2. Complex health needs and the transition to integrated care models

Abstract

This chapter discusses the rise of integrated care models to cater to the needs of patients with complex health needs. It includes information on the types of integrated care models implemented in OECD and EU27 countries and their objectives. The chapter concludes with a short discussion on why integrated care models, despite their benefits, are not dominant in health and social care systems.

    

Key messages

People today are living longer with complex health needs

• Stronger healthcare systems and better socio-economic conditions mean people today are living longer: between 1970 and 2019, life expectancy grew by, on average, 11 years among OECD countries

• As people age, they are at greater risk of living with disease, disability, and dementia

• In addition to ageing, poor lifestyle behaviours, such as unhealthy diets, have contributed to the burden of disease (e.g. from type 2 diabetes, cancer, stroke)

Vulnerable populations are more likely to live with complex health needs

• Vulnerable populations, such as those with lower socio-economic status, are more likely to lead an unhealthy lifestyle (e.g. higher rates of physical inactivity)

• Riskier lifestyle behaviours mean vulnerable populations are at greater risk of developing one or more chronic health conditions

In response to rising complex health needs, countries are transitioning towards patient-centred, integrated care models

• Patients with complex health needs require care from different providers across multiple healthcare settings, as well as informal care. For this reason, providing co-ordinated care is of high importance to these patients.

• Failing to deliver co-ordinated care to patients with complex needs worsens a patient’s experience and outcomes and is costly.

• To improve treatment for patients with complex health needs, OECD and EU27 countries are turning to patient-centred, integrated care models. These models aim to improve patient experiences and population health, reduce the per capita cost of healthcare, promote a good work-life balance for health professionals, and advance health equity.

• There are many types of integrated care models. The different types of integrated care models have been summarised in several taxonomies.

As highlighted by the COVID-19 pandemic, patient-centred, integrated care models improve the resilience of healthcare systems

• In response to the COVID-19 pandemic, countries introduced several policies that altered the delivery of healthcare – such as telemedicine and hospital-at-home services.

• Selected case studies for this review provide real-world examples of these policies, which improved the continuity of care during the pandemic.

Despite efforts to promote integrated care, co-ordination among providers is often fragmented

• Care models among OECD and EU27 countries remain disease focused

• Fragmented care continues for several reasons including organisational (governance) and financial barriers, as well as an underutilisation of digital tools

• Fragmentation not only exists within the healthcare system but also between the health and social care systems

People today are living longer with complex health needs

Life expectancy has been steadily increasing across OECD countries. Between 1970 and 2019, life expectancy at birth increased by over 11 years among OECD countries, that is, from 69.7 to 81.0 (Figure 2.1) (OECD, 2021[1]). Gains in life expectancy reflect stronger healthcare systems, rising incomes, better education and improved living environments. The onset of the COVID-19 pandemic, however, saw life expectancy fall in many countries, including those in the OECD (OECD, 2021[1]).

Figure 2.1. Life expectancy at birth in OECD countries, 1970-2019 (or nearest year)

Note: The data ends in 2019 due to the impact of COVID-19.

Source: OECD (2021[1]), Health at a Glance 2021: OECD Indicators, https://doi.org/10.1787/ae3016b9-en.

Increasing life expectancy means people are living longer with health problems. As people age, they are at greater risk of disease, disability, and dementia. Therefore, people today are more likely to die “slowly from degenerative diseases preceded by years of multiple morbidity and advanced ageing” (Brown, 2014[2]). For example, across OECD countries, nearly two in three people aged 65 years and over live with one or more chronic conditions (OECD, 2019[3]).

