1. Key findings and recommendations

A growing proportion of people in OECD and EU27 countries live with complex health needs. Stronger healthcare systems and better socio-economic conditions mean people today live longer: between 1970 and 2019, life expectancy (LE) among OECD and EU27 countries increased by over 11 years (OECD, 2021[1]). Concurrently, people lead increasingly unhealthy lifestyles characterised by poor diets and physical inactivity, and are more likely to suffer from poor mental health. As a result, a growing proportion of the population live with complex health needs and require care from different providers in multiple healthcare settings.

Better care co-ordination is necessary to meet the changing health needs of the population. It is important that patients with complex health needs receive co-ordinated care centred on their individual needs (see Chapter 2 for information on how integrated care promotes patient-centredness). OECD and EU27 countries have responded by implementing a number of patient-centred, integrated care models. These models aim to improve patient experiences and population health, reduce per capita costs of healthcare, create a better work/life balance among health professionals, and advance health equity.

The COVID-19 pandemic highlighted the need to deliver patient-centred, integrated care. COVID-19 led to a rapid surge in the number of acutely ill patients needing treatment. To maintain preventative care services as well as manage care for patients with chronic conditions, countries introduced policies that altered the delivery of care. For example, many OECD and EU27 countries relied on digital tools to deliver patient-centred, integrated care such as teleconsultations, ePrescriptions, and hospital-at-home services (OECD, forthcoming[2]).

Despite efforts to promote integrated care, co-ordination among providers remains fragmented. As outlined within a 2020 OECD report on primary care, international data shows there continues to be “significant problems with the co-ordination of care between primary healthcare teams, specialists, and hospitals” (OECD, 2020[3]; Barrenho et al., 2022[4]).

This report analyses a selection of strategically important integrated care models operating in OECD and EU27 countries using a validated performance assessment framework. Thirteen case studies were selected based on submissions from delegates to the OECD (see Table 1.1). For this reason, the report does not cover all models of integrated care, rather, it focuses on those that are of key strategic interest to policy makers. OECD’s Best Practice Identification Framework, which was co-created with member countries, formed the structure of the assessment (OECD, 2022[5]).

Findings and policy recommendations are grouped according to themes covering the key dimensions of integrated care. These themes are governance, financing (payment models), digital tools and health information systems, and the workforce (Wodchis et al., 2020[6]). In addition, the review covers monitoring and evaluation, health equality, and scaling-up and transferability, all of which are important for spreading best practices (OECD, 2022[5]). Findings and recommendations are based on a review of the 13 selected case studies. Therefore, this report does not comprehensively address all issues related to integrated care in all contexts, but rather offers interesting insights and highlights the value of applying a common assessment methodology.

Findings and recommendations from this report can help make health systems more resilient against future shocks. COVID-19 had a profound impact on health systems across the world. Future shocks are inevitable. Therefore, it is important countries enhance the resilience of their healthcare system by promoting integrated care based on the policies outlined in this report.

Many case studies pursued care integration at a specific level of care, such as primary care, and often for a specific disease. For example, the Finnish City of Oulu implemented a digital patient-provider portal at the primary care level, while programmes such as ParkinsonNet in the Netherlands cater to the needs of patients with Parkinson’s disease. Only a small number of case studies operate across the entire spectrum of healthcare services for whole populations, such as the OptiMedis model in certain regions of Germany and Badalona’s (Spain) integrated care organisation.

The limited number of integrated care models covering entire populations and all healthcare services is in large part due to existing governance structures. Governance systems across and within health and social care sectors are often fragmented making it difficult for providers to work together to deliver patient-centred, integrated care. For example, in some countries, primary care is governed at the national level while inpatient care falls under the responsibility of regions, which hinders vertical care integration. Further, in countries with social health insurance or private compulsory insurance, long-term care isn’t necessarily included in the scope of insurance and is therefore governed and financed separately (Barrenho, Fujisawa and Kendir, 2020[7]).

Traditional payment models can also discourage care integration. Specifically, in most OECD countries, providers are paid for the activities they perform – i.e. using fee-for-service (FFS) or diagnostic-related groups (DRGs). The former pays providers based on the service provided, while the latter pays providers for every patient treated. Both FFS and DRGs contribute to care fragmentation and excessive health expenditure (Lorenzoni and Milstein, 2022[8]). For example, in Badalona, Spain, despite integrating health and social care into one organisation, different types of care are financed separately – e.g. primary care is financed based on the population covered, which is adjusted for several factors such as age, while hospitals are paid for each service provided. The variability of financing methods “hinders the management of services, which are thought from an integrated perspective but financed from different budgets” (Vallve et al., 2016[9]) (see Chapter 7). Changes in financial payment models can have a significant impact on the way care is delivered, but ultimately are only a means, not an end, for integrating care.

