HOW TO DELIVERINTEGRATED CARE

European HealthManagement in Transition

Series Editors:

Federico Lega, Full Professor of Health Management andPolicy, Director of the Research and Executive EducationCenter in Health Administration, University of Milan

Usman Khan, Visiting Professor, KU Leuven

Healthcare is currently undergoing an unprecedented periodof change, which is presenting a challenge to the fundamentaltenants of health management and policy established over thelast decades. The differentiated nature of the change agendaand the pace of change has been such that there has beenlimited space or time to provide a structured or comprehensiveresponse, or to consider at a strategic level how health man-agement teaching and practice should evolve and develop.This then is the focus for the European Health Management inTransition series, published in alliance with the EuropeanHealth Management Association (EHMA).

Books in the series investigate how changes to the health andsocial care environment are leading to innovative and differentpractices in health management, health services deliverydesign, roles and professions, architecture and governance ofhealth systems, patient engagement and all other paradigmaticshifts taking place in the health context.

The books provide a roadmap for managers, educatorsresearchers and policy makers to better understand this rapidlydeveloping environment.

Books in the series:

Axel Kaehne and Henk Nies (eds): How to Deliver IntegratedCare: A Guidebook for Managers

Federico Lega and Usman Khan: Health Management 2.0:Meeting the Challenge of 21st Century Health

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HOW TO DELIVERINTEGRATED CARE: A

GUIDEBOOK FORMANAGERS

EDITED BY

AXEL KAEHNEEdge Hill University, UK

HENK NIESVilans, Centre of Expertise for Long-term Care;

Vrije Universiteit, The Netherlands

United Kingdom – North America – Japan – IndiaMalaysia – China

Emerald Publishing LimitedHoward House, Wagon Lane, Bingley BD16 1WA, UK

First edition 2021

Editorial matter and selection Copyright © 2021 Axel Kaehne and HenkNies. Individual chapters © their respective authors.Published under exclusive licence by Emerald Publishing Limited.

Reprints and permissions serviceContact: permissions@emeraldinsight.com

No part of this book may be reproduced, stored in a retrieval system,transmitted in any form or by any means electronic, mechanical,photocopying, recording or otherwise without either the prior writtenpermission of the publisher or a licence permitting restricted copyingissued in the UK by The Copyright Licensing Agency and in the USA byThe Copyright Clearance Center. Any opinions expressed in the chaptersare those of the authors. Whilst Emerald makes every effort to ensure thequality and accuracy of its content, Emerald makes no representationimplied or otherwise, as to the chapters’ suitability and application anddisclaims any warranties, express or implied, to their use.

British Library Cataloguing in Publication DataA catalogue record for this book is available from the British Library

ISBN: 978-1-83867-530-1 (Print)ISBN: 978-1-83867-527-1 (Online)ISBN: 978-1-83867-529-5 (Epub)

TABLE OF CONTENTS

List of Tables and Figures ix

List of Contributors xi

About the Contributors xiii

Foreword xix

1. Integrated Care – An Introduction 1Axel Kaehne and Henk Nies

2. Financing Care Integration: A ConceptualFramework of Payment Models That SupportIntegrated Care 15Eric van der Hijden and Jeroen van der Wolk

3. Leadership in Integrated Care 39Helen Dickinson and Catherine Smith

4. Engaging Patients for Integrating Care 59Rachael Smithson, Christina Wicker and KimberleyPierce

5. Social Dimensions of Care Integration 75Karin Kee, Henk Nies, Marieke van Wieringenand Bianca Beersma

6. Values in Integrated Care 95Nick Zonneveld, Henk Nies, Elize van Wijk andMirella Minkman

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7. Digital Health Enabling Integrated Care 115Carolyn Steele Gray, Dominique Gagnon,Nick Guldemond and Timothy Kenealy

8. Implementing Integrated Care 137Axel Kaehne

9. Evaluating Integrated Care 161Walter Wodchis, Carolyn Steele Gray, Jay Shaw,Kerry Kuluski, Gayathri Embuldeniya, G. RossBaker and Maritt Kirst

