Table 1 Review of the existing models of Integrated care in the world

Individual models of integrated care

 American Case Management Association

USA

Both Government/Non-Government as Medicare and Medicaid

Promotes collaboration between patients, caregivers, nurses, social workers, doctors, and the community. Focuses on individualized communication to improve access to care through resource coordination [32]. The case manager assesses the patient's and caregiver's needs to establish a customized care plan, monitors the quality of care, and maintains communication with the patient and caregiver [33]. Evidence demonstrates that case management reduces hospital (re)admissions and enhances patient satisfaction.

The Cost-effectiveness of case management is still debated [24] and thus limits its acceptance in LMIC

 Individual care plans

Countries under Organization for Economic Co-operation and Development (OECD)

Government

As Medicare

Considered for patients with multimorbidity and long-term conditions. Care coordinators assess a patient's needs, design care plans, and organize multidisciplinary care delivery [25]. A personal budget (PB) is a type of intervention that emphasizes the patient's active involvement in their care. It comprises a sum of money allocated to the individual and used for various things in accordance with personal needs [34].

Individual care plans are time-consuming and costly to implement [24]. As a result, they necessitate precise eligibility requirements and rigorous beneficiary selection, thus limiting their acceptability to highly populated LMICs [25].

 Patient-centred medical home(s)²(PCMH)

USA

Non-Government

PCMH provides an alternative to the primary care network by physician-directed groups with nurses as care coordinators assigned to particular medical homes. Patients act as partners in understanding the culture, unique needs, preferences, and values of patients with multi-morbidities and chronic diseases [35]. PCMH uses information technology and health information exchanges, as well as allocating interdisciplinary teams [24]. The PCMH has been able to cut hospital admissions by 20% and readmission rates by 12% among its beneficiaries [36].

PCMH has been chastised for being very fragmented, with delays in service delivery until reimbursement is rewarded [26].

 Personal health budgets (PHB)

England

Government

PHBs focus on solving the ongoing needs of patients in terms of lived experiences by involving clinical practitioners' learned expertise to improve the quality of life [37]. A personal health budget is a monetary amount set aside by a person, or by their agent, and approved by the local integrated care system to meet that individual's needs for health and wellness.

PHB has been challenged for not being cost-effective in the long term for patients [38]. Further, Personal budgets have been accused to risk the fundamental principle of accessing healthcare based on clinical need and not the ability to pay [27].

Group and disease-specific models 

 Chronic Care Model (CCM)

USA and Countries under OECD

Government and Non-Government

CCM focuses on integrated community-based longitudinal and preventive care, in place of acute and episodic care. CCM functions through productive interactions and establishing partnerships between a community-based proactive practice team and encouraging informed patients to participate in community programs. The success of CCM is projected mainly due to the bidirectional communications, multidisciplinary team approach, and encouraging self-care [39].

Barriers to the implementation of CCMs belong mainly to the patient’s will to change their behavior [28]. CCM is pitched to clinically oriented systems and is difficult to practice for the prevention and health promotion physicians. Also, slow response times from nurses and doctors, the need for regular training of staff [29], and patients may not actively contribute to self-care or may not have time for self-management support.

 Program of Research to Integrate the Services for the Maintenance of Autonomy (PRISMA)

Canada

Government

PRISMA model was designed to integrate the health and social services needs of elderly and frail patients which later on became the part of a Quebec-wide program called Réseau de Services Intégrés aux Personnes Âgées (RSIPA) [30]. The model aims to serve as a single-entry point to the system and coordinate care for the elderly and frail population. The model maintains people's functional stability, lowers the severity of unmet demands, and lightened the load on caregivers. A joint health and social care governing board establishes the strategy and allots funds to the network. It has been observed that participants in the PRISMA program had lower readmission rates to hospitals [40].

Limitations with PRISMA, RSIPA, and similar programs are that the elderly population has to get enrolled in the program through case managers and meet the defined criteria for admission. [41] Also, for the implementation of PRISMA/RSIPA models, reorganization of the entire health care system is required which has affected the application of the program [30].

