Handbook Integrated Care (eBook)

Volker Amelung, PhD is a professor of health management and international health services research at the Medical University of Hannover, Germany. His main research interests are managed care, integrated care und payment systems. He is also the president of the German Managed Care Association (BMC) and founded the private institute for applied health research (inav) in Berlin in 2011. Viktoria Stein, PhD is Head of the Integrated Care Academy(c) at the International Foundation for Integrated Care, and Co-Editor in Chief of the International Journal of Integrated Care. She has worked extensively to promote integrated care on the local, regional, national and international levels throughout her career. Her expertise lies in the systemic and organizational prerequisites necessary to promote transformational change, specifically strengthening the competencies of patients, service providers and decision makers to support sustainable integrated care. Nick Goodwin, PhD is the co-founder and CEO of the International Foundation for Integrated Care, and Co-Editor in Chief of the International Journal of Integrated Care. Nick is a social scientist, policy analyst and thought leader in health system integration and person-centered care, with an extensive background in policy and practice to design, implement and evaluate integrated care. He has published widely on the subject and holds a range of educational, research and consulting roles worldwide, collaborating with the WHO and its regional offices, governments and local authorities, as well as universities. Ran Balicer, PhD currently serves as Director of Health Policy Planning for Clalit – Israel’s largest healthcare organization, and as the Founding Director of the Clalit Research Institute. Professor Balicer’s managerial and research focus is on using extensive datasets and advanced analytics to drive innovation in clinical practice as well as care integration. He also serves as Chair of the Israeli Society for Quality in Healthcare. Ellen Nolte, PhD heads the two London offices of the European Observatory on Health Systems and Policies at the London School of Economics and Political Science and the London School of Hygiene & Tropical Medicine, where she is also an Honorary Professor. Her expertise is in health systems research, integrated and chronic care, international healthcare comparisons and performance assessment. She has published widely in both the international peer-reviewed literature and the wider literature, including 4 books and numerous scientific papers on chronic disease and integrated care. Esther Suter, PhD is the Director for the Workforce Research and Evaluation unit, an applied research unit within the largest provincial health authority in Canada, and an Adjunct Professor with the Faculty of Social Work, University of Calgary. She has more than 25 years of experience in health research. The focus of her work is on interventions to enhance collaborative practice, how to achieve integrated health systems, and the exploration of innovative care delivery models.

Preface 5
Contents 7
Part I: Foundations of Integrated Care 11
1: What Is Integrated Care? 12
1.1 Introduction 12
1.2 The Rationale for Integrated Care 15
1.3 Defining Integrated Care 16
Box 1.1 Four commonly used definitions of integrated care 18
1.4 The Core Dimensions of Integrated Care 21
1.5 The Building Blocks of Integrated Care 24
Box 1.2 The six interrelated components of the Chronic Care Model 25
Box 1.3 Ten Principles for Successfully Integrated Systems (Suter et al. 2007) 27
