Mrs Costa-Alvarez is a 78-year-old widow who suffers from dementia. She lives in an apartment on the third floor in a moderate-sized city. She emigrated from her native country with her husband in the early 1960s, and they raised three children, one of whom lives abroad. The others live on the other side of the country, 300 km away.
Two of her children visit her monthly and phone her every week. The son who lives abroad visits her a couple of times a year. Mrs Costa speaks only her native tongue with any confidence and fluency. She hardly has contact with neighbours. She receives a minimum old age pension because she did not have a formal job and has not lived all her life in the same country.
A couple of years ago, she started to become forgetful. When she had a mild stroke, the GP sent her to the hospital for observation. After some days she was discharged and sent home, although she remained rather confused.
At present, she has some difficulties moving around the house because she has arthritis. As a result of the stroke she still has difficulty performing refined locomotive tasks. In her view, she more or less manages to do the housework by herself. She has been losing weight for some time, and the children are concerned about whether she cooks properly for herself. They are also worried because she usually does not rise before noon. The children disagree whether professional help is required. Mrs Costa herself rejects all offers of professional assistance.
The situation described above demonstrates the rationale for integrated care for older people. It could be taking place anywhere in the European Union, and would be dealt with differently in each country. Moreover, within different countries and families, there would be a range of different responses to this case. One thing, however, is clear: Mrs Costa needs an integrated approach that combines:
The first step is to establish a relationship with Mrs Costa that opens the door to professional assistance, in combination with informal care by the family and possibly neighbours and volunteers. All this has to be co-ordinated to fit with the contents and timing of the interventions. The interventions have to be based on converging principles of all those who are involved, strengthening each other’s input. Moreover, the interventions have to be applied at times that are most suited to the needs of Mrs Costa and to principles of logistics.
Although different organisations, professions and agencies in the EU countries work within different legislative and financial contexts, and different expectations exist with respect of the roles of families, the need for managing integration is universal.
The case of Mrs Costa is one example of how integrated care can help older people. Complex problems and frailty in old age may evolve gradually, or may occur rapidly after an acute illness or crisis. Typically, they will interact and intensify each other, affecting all domains of life. These problems need to be dealt with systematically and coherently, and integrated care aims to do just that. It also has a preventive element – especially concerning risk reduction for those who are in vulnerable states.
‘Integration’ has many meanings and interpretations (Kodner and Spreeuwenberg 2002). Here, we define integrated care as a well planned and well organised set of services and care processes, targeted at the multi-dimensional needs/problems of an individual client, or a category of persons with similar needs/problems. We specifically concentrate on integration issues around older persons with complex, multiple needs, focusing on cross-organisational integration of services. Tasks and services also have to be integrated within organisations, but that type of integration is a more common management task, while integration across organisations and services is a relatively new issue for the long-term care sector.
Integrated care can be conceived as client- or consumer-driven care (Kodner 2003). As such, it is not very different from developments in industry, agriculture, commercial services, or other public sectors such as education, town and country planning, youth care or public transport. In all these sectors, supply-driven management systems are gradually being replaced by integrated, demand-driven systems. These systems are developed because of client demand, but also because they are cost effective and efficient, as well as offering employees more job satisfaction (van der Aa and Konijn 2001, Goodwin et al 2003).
Integrated and linked services can serve all these objectives, and the various services can fit together well in a range of areas, including care for older people. What is more, service users are demanding integrated services. In a time of increasing demands and decreasing resources, it is obvious and politically compelling that health services should work closely with community and social care services to fulfil their objectives. Finally, for care workers, integration provides new perspectives in career and professional development.
Integrated care is not an outcome, but a means to achieve optimum performance at service level – in this case, for older people. This shift from supply-driven to demand-driven care requires new management styles and skills. Managers are faced with multiple focuses and loyalties while integrating and connecting services around the client. Their challenge is to organise and secure care and service provision so that it:
The challenges in establishing integrated care are as follows:
The managers’ orientations towards the fields shown in the four boxes in Fig 1 require them to have multiple loyalties, responsibilities and accountabilities, which they have to balance out. Having to deal with these four fields, which may reflect contrasting or contradicting commitments, can cause ambiguities, and dealing with these ambiguities is one of the most challenging tasks that managers have to deal with (Carrier 2002).
