Integrated healthcare: the past, present and future

Abstract

To cite: Dawda P. Integrated healthcare: the past, present and future. Editorial © Author(s) (or their employer(s)) 2019. Re-use permitted under CC BY-NC. No commercial re-use. See rights and permissions. Published by BMJ. Integrated healthcare, an international buzz word, is not a new phenomenon or concept. For spectators of the health system, integrated care activity is very apparent across the developed nations, reflected in the exponential growth of scholarly interest in the subject over the last 20 years. For example, almost three-quarters of the results identified by Google Scholar for an exact match for 'integrated healthcare' were publications since the millennium (with two-thirds of them since 2010). This editorial presents a perspective on the past, present and future of integrated care. The understanding and learnings from integrated healthcare have been confused by a lack of definitional agreement. The literature is plagued by terms such as integrated care, coordinated care, comprehensive care, seamless care, chronic disease management or joined-up care, to name just a few. Over 175 definitions 1 are identified sometimes shaped by perspectives of different stake-holders, for example, patient, provider, policymaker, funder and evaluator. 2 Some are synonyms, and others have overlapping concepts, constructs and taxonomies. Integrated care is closely associated with other concepts such as continuity of care. However, common to all the definitions is an organising principle where the needs of the patient (or population) are central. 3 This principle has appeal, particularly if integrated healthcare is perceived to be a response to the adverse outcomes and experiences of care associated with fragmented care. 4 A patient-orientated definition of integration is 'a coherent set of methods and models on the funding, administrative , organisational, service delivery and clinical levels to create connectivity, alignment and collaboration within and between cure and care sectors'. 5 The desired impact articulated as a patient narrative for integrated care is 'my care is planned with people who work together to understand me and my carer(s), put me in control, coordinate and deliver services to achieve my best outcomes'. 6 Subject to the choice of definition, the origins of integration, that is, the set of 'processes, methods and tools that facilitate integrated care', 2 trace back to Hippocrates in 430 BC in the statement 'the body must be treated as a whole and not just a series of parts', for example seeking to integrate behavioural health and physical health (a common integration subject matter, particularly in the USA). 7 Examples of literature from the early 20th century consider solo medical practitioners reorganising themselves into collective and collaborative organisational forms to improve effectiveness and efficiency. 8 However, much of the initiatives and literature on integrated care are very much more recent. For example, initiatives in the National Health Service in the 1960s were mostly concerned with multidisciplinary care, with partnership working in the 1970s, and a focus on disease and care management in the 1980s and 1990s. 2 Early integrated healthcare initiatives were mechanistic and took a linear perspective of care delivery with mostly top-down initiatives demonstrating minimal impact. 9 Progressive emergent thinking was shaped by recognition of healthcare and well-being as a function of complex adaptive systems. The resultant paradigm change in the approach to integrated healthcare was one of contextual learning and sense-making. Over that time, fundamental strategic shifts in integrated healthcare were noted. 9 These shifts have led to the current form and shape of integrated care activities. The drivers for seeking better-integrated healthcare initially were financial, with payers seeking greater efficiencies or providers seeking higher profits. 9 The drivers are increasingly overlapping to improve effectiveness and efficiency, thereby focusing strategies for integration activities on people who are most likely to benefit from them, 9 for example, the elderly or frail people. Such population-based approaches to target activities seek to identify and segment populations with similar clinical