Amelung / Stein / Goodwin Handbook Integrated Care

1. Auflage 2017
ISBN: 978-3-319-56103-5
Verlag: Springer Nature Switzerland
Format: PDF
Kopierschutz: 1 - PDF Watermark

E-Book, Englisch, 578 Seiten

This handbook gives profound insight into the main ideas and concepts of integrated care. It offers a managed care perspective with a focus on patient orientation, efficiency, and quality by applying widely recognized management approaches to the field of health care. The handbook also provides international best practices and shows how integrated care does work throughout various health systems. The delivery of health and social care is characterised by fragmentation and complexity in most health systems throughout the world. Therefore, much of the recent international discussion in the field 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 it 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.

Volker Amelung, PhD is a professor of health management and international health services research at the Medical University of Hannover, Germany. His main research interests are managed care, integrated care und payment systems. He is also the president of the German Managed Care Association (BMC) and founded the private institute for applied health research (inav) in Berlin in 2011. Viktoria Stein, PhD is Head of the Integrated Care Academy(c) at the International Foundation for Integrated Care, and Co-Editor in Chief of the International Journal of Integrated Care. She has worked extensively to promote integrated care on the local, regional, national and international levels throughout her career. Her expertise lies in the systemic and organizational prerequisites necessary to promote transformational change, specifically strengthening the competencies of patients, service providers and decision makers to support sustainable integrated care. Nick Goodwin, PhD is the co-founder and CEO of the International Foundation for Integrated Care, and Co-Editor in Chief of the International Journal of Integrated Care. Nick is a social scientist, policy analyst and thought leader in health system integration and person-centered care, with an extensive background in policy and practice to design, implement and evaluate integrated care. He has published widely on the subject and holds a range of educational, research and consulting roles worldwide, collaborating with the WHO and its regional offices, governments and local authorities, as well as universities. Ran Balicer, PhD currently serves as Director of Health Policy Planning for Clalit - Israel's largest healthcare organization, and as the Founding Director of the Clalit Research Institute. Professor Balicer's managerial and research focus is on using extensive datasets and advanced analytics to drive innovation in clinical practice as well as care integration. He also serves as Chair of the Israeli Society for Quality in Healthcare. Ellen Nolte, PhD heads the two London offices of the European Observatory on Health Systems and Policies at the London School of Economics and Political Science and the London School of Hygiene & Tropical Medicine, where she is also an Honorary Professor. Her expertise is in health systems research, integrated and chronic care, international healthcare comparisons and performance assessment. She has published widely in both the international peer-reviewed literature and the wider literature, including 4 books and numerous scientific papers on chronic disease and integrated care. Esther Suter, PhD is the Director for the Workforce Research and Evaluation unit, an applied research unit within the largest provincial health authority in Canada, and an Adjunct Professor with the Faculty of Social Work, University of Calgary. She has more than 25 years of experience in health research. The focus of her work is on interventions to enhance collaborative practice, how to achieve integrated health systems, and the exploration of innovative care delivery models.

