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Integrated healthcare: the past, present and future
  1. Paresh Dawda1,2
  1. 1 Prestantia Health, Canberra, Australian Capital Territory, Australia
  2. 2 Research School of Population Health, ANU College of Health & Medicine, Australian National University, Canberra, Australian Capital Territory, Australia
  1. Correspondence to Dr Paresh Dawda; paresh{at}prestantiahealth.com

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Integrated healthcare, an international buzz word, is not a new phenomenon or concept. For spectators of the health system, integrated care activity is very apparent across the developed nations, reflected in the exponential growth of scholarly interest in the subject over the last 20 years. For example, almost three-quarters of the results identified by Google Scholar for an exact match for ‘integrated healthcare’ were publications since the millennium (with two-thirds of them since 2010). This editorial presents a perspective on the past, present and future of integrated care.

The understanding and learnings from integrated healthcare have been confused by a lack of definitional agreement. The literature is plagued by terms such as integrated care, coordinated care, comprehensive care, seamless care, chronic disease management or joined-up care, to name just a few. Over 175 definitions1 are identified sometimes shaped by perspectives of different stakeholders, for example, patient, provider, policymaker, funder and evaluator.2 Some are synonyms, and others have overlapping concepts, constructs and taxonomies. Integrated care is closely associated with other concepts such as continuity of care. However, common to all the definitions is an organising principle where the needs of the patient (or population) are central.3 This principle has appeal, particularly if integrated healthcare is perceived to be a response to the adverse outcomes and experiences of care associated with fragmented care.4 A patient-orientated definition of integration is ‘a coherent set of methods and models on the funding, administrative, organisational, service delivery and clinical levels to create connectivity, alignment and collaboration within and between cure and care sectors’.5 The desired impact articulated as a patient narrative for integrated care is ‘my care is planned with people who work together to understand me and my carer(s), put me in control, coordinate and deliver services to achieve my best outcomes’.6

Subject to the choice of definition, the origins of integration, that is, the set of ‘processes, methods and tools that facilitate integrated care’,2 trace back to Hippocrates in 430 BC in the statement ‘the body must be treated as a whole and not just a series of parts’, for example seeking to integrate behavioural health and physical health (a common integration subject matter, particularly in the USA).7 Examples of literature from the early 20th century consider solo medical practitioners reorganising themselves into collective and collaborative organisational forms to improve effectiveness and efficiency.8 However, much of the initiatives and literature on integrated care are very much more recent. For example, initiatives in the National Health Service in the 1960s were mostly concerned with multidisciplinary care, with partnership working in the 1970s, and a focus on disease and care management in the 1980s and 1990s.2 Early integrated healthcare initiatives were mechanistic and took a linear perspective of care delivery with mostly top-down initiatives demonstrating minimal impact.9 Progressive emergent thinking was shaped by recognition of healthcare and well-being as a function of complex adaptive systems. The resultant paradigm change in the approach to integrated healthcare was one of contextual learning and sense-making. Over that time, fundamental strategic shifts in integrated healthcare were noted.9 These shifts have led to the current form and shape of integrated care activities.

The drivers for seeking better-integrated healthcare initially were financial, with payers seeking greater efficiencies or providers seeking higher profits.9 The drivers are increasingly overlapping to improve effectiveness and efficiency, thereby focusing strategies for integration activities on people who are most likely to benefit from them,9 for example, the elderly or frail people. Such population-based approaches to target activities seek to identify and segment populations with similar clinical and social need.2 10 11 These approaches include empowering and enabling people, and varying intensity of integration activities proportional to meet the needs of the population segment.11 Those integrated healthcare activities may include creating linkages, care coordination or case management.12

In many successful integration initiatives, the role of primary care is significantly strengthened.3 A shift away from acute care and organisational approaches of integration at the same level of the health system (horizontal integration) to one which strives to bring together different levels of the health system (vertical integration) is increasingly common in a whole-of-system approach.9 Such initiatives may be driven by provider partnerships (eg, integrated care partnerships) working to a shared purpose and supported by strong leadership, accountability frameworks, clear pathways of care and clinical information flows (an example of functional integration).11 They may alternatively be funder-driven activities in a market environment, offering incentives for quality and outcomes, timely access to robust data and clinical information (functional integration).11 Whomever the driver, integration should always be a collaborative effort and requires a cultural change with a focus on normative integration9 enabled through effective relationships observed at the macro, meso and micro levels.13

Accompanying vertical and horizontal healthcare integration has been a shift of focus also to consider cross-sectoral integration and a community focus.9 The sectors may include social care, education and housing, in addition to healthcare. The recognition and acceptance of the broader determinants of health facilitate a focus away from hospitals as the centre points to one seeking stronger primary healthcare and an integrated multidisciplinary team-based and population-focused delivery system.11 Health economies enable multidisciplinary integrated team-based care to support the delivery function through the use of functional, clinical and professional integration. Examples include the following:

  • Registries to support care processes (functional integration).

  • Evidence-based protocols (clinical and professional integration).

  • Individualised care plans for patients that are regularly reviewed (clinical integration).

  • Enhanced communication between the team members facilitated by case conferencing (clinical integration).

  • Embedding learning systems (professional and normative integration) where the care team regularly review critical metrics for individual patients but also the population.

Several characteristics will shape the future trend of integrated healthcare. Characteristics include a change in values and needs of people and populations, complex external influences such as digitisation and globalisation, and greater visibility of new products and services.14 A recent report on the future of healthcare in Australia depicts some futuristic healthcare journeys.15 Typical aspects that are apparent in the journeys include the following:

  • Empowered people supported by the use of technology—the technology may be used to monitor their health, or support independent living, or facilitate connectedness or receive personalised healthcare by intelligent use of connected and comprehensive ‘small’ data contextualised by ‘big’ data.

  • The value of cocreating health, services and policies.

  • The power of technology, data and information flows accelerating a move towards more integrated care and supporting shifting models towards a value-based paradigm.

  • Health solutions that enable more personalised and precision care, including access to care using alternative delivery modes such as video conferencing.

Future population and individual care needs will require an even more responsive service. The response to these needs may translate into globalised service delivery partnerships, increasing the need for even more virtual integration. The future of healthcare is often perceived by what is possible with today’s digital technology. Given the law of accelerating returns16 evident in the technology sector, tomorrow’s digital technology will be more powerful and functional than today. The healthcare sector will need to be extremely versatile and agile to maintain the pace of the rapidly evolving capabilities of technology.

What is known to date is that there is no one way of delivering integration and achieving integrated healthcare. Integration is a solution to a complex problem and requires purposeful leadership. The need for enhanced integration is more significant than ever. While the future offers hope, the pace of change will require care systems to be hyper agile. Ultimately, what will always matter most from a patient perspective is what happens at the clinical and professional dimensions of integrated healthcare, where the rubber hits the road, and people become the recipient of care. Capturing and sharing the learnings from integrated healthcare activities around the world will be a critical enabler to support a necessary joined-up and connected approach for healthcare design and delivery, in which the plurality of stakeholders are brought together to collaborate in a unified and integrated approach. The Integrated Healthcare Journal looks forward to facilitating those learnings.

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Footnotes

  • Competing interests None declared.

  • Provenance and peer review Commissioned; internally peer reviewed.

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