This document discusses the challenges of measuring care integration. It identifies three main challenges: 1) defining integration and determining when it is needed, 2) measuring the execution of integration plans, and 3) deciding which measures to use. For the first challenge, there are over 175 definitions of integration and determining the appropriate level and areas to integrate is difficult. The second challenge involves measuring integration readiness, capacity, and tracking progress. The third challenge is that there are hundreds of potential measures but many are not well-validated. Additional complexities for measuring health and social care integration are discussed. Future trends may involve broader scopes of integration beyond health/social care and new tools for measurement.

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CHALLENGES OF MEASURING
CARE INTEGRATION
Yee Wei LIM
Yong Loo Lin School of Medicine
National University of Singapore
17 April 2018

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Outline
• Challenges:
– Definition
– The process of integration
– Measurement
• Unique considerations for health-social care
integration
• Recent and future trends of care integration
PRESENTATION TITLE

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CHALLENGE 1: WHAT IS
INTEGRATION AND DO WE
NEED IT?

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Many definitions…
At least 175 overlapping definitions of integrated
care (Armitage et al, 2009)
WHO definition (2002):
integrated care is bringing
together inputs, delivery,
management and
organization of services
related to diagnosis,
treatment, care, rehabilitation
and health promotion.
integration is a means to
improve access, quality,
user satisfaction and
efficiency.

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Intensity of the relationship: Is
integration needed?
Levels Of Integration And User Need As Described By Leutz (1999).

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Where Are We On This Map?
Peck E. (2002) and Gladsby J (2007)

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Assuming we want integration,
which area(s) to integrate?
• Vertical integration: e.g., primary and secondary
care
• Horizontal integration: e.g., hospital and
rehabilitation facility
• Integration centered around primary care: e.g.,
patient centered medical home
• Integration centered around social care: e.g.,
home-based service models

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Which dimension to integrate?

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CHALLENGE 2:
MEASURING EXECUTION

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Measuring the planning
process and execution
Questions include:
1. Do organizations have the same goal?
2. Was there a situational analysis?
3. Was a value case made? Risk management plan?
4. Are staff/teams ready to integrate?
5. Is there capacity building?
6. Is the infrastructure in place to integrate?
Technology use appropriate and effective?
7. What about governance?

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Example:
Scirocco
Model to
assess
integration
capabilities

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Tracking the journey of
integration
Important to measure readiness and capacity to
integrate so as to:
•Reduce the probability of failure
•Continuously improve the process of integration
•Gain insights for scale up or replication

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CHALLENGE 3:
WHAT MEASURES TO USE?

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Hundreds of measures out there!
• Focus on user groups and care pathways varies
• How a dimension is measured could vary. E.g.,
care continuity:
– 32 indices identified by Jee and Cabana
(2006)
– Concepts included: duration of provider
relationship, density of visits, dispersion of
providers, sequence of providers, subjective
assessment
• Measurement gaps exist

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Another example: Measuring
patient centeredness
15 dimensions identified: characteristics of
clinician, clinician-patient relationship, clinician-
patient communication, patient as unique person,
biopsychosocial perspective, patient information,
patient involvement in care, involvement of family
and friends, patient empowerment, physical
support, emotional support, integration of medical
and non-medical care, teamwork, access to care,
coordination and continuity of care.
Scholl I, Zill JM, Härter M, Dirmaier J (2014) An Integrative Model Of Patient-centeredness – A
Systematic Review And Concept Analysis. PLOS ONE 9(9): E107828.

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Measures are not always
Tested/Validated
Bautista et al (2016) systematic review found:
• <50% of the validation studies to be of good or
excellent quality
• Minority of instruments showed strong evidence
for internal consistency (15%), content validity
(19%), and structural validity (7%); with
moderate evidence of positive findings for
internal consistency (14%) and construct validity
(14%).
Bautista MA, Nurjono M, Lim YW, Dessers E, Vrijhoef HJ. Instruments Measuring Integrated Care: A
Systematic Review of Measurement Properties. Milbank Q. 2016 Dec;94(4):862-917.

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Multiple paths taken – what
worked?
• Integration programs may have several
simultaneous objectives
• Various disparate mechanisms used to improve
integration
• Time lag for impact
• Multiplicity of parallel initiatives – hard to
attribute cause and effect

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How to decide what to measure
and how to measure?
• Decide what dimensions will be assessed
– Need to prioritize with stakeholders
• Need to have a conceptual framework everyone
can agree on
• Select validated instruments
• Consider culture and context
• Mixed methods probably needed

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HEALTH AND SOCIAL CARE
INTEGRATION:
SOME THOUGHTS

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Health Social
Health
Social
Which form of health and
social care integration?
Social
Health

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A
B
CD
E
1
2
34
5
Measuring integration within
and across systems?
Healthcare Social care

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Health and social goals may differ
• Healthcare system may prioritize individual
clinical outcome and health system goals
• Social care may focus on individual wellbeing
and social relationships in the community
• Can joint ownership of goals and
responsibilities occur?

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FUTURE TRENDS

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Scope of integration will
broaden
• Beyond health and social care integration:
– Economic dimension
– Broader social goals – e.g., intergenerational
integration
• Beyond disease-specific care integration, focus on
whole person health
• Not limited to service delivery for individuals but
population management
• Taking a life-course approach
• Quadruple aim: beyond quality, access and cost, to
include staff wellbeing

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Tools of measurement will
multiply
• Participatory data collection
– Living labs
• Use of multi-media, e.g., video-diary
• Use of social media data
• Use of real time feedback
• Rapid pilots

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FINAL THOUGHT
The work of care integration is never
done -
Society evolves,
focus of integration shifts,
priorities change

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THANK YOU!
yee_wei_lim@nuhs.edu.sg