Abstract
In this chapter the authors draw attention to the fact that there is a lot to be gained from bringing together transitional care programmes with approaches that address the wider health system environment in order to address the increasing complexity in the management of care transitions. The chapter reviews various models from Health System Performance frameworks and improvement models and seeks to elicit the programme logic underpinning such improvements. The authors aim to illustrate the application of organizational models to improve quality and safety using an international best-practice example. Lastly, the chapter ends with recommendations for policymakers, health care decision-makers and evaluators regarding the alignment of theory, model specification, implementation and attribution of quality and safety outcomes to effects.
This is a preview of subscription content, log in via an institution.
References
Advisory Council on the Assessment of Developments in the Healthcare System. (2014). Coordination and integration – Health care in an ageing society. http://www.svr-gesundheit.de/fileadmin/user_upload/Gutachten/2009/KF_engl_final.pdf
Ahmed, F., Mays, N., Ahmed, N., Bisognano, M., & Gottlieb, G. (2015) Can the accountable care organization model facilitate integrated care in England? Journal of Health Services Research & Policy. ISSN 1355-8196 DOI: 10.1177/1355819615590845.
Amelung, V., Wolf, S., & Hildebrandt, H. (2012). Integrated care in Germany – A stony but necessary road! International Journal of Integrated Care. http://www.ijic.org/index.php/ijic/article/view/URN%3ANBN%3ANL%3AUI%3A10-1-112901. Accessed 7 July 2016.
Arah, O. A. (2009). On the relationship between individual and population health. Medicine, Health Care, and Philosophy, 12(3), 235–244.
Barr, V. J., Robinson, S., Marin-Link, B., Underhill, L., Dotts, A., Ravensdale, D., & Salivaras, S. (2003). The expanded chronic care model: An integration of concepts and strategies from population health promotion and the chronic care model. Hospital Quarterly, 7, 73–82. http://www.area-c54.it/public/the%20expanded%20chronic%20care%20model.pdf.
Batalden, M., Batalden, P., Margolis, P., Seid, M., Armstrong, G., Opipari-Arrigan, L., & Hartung, H. (2015). Coproduction of healthcare service. BMJ Quality & Safety. 2015 Sep 16. pii: bmjqs-2015-004315. doi:10.1136/bmjqs-2015-004315.
Berwick, D. M., Nolan, T. W., & Whittington, J. (2008). The triple aim: Care, health, and cost. Health Affairs (Millwood), 27, 759–769. doi:10.1377/hlthaff.27.3.759.
Busse, R. (2014). Integrated care experiences and outcomes in Germany, The Netherlands, and England. Health Affairs, 33(9), 1549–1558.
Cheen, M. H. H., Goon, C. P., Lim, P. S., et al. (2016). Evaluation of a care transition program with pharmacist-provided home-based medication review for elderly Singaporeans at high risk of readmissions. International Journal for Quality in Health Care, 1–6. doi:10.1093/intqhc/mzw150.
Coleman, E. A., & Boult, C. (2003). American Geriatrics Society health care systems committee. Improving the quality of transitional care for persons with complex care needs. Journal of the American Geriatrics Society, 51(4), 556–557.
Davis, K., Stremikis, K., Squires, D., Schoen, C. (2014). Mirror, mirror on the wall: How the performance of the U.S. Health Care System Compares Internationally. New York: The Commonwealth Fund. http://www.commonwealthfund.org/~/media/files/publications/fund-report/2014/jun/1755_davis_mirror_mirror_2014.pdf
Dixon-Woods, M., McNicol, S., & Martin, G. (2012). Ten challenges in improving quality in healthcare: Lessons from the Health Foundation’s programme evaluations and relevant literature. BMJ Quality and Safety, 21(10), 876–884.
Evans, R. G., Barer, M. L., & Marmor, T. R. (1988). Why are some people healthy and others not (1st ed.). London: Routledge.
Grothaus, F. J. (2009). Entwicklung der integrierten Versorgung in der Bundesrepublik Deutschland 2004–2008. Bericht gemäß § 140d SGB V auf der Grundlage der Meldungen von Verträgen zur integrierten Versorgung. http://www.bqs-register140d.de/dokumente/bericht-140d.pdf. Accessed 7 July 2016.
Hibbard, J. H. (2017). Patient activation and the use of information to support informed health decisions. Patient Education and Counseling, 100(1), 5–7.
Hildebrandt, H., Hermann, C., Knittel, R., Richter-Reichhelm, M., Siegel, A., & Witzenrath, W. (2010). Gesundes Kinzigtal integrated care: Improving population health by a shared health gain approach and a shared savings contract. International Journal of Integrated Care, 10, 1–14.
