How to support integration to promote care for people with multimorbidity in Europe? [Internet]

Excerpt

1. Integrated care initiatives do not currently focus on multimorbidity, but they can serve as models for services for people with multimorbidity, offering ideas on how to coordinate or customize care and overcome the fragmentation that comes from “disease oriented” systems organized around single medical specialities.

2. The practical examples of integrated care for multimorbidity are still in their early phases but it is already clear that implementing integration requires real effort.

3. Policy-makers trying to encourage integrated care for multimorbidity need to know that:

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      Primary care is often the most appropriate base for initiatives but must have the full cooperation of specialized care;

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      Effective connections between health and social care are key and should be an explicit policy objective;

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      Linking formal and informal care (e.g. patient associations, relatives as carers) ought to be part of any holistic approach.

4. There is a continuum between fragmented (segregated) care and full integration. Policy-makers and providers can move care towards integration by:

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      Stratifying people with multimorbidity according to their needs and the resources available to support them which helps care pathways and care inputs to be coordinated efficiently;

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      Promoting a culture of information sharing across organizational, professional and status boundaries, including by encouraging interdisciplinary meetings;

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      Developing information and communication technology that allows professionals and patients to share information easily wherever they are based;

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      Making sure new initiatives are treated as part of regular care and, not separate from the everyday work of professionals.

5. Other pre-requisites for implementing integrated care initiatives are:

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      Tailoring models to fit the specific (national or regional) health and social care context;

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      Support and commitment from management at all levels (from strategic to frontline);

   3. ○

      Training in collaboration and other relevant skills (ideally as part of health and social care education);

   4. ○

      Evaluation to capture the impact of integrated care (supported by relevant training).