For more information on this process, see Kodner and Spreeuwenberg (2002) and Carrier (2002).
In line with these requirements, the objectives and intended outcomes for the organisation can be understood as:
These principles, drawn from Gröne and Garcia-Barbero (2002), Kodner and Spreeuwenberg (2002), and Commission of the European Communities (2003), are attractive at first sight. Indeed, one hardly can oppose them. It is easy to adopt them verbally and continue with day-to-day work without changing working routines and division of tasks. However, to improve everyday practice, these principles need to be tested and translated in operational terms, by asking ‘How can we bring this particular principle into practice?’ and ‘How can we change our practice to further this principle?’. In other words, managers should not consider the principles to have been embraced simply because they have been verbally adopted. That is too easy.
So far, integrated care appears to be an attractive option. However, it is not a solution to every problem. Whether integration is meaningful – and if it is, what level of integration is most suitable – depends on the client’s characteristics and conditions. In this respect, the stability and the severity of the client’s condition are crucial (Leutz 1999).
Client characteristics and conditions can be related to a frequently used typology of degree or intensity of connections between services or organisations developed by Leutz (1999). He distinguishes three levels of integration:
These are explained in detail below:
This level operates within the setting of the existing services. By and large, it accepts the existing division of labour in the care system, and complies with eligibility criteria for the separate services. At this level, integration implies adequate referrals to guide older people to the right place at the right time in the system, as well as good communication between the professionals involved, to promote continuity of care when the person goes from service to service. Providers understand who is responsible for payments for each type of service, and costs and responsibilities are not shifted.
This level arises in settings where regulating agencies and service organisations seek new balances in care provision, re-definitions of core tasks, client flows, and eligibility criteria. This level is more structured than the linkage level, but it still operates largely through the separate structures of existing systems. It aims to:
Co-ordination identifies points of friction, confusion, or discontinuity between systems, and establishes structures and processes to address these problems.
This level aims to develop comprehensive care programmes or care packages attuned to the needs of specific client groups. It is connected with recently developed methods of care management. It creates new programmes or units that pool the resources of multiple systems, define new benefits and use common records. The integrated services are directly and specifically managed through one-to-one management, with no layers in between – only some type of joint governance above them. Full integration may include specialised types of intervention, ‘fast-track’ access to them, and close co-operation between knowledgeable professionals. The most pressing issues at this level are defining the target group, assembling the necessary services and allocating appropriate resources.
The characteristics and conditions of each client have different implications for the optimum level of integration, and for managing operations, as illustrated in Table 1, below.
|
Client's needs
|
Linkage
|
Co-ordination
|
Full Integration
|
|---|---|---|---|
|
Severity
|
Mid-to-moderate
|
Moderate-to-severe
|
Moderate-to-severe
|
|
Stability
|
Stable
|
Stable
|
Stable
|
|
Duration
|
Short-to-long term
|
Short-to-long term
|
Long-term-to-terminal
|
|
Urgency
|
Routine or non-urgent
|
Mostly routine
|
Frequent, urgent
|
|
Scope of services
|
Narrow-to-moderate
|
Moderate-to-broad
|
Broad
|
|
Self-direction
|
Self-directed or strong informal
|
Varied levels of self-direction
|
May accommodate weak self-direction or informal
|
Adapted from Leutz (1999)
|
Implications for:
|
Linkage
|
Co-ordination
|
Full Integration
|
|---|---|---|---|
|
Case management
|
–
|
Moderate-to-severe
|
Moderate-to-severe
|
|
Transitions and service delivery
|
Refer and follow up
|
Stable
|
Stable
|
|
Information
|
Ask whether it is needed
Provide when requested |
Define and provide items or reports routinely in both directions
|
Use commom record as part of daily joint practise and management
|
|
Finance
|
Understand who pays for each service
|
Decide who pays for what in specific cases, and in general guidelines
|
Pool funds to purchase from both side and new services
|
|
Benefits
|
Follow eligibility and coverage rules
|
Manage benefits to maximise efficiency and coverage
|
Merger benefits
Change and redefine eligibility |
Adapted from Leutz (1999)
Table 2 demonstrates that levels of integration need to be chosen very carefully. Integration has its advantages, but it also requires investment, implies new boundaries and, as mentioned earlier, it does not solve every problem.
