Start Submission Become a Reviewer

Reading: Integrated Care in Switzerland: Strengths and Weaknesses of a Federal System

Download

A- A+
Alt. Display

Policy papers

Integrated Care in Switzerland: Strengths and Weaknesses of a Federal System

Authors:

Séverine Schusselé Filliettaz ,

La Source School of Nursing, HES-SO University of Applied Sciences and Arts Western Switzerland, Av. Vinet 30, 1004 Lausanne; Association for the Promotion of Integrated Patient Care Networks (PRISM), Geneva; Forum Managed Care (FMC), Zugerstrasse 193, 6314 Neuägeri, CH
X close

Peter Berchtold,

College M, Laupenstrasse 7, 3001 Bern, CH
X close

Ursula Koch,

Forum Managed Care (fmc), Zugerstrasse 193, 6314 Neuägeri, CH
X close

Isabelle Peytremann-Bridevaux

Centre for Primary Care and Public Health (Unisanté), University of Lausanne, Route de la Corniche 10, 1010 Lausanne, CH
X close

Abstract

Introduction: Switzerland’s fragmented healthcare system mirrors its federal structure and mix of cultures and languages. Although the Swiss have a higher life expectancy than most of their neighbours, their healthcare system faces similar challenges that call for more integrated care (IC).

Aim/Method: This article aims to provide insight into the specificities of and latest developments in Switzerland’s healthcare system and how they may have influenced the development and implementation of IC there.

Description/Discussion: The number of local IC initiatives has been growing steadily for 20 years. With a certain lag, various policies supporting IC have been established. Among them, a recent democratic debate on the federal mandatory health insurance law could either induce a radical move towards centralised support for IC or continue to support scattered local IC initiatives.

Conclusion: In the future, Switzerland’s healthcare system will probably navigate between local IC initiatives and centralised, federal support for IC initiatives. This will be the reflection of a very Swiss way forward in a world without clear evidence on whether centralised or decentralised initiatives are more successful at developing IC.

How to Cite: Filliettaz SS, Berchtold P, Koch U, Peytremann-Bridevaux I. Integrated Care in Switzerland: Strengths and Weaknesses of a Federal System. International Journal of Integrated Care. 2021;21(S2):10. DOI: http://doi.org/10.5334/ijic.5668
188
Views
48
Downloads
  Published on 29 Oct 2021
 Accepted on 20 Sep 2021            Submitted on 12 Dec 2020

Introduction

Switzerland’s slightly more than 8.5 million inhabitants live in the heart of Europe, unevenly separated into three main linguistic regions [1]. Swiss residents have a high life expectancy compared to other Europeans (e.g. 85.6 years for women in 2020) [1], and they are globally satisfied with the accessibility and quality of their care [2, 3]. However, as in other European countries [4], the healthcare system is under pressure due to rising costs (11.2% of GDP in 2018) [2], the growing prevalence of non-communicable diseases and multimorbidity [5, 6], patients’ increasing needs and expectations [3], and expected shortages of qualified professionals [7]. Enhancing integrated care (IC) in Switzerland could alleviate this pressure.

Switzerland is a federal state in which government health responsibilities are split between the national, cantonal and municipal levels [1]. The federal level regulates areas such as financing (e.g. mandatory health insurance), the quality and safety of pharmaceuticals and medical devices, public health (e.g. control of infectious diseases), and education and training [2]. Each of the 26 cantons, with its own minister of health, is responsible for licensing its healthcare providers, regulating its hospital services and subsidizing its healthcare institutions (e.g. in-patient, homecare) [2]. Each canton can be considered to have a slightly different healthcare system [8]. The 2202 municipalities are mainly responsible for long-term care and social services [2]. Finally, thanks to its system of direct democracy, Swiss citizens are involved in shaping new laws or adjusting existing ones at all three levels, in addition to electing representatives [8]. These elements highlight the Swiss health system’s configuration of centralized and decentralized responsibilities for the building blocks of IC [9].

In Switzerland, universal access to healthcare was established through a mandatory health insurance (MHI) introduced in 1994 [10]. Following a principle of managed competition allowing citizens a free choice of health insurers and providers, the MHI aims to i) strengthen solidarity between healthy and sick people, ii) ensure high-quality healthcare and iii) contain costs [11, 12]. The basic MHI coverage includes a comprehensive package of benefits with direct and unrestricted access to healthcare services. However, around 70% of the Swiss population opt for a cheaper, alternative insurance model including gatekeeping [13]. The not-for-profit MHI scheme is operationalised by more than 50 insurers, which also operate for-profit complementary health schemes [2].