Autoren/Hrsg.

Amelung, Volker

Stein, Viktoria

Goodwin, Nicholas

Balicer, Ran

Nolte, Ellen

Suter, Esther

Inhaltsverzeichnis

1;Preface;5
2;Contents;7
3;Part I: Foundations of Integrated Care;11
3.1;1: What Is Integrated Care?;12
3.1.1;1.1 Introduction;12
3.1.2;1.2 The Rationale for Integrated Care;15
3.1.3;1.3 Defining Integrated Care;16
3.1.3.1;Box 1.1 Four commonly used definitions of integrated care;18
3.1.4;1.4 The Core Dimensions of Integrated Care;21
3.1.5;1.5 The Building Blocks of Integrated Care;24
3.1.5.1;Box 1.2 The six interrelated components of the Chronic Care Model;25
3.1.5.2;Box 1.3 Ten Principles for Successfully Integrated Systems (Suter et al. 2007);27
3.1.5.3;Box 1.4 The Rainbow Model of Integrated Care: Final Taxonomy Summary (from Valentijn 2016);29
3.1.6;1.6 Conclusions;30
3.1.7;References;31
3.2;2: Evidence Supporting Integrated Care;33
3.2.1;2.1 Introduction;33
3.2.2;2.2 Conceptualising Integrated Care;34
3.2.3;2.3 The Evidence Supporting Integrated Care;36
3.2.4;2.4 The Economic Impacts of Integrated Care;39
3.2.5;2.5 How to Interpret the Evidence Supporting Integrated Care;41
3.2.6;2.6 Conclusions;42
3.2.7;References;43
3.3;3: Patients Preferences;47
3.3.1;3.1 Patients´ Priorities for Integrated Health Care Delivery Systems;47
3.3.2;3.2 Stated Preference Studies: Method and Study Design;50
3.3.3;3.3 Preference for Integrated Health Care Delivery Systems;51
3.3.4;3.4 Discussion and Outlook;55
3.3.5;References;56
4;Part II: Tools and Instruments;61
4.1;4: Case-Managers and Integrated Care;62
4.1.1;4.1 The Story of Julia and John in 2025;63
4.1.2;4.2 The Definition of Case Manager;64
4.1.2.1;Box 4.1 The definition of a case manager;64
4.1.2.2;4.2.1 Complex Situations;65
4.1.2.3;4.2.2 All the Needs;66
4.1.2.4;4.2.3 Physicians´ Cooperation;67
4.1.2.5;4.2.4 The Life/Care Plan;67
4.1.2.6;4.2.5 Informal Care and the Case Manager;68
4.1.2.7;4.2.6 Within a Program;69
4.1.2.8;4.2.7 Target Population;69
4.1.2.9;4.2.8 Rejected Broader Definitions;69
4.1.2.10;4.2.9 Competencies and Skills of Case Managers;70
4.1.3;4.3 Specific Tools for Case Managers;71
4.1.3.1;4.3.1 Evaluating Health and Social Needs;71
4.1.3.2;4.3.2 Empowering Interviewing of Patients, Clients and Relatives;73
4.1.4;4.4 The Real World and the Ideal World of the Case Story;74
4.1.4.1;Box 4.2 Services of case managers with do not exist in 2016;74
4.1.5;4.5 Implementation Strategies to Disseminate the Function of Case Managers;75
4.1.6;References;77
4.2;5: Disease Management;79
4.2.1;5.1 Introduction;79
4.2.2;5.2 What Is Disease Management?;80
4.2.3;5.3 What Are the Impacts of Disease Management?;81
4.2.4;5.4 Interpreting the Existing Evidence Base;96
4.2.5;5.5 Conclusions;98
4.2.6;References;99
4.3;6: Discharge and Transition Management in Integrated Care;103
4.3.1;6.1 Introduction;103
4.3.2;6.2 What Is Discharge Management?;104
4.3.3;6.3 Why Discharge Management?;104
4.3.3.1;6.3.1 Demographic Challenges;104
4.3.3.2;6.3.2 Rising Costs and Financial Pressure;105
4.3.3.3;6.3.3 Declining Length of Stay;106
4.3.3.4;6.3.4 Financing and Reimbursement Systems;106
4.3.3.5;6.3.5 The Need to Manage Complexity;108
4.3.4;6.4 How to Put Discharge Management into Practice;108
4.3.4.1;6.4.1 Professionalization of Discharge Planning;111
4.3.4.2;6.4.2 Integrating Various Components;112
4.3.4.3;6.4.3 Patient Involvement;112
4.3.4.4;6.4.4 Information Exchange and Technology;113
4.3.4.5;6.4.5 Early Initiation and Predictive Models for Discharge Management;114
4.3.5;6.5 Conclusion;115
4.3.6;References;115
