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Care coordination / Integrated care

Definition: deliberate organization of patient care activities between two or more participants (including the informal care giver and the patient) involved in a patient’s care to facilitate the appropriate delivery of healthcare services in the right order, at the right time, and in the right setting.

Defining characteristics:

1.       Numerous participants are typically involved in care coordination. The more complex care becomes, the higher the number of potential participants and relationships among participants. Some common participants are patients, family caregivers, physicians, nurses, pharmacists, and social workers.

2.       Coordination is necessary when participants are dependent upon each other to carry out disparate activities in a patient’s care. Delivering a satisfactory response to the patient’s complex care needs often cannot be accomplished by a single participant. Instead these needs are addressed by multiple participants who each have their specialized skills.

3.     Coordination requires that each participant needs adequate knowledge about their own and others’ roles, and available resources. Without adequate knowledge about available resources and other participants, it is very hard for a participant to make the appropriate decisions and create a care plan.

4.       In order to manage all required patient care activities, participants rely on exchange of information. Participants need the critical patient-related information to facilitate effective coordination and medical decision making. This information needs to be exchanged between the different participants such as between a specialist and the referring physician.

5.       Integration of care activities has the goal of facilitating delivery of the right healthcare services in the right order, at the right time, and in the right setting.

Aim: Care coordination (integrated care) occurs with the deliberate purpose of achieving improved outcomes for the patient and healthcare system. The main goals that are hoped to be achieved through improved care coordination are better quality of care, better access to care, and at the same time a reduction of costs (e.g., reducing avoidable/unnecessary hospitalisation of older people with chronic conditions). Improved outcome should be accomplished while being safe, effective, patient-centered, timely, efficient and equitable.

Analysis & Details: Deployment of care coordination entails basic changes to support a local health care system to provide care that is evidence-based, population-based and patient-centered for the prevention and management of chronic diseases involving primary care, secondary care, social care and empowered patients, friends and family in close collaboration.



Care Pathway

Definition: A complex set of activities and/or choices undertaken by multidisciplinary care professionals, patients, and relatives for mutual decision making and organization of care processes for a well-defined group of patients during a well-defined period.

Defining characteristics:

1.       an explicit statement of goals and key elements of evidence-based care, best practice, and patient's expectations & their characteristics

2.       the facilitation of the communication among team members and with patients and families

3.       the coordination of the care process by coordinating the roles and sequencing the activities of the multidisciplinary care team, patients and their relatives

4.       the documentation, monitoring, and evaluation of variances and outcomes

5.       the identification of the appropriate resources

Aim: to enhance the quality of care across the continuum by improving risk-adjusted patient outcomes, promoting patient safety, increasing patient satisfaction, and optimizing the use of resources.

Analysis & Details: A care pathway is a set of appropriate actions (activities and/or choices) that need to be performed by a number of multidisciplinary care teams, patients and their relatives in order to tackle a specific medical condition. The “well-defined group of patients” mentioned in the definition includes the patients with the aforementioned medical condition. These actions comprise both the necessary – medical – decision making (which has to be mutual, i.e., agreed between the patient and the care professionals) and the organization (e.g., communication among the involved actors) of the overall effort to tackle the condition. A care pathway may reference guidelines and protocols. 

Sources: European Pathway Association, NHS “Care Pathways” Report

Care Plan

Definition: A – usually documented – agreement between a patient and her health professional (and/or social services) to help the patient manage her health day-to-day.

Care Plan Contents (not exhaustive):

·         the goals of the patient (e.g., getting out of the house more, returning to work, starting a hobby)

·         the support services the patient wants, along with information regarding who is the responsible service provider, what are the agreed support services and when the services are applied

·         emergency numbers (e.g., contact number in case the patient becomes very unwell and the doctor's surgery is closed)

·         medication

·         eating plan

·         exercise plan

Care Plan Categories (examples):

·         cancer care plan

·         clinical management plan (this one includes ACT's diseases of interest)

·         mental health crisis plan

·         psychiatry care plan

Analysis & Details: A care plan is a written (many definitions insist on this), agreed set of instructions and goals that is meant to help a patient deal with her medical condition. It is not meant to help the GP or other healthcare workers. The care plan is entirely patient-centric.

Care plan versus Care pathway: The two concepts are quite similar since both indicate proper actions for the efficient management of a medical condition. In fact, some sources suggest that they can be used a synonyms. However, they are distinct; their differences are summarized in the following list:

·         The Care Pathway refers to a group of patients (with a specific condition), while the Care Plan refers to a single patient.