In addition to MHI, healthcare services have other funding streams, such as out-of-pocket payments, direct and indirect public funding, and other social insurance schemes. These streams vary [14] between the numerous providers active in Switzerland. For instance, medical and non-medical providers of outpatient care are mainly reimbursed on a fee-for-service basis, and providers working in networks or health maintenance organisations (HMOs) are increasingly paid by salary and/or capitation [2]. These outpatient costs to the citizen are essentially covered by the MHI and out-of-pocket payments. On the contrary, inpatient care relies on a national diagnosis-related group (DRG) payment system [15], covered by both MHI and public funding. All health professionals are free to provide care and treatments that are covered by MHI. Except for some benchmarking used to monitor providers’ incomes (MHI law, art. 32 and 57), consistent and continuous quality controls have only recently emerged (e.g. patient outcomes [16]). Similarly, healthcare data transparency is still in its infancy [17].

Healthcare in Switzerland is provided by an array of private and public providers, ranging from individual to group practices and specialised institutions (e.g. homecare, long-term care), to large hospitals and health networks [2]. Additionally, providers are scattered geographically, housed in distinct buildings, and administratively separate and different (e.g. primary care medical networks and homecare institutions have different hierarchies). Moreover, although the number of multi-professional outpatient structures is increasing [18], many remain mono-professional and answer specific patients’ needs (e.g. homecare with nurses, physiotherapy practices). Regarding outpatient physicians, 48% worked in individual practices [19], and 55% were members of a physicians network in 2020 [20]. Furthermore, 75% of the general practitioners and 41% of the specialists were affiliated to such networks in 2020 [20]. Finally, new fields of work are emerging in these networks, such as triage and coordination by Advanced Practice Nurses [21].

This article aims to provide some insight into the specificities of and latest developments in Switzerland’s healthcare system and to discuss their influence on the development and implementation of IC.

Latest key policy developments

Over the past ten years, several programmes and policies have directly or indirectly favoured the development of IC in Switzerland. They are presented chronologically and succinctly described below.

2013–2019: National dementia [22] and palliative care [23] strategies

Endorsed by both the national and cantonal governments, these strategies aimed to develop common frameworks for managing these conditions. The strategies highlighted the specific professional expertise available but also the limited incentives for collaboration and coordination. Their recommendations included specific focuses on the continuity of care and on an optimised framework for interprofessional coordination and networking providers. Based on this, several cantons developed their own policy, and the recommendations above were included in subsequent national policies (see below).

2015: New models for primary care [24]

In 1998, a National Health Policy Dialogue was initiated by the national and cantonal governments to iteratively address the challenges facing Switzerland’s healthcare system. The resulting 2015 report on New Models for Primary Care called for IC and a more global approach to patients’ needs. Building upon the Chronic Care Model [25], this report also highlighted the needs to improve interprofessional collaboration, optimise tasks and competencies, and adjust contextual elements, such as working conditions and education.

2015–2020: National research programme [26]

The Smarter Healthcare research programme, launched by the Swiss National Science Foundation, included 34 projects aimed at providing fresh insights and potential improvements to healthcare structures and utilisation. The synthesis of this programme is expected in 2022, and policy briefs will be issued in six areas: quality; patient choice; coordination and care models; costs and reimbursement; healthcare data; and communities of researchers, decision-makers and practitioners.

2015 onwards: National project on the coordination of care [27]

This project aims to enhance the quality of care by focussing on improved processes for meeting patient’s various needs and ensuring the continuity of care. Without explicitly saying so, it is an attempt to shift from disease management, focussing on health outcomes, towards care/case management, focussing on care processes—in line with recommendations from the literature on multimorbidity [28]. This project led to several reports addressing, e.g. improved transitions between inpatient and outpatient care [29] and the remuneration of coordination activities [30].

2017–2020: Promotion of interprofessional collaboration in healthcare [31]

Under the umbrella of a larger initiative tackling shortages of qualified healthcare professionals, this programme intended to foster the coordination of care and interprofessional collaboration. Good practice models were identified in educational as well as clinical settings [32, 33]. Additionally, recommendations highlighted the needs for quality indicators, support for implementation, legal clarifications about the responsibilities of non-medical actors, improved funding and increased training [34].

