The framework structures relevant concepts in integrated care for multi-morbidity and can be applied by different stakeholders to guide development, implementation, description, and evaluation.

Most models and elements found in the literature focus on integrated care in general and do not explicitly focus on multi-morbidity. In line with this, most programmes identified in the literature build on the CCM. A comprehensive framework that better accounts for the complexities resulting from multi-morbidity is needed.

BackgroundDigital health tools comprise a wide range of technologies to support health processes. The potential of these technologies to effectively support health care transformation is widely accepted. However, wide scale implementation is uneven among countries and regions. Identification of common factors facilitating and hampering the implementation process may be useful for future policy recommendations.ObjectiveThe aim of this study was to analyze the implementation of digital health tools to support health care and social care services, as well as to facilitate the longitudinal assessment of these services, in 17 selected integrated chronic care (ICC) programs from 8 European countries.MethodsA program analysis based on thick descriptions—including document examinations and semistructured interviews with relevant stakeholders—of ICC programs in Austria, Croatia, Germany, Hungary, the Netherlands, Norway, Spain, and the United Kingdom was performed. A total of 233 stakeholders (ie, professionals, providers, patients, carers, and policymakers) were interviewed from November 2014 to September 2016. The overarching analysis focused on the use of digital health tools and program assessment strategies.ResultsSupporting digital health tools are implemented in all countries, but different levels of maturity were observed among the programs. Only few ICC programs have well-established strategies for a comprehensive longitudinal assessment. There is a strong relationship between maturity of digital health and proper evaluation strategies of integrated care.ConclusionsNotwithstanding the heterogeneity of the results across countries, most programs aim to evolve toward a digital transformation of integrated care, including implementation of comprehensive assessment strategies. It is widely accepted that the evolution of digital health tools alongside clear policies toward their adoption will facilitate regional uptake and scale-up of services with embedded digital health tools.

Background As the prevalence of multi-morbidity increases in ageing societies, health and social care systems face the challenge of providing adequate care to persons with complex needs. Approaches that integrate care across sectors and disciplines have been increasingly developed and implemented in European countries in order to tackle this challenge. The aim of the article is to identify success factors and crucial elements in the process of integrated care delivery for persons with complex needs as seen from the practical perspective of the involved stakeholders (patients, professionals, informal caregivers, managers, initiators, payers). Methods Seventeen integrated care programmes for persons with complex needs in 8 European countries were investigated using a qualitative approach, namely thick description, based on semi-structured interviews and document analysis. In total, 233 face-to-face interviews were conducted with stakeholders of the programmes between March and September 2016. Meta-analysis of the individual thick description reports was performed with a focus on the process of care delivery. Results Four categories that emerged from the overarching analysis are discussed in the article: (1) a holistic view of the patient, considering both mental health and the social situation in addition to physical health, (2) continuity of care in the form of single contact points, alignment of services and good relationships between patients and professionals, (3) relationships between professionals built on trust and facilitated by continuous communication, and (4) patient involvement in goal-setting and decision-making, allowing patients to adapt to reorganised service delivery. Conclusions We were able to identify several key aspects for a well-functioning integrated care process for complex patients and how these are put into actual practice. The article sets itself apart from the existing literature by specifically focussing on the growing share of the population with complex care needs and by providing an analysis of actual processes and interpersonal relationships that shape integrated care in practice, incorporating evidence from a variety of programmes in several countries.

We report of our work on a "thick description" of a population oriented integrated care programme in Austria, the Health Network Tennengau (HNT). The HNT is a bottom-up network comprised of social and health service providers and voluntary organisations in the Tennengau region, which is a rural area in the state of Salzburg. The HNT has its origin in a pilot project for medical home nursing care introduced in 1995 and has since gradually evolved into a comprehensive network, targeting all inhabitants of the Tennengau region. However, the activities are especially geared towards senior citizens with multiple medical and social requirements. Document analysis and interviews conducted during the Horizon 2020 project SELFIE show that the HTN puts the patient at the centre of the care process and aims to facilitate integrated care around the patient, namely to provide information, counselling, coordination and interface management through case and care management and improved communication.The interconnectedness with non-medical service providers is a central concern for all stakeholder of the HNT. Thus, the HNT is at its core not a medical programme, but a network between doctors, hospitals, care facilities and diverse social institutions in the region.The HNT has been successful for more than 20 years due to voluntary work and a culture of respect between all stakeholders. However, the sustainability has always been at risk as despite its success, continuous financing has been hard to secure, resulting in limited compensation for the involved partners, a lack of resources for public relations work, as well as a lack of funding especially at the start of pilot projects. As a consequence, the HNT still relies to a high degree on voluntary work. However, this also constitutes a weakness of the HNT, as it is not easily transferable. In other regions, not only the culture, but also voluntary stakeholders are lacking to build up integrated care without proper payment. Thus, the HNT offers manifold points for development that can only be spread by securing a sustainable financing. However, the fact that the HNT has persevered despite a lot of such adverse factors makes it an interesting case to learn from.