Index 183

vi i i Table of Contents

L IST OF TABLES AND FIGURES

Table 2.1. Overview of Payment Models by Type ofIntegrator. 21

Table 3.1. IC Leadership Competencies. 44

Table 3.2. Desirable Personal Characteristics of ICLeaders. 46

Table 3.3. Mechanisms for Change in ComplexSystems. 51

Table 7.1. Non-adoption, Abandonment, Scale-up,Spread and Sustainability Domains andGuiding Questions Adapted forIntegrated Care. 124

Table 7.2. Recommendations for ImplementingDigital Health Solutions in IntegratedCare. 127

Table 9.1. Summary of Selected EvaluationApproaches. 164

Figure 1.1. Framework for Integrated Care. 5

Figure 3.1. Medical Leadership CompetencyFramework. 43

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Figure 3.2. Different Levels of Care Integration andAssociated Leadership Styles and Tasks. 48

Figure 4.1. Design Thinking Process. 63

Figure 4.2. Workshop and Validation Flowchart. 66

Figure 6.1. Value Mapping Exercise. 107

Figure 7.1. Digital Health Technologies to SupportComponents of Integrated Models. 117

Figure 7.2. Steps in User-centred Co-design ofTechnology. 121

Figure 8.1. Kotter’s 8 Steps of Implementation. 146

Figure 9.1. Example Logic Model. 165

Figure 9.2. Summary of Evaluation Steps: TheEvaluation Framework. 176

x List of Tables and Figures

L IST OF CONTRIBUTORS

G. Ross Baker University of Toronto, Canada

Bianca Beersma Vrije Universiteit Amsterdam, TheNetherlands

Helen Dickinson University of New South Wales, Canberra,Australia

GayathriEmbuldeniya University of Toronto, Canada

DominiqueGagnon

University of Quebec, Abitibi-Temiscamingue, Canada

Nick Guldemond Sechenov First Moscow State MedicalUniversity, Russia and Leiden UniversityMedical Center, The Netherlands

Axel Kaehne Edge Hill University, UK

Karin Kee Vrije Universiteit Amsterdam, TheNetherlands

Timothy Kenealy University of Auckland, New Zealand

Maritt Kirst Wilfrid Laurier University, Canada

Carolyn SteeleGray

Sinai Health System and University ofToronto, Canada

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Kerry Kuluski Trillium Health Partners and University ofToronto, Canada

Mirella Minkman Vilans, Centre of Expertise for Long-termCare and TIAS School for Business andSociety, The Netherlands

Henk Nies Vilans, Centre of Expertise for Long-termCare and Vrije Universiteit Amsterdam,The Netherlands

Kimberley Pierce Gold Coast Private Hospital, Australia

Jay Shaw Scientist, Women’s College Hospital andUniversity of Toronto, Canada

Catherine Smith University of Melbourne, Australia

Rachael Smithson Gold Coast Health and Griffith University,Australia

Eric van der Hijden Vrije Universiteit Amsterdam, TheNetherlands

Jeroen van derWolk

Zilveren Kruis Health Insurance, TheNetherlands

Marieke vanWieringen

Vrije Universiteit Amsterdam, TheNetherlands

Elize van Wijk Vilans, Centre of Expertise for Long-termCare, The Netherlands

Christina Wicker Gold Coast Health, Australia

Walter Wodchis University of Toronto and Trillium HealthPartners, Canada

Nick Zonneveld Vilans, Centre of Expertise for Long-termCare and Tilburg University, TheNetherlands

xi i List of Contributors

ABOUT THE CONTRIBUTORS

G. Ross Baker is Professor in the Institute of Health Policy,Management and Evaluation at the University of Toronto andProgram Lead in Quality Improvement and Patient Safety. Hisresearch includes studies of patient safety, teamwork, patientengagement and integrated care systems.

Bianca Beersma is Professor in Organizational Behavior andTheme Leader for Care and Welfare Research at the Institutefor Societal Resilience at Vrije Universiteit Amsterdam. She isalso Associate Editor for the Journal of Management. Herresearch interests include teamwork, informal communication,cooperation and conflict, and she studies these topics partlywithin the context of health care.

Helen Dickinson is Professor of Public Service Research andDirector of the Public Service Research Group, University ofNew South Wales, Canberra, Australia. She is co-editor of theJournal of Health Organisation and Management and theAustralian Journal of Public Administration. Her researchinterests revolve around policy implementation, with aparticular focus on the health and disability fields.

