Integrated Health Services Network

1. Activity: Modules 1 – 3 Recap (5 minutes)

Let’s take a moment to assess our knowledge gained so far in this online course focused on implementing the chronic care model for the management of non-communicable diseases.

2. Video: Integrated Health Services Networks (8 minutes)

This video lecture will introduce you to Integrated Health Services Networks.

Downloads: Transcript

3. Optional Reading: Non-Communicable Disease (10 minutes)

Care for chronic noncommunicable diseases (CNCDs) such as cardiovascular disease (CVD), diabetes, cancer, and chronic obstructive pulmonary disease (COPD) is a global problem. Research demonstrates that the vast majority of people with CNCDs do not receive appropriate care. This report describes a model of health care that could deliver integrated management of NCDs within the context of primary health care (PHC), and provides practical guidance for health care program managers, policy-makers, and stakeholders on how to plan and deliver high-quality services for people with CNCDs or CNCD risk factors.

Note: Information about Jamaica and the Caribbean are located on pages 33 – 34.

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Source: PAHO. WHO. (2013). Innovative Care for Chronic Conditions: Organizing and Delivering High Quality Care for Chronic Noncommunicable Diseases in the Americas.

4. Case Study: Applying the Chronic Care Model to the Clinical Setting (15 minutes)

To illustrate the use of the CCM in practice, we will look at a scenario that focuses on the CCM as the organizing framework for the care of a patient with a complex health problem. 

5. Case Study: Applying the Chronic Care Model to the Clinical Setting (15 minutes)

Let’s work through a second case scenario focused on a patient with asthma. 

6. Module Summary

Congratulations on completing this course on “Implementing the Chronic Care Model for the Management of Noncommunicable diseases (NCDs) in the Primary Care Setting.”

Let’s take a moment, to recap what was covered in this final module. This module discussed various aspects of healthcare integration, including the definitions of integrated delivery systems and clinical integration. An integrated health services network refers to a comprehensive and interconnected system that brings together various healthcare providers, disciplines, and services to deliver cohesive and patient-centered care. Integrated care involves seamless coordination and collaboration among healthcare professionals, organizations, and systems to ensure the delivery of efficient, effective, and holistic healthcare. The integrated delivery system entails merging various healthcare components, such as primary care, specialty care, mental health services, and community resources, into a unified framework. Clinical integration involves aligning clinical protocols, information systems, and communication strategies to streamline patient care across different settings. Integration is vital to enhance care continuity, optimize resource allocation, improve patient outcomes, and empower individuals to manage their chronic conditions effectively through a patient-centric approach that fosters preventive care, self-management, and proactive health monitoring.

This module also highlighted the importance of structural and functional integration in achieving patient-centered care and vertical and horizontal integration, emphasizing their roles in bringing healthcare activities under one management umbrella or consolidating resources to increase efficiency. Virtual integration is described as collaboration among healthcare organizations without common ownership. Kaiser Permanente is noted as an example of a healthcare organization with a vertical integration model. Last, this module underscored the significance of integration in preventing the fragmentation of healthcare services, particularly for chronic conditions, and emphasized the need to address health determinants and risk factors through coordinated health promotion and non-communicable disease prevention efforts.

7. Resources

Download and save the following resources:

• Integrated Care Models: An Overview (WHO /Europe)
• The expanded Chronic Care Model: an integration of concepts and strategies from population health promotion and the Chronic Care Model
  
• Improving cervical cancer prevention in a developing country
• Twelve evidence-based principles for implementing self-management support in primary care

8. Activities: Module 4

Thank you for completing the module. Next, please complete the module 4 quiz. We have also included an optional discussion forum, if you would like to participate.