Box 1.4 The Rainbow Model of Integrated Care: Final Taxonomy Summary (from Valentijn 2016) 29
1.6 Conclusions 30
References 31
2: Evidence Supporting Integrated Care 33
2.1 Introduction 33
2.2 Conceptualising Integrated Care 34
2.3 The Evidence Supporting Integrated Care 36
2.4 The Economic Impacts of Integrated Care 39
2.5 How to Interpret the Evidence Supporting Integrated Care 41
2.6 Conclusions 42
References 43
3: Patients Preferences 47
3.1 Patients´ Priorities for Integrated Health Care Delivery Systems 47
3.2 Stated Preference Studies: Method and Study Design 50
3.3 Preference for Integrated Health Care Delivery Systems 51
3.4 Discussion and Outlook 55
References 56
Part II: Tools and Instruments 61
4: Case-Managers and Integrated Care 62
4.1 The Story of Julia and John in 2025 63
4.2 The Definition of Case Manager 64
Box 4.1 The definition of a case manager 64
4.2.1 Complex Situations 65
4.2.2 All the Needs 66
4.2.3 Physicians´ Cooperation 67
4.2.4 The Life/Care Plan 67
4.2.5 Informal Care and the Case Manager 68
4.2.6 Within a Program 69
4.2.7 Target Population 69
4.2.8 Rejected Broader Definitions 69
4.2.9 Competencies and Skills of Case Managers 70
4.3 Specific Tools for Case Managers 71
4.3.1 Evaluating Health and Social Needs 71
4.3.2 Empowering Interviewing of Patients, Clients and Relatives 73
4.4 The Real World and the Ideal World of the Case Story 74
Box 4.2 Services of case managers with do not exist in 2016 74
4.5 Implementation Strategies to Disseminate the Function of Case Managers 75
References 77
5: Disease Management 79
5.1 Introduction 79
5.2 What Is Disease Management? 80
5.3 What Are the Impacts of Disease Management? 81
5.4 Interpreting the Existing Evidence Base 96
5.5 Conclusions 98
References 99
6: Discharge and Transition Management in Integrated Care 103
6.1 Introduction 103
6.2 What Is Discharge Management? 104
6.3 Why Discharge Management? 104
6.3.1 Demographic Challenges 104
6.3.2 Rising Costs and Financial Pressure 105
6.3.3 Declining Length of Stay 106
6.3.4 Financing and Reimbursement Systems 106
6.3.5 The Need to Manage Complexity 108
6.4 How to Put Discharge Management into Practice 108
6.4.1 Professionalization of Discharge Planning 111
6.4.2 Integrating Various Components 112
6.4.3 Patient Involvement 112
6.4.4 Information Exchange and Technology 113
6.4.5 Early Initiation and Predictive Models for Discharge Management 114
6.5 Conclusion 115
References 115
7: Mobile Sensors and Wearable Technology 118
7.1 Commercial Mobile Sensors and Wearable Technologies 118
7.2 Mobile Sensors and Wearable Technologies in Health Care 119
7.3 Using Mobile Sensors and Wearable Technologies to Change Health Behaviour 120
7.4 Current Limitations and Potential Impact on Health 121
7.5 Integrating Mobile Sensors and Wearable Technologies in the Clinical Setting 122
References 123
8: Data Integration in Health Care 125
8.1 Types of Data Integration 125
8.1.1 Horizontal Integration 125
8.1.2 Vertical Integration 126
8.1.3 Historical Integration 126
8.1.4 Longitudinal Integration 126
8.1.5 Cross-Indexing Integration 127
8.1.6 Alternative Sources 127
8.2 The Importance of Data Integration 127
8.3 Impact of Data Integration 128
8.3.1 Types of Waste That Can Be Reduced with Data Integration 128
8.3.1.1 Repeat Testing 128
8.3.1.2 Manual Integration of Data 128
8.3.1.3 Informal Reports 128
8.3.2 Improving Decision-Making Capacity 128
8.3.2.1 Individual Level 128
8.3.2.2 Provider Level 129
8.3.2.3 Policy Level 129
8.3.2.4 International Level 129
8.4 Key Challenges in Integrating Data 129
8.4.1 Access and Privacy 129
8.4.2 Security 130
8.4.3 Quality 130
