportunities? Will the ICO contract for private services? If so, how will fair and ethical decisions be made by the ICO, for example between the CHE and private doctors if only the CHE is represented in the ICO governing body?