Integrated care aims to provide proactive, coordinated care for patients through collaboration between health sectors. It involves collecting common patient data, stratifying patients by risk level, and creating joint care plans in cross-sector teams. The goals are to improve the patient experience through more coherent care, support self-management, and make the health system more sustainable by preventing unnecessary hospitalizations and costs. An integrated care project in Odense has established the necessary foundations and is currently testing collaboration models and common digital tools for elderly patients and those with mental health issues, with the first patients enrolled. The project will be fully operational on September 1, 2014 and evaluated by the end of 2015.

1. Presentation of Integrated Care

2. Presentation of Integrated Care
1.
2.
3.
4.
What is Integrated Care?
The ambitions of Integrated Care
How do we work in Integrated Care?
Milestones and actual project status

3. 1. What is Integrated Care?
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•
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A visionary partnership project
A pro-active cooperation with the citizen/patient in the centre
A systematic approach
Common target
Specialized
treatment
The citizen
Own mastery
General
practitioner
Prevention
The municipal
employee
Hospital
practitioner
Treatment

4. Foundations
 Odense Municipality’s status as a free local
authority
 Local Government Denmark’s and Danish
Regions’ – Close and Complete Health Services
 The Government’s health political proposal
 North West London Integrated Care
 Managerial will
AND we are building on

5. Target group 1:
Citizens with stress, anxiety, and
depression

6. Target group 2:
The elderly medical patient

7. 2. The Ambitions of Integrated Care…..
Citizens with stress,
anxiety, and depression
Building up disease
1
2
3
The elderly
medical patient
Accelerating disease
4
Growthenhancing
5
6
7
8
Very sick and terminal
9
10
11
12
Cost controlling
Real and coherent citizen-/patient process, which makes the citizen experience
to be supported by complete and proactive health care services

8. The potentials of Integrated Care
For the citizen/patient
•Increased coherence and a whole process
•Early tracing and efforts
•Better quality of the patient treatment
•Increased mastery ability
•Increased function level
•Improved life quality
•Increased patient empowerment
For the organization
•New culture
•Improved co-operation methods
•Altered combinatination of specialists
•Changed assignment of responsibility and tasks
•Common supporting tools (e.g. IT)
•Other management skills

9. The potentials of Integrated Care
For the employee
•New holistic approach to the citizen/patient
•Interdisciplinary co-operation
•Cross-sectoral co-operation and relationship building
•Competence development and learning
•Job satisfaction
For the economy
•Financially more sustainable health care services
•Knowledge sharing => better basis for decision-making and prioritizing
•Cost effective courses and efforts
•Fewer unnecessary re-hospitalizations
•Prevention of hospitalizations
•Fewer citizens living on sickness benefit
•Prevention of life style diseases
•Increased focus on self-care

10. 3. How do we work in Integrated Care?
Test of large-scale co-operation models
(stress, anxiety, and depression/the elderly medical patient)
Proactive and common efforts rather than sectorial and late
treatment (common professional fundament)
Establishment of common data warehouse
Model for stratification of risk patients
Description of ideal typical courses (patient programs)
The user
organizations
are included
in the whole
process
Committing agreements
Common task and common responsibility in cross-sectoral
teams
Case conferences with the purpose
Annual evaluation
of learning and adjustment

11. Integrated Care – samarbejdsmodellen INGEN OVERSÆTTELSE
Proaktiv indsats:
Fælles data og stratificering => risikopatienter findes => fælles plan udarbejdes
Integrated Care samarbejdsmodellen
Forpligtende samarbejde:
Fælles opgave, ansvar og udvikling i tværsektorielle og tværfaglige teams

12. Illustration of the data process in Integrated Care
Complementary
data from the
region
Patient list
for general
practitioner
Consent before data
are visible for anybody but the general
practitioner
Stratification
Action
plan
General practitioner:
Meeting with patient,
agreement of data
and action plan
Complementary
data from the
municipality
Regional
health care
person
Municipal health care
person
Patient/citizen

13. EXAMPLE of data stratification (the elderly medical patient)
Low risk
Municipal data
Home help
Nursing
Medical record
Rehabilitation
Grant/aids
Transportation
Emergency device
Medical practice data
Diagnosis codes
Data from data capture
Number of medical
consultations
Regional data
Referral to specialists
Diagnoses
Hospitalization
frequency
Datawarehouse
Data are
collected
and processed in datawarehouse.
No other contemporary diagnoses
Good network
Good self-care ability
Stable medication
Middle risk
More than one diagnosis
Frequent changes of medication
Affected self-care ability
Treatment by specialist, general practitioner and
ambulatory
High age
Fragile network
Hig risk
Several hospitalizations
More competing illnesses
Many treating actors
Affected self-care ability
Lack of network
Bad housing conditions
Big resource requirements for local service
Cognitive deterioration

14. Actual project status
 The juridical and political foundations have been made
 The project organization is ready
 Time- and milestone schedule is followed
 Website: www.integratedcare.dk
 Common professional base (minipilot)
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Common data warehouse
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Stratification models version 2
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Digital action plan version
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Information material version 1
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Patients included
1
 Research collaboration being established
 Operation date 1/9 2014
 Evaluation 31st December 2015