The patient at the centre: evidence from 17 European integrated care programmes for persons with complex needs

Background: As the prevalence of multi-morbidity increases in ageing societies, health and social care systems face the challenge of providing adequate care to persons with complex needs. Approaches that integrate care across sectors and disciplines have been increasingly developed and implemented in European countries in order to tackle this challenge. The aim of the article is to identify success factors and crucial elements in the process of integrated care delivery for persons with complex needs as seen from the practical perspective of the involved stakeholders (patients, professionals, informal caregivers, managers, initiators, payers). Methods: Seventeen integrated care programmes for persons with complex needs in 8 European countries were investigated using a qualitative approach, namely thick description, based on semi-structured interviews and document analysis. In total, 233 face-to-face interviews were conducted with stakeholders of the programmes between March and September 2016. Meta-analysis of the individual thick description reports was performed with a focus on the process of care delivery. Results: Four categories that emerged from the overarching analysis are discussed in the article: (1) a holistic view of the patient, considering both mental health and the social situation in addition to physical health, (2) continuity of care in the form of single contact points, alignment of services and good relationships between patients and professionals, (3) relationships between professionals built on trust and facilitated by continuous communication, and (4) patient involvement in goal-setting and decision-making, allowing patients to adapt to reorganised service delivery. Conclusions: We were able to identify several key aspects for a well-functioning integrated care process for complex patients and how these are put into actual practice. The article sets itself apart from the existing literature by specifically focussing on the growing share of the population with complex care needs and by providing an analysis of actual processes and interpersonal relationships that shape integrated care in practice, incorporating evidence from a variety of programmes in several countries

Digital Health Transformation of Integrated Care in Europe: Overarching Analysis of 17 Integrated Care Programs

Background: Digital health tools comprise a wide range of technologies to support health processes. The potential of these technologies to effectively support health care transformation is widely accepted. However, wide scale implementation is uneven among countries and regions. Identification of common factors facilitating and hampering the implementation process may be useful for future policy recommendations. Objective: The aim of this study was to analyze the implementation of digital health tools to support health care and social care services, as well as to facilitate the longitudinal assessment of these services, in 17 selected integrated chronic care (ICC) programs from 8 European countries. Methods: A program analysis based on thick descriptions including document examinations and semistructured interviews with relevant stakeholders of ICC programs in Austria, Croatia, Germany, Hungary, the Netherlands, Norway, Spain, and the United Kingdom was performed. A total of 233 stakeholders (ie, professionals, providers, patients, carers, and policymakers) were interviewed from November 2014 to September 2016. The overarching analysis focused on the use of digital health tools and program assessment strategies. Results: Supporting digital health tools are implemented in all countries, but different levels of maturity were observed among the programs. Only few ICC programs have well-established strategies for a comprehensive longitudinal assessment. There is a strong relationship between maturity of digital health and proper evaluation strategies of integrated care. Conclusions: Notwithstanding the heterogeneity of the results across countries, most programs aim to evolve toward a digital transformation of integrated care, including implementation of comprehensive assessment strategies. It is widely accepted that the evolution of digital health tools alongside clear policies toward their adoption will facilitate regional uptake and scale-up of services with embedded digital health tools

Costs of delivering human papillomavirus vaccination using a one- or two-dose strategy in Tanzania.

