2. Complex health needs and the transition to integrated care models

Life expectancy has been steadily increasing across OECD countries. Between 1970 and 2019, life expectancy at birth increased by over 11 years among OECD countries, that is, from 69.7 to 81.0 (Figure 2.1) (OECD, 2021[1]). Gains in life expectancy reflect stronger healthcare systems, rising incomes, better education and improved living environments. The onset of the COVID-19 pandemic, however, saw life expectancy fall in many countries, including those in the OECD (OECD, 2021[1]).

Increasing life expectancy means people are living longer with health problems. As people age, they are at greater risk of disease, disability, and dementia. Therefore, people today are more likely to die “slowly from degenerative diseases preceded by years of multiple morbidity and advanced ageing” (Brown, 2014[2]). For example, across OECD countries, nearly two in three people aged 65 years and over live with one or more chronic conditions (OECD, 2019[3]).

Poor lifestyle behaviours contribute to an increasing burden of disease. Diets among OECD and EU27 countries are increasingly comprised of foods associated with weight gain (e.g. added fats and sugar) at the expense of foods with healthy dietary elements (e.g. fruits and vegetables). Concurrently, people today have fewer reasons to be physically active, for example, with the rise of labour-saving technologies. Combined, these two risk factors have fuelled high rates of obesity:1 as of 2019, over half of all men and women in OECD and EU countries live with overweight, which includes obesity, with rates higher for men than women (Figure 2.2). Overweight has contributed to poor population health given it increases the risk of developing several NCDs including type 2 diabetes, several cancers, stroke, and asthma (Nyberg et al., 2018[4]). Other risky lifestyle behaviours include alcohol and tobacco consumption.

Rising rates of poor mental health also add to the burden of disease. The COVID-19 pandemic had a devastating impact on people’s mental health due to factors such as financial insecurity, social isolation, and grief. Data collected from several OECD countries estimate that around 12% of people experienced anxiety or symptoms of anxiety before the pandemic compared to 25% in 2020. Countries also saw rates of depression rise by nearly 15 percentage points over the same period (OECD, 2021[1]). Despite the significant health and economic impact of mental ill-health, mental health support is not sufficiently integrated into social welfare, labour, and youth policies.

People from certain vulnerable groups are more likely to engage in unhealthy lifestyle behaviours and suffer from mental ill-health. There are various reasons why people from vulnerable groups2 engage in riskier lifestyle behaviours that contribute to poor health. These include, but are not limited to, restricted access to healthy foods due to high prices or physical proximity to stores that stock such foods (i.e. “food deserts”), as well as lower levels of health literacy. Therefore, it is not surprising that risk factors such as obesity, tobacco consumption, and physical inactivity are more prevalent among vulnerable populations. For example, a recent analysis by OECD and WHO-Europe found a third of people who consider belonging to the “upper class” report never doing sport or exercise compared to around two-thirds of “working class” people (63%) (Figure 2.3). Those from vulnerable groups are also more likely to suffer from mental ill-health including indigenous populations, LQBQTI+ communities, certain ethnic groups including ethnic minorities, older adults, and refugees (OECD, 2021[5]).

Riskier lifestyle behaviours mean vulnerable populations are more likely to live with one or more chronic health conditions. For the reasons outlined above, vulnerable populations are more likely to live with one or more chronic conditions. For example, a recent study by Mair and Jani (2020[7]) found that, after adjusting for lifestyle factors, those with low socio-economic status are at an increased risk of developing 18 of the 56 major diseases and health conditions compared to advantaged groups. This is reflected by data from EU27 countries showing that the proportion of people who report living with a long-standing illness or health problem is 15 percentage points higher among those living in the poorest income quintile compared to those in the richest quintile (43% versus 28%) (Figure 2.4).

Despite having greater healthcare needs, vulnerable populations are less likely to access healthcare services. For example, certain vulnerable populations are less likely to utilise preventative care services such as cancer screening as well as digital tools due to low levels of digital health literacy and issues accessing the internet. Furthermore, vulnerable populations may experience barriers to accessing care due to financial reasons, waiting times as well as difficulties navigating the healthcare system (see Box 2.1 for further details) (OECD, 2019[9]).

Uncoordinated care is particularly problematic for patients with complex health needs. People with complex health needs require care from different providers across multiple healthcare settings, as well as informal care. For example, a patient with type 2 diabetes and hypertension may require care from a general practitioner (GP), an endocrinologist, a dietician, a cardiologist, and a practice nurse. Without proper care integration, such patients may try to address their unmet needs by using “excessive health and social services in an uncoordinated way” (Hudon et al., 2018[11]). Not only does this worsen a patient’s experience, but it is also costly and sometimes dangerous. For example, a study in the United States by Frandsen et al (2015[12]). found that high levels of care fragmentation were associated with an increase in expenditure equivalent to USD 4 542 (EUR 4 180) per patient between the years 2004-08. Further, patients who experienced high levels of care fragmentation were less likely to receive care considered clinical best practice and had higher rates of preventable hospitalisations (Frandsen et al., 2015[12]).

