Health and Social Care Integration

Health and Social Care Integration Integration is defined as a collection of techniques and organisational models designed to create connections and collaboration within and between the health and social sectors. These techniques may relate to funding, administrative organisation and care. Unlike coordination among organisations, which seeks to manage the fragmentation inherent in the system as much as possible, integration seeks to reduce the fragmentation of the system by reorganising it. Key points The frail elderly are the main beneficiaries of integration, but other members of the public, such as the disabled and/or those with mental health problems may also benefit from it. The perception of a benefit by users and professionals is the condition for success. Integration is a work in progress and does not exist in a stable state. The integration process cannot be considered as an isolated action: its efficacy relies, in particular, on the development of practices as multidisciplinary teams and the deployment of support functions for professionals. There is no single integration model. However, there are commonalities: - concertation organised at all levels: the macro level to standardise public policies, the meso level to locally organise health, medical social and social services, and the micro level for the delivery of integrated care by multidisciplinary teams; - facilitation by a leader recognised as legitimate by all the participants and institutions in the region; - changes in the operation of organisations and procedures for collaboration among participants. What you need to know Integration is potentially beneficial to all populations requiring services, and especially to those who use health and social services intensively and for whom care is insufficiently coordinated. Its impact varies according to the integration strategy and target population. In observational studies, it has been especially assessed in the frail elderly or those at risk of dependence. In general, a reduction in hospitalisations and institutionalisations is observed, coupled with an increase in consumption of home care services. Integration does not improve care outcomes by itself. It can contribute to these results if it is combined with personalised case management follow-up actions for patients in complex situations. Integration is applied simultaneously at three levels: - The macro level consists of standardising public policy with decision-making that gives rise to a contractual relationship. It is generally positioned regionally or departmentally. It involves decision-makers and funding providers: ARS s [regional healthcare agencies] and County councils mainly, as well as user associations, URPS s [regional healthcare professional unions], health insurance, DRJSCS s [regional offices for youth, sports and social cohesion], pension funds, national education, etc. - The meso level is the one for organisation or reorganisation of services and structures on the relevant regional scale (catchment area, for example) This approach is indispensable for bringing together all participants who share the same objectives, identifying and eliminating obstacles to the integration dynamic: prioritised choice of problems to solve, adoption of common tools, response and orientation procedures shared at the level of integrated points of contact, regional protocols and vectors for information exchange. The following are involved at this level: local elected officials, September 2014 1

users, directors and managers of health, and social facilities and services, private healthcare professionals, CCAS [communal social action centres], etc. - The micro level is the one for delivering care and social support. It involves healthcare and social professionals. These professionals are encouraged to advance their practice procedures and coordinate their practices around each patient's overall needs and the regional offering of services. Integration requires meetings and shared information among these levels. The goal is to provide users with the continuum of health and social services that they need with the objectives of reducing care access inequalities, improving care quality and perceived health, and at the same or a lower cost (in particular via prevention of avoidable hospitalisations. What needs to be done The stages below are part of a process that considers the needs, initiatives and desires of participants on the local level. Their order may be changed depending on local context. Stage 1 Create effective spaces for cooperation among institutional and professional participants Rely on existing local dynamics; Set up a general framework and conditions for a shared vision among participants; Clarify the integration objectives and the changes necessary to achieve these goals. Be sure to mobilise, at all levels (macro, meso, micro), decision-makers (or their delegates with decision-making ability) and operational managers for health and social organisations; Strongly involve decision-makers and funding providers to gather their support and necessary impetus for integration. Stage 2 Designate a regional leader The leader is responsible for facilitating concertation and the integration process. Their legitimacy and neutrality relative to participants are conditions for their efficacy. Another condition is their recognition both by local participants and institutional decisionmakers. They must have strong listening skills. Training in the leadership function is indispensable. Several structures may be able to support integration and the leader thereof. Depending on local history, this could be: MAIA [method for action and integration of health and social services in the autonomy field] September 2014 2 supportershttp://www.cnsa.fr/img/pdf/ccn_mai A_BO_2011_10_15nov11.pdf; Local health contract (CLS) partners. A non-profit association structure; A health cooperation group (GCS) or a health and social cooperation group (GCSMS); A healthcare organisation; A healthcare network, etc. It is the role of the ARS to facilitate a dialogue between institutions and participants, for the appointment of leaders in each region. Stage 3 Define objectives: Conduct a shared healthcare local diagnosis (health and social) and anticipate 5-10 year needs; Define the target population, i.e., the patients who can fully benefit from the integration and, among these, those whose elevated risk of an adverse event requires assistance along the way; On this basis, establish a "shared plan of action"; Identify the services to integrate depending on the objectives selected; Separate the changes that are imposable on all participants from components that are adjustable depending on the situation and culture of each one. Stage 4 Set up drivers or essential components for integration Regular concertation according to the procedures that are appropriate to each level: "strategic round tables", "tactical round tables", multidisciplinary meetings, etc.; "Integrated point of contact" which permits providing a complete and comprehensive response to the individual regardless of their gateway (network, CLIC [local information and coordination centre, CCAS, etc.): this presumes being able to clarify requests and address patients according to common questionnaires and protocols. The possibility of obtaining the help of a care manager for management of complex situations; Adoption of a tool for multidimensional assessment of the individual that would be common among the various health and social service providers: this should provide a common response among professionals and prevent one individual from receiving several assessments; Planning complex paths with tools that depend on the level of complexity of the situation: "service plan" by MAIA case managers, individualised patient-centred care by healthcare