Gayathri Embuldeniya is Qualitative Researcher at the Uni-versity of Toronto’s Institute of Health Policy, Managementand Evaluation. She is a social scientist with research interests

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that include integrated health care models and patient andcommunity engagement in health care and research.

Dominique Gagnon is Professor of Social Work at the Uni-versity of Quebec in Abitibi-Temiscamingue. His researchinterests include Integrated Community-Based Primary Healthfor the elderly and use of standardized clinical tools amongproviders.

Nick Guldemond is Professor of Integrated Care and Tech-nology at Sechenov First Moscow State Medical Universityand Senior Researcher at the National eHealth Living Lab(NeLL) of Leiden University Medical Center. He holds amedical degree and a degree in electric engineering. During hiscareer, he worked as a clinical researcher on numerous healthinnovation projects. He is a key expert for various govern-ments, NGOs, multi-nationals and start-ups.

Axel Kaehne is Reader for Health Services Research at theMedical School at Edge Hill University, UK. He is also Editor-in-Chief of the Journal of Integrated Care. His research inter-ests include evaluating health care improvement programmesand implementation science. He is currently president of theEuropean Health Management Association (EHMA).

Karin Kee is PhD candidate at VU Amsterdam. Her researchinterests include employee voice behaviour, occupational roleidentity and shared decision-making in healthcare.

Timothy Kenealy is medical general practitioner and Asso-ciate Professor of Integrated Care at the University of Auck-land, New Zealand. His research often returns to improvingcare for diabetes and for long term conditions more generally.He currently co-leads an investigation into the associationsbetween models of primary care delivery and patient outcomes.

xiv About the Contributors

Maritt Kirst is Assistant Professor in the Department of Psy-chology at Wilfrid Laurier University. She has evaluatedseveral complex health interventions including integrated careprograms and Housing First programs.

Kerry Kuluski is Dr Mathias Gysler Research Chair in Patientand Family Centered Care at the Institute for Better Health atTrillium Health Partners and Associate Professor at theInstitute of Health Policy, Management and Evaluation at theUniversity of Toronto. Her research focuses on the health careexperiences of older adults with complex care needs and theircaregivers.

Mirella Minkman is Chief Executive Officer (CEO) at Vilans,Centre of Expertise for Long-term Care in the Netherlands.She is also Professor of Innovation of Organization andGovernance of Integrated Care at Tilburg University/TIASSchool for Business and Society. She is an Executive BoardMember of the International Foundation of Integrated Careand the Chair of the National advisory and innovationCommittee on governance in health care in the Netherlands.

Henk Nies is Director of Strategy and Development at Vilans,Centre of Expertise for Long-term Care in the Netherlands.He is also Endowed Professor at Vrije Universiteit Amsterdamand member of the Quality Council of the National HealthCare Institute in the Netherlands. He has been involved in anumber of national and European projects concerning inte-grated care.

Kimberley Pierce is the General Manager at Gold Coast Pri-vate Hospital, formally Chief Operating Officer at Gold CoastHealth. She thoroughly enjoys working with great clinicianswho have a vision to reform patient care and achieve worldclass clinical outcomes.

About the Contributors xv

Jay Shaw is Scientist at the Institute for Health System Solu-tion and Virtual Care at Women’s College Hospital, and isDirector of Artificial Intelligence, Ethics & Health at theUniversity of Toronto Join Centre for Bioethics. He is Status-Appointed Assistant Professor in the Institute of Health Pol-icy, Management and Evaluation at University of Toronto.

Catherine Smith is Lecturer in Education at the GraduateSchool of Education, University of Melbourne, Australia. Herwork examines the role of care practices and policy in socialjustice.

Rachael Smithson is Research Director in the Transformationand Digital Division at Gold Coast Health, and AdjunctAssociate Professor at Griffith University. Her research inter-ests include system reform, governance and integrated care.

Carolyn Steele Gray is Scientist at the Bridgepoint Collabo-ratory for Research and Innovation in the Lunenfeld-Tanen-baum Research Institute at Sinai Health System in Toronto,Canada. She is also Assistant Professor at the Institute ofHealth Policy, Management and Evaluation at the Universityof Toronto. Her research program focuses on the develop-ment, implementation and evaluation of digital health solu-tions used in models of integrated community-based primaryhealth care.