4.4;7: Mobile Sensors and Wearable Technology;118
4.4.1;7.1 Commercial Mobile Sensors and Wearable Technologies;118
4.4.2;7.2 Mobile Sensors and Wearable Technologies in Health Care;119
4.4.3;7.3 Using Mobile Sensors and Wearable Technologies to Change Health Behaviour;120
4.4.4;7.4 Current Limitations and Potential Impact on Health;121
4.4.5;7.5 Integrating Mobile Sensors and Wearable Technologies in the Clinical Setting;122
4.4.6;References;123
4.5;8: Data Integration in Health Care;125
4.5.1;8.1 Types of Data Integration;125
4.5.1.1;8.1.1 Horizontal Integration;125
4.5.1.2;8.1.2 Vertical Integration;126
4.5.1.3;8.1.3 Historical Integration;126
4.5.1.4;8.1.4 Longitudinal Integration;126
4.5.1.5;8.1.5 Cross-Indexing Integration;127
4.5.1.6;8.1.6 Alternative Sources;127
4.5.2;8.2 The Importance of Data Integration;127
4.5.3;8.3 Impact of Data Integration;128
4.5.3.1;8.3.1 Types of Waste That Can Be Reduced with Data Integration;128
4.5.3.1.1;8.3.1.1 Repeat Testing;128
4.5.3.1.2;8.3.1.2 Manual Integration of Data;128
4.5.3.1.3;8.3.1.3 Informal Reports;128
4.5.3.2;8.3.2 Improving Decision-Making Capacity;128
4.5.3.2.1;8.3.2.1 Individual Level;128
4.5.3.2.2;8.3.2.2 Provider Level;129
4.5.3.2.3;8.3.2.3 Policy Level;129
4.5.3.2.4;8.3.2.4 International Level;129
4.5.4;8.4 Key Challenges in Integrating Data;129
4.5.4.1;8.4.1 Access and Privacy;129
4.5.4.2;8.4.2 Security;130
4.5.4.3;8.4.3 Quality;130
4.5.4.3.1;8.4.3.1 Quality Assessment;130
4.5.4.3.2;8.4.3.2 Quality Control;131
4.5.4.4;8.4.4 Tracking Use of Integrated Data;131
4.5.4.4.1;8.4.4.1 Providers;131
4.5.4.4.2;8.4.4.2 Patients;131
4.5.4.4.3;8.4.4.3 Policy Makers;131
4.5.4.4.4;8.4.4.4 Insurers;132
4.5.5;8.5 Summary;132
4.5.6;References;132
5;Part III: Management of Integrated Care;134
5.1;9: Strategic Management and Integrated Care in a Competitive Environment;135
5.1.1;9.1 Integrated Care as a Strategic Option: Preliminary Remarks;135
5.1.2;9.2 Strategic Management: Definition and Differentiation;137
5.1.2.1;9.2.1 Strategy;137
5.1.2.2;9.2.2 Principles of Management;138
5.1.3;9.3 The Strategic Planning Process;138
5.1.4;9.4 Instruments for Strategic Planning;139
5.1.4.1;9.4.1 SWOT Analysis;139
5.1.4.2;9.4.2 Analysis of Value Chains and Competitive Environments;141
5.1.5;9.5 Options for Strategic Positioning;144
5.1.5.1;9.5.1 Ansoff´s Product/Market Matrix;144
5.1.5.1.1;9.5.1.1 Market Penetration;144
5.1.5.1.2;9.5.1.2 Product Development;145
5.1.5.1.3;9.5.1.3 Market Development;146
5.1.5.1.4;9.5.1.4 Diversification;146
5.1.5.2;9.5.2 Porter´s Competitive Strategies;146
5.1.5.2.1;9.5.2.1 Cost Leadership;147
5.1.5.2.2;9.5.2.2 Differentiation;148
5.1.5.2.3;9.5.2.3 Low Cost and Differentiation Focus Strategies;148
5.1.5.2.4;9.5.2.4 ``Stuck in the Middle´´;148
5.1.6;9.6 Integrated Care as a Quality Improvement Strategy;148
5.1.7;References;149
5.2;10: Governance and Accountability;150
5.2.1;10.1 What Is Governance and Accountability?;150
5.2.2;10.2 Appropriate, Agile, and Effective: New Directions for Governance and Accountability in Integrated Health Systems;153
5.2.3;10.3 Implementing Innovation: Next Steps for Governance and Accountability in Integrated Health Systems;154
5.2.3.1;10.3.1 Vanguard Integration Sites;156
5.2.4;10.4 Tools for Governance and Accountability;157
5.2.4.1;10.4.1 Frameworks;157
5.2.4.2;10.4.2 Tools;158
5.2.5;10.5 Conclusions;160
5.2.6;References;161
5.3;11: Financing and Reimbursement;165
5.3.1;11.1 Introduction;165
5.3.2;11.2 Principles of Financing of and Payment for Services;166
5.3.2.1;11.2.1 Financing of Health and Social Care;166
5.3.2.2;11.2.2 Payment Mechanisms in Health Care;168
5.3.3;11.3 Incentivising Coordination and Integration of Service Delivery: Examples from Different Countries;174
5.3.3.1;11.3.1 Commitment of Additional Funding;174