OBJECTIVE: As part of the Dose Reduction Immunobridging and Safety Study of Two HPV Vaccines in Tanzanian Girls (DoRIS; NCT02834637), the current study is one of the first to evaluate the financial and economic costs of the national rollout of an HPV vaccination program in school-aged girls in sub-Saharan Africa and the potential costs associated with a single dose HPV vaccine program, given recent evidence suggesting that a single dose may be as efficacious as a two-dose regimen. METHODS: The World Health Organization's (WHO) Cervical Cancer Prevention and Control Costing (C4P) micro-costing tool was used to estimate the total financial and economic costs of the national vaccination program from the perspective of the Tanzanian government. Cost data were collected in 2019 via surveys, workshops, and interviews with local stakeholders for vaccines and injection supplies, microplanning, training, sensitization, service delivery, supervision, and cold chain. The cost per two-dose and one-dose fully immunized girl (FIG) was calculated. RESULTS: The total financial and economic costs were US$10,117,455 and US$45,683,204, respectively, at a financial cost of $5.17 per two-dose FIG, and an economic cost of$23.34 per FIG. Vaccine and vaccine-related costs comprised the largest proportion of costs, followed by service delivery. In a one-dose scenario, the cost per FIG reduced to $2.51 (financial) and$12.18 (economic), with the largest reductions in vaccine and injection supply costs, and service delivery. CONCLUSIONS: The overall cost of Tanzania's HPV vaccination program was lower per vaccinee than costs estimated from previous demonstration projects in the region, especially in a single-dose scenario. Given the WHO Strategic Advisory Group of Experts on Immunization's recent recommendation to update dosing schedules to either one or two doses of the HPV vaccine, these data provide important baseline data for Tanzania and may serve as a guide for improving coverage going forward. The findings may also aid in the prioritization of funding for countries that have not yet added HPV vaccines to their routine immunizations

Exploring the training and scope of practice of GPs in England, Germany and Spain

OBJECTIVE: To explore general practitioner (GP) training, continuing professional development, scope of practice, ethical issues and challenges in the working environment in three European countries. METHOD: Qualitative study of 35 GPs from England, Germany and Spain working in urban primary care practices. Participants were recruited using convenience and snowball sampling techniques. Semi-structured interviews were recorded, transcribed and analysed by four independent researchers adopting a thematic approach. RESULTS: Entrance to and length of GP training differ between the three countries, while continuing professional development is required in all three, although with different characteristics. Key variations in the scope of practice include whether there is a gatekeeping role, whether GPs work in multidisciplinary teams or singlehandedly, the existence of appraisal processes, and the balance between administrative and clinical tasks. However, similar challenges, including the need to adapt to an ageing population, end-of-life care, ethical dilemmas, the impact of austerity measures, limited time for patients and gaps in coordination between primary and secondary care are experienced by GPs in all three countries. CONCLUSION: Primary health care variations have strong historical roots, derived from the different national experiences and the range of clinical services delivered by GPs. There is a need for an accessible source of information for GPs themselves and those responsible for safety and quality standards of the healthcare workforce. This paper maps out the current situation before Brexit is being implemented in the UK which could see many of the current EU arrangements and legislation to assure professional mobility between the UK and the rest of Europe dismantled

The patient at the centre: evidence from 17 European integrated care programmes for persons with complex needs

Background: As the prevalence of multi-morbidity increases in ageing societies, health and social care systems face the challenge of providing adequate care to persons with complex needs. Approaches that integrate care across sectors and disciplines have been increasingly developed and implemented in European countries in order to tackle this challenge. The aim of the article is to identify success factors and crucial elements in the process of integrated care delivery for persons with complex needs as seen from the practical perspective of the involved stakeholders (patients, professionals, informal caregivers, managers, initiators, payers). Methods: Seventeen integrated care programmes for persons with complex needs in 8 European countries were investigated using a qualitative approach, namely thick description, based on semi-structured interviews and document analysis. In total, 233 face-to-face interviews were conducted with stakeholders of the programmes between March and September 2016. Meta-analysis of the individual thick description reports was performed with a focus on the process of care delivery. Results: Four categories that emerged from the overarching analysis are discussed in the article: (1) a holistic view of the patient, considering both mental health and the social situation in addition to physical health, (2) continuity of care in the form of single contact points, alignment of services and good relationships between patients and professionals, (3) relationships between professionals built on trust and facilitated by continuous communication, and (4) patient involvement in goal-setting and decision-making, allowing patients to adapt to reorganised service delivery. Conclusions: We were able to identify several key aspects for a well-functioning integrated care process for complex patients and how these are put into actual practice. The article sets itself apart from the existing literature by specifically focussing on the growing share of the population with complex care needs and by providing an analysis of actual processes and interpersonal relationships that shape integrated care in practice, incorporating evidence from a variety of programmes in several countries