Poor lifestyle behaviours contribute to an increasing burden of disease. Diets among OECD and EU27 countries are increasingly comprised of foods associated with weight gain (e.g. added fats and sugar) at the expense of foods with healthy dietary elements (e.g. fruits and vegetables). Concurrently, people today have fewer reasons to be physically active, for example, with the rise of labour-saving technologies. Combined, these two risk factors have fuelled high rates of obesity:1 as of 2019, over half of all men and women in OECD and EU countries live with overweight, which includes obesity, with rates higher for men than women (Figure 2.2). Overweight has contributed to poor population health given it increases the risk of developing several NCDs including type 2 diabetes, several cancers, stroke, and asthma (Nyberg et al., 2018[4]). Other risky lifestyle behaviours include alcohol and tobacco consumption.

Figure 2.2. Measured overweight (including obesity) rates among adults, 2019 (or the nearest year)

Note: The OECD20 average is unweighted.

Source: OECD Health Statistics 2022, https://doi.org/10.1787/health-data-en.

Rising rates of poor mental health also add to the burden of disease. The COVID-19 pandemic had a devastating impact on people’s mental health due to factors such as financial insecurity, social isolation, and grief. Data collected from several OECD countries estimate that around 12% of people experienced anxiety or symptoms of anxiety before the pandemic compared to 25% in 2020. Countries also saw rates of depression rise by nearly 15 percentage points over the same period (OECD, 2021[1]). Despite the significant health and economic impact of mental ill-health, mental health support is not sufficiently integrated into social welfare, labour, and youth policies.

Disadvantaged groups are more likely to live with complex health needs

People from certain vulnerable groups are more likely to engage in unhealthy lifestyle behaviours and suffer from mental ill-health. There are various reasons why people from vulnerable groups2 engage in riskier lifestyle behaviours that contribute to poor health. These include, but are not limited to, restricted access to healthy foods due to high prices or physical proximity to stores that stock such foods (i.e. “food deserts”), as well as lower levels of health literacy. Therefore, it is not surprising that risk factors such as obesity, tobacco consumption, and physical inactivity are more prevalent among vulnerable populations. For example, a recent analysis by OECD and WHO-Europe found a third of people who consider belonging to the “upper class” report never doing sport or exercise compared to around two-thirds of “working class” people (63%) (Figure 2.3). Those from vulnerable groups are also more likely to suffer from mental ill-health including indigenous populations, LQBQTI+ communities, certain ethnic groups including ethnic minorities, older adults, and refugees (OECD, 2021[5]).

Figure 2.3. Sports and exercise by socio-economic group

The proportion of people who reported doing sports or exercise regularly, with some regularity, seldom and never, by socio-economic group, the average for EU28

Note: Question asked was “How often do you exercise or play sport?”; regularly: at least 5 times a week; with some regularity: at least once a week; seldom: less than once a week.

Source: OECD/WHO (2023[6]), Step Up! Tackling the Burden of Insufficient Physical Activity in Europe, https://doi.org/10.1787/500a9601-en.

Riskier lifestyle behaviours mean vulnerable populations are more likely to live with one or more chronic health conditions. For the reasons outlined above, vulnerable populations are more likely to live with one or more chronic conditions. For example, a recent study by Mair and Jani (2020[7]) found that, after adjusting for lifestyle factors, those with low socio-economic status are at an increased risk of developing 18 of the 56 major diseases and health conditions compared to advantaged groups. This is reflected by data from EU27 countries showing that the proportion of people who report living with a long-standing illness or health problem is 15 percentage points higher among those living in the poorest income quintile compared to those in the richest quintile (43% versus 28%) (Figure 2.4).

Figure 2.4. The proportion of people with a long-standing illness or health problem by income quintile

Data for EU27 countries in 2020, or the latest year

Source: Eurostat (2022[8]), “Database – Eurostat”, https://ec.europa.eu/eurostat/data/database.

Despite having greater healthcare needs, vulnerable populations are less likely to access healthcare services. For example, certain vulnerable populations are less likely to utilise preventative care services such as cancer screening as well as digital tools due to low levels of digital health literacy and issues accessing the internet. Furthermore, vulnerable populations may experience barriers to accessing care due to financial reasons, waiting times as well as difficulties navigating the healthcare system (see Box 2.1 for further details) (OECD, 2019[9]).

