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.