Source: Leutz 1999
In developing well-linked, co-ordinated or fully integrated services, continuity is the key priority (Haggerty et al 2003). The design of the services and the care pathways along which the services are provided needs to take into account that integration is a dynamic process. It changes over time and needs regular monitoring and adaptations. Both the content and timing must have continuity. Two dimensions of continuity are always at stake – the simultaneous and the sequential:
To safeguard eligibility and funding of service provision, the stages in the care process have to be connected to the relevant processes of control or administration. From the initial presentation of a problem through the stages of referral, needs assessment, and eligibility testing, the care packages have to fit care delivery smoothly. All concerned – from those responsible for care provision to the clients, carers, purchasers and governments – need to be accountable at each stage.
The task for managers is to achieve continuity on each of the three levels on which they have to focus – that of the client, that of organisations and networks, and that of the care system.
To orchestrate integrated care, a set of services needs to be linked, co-ordinated or integrated. These services are delivered by various professionals and/or providers who may work in various sectors. When linking or co-ordination is required, traditional services may be sufficient. In most EU countries these services already exist, but under different names or meanings, and they may function in different sectors and different policy frameworks. To mention the most relevant, more or less ‘traditional’ services:
Especially when full integration is required, new, innovative services are required. By definition, these services do not fit into the traditional classifications, nor do they fit the traditional roles, pathways and responsibilities.
Mrs Costa rejected all kinds of traditional professional assistance. One option that she may have preferred was a local ‘Alzheimer café’, which she could have attended with one of her children. Alzheimer cafés offer education and support, informal advice and consultation by professionals and fellow sufferers, in a relaxed atmosphere. Service users are encouraged to attend a series of ten monthly meetings. The content of each meeting is agreed in advance, but it generally covers the course of dementia.
The café concept is based on a fixed structure of five half-hour sessions:
The information sessions generally take the form of interviews with patients, family and experts, in front of the group, led by the discussion leader. The information and peer advice offered by this service can provide clients and carers with some insight into the condition. It can also give them practical information and reduce their reluctance to seek professional support. Alzheimer cafés are currently available in Australia, Belgium, Germany, Greece, the Netherlands, the United Kingdom and the United States (Miesen and Jones 2002).
Another option might have been a small-scale housing project for people with dementia, attuned to Mrs Costa’s minority ethnic group, providing housing, personal care, supervision and company in a homely atmosphere.
The majority of care is provided by informal carers, such as next of kin and neighbours, often at irregular hours, and volunteers can also be important in care provision. However, professional care providers do not always acknowledge the contribution of these groups, and they are seldom regarded as partners in the system. Instead, they are considered as an ‘overflow reservoir’ when other elements of the system fail or are unavailable. Informal carers, such as spouses and children should be legally entitled to be relieved of their responsibilities when caring is long term and becomes a burden. However, they should also be entitled to provide care if they want to do so and are able.
The specific role and contribution of volunteers differs between countries as a result of different cultural values and roles of the statutory and private sectors. The voluntary sector – and, in particular, its volunteers – has a specific, intrinsic value for those who receive their service, as well as for those who provide it. There is much potential for informal carers and volunteers to be used in a positive way to benefit the clients involved, not least through the special relationships that is often formed between service users and volunteers.