Box 2.1. Vulnerable populations and access to healthcare

Among OECD countries, vulnerable populations are less likely to access healthcare services. For example:

• Differences in screening rates between the highest and lowest income quintile for cervical, breast and colorectal cancer are 17, 13 and 6 percentage points, respectively (with rates higher for those in the top income quintile) (OECD, 2019[9]).

• Nearly all individuals in the highest income quartile (97.6%) used the internet to access healthcare services in the past three months compared to 78% in the lowest income quartile (OECD, 2019[10]). There are similar differences when measuring access to broadband internet at home.

• 72% of people in the highest income quintile have visited a general practitioner (GP) in the past 12 months compared to 67% of those in the lower income quintile after adjusting for needs. There are similar differences when measuring access to specialist care (OECD, 2019[9]).

Vulnerable populations are therefore less likely to benefit from policy changes that improve the delivery of care.

In response to rising complex health needs, countries are transitioning towards integrated care models

Uncoordinated care is particularly problematic for patients with complex health needs. People with complex health needs require care from different providers across multiple healthcare settings, as well as informal care. For example, a patient with type 2 diabetes and hypertension may require care from a general practitioner (GP), an endocrinologist, a dietician, a cardiologist, and a practice nurse. Without proper care integration, such patients may try to address their unmet needs by using “excessive health and social services in an uncoordinated way” (Hudon et al., 2018[11]). Not only does this worsen a patient’s experience, but it is also costly and sometimes dangerous. For example, a study in the United States by Frandsen et al (2015[12]). found that high levels of care fragmentation were associated with an increase in expenditure equivalent to USD 4 542 (EUR 4 180) per patient between the years 2004-08. Further, patients who experienced high levels of care fragmentation were less likely to receive care considered clinical best practice and had higher rates of preventable hospitalisations (Frandsen et al., 2015[12]).

“Uncoordinated care is a particular problem for people with chronic conditions that require care and support, many of whom have multiple conditions associated with complex social needs.” (OECD, 2020[13])

“Persons with multi-morbidity often require care from multiple professionals within the healthcare and social care sectors. In a fragmented care system, this creates conflicting, overly-demanding, treatment advice that may discourage compliance.” (Leijten et al., 2018[14])

To improve quality and efficiency, countries are seeking to deliver integrated care to patients with complex health conditions. Patients with complex health needs incur higher costs; in the United States, 71% of healthcare spending comes from patients with at least two chronic conditions, despite comprising just over a quarter of the total population (Chapel et al., 2017[15]; Boersma, Black and Ward, 2020[16]). At the individual level, the cost of multimorbidity varies widely depending on factors such as disease combination as well as the country. In a recent meta-analysis, Tran et al. (2022[17]) estimated the annual, per person cost of multimorbidity between USD 800 and USD 150 000 (using international dollars). These figures are likely conservative given costing studies typically exclude societal costs such as a reduction in work productivity3 for the patient and their carer(s). Higher costs and worse health outcomes and experiences have prompted policy makers to find better ways of delivering care to patients with complex health needs. Specifically, by delivering integrated, patient-centred care.

The remainder of this chapter defines what constitutes integrated care and its objectives, prominent taxonomies used to classify different integrated care models, and the link between integrated care and patient-centredness.

What is integrated care?

Integrated care represents a significant change in the way healthcare services are designed and delivered. For this reason, the term has no agreed interpretation (Goodwin, Stein and Amelung, 2021[18]). Commonly applied definitions in OECD and EU27 countries are listed in Table 2.1.

