Overview

This brief’s key messages are:

• The incidence of (multiple) chronic conditions is rising and has significant societal and economic implications. It is linked to lower quality of life, higher healthcare utilization and health inequalities.
• Integrated care provides a shift from a reactive approach to a proactive approach focused on prevention and integration between healthcare, long-term care and social care. It is a way of improving patient outcomes (and satisfaction), particularly for those living with multiple chronic diseases, and optimizing resource utilization.
• Delivering cohesive and integrated care depends on strategies to overcome barriers created by separate funding, regulation and delivery systems for social care and healthcare.
• Making integrated care effective, sustainable and person-centred requires policy-makers and healthcare providers to engage with key stakeholders, including patients and care professionals, to co-design and implement integrated care models that work.
• Empowering care providers and professionals matters because they can be the driving force of successful innovation and implementation.
• Implementing new integrated care programmes and scaling up successful programmes is crucial in meeting the complex needs of individuals with multiple chronic conditions and in achieving transformative improvements in healthcare delivery.
• There are a dozen effective strategies that together offer a comprehensive framework to help policy-makers, care managers and meso-level implementers deliver integrated care:
  

1. Engaging stakeholders, gaining their trust, defining the problem together and agreeing the way forward.
2. Overcoming fragmented leadership and assigning responsibility unambiguously.
3. Making a person-centred and community-based approach central to integrated care implementation.
4. Creating feedback loops and continuous monitoring.
5. Securing long-term funding for integration including through innovative payment systems that overcome fragmentation.
6. Building a multidisciplinary team culture with shared purpose.
7. Developing new roles and skills that enable care to be properly integrated (and person-centred).
8. Adapting health professional curricula and training to promote patient-centred care.
9. Using ICT innovatively to support collaboration and communication and not just administrative procedures.
10. Striking a balance between gradual expansion of integrated approaches and disruption.
11. Balancing flexibility and formal structures.
12. Aligning the work of different sectors and teams.