Integrated Framework of Care Toolkit

Presentation Overview• Drivers for change• What is integration?• Toolkit objectives• Leutz Integrated framework• Forms and types of service integration• Lessons from the literature• Leutz five laws • Quality measures• Summary• Where to from here?

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Drivers for Change

1. The Ministers expectations2. Demographic changes - ageing3. A range of providers supporting older

adults with multiple long-term conditions4. The need to improve the experience of

our service users through well planned community services preventing avoidable hospital and residential care admissions

5. Regionalisation of services - increased movement of service users & clinicians

6. Requirement for the most productive use of our health and social support workforces

“Although my inpatient care was very good, I had an

overall bad experience because

I was sent home without any

knowledge of how to access the

support services I needed”

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The Toolkit• Proposes a framework

specifying the different degrees of integration intensity required to meet different levels of client need

• Provides information on the different forms and types of service integration

• Offers a guide to planning integrated services

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What is Integrated Care?

An organising principle for service delivery aiming to achieve improved patient care through better coordination of services provided.

Integration is the combined set of methods, processes and models that seek to bring about this improved coordination. Done well, integration should lead to the outcome of integrated care.

Nuffield Trust: 2011

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All Integration is Local

The design of integrated services will vary depending upon;

- The particular issue creating difficulties for clients & service providers

- The constraints and possibilities within the local environment

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Leutz: First Law of Integration

‘You can integrate all of the services for some of the people, some of the services for all of the people, but you can’t integrate all of the services for all of the people’

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Levels of Integration Intensity• full integration resources are pooled

to create new services to meet the complex health/social needs of a targeted population group

• coordination bridges largely separate acute, long-term care, social support systems using case managers and agreed processes to help higher need clients manage transitions in and across care settings

• linkage people with mild to moderate health needs are cared for by systems which serve the whole population. No new services or care management required

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Operational Domains Matrix

• Design of integrated services varies depending upon the need of the client group/degree of integration intensity

• The ODI proposes operational domains which should be considered in service development demonstrating differences between the linkage, coordination and full integration levels

• Useful for development of new services or as an environmental scan on an existing suite of services to understand the intensity of integration across the services

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Operational Dimension

Linkage Coordination Full Integration Enablers in the Central Region context

Screening Screen population to identify emergent needs

Individualised needs assessment triggered by screening tool

Referral protocols to ensure that individuals who are screened and referred get to the service

Screen flow at key points (e.g. ED and hospital discharge, primary care providers) to find those who need special attention

Targeted selection of older adults for specific services designed to meet priority needs of service users and providers

Agreement between primary and secondary health care as to screening priorities

Agreement on common screening tools across Region, and access by service users, caregivers and professionals to those tools

Screening processes for high risk within integrated healthcare networks, accident and medical centres and Emergency Departments

Referral protocols and pathways locally and regionally

Identifying poor use of primary care

Reliable and common data extracts

Agreed stratification criteria for targeted services

Information regarding eligibility for services is easily locatable and contingencies to fund service gaps are available

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Matching Client Need to Integration LevelsNeed Dimensions Linkage Coordination Full Integration

Illness Severity Mild/moderate Moderate/severe Moderate/severe

Illness Stability Stable Stable Unstable

Illness Duration Short to long-term Short to long-term Long-term or terminal

Urgency of care Routine/non-urgent Mostly routine Frequent urgency

Scope of services needed

Narrow/moderate Moderate/broad Broad

Self-direction of client

Self-directed or strong

informal care

Varied levels of self direction

and informalcare

May accommodateweak self-directionand informal care

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Forms of Service Integration

Forms of integration which should be considered when an integrated service is being designed.

• Horizontal integration

• Vertical integration

• Virtual integration

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Types of Service Integration

Normative Integration

Systemic Integration

Organisational Integration

Functional Integration

Clinical Integration

Service Integration

Integrated Care to the

Patient

Organisational Integration

Functional Integration

Service Integration

Clinical Integration

Normative Integration

Systemic Integration

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Leutz Five Laws of Integration

1. You can’t integrate all the services for all the people

2. Integration costs before it pays3. Your integration is my fragmentation4. You can’t integrate a square peg into a round

hole5. The one who integrates calls the tune.

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Quality Measures

• Evidence on the impact of integration is limited• Measures for improvement should always be linked

to the programme objectives and aims, and be able to demonstrate that a change is an improvement (and not just a change)

• The IHI model for improvement questions can help define measures

• Structural, process, patient outcome measures can all be utilised.

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Summary1. Integrated services are a means to an end 2. Service design can be highly variable3. Leutz levels of integration intensity provide a global view of how much integration

is required for people at different levels of need4. The operational domains suggest activities that could be undertaken by

services/providers at various levels in order to meet client need and support service provision at other levels

5. Service planners should review the activities proposed at each level and apply them or not or in a variety of different ways

6. The need dimension table can be used to plan care for individual clients or to broadly analyse the numbers of people with needs which could be met by a linked, coordinated or 'fully' integrated service

7. Quality measures should be based upon the objectives of the service development - organisational, process and client health outcomes.

8. Great integrated service development requires a well informed and collaborative planning process

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• Provides a brief understanding of the Integrated Framework of Care

• References to the Framework document

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• International literature identifies that planning integrated care is a complex task

• To assist the Central Region DHBs to plan integrated care, a Planning Integrated Care Guide has been developed

• The guide provides a high level list of considerations for those involved in planning integrated services

• The questions posed are designed to promote a shared understanding of what the integration project expects to achieve and assist in a robust planning process

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• Case studies following Maria and Franz as they experience health changes and require different types of assistance

• Three case studies with emphasis on clinical / service integration

1. Linked2. Coordinated3. Integrated care

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Where To From Here?

• You can access the tool kit by going to: www.centraltas.co.nz/RegionalGroupsNetworks/

Central Region Health of Older People Network• Application in DHB planning processes• As a framework it is applicable to other areas such as

mental health• Follow up in April / May 2013 with DHBs• Report to the National Health Board in June 2013

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