5.3.3.2;11.3.2 Innovative Payment Schemes;176
5.3.3.2.1;Box 11.1 The Quality and Outcomes Framework in the United Kingdom;177
5.3.3.2.2;Box 11.2 The Alternative Quality Contract in Massachusetts, USA;179
5.3.3.3;11.3.3 Changes to Financing Mechanisms;180
5.3.4;11.4 Conclusions;182
5.3.5;References;183
5.4;12: Planning;188
5.4.1;12.1 Introduction;188
5.4.1.1;12.1.1 The Need for Planning;188
5.4.1.2;12.1.2 Planning Taxonomy;189
5.4.2;12.2 Workforce Planning Methodologies;191
5.4.2.1;12.2.1 Planning of Supply;191
5.4.2.2;12.2.2 Demand-Based Planning;193
5.4.2.3;12.2.3 Needs-Based Planning;195
5.4.2.3.1;Case Example 1;195
5.4.2.4;12.2.4 Benchmarks;197
5.4.2.5;12.2.5 Limitations of Current Planning Approaches in Integrated Care Settings;198
5.4.3;12.3 New Approaches to Workforce Planning in Integrated Care;199
5.4.3.1;12.3.1 Team-Based Workforce Planning;199
5.4.3.2;12.3.2 Pro-active Management of Health Care Utilization;200
5.4.3.3;12.3.3 Tackling Geographic Variations Through Technology;201
5.4.4;12.4 Conclusion;202
5.4.5;References;203
5.5;13: Integrated Care and the Health Workforce;207
5.5.1;13.1 Background;207
5.5.2;13.2 Staff Mix and Skill Management;209
5.5.3;13.3 Multidisciplinary Team Work;211
5.5.4;13.4 Workforce à la carte;214
5.5.5;13.5 Conclusions;215
5.5.6;References;217
5.6;14: Leadership in Integrated Care;219
5.6.1;14.1 The Neglected Topics in Designing Integrated Care;219
5.6.2;14.2 No Coincidence: What Management Literature Tells Us About Leadership;220
5.6.2.1;14.2.1 Manager Versus Leader;220
5.6.2.2;14.2.2 Types and Styles of Leadership;221
5.6.2.2.1;14.2.2.1 Theories;221
5.6.2.2.2;14.2.2.2 Learning from the Big Bosses´ Experience;221
5.6.2.2.2.1;Jack Welch: Former CEO of General Electric;222
5.6.2.2.2.2;Colin Powell: Former U.S. Secretary of State;223
5.6.2.3;14.2.3 Leadership Learnings from Empirical Data;223
5.6.2.3.1;14.2.3.1 Fundamental Practices by Kouzes and Posner (2009);223
5.6.3;14.3 Leadership in Networks;224
5.6.4;14.4 Leadership in Health Care: Learning from Best Practice;226
5.6.4.1;14.4.1 What Is Different in Health Care: The Logic of Health Care Delivery;226
5.6.4.2;14.4.2 Professional Cultures in Health Care;227
5.6.4.3;14.4.3 Leading a Health Care Organization: Personal Skills and Institutional Habits;229
5.6.5;14.5 Lessons to Be Learned for Leadership in Integrated Care;230
5.6.5.1;14.5.1 System-Related Pitfalls (Dark Blue);230
5.6.5.2;14.5.2 People-Related Pitfalls (Yellow);231
5.6.5.3;14.5.3 Organization-Related Pitfalls (Light Blue);231
5.6.6;14.6 Conclusion;232
5.6.7;References;233
5.7;15: Culture and Values;235
5.7.1;15.1 Introduction;235
5.7.1.1;Box 15.1 Examples of culture and values within evidence reviews and evaluations;236
5.7.2;15.2 What Is Meant by Culture?;237
5.7.3;15.3 What Is Meant by Values?;239
5.7.3.1;Box 15.2 Collaborative practice;241
5.7.3.2;Box 15.3 Value based competences within collaborative practice (IPEC 2011);241
5.7.4;15.4 How Do We Positively Develop Values and Cultures?;242
5.7.4.1;Box 15.4 Alternative approaches to culture change;242
5.7.4.2;15.4.1 Teamwork;242
5.7.4.3;15.4.2 Inter-professional Learning;244
5.7.4.3.1;Box 15.5 Example of inter-professional learning in practice (based on feedback from participants);245
5.7.5;15.5 Conclusion;246
5.7.6;References;247
5.8;16: Change Management;250
5.8.1;16.1 Introduction;250
5.8.2;16.2 A Conceptual Understanding of Change Management;251
5.8.3;16.3 The Evidence Base;252
5.8.4;16.4 Lessons from Practical Experience;254
5.8.4.1;Box 16.1 Key lessons for change towards integrated care from practical experience;255
5.8.5;16.5 The Components of a Change Management Process Towards Integrated Care;256
5.8.5.1;16.5.1 Needs Assessment;256
5.8.5.2;16.5.2 Situational Analysis;257