Stronger governance systems that facilitate care integration across and within health and social care sectors are necessary for deploying population-wide integrated care models covering all services. How countries achieve this is complex and context-specific. For this reason, this high-level report on integrated care does not seek to map out the multiple paths to achieve strong governance systems that support care integration. Instead, it acknowledges the importance of strengthening governance structures by breaking down silos across administrative systems in health and social care with the support of key stakeholders.

Among selected case studies, an integrated care model in the Basque Country, Spain, highlights how countries can strengthen governance structures to promote better care for multimorbid patients. At a high level, the region introduced integrated health organisations to replace independently run hospitals, primary and outpatient care centres (see Chapter 6). Similar changes were introduced in 2000 in the Spanish municipality of Badalona (see Chapter 7). See Box 1.1 for further details.

Payment models play a key role in incentivising providers to deliver high-quality, integrated care that is affordable. Three payment models of particular interest are 1) add-on payments; 2) episode-based (bundled) payments; and 3) comprehensive capitation payments.

Countries can consider these innovative payment models to promote integrated care delivery. However, it is noted that real-world evidence supporting these models of payment is mixed, ranging from no changes to standard delivery of care, or higher expenditures without quality improvements, to improved quality and lower health expenditures.

  • Add-on payments: Add-on payments refer to additional payments made on top of existing payment models to incentivise desired behaviours, including integrated care. Among OECD countries, 12 use this payment model to incentivise prevention or co-ordination: Australia, Austria, Canada, Denmark, France, Germany, Iceland, Israel, Italy, Mexico, Norway,1 and Sweden (OECD, 2018[14]). Add-on payments to incentivise integrated care may be referred to as pay-for-co-ordination (P4C). For example, an additional payment to primary care providers for undertaking a comprehensive review of a patient’s case involving notes from several providers, or a payment to employ a case manager (Struckmann et al., 2016[15]). Add-on payments typically target individual providers, usually physicians, and do not change the base structure of existing payment models. Therefore, add-on payments can be introduced more easily than bundled or comprehensive capitation payment models.

  • Episode-based (bundled) payments: Episode-based payment models bundle the activities of different providers, such as a hospital and an outpatient physician, along one care pathway (Lorenzoni and Milstein, 2022[8]; Lindner and Lorenzoni, forthcoming[16]). Providers then receive one comprehensive payment per patient for the clinical care pathway. Several OECD member countries have introduced episode-based payments for chronic conditions (e.g. the Netherlands and the United States) or for surgical interventions (e.g. France and Norway). For the former, providers receive a budget covering all condition-related services within a given period, while for the latter, a group of providers receive a joint price per patient treated (Lorenzoni and Milstein, 2022[8]; Lindner and Lorenzoni, forthcoming[16]).

  • Comprehensive capitation payments:2 comprehensive capitation payment models cover the activities of a set of providers that provide care over a given period. Under this model, a network of providers generally receives a yearly or monthly joint payment for every patient covered in a programme (Lorenzoni and Milstein, 2022[8]; Lindner and Lorenzoni, forthcoming[16]). The payment per patient is typically adjusted for age, sex, and health status to account for differences in costs. The payment may also include quality-related adjustments to further incentivise the provision of high-quality care. The OptiMedis model in Chapter 3 utilises a comprehensive capitation payment model with a shared savings contract, as summarised in Box 1.2. Under this model of care, provider networks are incentivised to deliver integrated care given they receive any realised healthcare expenditure savings. Comprehensive capitation payments are typically harder to implement given they require stronger governance arrangements, as well as improvements in data collection, analysis, monitoring, and reporting. Therefore, it is not surprising that only three OECD countries have implemented such payment models (i.e. France, Germany and the United States).

Patients with complex health needs access care from several health professionals. For example, a patient with type 2 diabetes and hypertension may require care from a general practitioner (GP), a dietician, a cardiologist, and a practice nurse. To ensure treatment is co-ordinated and patient-centred, these patients should receive care from a multidisciplinary care team (see Box 1.3). For example, evidence-based clinical guidelines are often disease-specific and do not consider the cumulative impact of different treatments (Hughes, McMurdo and Guthrie, 2012[17]). Therefore, it is important that a team of professionals, along with the patient or carer, develop individualised care plans based on factors such as interactions and the level of burden placed on the patient.