2017–2024: National strategy to tackle non-communicable diseases [35]

This strategy aims to redirect the healthcare system towards the prevention and management of chronic conditions. To this end, it strengthens health promotion and prevention, and it is also designed to improve health literacy, especially of vulnerable populations. Furthermore, it considers various health determinants and promotes inter-sectoral collaboration (e.g. business, urban planning). Innovatively, it prompts federal and cantonal synergies in prevention.

2018–2022: Swiss eHealth strategy [36]

This national strategy aims to foster the process of digitalisation in health, thus increasing the quality of care and patient safety. The law on electronic health records (EHRs) was adapted concomitantly [37]. Although EHRs are now mandatory in hospitals and nursing homes, adhesion to EHRs in the outpatient sector is left up to patients and their healthcare professionals. Additionally, the establishment of EHRs is facing resistance to digitalisation and technical challenges linked to the variety of existing medical softwares [38], which calls for improved standardisation and interoperability [39].

2019: Supporting cantons’ moves towards more IC [40]

To celebrate its 100th anniversary, the Conference of Cantonal Health Directors commissioned a Guide to Integrated Care [40] providing cantons with information on the basic principles of IC, suggestions on implementation and a checklist for assessing the feasibility of IC at the cantonal level.

2020–2030: Federal Council’s health strategy [41]

Building on 2013’s National Health Strategy and lessons learned from the policies above, the 2020–2030 strategy has eight main objectives: i) exploit health data and technologies; ii) strengthen health literacy; iii) make more professionals and funding available; iv) enable healthy ageing; v) increase the quality and coordination of care; vi) control costs and their burden on deprived households; and improve health through better vii) natural and viii) work environments. This strategy promotes “coordinated care” - a synonym for IC in Switzerland - through various policy initiatives at the micro (between providers), meso (between organisations) and macro levels (between federal, cantonal and local stakeholders).

Advances in IC in Switzerland

Whereas the previous section reflects the cautious but steady calls for IC across Switzerland’s healthcare system, this section describes the actual advances in the implementation of IC.

A national survey carried out in 2015 and 2016 aimed to produce a comprehensive overview of IC initiatives in Switzerland [18]. The survey evaluated initiatives fulfilling the following four criteria: i) a formalisation of IC principles (e.g. an agreement between several organisations, a public mandate, a research protocol, a report); ii) the integration of at least two levels of healthcare services (e.g. physician-led primary care, non-physician-led primary care, homecare services, community services, inpatient services); iii) the integration of at least two different groups of healthcare professionals (e.g. physicians, nurses, pharmacists, physiotherapists, social workers, volunteers, informal carers); and iv) the initiative was ongoing during the survey period.

The survey allocated the 155 initiatives identified to one of the six following categories: i) Specific groups (e.g. somatic disease-specific, 33% of the initiatives); ii) Mental health (26%); iii) Coordination of care (16%); iv) Healthcare centres (13%); v) Physicians’ networks (6%); and vi) Drug management (5%). Findings showed that the implementation of IC had accelerated over the past three decades. Indeed, whereas half of the 155 initiatives had started between 1990 and 2009, the other half had started between 2010 and 2016. The largest increase was found in the Specific groups and Mental health categories, two types of initiatives that require strong coordination and integration. Moreover, whereas Specific groups initiatives increased 3.5-fold between 1996 and 2009, but only 2-fold between 2010 and 2016, Coordination of care initiatives increased 4-fold and 4.2-fold, respectively. This might reflect an emerging shift towards initiatives fostering coordination of care processes instead of disease-centred initiatives.

The survey also showed that until 2012, most initiatives occurred in Switzerland’s German-speaking regions. However, by 2016, 52% were being implemented in French- and Italian-speaking regions, 45% were in German-speaking regions, and 3% were across Switzerland. Furthermore, the types of IC initiatives were different between the regions. Indeed, German-speaking regions had more Physicians’ networks and Healthcare centre initiatives, whereas in French- and Italian-speaking regions had more initiatives targeting Specific groups, Drug management and the Coordination of care. The range of professionals involved in initiatives varied too. The broadest spectrum was found in Healthcare centre initiatives (seven types of professionals), followed by Specific group initiatives (six types of professionals).

Secondary data analyses of this national IC survey explored the influences of organisation and the funding of care on the implementation of interprofessional collaboration. Findings suggested that financial barriers hindered the association of interprofessional collaboration and organisational improvements [42].