Eric van der Hijden is Project Leader of the research team;(financial) incentives for appropriate care at the Talma Insti-tute of the Vrije Universiteit Amsterdam. He is also seniorpolicy advisor health care procurement strategy and innova-tion at Zilveren Kruis Health Insurance in the Netherlands.

Jeroen van der Wolk is Senior Manager Healthcare Procure-ment Strategy and Analytics, Zilveren Kruis Health Insurancein the Netherlands.

xvi About the Contributors

Marieke van Wieringen is Post-Doctoral Researcher at VrijeUniversiteit Amsterdam. Her research interests include healthcare occupations (nurses), occupational role identity, devel-opment and change, and employee voice.

Elize van Wijk is Researcher and Advisor at Vilans, Centre ofExpertise for Long-term Care in the Netherlands. She holds aMaster’s degree in Sociology with a specialization inContemporary Social Problems and has been involved inprojects on interdisciplinary collaboration in IntegratedDementia Care and Specialised Youth Care.

Christina Wicker is Director of the Integrated Care Alliance atGold Coast Health. She has considerable international expe-rience in managing large strategic healthcare projects.

Walter Wodchis is Professor at the Institute of Health Policy,Management and Evaluation at the University of Toronto andResearch Chair in Implementation and Evaluation Science atthe Institute for Better Health, Trillium Health Partners inCanada. He has led a number of large-scale integrated careresearch and evaluation studies.

Nick Zonneveld is Senior Researcher at Vilans, Centre ofExpertise for Long-term Care in the Netherlands. He is also aPhD candidate at Tilburg University/TIAS School for Businessand Society. He has been involved in a number of national andinternational projects on the organization and governance ofintegrated health and social care.

About the Contributors xvi i

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FOREWORD

European Health Management in TransitionWhen the discussion to develop this series on European HealthManagement in Transition began two years ago the world wasa very different one to that which faces us as the first volume ofthe series is published. The seed for those early discussionsemanated from the community of European health policy andmanagement academics and practitioners, who regularly metunder the auspices of the European Health ManagementAssociation. Established over forty years ago during the earlydays of collaborative European engagement on matters relatingto health management and practice, discussion had turned to aconsideration of how best to bring together current thinking ina form readily accessible to a policy, practitioner and academicaudience.

On the basis of the value of collaborative Europeanengagement and exchange having been established, our seriesprovides a platform to consider how this prism maybe used tohighlight how health management could best respond to thisrapidly evolving health policy arena; the underpinningcontention being that in order to successfully respond to thedynamics of a rapidly evolving health policy environment,health management systems and processes must rapidly evolve.The rationale for such thinking stems from the contention thathealth management evolved out of the systems of health

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administration introduced in the post war period to support thesubstantive widening of publicly funded healthcare. Hence,while health management was evidently more dynamic andpurposeful in form, the connector between them was that bothwere orientated around the same predict and provide publicservice model, where the parameters of economic growth,sociodemographic change and health need were to a greaterextent linear and foreseeable.

Such assumptions held for a period, but came to bechallenged as the balance between infectious and non-communicable disease tipped firmly towards the latter;manifest not only through well-established post war trendsrelating to smoking, cancer and coronary heart disease, butlatterly with obesity, diabetes and Alzheimer’s diseaseaccounting for a greater proportion of health need. Thecomplex, multi sectoral and interdisciplinary nature of needdid not lend itself well to single domain management prac-tice, versed at it is in the centrality of the hospital and thehealthcare professional. This is not to say that the disciplineof health management has not offered significant value tothose seeking to establish efficient and effective health sys-tems, able to meet fundamental population health need.Rather as the new century replaced the old, it was becomingincreasingly apparent that traditional health managementpractice, was finding the challenge of delivering patientcentred value-based healthcare a significant one.

Developments within health systems, as the planning,organizing and delivering of health services were experiencing anever before achieved level of complexity and challenge. Pop-ulation health management and medicine of initiative aresubstituting the traditional ‘reactive’ posture of medical envi-ronment. Co-creation and co-production of services arereplacing the notion of patient empowerment. Integrated care,from a sterile discussion among academics and policy-makers,

xx Foreword

has morphed into managed clinical networks, hub & spokessystems, hot & cold structural solutions, multi-discipline andmulti-professional clinical services lines, and much more. Less‘shuffling boxes around’, more management on the ‘shopfloor’. New professions are gaining turf as the hierarchicalrelationship between doctors and rest of the health pro-fessionals is slowly but steadily moving toward a more hori-zontal positioning.