5.8.5.3;16.5.3 Value Case Development;258
5.8.5.4;16.5.4 Vision and Mission Statement;259
5.8.5.5;16.5.5 Strategic Plan;259
5.8.5.6;16.5.6 Ensuring Mutual Gain;259
5.8.5.7;16.5.7 Communications Strategy;261
5.8.5.8;16.5.8 Implementing and Institutionalising the Change;261
5.8.5.9;16.5.9 Monitoring and Evaluation: Developing Systems for Continuous Quality Improvement;262
5.8.6;16.6 Building an Enabling Environment;263
5.8.6.1;16.6.1 Developing a Guiding Coalition;263
5.8.6.2;16.6.2 Building Support for Change;264
5.8.6.3;16.6.3 Developing Collaborative Capacity;266
5.8.6.4;16.6.4 The Facilitating Role of Managers and Decision-makers in Supporting the Process of Change;267
5.8.7;16.7 Conclusions;268
5.8.8;References;269
5.9;17: How to Make a Service Sustainable? An Active Learning Simulation Approach to Business Model Development for Integrated Care;273
5.9.1;17.1 Introduction;273
5.9.2;17.2 ASSIST: Socio-economic Impact Assessment Using Cost-Benefit Analysis;275
5.9.2.1;17.2.1 Background;275
5.9.2.2;17.2.2 Assessment in Four Steps;276
5.9.2.3;17.2.3 A Cost-Benefit Indicator Set for Integrated Care;278
5.9.3;17.3 Learning by Example: The Service Implementation Simulator;279
5.9.3.1;17.3.1 Integrated eCare Example Case;280
5.9.3.2;17.3.2 Overall Service Model;280
5.9.3.3;17.3.3 Elements of the Service;280
5.9.3.4;17.3.4 Assessment of the Example Case in Four Steps;281
5.9.3.4.1;17.3.4.1 Step 1: Stakeholders;281
5.9.3.4.2;17.3.4.2 Step 2: Impact Identification;282
5.9.3.4.3;17.3.4.3 Step 3: Data Collection;283
5.9.3.4.4;17.3.4.4 Step 4: Analysing the Value Case;286
5.9.3.5;17.3.5 A Set of Lessons to Be Learned;288
5.9.4;17.4 Conclusions and Outlook;289
5.9.5;References;289
6;Part IV: Evaluation and Health Services Research;291
6.1;18: Evaluating Complex Interventions;292
6.1.1;18.1 Definition of Complex Intervention;292
6.1.1.1;Box 18.1 Examples of complex interventions;293
6.1.2;18.2 The Rationale for Evaluation;295
6.1.3;18.3 Challenges in Evaluating Complex Interventions;296
6.1.4;18.4 Evaluation Frameworks;297
6.1.5;18.5 Process Evaluation;298
6.1.5.1;18.5.1 Fidelity and Quality of Implementation;299
6.1.5.2;18.5.2 Context;300
6.1.5.3;18.5.3 Causal Mechanisms;301
6.1.6;18.6 Formative and Summative Evaluation;302
6.1.6.1;18.6.1 Study Design;302
6.1.6.1.1;Box 18.2 Choosing between randomised and non-randomised designs;303
6.1.6.2;18.6.2 Outcomes;304
6.1.7;18.7 Reporting and Reviewing Evaluation Results;304
6.1.8;References;306
6.2;19: Economic Evaluation of Integrated Care;309
6.2.1;19.1 Need for Economic Evaluation of Integrated Care;309
6.2.2;19.2 Current Economic Evaluation Frameworks;310
6.2.2.1;Box 19.1 Forms of economic evaluation;311
6.2.3;19.3 Challenges and Recommendations in Economic Evaluation of Integrated Care;312
6.2.3.1;19.3.1 Defining the Intervention;312
6.2.3.2;19.3.2 Comparator;312
6.2.3.3;19.3.3 Study Design;313
6.2.3.4;19.3.4 Evaluation Period;315
6.2.3.5;19.3.5 Outcome Measures;316
6.2.3.6;19.3.6 Measurement and Valuation of Costs;317
6.2.3.7;19.3.7 Broader Economic Evaluation;318
6.2.3.8;19.3.8 Determinants of Cost-Effectiveness;319
6.2.3.9;19.3.9 Policy Evaluation and Implementation Analysis;320
6.2.3.10;19.3.10 Standardised Reporting;321
6.2.4;19.4 Conclusion;321
6.2.5;References;322
6.3;20: Claims Data for Evaluation;327
6.3.1;20.1 Background;327
6.3.2;20.2 Claims Data;328
6.3.3;20.3 Methodological Aspects of Using Claims Data;329
6.3.4;20.4 Methods;331
6.3.5;20.5 Prerequisites for Data Usage;332
6.3.6;20.6 Examples;333
6.3.6.1;20.6.1 Evaluating Disease Management Programs;333
6.3.6.2;20.6.2 Gesundes Kinzigtal;334
6.3.7;20.7 Limitations;336
6.3.8;20.8 Perspective: Data Linkage;337
6.3.9;20.9 Conclusions;337
6.3.10;References;339
7;Part V: Client Groups;344