A more recent nationwide survey showed that the Swiss healthcare system’s readiness for IC could be improved [43]. Indeed, seven of the SCIROCCO tool’s [44] twelve items were rated as low (Readiness to Change, Structure and Governance, Standardisation and Simplification, Funding, Breadth of Ambition, Innovation Management and Capacity Building). Results also varied slightly, with German-speaking respondents giving lower ratings to three items (Population Approach, Citizen Empowerment and Evaluation Methods) than did French- and Italian-speaking respondents and higher ratings to Readiness to Change and Structure and Governance. Furthermore this survey highlighted several barriers to IC at two levels: at the professional level (e.g. threat to financial benefits) and at the system level (lack of support and training for professionals, lack of political will) [45].

Future challenges and opportunities

Health patterns worldwide and in Switzerland have been changing [5, 46]. Indeed, not only has the prevalence of chronic diseases such as cancer, diabetes, COPD, asthma and depression increased significantly, but many people have multiple coexisting (chronic) somatic and mental health conditions (multimorbidity) as well as social needs [3]. In spite of this epidemiological situation, data about the distribution of care provision in Switzerland is scarce [47], making it difficult to assess the numbers and specialities of the professionals involved in patient care or their degree of collaboration. However, in light of the increasing financial burden and number of annual medical consultations per capita, we may wonder whether Swiss patients face risks of information loss or discrepancies, potential concomitant over-investigation, over-treatment, complications, emergencies and rehospitalisation, with their concurrent negative effects on patient outcomes and costs [3, 48, 49, 50].

These elements call out for improvements to IC. However, its potential to improve efficiency, patient safety and the quality of outcomes is only being exploited minimally in Switzerland, despite the various policies previously described showing that IC is acknowledged by growing numbers of stakeholders at the national, cantonal and local levels. This can probably be explained by Switzerland’s federal system [51]. From a change management perspective [52], this federal, decentralised system enables ad hoc innovations to be triggered by local leaders of change. However, it also leaves space for inertia and resistance to change. In order to implement IC more broadly, all across the country and in its various local contexts, the Swiss healthcare system needs robust health system building blocks [9, 53]. These building blocks include initial and continuous education addressing IC both for practitioners and managers [34], adjusted financing schemes promoting coordination [54], and interoperable clinical information tools [36]. While most of these building blocks have emerged already, they will only stabilise and spread with a subtle combination of centralized and decentralized impulses. In addition to these building blocks, proactive change management strategies should make IC easy and desirable, not only to early adopters, but also to the majority of the country’s healthcare stakeholders [52, 55]. Among them, healthcare system users should be more explicitly included as their perspectives would reinforce the relevance and desirability of IC [56]. While direct democracy enables lobbies such as health insurers or health professionals to have representatives at the federal level, the patients’ lobby remains poorly represented and still lacks power of action in Switzerland. However, whereas the patient-as-partners approach has been adopted at the international level (e.g. Canada [57]), care institutions in Switzerland have only recently included formal patient expertise in their governance (e.g. Geneva [58]). Finally, supporting IC in Switzerland will also contribute to its health system performance, as advocated for by the successive Triple to Quintuple Aim approaches [59, 60, 61, 62]. However, due to the lack and/or the opacity of data (e.g. quality of services, negotiation of payment rates) [17, 47], assessing this performance remains a challenge.

Against this background, the most recent developments regarding IC in Switzerland are of particular interest. Indeed, an adaptation of the MHI law is currently going through Switzerland’s democratic discussion process [63], and it would definitely support the development of IC in Switzerland:

  • A mandatory first point of contact: all individuals would choose a first point of contact (e.g. physician, call centre, group practice or coordinated care network) for advice, treatment prescription or referral to another healthcare provider; the first point of contact would receive a flat-rate payment for each insured patient; exceptions to this mandatory contact would include emergency and gynaecological consultations.
  • Coordinated care networks: these networks would bring together professionals from different disciplines to coordinate the entire care process; all services—including coordination activities—would be covered by a flat-rate payment.
  • Patient care programmes: more evidence-based, structured processes of care—such as disease-management, prevention or rehabilitation programmes—would be developed; patients would be included in such initiatives more systematically.