professionals alone or with network care managers; The possibility of exchanging and sharing data via an information system: secured messaging, summary documents such as the Electronic Medical Summary and the emergency liaison dossier in EHPADs [Nursing homes], etc. Stage 5 Maintain the integration dynamic Support reorganisations with sustained funding consistent across the region; Continue the cooperation at all levels; Collect feedback right away from all participants and profit from the changes made and results obtained; Encourage feedback of information to the leader and the governing body on unmet needs and difficulties encountered; Organise decision follow-up; Manage any conflicts of interest. Stage 6 Assess and readjust the process periodically Adopt criteria with participants to judge the efficacy of the processes; Adapt these processes according to the first results obtained and the difficulties identified (Focus 1 and 2); Assess at the end of a realistic period: a 3-year period is the minimum mentioned in the literature. Centre the integration process around the needs of users and professionals; Involve healthcare professionals from the beginning, especial general practitioners; Involve elected officials in the initiative and when convening cooperation meetings; Ensure close collaboration of case managers or care managers with general practitioners and primary care teams; Foster the development of multidisciplinary training programs common to professionals from the health and social sectors. Proposed practical indicators Number of health and social structures sharing a same orientation procedure in response to requests, out of the total number of structures in the region; Number of partners and institutions who signed a common plan of action, out of the number of partners and institutions in the region; Number of elderly persons who received a single assessment shared among several providers relative to the total number of elderly persons assessed; Number of calls to an integrated point of contact that obtained a response out of the number of calls to the integrated point of contact. What to avoid Starting by only integrating structures; Reducing integration to an administrative merger process (Focus 3). E.g.: confusing integration and merger or network sharing. Reducing integration to a clinical process for resolution of complex cases; Adopting a top-down only or bottom-up only approach to integration; Confusing integration and quality professional relations; Ignoring policies and elected representatives; Letting decisions stand regardless of their efficacy; Wanting immediate results and prematurely assessing the impact of the integration procedure. Conditions to meet Make public policies consistent; reduce and manage discrepancies; Only one integration leader in a region, recognised by all participants; September 2014 3

