Why is the integration of services not encouraged?

Jordi Varela
Editor

 

@varelalaf

Health and social services are fragmented between various institutions, levels of care and a lot of specialities and each one of the fractions of the system provides a service that makes sense in itself, such as a three-hour weekly service of a family worker for lending a hand at the home of an elderly person who lives alone, or angioplasty intervention for a woman who has just suffered a myocardial infarction and, according to this system, funders pay differently for each activity.

This fractional model, however, when treating complex, fragile or vulnerable patients behaves inefficiently for the sick and negatively for the economy. Suppliers also suffer from it and, therefore, they try to force the coordination of their professionals to better serve people with more difficulties, but with agendas, routines and incentives circulating in the opposite direction, everything is challenging for them.

What are we talking about when we talk about integration services?

Sebastià Santaeugènia in "Integrated health and social care: definition, challenges and glass ceilings", says that service integration is a coherent set of financing, organisation, service delivery and clinical practise models, designed to generate collaboration between different sectors, to improve care for people with complex and long-term needs.

What is the English doing to advance integration?

In England, Integrated Care Systems in evolution since 2018, manage in an integrated way local NHS resources (hospitals and primary care), community, social, municipal, mental health and others that may be in the 18 health areas where they have been deployed, to expand, count on the push of the NHS long-term plan, throughout the English territory by the end of 2021. The ICS are provided with a certain local governance structure (without legal entity own), in the style of the Integrated Health Areas (AIS) of the Consorci Sanitari de Barcelona. However, the perception is that the English ICS have more integrating force and more funding than the Barcelona AIS.

And the Americans?

The United States has a very fragmented health care system, mainly oriented to carry out a lot of care and business activity and, for this reason, CMS (Medicare + Medicaid), created "Accountable Care Organizations" (ACO), a financing model born under the "Affordable Care Act", to value the integration of services. ACOs are groups of doctors, hospitals and other providers, who decide to coordinate to provide a more efficient service to patients with public coverage and, accordingly, when an ACO manages to improve the quality of services, and at the same time spend money more valuable, CMS shares the savings made with the provider pool.

With the experience of the ACO's ten years, Allison Hamblin (CHCS) and Kedar Mate (IHI) have published in Health Affairs Blog, recommendations to help the new Biden-Harris administration to more efficiently manage the complexity of patients who have public insurance, of which I would like to highlight two: a) it is necessary to invest more time in knowing the causes and circumstances of the complexity of each person to be able to develop truly effective individualised plans at the community level, and b) CMS should pay complexity as a concept with its entity, to further force providers to integrate services.

And the Basques?

In Euskadi, the first Integrated Health Organization (Organización Sanitaria Integrada - OSI) was established in January 2011 and has now spread throughout the region. The OSI intends to promote multidisciplinary and coordinated assistance between all the services that work for the same population, especially between primary care and hospitals. Ten years later, a qualitative evaluation prepared by three academics from the University of the Basque Country, highlights that, despite the benefits observed in some results, such as the reduction in hospitalisations due to ambulatory care sensitive conditions, OSIs have difficulties in moving resources towards community care and primary care, as the basis for more appropriate care for complex patients and, on the other hand, they are finding it difficult to consolidate fruitful relationships between health and social services.

And in Catalonia?

In Catalonia, in 1986, the "Vida als anys" program generated expectations and encouraged the creation of a social health sector that has been efficiently building bridges between hospitals and the community. Afterwards there has been a trickle of inclusive government initiatives, some of which are very ambitious, but which have had results below expectations. According to Santaeugènia, despite the proposals made over the years from the different integrated care programs, the social and health services systems still do not have a clear vision of joint territorial governance, which means that many integration projects that have stimulating professional leaderships do not bear fruit due to lack of support from the administrations. Two very different situations are worth examples. In Sabadell, it was decided, in the last century, to include the municipal social services within the primary care centres, but the coexistence was not provided with content and now the primary care teams ask the municipal social services to leave because they need the space. In Vilanova i la Geltrú, on the other hand, the CAPI Baix-a-Mar, managed by a municipal company, has integrated the primary care team and the municipal social services in the same building with a "Chronic Care Model" integration methodology, which is facilitating the genesis of individualised plans developed jointly.

Complexity, as such, is a concept that must be subject to specific evaluation and funding and not each of the services that flow from it and if progress is not made in that direction, the services are aimed at people with complex social and health needs will continue to remain inadequate.