Improving care delivery to patients with complex care needs

16 January 2023

Fragmentation between care services is one of the key barriers to providing high quality care to patients. The loss of patient information in the continuum of care, the lack of readily accessible treatment history and poor organisational links between professionals working in different care sectors are just a few factors leading to disrupted care pathways especially in the case of patients with chronic and multimorbid conditions. New tools and solutions are being developed to address these challenges, such as policy frameworks, or instruments that improve seamless care for patients.

On 12 January 2023, Prof Axel Kaehne, Professor at Edge Hill University and Vice-president of EHMA, moderated a webinar on this issue from two perspectives. Ms Nadia Benahmed, who is a health service research expert at KCE, spoke about Belgium integrated care policy development; while Prof Paul Lillrank of Aalto University presented the University’s Virtual Care Operator project (MASSE) which enables personalised care delivery to large groups through tailor-made patient cards. The two case studies had a common element: data collected in a systematic way allows for improved treatment, higher quality of care and patient satisfaction.

As in many countries, Belgium also has a multi-level governance for health. Therefore, geographical units must be defined according to the territories of these governance levels: at decision maker level (macro), at the organisational care level (meso e.g. hospital network, organisation of the primary care) and patient level (micro e.g. at point of care). As a consequence, the data collection to define population health needs must be sufficiently granular to fit each territory level and adapt the care provision accordingly. Data is thus the core element to transform the concept of integrated care into concrete integration of care in the different geographical territories.

Integrated care requires indicators based on Findable, Accessible, Interoperable and Reusable data (FAIR principles). However, some challenges in creating a data ecosystem were identified, particularly in Belgium, where data availability is in different languages (French and Flemish) and the multiple number of sources and standards available.

Prof Paul Lillrank presented the Virtual Care Operator project (MASSE). This project includes the benefits of both population and personalised healthcare and it enables tailored care provision at the efficiency level of population health (mass-production efficiency). Whilst a personalised care manager, justified in certain very complex cases would be extremely costly, the Virtual Care Operator enables each service provider to understand each patient’s situation and needs through a personalised Patient Card in a simple and cost-efficient manner. Such a card contains only the information relevant to the specific professional in a specific care situation. One of the principal questions around this project concerns data needs and the stratification of data selected from the large pool of all available data. The Virtual Care Operator project in this sense shows a lot of similarities with the Belgian integrated care policy study.

Portability of interoperable patient data becomes extremely important and an urgent issue in order to ensure continuum of care, integration of health and social care data for each individual but particularly for patients with multimorbidity or citizens working across borders within the Union.

Whilst providing high quality personalised care as efficiently as population care provision, there are solutions available that can really help tailor personalised care provision to the wider population and to patients with complex care needs. This personalisation is enabled by stratified data on a digital card, accessible to the multidisciplinary care team. Data is key in order to operationalise care integration in practice. Granular data collection allows for adapting the care supply to the needs of the population.



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