8.4.3.1 Quality Assessment 130
8.4.3.2 Quality Control 131
8.4.4 Tracking Use of Integrated Data 131
8.4.4.1 Providers 131
8.4.4.2 Patients 131
8.4.4.3 Policy Makers 131
8.4.4.4 Insurers 132
8.5 Summary 132
References 132
Part III: Management of Integrated Care 134
9: Strategic Management and Integrated Care in a Competitive Environment 135
9.1 Integrated Care as a Strategic Option: Preliminary Remarks 135
9.2 Strategic Management: Definition and Differentiation 137
9.2.1 Strategy 137
9.2.2 Principles of Management 138
9.3 The Strategic Planning Process 138
9.4 Instruments for Strategic Planning 139
9.4.1 SWOT Analysis 139
9.4.2 Analysis of Value Chains and Competitive Environments 141
9.5 Options for Strategic Positioning 144
9.5.1 Ansoff´s Product/Market Matrix 144
9.5.1.1 Market Penetration 144
9.5.1.2 Product Development 145
9.5.1.3 Market Development 146
9.5.1.4 Diversification 146
9.5.2 Porter´s Competitive Strategies 146
9.5.2.1 Cost Leadership 147
9.5.2.2 Differentiation 148
9.5.2.3 Low Cost and Differentiation Focus Strategies 148
9.5.2.4 ``Stuck in the Middle´´ 148
9.6 Integrated Care as a Quality Improvement Strategy 148
References 149
10: Governance and Accountability 150
10.1 What Is Governance and Accountability? 150
10.2 Appropriate, Agile, and Effective: New Directions for Governance and Accountability in Integrated Health Systems 153
10.3 Implementing Innovation: Next Steps for Governance and Accountability in Integrated Health Systems 154
10.3.1 Vanguard Integration Sites 156
10.4 Tools for Governance and Accountability 157
10.4.1 Frameworks 157
10.4.2 Tools 158
10.5 Conclusions 160
References 161
11: Financing and Reimbursement 165
11.1 Introduction 165
11.2 Principles of Financing of and Payment for Services 166
11.2.1 Financing of Health and Social Care 166
11.2.2 Payment Mechanisms in Health Care 168
11.3 Incentivising Coordination and Integration of Service Delivery: Examples from Different Countries 174
11.3.1 Commitment of Additional Funding 174
11.3.2 Innovative Payment Schemes 176
Box 11.1 The Quality and Outcomes Framework in the United Kingdom 177
Box 11.2 The Alternative Quality Contract in Massachusetts, USA 179
11.3.3 Changes to Financing Mechanisms 180
11.4 Conclusions 182
References 183
12: Planning 188
12.1 Introduction 188
12.1.1 The Need for Planning 188
12.1.2 Planning Taxonomy 189
12.2 Workforce Planning Methodologies 191
12.2.1 Planning of Supply 191
12.2.2 Demand-Based Planning 193
12.2.3 Needs-Based Planning 195
Case Example 1 195
12.2.4 Benchmarks 197
12.2.5 Limitations of Current Planning Approaches in Integrated Care Settings 198
12.3 New Approaches to Workforce Planning in Integrated Care 199
12.3.1 Team-Based Workforce Planning 199
12.3.2 Pro-active Management of Health Care Utilization 200
12.3.3 Tackling Geographic Variations Through Technology 201
12.4 Conclusion 202
References 203
13: Integrated Care and the Health Workforce 207
13.1 Background 207
13.2 Staff Mix and Skill Management 209
13.3 Multidisciplinary Team Work 211
13.4 Workforce à la carte 214
13.5 Conclusions 215
References 217
14: Leadership in Integrated Care 219
14.1 The Neglected Topics in Designing Integrated Care 219
14.2 No Coincidence: What Management Literature Tells Us About Leadership 220
14.2.1 Manager Versus Leader 220
14.2.2 Types and Styles of Leadership 221
14.2.2.1 Theories 221
14.2.2.2 Learning from the Big Bosses´ Experience 221
Jack Welch: Former CEO of General Electric 222
Colin Powell: Former U.S. Secretary of State 223
14.2.3 Leadership Learnings from Empirical Data 223
14.2.3.1 Fundamental Practices by Kouzes and Posner (2009) 223