Table 2.1. Commonly used integrated care definitions
Author	Definition
Leijten et al. (2018[14])	“Integrated care is defined as structured efforts to provide co-ordinated, pro-active, person-centred, multidisciplinary care by two or more well-communicating and collaborating care providers either within or across sectors”
WHO Regional Office for Europe (2016[19])	“Integrated health services delivery is defined as an approach to strengthen people-centred health systems through the promotion of the comprehensive delivery of quality services across the life-course, designed according to the multidimensional needs of the population and the individual and delivered by a co-ordinated multidisciplinary team of providers working across settings and levels of care. It should be effectively managed to ensure optimal outcomes and the appropriate use of resources based on the best available evidence, with feedback loops to continuously improve performance and to tackle upstream causes of ill health and to promote well-being through intersectoral and multisectoral actions”
Contandriapoulos et al. (2003[20])	“Integrated health services: health services that are managed and delivered so that people receive a continuum of health promotion, disease prevention, diagnosis, treatment, disease-management, rehabilitation and palliative care services, co-ordinated across the different levels and sites of care within and beyond the health sector, and according to their needs throughout the life course”
Lewis et al. (2010[21])	“I can plan my care with people who work together to understand me and my carer(s), allow me control, and bring together services to achieve the outcomes important to me”
Kodner and Spreeuwenberg (2002[22])	“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. The goal of these methods and models is to enhance quality of care and quality of life, consumer satisfaction and system efficiency for people by cutting across multiple services, providers, and settings. Where the result of such multi-pronged efforts to promote integration lead to benefits for people, the outcome can be called ‘integrated care”

What are the objectives of delivering integrated care?

At a high-level, integrated care models aim to achieve the following five objectives (“Quintuple aim”) (Nundy, Cooper and Mate, 2022[23]):

• Improve patient experiences of care (including quality and satisfaction)

• Improve population health

• Reduce the per capita cost of healthcare

• Improve the work-life balance of healthcare providers

• Advance health equity.

What types of integrated care models are there?

Integrated care models come in many forms. This section summarises key taxonomies of integrated care. These include taxonomies developed by the World Health Organization (WHO), the EU and the King’s Fund (United Kingdom).

World Health Organization (WHO)

As part of the 2016 working document, the WHO developed a taxonomy of integrated care comprised of four types of integration: organisational, functional, service, and clinical (Table 2.2). The taxonomy was adapted from Lewis et al. (2010[21]). One integrated care model may include several types of integration.

Table 2.2. WHO taxonomy of integrated care models
Integrated care model type	Definition
Organisational	“Integration of organisations are brought together formally by mergers or through ‘collectives’ and/or virtually through co-ordinated provider networks or via contacts between separate organisations brokered by purchaser”
Functional	“Integration of non-clinical support and back-office functions, such as electronic patient records”
Service	“Integration of different clinical services at an organisational level, such as through teams of multidisciplinary professionals”
Clinical	“Integration of care delivered by professional and providers to patients into a single or coherent process within and/or across professions, such as through use of shared guidelines and protocols”
Source: WHO (2016[19]), Integrated care models: an overview.

The WHO taxonomy aligns closely with the four types of integration outlined by Nolte and Pitchforth (Nolte and Pitchforth, 2014[24]).

SELFIE (Sustainable Integrated Care Models for Multimorbidity: delivery, financing, and performance)

The EU-funded Horizon 2020 project, SELFIE, developed a conceptual framework for integrated care specific to multimorbidity.4 The different types of integrated care models (or integrated care concepts) are grouped into one of six components: service delivery, leadership and governance, workforce, financing, technologies and medical products, and information and research. The models in each of these components are further categorised as to whether the model exists at the micro-, meso- or macro-level. A few examples are listed below:

• Multidisciplinary care teams are a micro-level workforce integrated care model

• Developing a culture of share vision, ambition and values is a meso-level leadership and governance integrated care model

• Policies to integrate care across organisations and sectors is a macro-level service delivery integrated care model.

Integrate Framework

As part of the EU-funded “Project Integrate”, Calciolari et al. (2016[25]) developed a conceptual framework outlining the key dimensions and associated items related to integrated care (Table 2.3). Several of these dimensions overlap with the framework developed by the WHO (e.g. functional integration).

