International Journal of Integrated Care, 8 June 2011 - ISSN 1568-4156
Integrate now, create health
Jason Cheah, Dr, MBBS (Singapore), MMed (Public Health), MSc (Wales), MBA, FAM (Singapore), Chief Executive Officer Agency for Integrated Care Republic of Singapore

On a bright early morning of 25 February 2011, almost 1200 healthcare professionals gathered in a packed hotel ballroom in Singapore to witness the opening of a 2 day Conference on Integrated Care—the first academic and practitioner focused event solely devoted to the challenges of Integration of Care in Asia. The theme of the Conference was “Integrate Now, Create Health”. It signified the urgency needed to integrate care for different populations of patients and also focused on the eventual goal of attaining better health outcomes through care integration. The 2 day Conference covered a wide array of topics from the “mechanics, tools and models” of care integration, to issues, such as financing, patient motivation (incentive) models, the use of technology to enhance care integration, chronic disease management, the challenges of transitional care and the frail elderly, to the need to integrate care for patients with terminal illnesses. For our journal readers who could not make it to this momentous event, you can read the presentation slides and scan through the programme at Needless to say, much of the ‘richness’ of the content of the Conference was due to the eclectic and international representation of speakers and experts from the US, UK, Sweden, Netherlands, Australia, Spain, and parts of Asia. Clearly, integration of care has become a worldwide challenge and we have only just begun the journey towards creating an international ‘platform’ for the sharing of best practices, models and tools that could be adapted or adopted across nations and health systems that would improve the care of patients with chronic illnesses and the frail elderly.

A number of key useful lessons were highlighted during the course of the Conference, which I think are worth emphasising here:

  • Governments and providers need to invest resources to integrate care. Professor Walter Leutz was one of the first to recognise this when he wrote about the ‘Laws of Integration’. Integration costs before it pays off. Much of the costs are for manpower and technology needed to start pilot programmes and services. It is evident that most countries in the world are still struggling to develop national frameworks and policies that incentivise, drive and foster better integrated care. This is especially so since most healthcare systems are either financed by ‘fee-for-service’ models coupled with an emphasis on acute episodic care. With the growing world-wide epidemic of chronic illnesses, a number of governments are now shifting their focus and mindsets towards creating new policy initiatives and mechnisms that fundamentally change the traditional incentive systems that are biased towards output-based payment systems. To date, it is clear that there is still no ‘perfect health policy and financing model’ that exists that combines the ‘best’ of efficiency-driven payment systems with an outcomes focused agenda that encourages integrated care.

  • A number of key and useful models of integrated care have emerged over the last decade that seem to have demonstrated cost-effectiveness and/or good outcomes for different patient populations. These include the US-based ‘PACE’ model and a number of community-based and home care-based models (in the UK, Netherlands, Denmark and Sweden, Australia, Singapore, etc.), all of which are geared towards keeping patients out of the acute hospitals and even long-term care residential facilities. For countries and health systems which have yet to embark on integrated care pilot programmes, this is a good starting point.

  • Technology has much potential usefulness as a tool and an enabler for integrated care. These include a variety of telehealth tools, tele-monitoring systems and web-based interactive communications. The important point to note is that before a significant investment is made in such technologies, it is imperative to understand the real objective of its use and to determine the sustainability of financing these technologies. Inter-operable personal e-health records are also another powerful tool that has emerged over the recent 5 years as a major enabler for integrated care. This is something which Denmark has done remarkably well, as have a few health systems in the US, such as Kaiser, Geisinger and the VA System.

  • With the increasing prevalence of chronic illnesses, transitional care has emerged as a great challenge to providers especially since the ‘hand offs’ are often the most vulnerable points in a patient’s journey. Errors and miscommunications often occur during these ‘hand offs’ resulting in poor outcomes and unnecessary readmissions to hospitals. Poorly executed transitions are associated with inefficiencies and duplication of services that needlessly increase the cost of care and potentially lead to greater utilisation of hospital, emergency, post-acute, and ambulatory services [1]. One important component of ensuring a successful process is open, regular communication with all the critical channels [2]. Improved transitions may lead to better health outcomes and reductions in unnecessary re-hospitalisations and health costs [3]. The ‘science’ of transitional care is still relatively new and the work of Dr. Eric Coleman, Dr. Mary Naylor, Dr. Chad Boult and many others will be crucial towards defining the best practice for seamless and continuous care.

  • Another key lesson that has emerged is that the quality and scope of primary care has a great impact on integration of care. A number of new models of primary care have started in the UK and the US that redefines the role of the family physician and nurse clinician in advocating for a holistic and integrated care delivery system for patients [46].

  • As world-wide shortages in healthcare professionals continue to plague many countries, new models of integrated care are beginning to address this issue as well by advocating for the increasing training and deployment of allied health professionals and even care-givers instead of the traditional doctor-nurse models. This is an area which I think will see tremendous growth over the next decade as health systems and providers strive to keep costs down and increase the overall ‘efficiency’ of caring for patients with long-term conditions.

  • There is growing evidence that support groups of varying types and designs for patients and/or care givers are a very cost-effective tool that fosters better and integrated care, especially for patients with chronic life-long illnesses (including mental disorders). Most health systems give little emphasis or resources to care givers, yet these form a significant part of the healthcare ecosystem. Some countries are now beginning to realise that care givers (both formal and informal) need to be adequately resourced and trained and they could play a vital role in the overall integrated care system.

  • Finally, the issue of “integrated end of life care” is only just beginning to be seriously addressed—mostly through isolated pilot programmes for now. This will become an increasingly important issue as our populations age and become increasingly frail, yet living in the community. Much work and research will need to be done to study the complexities of this population of patients including the medico-legal and ethical dimensions of care and the issue of advanced care planning.

In Singapore, much work has started on a variety of key initiatives that lead towards better integrated care. It is a long drawn journey that requires a thoughtful step-by-step process, tackling policy, resource and implementation issues. Clearly, our limited experience has shown that integration of care must be taken as a national agenda in order for the outcomes to be impactful and sustainable, yet the actual work and activities of integration must be localised and adapted to the needs of those we serve.

Coleman EA, Fox PD. [on behalf of the HMO Care Management Workgroup]. One patient, many places: managing healthcare transitions. Part I: Introduction, accountability, and information transfer. Annals of Long-Term Care 2004; 12(9):25-32.
Coleman EA, Boult CE. [on behalf of the American Geriatrics Society Health Care Systems Committee]. Improving the quality of transitional care for persons with complex care needs. Journal of the American Geriatrics Society 2003; 51(4):556-7.
Parry C, Coleman EA, Smith JD, Frank JC, Kramer AM. The care transitions intervention: a patient-centered approach to facilitating effective transfers between sites of geriatric care. Home Health Services Quarterly 2003; 22(3):1-18.
Boult C, Reider I, Frey K, Leff B, Boyd C, Wolff J, et al. Early effects of “Guided Care” on the quality of health care for multi-morbid older persons: a cluster-randomized controlled trial. Journal of Gerontology: Medical Sciences 2008; 63A:321-7.
Boyd C, Boult C, Shadmi E, Leff B, Brager R, Dunbar L, et al. Guided Care for multi-morbid older adults. The Gerontologist 2007; 47:697-704.
Wolff JL, Giovannetti ER, Boyd CM, Reider L, Palmer S, Scharfstein D, et al. Effects of guided care on family caregivers. The Gerontologist 2009; 50(4):459-70.