14.3 Leadership in Networks 224
14.4 Leadership in Health Care: Learning from Best Practice 226
14.4.1 What Is Different in Health Care: The Logic of Health Care Delivery 226
14.4.2 Professional Cultures in Health Care 227
14.4.3 Leading a Health Care Organization: Personal Skills and Institutional Habits 229
14.5 Lessons to Be Learned for Leadership in Integrated Care 230
14.5.1 System-Related Pitfalls (Dark Blue) 230
14.5.2 People-Related Pitfalls (Yellow) 231
14.5.3 Organization-Related Pitfalls (Light Blue) 231
14.6 Conclusion 232
References 233
15: Culture and Values 235
15.1 Introduction 235
Box 15.1 Examples of culture and values within evidence reviews and evaluations 236
15.2 What Is Meant by Culture? 237
15.3 What Is Meant by Values? 239
Box 15.2 Collaborative practice 241
Box 15.3 Value based competences within collaborative practice (IPEC 2011) 241
15.4 How Do We Positively Develop Values and Cultures? 242
Box 15.4 Alternative approaches to culture change 242
15.4.1 Teamwork 242
15.4.2 Inter-professional Learning 244
Box 15.5 Example of inter-professional learning in practice (based on feedback from participants) 245
15.5 Conclusion 246
References 247
16: Change Management 250
16.1 Introduction 250
16.2 A Conceptual Understanding of Change Management 251
16.3 The Evidence Base 252
16.4 Lessons from Practical Experience 254
Box 16.1 Key lessons for change towards integrated care from practical experience 255
16.5 The Components of a Change Management Process Towards Integrated Care 256
16.5.1 Needs Assessment 256
16.5.2 Situational Analysis 257
16.5.3 Value Case Development 258
16.5.4 Vision and Mission Statement 259
16.5.5 Strategic Plan 259
16.5.6 Ensuring Mutual Gain 259
16.5.7 Communications Strategy 261
16.5.8 Implementing and Institutionalising the Change 261
16.5.9 Monitoring and Evaluation: Developing Systems for Continuous Quality Improvement 262
16.6 Building an Enabling Environment 263
16.6.1 Developing a Guiding Coalition 263
16.6.2 Building Support for Change 264
16.6.3 Developing Collaborative Capacity 266
16.6.4 The Facilitating Role of Managers and Decision-makers in Supporting the Process of Change 267
16.7 Conclusions 268
References 269
17: How to Make a Service Sustainable? An Active Learning Simulation Approach to Business Model Development for Integrated Care 273
17.1 Introduction 273
17.2 ASSIST: Socio-economic Impact Assessment Using Cost-Benefit Analysis 275
17.2.1 Background 275
17.2.2 Assessment in Four Steps 276
17.2.3 A Cost-Benefit Indicator Set for Integrated Care 278
17.3 Learning by Example: The Service Implementation Simulator 279
17.3.1 Integrated eCare Example Case 280
17.3.2 Overall Service Model 280
17.3.3 Elements of the Service 280
17.3.4 Assessment of the Example Case in Four Steps 281
17.3.4.1 Step 1: Stakeholders 281
17.3.4.2 Step 2: Impact Identification 282
17.3.4.3 Step 3: Data Collection 283
17.3.4.4 Step 4: Analysing the Value Case 286
17.3.5 A Set of Lessons to Be Learned 288
17.4 Conclusions and Outlook 289
References 289
Part IV: Evaluation and Health Services Research 291
18: Evaluating Complex Interventions 292
18.1 Definition of Complex Intervention 292
Box 18.1 Examples of complex interventions 293
18.2 The Rationale for Evaluation 295
18.3 Challenges in Evaluating Complex Interventions 296
18.4 Evaluation Frameworks 297
18.5 Process Evaluation 298
18.5.1 Fidelity and Quality of Implementation 299
18.5.2 Context 300
18.5.3 Causal Mechanisms 301
18.6 Formative and Summative Evaluation 302
18.6.1 Study Design 302
Box 18.2 Choosing between randomised and non-randomised designs 303
18.6.2 Outcomes 304