Table 2.3. Project Integrate: dimensions of integrated care
Dimension	Example aligning items*
Person-centred care “Perspective of improving someone’s overall well-being – and not focusing solely on a particular condition/disease – through the active engagement of service users (patients, carers, etc.) as partners in care.”	Shared decision-making Shared care planning Patient access to their healthcare record
Clinical integration “How care services are co-ordinated and/or organised around the needs of service users.”	Assigned care co-ordinators Care professionals work together to undertake care assessments and planning
Professional integration “The existence and promotion of partnerships between professionals to work together (e.g. in teams).”	Formal agreements to support collaborative work between health professionals Multidisciplinary care teams
Organisational integration “How providers come together to deliver care services in a linked-up fashion across partner organisations”	Use of measures and indicators to monitor outcomes and performance Shared strategic objectives and written policies or procedures to promote integrated care
Systemic integration “How the care system provides an enabling platform for integrated care, such as through the alignment of key systemic factors” (e.g. financing mechanisms)	The care system aligns its regulatory framework with the goals of integrated care National and regional policies proactively support multi-sectoral partnerships and person-centred care
Functional integration “The capacity to communicate data and information effectively within an integrated care system”	A unique patient identifier that is used across the health and social care system Decision support systems foster shared decision-making
Normative integration “The extent to which different partners in care developed and shared a common reference frame (e.g. vision, norms, values) on care integration”	Existence of a collective vision of person-centred, holistic care Presence of leaders with a clear and common vision of integrated care
Note: *Not all aligning items are outlined in this table.
Source: Calciolari et al. (2016[25]), “The Project Integrate Framework”, http://projectintegrate.eu.com/wp-content/uploads/2017/04/The-Project-Integrate-Framework-TOP.pdf.

Other

Other classifications of integrated care include:

• Horizontal versus vertical integration: horizontal integration refers to co-ordination that occurs at the same stage of care delivery (e.g. mergers across hospitals). Conversely, vertical integration refers to when two or more organisations or services delivering care at different levels come together. These types of integration are not mutually exclusive, with many programs addressing both vertical and horizontal integration.

• Levels of integration: Curry and Ham (2010[26]) distinguish between different levels of integration:

  • Macro-level: where providers seek to deliver integrated care to the populations they cover

  • Meso-level: where providers seek to deliver integrated care for a particular population (e.g. disease management programs)

  • Micro-level: providers seek to deliver integrated care to individual patients and their carers through care co-ordination, planning and use of technology, for example.

How does integrated care promote patient-centredness?

Given the importance of incorporating peoples’ voices into the development of health systems, countries are increasingly interested in delivering patient-centred care (OECD, 2021[1]). Specifically, care that is “respectful of, and responsive to, individual patient preferences, needs and values, and ensures values guide all clinical decisions” (Goodwin, Stein and Amelung, 2021[18]).5

An important dimension of patient-centred care is care integration (see Box 2.2) (OECD, 2020[13]). Specifically, patient-centred care requires a “good flow of information and consistency of decisions across different levels of care in the health system, including primary healthcare settings, specialist settings and hospitals” (OECD, 2020[13]). Failing to co-ordinate care leads to patients repeating information and diagnostic tests, receiving conflicting information, and experiencing a breakdown of care when transitioning between providers, all of which worsen patient experiences and outcomes. Among selected case studies, there are several examples of how integrated care models promote patient-centredness. For example, in Finland, the City of Oulu’s patient-provider portal promotes information sharing between patients, and primary and social care professionals (see Chapter 5). Further, the integrated care model for multimorbidity in the Basque Country, Spain, utilises unified electronic health records (EHRs), which are accessible to all health professionals, as well as a “Personal Health Folder” that gives patients access to their data (see Chapter 6).

