Integrated Care Procurement Cases

COPD

The chronic lung disease COPD is characterized by reduced airflow, inflammation and flare-ups, called exacerbations, in which the patient may experience increased coughing, mucus, shortness of breath, wheezing, and a feeling of tightness in their chest. If those symptoms are not detected and treated in a timely fashion, they can escalate and lead to hospitalizations, disability and a diminished quality of life.
COPD is the third leading cause of death in the United States. By 2030, COPD will become the third cause of mortality and seventh cause of morbidity worldwide.

Cross-Cutting

Existing health and social care systems were created in a completely different epidemiological context compared to the current situation. They were organised to deliver care to people who experienced acute adverse events and were living with diseases and existing chronic diseases at the time, such as tuberculosis, leprae with those having mental health illnesses being secluded in institutions away from society. The profound change in the epidemiology of the diseases, disabilities, survival and life expectancy in the past decades has necessitated care authorities to rethink and redesign how care can and should be provided. There has been a shift from acute disease, episodic-orientated systems to an integrated approach designed to respond to complex situations, often with accumulating chronic conditions and disabilities with increasing disease burden over the life-course in a population with increasing life-expectancy (see Figure 1). These changes have influenced a cultural awareness and understanding of health, social care and support services and how these should be integrated with the introduction of new concepts of health and wellbeing which can take advantage of new technological evolution and the information and data revolution in the 21st century. This complex situation has resulted in the development of new integrated models of care and pathways designed to bring together all the care interventions, treatment, services and support from a care team made up of care practitioners from multiple care delivery organisations and disciplines together with the patient and family carers.

Dementia

Worldwide, around 50 million people have dementia, and there are nearly 10 million new cases every year. It mainly affects older people, but is not a normal part of the process of ageing. Dementia is one of the major causes of disability and dependency among older people worldwide and has a physical, psychological, social, and economical impact, not only on people with dementia, but also on their carers, families and society at large. The organisation of care and provision of support to people with dementia is of complex nature as includes many elements such as early diagnosis in order to promote early and optimal management, optimising physical health, cognition, activity and well-being, identifying and treating accompanying physical illness, detecting and treating challenging behavioural and psychological symptoms and providing information and long-term support to carers.

Multimorbidity

Multimorbidity, defined as a co-occurrence of two or more chronic conditions, is an increasing problem worldwide and is already a significant epidemiological problem in Europe related to the increase of life-expectancy and rapidly aging population. Observational study reviews have estimated that up to 95% of people older than 65 years may be affected by multimorbidity. Although multimorbidity prevalence increases with age and frailty, it is not only associated with aging and can affect younger people too, where frailty assessment tools are not well developed. It is also strongly associated with social determinants and people from deprived areas are in higher risk of complex conditions, less access to care delivery system and poorer health outcomes. However, there is a lack of effective risk stratification tools.

Stroke

Stroke is a complicated, heterogeneous condition with acute onset but complex and enduring treatment and follow-up. Consequently, stroke care is complex and covers a whole spectrum of care including acute care, rehabilitation and long-term care with in-hospital, outpatient and community-based care. Stroke care is thus per definition multidisciplinary and the integration of care is of particular concern.

Others

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Integrated care good practices, papers, reports and case studies

1. Care Pathways

2. Care Team Building

3. Co-production

4. Data&Info Sharing

5. Digital Health

6. Health Literacy

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7. Holistic

8. Care Records

9. Joint Service Provision

10. Joint Assessment

11. MDT

12. Patient education

13. Personalized care

14. Person-Centered

15. Proms & Prems

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16. Self-care and management

17. Care Integration

18. Single point of Access

19. Integrated Hospital Discharge Programme