18.7 Reporting and Reviewing Evaluation Results 304
References 306
19: Economic Evaluation of Integrated Care 309
19.1 Need for Economic Evaluation of Integrated Care 309
19.2 Current Economic Evaluation Frameworks 310
Box 19.1 Forms of economic evaluation 311
19.3 Challenges and Recommendations in Economic Evaluation of Integrated Care 312
19.3.1 Defining the Intervention 312
19.3.2 Comparator 312
19.3.3 Study Design 313
19.3.4 Evaluation Period 315
19.3.5 Outcome Measures 316
19.3.6 Measurement and Valuation of Costs 317
19.3.7 Broader Economic Evaluation 318
19.3.8 Determinants of Cost-Effectiveness 319
19.3.9 Policy Evaluation and Implementation Analysis 320
19.3.10 Standardised Reporting 321
19.4 Conclusion 321
References 322
20: Claims Data for Evaluation 327
20.1 Background 327
20.2 Claims Data 328
20.3 Methodological Aspects of Using Claims Data 329
20.4 Methods 331
20.5 Prerequisites for Data Usage 332
20.6 Examples 333
20.6.1 Evaluating Disease Management Programs 333
20.6.2 Gesundes Kinzigtal 334
20.7 Limitations 336
20.8 Perspective: Data Linkage 337
20.9 Conclusions 337
References 339
Part V: Client Groups 344
21: Children 345
21.1 Challenges in Providing Care for Infants, Children and Young People 345
21.2 Goals of Integrated Care for Children 346
21.3 Value Proposition of Integrated Care for Children 347
21.4 The Integrated Treatment Path: Examples and Outcomes 351
21.5 Lessons Learned and Outlook 356
References 357
22: Integrated Care for Frail Older People Suffering from Dementia and Multi-morbidity 360
22.1 The Challenge 360
22.2 Service Users´ Needs for Integrating Services 361
22.3 Inter-organisational Collaboration by Care Standards 364
22.4 Implementation 366
22.5 Personalization 367
22.6 Future Perspectives 369
22.7 Conclusions 370
References 371
23: Physical and Mental Health 374
23.1 Challenges Involved in Integrating Physical and Mental Health Care 376
23.1.1 Disease Factors 376
23.1.2 Patient Factors 377
23.1.3 Professional Factors 378
23.1.4 Institutional and Systems Factors 378
23.2 Goals of Integrated Physical and Mental Health Care 379
23.3 Key Components of Integrated Physical and Mental Health Care 380
23.3.1 Collaborative Care 380
Box 23.1 Case Study: Mental Health Integration in Intermountain Healthcare 381
23.3.2 Multidisciplinary Case Management 382
Box 23.2 Case Study: Three Dimension of Care for Diabetes 382
23.3.3 Liaison Mental Health 383
23.3.4 Managing Medically Unexplained Symptoms in Primary Care 384
23.4 Results of Integrated Care Approaches 385
23.5 Lessons Learned 385
References 386
24: Integrated Palliative and End-of-Life Care 390
24.1 Introduction 390
24.2 Defining Palliative Care and End-of-Life Care 391
24.3 Challenges for Providing Care to Palliative and End-of-Life Patients 392
24.4 Goal of Integrated Care 393
24.4.1 What Needs Do End-of-Life Patients Have? 393
24.4.2 Health and Social Integrated Care Based on Empathy and Compassion 394
24.5 The Integrated Care Path 395
24.6 Results of Integrated Palliative Care 397
24.7 A New Paradigm: Compassionate Communities 398
24.8 Conclusion 399
References 400
25: Rare Diseases 403
25.1 Challenges Faced When Providing Care to People Living with a Rare Disease 403
25.1.1 Background on Rare Diseases 403
25.1.2 Unmet Needs of People Living with a Rare Disease 404
25.1.3 Challenges in Care Provision 406
25.2 Goal of Integrated Care for Rare Diseases 407
25.3 The Integrated Care Pathway for Rare Diseases 408
25.3.1 Proposals for the Provision of Integrated Care to Rare Disease Patients 408
25.3.1.1 Centres of Expertise 409
25.3.1.2 Individual Care Plans 409
