Integrated health care delivery

This book comprises an edited collection of research studies and conceptual essays on the topic of integrated care. There is no specific logic to the presentation of the material and the contents represent a highly varied and eclectic mix of subjects. Indeed, the contents have all the hallmarks of a set of conference papers that have been collated together without a huge amount of thought. As a result, the book and its contents are partly good and partly bad—like a ‘curate’s egg’.

Edited by Leonie A. Klein and Emily L. Neumann New York Nova Science Publishers Inc. 2008, pp 171 ISBN 978 1 60876 302 3 This book comprises an edited collection of research studies and conceptual essays on the topic of integrated care. There is no specific logic to the presentation of the material and the contents represent a highly varied and eclectic mix of subjects. Indeed, the contents have all the hallmarks of a set of conference papers that have been collated together without a huge amount of thought. As a result, the book and its contents are partly good and partly bad-like a 'curate's egg'.
The book comprises nine separately authored papers each about 15-20 pages long. In this review, the contents of each of these nine papers are examined and the value of their contribution to the study of integrated care assessed.
Chapter 1 examines the limitations of the US health system in managing patients with multiple and complex chronic illness and describes the development of the Integrative Health Advocacy Program ® (IHAP). We learn that IHAP is a model of care based around 'advocacy' teams of professionals from various backgrounds who share information about patients. IHAP is a variant on the health coaching method that seeks to guide and support patients in managing their own health and making incremental behavioural changes to improve their well-being. The chapter reports specifically on the results of a before-and-after evaluation of IHAP on participants' level of satisfaction with their health care services. It found improved perceptions of physical health and their ability to manage independently. The chapter provides a well-documented case study in support of multidisciplinary care planning and advocacy as a system feature for long-term conditions management-the 'integrating mechanism' being the advocate team who is able to help secure the right packages of care in full consultation with the patient.
Chapter 2 provides an analysis of 'integrated dual diagnosis delivery models' to better support 'treatment fidel- ity' (what in other countries might be called adherence or concordance to treatment plans). In what seems a well-designed trial, the authors examined 256 clients with severe mental illness and substance use disorders to determine the impact of the 'integrated' model on treatment fidelity and also on one-and two-year rates of psychiatric hospitalisation. However, the chapter does not articulate well the details of the integrated model making it problematic to understand the difference of this intervention with usual care. In any case, the authors found no significant differences in levels of hospitalisation, though levels of fidelity in treatment adherence had improved in the integrated model.
Chapter 3 examines the effectiveness of lumbar fusion treatments in different hospitals and found costs varied markedly by the severity of patients' physical status. The paper has little relevance to integrated care other than in its conclusions which suggested care systems would be more cost efficient if care was more 'vertically integrated', though the assertion is not explored.
Chapter 4 examines the importance of trust and cooperation in the functioning of primary and community care networks (PCCNs) in Taiwan. It concluded that investing in social capital was an important managerial task in fostering a culture of joint working within such networks. The paper provides an interesting perspective on network management though did not seek to bring in information from the significant literature on this subject through which to compare and contrast their observations. If they had, they would have realised that PCCNs in Taiwan are highly context-specific and that the building of social capital is highly important for certain types of network, but not others. Nonetheless, the paper is a worthy contributor to understanding professional networks.
Chapter 5 provides a broader assessment of the commonalities to be found across different programmes of chronic disease management. In a well-written chapter, the authors show how the aims of the programmes tend to follow five basic principles: patient-centredness; multidisciplinary care; care co-ordination; evidencebased medicine; and a commitment to quality improvement. The first three are, in the opinion of the authors,

Book review
Integrated health care delivery essential for care integration and the last two to ensure high quality care. The chapter provides a good case for improving the way these dimensions can be measured and valued as part of a multi-component programme of care improvement.
Chapter 6 concentrates on the importance of data and information management so that patient-level data can be shared between professionals to enable better decision-making. In particular, the paper advocates the role for a case manager to work in partnership with patients (and by implication, their carers) to ensure patient-level information is communicated between patients and care deliverers effectively as well as to ensure patients receive the care and treatment they need. The need for such a model of care in the management of individuals with complex needs is a growing feature of both policy and think-pieces such as this. The chapter provides a useful overview of the potential importance of the approach, though the next level would be to show empirically the value of such care co-ordination.
Chapter 7 is another chapter with little real relevance to integrated care. Rather, it proposes a process to evaluate the deficiencies of current care systems and a method for addressing them. In the context of Botswana, the approach described is four-fold: systematic analysis to examine gaps in provision or service wastage; service redesign potentially based on a more integrated delivery model of care; rules of action that provide the governance and incentive framework that promote joint working; and finally, an understanding of transaction costs that would result from any significant reform. The authors assert that the approach would help policy makers and managers think about core issues in whether and how integrated care strategies might work, but the framework appears to be light on specifics and little different from many others looking at sustaining innovations or in change management.
Chapter 8 is an interesting, if overtly conceptual, paper looking at how care fragmentation results (and has resulted) from the interplay between three driving forces-decentralisation, specialisation and professionalization. The authors examine the interaction of these three forces to describe different elements of fragmentation that need to be addressed: organisa-tional fragmentation; clinical fragmentation and cultural fragmentation. In my favourite phrase in the book, they call this phenomenon the Patient Bermuda Triangle and so describe how the purpose and logic of integrated care ought to be to bring order in the chaotic condition of fragmented health care that leads to patients becoming lost in the system.
The authors go on to describe a range of strategies commonly used to address this, including clinical guidelines and networks. They describe how top-down managerial solutions are less likely to succeed since they cannot readily tackle cultural fragmentation. Instead, the authors advocate the power of bottom-up changes where patients become 'change agents' and professionals respond to their demands.
Whilst it is often observed how top-down and/or mandated partnerships fail, the authors are perhaps a little optimistic in their view that patients as consumers are likely to be more successful or powerful in overcoming entrenched professional cultures. Indeed, patients themselves have competing views on what good quality care should look like whilst we know that choice-led systems tend to lead to greater fragmentation of care and that a 'guiding hand' (say, of an insurance or government agency) is needed to act on people's behalf. Hence, the chapter seems naive in its conclusions, but it is still one of the most powerful conceptual overviews of the problems of care fragmentation that one is ever likely to read.
Chapter 9 looks at the issue of sharing images between radiologists and belongs in a book on e-health. Whilst there is clear value in the use of new technologies in enabling integrated care, this chapter does not examine the issue.
Overall, various chapters in the book are very good indeed (particularly Chapters 1, 4 and 8 which are valuable contributions in the integrated care field). However, overall, readers need to be aware that the book contains an eclectic mix of papers without a common thematic narrative and so should not be mislead by the attractiveness of its title.