·         The Care Pathway indicates actions undertaken by care professionals, patients and their relatives, while the Care Plan indicates actions undertaken exclusively by patients.

·         The Care Pathway includes both decision making and organization actions, while the Care Plan does not include decision making actions.

Thus, the Care Plan can be perceived as a personalized instantiation of a patient-oriented view of (or the patient-related part of) a Care Pathway. Moreover, we can say that almost all the information needed to produce a Care Plan can be extracted from an appropriate Care Pathway. We use the phrase “almost all” instead of all to indicate that the Care Plan of a patient can be adjusted (or fine-tuned) to reflect the needs of the specific patient.

Sources: NHS “What is a care plan?” Report, NCI Thesaurus


Definition: Efficacy refers to the level of the desired beneficial effects (good over harm, benefits over costs) of a programme (clinical intervention) when delivered and received under optimum conditions.


Defining characteristics: Efficacy addresses the question: Can it work? Does the health procedure, service or programme do more good than harm to people who fully comply with the associated recommendations or treatments? In other words efficacy measures patient benefit and short term harm in scientific, usually experimental studies. Health technology assessments concerned with efficacy place particular emphasis on Randomized Controlled Trials (RCTs) and systematic reviews trials. The RCTs emerged as the golden standard for evaluating the efficacy of an intervention since the mid-20th century.

However, because of the highly controlled environment required for conducting an RCT, clinicians and researchers recognize that findings concerning efficacy evaluation do not necessarily indicate a given treatment will yield similar results when applied in daily clinical practice


Efficacy versus Effectiveness: Effectiveness is defined as the level of the desired beneficial effects (good over harm, benefits over costs) that a program achieves when received under typical real-world conditions of availability and acceptance.

Effectiveness addresses the question: Does it work? Does the procedure, service or programme do more good than harm to those people to whom it is offered?

When talking in terms of efficacy versus effectiveness, effectiveness relates to how well a treatment works in the practice of medicine, as opposed to efficacy, which measures how well treatment works in clinical trials or laboratory studies. Thus, the concept of effectiveness might be better-fitted to the purposes of ACT than the concept of efficacy.


  • Drummond, M, Sculpher, M., Torrance, G., O’Brien, B. and Stoddart, G. (eds) (2005) Methods for the Economic evaluation of health care programmes. Oxford University Press, New York.
  • Stevens, A., Abrams, K, Brazier, J., Fitzpatrick, R. and Lilford, R. (eds) (2001). The Advanced Handbook of Methods in Evidence Based Healthcare. Sage, London, pp. 141.
  • Flay, B.R. and Phil, D. (1986) Efficacy and effectiveness trials (and other phases of research) in the development of health promotion programs. Preventive Medicine, 15(5), pp.451-474.
  • Van Rijswijk, L. and Gray, M., 2012. Evidence, Research, and Clinical Practice A Patient-Centered Framework for Progress in Wound Care. Journal of Wound, Ostomy and Continence Nursing, 39(1), pp.35-44.





Definition: Efficiency is referred to the state that a given output is achieved by sparingly using a certain amount of all kind of inputs/resources (technical definition of efficiency).


Different perspectives of Efficiency: Besides the technical efficiency there is also the productive one, which is referred either to the maximization of output for given input or to the minimization of input for given output. We could also mention allocative efficiency situations in which either inputs or outputs are put to their best possible uses in the economy so that no further gains in output or welfare are possible. Finally there is Pareto efficiency which is related to the allocation of resources in a way that it is impossible to improve the level of welfare of one party without hurting the welfare level of another party.


Analysis & Evaluation of Efficiency: With the evaluation of efficiency we are asking the following questions:

  1. Is this health procedure, service or programme worth doing compared with other things we could do with these same resources?
  2. Are we satisfied that the health care resources (required to make the procedure, service or programme available to those who could benefit from it) should be spent in this way rather than some other way?

The efficiency is highly associated with the economic theory. It is considered that there are four main forms of efficiency evaluation (or economic evaluation), each dealing with costs but differing in the way that the consequences of health care programmes are measured and valued. These forms are cost analysis, cost effectiveness analysis, cost utility analysis and cost benefit analysis.



  • Folland, S., Goodman, A.C. and Stano, M. (eds) (2010). The economics of health and health care. Pearson, New Jersey.
  • Drummond, M, Sculpher, M., Torrance, G., O’Brien, B. and Stoddart, G. (eds) (2005) Methods for the Economic evaluation of health care programmes. Oxford University Press, New York.

