Clinical Continuity by Integrated Care

Clinical Continuity by Integrated Care

Torben Larsen (University of Southern Denmark, Denmark)
DOI: 10.4018/978-1-60960-183-6.ch014
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The fragmented delivery of healthcare and social services was put on the research agenda by WHO in 2002. Integrated Homecare (IHC) combining efficacy with net savings represents a prototype of integrated care for better clinical continuity. Frequent chronic conditions as stroke, heart failure and chronic obstructive pulmonary disease exhibit parallel results as explained by a common neuroeconomic framework. A SWOT analysis of IHC emphasizes: 1) Strength: health economic dominance; 2) Weakness: fragmented financial conditions; 3) Opportunity: low-tech patient benefits affordable to European countries facing tight finances as the elder share grows; 3) Threat: low levels of trust across professions and settings. A meso-strategy for EU recommends: 1) A health technology assessment (HTA) of IHC by multidisciplinary teamwork across the hospital and primary care interface synthesizes existing research for health care decision-makers. 2)Dissemination focuses on a regional level with direct contact between the clinical and financial level, see information on practical implementation guides at
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Methods And Materials

General Strategy of Evaluation

The essence of IC is ‘overlapping’ services in the secondary/primary interface after discharge in contrast to coordination at the management level alone (Gröne, 2002, p. 2). IC should apply only as far as quality outcomes are improved with the overall aim to improve equitably distributed population health (Gröne, 2002, p. 3). He illustrates the causal relationships derived from IC as reproduced in figure 1.

Figure 1.

Action model for integrated care (IC)


Operational quality outcomes are crucial for the design of IC. Mortality is seldom a major indicator for IC. Typically, studies of effectiveness on IC address activities of daily living (ADL) as:

  • 1.

    Referrals to permanent institutional care (i.e. nursing homes)

  • 2.

    Independence in ADL as indicated by functional indices as Barthel Index (BI) or Functional Independence Measure (FIM)

  • 3.

    Shortened length-of-stay at hospitals / less readmissions

Evaluation of the relationship between IC and outcomes will follow best international practice as formalised in the international operation of Health Technology Assessment (HTA). According to the definition of HTA by EUnetHTA:

Health technology assessment (HTA) is a multidisciplinary process that summarises information about the medical, social, economic and ethical issues related to the use of a health technology in a systematic, transparent, unbiased, robust manner. It aims to inform the formulation of safe and effective health policies that are patient focused and seek best value.

HTA may address direct and intended consequences of technologies as well as indirect and unintended consequences. The main purpose of an HTA is to assist informed technology-based policymaking in health care. Most health professionals and many decision-makers in health care might comply with the conclusions from an HTA as far as it investigates all of the following aspects:

  • 1.

    Effectiveness regarding the physiologic outcome of the intervention

  • 2.

    Patient safety and satisfaction, solicited i.e. by focus group interviews

  • 3.

    Economic efficiency based on the principle of alternative costs

  • 4.

    Organizational implementation of the intervention

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