Hildebrandt, H., Pimperl, A., Schulte, T., Hermann, C., Riedel, H., Schubert, I., Köster, I., Siegel, A., & Wetzel, M. (2015). Triple-Aim-Evaluation in der Integrierten Versorgung Gesundes Kinzigtal – Gesundheitszustand, Versorgungserleben und Wirtschaftlichkeit. Bundesgesundheitsblatt, 58, 383–392.
Hildebrandt, H., Stunder, B., & Schulte, T. (2012). Triple aim in Kinzigtal, Germany: Improving population health, integrating health care and reducing costs of care – Lessons for the UK? Journal of Integrated Care, 20, 205–222.
Ivers, N., Jamtvedt, G., Flottorp, S., Young, J. M., Odgaard-Jensen, J., French, S. D., et al. (2012). Audit and feedback: Effects on professional practice and healthcare outcomes. Cochrane Database of Systematic Reviews, 6, CD000259.
Kindig, D., & Stoddart, G. (2003). What is population health? American Journal of Public Health, 93(3), 380–383.
Kringos, D. S., Boerma, W. G. W., Hutchinson, A., & Saltman. R. D. (2015). Building primary care in a changing Europe. WHO European observatory on health care systems. http://www.euro.who.int/__data/assets/pdf_file/0018/271170/BuildingPrimaryCareChangingEurope.pdf. Accessed 7 July 2016.
Kringos, D. S., Sunol, R., Wagner, C., Mannion, R., Michel, P., Klazinga, N. S., & Groene, O. (2015). DUQuE consortium. The influence of context on the effectiveness of hospital quality improvement strategies: A review of systematic reviews. BMC Health Services Research, 15, 277. doi:10.1186/s12913-015-0906-0.
McCarthy, D., & Klein, S. (2012). The triple aim journey: improving population health and patients’ experience of care, while reducing costs. http://www.commonwealthfund.org/~/media/files/publications/case-study/2010/jul/triple-aim-v2/1421_mccarthy_triple_aim_journey_overview.pdf
Organization for Economic Cooperation and Development. Health at a Glance. (2015). OECD indicators. http://www.oecd.org/berlin/publikationen/health-at-a-glance-2015.htm
Phatak, A., Prusi, R., Ward, B., Hansen, L. O., Williams, M. V., Vetter, E., Chapman, N., & Postelnick, M. (2015). Impact of pharmacist involvement in the transitional care of high-risk patients through medication reconciliation, medication education, and postdischarge call-backs (IPITCH study). Journal of Hospital Medicine. doi:10.1002/jhm.2493.
Schoen, C., Osborn, R., Huynh, P. T., Doty, M., Zapert, K., Peugh, J., & Davis, K. (2005). Taking the pulse of health care systems: Experiences of patients with health problems in six countries. Health Affairs (Millwood), (Suppl Web Exclusives): W5–509–25.
Siegel, A., & Stößel, U. (2013). Evaluation der Integrierten Versorgung Gesundes Kinzigtal: Bisherige Ergebnisse. Public Health Forum, 21, 13–15.
Sundmacher, L., Fischbach, D., Schuettig, W., Naumann, C., Augustin, U., & Faisst, C. (2015). Which hospitalisations are ambulatory care-sensitive, to what degree, and how could the rates be reduced? Results of a group consensus study in Germany. Health Policy, 119(11), 1415–1423. doi:10.1016/j.healthpol.2015.08.007.
The King’s Fund. (2015). Population health systems – Going beyond integrated care. London: King’s Fund. https://www.kingsfund.org.uk/sites/files/kf/field/field_publication_file/population-health-systems-kingsfund-feb15.pdf
Wagner, E. H. (1998). Chronic disease management: What will it take to improve care for chronic illness? Effective Clinical Practice, 1(1), 2–4.
Wennberg, J. (2011). Time to tackle unwarranted variations in practice. BMJ, 342. doi:10.1136/bmj.d1513.
Whittington, J. W., Nolan, K., Lewis, N., & Torres, T. (2015). Pursuing the triple aim: The first 7 years. The Milbank Quarterly, 93(2), 263–300. doi:10.1111/1468-0009.12122.
World Health Organization. World Health Report. (2000). Health systems. Geneva: WHO. http://www.who.int/whr/2000/en/.
Author information
Authors and Affiliations
Editor information
Editors and Affiliations
Rights and permissions
Copyright information
© 2017 The Author(s)
About this chapter
Cite this chapter
Groene, O., Pimperl, A., Hildebrandt, H. (2017). The Role of Integrated Care and Population Health. In: Aase, K., Waring, J., Schibevaag, L. (eds) Researching Quality in Care Transitions. Palgrave Macmillan, Cham. https://doi.org/10.1007/978-3-319-62346-7_14
Download citation
DOI: https://doi.org/10.1007/978-3-319-62346-7_14
Published:
Publisher Name: Palgrave Macmillan, Cham
Print ISBN: 978-3-319-62345-0
Online ISBN: 978-3-319-62346-7
eBook Packages: Social SciencesSocial Sciences (R0)