Examples of implementations or projects in progress The Paris-Centre MAIA (1st to 6th arrondissements), supported by the Paris Emeraude Centre CLIC association, has the gerontological network MEMORYS as its nearest neighbour. This geographical proximity among providers of coordinated gerontology in Paris Centre allows three teams (CLIC, gerontology network and case managers) to develop a collaboration dynamic implemented through holding weekly inclusion meetings and by setting up a single telephone number. The network's charter was signed by the supporter of the MAIA The Île-de-France regional healthcare agency has held a strategic round table three times, at the departmental level. It encompasses all the MAIAs of Paris. The leader moderates the tactical cooperation round table while ensuring its practical organisation. These cooperation spaces are necessary for setting up a collective project and co-management in a common region. Thanks to the development of an analysis form at the departmental level and liaison among services for the elderly, and combining all the alert criteria for a comprehensive and multidimensional assessment, a procedure built in common and shared on the analysis of demand in a comprehensive way could be initiated. Provided in the MAIA specifications, it permits the CLIC secretary, in charge of telephone reception, to better direct requests. The local health contract (CLS) of Haut-Allier (Langogne, Lozère) aims to improve the health status at the local level and reduce social and regional inequalities in health, based on the perceived needs of the region rather than epidemiological data. Cooperation spaces have been set up: technical and professional steering committee (meso level, tactical round table), a policy steering committee (macro level, strategic round table) and working groups (micro level). The coordinator or leader plays a central role: they are responsible for facilitating and ensuring technical monitoring of the CLS in a project management approach, as well as for providing support to the political and technical governance bodies mentioned previously. The Alliage association supports the MAIA for Pays Salonais and a CLIC in the Salon-de- Provence region and its surroundings. The leader participated in the implementation of the departmental strategic round table and moderates the tactical round table while ensuring its practical organisation. The leader ensures follow-up of decisions validated by the various cooperation bodies. After diagnosing resources and organising healthcare products and services in the region to which the products are to be adjusted, the leader and ensured the implementation of the integrated point of contact. One of the first steps of the cooperation was formalised via a questionnaire designed to collect needs from the non-covered population and identified by participants in the region. Follow-up meetings among case managers, ADMR [home help in rural areas] services and home care, APA [personal autonomy allowance] social workers are regularly organised by the leader to take stock of common situations. Bi-monthly meetings, with the same objective, took place with the Salon mobile geriatrics team. These various participants as well as a few others (CCAS, MDPH [regional homes for the disabled], etc.) participate in the preliminary integrated point of contact. Two case managers followed 46 complex situations in 2013, with a scalability that was parallel to the deployment of integration. The PSI [nursing care plan], systematically developed by these managers from the multidimensional assessment, is shared during clinical cooperation meetings and a summary is rendered to those involved at home, especially the treating doctor. The MAIA website is a shared collaborative digital tool including mission guidelines and a directory The MAIA of northern Hauts-de-Seine is supported by the AGEKANONIX health network. It is part of a very populous region characterised by a fairly long-standing dynamic of cooperation among the various participants in the health and social fields, which relies in particular on meetings and common staff. 2013 was dedicated to communication about integration, making a regional diagnosis and striving to ensure consistency of actions. As part of the integrated point of contact, network teams from the CLIC and MAIA case managers meet regularly to analyse the situations submitted to them. Since 2000, the activities of the Association gérontologique de Gâtine [Gâtine Gerontology Association] (Deux-Sèvres) have continued to expand and now include a health network, a CLIC, the assessment mission of CARSAT [insurance fund for retirement and health at work], a collaborative MAIA project, a platform for respite care in connection with a depository for authorisation and the "council support" mission. A single phone number filters and directs requests from those responsible for CLIC reception, either towards the network or towards a case manager, on the basis of the elderly person s orientation liaison form. This brief was required for setting up an integrated point of contact. A tool for the analysis of September 2014 4

