Providing integrated care for older people with complex needs: Lessons from seven international case studies

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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.

Related document: Providing integrated care for older people with complex needs: Background to case studies



providence house of ageing
Comment date
22 August 2014
how can we find grant and support for this eldery house

mvuleni mkhabela

project cordinator,
sinelisiwe our home of safety
Comment date
29 March 2014
We would like to get financial help from international organisation so as to work on our programs in place for the benefit of the elderly in our community.


Digital Communications Assistant,
The King's Fund
Comment date
06 February 2014
Hi Jonathan,

Thanks for your comment and I'm pleased that you found the paper useful.

We've checked with the author, and should mention that Figure 1 is actually adapted from the original by Valntijn et al. Our version places an additional layer in the framework to highlight the importance of functional integration as a technical task to support effective information and communication sharing.

We asked the author for more background on these changes and have copied this for you below:

As the text in the report explains, it would indeed be correct to recognise information and communication as a transversal issue alongside normative integration. Yet in our case studies we found the need for someone, or some agency, to play the 'stewardship' role to support this flow of communication and information – for example, to act as a repository of data and information and then to use this to communicate actions. This role tended to happen best when located somewhere between the organisational and professional levels, which is why we have placed this additional feature in the diagram.

At the clinical and service level, there is clearly an important relationship between the cultural affinity to work together in teams and the subsequent effectiveness of information and communication flow, yet what appears to be the case is the need for an 'information broker'. Typically, in our sites, the main point of information exchange was in multi-disciplinary team meetings where information from all levels is gathered to make effective decisions. Effective gathering and sharing of data to supply the right information for decision-making is needed for this.

I hope that explains the figure a little more. The report should have mentioned that it was adapted so our apologies for that.



Jonathan Oldman

Comment date
05 February 2014
Great article - thanks. FYI: you mislabelled one of the axis on the Valentijin Fig 1 on page 9. One should be "Functional Integration". it confused me so I looked it up!

anne simmonds

penninecare tameside hospital
Comment date
01 February 2014
As I am A clinical scholar in the process of developing an integrated-care coordinated service pathway for older adults whom are at risk of hazardous /harmful drinking this is encouraging! -useful evidence in removing the managerial barriers to change in an overloaded, change saturated system.Good to remember that the client need is the only constant.

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