Multimorbidity – a challenge for European health systems : an analysis of integrated care as an approach to a solution

Europe's health systems, like many others worldwide, face the challenge of an increasing number of people being affected by multimorbidity. Multimorbidity is often defined as two or more chronic diseases occurring simultaneously in one person. At present, health systems in Europe are often fragmented and predominantly focused on improving clinical outcomes, which does not meet the needs of multimorbid individuals. Integrated care is increasingly being described as a promising concept for redesigning care for the chronically ill, particularly in cases of multimorbidity. As a result, innovative integrated care programmes are currently being developed and implemented in many European countries, although evidence of their effectiveness remains limited. Therefore, integrated care programmes that have already been implemented have been examined in this work to identify innovative approaches, elements and existing gaps and at the same time to formulate recommendations for further systematic description, analysis and financing. The work is based on cross-national comparisons and combines systematic literature and document analyses with qualitative interviews. The following elements were identified which, especially in combination, could contribute to the implementation of integrated care: the creation of new collaborative partnerships, the redefinition of roles and responsibilities, the creation of new professional roles, as well as a supportive management approach that promotes networking and division of labour cooperation, clearly defined responsibilities, coordination of care, good communication and a paradigm shift towards a person-oriented approach. It has been shown that so far there is no basis for a systematic and standardised description, development and evaluation of integrated care programmes for multimorbid persons, thus this basis was developed in the form of a framework in the present work. The results also point to the fact that, despite the discourses on the importance of new remuneration mechanisms for the implementation of integrated care, there are comparatively few concrete measures in practice to date. Further research on the impact of different financial incentives on the behaviour of providers towards multimorbid persons is therefore urgently needed. For some countries, it also means concentrating first on further developing their current remuneration approaches before introducing more complex ones, such as bundled payments or population-based remuneration models. In order to overcome systemic hurdles and facilitate future investment and analysis in integrated care, greater consideration must also be given to evaluation through legislative measures.Europas Gesundheitssysteme stehen, wie weltweit viele andere ebenfalls, vor der Herausforderung, dass zunehmend mehr Menschen von Multimorbidität betroffen sind. Multimorbidität wird häufig definiert als zwei oder mehrere chronische Erkrankungen, die gleichzeitig bei einer Person auftreten. Europäische Gesundheitssysteme sind zurzeit häufig fragmentiert und überwiegend auf die Verbesserung klinischer Ergebnisse ausgerichtet, dies wird den Bedürfnissen multimorbider Personen oftmals nicht gerecht. Die integrierte Versorgung wird zunehmend als vielversprechendes Konzept für die Neugestaltung der Versorgung für chronisch Kranke, insbesondere bei Multimorbidität, beschrieben. Daher werden derzeit in vielen europäischen Ländern integrierte Versorgungsprogramme entwickelt und implementiert, obwohl der Nachweis deren Wirksamkeit nach wie vor begrenzt ist. In dieser Arbeit wurden bereits implementierte integrierte Versorgungsprogramme untersucht, um innovative Ansätze, Elemente und vorhandene Lücken aufzuzeigen und gleichzeitig Empfehlungen für die weitere systematische Beschreibung, Analyse sowie Finanzierung zu formulieren. Die Arbeit basiert auf länderübergreifenden Vergleichen und kombiniert systematische Literatur- und Dokumentanalysen mit qualitativen Interviews. Folgende Elemente wurden identifiziert, die, insbesondere in Kombination, zur Umsetzung integrierter Versorgung beitragen konnten: die Schaffung neuer Kooperationspartnerschaften; die Neudefinition von Rollen und Verantwortlichkeiten; die Schaffung neuer beruflicher Rollen sowie ein unterstützender Führungsstil; klar geregelte Verantwortlichkeiten; Koordination der Versorgung; eine gute Kommunikation und ein Paradigmenwechsel hin zu einem personenorientierten Ansatz. Es konnte gezeigt werden, dass bisher eine Grundlage für eine systematische und standardisierte Beschreibung, Entwicklung und Evaluation von integrierten Versorgungsprogrammen für Multimorbide fehlt. Daher wurde diese Grundlage in der vorliegenden Arbeit in Form eines Frameworks entwickelt. Ebenso deuten die Ergebnisse daraufhin, dass trotz der Diskurse über die Bedeutung neuer Vergütungsmechanismen für die Umsetzung der integrierten Versorgung bislang vergleichsweise wenig konkrete Maßnahmen in der Praxis vorliegen. Weitere Forschung bezüglich der Auswirkungen unterschiedlicher finanzieller Anreize auf das Verhalten von Leistungserbringern gegenüber multimorbiden Menschen ist daher dringend erforderlich. Für einige Länder bedeutet dies auch, sich zunächst auf die Weiterentwicklung der derzeitigen Vergütungsansätze zu konzentrieren, bevor komplexere Vergütungsmodelle, wie sog. „bundled payments”, eingeführt werden. Um systemimmanente Hürden zu überwinden und künftige Investitionen und Analysen in der integrierten Versorgung zu erleichtern, ist ebenfalls eine stärkere Berücksichtigung der Evaluation durch gesetzgeberische Maßnahmen erforderlich.EU, ICARE4EU, Innovating care for people with multiple chronic conditions in EuropeEC/H2020/634288/EU/Sustainable intEgrated care modeLs for multi-morbidity: delivery, FInancing and performancE/SELFI