Doctor-manager roles are reconfigured toward clinical-leaders, as health systems are aware that sustainability is notjust a matter of controlling costs, but rather an exercise ofpriority-setting, engagement and collective and individualaccountability. Universalism is now widely re-conceptualizedin selective universalism. Universal Payer systems are movingquickly toward mixed systems, with increasing levels of healthcare intermediated by private third payors. Health servicesconsumerism is reality, if not a want of patients. For sure, it’snot any more an ideological or abstract thinking. Hence,health management is more central than ever, being pivotal tothis revolution.

Additionally, we have the poignant irony of the COVID-19pandemic, as a twenty-first century manifestation of the typeof public health calamity that had been thought to have beenconsigned to a chapter of medical social history, returns tofurther challenge the fundamental tenants of traditionalhealthcare management. Equally, whilst many aspects of thehealth management response to the pandemic were highlylaudable, it has also been evident that traditional healthmanagement often appeared to lack the flexibility necessary torespond to medial and political direction efficiently andeffectively.

The European Health Management in Transition Seriestackles all the ‘disruptive’ changes that are re-framing the waymanagement needs to develop within health systems and

Foreword xxi

organizations. It includes a scene setting volume, which setshealth management practice to be at a turning point. Thisimagining of European health systems facing a dynamic andrapidly evolving need profile, fuelling a radical change inhealth management practice, forms then the central horizontalpillar of the Series. Rest of the volumes of the series thenconsider how the principal domains of health policy andpractice are evolving in the light of these changes. Themesidentified as vertical columns in the wider structures of mod-ern day health and social care are integrated care, patientengagement, personalization and value based care, digitalhealth and the future governance of health systems.

The European Health Management in Transition seriescomes then at a timely juncture. Health systems are having torapidly respond to the now common notion of the newnormal, where the challenge of meeting the real and presentdanger of the existing pandemic continuing to impact onhealthcare for the foreseeable future. Combined with thechallenge of non-communicable disease remaining in thehealth policy ‘pending tray’, leaves today’s healthcare man-ager seeing challenge coming from every side. Our Series willaddress these challenges head on, providing foundations toframe the new context and adopting a forward (and lateral)looking perspective in order to help those working in this fieldto more fully understand and to be better prepared to respondto these challenges ahead.

xxi i Foreword

1

INTEGRATED CARE – ANINTRODUCTIONAxel Kaehne and Henk Nies

WHY INTEGRATED CARE?

Over the last decades, the health of populations has improveddramatically. As life expectancy is increasing all across theworld, chronic and complex conditions are becoming a keyissue for care systems everywhere. Where, previously, inter-ventions for acute infections constituted the bulk of carerelated tasks, now, continuing and long-term health condi-tions are the norm for many people. These ongoing healthconditions require the collaboration of many different staff,often across professional and organizational boundaries.However, our health systems are often ill prepared for thisshift from acute to long-term care. Where single specialtiesused to be sufficient, now multi-professional and multi-agencyinterventions are often needed. This calls for flexible person-centred services that can deliver effective care to individuals,often across the life course.

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As health systems developed historically in response toacute intervention models, they are not set up to cope wellwith patients with long terms care needs. Worse, funding,infrastructure, and organizational structures are often notgeared toward the new models of care necessary to addressongoing care requirements. ‘One-size-fits-all’ is often still whatis routinely offered by many health services. Yet it is not justthe personalization of services that poses a problem. Theinterprofessional nature of today’s care means that differentorganizations need to work together to create smooth carepathways for patients often suffering many different condi-tions at the same time. It makes collaboration across pro-fessions with different status, training and values essential,something for which medics, nurses and care staff have beenill prepared in their education and training. Moreover, fund-ing systems and legislation are poorly adjusted to this newreality.

Integrated care takes up this challenge around the signifi-cant demographic change and its attendant shift in patientneeds from acute to long term care. It tries to design servicesthat provide holistic and seamless care for individuals, takingtheir specific needs into account. This is not a simple thing todo. As a recent study pointed out care integration is

…an emergent set of practices intrinsically shaped bycontextual factors, and not as a single intervention toachieve predetermined outcomes.