“Uncoordinated care is a particular problem for people with chronic conditions that require care and support, many of whom have multiple conditions associated with complex social needs.” (OECD, 2020[13])

“Persons with multi-morbidity often require care from multiple professionals within the healthcare and social care sectors. In a fragmented care system, this creates conflicting, overly-demanding, treatment advice that may discourage compliance.” (Leijten et al., 2018[14])

To improve quality and efficiency, countries are seeking to deliver integrated care to patients with complex health conditions. Patients with complex health needs incur higher costs; in the United States, 71% of healthcare spending comes from patients with at least two chronic conditions, despite comprising just over a quarter of the total population (Chapel et al., 2017[15]; Boersma, Black and Ward, 2020[16]). At the individual level, the cost of multimorbidity varies widely depending on factors such as disease combination as well as the country. In a recent meta-analysis, Tran et al. (2022[17]) estimated the annual, per person cost of multimorbidity between USD 800 and USD 150 000 (using international dollars). These figures are likely conservative given costing studies typically exclude societal costs such as a reduction in work productivity3 for the patient and their carer(s). Higher costs and worse health outcomes and experiences have prompted policy makers to find better ways of delivering care to patients with complex health needs. Specifically, by delivering integrated, patient-centred care.

The remainder of this chapter defines what constitutes integrated care and its objectives, prominent taxonomies used to classify different integrated care models, and the link between integrated care and patient-centredness.

Integrated care represents a significant change in the way healthcare services are designed and delivered. For this reason, the term has no agreed interpretation (Goodwin, Stein and Amelung, 2021[18]). Commonly applied definitions in OECD and EU27 countries are listed in Table 2.1.

At a high-level, integrated care models aim to achieve the following five objectives (“Quintuple aim”) (Nundy, Cooper and Mate, 2022[23]):

  • Improve patient experiences of care (including quality and satisfaction)

  • Improve population health

  • Reduce the per capita cost of healthcare

  • Improve the work-life balance of healthcare providers

  • Advance health equity.

Integrated care models come in many forms. This section summarises key taxonomies of integrated care. These include taxonomies developed by the World Health Organization (WHO), the EU and the King’s Fund (United Kingdom).

As part of the 2016 working document, the WHO developed a taxonomy of integrated care comprised of four types of integration: organisational, functional, service, and clinical (Table 2.2). The taxonomy was adapted from Lewis et al. (2010[21]). One integrated care model may include several types of integration.

The WHO taxonomy aligns closely with the four types of integration outlined by Nolte and Pitchforth (Nolte and Pitchforth, 2014[24]).

The EU-funded Horizon 2020 project, SELFIE, developed a conceptual framework for integrated care specific to multimorbidity.4 The different types of integrated care models (or integrated care concepts) are grouped into one of six components: service delivery, leadership and governance, workforce, financing, technologies and medical products, and information and research. The models in each of these components are further categorised as to whether the model exists at the micro-, meso- or macro-level. A few examples are listed below:

  • Multidisciplinary care teams are a micro-level workforce integrated care model

  • Developing a culture of share vision, ambition and values is a meso-level leadership and governance integrated care model

  • Policies to integrate care across organisations and sectors is a macro-level service delivery integrated care model.

As part of the EU-funded “Project Integrate”, Calciolari et al. (2016[25]) developed a conceptual framework outlining the key dimensions and associated items related to integrated care (Table 2.3). Several of these dimensions overlap with the framework developed by the WHO (e.g. functional integration).

Other classifications of integrated care include:

  • Horizontal versus vertical integration: horizontal integration refers to co-ordination that occurs at the same stage of care delivery (e.g. mergers across hospitals). Conversely, vertical integration refers to when two or more organisations or services delivering care at different levels come together. These types of integration are not mutually exclusive, with many programs addressing both vertical and horizontal integration.

  • Levels of integration: Curry and Ham (2010[26]) distinguish between different levels of integration:

    • Macro-level: where providers seek to deliver integrated care to the populations they cover

    • Meso-level: where providers seek to deliver integrated care for a particular population (e.g. disease management programs)

    • Micro-level: providers seek to deliver integrated care to individual patients and their carers through care co-ordination, planning and use of technology, for example.

Given the importance of incorporating peoples’ voices into the development of health systems, countries are increasingly interested in delivering patient-centred care (OECD, 2021[1]). Specifically, care that is “respectful of, and responsive to, individual patient preferences, needs and values, and ensures values guide all clinical decisions” (Goodwin, Stein and Amelung, 2021[18]).5

An important dimension of patient-centred care is care integration (see Box 2.2) (OECD, 2020[13]). Specifically, patient-centred care requires a “good flow of information and consistency of decisions across different levels of care in the health system, including primary healthcare settings, specialist settings and hospitals” (OECD, 2020[13]). Failing to co-ordinate care leads to patients repeating information and diagnostic tests, receiving conflicting information, and experiencing a breakdown of care when transitioning between providers, all of which worsen patient experiences and outcomes. Among selected case studies, there are several examples of how integrated care models promote patient-centredness. For example, in Finland, the City of Oulu’s patient-provider portal promotes information sharing between patients, and primary and social care professionals (see Chapter 5). Further, the integrated care model for multimorbidity in the Basque Country, Spain, utilises unified electronic health records (EHRs), which are accessible to all health professionals, as well as a “Personal Health Folder” that gives patients access to their data (see Chapter 6).