Despite the desirability of integrated care, incorporating it into day-to-day practice is not necessarily easy. Neither the care delivery system nor the professional systems is based on principles of integrating services. On the contrary, many have been fragmented as a result of specialisation and task differentiation.
The main obstacles for implementing integrated care are deeply rooted in the prevailing organisational and policy systems (see also Leichsenring and Alaszewski 2004). The CARMEN network has analysed the various systems in EU member states, as well as day-to-day management challenges. From this analysis it appears that managers in these countries face many of the same obstacles:
In spite of these obstacles, various examples have shown that they are not insurmountable. Sometimes, the obstacles are used merely as an excuse for non-collaboration. Managers have to deal with these issues to achieve integration, implementing interventions at client, organisation or network and care system levels. Various processes, mechanisms and instruments have proven to be valuable. There is some consensus about the usefulness of some, but much of the evidence still has to be provided.
This resource book addresses a number of possible management interventions. However, not all interventions can be extensively addressed here. Policy measures are also necessary to further integrated care. As such, they may be regarded as prerequisites or supports for integration. CARMEN has separately published a booklet on policy development with regard to integrated care by national governments (Banks 2004).
When an organisation’s members decide that their clients would benefit from integrated care, that they can manage the context, and that they share the core principles, the next question is how to take up the process of integration.
In strategic and innovation management, there are a number of distinct phases in the process of working towards implementation. At each phase, there are specific tasks that need to be accomplished. To ensure that they have completed all the necessary tasks, managers can ask themselves a series of questions (outlined below). Their answers will determine what tasks the organisation need to carry out.
In theory, each phase should result in a ‘go’ or ‘no go’ decision. In practice, separate phases and decisions are often not explicit. Nevertheless, the phases outlined below (based on Nies and Können 1996) may help give some direction to the decision process.
The ethical issues relating to integrated care of older people relate to the tension between empowerment and the client’s individual rights on the one hand, and the rules and regulations of the ‘system’ on the other (Defever 2002). Managers need to make addressing ethical issues a priority. The ethical issues that may face a manager working in this area include:
These issues are discussed in detail below.
These and other questions are part of the reality of integrated care and the ethical and moral issues with which managers are confronted every day. These issues require careful deliberation before and during the implementation process. Discussions in this topic often reflect different professional and organisational norms and cultures, but they are absolutely necessary. There are no ‘right’ or ‘wrong’ answers to the ethical dilemmas of integrated care, and Mrs Costa will not be helped by general answers. However, general principles may be helpful to provide her, in her individual circumstances, with the care that meets her individual needs. This is what integrated care is all about.
Åhgren B (2003). ‘Chains of care are here to stay’. International Journal of Integrated Care, vol 3. Available at: www.ijic.org.
Andersson G, Karlberg I (2000). ‘Integrated care for the elderly’. International Journal of Integrated Care, vol 1. Available at: www.ijic.org.
Banks P (2004). Policy Framework for Integrated Care for Older People. London: King’s Fund.
Blackman T, Brodhurst S, Convery J eds (2001). Social Care and Social Exclusion. A comparative study of older people’s care in Europe. New York: Palgrave Macmillan.
Carrier J (2002). Integrated Services for Older People. Building a whole system approach in England. London: Audit Commission.
Commission of the European Communities (2003). Health Care and Care for the Elderly: Supporting national strategies for ensuring a high level of social protection. Communication from the Commission to the Council, the European Parliament, the European Economic and Social Committee and the Committee of the Region.
Coolen J (2002). Integrated Care for Older People: General perspective. Dublin: EHMA, unpublished.
Defever M (2002). ‘Resource allocation in health care’, in Lie RK, Schotsmans PT eds Healthy Thoughts. European perspectives on health care ethics. Leuven: Peeters, pp 249–63.
Glendinning C (1992). The Costs of Informal Care: Looking inside the household. London: HMSO.
Goodwin N, 6 P, Peck E, Freeman T, Posaner R (2003). Managing Across Diverse Networks of Care: Lessons from other sectors. Birmingham: Health Services Management Centre.