Barriers to implementing patient-centred, multidisciplinary care include, but are not limited to, a culture of professional silos, lack of resources, national or regional legislation that restricts providers from sharing patient information, lack of financial incentives to encourage professionals to work together, and undefined relationships across professionals. Furthermore, professionals often do not have the skills to work as a team given they receive their training and work experience in different settings (e.g. one in four general practitioners work in private solo practices, see Figure 1.1) (OECD, 2020[3]). Difficulties transitioning to multidisciplinary care occurred in Badalona, Spain, which saw “resistance and conflict among professionals”. Specifically, social care workers did not support their portfolio of services being managed by an enterprise from the health sector, while medical staff resisted the introduction of domiciliary services (Vallve et al., 2016[9]) (see Chapter 7 for more details).

Primary healthcare workers are often the first point of contact for people accessing the healthcare system. This includes people with minor ailments to those with complex health needs. Therefore, primary healthcare professionals play a key role in providing co-ordinated, patient-centred care from the earliest possible point in time. Despite growing consensus that a strong primary healthcare sector is essential for an effective, efficient, and equitable healthcare system, countries often prioritise secondary and tertiary care (Hanson et al., 2022[21]).

From selected case studies, there is some evidence that primary care staff are not sufficiently supported. For example, a review of the Basque Country’s integrated care model found primary care professionals felt their workload markedly increased, particularly among nurses who were now responsible for leading weekly education sessions and following-up with patients more regularly (Mateo-Abad et al., 2020[13]). See Chapter 6 for further details.

The workforce requires appropriate skills to deliver patient-centred, integrated care to those with complex health needs. Health systems must therefore invest in training programmes that teach health workers vital “hard” and “soft” skills:

  • Hard skills: New ways of work require health professionals to develop new technical skills. Building digital health literacy among the health workforce is of particular importance given ICT tools play a key role in promoting care integration (e.g. electronic health records and patient provider portals). See the section on “Digital tools and health information systems” for further details.

  • Soft skills (or transversal skills): The transition towards patient-centred, multidisciplinary care represents a major cultural shift for many health professionals. To adjust to this new way of work, health professionals must acquire new soft skills (i.e. non-technical skills). These include shared behavioural counselling, communication, collaboration, and relationship building (Ranjan, 2015[22]). For example, in Badalona, Spain, health professionals highlighted the importance of those providing care in a patient’s home to have specific skills related to “flexibility, teamwork, communication, and empathy” (Vallve et al., 2016[9]).

Introducing training programmes into the formal curriculum can ensure all health professionals obtain the same skills thereby promoting multidisciplinary care. It is possible to supplement formal training (i.e. continuing medical education) with informal training by establishing “learning networks”. Learning networks led by health professionals can help spread good practices, for example, through webinars, conferences, as well as online materials and guidebooks.

Integrated care requires the establishment of new professional roles, in particular case managers (Looman et al., 2021[23]). Case managers are responsible for co-ordinating professionals, the patient and their carer (see Box 1.3). Case managers represent a relatively new professional role; therefore, it is important that:

  • Case managers have a well-defined role: there needs to be clarity on their role and that this is well understood among the multidisciplinary care team, patient, and carer.

  • Case managers have the right skills: an effective case manager has many skills that extend beyond clinical knowledge. These include interpersonal skills, problem-solving skills, and negotiation and brokerage skills.

Among selected case studies, case managers were typically nurses, however, they may also come from other qualified backgrounds such as social and community workers. For example, case management within Badalona’s integrated care organisation in Spain is led by both nurses and social workers (see Chapter 7). Another example comes from Austria, which, as part of its Recovery and Resilience Plan, will implement “Project Community Nursing” to promote the role of community nurses in delivering integrated care (Box 1.4).

In the right context, assigning case manager roles to community or social workers can result in several benefits. These include (Kim et al., 2016[24]; Berini, Bonilha and Simpson, 2021[25]; Kim et al., 2016[26]; OECD, 2020[3]):

  • An improvement in patient satisfaction and health outcomes

  • Reduced pressure on primary care nurses and doctors

  • A reduction in healthcare costs

  • A reduction in health inequalities.

Assigning community workers as case managers is particularly beneficial when treating vulnerable and hard to reach patients such as racial and ethnic minorities, as well as those with a low socio-economic status and/or living in a rural area. For example, a community worker with a close understanding of the population being served can act as a liaison between health, social and community services thereby facilitating access to culturally appropriate care (American Public Health Association, 2022[27]). For the reasons outlined above, health systems should develop their community health workforce and ensure they can take on new roles, including case management.

