Integrated Care for Chronic Diseases – State of the Art

Abstract

Chronic diseases represent a high cost for healthcare systems, for individuals, fami‐ lies, businesses and governments. The World Health Organization (WHO) esti‐ mates that an increase of 10% of chronic diseases is associated with a reduction of 0.5% of annual economic growth. Primary care has proven to ensure high levels of efficiency, effectiveness, equity, safety, timely and centrality of the patient achieving better health outcomes and lower costs. The Chronic Care Model (CCM) proposes a proactive approach in assisting the empowerment of patients and their community. The CCM contributes to improving the quality of care and health outcomes and the reduction of inequalities (e.g., ethnicity, social status) too. The primary care team has the responsibility for coordination of care for patients living in the community. The teamwork integration is a crucial point. The integrat‐ ed care involves various programs designed to promote coordination within and between health care organisations, with the aim to improve patient care and health outcomes and to boost the overall efficiency of health care systems. Scientific evi‐ dence shows that integrated care reduces the use of some resources (hospitalisa‐ tions, emergency room visits, direct costs) in the management of chronic diseases, such as chronic heart failure, diabetes mellitus and chronic obstructive pulmonary disease. Vice versa, lack of integrated care risks making the care inappropriate, frag‐ mented and/or redundant and at risk of errors. The integration of system activity in chronic disease management, entrusted to the primary care, must be transposed and implemented by all health professionals who follow the patient. Health profes‐ sionals must organize care by adopting a patient-centred approach, supporting the paths of self-management and ensuring the exchange of information among both professionals and patients themselves and working in a public-health perspective. Continuity of care is one of the fundamental aspects of the integration programmes. Intermediate care and transitional care should assure the multi-professional coordi‐ nation and cover the connection and the patient's transition between the various areas of assistance, between the hospital and the patient's home. Last but not least, integrated care needs the patient's involvement as an essential tool of the process. There is growing evidence that effective self-management is critical to optimising health outcomes for people with chronic diseases.