Gröne O, Garcia-Barbero M (2002). Trends in Integrated Care – Reflections on conceptual issues. EUR/02/5037864. Copenhagen: World Health Organisation. Also available at: www.euro.who.int/document/ihb/Trendicreflconissue.pdf.
Haggerty JL, Reid RJ, Freeman GK, Starfield BH, Adair CA, McKendry R (2003). ‘Continuity of care: a multidisciplinary review’. British Medical Journal, vol 327, pp 1219–21.
Kodner D, Spreeuwenberg C (2002). ‘Integrated care: meaning, logic, applications, and implications – a discussion paper’. International Journal of Integrated Care. Available at: www.ijic.org.
Kodner DL (2003). ‘Consumer-directed services: lessons and implications for integrated systems of care’. International Journal of Integrated Care. Available at: www.ijic.org.
Leichsenring K, Alaszewski AM (2004). Providing Integrated Health and Social Care for Older Persons. A European overview of issues at stake. Abingdon: Ashgate. Also available at: www.euro.centre.org/procare.
Leutz W (1999). ‘Five laws for integrating medical and social services: lessons from the United States and the United Kingdom’. The Millbank Quarterly, vol 77:1, pp 77–110.
Miesen B, Jones G (2004). ‘The Alzheimer café concept: a response to the trauma, drama and tragedy of dementia’. In Jones G, Miesen B eds Care-giving in Dementia – Research and applications, vol 3. London/New York: Brunner/Routledge.
Nies H, Können E (1996). Gids voor Samenwerking Tussen Verpleeghuizen en Verzorgingshuizen (Guide for collaboration between nursing homes and residential homes). Utrecht: Nederlandse Vereniging voor Verpleeghuiszorg (Netherlands Association of Nursing Homes).
Paton C (2000). The Impact of Market Forces on Health Systems. Dublin: EHMA.
Paton C, Berman PC, Busse R, Ong BN, Rehnberg C, Renck B, Romo Aviles N, Silio Villamil F, Sundh M, Wismar M (2002). ‘The European Union and health services: summary’, in Busse R, Wismar M, Berman PC eds The European Union and Health Services. The impact of the single European market on member states. Amsterdam: IOS Press, pp 1–13.
Timmermans J ed (2003). Mantelzorg Over de Hulp van en aan Mantelzorgers (Informal help on the assistance to and from informal carers). The Hague: Den Haag Sociaal en Cultureel Planbureau.
Van der Aa A, Konijn T (2001). Ketens, Ketenregisseurs en Ketenontwikkeling (Chains, chain directors and the development of chains). Utrecht: Lemma.
Van Raak A, Mur-Veeman I, Hardy B, Steenbergen M, Paulus A eds (2003). Integrated Care in Europe. Description and comparison of integrated care in six European countries. Maarssen: Elsevier Gezondheidszorg.
Woods K (2001). ‘The development of integrated health care models in Scotland’. International Journal of Integrated Care, vol 1. Available at: www.ijic.org
www.ehma.org – The website of the European Health Management Association (EHMA). It contains information on CARMEN, with many of its documents and publications, as well as on other projects. It also gives an overview of EHMA’s activities, members and various relevant web links.
www.ijic.org – The International Journal of Integrated Care is a peer-reviewed digital journal of scientific articles. The journal is practice-oriented and publishes on theory and research as well as projects and policy developments. It also hosts the International Network on Integrated Care.
www.integratedcarenetwork.gov.uk – The website of the Integrated Care Network in the United Kingdom aims to help frontline organisations to deliver integrated care. The content is organisted around seven key themes: integration, organisation, policy, research, inclusion, performance and evaluation, and governance. It provides an overview of activities, publications, guidelines and a discussion area.
www.euro.centre.org/procare – The Procare project focuses on a new contept of integrated health and social care for older people. It does this through comparing and evaluating different modes of care delivery in EU member states. The website provides national reports as well as general papers and a number of useful web links.