Case managers are not the only new professional role to emerge from the transition to integrated care. New professional roles identified among selected case studies include:

  • Referent internist who supports decisions made at the primary care level as well as co-ordinating specialists involved in treating the patient in the hospital

  • Hospital liaison nurse who works with a primary care nurse (who is also the case manager) to co-ordinate care when the patient is discharged from the hospital

  • Domiciliary attention physician who provides care to patients either in the hospital or in a home setting.

Digital tools enable integrated care by improving communication and co-ordination across service providers, for example, between hospitals and home- and community-based care as well as transitions between health and social care. Digital tools also enable communication channels between patients and providers, thereby promoting patient-centredness (OECD, 2019[28]).

Digital tools included within selected case studies can be categorised into one of three groups: eHealth, big data and mHealth (Fahy and Williams, 2021[29]). The role each of these technologies plays in promoting integrated care is summarised below, with real-world examples from selected case studies available in Box 1.5:

  • eHealth uses information and communication (ICT) technologies to improve communication processes and ways of recording patient information. Example technologies include electronic health records (EHRs), patient portals and telehealth.

  • Big data collected from sources such as EHRs can be used to stratify the population into different risk categories, which helps deploy population-based integrated care models. Big data also supports population monitoring, research, innovation, and continuous improvement of health system effectiveness.

  • mHealth offers people access to new services using mobile phone devices and apps. These services aim to empower people and encourage healthy lifestyle behaviours, improve communication between patients and providers, and may also provide important diagnostic and treatment information.

OECD populations are increasingly reliant on the internet to access information and services, including in the health sector. For example, between 2007 and 2021 the proportion of adults seeking health information online in the last three months increased by over 150% (i.e. from 25% to 62%) (OECD, 2019[31]). Nation-wide averages on the use of digital health tools, however, mask stark differences across population groups. Specifically, vulnerable populations including the elderly, racial and ethnic minorities, and those with a lower socio-economic status and/or living in a remote area are less likely to: a) be digitally literate and b) have access to the internet as well as smartphone devices. For these reasons, digital tools risk exacerbating existing health inequalities as highlighted by selected case studies:

  • Age inequalities: health professionals involved in the integrated care model operating in the Basque Country, Spain, highlighted that digital tools within the model of care (e.g. Personal Health Folders, which allow patients access to their information) hold great promise, but are limited given older patients lack the necessary technical skills.

  • Geographical inequalities: administrators of TeleHomeCare, as implemented in the Italian city of Ceglie Messapica for multimorbid patients, identified technical difficulties implementing TeleHomeCare in areas where there was poor or no internet network coverage.

Several factors prevent health professionals from supporting digital health technologies. These include:

  • Low levels of digital health literacy with up to 70% of health workers stating they do not feel accustomed to using digital solutions “due to gaps in knowledge and skills in data analytics” (OECD, 2019[28]).

  • Additional burden posed by the digital tool due to insufficient training and/or poor design, which do not consider the needs of end users.

  • Distrust that the digital tool improves service delivery and therefore patient outcomes.

Many case studies selected for this review include digital tools implemented locally, and often for a specific disease. Therefore, the selected case studies only covered a small number of eligible patients, which limited their overall impact. For example:

  • TeleHomeCare for certain chronic conditions in the Italian town of Ceglie Messapica only covered 207 patients (see Chapter 9)

  • Telemonitoring for patients with advanced heart failure has been implemented in just one hospital in the Czech Republic, which covers between 100 and 250 eligible patients (see Chapter 12).

This key finding aligns with previous OECD work on digital health, which states that innovative ways of delivering healthcare and supportive ICT are typically deployed as pilots or research projects, with project-specific funding (OECD, 2019[28]). Further, many digital tools are not scaled to reach a larger population even if they are successful or show promise (OECD, 2019[28]). There are several reasons for this such as issues with reimbursement mechanisms, interoperability and ICT infrastructure, culture of change and adoption of new technologies, and suitability of skills among staff (Oliveira Hashiguchi, 2020[32]).

Digital inclusion activities ensure all individuals and communities, including the most vulnerable, have access to and use ICTs (National Digital Inclusion Alliance, 2022[33]). Specific activities to promote digital inclusion include:

  • Digital literacy training

  • Affordable and reliable broadband internet services

  • Internet-enabled devices that incorporate feedback from end-users, including patients

  • High-quality technical support

  • Applications and online content designed to enable and encourage self-sufficient, participation and collaboration

  • Offering incentives for and improving access to adult learning activities.

