Qudsia Anjum ( Family Medicine, Primary Health Care, Dubai Health Authority, Dubai, UAE. )
The advent of integrated care dates back to 1970s and 1980s where it gained popularity in the developed world. It caught attention of health care providers and became a public health concern in the 1990s. Integrated care is now a buzz word internationally; it is gaining attention with an aim to develop better and more cost effective health systems. Integration per se means to complete in Latin, whereas integrated means organic part of a whole or reunited part of a whole. It is important to understand the difference between integration and integrated care: integrated care is the systematic principle for care delivery whereas integration describes methods, processes and models to achieve such delivery of care. It can not only overcome fragmentation, but can also improve continuity of care and quality of life with better coordination and patient centered aspect. The need is more emphasized with changing demographics, rapidly growing medical scientific knowledge and increasing awareness of patients and populations.
Kodner and Spreeuwenberg proposed a definition as: "Integration is a coherent set of methods and models on the funding, administrative, organizational, service delivery and clinical levels designed to create connectivity, alignment and collaboration within and between the cure and care sectors".1 This system aims to bring together various professionals, services and organizations together and replacing the fragmented care concept. A systematic review revealed multiple perceptions of integration, e.g., virtual, vertical, horizontal, functional, clinical and physician. In addition, integration can be pursued at system level or coordination of services and programmes for a defined population.2 An article emphasizes on defining integrated care with an emphasis on patients\' central role as active participants in management of ailments, thereby keeping patient centered care as a key element.3 This is again laying emphasis on patient autonomy and giving importance to his contribution in treatment.
Integrated health care is an emerging entity posing a challenge for health care delivery especially in patients with complex chronic conditions. Literature reviews on the topic has failed to find out a universal definition or concept of integration. This became evident from a systematic review that has discussed definitions, concepts, models, measurement tools, indicators and outcomes of integration. The review has also highlighted gaps in research targeted towards a standardized universally acceptable integration in health care delivery system.4 WHO gives a working definition for integrated service delivery as: "The management and delivery of health services so that clients receive a continuum of preventive and curative services, according to their needs over time and across different levels of the health system".5
Keeping in view these limitations, an article drew ten key principles for successful health systems integration. These are comprehensive services across the continuum of care, patient focus, geographic coverage and rostering, standardized care delivery through interprofessional teams, performance management, information systems, organizational culture and leadership, physician integration, governance structure and financial management.6 A meta-review added to the evidence and revealed that integrated care programmes can improve patient-centered outcomes and process quality in chronic diseases like DM, CHF and COPD.7 Another systematic review has looked into assessment of quality and cost related to delivery of integrated delivery system in the US. Their results revealed a positive effect on quality of care, whereas they were unable to find evidence on cost reduction.8
It needs to be emphasized that literature fails to reproduce a one-size-fits-all model for successful integration; yet, these key principles can be a useful guide for decision makers in assisting and guidance for efforts towards integration. Integration is an ongoing process; it must be developed and implemented with a patient centered approach taking into account population needs, and a focus on improved outcomes of health and enhanced quality of care.
1. Kodner DL, Spreeuwenberg C. Integrated care: meaning, logic, applications, and implications--a discussion paper. Int J Integr Care 2002;2: e12
2. Armitage GD, Suter E, Oelke ND, Adair CE. Health systems integration: state of the evidence. Int J Integr Care 2009; 9: e82
3. Singer SJ, Burgers J, Friedberg M, Rosenthal MB, Leape L, Schneider E. Defining and measuring integrated patient care: promoting the next frontier in health care delivery. Med Care Res Rev 2011; 68: 112-27.
4. Armitage GD, Suter E, Oelke ND, Adair CE. Health systems integration: state of the evidence. Int J Integr Care 2009; 9: e82.
5. Integrated health services - what and why? WHO Technical Brief No.1, May 2008. [online] [cited 2014 Dec 25]. Available from: URL: http://www.who.int/healthsystems/technical_brief_final.pdf
6. Suter E, Oelke ND, Adair CE, Armitage GD. Ten key principles for successful health systems integration. Healthc Q 2009;13: 16-23.
7. Martínez-González NA, Berchtold P, Ullman K, Busato A, Egger M. Integrated care programmes for adults with chronic conditions: a meta-review. Int J Qual Health Care 2014; 26: 561-70.
8. Hwang W, Chang J, Laclair M, Paz H. Effects of integrated delivery system on cost and quality. Am J Manag Care 2013; 19: e175-84.