These three measures would bring major changes to Switzerland’s healthcare system. Indeed, they would i) recognize the worth and importance of coordination activities, ii) partly replace fee-for-service payments by flat-rate payment systems, and iii) mitigate the central role of single physicians and facilitate care and case-management activities by a range of professionals. Because of Switzerland’s democratic processes, these measures are still far from implementation. Indeed, the dichotomy between centralised control and decentralised autonomy—representing the extremities of Switzerland’s spectrum of political combinations—has long been the subject of debate both inside and about the country’s health systems [64, 65]. The dichotomy relies on two main aspects. Firstly, in the West, health is generally understood to be a public good requiring strong central leadership. Secondly, the importance of personal responsibility for one’s own health calls for reduced public involvement [66]. In Switzerland, this configuration and the various strengths and weaknesses discussed in this article offer interesting material with which to explore the diverse developments in healthcare in general and IC in particular.

Conclusion

The number of local integrated care (IC) initiatives in Switzerland has been steadily growing over the last 20 years. With a certain lag, momentum in favour of IC policies has developed. In the future, Switzerland’s healthcare system will probably navigate between centralised support for IC and scattered local IC initiatives. This will be the reflection of a very Swiss way forward in a world without much clear evidence of whether centralised (state) incentives or decentralised (field) initiatives are more successful at developing and scaling up IC.

Reviewers

Two anonymous reviewers.

Competing Interests

The authors have no competing interests to declare.

References

  1. FSO. Memento statistique de la Suisse 2020 [Statistical memento of Switzerland 2020]. Neuchâtel, Switzerland: Federal statistical office (FSO); 2020. 

  2. Sturny I. International health care system profiles: Switzerland 2020. www.commonwealthfund.org (accessed November 17, 2020). 

  3. Pahud O. Erfahrungen der Wohnbevölkerung ab 18 Jahren mit dem Gesundheitssystem – Situation in der Schweiz und im internationalen Vergleich [Experiences of the resident population aged 18 and over with the health care system – situation in Switzerland and in international comparison]. Neuchâtel, Switzerland: Swiss Health Observatory (OBSAN); 2020. 

  4. Kirchgässner G, Gerritzen B. Leistungsfähigkeit und Effizienz: Das Gesundheitssystem der Schweiz im internationalen Vergleich [Performance and efficiency: Switzerland’s healthcare system in international comparison]. Die Volkswirtschaft. 2011; 84: 59–63. 

  5. Bachmann N, Burla L, Kohler D. La santé en Suisse – Le point sur les maladies chroniques (Rapport national sur la santé 2015) [Health in Switzerland – Update on chronic diseases (National health report 2015)]. Bern, Switzerland: Swiss health observatory (Obsan); 2015. 

  6. OBSAN. Rapport national sur la santé 2020: Enfants, adolescents et jeune [National Health Report 2020: Children, Adolescents and Youth]. Neuchâtel, Switzerland: Eds Hogrefe; 2020. 

  7. Merçay C, Burla L, Widmer M. Personnel de santé en Suisse: Etat des lieux et projections à l’horizon 2030 [Health professionals in Switzerland: Current situation and projections up to 2030]. Neuchâtel, Switzerland: Swiss Health Observatory (OBSAN); 2016. 

  8. Crivelli L, De Pietro C. Federal government, cantons and direct democracy in the Swiss health system. Health Reforms Across the World: The Experience of Twelve Small and Medium-sized Nations with Changing Their Healthcare Systems, World Scientific; 2020. DOI: https://doi.org/10.1142/9789811208928_0007 

  9. Amelung V, Stein V, Goodwin N, Balicer R, Nolte E, Suter E, (eds). Handbook integrated care. 1st edition. Cham (Switzerland): Springer; 2017. DOI: https://doi.org/10.1007/978-3-319-56103-5 

  10. Federal office of public health. Loi fédérale sur l’assurance-maladie (LAMal) du 18 mars 1994 [Federal Law on Health Insurance]. Bern (Switzerland): Swiss confederation; 2021. 

  11. Enthoven AC. The history and principles of managed competition. Health Affairs. 1993; 12: 24–48. DOI: https://doi.org/10.1377/hlthaff.12.Suppl_1.24 

  12. Frei A, Hunsche E. The Swiss health care system. HEPAC. 2001; 2: 76–8. DOI: https://doi.org/10.1007/PL00012220 

  13. Berchtold P, Cikes M. Aerztenetze und Integration: Was koordinieren? Wie kooperieren? [Medical networks and integration: What should be coordinated? How to cooperate?]. Schweiz Aerzteztg. 2019; 100: 578–9. DOI: https://doi.org/10.4414/bms.2019.17758 

  14. FSO. Coûts et financement du système de santé 2018: données définitives [Health system, costs and financing 2018: final data]. Neuchâtel, Switzerland: Federal statistical office (FSO); 2020. 