7.1;21: Children;345
7.1.1;21.1 Challenges in Providing Care for Infants, Children and Young People;345
7.1.2;21.2 Goals of Integrated Care for Children;346
7.1.3;21.3 Value Proposition of Integrated Care for Children;347
7.1.4;21.4 The Integrated Treatment Path: Examples and Outcomes;351
7.1.5;21.5 Lessons Learned and Outlook;356
7.1.6;References;357
7.2;22: Integrated Care for Frail Older People Suffering from Dementia and Multi-morbidity;360
7.2.1;22.1 The Challenge;360
7.2.2;22.2 Service Users´ Needs for Integrating Services;361
7.2.3;22.3 Inter-organisational Collaboration by Care Standards;364
7.2.4;22.4 Implementation;366
7.2.5;22.5 Personalization;367
7.2.6;22.6 Future Perspectives;369
7.2.7;22.7 Conclusions;370
7.2.8;References;371
7.3;23: Physical and Mental Health;374
7.3.1;23.1 Challenges Involved in Integrating Physical and Mental Health Care;376
7.3.1.1;23.1.1 Disease Factors;376
7.3.1.2;23.1.2 Patient Factors;377
7.3.1.3;23.1.3 Professional Factors;378
7.3.1.4;23.1.4 Institutional and Systems Factors;378
7.3.2;23.2 Goals of Integrated Physical and Mental Health Care;379
7.3.3;23.3 Key Components of Integrated Physical and Mental Health Care;380
7.3.3.1;23.3.1 Collaborative Care;380
7.3.3.1.1;Box 23.1 Case Study: Mental Health Integration in Intermountain Healthcare;381
7.3.3.2;23.3.2 Multidisciplinary Case Management;382
7.3.3.2.1;Box 23.2 Case Study: Three Dimension of Care for Diabetes;382
7.3.3.3;23.3.3 Liaison Mental Health;383
7.3.3.4;23.3.4 Managing Medically Unexplained Symptoms in Primary Care;384
7.3.4;23.4 Results of Integrated Care Approaches;385
7.3.5;23.5 Lessons Learned;385
7.3.6;References;386
7.4;24: Integrated Palliative and End-of-Life Care;390
7.4.1;24.1 Introduction;390
7.4.2;24.2 Defining Palliative Care and End-of-Life Care;391
7.4.3;24.3 Challenges for Providing Care to Palliative and End-of-Life Patients;392
7.4.4;24.4 Goal of Integrated Care;393
7.4.4.1;24.4.1 What Needs Do End-of-Life Patients Have?;393
7.4.4.2;24.4.2 Health and Social Integrated Care Based on Empathy and Compassion;394
7.4.5;24.5 The Integrated Care Path;395
7.4.6;24.6 Results of Integrated Palliative Care;397
7.4.7;24.7 A New Paradigm: Compassionate Communities;398
7.4.8;24.8 Conclusion;399
7.4.9;References;400
7.5;25: Rare Diseases;403
7.5.1;25.1 Challenges Faced When Providing Care to People Living with a Rare Disease;403
7.5.1.1;25.1.1 Background on Rare Diseases;403
7.5.1.2;25.1.2 Unmet Needs of People Living with a Rare Disease;404
7.5.1.3;25.1.3 Challenges in Care Provision;406
7.5.2;25.2 Goal of Integrated Care for Rare Diseases;407
7.5.3;25.3 The Integrated Care Pathway for Rare Diseases;408
7.5.3.1;25.3.1 Proposals for the Provision of Integrated Care to Rare Disease Patients;408
7.5.3.1.1;25.3.1.1 Centres of Expertise;409
7.5.3.1.2;25.3.1.2 Individual Care Plans;409
7.5.3.1.3;25.3.1.3 Care Pathways and Standards of Care;409
7.5.3.1.4;25.3.1.4 Case Managers;410
7.5.3.1.5;25.3.1.5 One-Stop-Shop Services for Rare Diseases;411
7.5.3.1.6;25.3.1.6 Networking and Training Programmes for Service Providers;412
7.5.3.1.7;25.3.1.7 Integration of Rare Diseases into National Functionality Assessment Systems;413
7.5.3.1.8;25.3.1.8 eHealth to Facilitate Data Sharing and Interoperability;413
7.5.3.2;25.3.2 An Innovative Patient-Centred Approach for Integrated Care for People with Rare Diseases;413
7.5.4;25.4 Results of Integrated Care Approaches to Care Delivery;414
7.5.5;25.5 Lessons Learned and Outlook;415
7.5.6;References;415
7.6;26: Pathways in Transplantation Medicine: Challenges in Overcoming Interfaces Between Cross-Sectoral Care Structures;418
7.6.1;26.1 Introduction;418
7.6.2;26.2 Structures of Care;419
7.6.2.1;26.2.1 Outpatient and Inpatient Care;419
7.6.2.2;26.2.2 Living Donations;421
