Hi Elsa

This is a great question and I think there are a number of places to look for answers, such as IHI.org. 

For me, I think integrated care should start with the patient / population you are serving and then consider (ideally with them) what are the expected services that are needed to provide the most care.

I work in the inner city and so that looks different to an average clinic. Our integration includes nurses with extra skills in wound care and hepatitis C management, nurse practitioners, counsellors, on site pharmacy, dietitian, acupuncture, psychiatrists doing "in-reach" to our clinic and the team doing out reach to the streets and shelter.

Being patient centric is  key piece when thinking about how to better integrate care in the community.

Thanks Morgan. That is a really good insight.

You may find pertinent information on SAMHSA-HRSA Center for Integrated Health Solutions. They also have a listserv (PC-BH Integration listserv) that you may find helpful (http://www.integration.samhsa.gov/about-us/connect-with-us).

I like Morgan's approach but he only lists professionals looking at health care. There is a body of work showing that 'episodes of unscheduled care' - that is emergency admission of ED attendance are due to a breakdown of social care support rather than new illness. The integrration of care once offered by general practitioner models of care in UK, Denmark, Netherlands and Ireland where there was continuity and integration of many aspects of care is now all but gone so read anything by Barbara Starfield and as Morgan says, keep the person who is the patient at the centre of your work.

You may already have found an American paper by Rosenthal in 2008 about medical homes (JABFM) but again is more focused on medical problems.

Henry - absolutely correct! And, yes, Barbara Starfield is also a fabulous reference and a great source of wisdom.

Much has been written (and developed) in this topic in Australia (including Adelaide), UK, US and Europe. Mot are agreed that the patient is central to any definition or model. Many also describe different levels of integration. Which raises the need to be precise in the way we use the terminology in the domain. For instance, we integrate systems to provide patient-centred and coordinated multidisciplinary care.   

I would be interested more about what you are considering "integration".  WHO has a technical brief pointing out that people mean different things when they use the term.  See: http://www.who.int/healthsystems/service_delivery_techbrief1.pdf   That brief states: "An overall working definition of integrated service delivery is 'The management and delivery of health services so that clients receive a continuum of preventive and curative services, according to their needs over time and across different levels of the health system.'”  

I'm going to assume that you do not necessarily mean that all services must be under one roof but rather that the practice is able to make needed services available to patients smoothly and coordinate their care.  If I'm in the right ballpark about your intent, then a way to get into providing integrated care for most of the patients in the practice begins with understanding their needs and making appropriate arrangements either inside or outside the practice to be able to address those kinds of needs.  When I was directly involved in practice management we thought of these as "make vs. buy" decisions; but the key issue is planning based on need.  I would like to suggest an equally simplistic approach to assessment of your effectiveness: Ask the patients whether they think their care is integrated and coordinated!  The Commonwealth Fund several years ago developed a few questions to assess whether patients feel they have a medical home.  In most countries, at least as of a few years ago, a high percentage of patients who did have a primary source of care did not meet the criterion for having a medical home.  One of the deficits was feeling that their care was coordinated.  This was particularly true for patients with chronic conditions or serious illnesses. See: Schoen C, Osborn R, Squires D, Doty M, Pierson R, Applebaum S.  " New 2011 survey of patients with complex care needs in eleven countries finds that care is often poorly coordinated."  Health Affairs  2011 Dec;30(12):2437-48. doi: 10.1377/hlthaff.2011.0923. Epub 2011 Nov 9

Agree absolutely with your thoughts and clarification of mine, Stephen. The PCMH and "Health neighbourhood" are some of the different ways we need to think about "integration" of of systems to coordinate services cost-effectively for the patient primarily and for the service secondarily.  The more traditional term would be a referral network, but I think integration is conceptualised as more that that - ranging from co-location to virtual networks.

I absolutely agree with you, too.  As this discussion proceeds I've been reminded of the fact that back in May, 2010, I was invited by AGPAL (Australian General Practice Accreditation Limited) to give the keynote address for their their bienniel meeting.  It was in Melbourne, and the several day conference was well-attended by a mixed group of practitioners and practice managers.  I'm attaching a copy of the PowerPoint I prepared for the keynote.  Although I was given the subject of addressing quality of care around the world, I did focus on primary care and on comparative international data that was available to me at the Commonwealth Fund, a grant-making foundation in New York City, where I worked.  In slide 6, I introduced "medical homes" and "medical neighborhoods" and later went on to give examples of various make vs. buy approaches.  fyi - slide 26 shows where I used to practice in Cambridge, Massachusetts and the kinds of services we had available on site for our patients.  

Although in general, as shown in some of the slides, Australia does better than the US, I am not sure that the average Australian general practice can provide as integrated care as we could at Harvard Community Health Plan or than Kaiser Permanente can do today.  I do not know the degree to which Australia is now developing a cadre of nurse practitioners, but back in 2010 when I also spoke at that meeting about the roles of advance practice nurses in the US we had proportionately many times more than existed in Australia.  I believe I was told that then there were only 400 in the country, and I calculated that to have our ratio of nurse practitioners to physicians in primary care practices, Australia would have needed 10,000 NPs.  In the US, the existence of NPs and physicians' assistants are making it easier to develop team-based care in primary care practices, and at places like Harvard Community Health Plan we adopted that model around 40 years ago! (seriously)  

Re-inventing the wheel is sometimes fun. But seriously, the context is important. so wheels work with different degrees of efficiency or effectiveness in different settings. Likewise, the Australian manifestation of integration will differ qualitatively from implementations of the same model in another country with a different health system. And we are not even considering the heterogeneity e.g. rural-metro in Australia or USA. The sad thing is that the Australian Health Workforce Agency has been mothballed with its functions absorbed with the Department of Health...

Interesting discussion and aligned with my work. In searching for measures of integration i have come across a paper form NZ by Sue Pullon et al: Developing Indicators of Service Integration for child health: Perception of service providers and families of young children in an area of high need in New Zealand, published in the Journal of Child Health care 12 august 2013. http://chc.sagepub.com/content/early/2013/08/02/1367493513496673

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