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Katharina Viktoria Stein, editor. [Vienna: s.n.] 2010. p. 147Austria: Doctoral Thesis Vienna University of Economics and Business Administration .
Integrated care has caught the attention of health professionals and decision-makers alike as one solution to the necessary reforms and the challenges arising from ageing societies, chronic diseases and resource restrictions. However, the outcomes of integrated care models have neither been properly evaluated and compared nor have the reasons for initiating such models. At both ends of the spectrum, there exist assumptions and opinions based on common sense and few validated data but when and how it really pays to implement integrated care and which are the key indicators and priorities decision-makers want to achieve still remain largely unexplored. This thesis investigated the starting point of integrated care, exploring the indicators most crucial for actors in health and social care services and identifying those which lead up to the initiation and implementation of integrated care. By analysing the reasons why integrated care is chosen and initiated, the thesis highlights underlying mechanisms and decision-making processes of integrated care.
Based on a comprehensive discussion of the existing theories on health systems analysis, decision-making and performance measurement in health as well as the trade-offs emerging therefrom, the first part of this thesis examined the changing conditions and expectations as well as problem areas of organisation and restructuring in health care systems. This analysis served as a foundation for the introduction of the integrated care concept, an international expert questionnaire on the decision-making in integrated care and conclusions on priority setting of decision-makers in health.
The theoretical layout of a literature review was transferred into the specific context of integrated care, first establishing the status quo of integrated care research and identifying open research questions of the field, being the results of an international scientific workshop. With these, the research question and the methodologies for the elaboration of the hypotheses were described, as well as the quantitative analysis with which the hypotheses were tested. For that matter, an international survey was conducted via an expert questionnaire, contacting integrated care managers and decision-makers in Europe, North America and Australasia. The response rate was 18% with the majority of responses coming from Germany, The Netherlands, UK and the USA.
Integrated care is stipulated to offer solutions to the demographic changes, the concurring increase of chronic disease and the pressures on restricted resources experienced in the modern health systems of today. The survey conducted during this research project, along with the literature presented, suggested a more diversified picture regarding the expectations and priorities set into the concept by health care decision-makers. While all of these challenges are perceived by them, their undisputed priority is on the introduction and enhancement of management structures on all levels. They do not value financial restrictions as severely as may have been anticipated and they revealed that neither active patient participation nor the introduction of outcome measurement are high priorities when introducing integrated care. Also, despite the propagation of being a new and improved form of service delivery, it has scarcely made the transition from project to programme implementation. Whether this fact stands in relation to the constant state of reform in which many health systems seem to be caught up in, or whether this is an immanent trait of current integrated care models remains to be investigated.
In conclusion, two levels of priority setting have been identified as highly important for integrated care initiation: on the policy level, prioritisation of integrated care along with specific promotion measures influence decision-making; on the organisational level, the need for clear structures and better management tools both in the organisation itself and in the management of the targeted patient population, reflect the highest priorities for the decision-making process.
Integrated care has come a long way from the first projects implemented by health insurance organisations to a colourful array of projects and permanent programmes, spanning from local to national level and from very targeted to very broad inclusion criteria, initiated, owned and financed by a mix of all stakeholders and agents in the system. Hence, integrated care developed into a ‘Jack-of-all-trades’ approach, stimulating change and confusion at the same time. Still, in most countries, it has not entered mainstream health care organisation and management and continues to struggle in proving its value. More data need to be collected on the influencing factors and interrelationships of agents and systems with regard to integrated care.
The results presented in this review are based on the author's thesis presented at the Vienna University of Economics and Business Administration on 1st July 2010.
Further articles by this author in the International Journal of Integrated Care:
Stein KV, Rieder A. Lost in transition—meeting the challenge through integrated care. Highlights from the 9th International Conference on Integrated Care in Vienna. Conference Proceedings. International Journal of Integrated Care [serial online] 2009 Dec 31; 9. Available from: http://www.ijic.org. URN:NBN:NL:UI:10-1-100710
Eger K, Gleichweit S, Rieder A, Stein KV. Prioritising integrated care initiatives on a national level. Experiences from Austria. International Journal of Integrated Care [serial online] 2009, Jul–Sep 2009; 9 Available from: http://www.ijic.org/. URN:NBN:NL:UI:10-1-100565
Stein KV, Rieder A. Integrated care at the crossroads—defining the way forward. International Journal of Integrated Care [serial online] 2009 Apr 8; 9. Available from: http://www.ijic.org/. URN:NBN:NL:UI:10-1-100557
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