25.3.1.3 Care Pathways and Standards of Care 409
25.3.1.4 Case Managers 410
25.3.1.5 One-Stop-Shop Services for Rare Diseases 411
25.3.1.6 Networking and Training Programmes for Service Providers 412
25.3.1.7 Integration of Rare Diseases into National Functionality Assessment Systems 413
25.3.1.8 eHealth to Facilitate Data Sharing and Interoperability 413
25.3.2 An Innovative Patient-Centred Approach for Integrated Care for People with Rare Diseases 413
25.4 Results of Integrated Care Approaches to Care Delivery 414
25.5 Lessons Learned and Outlook 415
References 415
26: Pathways in Transplantation Medicine: Challenges in Overcoming Interfaces Between Cross-Sectoral Care Structures 418
26.1 Introduction 418
26.2 Structures of Care 419
26.2.1 Outpatient and Inpatient Care 419
26.2.2 Living Donations 421
26.3 General Key Elements for the Future 422
26.3.1 Communication 422
26.3.2 Forms of Compensation 423
26.3.3 Leadership 424
26.4 Conclusions 424
References 425
27: Integrated Care Concerning Mass Casualty Incidents/Disasters: Lessons Learned from Implementation in Israel 427
27.1 Introduction 427
27.2 Basic Assumptions 427
27.3 Main Components of Integrated Care 428
27.3.1 The Preparatory Phase 428
27.3.1.1 Development of Integrated Guidelines and SOPs 428
27.3.1.2 Training and Exercise Programs 429
27.3.1.3 Ongoing Monitoring Systems 429
27.3.1.4 Information Systems 430
27.3.1.5 Equipment and Infrastructure 430
27.3.2 The Response Phase 431
27.3.2.1 Implementation of an Automatic Response 431
27.3.2.2 Central Control and Coordination 431
27.3.2.3 Connectivity Between Response Agencies 432
27.3.2.4 Collaboration Between Military and Civilian Entities 433
27.3.2.5 Coordinated Risk Communication 433
27.3.3 The Post-Response Phase (Return to Normalcy) 434
27.4 Conclusions 435
References 435
28: Integrated Care for People with Intellectual Disability 437
28.1 Definition and Classification of Intellectual Disability (Intellectual Developmental Disorder) 437
28.2 General Health Issues 439
28.3 Mental Health Issues 440
28.4 Access to Care 442
28.5 Specialized Services for ID Associated to Other Mental Disorders 443
28.6 Integrated Care and Person-Centred Approaches 446
28.6.1 Integrating Care of Somatic Illnesses 447
28.6.2 Integrating Care of Psychiatric Disorders 447
28.6.3 Integrating Specialised or Secondary Mental Health Care 449
28.7 Conclusion 450
References 451
29: Integrated Care for Older Patients: Geriatrics 457
29.1 Introduction 457
29.2 Challenges for Providing Care for the Geriatric Patient 458
29.2.1 Multimorbidity and Geriatric Syndromes 458
29.2.2 Fragmentation of Care 460
29.2.3 Place of Living: From Community to Institutions 461
29.3 Goals of Integrated Care 465
29.4 The Integrated Treatment Plan 468
29.5 Results of Integrated Care Approaches to Care Delivery 472
29.6 Matters of Integration in Technology Design for Ageing People 474
29.7 Lessons Learned and Outlook 477
References 478
Part VI: Case Studies 484
30: Canada: Application of a Coordinated-Type Integration Model for Vulnerable Older People in Québec: The PRISMA Project 485
30.1 Integrated Care in Québec and Canada 485
30.2 Integrated Care in Practice 486
30.2.1 Problem Definition 486
30.2.2 Description of the PRISMA Model 487
Box 30.1 Functional Autonomy Measurement System: SMAF (Système de mesure de l´autonomie fonctionnelle) 488
30.3 Experimental Implementation and Impact 490
30.3.1 Dissemination and Replication 491
30.3.2 Lessons Learned and What´s Ahead 493
References 495
31: Germany: Evolution and Scaling Up of the Population-Based Integrated Health Care System ``Healthy Kinzigtal´´ 497
31.1 Integrated Care in Germany 497