Efforts to promote digital inclusion among selected cases studies include Scotland’s Technology Enabled Care (TEC) programme, which, during the COVID-19 pandemic created the “Connecting Scotland” initiative. As part of this initiative, TEC invested GBP 5 million (EUR 5.73 million) to provide internet connection, training and support, and a laptop or tablet to 9 000 people who were considered at clinically high risk. Further, as part of its latest strategic plan, TEC will offer support and funding to ensure care homes have reliable internet connections, devices and other infrastructure needed for digital care. It will also support the development and adoption of a suite of tools that can be used in care homes, such as telecare, video-consultations, messaging, and assessment tools.

This review identified several activities needed to promote the widespread use of digital health technologies among health professionals, namely:

  • Developing formal digital health literacy training by implementing digital health competency frameworks. For example, every university in Finland plans to provide medical students with streamlined digital health education – MEDigi – to ensure all doctors have appropriate digital skills. Curricula related to digital health should be frequently revised to reflect ongoing technological changes.

  • Providing additional training specific to the digital tool. For example, health professionals in the Finnish City of Oulu receive two-hour training sessions on how to use the patient-provider portal, Self Care Service (SCS). Further, as part of TeleHomeCare in the Italian city of Ceglie Messapica, GPs and specialists receive two weeks’ worth of training run by control room operators and telemedicine experts. (See Chapters 5 and 9 for further details).

  • Involving health professionals in the design of digital tools to ensure technologies are integrated into current workflows, are non-burdensome, and are interoperable with patients.

  • Ensuring digital tools align with current practices to ensure they do not create additional work for health professionals.

  • Undertaking robust evaluations of digital health technologies to promote trust (discussed further under the section on “Monitoring and evaluation”). Given evidence is rapidly evolving in this space, there must be a supportive environment for knowledge accumulation and up-to-date evidence (e.g. publication of regular rapid reviews).

This review looked at a small selection of integrated care models, most of which are confined to a specific region within a country and in some cases are just pilots. Therefore, this review did not explore in detail the wider digital health system in which these models operate. Nevertheless, it is recognised that population-wide integrated care requires digitally advanced health systems.

Previous work by the OECD identified three main government actions to digitally transform health systems (OECD, 2019[28]). These are:

  • An overarching digital strategy that is comprehensive and includes a consolidated vision, plan, and policy framework.

  • Strengthening the governance of health data to enable data and digital technologies to be put to productive use while ensuring security and respect for individuals. At present, legal issues, a lack of trust among stakeholders, and non-unified data standards and exchange formats act as barriers to realising the potential of health data to improve outcomes.

  • Building institutional and operational capacity including preparing the workforce to harness opportunities presented by digital technology, as well as empowering the population. In addition, institutional systems must be in place to link, share and analyse patient data.3 This last point is of key importance given data fragmentation, weak data-sharing practices and a lack of interoperability between systems are some of the key barriers to providing integrated care.

Across the 13 selected case studies, less than half collected data on objective health outcomes such as changes in mortality. Selected case studies instead focused on measuring changes in patient experiences and utilisation of healthcare services (see Table 1.2). Further, two of the selected cases studies provided no evidence at all.

The finding above aligns with the broader literature whereby (Baxter et al., 2018[34]):

  • Evidence supporting integrated care is strongest regarding patient satisfaction, perceived quality of care and access to care

  • Objective quality of care outcome measures is limited.

Efficiency refers to how well the mix of monetary and non-monetary inputs were used to achieve desired outcomes in a real-world setting (OECD, 2022[5]). In the health sector, economic evaluations such as cost-benefit or cost-effectiveness analyses are frequently used to measure efficiency.

Among selected case studies, none included results from an economic evaluation. Instead, many case studies relied on estimates measuring changes in health expenditure to prove efficiency (see Table 1.3). These estimates fail to show the whole picture given cost savings should be measured in relation to changes in outcomes. For example, an integrated care model may increase expenditure but still be efficient if changes in health outcomes are large.

The lack of robust data measuring the efficiency of selected case studies aligns with the broader literature. For example, a 2020 systematic review and meta-analysis of integrated care models concluded there is a paucity of studies measuring cost-effectiveness and studies are not of high quality (Rocks et al., 2020[35]). Further, the 2021 Handbook on Integrated Care noted that the “substantial resources” necessary for collecting high-quality data pose a significant barrier to undertaking cost-effectiveness analyses (Tsiachristas and Rutten-van Mölken, 2021[36]).