Box 2.2. OECD Framework for People-Centred Health Systems

The OECD Framework for People-Centred Health Systems includes five dimensions – voice, choice, co-production, integration, and respectfulness

• Voice: People have a formal role in health policy decision-making bodies or processes

• Choice: People have a choice of healthcare providers; people do not face barriers to access

• Co-production: People are given accessible information during care; people are consulted about their care; people are engaged in their care; people use digital tools to engage with their health and with the health system

• Integration: digital technology is used for the integration of care; electronic clinical records are used; people experience integrated and co-ordinated care

• Respectfulness: people receive high personal attention during care; people feel the treatment is fair; people are treated with respect by health professionals.

These dimensions allow policy makers to methodically analyse people-centredness within the health sector.

Source: OECD (2021[27]), Health for the People, by the People: Building People-centred Health Systems, https://doi.org/10.1787/c259e79a-en.

To address the social determinants of health, integration is needed across the health, social and long-term care settings, as well as in the home and community. For example, equitable access to housing, education, and nutritious foods, among others. Further, any effort to promote integration must consider the role of informal carers given they are responsible for a significant amount of care for older persons and persons with disabilities.

As highlighted by the COVID-19 pandemic, patient-centred, integrated care models improve the resilience of healthcare systems

The COVID-19 pandemic highlighted the need to deliver patient-centred, integrated care. COVID-19 saw a rapid surge in demand for treating acutely ill patients. To maintain preventive care services as well as manage care for patients with chronic conditions, countries introduced several policies that altered the delivery of healthcare. For example, many OECD and EU27 countries implemented policies that promote the use of digital tools to promote patient-centred, integrated care such as telemedicine, ePrescriptions, and hospital-at-home services.

Selected case studies for this review provide real-world examples of digital integrated care models used during the pandemic. Example case studies include the Finnish City of Oulu’s patient-provider portal, the Hospital-at-Home Programme in Catalonia, Spain, TeleHomeCare for patients with chronic conditions in the Italian city of Ceglie Messapica, and Telemonitoring for patients with advanced heart failure in Oloumuc, the Czech Republic. These case studies require countries to have advanced digital health systems, a workforce with the necessary skills to deliver digital care, as well as a population with access to digital tools and broadband internet access (for further details see Chapter 1: “Digital tools and health information systems”).

Policies, such as those outlined above, play a key role in making health systems more resilient against future shocks.

Despite efforts to promote integrated care, co-ordination among providers is often fragmented

Countries have implemented national policies to promote integrated care. These include policies related to the key dimensions of integrated care, namely financing, the workforce, and digital tools and health information systems. A summary of the policy landscape across OECD countries is in Table 2.4. Please note, the analysis only includes indicators where there is data for a significant number of OECD countries.