  15. SwissDRG. Fixed rate per case payments in Swiss hospitals: basic information for healthcare professionals. Bern, Switzerland: SwissDRG AG; 2015. 

  16. Saxera F, Degen M, Brodbeck D, Jakob M, Vach W. Implementing systematic outcome assessments in a Swiss healthcare practice: points to consider. Swiss Med Wkly. 2020; 7. 

  17. Vincent C, Staines A. Enhancing the quality and safety of Swiss healthcare. Bern, Switzerland: Federal office of public health (FOPH); 2019. 

  18. Schusselé Filliettaz S, Berchtold P, Kohler D, Peytremann-Bridevaux I. Integrated care in Switzerland: results from the first nationwide survey. Health Policy. 2018; 122: 568–76. DOI: https://doi.org/10.1016/j.healthpol.2018.03.006 

  19. FMH. Statistique médicale de la FMH 2020 [FMH Medical statistics 2020]. Bern, Switzerland: Swiss medical federation (FMH); 2021. 

  20. Hostettler S. Résultats tirés des statistiques médicales de la FMH 2020 [Further results from the FMH physicians statistics 2020] (personal communication) 2021. 

  21. Schönenberger N, Sottas B, Merlo C, Essig S, Gysin S. Patients’ experiences with the advanced practice nurse role in Swiss family practices: a qualitative study. BMC Nurs. 2020; 19: 90. DOI: https://doi.org/10.1186/s12912-020-00482-2 

  22. FOPH, GDK/CDS. La démence en Suisse: Synthèse des résultats de la Stratégie nationale en matière de démence 2014–2019 [Dementia in Switzerland: Summary of the results of the National Dementia Strategy 2014–2019]. Bern, Switzerland: Federal office of public health (FOPH) & Swiss conference of the cantonal ministers of public health (GDK/CDS); 2019. 

  23. von Wartburg L, Naef F. Stratégie nationale en matière de soins palliatifs 2013–2015: Bilan et actions requises [National Strategy for Palliative Care 2013–2015: assessment and actions needed]. Bern, Switzerland: Federal Office of Public Health (FOPH) & Swiss Conference of Cantonal Health Directors; 2012. 

  24. Schibli D, Hodel M. Rapport du Groupe de travail “Nouveaux modèles de soins pour la médecine de premier recours” de la CDS et de l’OFSP [Report of the CDS-FOPH Working Group on “New Models of Care for Primary Care Medicine”]. Bern, Switzerland: Federal office of public health (FOPH) & Swiss conference of the cantonal ministers of public health; 2012. 

  25. ICIC. The Chronic Care Model: Model Elements. Improving Chronic Illness Care (ICIC). 2006. www.improvingchroniccare.org (accessed April 1, 2021). 

  26. FNRS. Smarter health care: programme national de recherche No 74 “Système de santé” (2016–2022) [Smarter health care: national research programme No. 74 “Health system” (2016–2022)]. Bern, Switzerland: Swiss Fund for Scientific Research (FNRS); 2017. 

  27. von Wartburg L. Soins coordonnés [Coordinated care]. Bern, Switzerland: Federal office of public health (FOPH); 2016. 

  28. Boyd CM, McNabney MK, Brandt N, Correa-deAraujuo R, Daniel M, Epplin J, et al. Guiding principles for the care of older adults with multimorbidity: an approach for clinicians. J Am Geriatr Soc. 2012; 60: E1–25. DOI: https://doi.org/10.1111/j.1532-5415.2012.04188.x 

  29. Dietschi I. Planifier et coordonner la sortie de l’hôpital [Hospital Discharge Planning and Coordination]. Bern, Switzerland: Federal office of public health (FOPH); 2016. 

  30. Giger M-A, Häusler E, Sander M, Staffelbach D. Rémunération des prestations dans le cadre des soins coordonnés [Remuneration in the context of coordinated care]. Bern, Switzerland: Federal office of public health (FOPH); 2018. 

  31. Federal office of public health. Programme de promotion de l’interprofessionnalité dans le domaine de la santé 2017–2020 [Promotion of interprofessional collaboration in health – 2017–2020 programme]. Bern, Switzerland: Department of home affairs; 2017. 

