Integrated health care for people with chronic conditions. A policy brief.

1-page key messages\ud \ud * Uncoordinated care can affect the quality and efficiency of health care, access to care, participation in and satisfaction with care, and health outcomes for chronically ill patients. However, there is a paucity of data in Norway that provide a basis for estimating the size of the problem or clarifying the underlying reasons for inadequate coordination.\ud * The impact of many changes in delivery, financial and governance arrangements that could be made to improve the coordination of care for people with chronic conditions is uncertain; evaluation is critical when such changes are made. \ud * Components of the Chronic Care Model and disease management programs, alone or in combination, can improve quality of care, clinical outcomes and health care resource use, but the effects are not consistent and a number of obstacles may hinder their use.\ud * The impacts of delivery arrangements that have been shown to be effective (e.g. patient education and motivational counselling, provider education, feedback, reminders, and multidisciplinary team work) are generally modest, but important. There is uncertainty about the impacts of other arrangements (e.g. care pathways, case management, and shared care).\ud * Targeted financial incentives with the aim of achieving specific changes in how care is delivered probably influence discrete individual behaviours in the short run, but are less likely to influence sustained changes, and they can have unintended effects, including motivating unintended behaviours, distortions, gaming, cream skimming or cherry-picking, and bureaucratisation. Therefore, they require careful design and monitoring.\ud * Similarly, changes in the basic payment methods that are used for both clinicians and institutions in order to offset the inherent limitations of each require careful design and monitoring. A long-term perspective with continual adjustments is more likely to be successful, than dramatic one-off changes.\ud * There is not evidence to support any one governance model as being better than others. However, specific structures are likely needed at different levels to improve coordination:\ud *\ud o Clinical governance (healthcare professionals' accountability for quality of care) for both primary and secondary care\ud o Boards at the local level that conduct detailed oversight and monitoring for both primary and secondary care\ud o A regional board that coordinates different local networks in the region\ud o A central governance structure that sets broad standards, which the regional and local boards are responsible to adhere to and implement\ud * Consumer and stakeholder involvement in governance arrangements at all levels is a strategy for achieving better coordination of care and other health goals, as well as a goal in itself, but there is little evidence of how to best to achieve this.\ud * Because there are multiple barriers to organisational and professional change, simple approaches to implementing change are unlikely to be effective, change is likely to occur incrementally and to require ongoing attention. \ud \ud There are many tools that may be useful for implementing organisational changes, including analytic models, tools for assessing why change is needed, such as SWOT analysis, and tools for making changes, such as organisational development and project management. However, there is almost no evidence of their effectivenes