Integration of health and social care – predicting the quality, costs and consequences 17.4.2018

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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