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SELFIE Report Summary

Project ID: 634288
Funded under: H2020-EU.3.1.

Periodic Reporting for period 1 - SELFIE (Sustainable intEgrated care modeLs for multi-morbidity: delivery, FInancing and performancE)

Reporting period: 2015-09-01 to 2017-02-28

Summary of the context and overall objectives of the project

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.

Work performed from the beginning of the project to the end of the period covered by the report and main results achieved so far

In WP1 a conceptual framework on integrated care for multi-morbidity was developed. It is shown in Figure 2. A scoping review of scientific and grey literature and expert discussions were used to identify and structure relevant concepts of integrated care for persons with multi-morbidity into a framework. 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. Papers on the scoping review and the conceptual framework will appear in a special issue of Health Policy scheduled for 2017. The framework is also available on the SELFIE website.

The conceptual framework guides the description and evaluation of the 17 promising integrated care programmes for multi-morbidity that were selected as case studies. These 17 selected programmes can be categorised as: 1) population-health management programmes targeting the entire population of citizens in particular regions, 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, 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. The thick descriptions were structured according to the SELFIE conceptual framework. There is a specific focus on barriers of implementing the programmes and strategies to overcome them. The thick descriptions are placed in full on the SELFIE website.

WP3 on funding and payment arrangements is ongoing. A review of the literature was done 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. The conditions for a successful implementation of these schemes were studied. We found that the majority of programmes in SELFIE did not introduce new provider payment mechanisms to incentivise integration. Exceptions to this were Germany, the Netherlands and the UK, where examples were found of payers pooling budgets within or across sectors to share risk/reward. A new classification of integrated payment systems is under development. Panel data analyses of the impact of funding and payment systems on outcomes are underway.

In WP4 the methods to perform the Multi-Criteria Decision Analysis (MCDA) were developed. We have opted for a value-based method based on Multi-Attribute Utility Theory (MAUT), in which a single overall value for the integrated care programme is compared with a single overall value for the comparator. Value 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 performance of the 17 integrated care programmes for multi-morbidity in SELFIE on these outcomes is currently being measured in the empirical evaluations of these programmes in WP5. A detailed study protocol was written for each programme.

The importance-weights of these outcomes are currently being determined in a separate weight elicitation study using a Discrete Choice Experiment and Swing Weighting. Weights will be obtained in each of the 8 countries from 5 groups of stakeholders, the 5Ps: 1) Patients, 2) Partners and informal caregivers, 3) Professionals, 4) Payers, and 5) Policy makers.

Progress beyond the state of the art and expected potential impact (including the socio-economic impact and the wider societal implications of the project so far)

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 is being applied because we are 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 are determining 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.

We aim to strengthen 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.

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