A system-wide transformation towards integrated care in the Basque Country: A realist evaluation

Abstract

Introduction: In 2010, in a context of severe economic recession, the Basque Government launched the Strategy to tackle the challenge of chronicity in the Basque Country to transform the Basque health system to cope with the challenges of chronicity, ageing, health system fragmentation and sustainability in the long run. Methods: A realist evaluation has been conducted, and through a combination of research methods, information has been analysed to identify context, mechanisms and outcomes. The research provides a snapshot of the experience of a system-wide, complex health system transformation, which aims to identify 'what has worked, for whom and under what circumstances'. Twenty-two semi-structured interviews held between June 2015 and December 2016, allowed us to obtain both retrospective and real-time accounts on the transformation phenomenon. Results: Research pointed out that system-wide transformation requires time, effort, leadership, vision and narrative, as well as commitment, inclusiveness, collaborative decision-making processes with local implementers, 'muddling through' and constant learning. Key levers to shake and shift the health and social care systems towards closer alignment, coordination and integration to meet the needs of people include promoting collaborative relationships between health professionals to ensure care continuity, developing new staff roles, investing in integrated electronic health records, stratifying the population by risk and facilitating bottom-up innovation. Discussion: Research has shown that system-wide changes in health and social care have been viable in the Basque Health System, although the interplay between context, mechanisms and outcomes is more complex than expected, leading to many unexpected factors, patterns and relationships.

Improving performance intelligence for governing an integrated health and social care delivery network: a case study on the Amsterdam Noord district

“…However, expanding in the direction of social care and upscaling local initiatives is still unusual as many challenges exist due to misalignment in culture, governance, and information infrastructure [29,30]. International evidence shows that the use of feedback information and a shared savings model like in the Healthy Kinzigtal region in Germany [31], cultural integration in local initiatives in Finland [32] and New Zealand [33] and multi-level policy interventions in the Basque region [34,35] are longterm investments that can boost performance of integrated care networks. The strengths of a network like the Krijtmolen Alliantie is their 10 year investment in mutual trust and vision between health and social care providers to build the foundation of its integrating care network.…”

Mental Illness Inequalities by Multimorbidity, Use of Health Resources and Socio-Economic Status in an Aging Society

“…At the same time, the health system should promote the right continuity and coordination of care for individuals suffering from mental health conditions and other chronic conditions [ 10 , 72 ]. Additionally, inequalities are being alleviated through the co-creation of value in the design of public provision of both health and social services addressed to those in need, as it has been shown that social disconnectedness could affect perceived isolation and symptoms of depression and anxiety among the elderly [ 73 , 74 ]. In the absence of well-designed access to social services and social care, an increase in socioeconomic inequalities can be expected, especially for the elderly, as a more vulnerable population.…”

“…Managers and decision-makers should not take them as ‘given’ but as something that can be tackled with policies and well-targeted interventions, resulting in a pro-poor orientation like the case of the Basque Country has shown. This Region has adopted a system-wide transformation towards integrated care [ 74 ], oriented to be based on primary care in the community; good integration of primary care and mental health; and successful implementation of a model of comprehensive care for chronic conditions, promoting the right continuity and coordination of care for individuals suffering mental health conditions and other chronic conditions. The emerging mental health delivery model offers excellent potential for international comparisons and benchlearning.…”

Supporting integrated care in practice

“…Over recent decades, there have been numerous examples of international integrated care models focusing on the needs of community-dwelling older people that have sought to embed these factors and tackle the implementation challenges they bring with varying degrees of success (WHO, 2016). Examples of the most cited include the Canadian PRISMA model (Program of Research to Integrate the Services for the Maintenance of Autonomy) (MacAdam, 2015), the Basque Country integrated care model (Urtaran-Laresgoiti et al , 2018), the Buurtzorg model originating in the Netherlands (Monsen and Deblok, 2013) and the population-based Kaiser Permanente in the USA (Pines et al , 2015). Looking across the models, it would appear that there are a set of components and delivery strategies that are associated with successful integrated care models (WHO, 2016) including the characteristics highlighted by our research.…”