Table 2.4. Integrated care: Policy landscape across OECD countries
A darker shade indicates a stronger policy response to promote integrated care
Country	Financing	Workforce	Digital tools and health information systems
	Financial incentive for co-ordination	Policies to strengthen the primary healthcare workforce	Share (%) of primary care physicians using electronic heath records	Computers used by primary care physicians to prescribe, refer, and make orders**
Australia	Bundled payments & add-on payments*	Concrete measures	96.2	High
Austria	Add-on payments	Concrete measures	80.0	High
Belgium	Bundled payments	Concrete measures	..	..
Canada	Bundled payments & add-on payments	Concrete measures	77.2	Low
Chile	..	..	65.0	High
Colombia	..	..	..	..
Costa Rica	..	Concrete measures	..	..
Czech Republic	..	Planned	77.6	Low
Denmark	Add-on payments	..	100.0	High
Estonia	..	Concrete measures	99.0	High
Finland	..	..	100.0	High
France	Bundled payments, population-based financing & add-on payments	Concrete measures	80.0	Low
Germany	Population-based financing & add-on payments	Concrete measures	..	..
Greece	..	Planned	100.0	High
Hungary	..	..	..	..
Iceland	Add-on payments	Concrete measures	100.0	Medium
Ireland	..	Planned	95.0	High
Israel	Add-on payments	Concrete measures	100.0	High
Italy	Bundled payments & add-on payments	Concrete measures	..	Medium
Japan	..	..	..	..
Latvia	..	Planned	70.0	Low
Lithuania	..	Concrete measures	..	..
Luxembourg	..	Concrete measures	..	Low
Mexico	Add-on payments	Concrete measures	..	..
Netherlands	Bundled payments	Concrete measures	..	High
New Zealand	..	..	..	..
Norway	Bundled payments & add-on payments	Concrete measures	100.0	High
Poland	..	..	30.0	..
Portugal	..	..	..	High
Republic of Korea	..	Planned	..	..
Slovak Republic	..	Planned	89.0	..
Spain	..	..	99.0	High
Slovenia	..	Concrete measures	..	Medium
Sweden	Add-on payments	No plan	100.0	High
Switzerland	..	Planned	40.0	Medium
Türkiye	..	Concrete measures	..	Medium
United Kingdom	..	Concrete measures (England)	99.0	High
United States	Population-based financing	..	83.0	..
Note: *Add-on payments may be for co-ordination or prevention. **Composite indicator based on country responses to six questions. Each question refers to whether 75% or more of primary care physicians use computers for each of the following tasks: (1) making appointments, (2) ordering laboratory tests, (3) sending referral letters to specialists, (4) issuing drug prescriptions, (5) receiving alerts or prompts about drug dose or drug interaction, and (6) sending prescriptions to pharmacy. Countries are scored on a 1-3 (low to high) scale depending on the number of areas in which primary care practitioners use a computer. To establish three groups with a similar number of countries, countries with zero to four affirmative responses were given a score of one, countries with five affirmative responses were given a score of two, and countries with six affirmative responses were given a score of two. “..” means there is no data for that country.
Source: OECD (2021[27]), “Health for the People, by the People: Building People-centred Health Systems”, https://doi.org/10.1787/c259e79a-en; OECD (2020[13]), “Realising the Potential of Primary Healthcare”, https://doi.org/10.1787/a92adee4-en.

Despite efforts to promote integration, care models continue to be disease-focused and tailored to younger, healthier populations. Offering integrated, patient-centred care is a key policy priority among OECD and EU27 countries. As a result, several, mainly local level, integrated care models have emerged. Many of these models have shown great promise. Nevertheless, predominant models of care remain disease-focused and for this reason, disproportionately benefit younger patients to restore them to full health. See Box 2.3 for data summarising the level of care co-ordination among OECD and EU27 countries.

Box 2.3. Data measuring levels of care co-ordination among OECD and EU27 countries

There are several indicators to measure the level of care co-ordination in OECD and EU27 countries. This box presents salient indicators from both a patient and provider perspective.

Patient perspective

Figure 2.5 shows results from a 2016 survey of adult patients in 11 OECD countries. Results from the survey show around one-third (27%) of patients experienced care co-ordination problems. This was due to issues such as duplicate tests ordered, the specialist not having the patient’s medical history, and/or receiving conflicting information from different doctors (The Commonwealth Fund, 2016[28]).

Figure 2.5. The proportion of patients who experienced a problem with care co-ordination*

Note: *Care co-ordination issues include: test results/records not being available at appointment or duplicate tests ordered; specialist lacking medical history or regular doctor not informed about specialist care; and/or receiving conflicting information from different doctors or healthcare professionals in the past two years.

Source: The Commonwealth Fund (2016[28]), “Commonwealth Fund 2016 International Health Policy Survey of Adults in 11 Countries”, https://www.commonwealthfund.org/publications/surveys/2016/nov/2016-commonwealth-fund-international-health-policy-survey-adults.