To understand the true impact of integrated care models, it is important to develop and measure indicators specific to the model of care under evaluation. Drawing upon the Donabedian approach to evaluating care quality, indicators should cover structures, processes and outcomes (Donabedian, 1988[37]; Report by the Expert Group on Health Systems Performance Assessment, 2017[38]):

  • Structures to assess the system levers necessary to transition to an integrated care system (e.g. use of digital tools for integration of care among primary care physicians, and share of primary care offices using electronic health records (OECD, 2021[39]))

  • Processes such as care transitions between and within sectors and task shifting across health professionals

  • Outcomes by population groups and/or disease areas, self-reported outcomes, as well as utilisation indicators that act as a proxy for health outcomes. See Box 1.6 for further examples.

“Good structure increases the likelihood of good process, and good process increases the likelihood of good outcomes.” (Donabedian, 1988[37])

The SMART framework provides useful information on how to select high-quality integrated care indicators. Criteria within the framework cover relevance, accessibility, reliability, validity, and timeframe, as described in Box 1.6 (OECD, 2022[5]).

Data measuring changes in outcome indicators should be collected over a period that allows researchers to understand the long-term impact of integrated care models. For example, by setting up continuous monitoring systems that track set indicators over time (i.e. data collection is not part of a once-off study, but forms part of routine practices) (Tsiachristas and Rutten-van Mölken, 2021[36]). This is important given improvements in chronic disease take time to eventuate.

As discussed under “Digital tools and health information systems”, the collection of robust data over time requires countries to have health information systems that support data linkage and sharing of patient information.

Studies measuring the impact of selected integrated care models used a range of indicators. Therefore, it is difficult to assess the relative impact of different integrated care models implemented across OECD and EU27 countries. To understand which integrated models work best and therefore which to scale-up and transfer, countries should prioritise the collection of internationally comparable data (Report by the Expert Group on Health Systems Performance Assessment, 2017[38]).

As part of its work on integrated care, the OECD have outlined 13 promising internationally-comparable outcome indicators to be routinely collected with a focus on ischaemic stroke and congestive heart failure (CHF) (Barrenho et al., 2022[4]). Indicators relate to either hospital readmissions, mortality, or prescription of appropriate medication for secondary care prevention after hospital discharge. These are calculated for people admitted to the hospital with an acute non-elective (urgent) episode of care for a first-time event of ischaemic stroke or CHF. Data for these indicators submitted by countries used at least seven years of patient-linked datasets from hospitals (inpatient care), emergency care, death registries, and pharmaceutical and prescribing data. (See Chapter 6 of the latest OECD Health at a Glance report for initial findings across 11 OECD countries (OECD, 2021[1])).

The use of several data points from different datasets to measure the impact of integrated care highlights the importance of having governance structures that support data linkage and sharing of patient information (see “Digital tools and health information systems” for further details).

Evidence supporting the economic value of integrated care models is of key importance given tight budgetary constraints in government. Types of economic evaluations, such as cost-utility and cost-effectiveness analyses, are in Box 1.7 with details on factors to consider when developing an economic evaluation study below (Tsiachristas and Rutten-van Mölken, 2021[36]):

  • The integrated care model under evaluation must be clearly and thoroughly defined. The definition should include information on the setting, target population, intervention components, and duration of the intervention, for example.

  • Comparator(s) to the integrated care model should be defined – for example, usual care practices and/or alternative models of care.

  • An appropriate study design should be confirmed at the outset before the model of care is introduced to establish baseline data. Example study designs include observational studies and randomised controlled trials (see OECD’s Guidebook on Best Practices in Public Health for information on the types of study designs available) (OECD, 2022[5]).

  • Define an evaluation period that is suitable for the benefits of the integrated care model to be realised and ensure baseline data is collected before the model is implemented.

  • Define appropriate outcome measures, such as those outlined in Box 1.6, which include routinely collected indicators by the OECD as well as new integrated care indicators recently piloted by the OECD (Barrenho et al., 2022[4]).

  • Define how to measure and value costs such as labour, capital, consumables, administrative and overhead costs, as well as societal costs more broadly. For example, evaluations of telehealth should consider their impact on patient travel and waiting times, both of which result in lost productivity. As an example, research undertaken in Canada found the Canadian Ontario Telemedicine Network reduced patient travel distance by 270 million km in one year, leading to costs savings from a reduction in travel grants by CAD 71.9 million (EUR 50.2 million) (OTN, 2018[40]).

Vulnerable populations include, but are not limited to, people with a low socio-economic status (SES), older populations, racial and ethnic minorities, and those living in rural and remote areas (OECD, 2022[5]). People in these groups are at greater risk of living with complex health needs for several reasons including lower levels of health literacy thereby making it difficult to navigate the health system, as well as reduced access to healthcare services. For example, across EU27 countries, 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%) (Eurostat, 2022[41]).