A review regarding the perspectives on rural care : an overview of internationally applied measures

Dieser Titel ist parallel zur Online-Version in gedruckter Form im Universitätsverlag der TU Berlin erschienen: ISBN 978-3-7983-2718-4; ISSN 2197-8123Hintergrund: Der demographische Wandel und die Zunahme chronischer Krankheiten, verbunden mit einer immer komplexer werdenden Pflegebedürftigkeit, stellen die deutsche Gesundheitspolitik vor immer neue Herausforderungen. Insbesondere in den strukturschwachen, ländlichen Regionen besteht Handlungsdruck, um hier eine bedarfsgerechte medizinische Versorgung zu gewährleisten. Wichtig ist es in diesem Zusammenhang, die Zusammenarbeit von Ärzten und anderen Gesundheitsprofessionen neu zu organisieren. Dies ist möglich indem innovative Versorgungsformen gefördert und neue Gesundheitsprofessionen geschaffen werden, da die Versorgung chronisch Kranker und alter Menschen mehr als nur eine akute Versorgung erfordert. Ziel: Dieser Review betrachtet inwieweit international angewandte Maßnahmen zur Rekrutierung von Gesundheitspersonal einem Fachkräftemangel im ländlichen Raum entgegenwirken können. Außerdem werden neue Professionen und innovative Strukturen der Versorgung im ländlichen Raum beschrieben. Methodik: Für die Untersuchung erfolgte eine Literaturrecherche mittels einer umfangreichen Suchstrategie in den Datenbanken PubMed und Scopus. Eingeschlossen wurden Studien, die im Zeitraum 1990-2013 durchgeführt wurden, die Maßnahmen zur Rekrutierung von Gesundheitspersonal in den ländlichen Raum beschrieben und die neue Versorgungsformen vorstellten. Ergänzend wurde eine Expertenbefragung per E-Mail durchgeführt. Insgesamt wurden 65 Experten über das „Health Systems and Policy Monitor-Netzwerk“ angeschrieben, überdies wurden Experteninformation aus dem Europäischen Forschungsprojekt MUNROS verwendet. Ergebnisse: Für einen Großteil der betrachteten Maßnahmen liegt keine Evidenz vor, ein ländlicher Hintergrund jedoch gilt als am besten evaluiert und als wirksamste Maßnahme zu Rekrutierung von Ärzten in den ländlichen Raum. Inkonsistente Ergebnisse zeigen medizinische Fakultäten in ländlichen Gebieten sowie eine finanzielle Unterstützung während des Studiums mit einhergehender Verpflichtung im ländlichen Raum tätig zu werden. Studienergebnisse ergeben, dass die Berufsgruppen der PAs und NPs eine qualitativ hochwertige und kosteneffektive Arbeit leisten. In den USA, Kanada, Neuseeland, Australien und Großbritannien konnten die meisten neuen Versorgungsmodelle identifiziert werden, jedoch besteht hier das Problem, dass diese häufig noch nicht evaluiert worden sind. Schlussfolgerungen: Insgesamt ist deutlich geworden, dass keine der betrachteten Maßnahmen allein gegen einen zukünftigen Fachkräftemangel wirken kann. Verschiedene Modelle wenden daher bereits Kombinationen aus den vorgestellten Ansätzen an. Hierbei sollte auf eine Vertrautheit des medizinischen Personals mit den speziellen Gegebenheiten in ländlichen Regionen sowie auf eine attraktive Gestaltung der Arbeitsbedingungen geachtet werden.Background: The demographic change and the increase of chronic diseases, combined with the increasingly complex need for care, presents new challenges to health policy in Germany. Especially in underdeveloped rural regions the need for action exists in order to ensure an appropriate medical care in these regions. In this context it is important to organize collaboration between physicians and other health care professionals. This is possible with the support of innovative forms of health care and the creation of new roles for health professionals, as the care of chronically ill people and the elderly requires more than just acute care. Objective: This