Provider perspective

Figure 2.6 shows that, on average, just one in five primary care physicians receive results from the patient’s specialist within one week with data ranging from 9% in the United Kingdom to 33% in Switzerland. Other results from the same survey are summarised below:

• Just over half (56%) of primary care physicians are informed about changes to a patient’s medication or care plan

• Only a third (34%) of primary care physicians receive the necessary information to treat a patient once they have been discharged from the hospital within two days.

Figure 2.6. The proportion of primary care physicians who usually receive results from specialists within one week

Source: The Commonwealth Fund (2019[29]), “2019 Commonwealth Fund International Health Policy Survey of Primary Care Physicians”, https://www.commonwealthfund.org/sites/default/files/2019-12/PDF_2019_intl_hlt_policy_survey_primary_care_phys_CHARTPACK_12-10-2019.pdf.

Fragmented healthcare continues for several reasons. These include organisational and financial structures that do not support integrated care, and underutilisation of digital tools (OECD, 2021[27]; OECD, 2017[30]). For example, population-based payment models that pay a set of providers a lump payment (e.g. every month or year) to serve patients in the population-based network have been shown to incentivise care co-ordination as well as disease prevention activities (see “Governance and Financing” under Chapter 1 for further details and Chapter 3 for a real-world example) (OECD, 2020[13]). Despite this, only three OECD countries have population-based payment models in place (i.e. France, Germany and the United States). Regarding digital tools, data on the use of computers in primary care for tasks related to care integration as well as the share of primary care physician offices using EHRs indicate there is room for improvement (Box 2.4).

Box 2.4. Use of digital health technologies to co-ordinate care

This box outlines two key indicators measuring the use of digital health technologies to promote care co-ordination. Both indicators are collected from the primary care sector.

Use of indicators in primary care for tasks related to care integration

Fifteen out of 25 OECD countries with available data state that at least 75% of primary care physicians use computers to complete tasks that promote care co-ordination – e.g. making appointments, issuing prescriptions, ordering laboratory tests, sending referrals, sending prescriptions to pharmacies, and being alerted of drug dose or drug interaction issues.

Share of primary care physician offices using electronic clinical records

Among a selection of 10 OECD countries, nine have primary care offices that use EHRs as of 2021, which represents an increase from 70% in 2012. Despite progress, linking EHRs across the healthcare system has been slow, with primary care often excluded.

Source: OECD (2021[27]), Health for the People, by the People: Building People-centred Health Systems, https://dx.doi.org/10.1787/c259e79a-en.

Integration is also a problem between the health and social care system. Previous work by OECD in areas such as dementia, cancer, and cardiovascular diseases (CVDs) has highlighted the need to address care fragmentation between health and social care systems (Barrenho et al., 2022[31]). Data from the Commonwealth Fund’s survey of primary care physician supports the need to improve co-ordination between health and social care systems (The Commonwealth Fund, 2019[29]):

• Less than half (45%) of primary care physicians report frequently co-ordinating with social services or community providers, with the figure as low as 12% in Sweden

• On average, less than a third (30%) of primary care physicians noted a lack of a referral system or mechanism to make referrals to social care services

• Around 40% of primary care physicians noted a lack of follow-up from social service organisations about the services patients received or needed.

References

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Notes

← 1. For adults, WHO define overweight and obesity as having a BMI >=25Kg/m² and 30Kg/m², respectively. BMI is the most widely used proxy for body adiposity to assess population-level rates of overweight, as it is easily derived from a person’s weight and height (i.e. weight (kg) divided by height in metres squared).

← 2. There is no single definition of what constitutes being in a vulnerable group, however, in general it includes the following: lower incomes, lower education levels, living in rural/remote areas, or part of an ethnic minority group (OECD, 2022[32]).

← 3. Loss of productivity is caused by absenteeism, presenteeism, disability and premature mortality.

← 4. A diagrammatic overview of the framework is available using this reference (Leijten et al., 2018[14]).

← 5. Similar to the concept of “integrated care”, there is no single definition of “patient-centred care”. Several other definitions exist, including those outlined (Goodwin, Stein and Amelung, 2021[18]).