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Providing integrated care for older people with complex needs

Lessons from seven international case studies


Around the world, rapidly ageing populations are resulting in increased demand for health and social care services, which presents significant challenges for national health and care systems. Many have adopted an integrated care approach to meet the needs of older people with chronic or multiple conditions. This approach often involves a single point of entry – designating a care manager to help with assessing needs, sharing information, and co-ordinating care delivery by multiple caregivers (formal and informal).

This report synthesises evidence from seven case studies covering Australia, Canada, the Netherlands, New Zealand, Sweden, the United Kingdom and the United States. It considers similarities and differences of programmes that are successfully delivering integrated care, and identifies lessons for policy-makers and service providers to help them address the challenges ahead.

Key findings

  • There is no single organisational model or approach that best supports integrated care. The starting point should be a clinical/service model designed to improve care for people, not an organisational model with a pre-determined design.

  • Although all seven programmes made considerable efforts to improve communication between professionals and organisations, few used shared electronic medical records or integrated IT systems. Evidence from the case studies suggests that personal contact with a named care co-ordinator and/or case manager is more effective than remote monitoring or telephone-based support.

  • Organisational integration does not necessarily lead to patients receiving integrated care. Four of the seven case study programmes focused on integrating care at the micro-service level.

  • The literature on care co-ordination suggests that effective approaches often have a GP or primary care physician at the centre of a team-based approach. However, within the case study programmes, primary care physicians are rarely part of the ‘core’ team. Professionals need to work together in multidisciplinary teams (with clearly defined roles) or provider networks – generalists and specialists, in health and social care.

Policy implications

National policy-makers should:

  • recognise the importance of addressing the agenda of integrated care for older people with complex needs

  • provide stimulus through funding or other means to support the development of local initiatives to improve care for this group of patients

  • avoid a top-down policy that requires structural or organisational mergers

  • remove barriers, such as differences in financing and eligibility, in the system.