How to identify the ones who might benefit from integrated care?

Introduction Care integration has been a policy aim in Finland since the1990s. The service system in Finland is rather integrated organizationally. Municipalities have responsibility to organize all health and social care and usually they also provide most of the services, except specialized care, which is provided by hospital districts. Despite the organizational integration, professionals are in many cases working in silos and the patient/client information systems are separate in many health and social services. There is a growing amount of people who need or use several different services. In siloed systems it is, however, difficult to identify these people. Models, practices and tools have been developed to identify these individuals. The aim of this paper is to describe and evaluate these practices. Methods The study is a part of a project on identifying the individuals who use several different services or might need care integration. This paper is based on a survey for health and social service providers in 2019 and comprising structured and open ended questions. Altogether 442 respondents filled in the questionnaire, of which 119 described a tool, model or practice to identify the individuals who use or might need several services. The data was analyzed using inductive content analysis. Results The clients who might benefit from care integration were identified most often because of concerns expressed by professionals. Secondly, they were identified through use of advisory services and thirdly because of multiple visits. The methods identifying these individuals were different working practices, segmentation of clients and tools using the patient information system. Typical practices were such as case manager system, multiprofessional teams in assessment of care needs, multiprofessional care plans and meetings, walk in services or reporting system of professionals' concerns of a client. These practices were described in social services, substance abuse or mental health services and in primary care. Segmentation of client was used especially in primary care provided at health center outpatient services. The clients were divided to chronic patients whose care was not in balance and who would benefit integration and to clients who need only one service and in short episode. Tools using patient information systems are based on clear criteria, such as a certain number of visits in outpatient care, or use of several services. Also certain health indicators, such as smoking, high BMI, can be indicators. In some cases the system can inform the professionals that the client uses several services. Conclusion The study showed that methods to identify the individuals in need for service integration are needed and that they are already in active use in several municipalities. Also several common tools exist, but coordination between providers is relatively scarce. Lessons learned Identifying the individuals who use several services is a challenge which requests a planned, national approach rather than local initiatives Limitations The survey to service providers can’t give a thorough understanding of methods used among service providers Suggestions for future research In-depth studies are needed to understand the use of methods and to evaluate their weaknesses.