Chapter 3: Population segmentation for patient-centred integrated care - a theoretical
3.2 Population strategies in integrated care
Integrated care models can take many forms.19, 21 Besides the degree of integration in terms of the type and number of care organisations involved, there is a range of areas within which integration can occur: co-localisation of services, transfer agreements, mergers, centralised information, care management, joint care planning, inter-agency planning and on-call
arrangements are just a few examples.21 Nevertheless, several research groups have defined broad levels of integration.
Leutz identified three levels of integration, reflecting different degrees of cooperation and coordination61:
Full integration occurs when new programmes or models are created that pool resources and responsibilities from several systems. Instead of merely coordinating
services, the new model holds control of the resources and is fully responsible for delivery.
Coordination depends on providers working together to provide ongoing care for patients in a coordinated manner, through joint planning, information sharing and clear accountability.
Linkage happens when clinicians are trained to identify the needs of their patients beyond their own services, and have ways to interact with other providers to deliver coordinated care.
The King’s Fund identified three population strategies for integrated care, which are similar to Leutz’ classification19, 62:
Macro-level integrated care, which provides a full set of services to an entire population. These models are more common in the United States, with examples such as Kaiser Permanente and the Veterans Health Administration.
Meso-level integrated care, which provides integrated care services to a specific sub-population. Often this sub-population is defined based on a chronic condition (e.g. diabetes, mental health) or age (e.g. older people), allowing specific specialist services to be included in the integrated care package.
Micro-level integrated care focuses on selected individuals, by providing them with care coordination services and focused care. Rather than integrating the entire care delivery system, this type of integrated care relies on specific teams to provide coordination and deliver additional services.
Valentijn et al. also describe macro-, meso- and micro-levels of care integration, however their definitions are slight different as they approach classification from an organisational angle rather than a population view63:
Macro-level system integration, a holistic integration of the entire health system, designed to provide patient-centred care.
Meso-level organisational and professional integration, focusing on relations between care organisations and between clinicians. Through collaboration and coordination between organisations and professionals, continuous and comprehensive care can be delivered.
Micro-level clinical integration, centring around the individual patient and the care process, where care services need to be coordinated across professional and institutional boundaries.
While the classifications differ slightly, at a high-level they describe three comparable levels of
38 Figure 6: Population strategies in integrated care
Whole population: While the care settings included may vary, macro integrated care models are developed for an entire population. These programmes are system-wide approaches to link up different care providers and settings. For example, integrated care organisations such as Kaiser Permanente provide an integrated service for their entire covered population.
Subpopulation: Meso-level integration focuses on a specific subpopulation of patients, and provides them with integrated services specific to their needs. This may be condition specific care, such as COPD or diabetes care, or care services tailored to older people. By integrating care for a defined subpopulation, specialist services required by that group can be included in the integrated care package. Bundled payments in the Netherlands are an example of meso-level integration.32 These payments are capitated, and intended to cover all disease-specific care needed to manage a patient’s condition over a set period of time.
High-risk population: By identifying high-need or high-risk individuals, care integration can be provided to those who need it most. Micro-level integrated care does not make systematic changes to the way care is provided, but rather integrates on a case-by-case basis by providing coordination services and case management. An example is the NHS in England, where risk stratification is used in primary care to identify high-needs patients, who are then provided with care planning and coordination.64
The majority of integrated care programmes in England focus on a subpopulation (see Table 7). Among the programmes in the Integrated Care Pilots scheme, a two-year initiative started in 2009 by the Department of Health,65 and in the Integrated Care Pioneers scheme,
launched by Monitor to identify local best practices,31 common subpopulations include older people and people with long-term conditions, specifically COPD and dementia. Of the three whole population integrated care models, only one specifies a population segmentation approach to better understand variations in care needs within the population.
Table 7: Population strategies of selected integrated care models in England
Organisation Population strategy Specific groups targeted
Dementia End-of-life Cancer Older people Mental health LTCs COPD CVD Diabetes Learning disab. Young people High risk Other
Barnsley20, 2 Subpopulation I
Bournemouth & Poole65 Subpopulation ✓
Cambridge Assura65 Subpopulation ✓
Cheshire31 Subpopulation ✓ II
Church View, Sunderland65 Subpopulation &
High-risk population ✓ ✓
Cornwall & the Isles of Scilly31 Subpopulation &
High-risk population ✓ ✓
North Cornwall65 Subpopulation ✓
Cumbria65 High-risk population ✓
Durham Dales65 Whole population I
Greenwich31 Subpopulation &
High-risk population ✓ ✓ ✓ III
Principia, Nottinghamshire65 Subpopulation &
High-risk population ✓ ✓
Southend31 Subpopulation ✓ ✓
South Devon & Torbay31 Subpopulation ✓ ✓ ✓ ✓ ✓ V
Staffordshire & Stoke on Trent31 Subpopulation ✓ ✓
Tameside & Glossop65 Subpopulation ✓
Torbay65 Subpopulation ✓ ✓ ✓ ✓ ✓
Tower Hamlets65 Subpopulation ✓
North Tyneside65 Subpopulation ✓
South Tyneside31 High-risk population ✓
Wakefield65 Subpopulation ✓ VI
Waltham Forest, East London & City31 High-risk population ✓
Worcestershire31, 66 Whole population I
I. No population explicitly defined II. Other: Families with complex needs III. Other: People with physical disabilities
IV. Whole population was segmented, some groups indicated in table
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