Table 1 The development phases of integrated care

PHASE 1 Initiative and design phase

The collaboration between health care providers has been intensified or started up. The starting point is a common problem or chance occurrence, or builds on current cooperation among care professionals. There is a sense of urgency and there are possibilities for working on these challenges in collaboration. The targeted patient group, the care chain and care process have been defined, as also the needs of patients and stakeholders. The level of ambitions, motivation and leadership determine the progress achieved. A multidisciplinary team designs an experiment or project to execute the current ideas. The collaboration can be signed up to in an agreement among care partners.

Key words: Exploring possibilities/impossibilities, ambitions and chances, (project) design and collaboration agreements.

PHASE 2 Experimental and execution phase

New initiatives or projects are being executed in the care chain. The aims, content, roles, and tasks in the care chain have been clarified and written down in care pathways and protocols. There is coordination at the level of the care chain by for instance installing coordinators or setting up meetings. Information about patient groups, working procedures or professional knowledge is exchanged. There are experiments within the collaboration, results are evaluated to learn from and reflect on. Preconditions for projects have been considered and boundary conditions have been solved by collaborative means or agreements among care providers.

Key words: Writing down aims and content of the collaboration, coordination at care chain level, experimenting and reflecting.

PHASE 3 Expansion and monitoring phase

Projects have been expanded or integrated in integrated care programmes. Agreements on the content, tasks and roles within the care chain are clear and signed up. Collaboration is no longer on an informal basis. Results are systematically monitored and improvement areas identified. The targeted population has been surveyed. More collaborative initiatives emerge such as mutual education programmes. There is a continuous commitment to the ambition of the integrated care programme. Interorganisational barriers and fragmented financial structures are on the agenda of the care partners.

Key words: Further development and maturity, monitoring and improving results, new questions and innovation.

PHASE 4 Consolidation and transformation phase

The integrated care programme is the regular way of working and providing care. Coordination at care chain level is operational; information is shared, transferred and fed back. A monitoring system periodically shows if results are being sustained, what specific improvement possibilities have been identified and to what extent patient needs have been met. The programme builds further on successful results. Organisational structures transform or are newly designed around the integrated care programme. Financial agreements are arranged with financers by means of integral contracts covering the care chain as a whole. Partners in the care chain explore new options for collaboration in the external environment with other partners.

Key words: Continuous improvement, new ambitions, structures fitting the integrated care programme (organisational structures, integral financing).