Bridging Health and Social Care – An Innovative Framework

Abstract

Introduction: There is broad consensus that patient –centered care demands that health and social care be viewed as a single, interdependent system, taking into account all of the individual’s needs. In most countries, barriers must be overcome to achieve this. In Israel, Assuta Medical Centers, a private hospital network now building a new public hospital in the city of Ashdod, initiated the development of an integrated care system for Ashdod with Maccabi Healthcare Services, the second largest non-profit HMO with an integrated community healthcare system, the Municipality of Ashdod Social Services department, and the National Insurance Institute's Southern Region (NII), responsible for domiciliary care as well welfare subsidies system. The challenges faced included different organizational cultures, a lack of work processes to support integration and separate IT systems that do not ‘speak’ to each other. Methodology: A multidisciplinary task force, representing all four organizations, has been working together for over a year to develop a comprehensive, integrated-care model wherein municipality social services, the NII, the hospital and community healthcare services will work together to meet the needs of Ashdod citizens. Sub-task forces have been set up to address four target populations: Complex elderly patients Oncology patients Children with juvenile diabetes Maternity and newborns, including premature births The task forces are multidisciplinary, with representatives from all four organizations, and are in advanced stages of delineating work processes and interventions. Results: The task force has successfully established an ongoing collaborative dialogue and has agreed to create the necessary interfaces among the IT systems of all four organizations. They have established what information will be shared, conditional upon signed consent of the patient. Interfaces have been defined and are in the process of development. The Assuta Ashdod hospital will begin operation mid-2017 and the interfaces with the social services department and NII will be completed by February 2017. The interfaces with Maccabi exist and are being upgraded. A major structural change will be the creation of a case manager function in the hospital for each target group to assure full integration. Maccabi already has a multidisciplinary unit to assure integration of community services for newly discharged complex patients. To improve integration, a care manager in the community will be assigned to coordinate ongoing care for the complex elderly. For oncology patients, a joint Assuta-Maccabi care manager will be assigned to assure full integration between hospital, community healthcare and social services. For children with diabetes, the municipality's department of education has become a full partner. Discussion: The process of collaboration has already made major changes in the organizational cultures of the participating organizations. The commitment to full implementation of integrated care processes is very high at all levels of the organizations. While this has been a bottom-up innovation, the relevant Ministries are closely following developments and other parts of the country are eager to follow suit. Multi-national research is already underway to assess the impact of these processes on the quality and cost of care for the target populations, as well as transferability to other countries.