People with complex health needs often require multiple treatments and interact with several providers. For these reasons, vulnerable populations are at greater risk of “poor quality care, poor health outcomes, and poor experiences of care as a result of fragmentation” (Barrenho et al., 2022[4]).

The importance of designing integrated care models to reduce health inequalities is well recognised. Despite this, only three of the 13 selected case studies have activities in place to address the specific needs of vulnerable populations:

  • Incorporating new languages into existing services: the Finnish city of Oulu’s patient-provider portal is in the process of adding Arabic, Dari, and Somali languages to its service. Refugees in Finland typically speak these languages. Similarly, the OptiMedis Health Kiosk offers counselling services in Arabic, Farsi, Russian and Polish.

  • Offering user friendly interfaces: the patient-provider portal in Oulu has also adapted its video platform to include an easy-to-use function for patients with a disability.

  • Providing technological support: Scotland’s Technology-Enabled Care (TEC) intervention offers support and funding to ensure older people in care homes have reliable internet connections, devices and other infrastructure needed for digital care.

The remaining case studies may indirectly reduce health inequalities by targeting patients with complex health needs, which, as previously mentioned, are more likely to be vulnerable. However, this assumption is dependent on patients from vulnerable groups having equal access to healthcare in the first place, which is not always supported by real-world evidence among OECD countries. For example, poorer populations are less likely to access preventative care, such as screening, as well as primary care via a visit to their general practitioner (OECD, 2019[42]).

As outlined under “Monitoring and evaluation”, studies measuring the impact of integrated care models focus on patient experience and utilisation of healthcare services. Just one case study, the integrated care model for multimorbidity in the Basque Country, Spain, produced evaluation results disaggregated by different population groups. Specifically, an evaluation by Sorto-Gordoa et al. (2019[43]) found that the most deprived economic group had a higher probability of accessing primary care and a lower probability of utilising hospital services among all participants.

Given the limited amount of data among selected case studies, it is not possible to determine if integrated care models narrow or widen existing health inequalities.

When studying the impact of healthcare interventions, such as integrated care models, it is important to look at their impact on inequalities. Future research should therefore prioritise collecting patient information on variables relevant to assessing inequalities. These variables include (O’Neill et al., 2014[44]):

  • Gender

  • Age

  • Race and ethnicity

  • Education

  • Income

  • Geographical location.

Further details on stratifying data and undertaking rigorous evaluations are available in OECD’s Guidebook on Best Practices in Public Health (OECD, 2022[5]).

Evaluations that stratify findings according to key sociodemographic variables provide important information on how integrated care models affect population groups differently. For example, differences in access to and outcomes from integrated care. This information can subsequently be used to adapt specific integrated care models as well as larger policy plans for integrated care to ensure the needs of vulnerable populations are met.

Health literacy (HL) refers to an individual’s knowledge, motivation, and skills to access, understand, evaluate, and apply health information. As outlined above, HL is lower among vulnerable populations. For example, a nationwide study of HL in Denmark found immigrants and individuals with basic education and below-average income had lower levels of HL (Svendsen et al., 2020[45]). Activities to promote HL among vulnerable populations have the potential to improve overall population health and narrow existing health inequalities.

Four of the 13 selected case studies have been transferred from their original “owner” country to another “target” country (see Table 1.4). For example, the mHealth app, Mobile Airways Sentinel Network (MASK), operates in 28 countries, most of which are OECD member countries. Further, the United States (California), Luxembourg, the Czech Republic and Norway adopted the nationwide Dutch programme, ParkinsonNet. Most case studies, however, operate within a specific region in a country, either permanently or as a pilot programme. The City of Oulu in Finland, for example, scaled-up the Self Care Service patient portal from a pilot to the whole city in 2011. (See Chapter 5 for further details).

Although most selected case studies were not widely scaled-up or transferred, they are, in most cases, based on a well-known model of care. For example:

  • The City of Oulu’s patient portal: patient portals are increasingly common in OECD and EU27 countries; based on a 2016 EHR survey, 12 (out of 15) OECD countries reported they have or are in the process of implementing a patient portal (OECD, 2019[28]).

  • The Basque Country’s integrated care model of multimorbidity and Poland’s Medical Diagnostic Centres (MDC): 17 OECD member countries have developed “new models of primary care” that promote care integration. Like the Basque Country’s integrated care model and Poland’s MDC, these new models of care offer (OECD, 2020[3]):

    • Multidisciplinary practices or inter-professional practices

    • Comprehensive health services in the community

    • Population health management (generally based on risk stratification using sophisticated IT systems, although not in the case of MDC)

    • Engage patients in shared decision-making.