Key drivers

Definition: An essential aspect of a health care program that, when altering/modifying or adjusting that aspect, has as its effect an intended change in an outcome.

Defining characteristics:

1.       Key driver (i.e., its maximization) is vital for continued success and further deployment of a health care program.

2.       Key drivers are under the control of those deploying a health care program.

3.       Key drivers need to be few in number for good understanding.

4.       Key drivers provide best results under limited resources.

5.       Key drivers help in disentangling conflicting goals to ease decision making.

6.       Assessment of key drivers by means of outcome indicator helps to plan action for improvement but is also informative what not to change.

Aim:  Key drivers are explained as the crucial factors which lead to success in health care program deployment or business, in general.

Analysis & Details: There is no single formula or recipe for guaranteed success. The use of key drivers is more of an art than science, crippled by mistakes in reasoning.

Sources: Phil Rosenzweig, The Halo Effect.

Staff engagement


Definition: The term refers to the degree of involvement of the professionals into the process of transition toward the novel healthcare model. It has been identified as one of the major factors determining success of the deployment of the integrated care services.  There are two main dimensions to be considered to achieve a high degree of staff engagement:

  • Preparation and skills of the workforce contributing to the change
  • Motivation and degree of involvement in the process of change


Defining characteristics: The highly recommended WHO booklet (1) addresses the first dimension. It identifies five core capacities to be considered for the preparation of the professionals for deployment of the chronic care model. Moreover, it is accepted that the process of change toward the chronic care model should be addressed as a complex adaptive system (2-4) wherein strategies for an effective management of the change are of most importance to achieve a high level of involvement of the staff. In summary, the strategies for staff engagement in the process of transition toward the new model of care for chronic patients show higher degree of complexity than those formulated in standard approaches to staff engagement (5-7)



  1. Preparing a HealthCare Workforce for the 21st Century: The Challenge of  Chronic Conditions.  WHO 2005
  2. WB, R. 2008. Health Care as a Complex Adaptive System: Implications for Design and Management. The Bridge, Spring 17-25
  3. Kenagy, J., 2009. Designed to Adapt: Leading Healthcare in Challenging Times: Second River Healthcare.
  4. Tinetti, M.E. and S.A. 2011. Studenski, Comparative effectiveness research and patients with multiple chronic conditions. N Engl J Med, 364(26): p. 2478-81.
  5. Lowe G. 2012. How Employee Engagement Matters for Hospital Performance. Healthcare Quarterly15(2):209- 39.
  6. Weeks S.  2010-Staff Engagement top tips.Healthcare 100. (
  7. The top tens of employee engagement. The employee engagement network. Ed. David Zinger (

Stratification of services

Definition: Stratification of services implies identification of levels of care and allocation of patients into those care categories according to their predicted health risk. It constitutes the basis for risk-stratified care management. It is accepted that identification of patient health risk category is the first, but not the only, step towards planning and implementing a personalized patient care plan by the care team, in collaboration with the patient.  We understand that the combination of patient health risk and the therapeutic strategy decided (care plan) will ultimately determine allocation of a patient into a specific service category (or integrated care program). The ultimate goal is to optimize healthcare efficiencies by matching patient needs and available resources.  Periodic and systematic assessment of patient’s health risk status is done using criteria from multiple sources: clinical, history of use of healthcare resources, socio-economic and educational background, etc...


Defining characteristics: A patient health status may be reflected by a score or placement in a specific category. Such a category or health risk level may fluctuate over time due to different factors such as change in health status, change in therapeutic priorities, etc...


Health risk categories

Among the many options to categorize health risk as indicated in the references below, one simple method proposed by the American Academy of Family Physicians (2013) creates six levels of risk within the three existing public health prevention categories to determine the patient health status:


  • Primary Prevention (Level 1 and 2): Healthy citizens who could be assigned to a low risk category, or Level 1. Individuals that are healthy but showing warning signs of potential health risks may be assigned to Level 2. Patients in the primary prevention category tend to be lower in their health care resource expenditures.
  • Secondary Prevention (Level 3 and 4): A patient who has a chronic disease, is managing it well, and meeting their desired goals, may be assigned to an intermediate category (Level 3). Those who are not in control of his/her disease but have not developed complications may be assigned to Level 4. Patients in the Secondary Prevention category tend to be moderate users of health care resources.
  • Tertiary Prevention (Level 5): If a patient's chronic disease has progressed, become unstable, or new conditions and/or significant complications have developed, they may progress to the tertiary category (Level 5). Patients in the tertiary prevention category usually rank high in health care resource expenditures.
  • Catastrophic (Level 6): An additional, non-public health Level 6 category is reserved for extreme situations, such as a pre-term baby who needs intensive long-term care, a patient who has a severe head injury, or anyone requiring highly complex treatment. Patients in the catastrophic category have extremely high health care resource expenditures and may be under the care of several sub-specialists.


