Integrated Care & Population Health

The provision of health and social care for patients is complex. That complexity and the silos and barriers between care providers has led to greater cost and often gaps where care becoming fragmented or delivered to the detriment of patients. Recognising that patient care is delivered across different care settings, whether it be primary, acute, mental health or in the community, the models for care provision are changing. To support those new models of care, how providers, and their systems and data work, is also having to change.

Integrated care results when the culmination of these processes directly benefits communities, patients or service users – it is by definition ‘patient-centred’ and ‘population oriented’. This is where the term population health has emerged. The intention of integrated care contributes to better care experiences; improved care outcomes; delivered more cost effectively.

There are different forms of integrated care, these include:

• Horizontal integration – Integrated care between health services, social services and other care providers
• Vertical integration – Integrated care across primary, community, hospital and tertiary care services
• One sector Integrated care e.g. within mental health services through multi-disciplinary teams or networks
• Integrated care between preventive and curative services
• Integrated care between providers and patients to support shared decision-making and self-management

What is important to consider that integration without care co-ordination will not and cannot lead to integrated care. There must be a unified approach to ensure both clinical and service integration takes place.

Key organisational and management barriers

• Bringing together primary medical services and community health providers around the needs of individual patients
• Addressing an unsustainable acute sector
• Developing capacity in primary care to take on new services
• Managing demand and developing new care models
• Establishing effective clinical leadership for change
• Overcoming professional tribalism and turf wars
• Addressing the lack of good data and IT to drive integration
• Involving the public and creating a narrative about new models of care
• Establishing new forms of organisation and governance

Populo has developed unique and robust approaches to helping organisations adapt to integrated care and adopt population health management. We identify the local challenges associated with bringing together systems that were not designed to naturally work together focusing on not just interoperability and integration, but how these will work together and be used by staff to realise the benefits from integrated care for patients.

For more information on this service please download the PDF here

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