3. Evidence for integrated care

I believe there are five opportunities for health systems to better integrate the way they fund and deliver health care. These are defined by the time between intervention and hospital avoidance, as relevant to patients with chronic disease:

  1. Up to 5 years: We can prevent chronic disease from de-conditioning by consistently managing according to best evidence. For Australians living with diabetes, up to two-thirds of cardiovascular risk indicators are above clinical desired targets at any time, resulting in early cardio-vascular complications. The UK prospective diabetes study showed that better glycaemic (sugar) control is correlated with a 16 percent reduction in heart attacks, 24 percent reduction in eye/kidney disease and 27 percent reduction in death after 10 years. For Australians with chronic lung disease (COPD), providing pulmonary rehabilitation (e.g. chest physio) for only 4 patients will reduce 1 hospital admission, yet this simple and cost-effective intervention only has 15 percent uptake for this disease group. Overall, a large clinical audit in Australia (CareTrack study) identified 50 percent care gaps for Australians with chronic disease, gaps that are easily addressed by following clinical guidelines.
  2. Up to 1 year: We can address warning signs of chronic disease deterioration before it becomes a hospital presentation. According to Medicare statistics, less than half of Australians with chronic disease receive an annual care plan designed to proactively support their health conditions – routine vaccinations of COPD patients, weight loss in overweight hip and knee osteoarthritis patients, and physical strengthening in falls risk patients, can all demonstrate significant hospital risk reductions via team-based care. Tele-monitoring can also catch chronic conditions before they get worse – a CSIRO study demonstrated a 36 percent reduction in hospital admissions as well as a 40 percent reduction in mortality.
  3. Up to 1 month: If chronic disease does deteriorate, we can support patients in more convenient and lower acuity settings. Extending longitudinal care afterhours, providing home-based care, and enabling telehealth services such as virtual GP consultations. In some US health systems today, already 50 percent of primary care consultations are virtual. Moreover, supporting patients through education, service directories and symptom action plans helps one understand what can go wrong (e.g. anxiety making breathlessness in lung disease worse), what to do when it happens (e.g. relaxation, inhalers) and who to call for help (e.g. nurse on call, family support). Tele support by phone, provided by care coordinators or navigators, can proactively detect health issues before they escalate.
  4. Upon hospital presentation: If hospital presentation is eminent, we can support decision making at the point of care to avoid automatic admission to in-patient care. Sharing GP records in emergency departments (like in New Zealand through acute care plans) enables more informed management. For example, if an end stage COPD patient on home oxygen de-saturates from a baseline of 90 percent oxygenation (oxygen levels), treating a chest infection and exacerbation with inhaled medication, and getting the patient back to 90 percent may mean he or she can go home.
  5. At hospital discharge. Scrutinising discharge letters, timely communication with GPs and primary care teams, plus proactive follow-up can reduce unfortunate and costly hospital readmissions. Australians over 65 years of age who are admitted to hospital suffer a 30-day readmission rate of 15 percent, and 40 percent of these readmissions are related to medications. Providing more comprehensive discharge care (e.g. involving GPs at discharge) or proactive follow-up (e.g. telephonic support) can reduce 28-day readmissions by up to 30 percent, compared to controls. We don’t do this consistently – there is still a public hospital in Australia today that has a room, where rostered resident medical officers write discharge letters for patients they never saw, up to 9 months after discharge.

Given these opportunities, it is worthwhile learning from examples of successful integrated care providers and programs.


  • Australian Diabetes Care Project, Federal Health Department
  • UK Prospective Diabetes Study, 10 year follow-up
  • Int J Chron Obstruct Pulmon Dis. 2009;4:315-9. Epub 2009 Sep 1: Effects of pulmonary rehabilitation on exercise capacity in patients with COPD: a number needed to treat study
  • MJA 2012, CareTrack study
  • Medicare statistics
  • https://www.csiro.au/en/News/News-releases/2016/Home-monitoring-of-chronic-disease-could-save-up-to-3-billion-a-year
  • Australian Health Review, CSIRO publishing: Effect of post-hospital discharge telephonic intervention on hospital readmissions in a privately insured population in Australia
  • JAMA, 2004: Comprehensive Discharge Planning With Post discharge Support for Older Patients With Congestive Heart Failure