7.6.3;26.3 General Key Elements for the Future;422
7.6.3.1;26.3.1 Communication;422
7.6.3.2;26.3.2 Forms of Compensation;423
7.6.3.3;26.3.3 Leadership;424
7.6.4;26.4 Conclusions;424
7.6.5;References;425
7.7;27: Integrated Care Concerning Mass Casualty Incidents/Disasters: Lessons Learned from Implementation in Israel;427
7.7.1;27.1 Introduction;427
7.7.2;27.2 Basic Assumptions;427
7.7.3;27.3 Main Components of Integrated Care;428
7.7.3.1;27.3.1 The Preparatory Phase;428
7.7.3.1.1;27.3.1.1 Development of Integrated Guidelines and SOPs;428
7.7.3.1.2;27.3.1.2 Training and Exercise Programs;429
7.7.3.1.3;27.3.1.3 Ongoing Monitoring Systems;429
7.7.3.1.4;27.3.1.4 Information Systems;430
7.7.3.1.5;27.3.1.5 Equipment and Infrastructure;430
7.7.3.2;27.3.2 The Response Phase;431
7.7.3.2.1;27.3.2.1 Implementation of an Automatic Response;431
7.7.3.2.2;27.3.2.2 Central Control and Coordination;431
7.7.3.2.3;27.3.2.3 Connectivity Between Response Agencies;432
7.7.3.2.4;27.3.2.4 Collaboration Between Military and Civilian Entities;433
7.7.3.2.5;27.3.2.5 Coordinated Risk Communication;433
7.7.3.3;27.3.3 The Post-Response Phase (Return to Normalcy);434
7.7.4;27.4 Conclusions;435
7.7.5;References;435
7.8;28: Integrated Care for People with Intellectual Disability;437
7.8.1;28.1 Definition and Classification of Intellectual Disability (Intellectual Developmental Disorder);437
7.8.2;28.2 General Health Issues;439
7.8.3;28.3 Mental Health Issues;440
7.8.4;28.4 Access to Care;442
7.8.5;28.5 Specialized Services for ID Associated to Other Mental Disorders;443
7.8.6;28.6 Integrated Care and Person-Centred Approaches;446
7.8.6.1;28.6.1 Integrating Care of Somatic Illnesses;447
7.8.6.2;28.6.2 Integrating Care of Psychiatric Disorders;447
7.8.6.3;28.6.3 Integrating Specialised or Secondary Mental Health Care;449
7.8.7;28.7 Conclusion;450
7.8.8;References;451
7.9;29: Integrated Care for Older Patients: Geriatrics;457
7.9.1;29.1 Introduction;457
7.9.2;29.2 Challenges for Providing Care for the Geriatric Patient;458
7.9.2.1;29.2.1 Multimorbidity and Geriatric Syndromes;458
7.9.2.2;29.2.2 Fragmentation of Care;460
7.9.2.3;29.2.3 Place of Living: From Community to Institutions;461
7.9.3;29.3 Goals of Integrated Care;465
7.9.4;29.4 The Integrated Treatment Plan;468
7.9.5;29.5 Results of Integrated Care Approaches to Care Delivery;472
7.9.6;29.6 Matters of Integration in Technology Design for Ageing People;474
7.9.7;29.7 Lessons Learned and Outlook;477
7.9.8;References;478
8;Part VI: Case Studies;484
8.1;30: Canada: Application of a Coordinated-Type Integration Model for Vulnerable Older People in Québec: The PRISMA Project;485
8.1.1;30.1 Integrated Care in Québec and Canada;485
8.1.2;30.2 Integrated Care in Practice;486
8.1.2.1;30.2.1 Problem Definition;486
8.1.2.2;30.2.2 Description of the PRISMA Model;487
8.1.2.2.1;Box 30.1 Functional Autonomy Measurement System: SMAF (Système de mesure de l´autonomie fonctionnelle);488
8.1.3;30.3 Experimental Implementation and Impact;490
8.1.3.1;30.3.1 Dissemination and Replication;491
8.1.3.2;30.3.2 Lessons Learned and What´s Ahead;493
8.1.4;References;495
8.2;31: Germany: Evolution and Scaling Up of the Population-Based Integrated Health Care System ``Healthy Kinzigtal´´;497
8.2.1;31.1 Integrated Care in Germany;497
8.2.2;31.2 Case Study: Healthy Kinzigtal (HK);499
8.2.2.1;31.2.1 Governance and Participation;499
8.2.2.2;31.2.2 The Business Model of Healthy Kinzigtal;500
8.2.2.3;31.2.3 Coverage and Programmes;501
8.2.2.3.1;Box 31.1 Prevention and Health Promotion Programmes that have been developed so far:;501
8.2.2.4;31.2.4 A Cross-Cutting Theme: People Involvement/Service User Perspective;503
8.2.2.5;31.2.5 Impact;503
8.2.2.6;31.2.6 Dissemination and Replication;504
8.2.3;References;508
