Managing chronic diseases − a framework for integrated services

Abstract

The management of chronic diseases has replaced acute care in today’s work portfolio of ambulatory care providers. According to World Health Organization (WHO) the burden of largely preventable Non-communicable diseases (NCDs) in the WHO European region is estimated at 80% [1]. The preference for hospital care, low quality of primary care services, out-dated clinical procedures and limitations in home based care generate a high number of unnecessary hospitalizations. The 2015 study report on Ambulatory care sensitive conditions in the Republic of Moldova [2] showed that 60% of hospitalization for hypertension and 40% for diabetes could be avoided by a better performing Primary Health Care system. Increasing disease focus advances in medical technology and specialization as well as the lack of patient information across provider systems leads to a fragmentation of care, duplication of services and possibly overmedication. In older populations, however, a single morbidity focus is not improving patients’ quality of life. The contribution of a single disease to the mortality risk continuously decreases with age and factors like frailty and disability become stronger predictors of adverse health outcomes [3]. The management of chronic diseases in older people needs to shift from prolonging life towards extending disability-free life expectancy [4]. This shift requires an integrated approach to the provision of services with people at its centre. WHO launched its Global Framework for Integrated People centred Health Services (IPCHS) during the 2016 World Health Assembly [5]. The approach requires the health system to think beyond disease and rather focus on the comprehensive needs of people and communities including empowering people to play a more active role in their own health. There are a variety of concepts on care integration in the literature but the common denominator of all is their focus on people, services, provider systems and change management. Conventional care systems mostly focus on vertical delivery of disease specific care. Service quality is evaluated by the quality of its inputs through professional mechanisms (guidelines, provider performance, audits). The focus on people and communities requires a broader range of services of different provider groups leading to a higher integration and coordination. In an integrated service approach the whole person with his complex needs is considered and services are provided through close collaboration of the entire provider system. Service performance and quality in this context are evaluated by considering the quality of patient outcomes, such as functional status, maintenance of independence and quality of life. People centred care includes by definition services closer to home through care networks, prevention of unnecessary hospitalization, offering choice and probably the use of new technologies, particularly for information sharing. Putting people in the centre of a service network requires support and coordination, which can be delivered by family physicians networks, (community) nurses, home based care and social work, like in Germany or Switzerland; through hospital networks like the Health Maintenance Organizations (HMO) of the United States or through Government systems like the National Health System (NHS) of Great Britain. There are a variety of innovative responses to patient needs in the framework of IPCHS. However, most systems use some of these innovations and there is little experience with countrywide coverage. In Switzerland for example physicians operate within geographical networks sharing patient data, subscribing to joint quality standards and using peer review mechanisms (quality circles) for continuous quality improvement of their services. People centred care is quite common in rehabilitation work, particularly for brain injuries, where complex service interactions are required. Estonia is probably one of the most advanced countries concerning the use of electronic platforms to securely sharing patient data across the entire country. An important part of the instrument is an online patient portal with access to personal health information including treatments, test results and prescriptions. The Scotland NHS subscribes to a lead agency model under which health and social services are integrated to coordinate comprehensive services for adults and children, a model closely related to the WHO model of health through the life-course approach. Current models of care integration provide useful examples for the organization of people centred care. Provider coordination of health, social and health education services are of key importance independent of who the coordination body finally is. Sharing patient information across provider networks and opening this information to patients themselves facilitates quality control and continuous improvement and keeps the patient in the driving seat. Service providers need to seamlessly connect and interact, focusing on people’s outcomes rather than on professional inputs.