  32. FOPH. Interprofessionnalité dans le domaine de la santé: exemples pratiques [Interprofessionality in healthcare: practical examples]. Bern, Switzerland: Federal office of public health (FOPH); 2018. 

  33. FOPH. Interprofessionnalité dans le domaine de la santé: exemples issus de la formation et de l’enseignement [Interprofessionality in healthcare: training and education]. Bern, Switzerland: Federal office of public health (FOPH); 2020. 

  34. FOPH. Interprofessionnalité dans le domaine de la santé: quatre policy briefs [Interprofessionality in healthcare: four policy briefs]. Bern, Switzerland: Federal office of public health (FOPH); 2020. 

  35. Federal office of public health, Swiss conference of the cantonal ministers of public health. Stratégie nationale ‘Prévention des maladies non transmissibles’ (Stratégie MNT) 2017–2024 [National Strategy “Prevention of non-communicable diseases” (NCD Strategy) 2017–2024]. Bern, Switzerland: Department of home affairs; 2016. 

  36. ehealthsuisse. Stratégie Cybersanté Suisse 2.0 2018–2022 [Swiss e-Health Strategy 2.0 2018–2022]. Bern, Switzerland: Swiss confederation & Swiss conference of the cantonal ministers of public health; 2018. 

  37. Swiss confederation. Loi fédérale sur le dossier électronique du patient (LDEP) [Federal law on the electronic health record]. Bern, Switzerland: 2020. 

  38. Thiel R, Deimel L, Schmidtmann D, Piesche K, Hüsing T, Rennoch J, et al. #SmartHealthSystems: Digitalisierungsstrategien im internationalen Vergleich [#SmartHealthSystems: digitalisation strategies in international comparison] 2018. 

  39. SPNH. SNPHS’s Fact-Sheet 2020. Swiss Personalized Health Network (SPHN); 2020. 

  40. Berchtold P, Schusselé Filliettaz S, Zanoni U. Nouvel élan pour les soins intégrés dans les cantons: un guide [New impulse for care integration in the cantons: a guide]. Bern, Switzerland: Swiss conference of the cantonal ministers of public health; 2019. 

  41. Federal office of public health. Politique de la santé: stratégie du Conseil fédéral 2020–2030 [Health policy: Federal Council’s strategy 2020–2030]. Bern, Switzerland: Swiss confederation; 2019. 

  42. Gilles I, Schusselé Filliettaz S, Berchtold P, Peytremann-Bridevaux I. Financial barriers decrease the benefits of interprofessional collaboration within integrated care programs: Results of a nationwide survey. IntJIntegrCare. 2020; 1: 1–9. DOI: https://doi.org/10.5334/ijic.4649 

  43. Peytremann-Bridevaux I, Schusselé Filliettaz S, Berchtold P, Grossglauser M, Pavlickova A, Gilles I. Healthcare system maturity for integrated care: results of a Swiss nationwide survey using the SCIROCCO tool. BMJ Open. 2021; 11: 12. DOI: https://doi.org/10.1136/bmjopen-2020-041956 

  44. Grooten L, Vrijhoef HJM, Calciolari S, Ortiz LGG, Janečková M, Minkman MMN, et al. Assessing the maturity of the healthcare system for integrated care: testing measurement properties of the SCIROCCO tool. BMC Med Res Methodol. 2019; 19: 63. DOI: https://doi.org/10.1186/s12874-019-0704-1 

  45. Peytremann-Bridevaux I. Further results from the 2019 Swiss nationwide survey using the SCIROCCO tool (personal communication). Centre for Primary Care and Public Health (Unisanté), University of Lausanne, Switzerland; 2021. 

  46. Schuler D, Tuch A, Buscher N, Camenzind P. La santé psychique en Suisse: monitorage 2016 [Mental health in Switzerland: Monitoring 2016]. Neuchâtel, Switzerland: Swiss Health Observatory (OBSAN); 2016. 

  47. De Pietro C, Camenzind P, Sturny I, Crivelli L, Edwards-Garavoglia S, Spranger A, et al. Health system review: Switzerland. Copenhagen (Denmark): European Observatory on Health Systems and Policies; 2015. 

  48. FSO. Enquête suisse sur la santé 2017 [Swiss Health Survey 2017]. Neuchâtel, Switzerland: Federal statistical office (FSO); 2018. 

