People with multiple chronic conditions often have complex needs and are more likely to experience hospitalization, which may lead to further functional decline. These factors contribute to longer lengths of stay, increased risk of complications and adverse events.
The key practices that support integration include: single point of entry, “at risk” screening, comprehensive assessment, service coordination and case management, care planning including advance care planning, clear communication processes including shared health records, patient empowerment and self-management, quality use of medications and ongoing monitoring.
The healthcare system is complex and people have difficulty navigating the system due to inadequate linkage between organisations and services
People with complex needs require a comprehensive range of services, delivered across organisational boundaries, with clear assessment processes, access routes and pathways through services.
Both overseas and Australian experience indicate that case management is ideally targeted to individuals who are likely to receive the most benefit i.e. those with complex needs requiring intense management from a range of different organisations, as this is where case management is deemed most cost effective.
Therefore, the focus of many integrated care projects is on service coordination as a way of integrating care management and creating care pathways through the system.
The move towards models of integrated care is an effort to manage the labyrinth of the healthcare system that has become increasingly complicated as additional services and funding streams have been introduced to encourage innovation, change traditional healthcare practices and address gaps in service provision.
However, the delivery of services to people with complex needs is the responsibility of many different healthcare