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Sustainable intEgrated care modeLs for multi-morbidity: delivery, FInancing and performancE

Periodic Reporting for period 3 - SELFIE (Sustainable intEgrated care modeLs for multi-morbidity: delivery, FInancing and performancE)

Reporting period: 2018-09-01 to 2019-08-31

Over 50 million people in Europe have more than one chronic disease. This number will increase dramatically in the near future. Multi-morbidity is becoming the number one threat to population health and economic sustainability of health care systems. In a fragmented system, the care for individuals with multi-morbidity is not well-aligned; it may include duplications and create conflicting, overly-demanding, treatment advices that may discourage an individual’s compliance. New models of integrated care for individuals with multi-morbidity are urgently needed.

SELFIE aims to improve person-centred care for persons with multi-morbidity by proposing evidence-based, economically sustainable integrated care models that stimulate cooperation across health and social care sectors and are supported by appropriate financing/payment schemes. SELFIE specifically focuses on generating empirical evidence of the impact of ICC and financing/payment schemes. It is methodologically innovative by applying Multi-Criteria Decision Analysis (MCDA) to evaluate promising ICC models.

The SELFIE consortium includes Austria, Croatia, Germany, Hungary, the Netherlands (coordinator), Norway, Spain, and the UK. The work is organised into 9 work packages (WP), as shown in Figure 1. In October 2019, 16 scientific articles about the SELFIE project have been published. They can be found on the project's website.
In WP1 a conceptual framework on integrated care for multi-morbidity was developed (Figure 2). The framework is comprised of a heart in which the individual with multi-morbidity and his or her environment is placed centrally. Around the heart, concepts were grouped into six different components: service delivery, leadership & governance, workforce, financing, technologies & medical products, and information & research. Within each component micro, meso, and macro levels are distinguished.

The conceptual framework guided the description and evaluation of the 17 promising integrated care programmes for multi-morbidity that were selected as case studies. These programmes were categorised as: 1) population-health management programmes, 2) programmes for frail elderly, 3) palliative care and oncology programmes, and 4) programmes for individuals with problems in multiple life domains. Many programmes include the integration across health and social care.

In WP2 detailed ‘thick descriptions’ of the 17 integrated care programmes were made. These go beyond describing the facts and try to explain what lies beneath the surface, i.e. what implicit factors cause things to work or not. These thick descriptions were based on document analyses and interviews with individuals involved in the design, organisation, management, provision and payment of these programmes, as well as patients and their informal caregivers. They specifically focused on barriers of implementing the programmes and strategies to overcome them. The thick descriptions are placed in full on the SELFIE website and two overarching analysis have been performed, one focusing on 'service delivery' and one 'Digital transformation'.

WP3 focused on financing and payment arrangements. We reviewed the literature to identify payment arrangements and financial incentives that aim to stimulate integration within and across sectors. Especially novel here is the focus on multi-morbidity. We also studied payment reforms in the SELFIE countries and the conditions for a successful implementation. We developed a new typology of payments for integrated care (Figure 3) and did cross-country and within-country panel data analyses of the impact of specific funding and payment reforms to stimulate integration of care.

In WP4 the methods to perform the Multi-Criteria Decision Analysis (MCDA) were developed. In an MCDA, a single overall value for the integrated care programme is compared with a single overall value for the comparator. Values are calculated by combining information on the performance of the programmes on particular criteria with importance-weights for these criteria. The criteria used in the MCDA are defined in terms of outcomes that cover the Triple Aim, i.e. improvements in health/wellbeing, experience of care and costs. We have specified a core set of outcomes that is used in the evaluations of all programmes and 4 programme-type specific sets of outcomes for the 4 categories of programmes. The core set includes the following outcomes: physical functioning, psychological wellbeing, social relationships and participation, enjoyment of life, resilience, person-centeredness, continuity of care, and total health and social care costs.The importance-weights of the outcomes have been determined in a separate weight elicitation study.

In WP5 the performance of the 17 integrated care programmes for multi-morbidity in SELFIE on these outcomes is being measured in quasi-experimental studies with control groups. Across the 17 programs, we generally found higher overall value scores for integrated care than for usual care, although the differences were small. These differences were often driven by improvements in the outcome ‘enjoyment of life’, which had the highest weight. Eight programs showed statistically significant improvements in ‘person-centeredness’ and/or ‘continuity of care’, but the value of especially that first outcome measure was relatively low compared to the other outcome measures. Some programs even generated net cost savings.

In WP6, we synthesized the evidence generated in the SELFIE project and formulated 10 mechanisms of successful implementation (Figure 4).

WP7 was dedicated to the transferability of the programmes to Central and Eastern European countries and pragmatic recommendations were provided.
A conceptual framework for integrated care in multi-morbidity was not available before.

We believe that the depth of the thick descriptions in WP2 can be of great value to those designing, implementing, and evaluating integrated care programmes. The same is true for the work on funding and payment arrangements. There are many examples of such arrangements resulting in conflicting provider interests that may in turn act as a barrier to integrating care. Understanding which arrangements and financial incentives do stimulate collaboration within and across sectors, and under which conditions, is of great value.

MCDA was applied because we were evaluating complex interventions, for which a traditional cost-effectiveness analysis is not sufficient. The programmes aim to improve a much wider array of outcomes than can be captured by a QALY. The outcomes included in the MCDA focus more broadly on well-being and experience of care.

What is further unique in SELFIE is that we have determined the importance of these outcomes from the perspective of 5 different groups of stakeholders in 8 countries, enabling us to study cross-cultural and cross-stakeholder differences. This way we can explicitly take the preferences of different stakeholders into account, which may lead to different recommendations on the adoption of certain integrate care programmes.

We strengthened the evidence base of integrated care by ensuring that each of the 17 integrated care programmes is compared to a control situation and includes patient-reported outcomes and experience measures in addition to more routinely available outcomes.