review depicts, to what extent internationally applied measures for the recruitment of health care professionals, are able to counteract the shortage of skilled professionals in rural areas. Moreover, new professional roles and innovative structures of health care in rural areas are described. Methods: A literature review was conducted by means of a comprehensive search strategy in the databases PubMed and Scopus. We included studies which were conducted between the years 1990 and 2003, which described measures for recruitment of health care personal into rural areas and introduced new ways of health care. In addition, an expert survey was conducted via e-mail. Overall 65 experts were contacted via the „Health Systems and Policy Monitor-Network“, besides expert information from the European research project MUNROS was used. Results: For the majority of considered measures no evidence is available, however, a rural background is classified as the best evaluated and most effective measure to recruit physicians into rural areas. Measures as the establishment of medical faculties in rural areas and financial support during the studies along with the obligation to practice in a rural area show inconsistent results. Study results illustrate that the professional groups of the PAs and the NPs provide a high quality and cost effective work. In the USA, Canada, New Zealand, Australia and the UK most of the new care delivery models could be identified, however most of them have often not yet been evaluated. Conclusions: Overall, it has become clear that none of the considered measures can act alone against a future health professional’s shortage in rural areas. Therefore, different models are already applying combinations of the presented approaches. In this context a familiarity with the specific context of the medical personal should be regarded as well as an attractive design of the working conditions

Wie können Finanzierungsmethoden die Versorgung von Menschen mit Multimorbidität in Europa verbessern?

Payment mechanisms that take multiple chronic conditions into account and actually promote better integration of care are sadly lacking. This policy brief examines the steps policy makers must take if they are to adapt financing systems to support people with multimorbidity better. It looks at securing sustainable funding; options for upgrading payment mechanisms; and how financing mechanisms can stimulate good quality integrated care for people with multimorbidity. Key messages include that: * Payment mechanisms can provide key incentives for providers to collaborate, enable better care and create efficiency savings (while paying individual providers separately tends to block integration). * Innovative payment mechanisms (shared savings models, bundled payments, pay for performance) can be combined with more traditional models (budget, capitation, fee for service) but are inevitably complex. They need to adequately account for the complexity of cases treated which means drawing on very extensive data on cost and quality and considerable technical expertise. * Policy makers, who are working to make financing support integrated care, need to give a strong leadership signal and create supportive national and programme structures. They must: - Put in place information and support systems to deal with the complexity - Give proper thought to local conditions (and local capacity to cope) - Consider funding guarantees and other strategies for mainstreaming new approaches so that providers are encouraged to innovate, and - Take an incremental and long-term approach to change (including ongoing evaluation).EU, ICARE4EU, Innovating care for people with multiple chronic conditions in Europ