IFIC 9 Pillars of Integrated Care
Service delivery for coordinated and integrated care
Coordination and continuity of care are central features of integrated care services. With these central features in mind, integrated care service delivery is co-created with individuals, families, communities, public health, primary care, secondary care (hospitals), social care, care homes, care at home and others including private providers.
It is focused on the health outcomes desired by the population and builds on the assets they already have, is informed by evidence, and covers the care journey from prevention through to end-of-life care. The cycle of delivery encompasses integrated care service design, testing, implementation and expansion, monitoring and evaluation and continuous improvement.
Approaches such as case management, care coordination and integrated care pathways are three examples of approaches that care providers use when developing integrated care. Service delivery is dynamic and responsive to the changing coordination needs of people.
For people and communities
Care that is integrated enables people to lead on their own care and meaningfully shape the delivery of seamless and responsive services across various health and care settings. Integrated services nurture collaboration between people with lived experience and care providers. Through co-creation, people’s lived knowledge, life goals and perspectives are valued alongside professional expertise. Care is personalised, proactive, comprehensive, coordinated, and continuous, with shared decision-making guiding assessments, care planning, and delivery.
Integrated service models may focus on one or more specific conditions (for example, integrated diabetes care), on populations with similar needs (for example, integrated neighbourhood teams for people who need care and support at home), equity-deserving populations, whole populations in a locality of identify-sharing groups (for example, migrants, indigenous and other culture-sharing groups).
For care providers
Care providers bring a range of professional and other skills and competencies that inform the design, testing, implementation and expansion, monitoring and evaluation and continuous improvement of integrated care. It may focus on one or more specific conditions (for example, integrated diabetes care) but should also take into consideration other co-morbidities and/or needs of the person. It may also focus on multiple conditions simultaneously (for example, integrated neighbourhood teams). Approaches such as case management, care coordination and integrated care pathways are three examples of approaches that care providers use when developing integrated care. These are used co-creatively with people and communities to ensure the population needs, local context, living spaces, and available resources are included. Service delivery is dynamic and responsive to the changing coordination needs of people.
For system-level decision-makers
System-level decision-makers create conditions in which care and support services develop integrated and coordinated care focusing on providing the necessary resources (financial, human, development and infrastructural) to deliver proactive and preventative care and services and monitoring performance to outcomes. The overall care provision is based on collective planning and shared decision-making among all the relevant partners.