To address the social determinants of health, integration is needed across the health, social and long-term care settings, as well as in the home and community. For example, equitable access to housing, education, and nutritious foods, among others. Further, any effort to promote integration must consider the role of informal carers given they are responsible for a significant amount of care for older persons and persons with disabilities.

The COVID-19 pandemic highlighted the need to deliver patient-centred, integrated care. COVID-19 saw a rapid surge in demand for treating acutely ill patients. To maintain preventive care services as well as manage care for patients with chronic conditions, countries introduced several policies that altered the delivery of healthcare. For example, many OECD and EU27 countries implemented policies that promote the use of digital tools to promote patient-centred, integrated care such as telemedicine, ePrescriptions, and hospital-at-home services.

Selected case studies for this review provide real-world examples of digital integrated care models used during the pandemic. Example case studies include the Finnish City of Oulu’s patient-provider portal, the Hospital-at-Home Programme in Catalonia, Spain, TeleHomeCare for patients with chronic conditions in the Italian city of Ceglie Messapica, and Telemonitoring for patients with advanced heart failure in Oloumuc, the Czech Republic. These case studies require countries to have advanced digital health systems, a workforce with the necessary skills to deliver digital care, as well as a population with access to digital tools and broadband internet access (for further details see Chapter 1: “Digital tools and health information systems”).

Policies, such as those outlined above, play a key role in making health systems more resilient against future shocks.

Countries have implemented national policies to promote integrated care. These include policies related to the key dimensions of integrated care, namely financing, the workforce, and digital tools and health information systems. A summary of the policy landscape across OECD countries is in Table 2.4. Please note, the analysis only includes indicators where there is data for a significant number of OECD countries.

Despite efforts to promote integration, care models continue to be disease-focused and tailored to younger, healthier populations. Offering integrated, patient-centred care is a key policy priority among OECD and EU27 countries. As a result, several, mainly local level, integrated care models have emerged. Many of these models have shown great promise. Nevertheless, predominant models of care remain disease-focused and for this reason, disproportionately benefit younger patients to restore them to full health. See Box 2.3 for data summarising the level of care co-ordination among OECD and EU27 countries.

Fragmented healthcare continues for several reasons. These include organisational and financial structures that do not support integrated care, and underutilisation of digital tools (OECD, 2021[27]; OECD, 2017[30]). For example, population-based payment models that pay a set of providers a lump payment (e.g. every month or year) to serve patients in the population-based network have been shown to incentivise care co-ordination as well as disease prevention activities (see “Governance and Financing” under Chapter 1 for further details and Chapter 3 for a real-world example) (OECD, 2020[13]). Despite this, only three OECD countries have population-based payment models in place (i.e. France, Germany and the United States). Regarding digital tools, data on the use of computers in primary care for tasks related to care integration as well as the share of primary care physician offices using EHRs indicate there is room for improvement (Box 2.4).

Integration is also a problem between the health and social care system. Previous work by OECD in areas such as dementia, cancer, and cardiovascular diseases (CVDs) has highlighted the need to address care fragmentation between health and social care systems (Barrenho et al., 2022[31]). Data from the Commonwealth Fund’s survey of primary care physician supports the need to improve co-ordination between health and social care systems (The Commonwealth Fund, 2019[29]):

  • Less than half (45%) of primary care physicians report frequently co-ordinating with social services or community providers, with the figure as low as 12% in Sweden

  • On average, less than a third (30%) of primary care physicians noted a lack of a referral system or mechanism to make referrals to social care services

  • Around 40% of primary care physicians noted a lack of follow-up from social service organisations about the services patients received or needed.


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← 1. For adults, WHO define overweight and obesity as having a BMI >=25Kg/m2 and 30Kg/m2, respectively. BMI is the most widely used proxy for body adiposity to assess population-level rates of overweight, as it is easily derived from a person’s weight and height (i.e. weight (kg) divided by height in metres squared).

← 2. There is no single definition of what constitutes being in a vulnerable group, however, in general it includes the following: lower incomes, lower education levels, living in rural/remote areas, or part of an ethnic minority group (OECD, 2022[32]).

← 3. Loss of productivity is caused by absenteeism, presenteeism, disability and premature mortality.

← 4. A diagrammatic overview of the framework is available using this reference (Leijten et al., 2018[14]).

← 5. Similar to the concept of “integrated care”, there is no single definition of “patient-centred care”. Several other definitions exist, including those outlined (Goodwin, Stein and Amelung, 2021[18]).

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