Future developments: A future Systems Medicine (SM) approach to chronic care promotes predictive and personalized medicine based on different grounds than the current risk-stratified care management described above.  The current risk-stratified care management is strongly based on the patient’s history of use of healthcare resources, whereas SM aims at capturing patient-specific disease mechanisms.  The knowledge of disease mechanisms will constitute the basis for subject-specific predictive modeling for the design of preventive health strategies.  Such a predictive modeling will include disease mechanisms as well as their interplay with genetic susceptibility and influences from environmental, lifestyle and socioeconomic factors. In other words, while current risk-stratified care management is mostly reactive, predictive medicine will be fundamentally preventive aiming at disease modulation. We should emphasize that Systems Medicine is still in its childhood.



  • Risk-stratified care management. 2013 American Academy of Family Physicians (
  • Improving Care for People with Long-term Conditions: a review from UK and International networks. 2006. University of Birmingham. NHS. Institute for Innovation and  Improvement
  • Bardsley M, Billings J, Dixon J, Georghiou T, Lewis GH, Steventon A (2011) ‘Predicting who will use intensive social care: case finding tools based on linked health and social care data’, Age and Ageing 40(2): 265-270 (Nuffield Trust)
  • Sanderson M. 2010. SPARRA. Recent and Future Developments. Health and Social Care Pathways. ISD Scotland
  • Frieden TR. 2010.  A Framework for Public Health Action: The Health Impact Pyramid. Am J Public Health. 100(4):590-95
  • Development and  Implementation of  Risk Stratification Tools:  Practical tools to identify patients with complex needs. O+berry. Working Paper 1/2013.
  • Lewis G, Curry N, Bardsley M. 2011. Choosing a Predictive Risk Model: A guide for Commissioners in England.  Evidence for better healthcare. Nuffield Trust. UK.  (

Outcome indicators

Definition: A specific, observable, and measurable characteristic or change that will represent achievement of an outcome. An indicator provides evidence that a certain condition exists or certain results have or have not been achieved.

Defining characteristics:

1.       Outcome indicators measure the broader results achieved through the deployment of a health care program. These indicators can exist at various levels: population, program or patient.

2.       An outcome indicator may be used to drive improvements to a local health care system or to set priorities in a health care program. This can be established by setting thresholds or a target level of ambition.

3.       A primary outcome indicator is a measure that signifies an overall success of the health care program deployed (e.g., to justify further deployment approval).

4.       Some criteria for outcome indicators:

·         Does an indicator enable one to know about the expected result or condition?

·         Are data for an indicator collected in the same way over time and across regions?

·         Will data be available for an indicator?


Aim:  The use of outcome indicators is to make explicit (i.e. quantify) to what extent health care programs are effective and resources are being used wisely. Outcome indicators may address particular components (Key Drivers) of a health care program.

Analysis & Details: To justify the deployment of health care programs, for instance, for sustainable fundings, legislators, policy makers, health care professionals and health care industries want to see evidence in the effectiveness and affordability of health care programs. Indicators assess the progress towards the achievement of intended objectives.

Sources: United Way of America. Measuring Program Outcomes: A Practical Approach.Alexandria, VA: United Way of America; 1996.

Patient Adherence

Definition: The WHO’s Adherence Project (1-3) adopted the following definition for adherence to long-term therapies:


“Adherence is the extent to which a person’s behavior – taking medication, following a diet and/or executing lifestyle changes, corresponds with agreed recommendations from a healthcare provider”  (4).


 It has also been defined as the extent to which the patient continues the agreed-upon mode of treatment under limited supervision when faced with conflicting demands, as distinguished from compliance or maintenance(5).



  1. Sabate E. WHO. Adherence Meeting Report. Geneva. World Health Organization. 2001
  2. Haynes RB. Determinants of compliance: Thediseaseand the mechanics of treatment. BaltimoreMD Johns Hopkins University Press, 1979
  3. Rand CS. Measuring adherence with therapy for chronic diseases: implications for the treatment of heterozygous familial hypercholesterolemia. Am J Cardiology 1993;72:680-740
  4. Adherence to long-term therapies: evidence for action. WHO 2003
  5. The American Heritage® Medical Dictionary 2007. Published by Houghton Mifflin Company