(Greenhalgh, Shaw, & Hughes, 2020)

It makes integrated care an endeavour requiring and, inturn impacting on, policy, clinical practices as well as the careorganizations themselves. This shift to collaborative caremodels demands a sea change in how we organize care forpatients in the long run.

2 Axel Kaehne and Henk Nies

As pandemics like COVID-19 are turning health systemsacross the world upside down, managers and service directorsmay temporarily have to fight sudden health system emer-gencies. Yet the long term trend in health systems remainsorientated towards providing person-centred, well-coordinatedservices to people with chronic and complex conditions.

Collaboration and adaptation have therefore become by-words for the urgent demands on health management andpolicy. This book will help managers identify and implementinnovative integrative solutions for care services stretched byrising demand, rapid change and soaring costs.

The magnitude of change currently occurring in healthsystems is humbling. Our notion of health itself is being revisedin the face of unprecedented challenges. Huber et al. (2011)argue that resilience and self-management will play key roles inour understanding of what health is. As resilience, asset basedapproaches and self-management take centre stage for allservices contributing to health of individuals, the notion ofquality of life, as a way for framing health as a holistic concept,becomes ever more important. Although, many health careorganizations and health care workers recognize this implic-itly, traditional single disease oriented approaches of healthcare are still being employed routinely, in particular withpeople with long-term, chronic and multiple conditions. Itspeaks to reason that the traditional ‘silos’ of specialties needto give way to collaborative, integrative, cross-sectoralapproaches to care.

The debates around how to bring about person-centred careillustrate this clearly. Standardized, off-the-shelf solutionscome increasingly under pressure to be replaced by specificallytailored and individual care management approaches whichtake into account multiple care needs of patients and serviceusers.

Integrated Care – An Introduction 3

What person-centred care, resilience, asset-based approachesand self-management have in common is that they requiremulti-professional and inter-organizational interventions andsupport mechanisms to achieve the best outcomes for patientsand users. This is what integrated care is all about.

WHAT IS CARE INTEGRATION?

In this book, we will provide directions for answers to thequestion of how to deliver integrated care. But first, we need todefine what we mean by integrated care. Care integration isdefined as ‘a coherent set ofmethods andmodels on the funding,administrative, organizational, service delivery and clinicallevels designed to create connectivity, alignment and collabo-ration within and between the cure and care sectors’ (Kodner&Spreeuwenberg, 2002). It relates to connectivity, alignment of,and collaboration between social services, public health, citizensand communities (van Duijn, Zonneveld, Lara Montero,Minkman, & Nies, 2018). It may extend to issues of substanceabuse, addictions, mental health, old age and frailty, or socialexclusion of people with disabilities. At present, most integratedcare research is generated by studies in acute and long-term care,but the knowledge about integration in other sectors is growing.The main purpose of integrated care is to reduce ‘fragmenta-tions in service delivery and to foster both comprehensiveness ofcare and better care co-ordination around people’s needs’(Gonzalez-Ortiz, Calciolari, Goodwin, & Stein, 2018).

Valentijn and colleagues have summarized the variousdomains of integrated care in a useful framework (Valentijn,Schepman, Opheij, & Bruijnzeels, 2013). As can be seen inFig. 1.1, integration takes place at various levels, in a hori-zontal or vertical direction.

4 Axel Kaehne and Henk Nies

1. a personal or clinical level refers to the extent to whichservices are coordinated in consultation with the person.

2. a professional level refers to the extent to which pro-fessionals coordinate services across different fields ofspecialty.

3. an organizational level refers to the extent to which orga-nizations coordinate services between differentorganizations.

4. a system level refers to the alignment of organizationalstructure, governance and policies in various policydomains.

Moreover, integration can occur in a vertical direction too.There, the four levels are to be aligned through measures at

Source: Valentijn et al. (2013) under the terms of the Creative CommonsAttribution-NonCommercial-NoDerivs 4.0 Unported (CC BY-NC-ND4.0).

Fig. 1.1. Framework for Integrated Care.