8.3;32: Scotland;511
8.3.1;32.1 Introduction;511
8.3.2;32.2 Integrated Care in Practice;513
8.3.2.1;32.2.1 Problem Definition;513
8.3.2.1.1;Box 32.1 NHS Highland at a glance;513
8.3.2.2;32.2.2 Description of the Lead Agency Model;515
8.3.2.2.1;Box 32.2 Legal, financial and management implications of lead agency model;516
8.3.2.3;32.2.3 Governance;516
8.3.2.4;32.2.4 New Ways of Working;517
8.3.2.5;32.2.5 People Involvement/Service User Perspective (Value);519
8.3.2.6;32.2.6 Impacts;520
8.3.2.7;32.2.7 Dissemination and Replication of the Case Study;522
8.3.2.8;32.2.8 Lessons Learned and Outlook;522
8.3.3;References;523
8.4;33: USA: Innovative Payment and Care Delivery Models-Accountable Care Organizations;526
8.4.1;33.1 Integrated Care in the United States of America;526
8.4.2;33.2 Integrated Care in Practice: Accountable Care Organizations;528
8.4.2.1;33.2.1 Problem Definition;528
8.4.2.2;33.2.2 Description of the ACO Model;529
8.4.2.3;33.2.3 Impact;530
8.4.2.4;33.2.4 Dissemination;531
8.4.2.5;33.2.5 Lessons Learned and Challenges Ahead;532
8.4.3;References;533
8.5;34: Switzerland;535
8.5.1;34.1 Integrated Care in Switzerland;535
8.5.2;34.2 Integrated Care in Practice;537
8.5.2.1;34.2.1 Problem Definition;537
8.5.2.2;34.2.2 Description of the ``Programme cantonal Diabète´´;538
8.5.2.3;34.2.3 People Involvement/Service User´s Perspective (Value);541
8.5.2.4;34.2.4 Impact;541
8.5.2.5;34.2.5 Dissemination and Replication;542
8.5.2.6;34.2.6 Lessons Learned and Outlook;542
8.5.3;References;543
8.6;35: Netherlands: The Potentials of Integrating Care via Payment Reforms;545
8.6.1;35.1 Integrated Care in the Netherlands;545
8.6.1.1;35.1.1 The Dutch Health Care Reform in 2006: The Introduction of Managed Competition;545
8.6.2;35.2 Integrated Care in Practice;547
8.6.2.1;35.2.1 Problem Definition;547
8.6.2.2;35.2.2 Description of the Bundled Payment Model for Diabetes Care;548
8.6.2.3;35.2.3 People Involvement/Service User Perspective;550
8.6.2.4;35.2.4 Impact;550
8.6.2.5;35.2.5 Lessons Learned;551
8.6.2.6;35.2.6 Outlook;553
8.6.2.6.1;35.2.6.1 Bundled Payment for Pregnancy and Child Birth;553
8.6.2.6.2;35.2.6.2 Population Health Management;553
8.6.3;References;554
8.7;36: New Zealand: Canterbury Tales;557
8.7.1;36.1 Integrated Care in New Zealand;557
8.7.2;36.2 Integrated Care in Practice;558
8.7.2.1;36.2.1 Problem Definition;558
8.7.2.2;36.2.2 People Involvement/Service User Perspectives;560
8.7.2.3;36.2.3 Impact;561
8.7.2.3.1;36.2.3.1 Building a Social Movement;561
8.7.2.3.1.1;Box 36.1 Creating a shared purpose;562
8.7.2.4;36.2.4 The 2010-2011 Earthquakes;563
8.7.2.5;36.2.5 Vision 2020 Becomes Vision 2011;563
8.7.2.5.1;Box 36.2 Keys to innovation (State Services Commission 2013);565
8.7.2.6;36.2.6 Dissemination and Replication;565
8.7.2.7;36.2.7 Lessons Learned and Outlook;565
8.7.2.7.1;Box 36.3 Benefits of supporting people to stay well in the community in Canterbury Health System;567
8.7.3;36.3 Conclusion;568
8.7.3.1;Box 36.4 Some learnings of the Canterbury Health System journey so far;568
8.7.4;References;569
8.8;37: Israel: Structural and Functional Integration at the Israeli Healthcare System;570
8.8.1;37.1 Integrated Care in Israel;570
8.8.1.1;37.1.1 A National Perspective: How Integration in Practice Can Improve Quality of Outpatient Care;572
8.8.2;37.2 Integrated Care in Practice: Clalit Health Services;572
8.8.2.1;37.2.1 Problem Definition: Unplanned Readmissions;574
8.8.2.1.1;37.2.1.1 The Strategy: Vertical Integration;574
8.8.2.1.2;37.2.1.2 Predictive Modelling;574
8.8.2.1.3;37.2.1.3 Transitional Care Interventions;575
8.8.2.1.4;37.2.1.4 Quality Monitoring;575
8.8.2.2;37.2.2 Impact;575
8.8.2.3;37.2.3 Dissemination and Replication;576
8.8.2.4;37.2.4 Lessons Learned and Outlook;576
8.8.3;References;577