  49. Gupta P, Gupta M, Koul N. Overdiagnosis and overtreatment; how to deal with too much medicine. J Family Med Prim Care. 2020; 9: 3815–9. DOI: https://doi.org/10.4103/jfmpc.jfmpc_433_20 

  50. Regard S, Gaspoz J-M, Kherad O. Less is more. Rev Med Suisse. 2013; 9: 770–4. 

  51. Sager F, Ingold K, Balthasar A. Policy-Analyse in der Schweiz: Besonderheiten, Theorien, Beispiele [Policy analysis in Switzerland: particularities, theories, examples]. Zurich (Switzerland): NZZ libro, Neue Zürcher Zeitung AG; 2017. 

  52. Greenhalgh T, Robert G, Macfarlane F, Bate P, Kyriakidou O. Diffusion of innovations in service organizations: systematic review and recommendations. The Milbank Quarterly. 2004; 82: 581–629. DOI: https://doi.org/10.1111/j.0887-378X.2004.00325.x 

  53. WHO (eds). Monitoring the building blocks of health systems: a handbook of indicators and their measurement strategies. Geneva (Switzerland): World Health Organization; 2010. 

  54. Berchtold P, Reich O, Schimmann F, Zanoni U. Modèles de rémunération liée à la performance à l’horizon 2025 [Pay-for-performance models towards 2025]. Neuaegeri (Switzerland): Forum Managed Care; 2017. 

  55. Goodwin N. Change management. In: Amelung V, Stein V, Goodwin N, Balicer R, Nolte E, Suter E, (eds.), Handbook integrated care. 1st edition, Cham (Switzerland): Springer; 2017, p. 253–75. 

  56. Sadler E, Potterton V, Anderson R, Khadjesari Z, Sheehan K, Butt F, et al. Service user, carer and provider perspectives on integrated care for older people with frailty, and factors perceived to facilitate and hinder implementation: A systematic review and narrative synthesis. PLoS One. 2019; 14: e0216488. DOI: https://doi.org/10.1371/journal.pone.0216488 

  57. Karazivan P, Dumez V, Flora L, Pomey M-P, Del Grande C, Ghadiri DP, et al. The Patient-as-Partner approach in health care: a conceptual framework for a necessary transition. Acad Med. 2015; 90: 437–41. DOI: https://doi.org/10.1097/ACM.0000000000000603 

  58. HUG. Projet patient partenaire [Patient-as-Partner project]. Vision 20/20: plan stratégique HUG 2015–2020 [HUG strategic plan 2015–2020]. Geneva (Switzerland): Geneva University Hospitals (HUG); 2015, p. 48. 

  59. IHI. The IHI Triple Aim Initiative. Institute for Healthcare Improvement (IHI) 2021. www.ihi.org (accessed April 1, 2021). 

  60. Epperson WJ, Childs SF, Wilhoit G. Provider Burnout and Patient Engagement: The Quadruple and Quintuple Aims. J Med Pract Manage. 2016; 31: 359–63. 

  61. Bodenheimer T, Sinsky C. From Triple to Quadruple Aim: Care of the Patient Requires Care of the Provider. The Annals of Family Medicine. 2014; 12: 573–6. DOI: https://doi.org/10.1370/afm.1713 

  62. Berwick DM, Nolan TW, Whittington J. The triple aim: care, health, and cost. Health Aff (Millwood). 2008; 27: 759–69. DOI: https://doi.org/10.1377/hlthaff.27.3.759 

  63. FOPH. Rapport explicatif relatif à la modification de la loi fédérale du 18 mars 1994 sur l’assurance-maladie (mesures visant à freiner la hausse des coûts, 2e volet) [Explanatory report on the amendment of the Federal Law of 18 March 1994 on health insurance (measures to curb rising costs, 2nd part)]. Bern, Switzerland: Federal department of home affairs; 2020. 

  64. Costa-Font J, Greer SL, (eds.). Federalism and decentralization in European health and social care. London (UK): Palgrave Macmillan UK; 2013. DOI: https://doi.org/10.1057/9781137291875 

  65. Sumah AM, Baatiema L, Abimbola S. The impacts of decentralisation on health-related equity: A systematic review of the evidence. Health Policy. 2016; 120: 1183–92. DOI: https://doi.org/10.1016/j.healthpol.2016.09.003 

  66. Wikler D. Personal and social responsibility for health. Ethics Int Aff. 2002; 16: 47–55. DOI: https://doi.org/10.1111/j.1747-7093.2002.tb00396.x