Integrated Care – An Introduction 5

clinical level, mirroring professional integration and collabo-ration. Systems ideally facilitate these coordinated and inte-grated actions at the various levels. Macro-level integrationsupports processes at meso level (organizational integrationand professional integration) in order to deliver a coherentpackage of services and treatment to the individual. Thisdemonstrates that care delivery is embedded in the socialcontext of the particular individual, such as next of kin,family, household, neighbours and friends, work, or school.

What Does In tegrated Care Look Like in Pract ice?

So far, we spoke about integrated care in an abstract way. Ithas become clear that integration is about making usefulconnections to serve the relevant needs of individuals. Butwhat are ‘useful’ connections and what are ‘relevant needs’?

As needs of patients and service users differ there areusually several solutions to one problem. There may be carequality standards or clinical guidelines for some issues, but nostandard can tell us all about the quality of care an individualrequires. Therefore, there is a need to align the professionaland clinical protocols with the individual needs profile. Whatis the ‘right’ thing to do in a specific situation? How can weachieve the best result for somebody in our care? Integratedcare helps us define the balance between what is most effectivein terms of health and what has most value to the patients andusers in our care.

The recent COVID-19 crisis amply illustrates that in orderto achieve a good person-centred solution, all clinicians andcare workers need to work towards what they agree to be themost effective decision. This is to align with what the personand his or hers relatives see as the most appropriate solution.Following Pim Valentijn et al. (2013), this may be called

6 Axel Kaehne and Henk Nies

normative integration. It takes place within the context of theprofessionals’ standards of care quality, the norms espousedby the person involved, as well as the norms and values webring to bear on our decisions on a daily basis. It is ofconsiderable importance in the context of integrated care.

Besides normative consensus, functional integration of caredelivery is also required. Functional integration is about theissue of ‘who does what’. Questions about what patientsthemselves do or want may help us to define the division oflabour. What are the tasks for the professionals caring for anindividual, what do informal carers do and what can be dealtwith by the patient him or herself? Professionals have assess-ment tools and protocols to coordinate across their deliveryactivities. They make decisions about care inputs, skills,expertise, resources and information needed to act. Aligningthis with organizational and staff roles as well as responsi-bilities and resources is a key task for managers. Carefullycalibrated integrated care packages may provide the answer tothe problems of allocation and coordination. However, theyare not an answer that is easy to identify, but once found,integrated services will make for better outcomes. Morerecently, the issues of self-management and shared decisionmaking have received considerable attention. What a patientcan and wants to contribute to the decisions about their care iscritical to make the resulting care package a success. This linkswith the issue of informal care which now contributes theoverwhelming bulk of care activities.

That is why normative and functional integration areinterdependent: the choices we take as professionals whenplanning functional integration reflect normative principles wehold dear about quality, access and equity of care. In addition,those who receive care must be part of this conversation. Theyare the ultimate arbiters of care quality.

Integrated Care – An Introduction 7

The Nuts and Bol ts of In tegrated Care

There are different ways of making connections between thevarious domains of integrated care. Leutz argued (Leutz,1999) that there are mainly three types of integration; linkage,coordination, or full integration.

Linkage is about arranging services in line with existingdivisions of labour in the health system. It is a useful approachin those situations were clinical and professional roles are welldefined in the care process. For instance, in the case of strokeservices, the various tasks of different services are well knownand distinct from each other. Linking services focuses onproviding referral routes ensuring that patients are at the rightplace at the right time. Linkage calls for clear communicationbetween professionals, facilitating continuity of care whenpeople move from one service to another.

Coordination is a way of integrating services where careprovision, definitions of core tasks, patients flows and eligi-bility criteria require mutual adjustment. The aim is to opti-mize service use, share clinical information, managetransitions of patients between settings and assign responsi-bilities, including overall network governance and leadership.Coordination entails more shared responsibilities andresources than linkage, but operates largely with organiza-tionally distinct structures in care services. Co-ordinating thepoints of friction and discontinuity between services and sys-tems is a key objective of this type of integration.

Full integration develops comprehensive care programmesor care packages for specific client groups. It usually takesplace where new programmes or units are created which poolorganizational resources drawing on multiple care systems.Full integration programmes tend to define new tasks andtransform professional practices and delivery for everyoneinvolved. Fully integrated services are likely to be jointly

8 Axel Kaehne and Henk Nies