Integrated care for older people with complex needs

Industrialised countries face the common challenge of caring for a growing number of older people. In 2010, 15 per cent of the population of countries belonging to the
Organisation for Economic Co-operation and Development (OECD) were aged 65 or over, and by 2030 this is expected to reach 22 per cent (OECD 2009). Not only is there a growing proportion of people aged 65 and over, but they are living longer. For example, a woman who was aged 65 in 2009 could expect to live for another 21 years – an almost 40 per cent increase in life expectancy compared with 50 years ago (OECD 2011).

Although longevity is worth celebrating, older age is associated with an increased incidence of multiple chronic conditions and a growing number of functional and cognitive impairments. Studies in the United States show that about half the population aged over 75 have three or more chronic conditions, and that individuals aged 85 or older are six times more likely to have multiple functional impairments than those aged between 65 and 69 (Anderson 2011). There is also evidence that the number of older people who are living alone is increasing at the same time as the availability of informal care by spouses or family members is declining (Coyte et al 2008).

These trends have resulted in a growing demand for health care services to treat multiple chronic medical conditions as well as services to help individuals cope with everyday activities such as dressing, bathing, shopping, or preparing food. The latter – commonly referred to as social care services – are often provided by family members or informal caregivers but can also be provided by formal service providers, either as home care services or as part of residential long-term care.

Often, these formal social care services are organised and funded separately from health care or medical services, which can result in fragmented care for people who need both types of service. A common response is to develop integrated health and social care for] older people with complex needs. Integrated care can mean different things in different settings; however, a common feature of this approach is that it seeks to improve the quality of care for individual patients, service users and carers by ensuring that services are well co-ordinated around their needs.

In October 2013, The King’s Fund published a report from a two-year research project funded by Aetna and the Aetna Foundation that examined the key lessons and markers for success in delivering co-ordinated care to people with long-term and complex medical problems across five UK-based programmes (Goodwin et al 2013).

The report found a number of recurrent design features associated with success, yet many of the key themes – such as the extent of GP engagement or the ability to develop integrated health and social care teams – seemed particular to the UK context. Hence, it was not necessarily clear that the same organisational and management strategies towards integrated care would be transferred successfully to other care systems.

This report synthesises evidence from seven case study programmes, each from a different country, that are successfully delivering integrated health and social care for older people with complex needs. The aim is to identify lessons for policy-makers and service providers to help them improve how care is designed and co-ordinated. The seven countries that provide our case studies – Australia, Canada, the Netherlands, New Zealand, Sweden, the United Kingdom and the United States – all have a large proportion of their populations aged 65 and over and can expect many of these people to live for at least another two decades.

The added value of examining case studies from different countries is to elicit those features of integrated care development that appear to be universal determinants for successful deployment, thus overcoming some of the constraints from previous work that has general been highly context-specific.