The Integration of Care in the Portuguese NHS - A methodological proposal.

Introduction: The lack of integration of care in Portugal is perceived as a major constrain to the health system and, consequently, to the quality of care provided to patients. The improvement of integration is seen as a more effective way to provide quality care and to optimize scarce resources available. There were identified more than 175 definitions published in scientific papers (Armitage et al., 2009), and consensually adopted the WHO (2008) definition of integrated service delivery: "The management and delivery of health services so that clients receive a continuum of preventive and curative services, according to their needs over time and across different levels of the health system." From this point, the group established a theoretical framework of four dimensions of integration of care: structural (horizontal and/or vertical), functional, normative and systemic (clinical, information, financing and administrative perspective), in order to justify the recommendations on integration. Policy context and objective: Since 2011 the Portuguese Health Ministry has promoted technical Working Groups to study the integration of care. Several reports have been elaborated on this topic, identifying strategic initiatives to be implemented by the Government and public entities. The focus on the study of integration of care cannot be disconnected of the financial crisis that Portugal suffered and the goals established by the intervention of the International Monetary Fund, European Central Bank and the European Union. By order of the Secretary of State Assistant to the Minister of Health (9567/2013, 22 of July) a Work Group responsible for the elaboration of a report on the integration of the different health care levels in Portugal (Primary Care, Hospital and Palliative Care) was nominated. This Work Group was composed by multidisciplinary profiles with different professional background and work places, in order to reduce some bias derived from the personal experiences and influences. The document "Report of Integrated Care in the Portuguese Health System: Recommendations for the future" was produced in a six month period, and the members of the Work Group participated on a non- paid partial time regimen. Target population: The Final Report of the Work Group aims to the Health Ministry policy makers, as well as the responsibles for the delivering of care in the Portuguese NHS. The measures defined should be promoted by the Health Ministry, but they can be applied locally, having a firm connection to a broader framework (regional or national). Highlights (innovation, Impact and outcomes): The Work Group established a focus on tangible recommendations, being aware of the financial context that Portugal is subjected, and the need to improve the efficiency of the system as well as the quality of care provided. All the recommendations were presented with a rationale, with the conditions for operationalization, the estimated impact and the scientific evidence found for each one: • Introduce the concept of case management; • Create and implement a national referral management system; • Implement integrated guidelines, protocols and clinical pathways; • Create functional units shared by different levels of care (levels of decision); • Financial model based on capitation (risk adjustment) plus pay for performance (same objectives for different units); • Integrate administrative functions and procedures (for example: payroll salaries; logistics); • Integrate cost accounting systems. Conclusions: In Portugal, despite the focus on this topic the Working Group found an almost non existing evidence on integration of care, and the experiences identified, promoted locally by the providers revealed a more personal commitment and single initiatives rather than a national, or regional framework or a medium long term perspective. The recommendations of the Work Group where based on the real and theoretical diagnosis of the current state, and on the discussion based in evidence on this topic. Due to the nature of the recommendations, there is the need to develop the definition and the application of some of them, being estimated that they can be implemented with success in a medium/long term. [ABSTRACT FROM AUTHOR]