the first request helps them analyse requests and provide answers to users. The Local Mental Health Council (CLSM) is a local body for cooperation and coordination based on circulars DGS-2030 of 12 December 1972, DGS- 891 of 9 May 1974, the circular of 14 March 1990 on guidelines for mental health policy and, more recently, on mental health plans 2005-2008 and 2011-2015. There are a hundred in France. The CLSM brings together in the same region all the participants concerned with mental health problems: local officials, health professionals, social services, users, carers, housing, national education, police, public prosecutor, etc. Its missions are to promote cooperation in the field of prevention, access to care, crisis management and integration of people with mental health disorders. This concerted effort seeks to implement procedures that are likely to provide solutions while respecting the responsibilities of each provider. Chaired by an elected official, it operates with a plenary session, a place for periodic cooperation that brings together all the participants likely to be involved, a steering committee responsible for facilitating exchanges and thematic working groups. The experience acquired in these past few years shows that the involvement of elected representatives in terms of inviting them to meetings promotes the participation of those involved in the cooperation. An integrated point of contact approach: the Local Support Coordination (CTA) for the PAERPA [Elderly persons at risk of a loss of independence] programs. The CTA is supported by one or more responsible structures. It offers an information service for the elderly and their carers: a physical reception is available to them, as well as a single number to answer their questions. At the request of the treating doctor or other regional healthcare professionals, it may fulfil various functions: informing and directing regional professionals by means of a directory or operational register of health, social and medical social resources; directing professionals towards Patient education (TPE) services; activating social aids; activating geriatric expertise by mobilising the local geriatric network; activating psychiatric and palliative care expertise; during admission to the hospital, especially emergencies, connecting hospital teams with healthcare professionals in charge of the individual to organise discharge; ensuring a follow-up mission for individualised patient-centred care, in particular their social component, and informing the care contact person as needed. September 2014 5

Focus 1. Integration glossary Bottom-up approach: Approach which pays a lot of attention to local initiatives and the wishes of the providers in the field. It is the opposite of the top-down approach, in which integration is implemented solely by a policy defined in advance by institutions. The combination of both approaches is often considered optimal. Cooperation: this aims to include collaborative spaces in a given region where various participants meet, thus promoting decompartmentalisation. Cooperation takes place on several levels: strategic, tactical and clinical. Coordination: Deliberate organisation within the field of health of care activities with one patient between several participants in the system. It involves the mobilisation of staff and other resources necessary for patient management and is often handled by (information sharing) among participants responsible for different aspects of care. Management of complex situations: Collaborative approach for multidimensional needs assessment, planning, facilitation, intensive coordination of assistance and care over the long term, assessment and defence of the interests of an individual in a complex situation, the purpose of which is to meet needs. Integrated point of contact: The information and orientation are the same regardless of the gateway (e.g.: MAIA), thanks to common orientation and assessment tools. Single point of contact: There is a single gateway for information and orientation. Leader: Guarantees integration, which they promote and lead in the region. They organise the construction of integration tools and the implementation thereof. Focus 2. Obstacles to integration Not considering local context; Lack of visibility regarding funding over time; No shared information system; Professional cultural resistance; Poor dynamics and lack of trust among partners; Lack of legitimacy of the leader; Refusal of professionals to change their way of working; Lack of communication; Withdrawal of a participant; Unsuitable and inconsistent incentives. September 2014 6

Focus 3. Merging of structures: only if desired by the region In order to reduce the fragmentation that characterised the healthcare system, Quebec authorities conducted a series of mergers in the 1970s, reducing the number of public institutions from 1000 to 200. The subsequent finding was that a number of these structures remain compartmentalised or even unstable and inefficient, particularly because of conflicting values, distrust and opposition of participants. Mergers can contribute to integrated care only if they are wanted by the region and if they represent for all the participants involved a relevant answer to the problems of organisation of health, medical social and social services. Otherwise, they can hinder the integration process. It is preferable to allow the participants in the region to choose the most appropriate organisational model for integration for their specific context (reference: Mergers and integrated care: the Quebec experience. Int J Integr Care 2013; Jan Mar, URN:NBN:NL:UI:10-1-114229). Focus 4. Progression criteria for the integration dynamic Local organisational diagnosis by the leader; Concertation spaces set up at all levels; Effective representation for each structure involved; Setting up an observatory for the needs of the population; Routine connection among care managers and treating doctors; Continuity of patient management in the absence of their general practitioner or the care manager. September 2014 7

All HAS publications can be downloaded from www.has-sante.fr September 2014 8