31.2 Case Study: Healthy Kinzigtal (HK) 499
31.2.1 Governance and Participation 499
31.2.2 The Business Model of Healthy Kinzigtal 500
31.2.3 Coverage and Programmes 501
Box 31.1 Prevention and Health Promotion Programmes that have been developed so far: 501
31.2.4 A Cross-Cutting Theme: People Involvement/Service User Perspective 503
31.2.5 Impact 503
31.2.6 Dissemination and Replication 504
References 508
32: Scotland 511
32.1 Introduction 511
32.2 Integrated Care in Practice 513
32.2.1 Problem Definition 513
Box 32.1 NHS Highland at a glance 513
32.2.2 Description of the Lead Agency Model 515
Box 32.2 Legal, financial and management implications of lead agency model 516
32.2.3 Governance 516
32.2.4 New Ways of Working 517
32.2.5 People Involvement/Service User Perspective (Value) 519
32.2.6 Impacts 520
32.2.7 Dissemination and Replication of the Case Study 522
32.2.8 Lessons Learned and Outlook 522
References 523
33: USA: Innovative Payment and Care Delivery Models-Accountable Care Organizations 526
33.1 Integrated Care in the United States of America 526
33.2 Integrated Care in Practice: Accountable Care Organizations 528
33.2.1 Problem Definition 528
33.2.2 Description of the ACO Model 529
33.2.3 Impact 530
33.2.4 Dissemination 531
33.2.5 Lessons Learned and Challenges Ahead 532
References 533
34: Switzerland 535
34.1 Integrated Care in Switzerland 535
34.2 Integrated Care in Practice 537
34.2.1 Problem Definition 537
34.2.2 Description of the ``Programme cantonal Diabète´´ 538
34.2.3 People Involvement/Service User´s Perspective (Value) 541
34.2.4 Impact 541
34.2.5 Dissemination and Replication 542
34.2.6 Lessons Learned and Outlook 542
References 543
35: Netherlands: The Potentials of Integrating Care via Payment Reforms 545
35.1 Integrated Care in the Netherlands 545
35.1.1 The Dutch Health Care Reform in 2006: The Introduction of Managed Competition 545
35.2 Integrated Care in Practice 547
35.2.1 Problem Definition 547
35.2.2 Description of the Bundled Payment Model for Diabetes Care 548
35.2.3 People Involvement/Service User Perspective 550
35.2.4 Impact 550
35.2.5 Lessons Learned 551
35.2.6 Outlook 553
35.2.6.1 Bundled Payment for Pregnancy and Child Birth 553
35.2.6.2 Population Health Management 553
References 554
36: New Zealand: Canterbury Tales 557
36.1 Integrated Care in New Zealand 557
36.2 Integrated Care in Practice 558
36.2.1 Problem Definition 558
36.2.2 People Involvement/Service User Perspectives 560
36.2.3 Impact 561
36.2.3.1 Building a Social Movement 561
Box 36.1 Creating a shared purpose 562
36.2.4 The 2010-2011 Earthquakes 563
36.2.5 Vision 2020 Becomes Vision 2011 563
Box 36.2 Keys to innovation (State Services Commission 2013) 565
36.2.6 Dissemination and Replication 565
36.2.7 Lessons Learned and Outlook 565
Box 36.3 Benefits of supporting people to stay well in the community in Canterbury Health System 567
36.3 Conclusion 568
Box 36.4 Some learnings of the Canterbury Health System journey so far 568
References 569
37: Israel: Structural and Functional Integration at the Israeli Healthcare System 570
37.1 Integrated Care in Israel 570
37.1.1 A National Perspective: How Integration in Practice Can Improve Quality of Outpatient Care 572
37.2 Integrated Care in Practice: Clalit Health Services 572
37.2.1 Problem Definition: Unplanned Readmissions 574
37.2.1.1 The Strategy: Vertical Integration 574
37.2.1.2 Predictive Modelling 574
37.2.1.3 Transitional Care Interventions 575
37.2.1.4 Quality Monitoring 575
37.2.2 Impact 575
37.2.3 Dissemination and Replication 576
37.2.4 Lessons Learned and Outlook 576
References 577