I believe there are 6 challenges we need to overcome, in order to achieve integrated care objectives:
- Aligning the right objectives and interventions
- Agreeing governance and funding partnerships
- Engaging with participants
- Recruiting at scale and transitioning from current practices
- Building capability and capacity for change
- Measuring impact and ROI
Aligning the right objectives and interventions – Specific interventions delivered to specific patient cohorts in a specific way will deliver a particular set of results. For example, a primary prevention food and exercise program for the general population is unlikely to demonstrate a tertiary prevention goal of hospital avoidance in the near term. So the first challenge is correct design of a package of integrated care interventions, applied to a target risk group, with an appropriate objective or measure for success.
Agreeing governance and funding partnerships – Funding silos in Australia’s health system arguably prevent collaboration along a patient’s journey through different services. Disagreement between primary, community, secondary and tertiary health payers and providers is a common bottleneck to health reform, even when the changes are compelling and obvious. For example, care coordination is commonly identified as an unmet need for patients with complex health conditions, yet State and Federal Government debate who should fund, deliver and capture potential cost savings. I know of a few examples at a health service level where integrated care efforts fell over with this early challenge – to agree partnership arrangements that achieve net system and patient benefits.
Engaging with participants – by definition, integrating care means working with a plethora of consumers, clinicians, administrators, payers, providers and peak bodies. Healthcare is a relationship business and siloed efforts to deliver improvements often prove challenging and unsuccessful. For example, a Sydney hospital claims to be already providing integrated care for chronic disease patients, even though their records are not shared with primary care providers (that see the same patients) nor have team discussions with these providers. Likewise, a general practitioner by themselves, or working only within the 4 walls of their medical centre, will find it hard to support patients throughout all their touch points with the health system.
Recruiting at scale and transitioning from current practices – good designs, aligned governance and robust stakeholder engagement may still result in sub-scale implementation (or type 3 error) if execution is sub-optimal. Driving recruitment is a hands-on, intensive project management exercise that requires a multi-channel, peer-to-peer, high-energy approach. Enrolment into new programs or services by both patients and providers requires careful change management. Thus the fourth challenge is implementing at scale (often to prove a statistical outcome or generate adequate return on investment to cover fixed costs) and managing the necessary change in behaviours.
Building capability and capacity for change – Achieving sustainable improvement in the quadruple aims through integrated care requires building skills and capacity for change. Participants need to understand the delta from today, be trained or coached in the new behaviours required, have change agents or role models to learn from, and have mechanisms that reinforce positive changes, such as incentives or measurements. Two out of three change programs fail in any industry – the fifth challenge is managing long-term change. For example, most first nation health systems are pivoting from fee for activity to value-based funding; those that change quickest and most effectively will achieve the best clinical and economic outcomes.
Last, many services and programs are not properly measured and evaluated. Adequate measurement requires adequate sample size to eliminate chance findings, controlling for co-founding factors and type 3 error, allowing multiple comparison points (such as control comparison as well as time series to accommodate any mean regression), ensuring adequate intervention time and follow-up, and independence and skill in appropriate research methodology. Given the rising costs of healthcare, and opportunity costs in that spending, it is imperative we measure impact and the return on investment in order to steer funding toward services and patients that have greatest bang for buck benefit.
I’ll give my 5 cents on how to overcome each of these challenges next.