  • Personalised Actions Plans in Andalusia, Spain: personalised care plans have been widely used across developed countries for many years including in Australia, England (United Kingdom) and even different regions of Spain (OECD, 2020[3]).

  • Hospital-at-Home, Catalonia, Spain: healthcare systems increasingly provide post-discharge care at home as an alternative to hospital-based care. Example countries include Australia, Canada, Germany, Israel, and the United Kingdom.

  • Telemonitoring for Advanced Heart Failure (HF), Olomouc, the Czech Republic: Sweden, Spain and Japan have national-level telemonitoring programmes for HF patients, while pilot interventions operate in countries such as Austria, Denmark, Portugal and the United Kingdom.

  • TeleHomeCare, Ceglie Messapica, Italy: similar telemonitoring programmes are in place in many countries either at the local, regional or national level, for instance, the Ontario Telemedicine Network in Canada (Oliveira Hashiguchi, 2020[32]).

Several of the selected case studies have or currently participate in international programmes dedicated to transferring best practice integrated care models. These programmes include the Joint Action on implementation of digitally enabled integrated person-centred care (JADECARE), SCIROCCO (Scaling Integrated Care in Context) Exchange project, Digital Health Europe Twinning Project, and the European Innovation Partnership on Active and Health Ageing (EIP-AHA) Twinning Project. Box 1.8 outlines how selected case studies were involved in these programmes.

The design, implementation and delivery of integrated care models involve multiple stakeholders across different levels of health and social care systems. Transferring such models of care within and across countries is therefore complex.

Several publicly available frameworks to begin the process of scaling-up or transferring an integrated care model are available. These frameworks assist stakeholders to compile information to assess whether the model of care can be transferred and, if so, what steps need to be taken to adapt the model to the local setting. Box 1.9 describes a selection of frameworks identified as part of this review.

A review of health promotion intervention transfers as part of the EU’s Joint Action on Chronic Diseases found building a “strong relationship between the good practice owner and implementer” was a key transfer facilitator (Stegeman et al., 2020[48]). This finding aligns with feedback from owners of selected cases studies who highlighted the importance of sharing “lessons learnt” and “core features” of their best practice model. Examples of how to facilitate the transfer of selected case studies are below, several of which highlight the importance of local authorities in spreading best practice models of care:

  • The transfer of ParkinsonNet from the Netherlands to the German region of Niederrhein identified several valuable lessons from the failure of the intervention to “take off”. Specifically, the need for a “champion” with expertise in Parkinson’s disease to promote the programme, a “super trouper” who receives ongoing training and educates other trainers, and lastly a “business case” to capitalise on healthcare savings made by the programme.

  • Administrators of the Personalised Action Plans (PAPs) in Andalusia, Spain, shared key factors to consider before transferring PAPs. These factors include having a team of experts to develop training materials on how to treat patients with complex needs, ensuring there is sufficient training for health professionals and patients, linking PAPs with patient EHRs, and ensuring health professionals have the time and resources to develop PAPs.

  • Administrators of the Hospital-at-Home programme in Catalonia, Spain, identified three key factors necessary for the successful transfer of the programme: strong and supportive leadership at the hospital level, a culture of integrated care, and reimbursement arrangements that incentivise care delivered in a home setting.

  • Administrators of the integrated care organisation in the Spanish municipality of Badalona outlined several transfer facilitators regarding integrated care models that bring together health and social care. These facilitators cover policy, governance, workforce and culture, and digital tools (see Box 1.10).

International transfer projects, such as those outlined in Box 1.9, help build ties between implementers and adopters, and therefore create an international learning network. (See Chapters 3 to 15 for further details on each case study mentioned above).


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← 1. Norway has introduced several add-on payments to incentivise integrated care. For example, an add-on tariff to the existing DRG-based activity financing system that is dedicated to specialised treatment provided outside the hospital/patient clinic (e.g. at a patient’s home or long-term care facility). Specialised treatment here refers to mental health and drug abuse treatment (introduced in 2017) and somatic care (introduced in 2018). Other examples of add-on payments in Norway include a DRG for collaborative activities between hospital and other institutions (e.g. social services and schools) and a results-based financing scheme targeting specialised healthcare services.

← 2. These payment models are also referred to as “population-based payment models”.

← 3. The level of government most appropriate to facilitate data linkages is context specific and will therefore differ across countries.

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