 Chains of care model

Sweden

Government

The Sweden-based Chains [42] of care model was planned to connect screening components in a primary care facility, treatment plans developed in a specialty facility, and rehabilitation services offered in the community [43]. It acts by making use of contracts and aligns incentives to promote effective resource utilization.

Despite planned goals and activities, seven out of ten councils are unsure of the effectiveness of the development work. The most frequently cited causes of the failure include limiting vertical organizational structure and inadequate involvement of the local authorities [44].

 Managed Clinical Network

Scotland

Government

The managed clinical network developed in Scotland moves from competition to cooperation [45] among the healthcare providers working in primary, secondary, and tertiary care, in a coordinated manner. Networks mainly work to improve service for patients with rare conditions or complex care needs. Clinical Networks are designed separately for a wide range of conditions ranging from Care of Burns in Scotland (COBIS), Children and Young People's Allergy Network (CYANS), Children with Exceptional Healthcare Needs (CEN), Cleft care Scotland, Network for Inherited Cardiac Conditions Scotland (NICCS), Inherited Metabolic Disorders Scotland (IMD), National Gender Identity Clinical Network Scotland (NGICNS), and so on [46]. Managed clinical networks offer better access to services with Improved coordination and Consistent advice for better care and prevention [45].

Improvement is not linear for all the conditions and age groups as the network mainly focused on adults, young people, and children [45]. Further progress was significantly slower than expected, which at times caused frustration due to a lack of knowledge about leading practice, as well as inexperience with change management.

 Disease Management Programmes (DMPs)

Germany & Israel

Government

DMPs were introduced in the German health system to standardize nationwide programs regulating the entire duration of care in chronic conditions. While enrolment is voluntary, patients are required to adhere to the treatment goals and participate in self-management programs and disease-specific education [47].

Barriers in implement DMPs include a lack of budgetary allocations and prolonged delivery time compared to compensation [48].

Population-based models

 Kaiser Permanente

USA

Non- Government

With more than 9.6 million members across eight different states, Kaiser Permanente (KP) is one of the biggest health maintenance organizations in the USA. KP acts as an independent organization, separate from the government-provided healthcare delivery system. KP is a virtually integrated system comprised of three interconnected entities: a self-governing for-profit physician group (Permanente Medical Groups), a non-profit hospital system Kaiser Foundation Hospitals), and a non-profit health plan that covers insurance risks (Kaiser Foundation Health Plan). All three systems are mutually exclusive with regard to the purchasing and provision of services, but remain bound together by a single mission, combining systemic and normative integration [49].

Since patients have to choose either the tax-based government coverage or the KP system, benefits based on government universal coverage may not be provided to enrolled patients. Health coverage to enlisted individuals is based on health plans ranging from low coverage to high coverage, based on the co-payments [31]. Thus, the KP model will be difficult to adopt in resource-limited LMIC where financers and insurance-based coverage is limited

 Veterans’ Health Administration

USA

Non-Government

Older adults with chronic diseases in the United States can receive integrated treatments from the Veterans Health Administration (VA). The VA owns and operates hospitals and employs clinicians to provide services within its network. The VA consists of 21 regionally based integrated service networks [50].

Only works within the network and thus cannot be implemented in the regions outside the VA integrated service networks

 Integrated care in the Basque country

Basque

Government

In order to improve the outcome of care for chronic patients, Basque integrated care recognizes the interdependencies between primary care, social services, and hospitals to produce better results. Integrated care was provided using two different strategies. A bottom-up approach where primary and secondary care physicians were emphasized on coordination of care procedures. Integrated Healthcare Organizations (IHOs) were formed by combining hospital and primary care institutions. Important aspects of the model include simultaneous activation of all systems that aid integrated care. Units for Continuity of Care (CCU), established by IHOs to serve high-risk patients have enhanced coordination. CCUs are staffed with dedicated referral internists who are in charge of admitting and stabilizing chronic patients and transfer from the hospital to home, where they will subsequently be followed up on by their general practitioner. The use of strategies including patient education and information technology has been another factor in the success of the Basque integrated care strategy [51].

The primary care practitioners value the integrated system, but professionals at all the central levels impose barriers to implementation as lack of funding and political backing, time restrictions for consultations, and trouble juggling conflicting daily needs [52].