6. Designing the right model of care

A business case for integrated care needs to have:

  1. Right objectives: For example primary prevention (reducing chronic disease incidence) vs secondary prevention (reducing complications and progression of chronic disease once diagnosed) vs tertiary prevention (reducing hospital admission and improving quality of life once progressed) objectives need to be clearly defined.
  2. Right interventions: The correct evidence-based services and levers need to be applied to achieve the defined objective. For example for hospital avoidance, care planning and review, team-based care, rapid response teams, discharge planning and care coordination have been shown to be the most effective interventions. For health behaviour change, it is health coaching, self-management, group education and service navigation.
  3. Right cohort: Patients need to be ‘impactable’ by the interventions proposed – proactive care planning and coordination may have limited impact on major trauma, dialysis and palliative care patients for example, that require specialised tertiary services.
  4. Right enablers: Delivering a new model of care requires appropriate financing, clinical leadership, information technology, reporting systems and patient engagement. Healthcare homes for example, will struggle if there is no additional funding, does not empower clinical leaders to adopt new ways of working, does not provided connected IT, does not share real-time progress, and does not engage patients in a different way.
  5. Right KPIs: In line with the set objectives, the appropriate key performance indicators must be measured and reported back to participants. This may include customer net promoter score, patient activation measure, portion of patients with chronic disease managed to clinical guidelines and clinical metrics meeting clinical target range, rates of ED presentation and hospital admission (and readmission) and patient mortality.