What can be done to support integrated care?

Integrated care can be supported by investing in and applying the tools available for integrated care. There are many different ways in which professionals and providers can work directly with communities, patients/clients to support integrated care. These ‘tools’ of integrated care focus on the ‘how’ of clinical and service integration.

Different approaches have been used to integrate care, but they share this trait: they design all stages of care delivery around what is best for patients. The main strategy to improve access is to concentrate services in one location and provide them free-of-charge. An integrated service provision model minimizes the chances of stigmatization based on the fact that a client has come to receive certain services.

Effective linkage is based on an understanding of who is using drugs, which drugs are being used, what kinds of risk behaviours are related to drug use (e.g., sharing injection equipment and increased frequency of unprotected sex) and what steps need to be taken to reach out to and encourage PWUD to engage with HIV prevention activities and services.

There are clearly many issues going on “behind” this general definition and it is useful to look at “integration”- from various perspectives.

For the user, integration means health care that is seamless, smooth and easy to navigate. Users want a coordinated service which minimizes both the number of stages in an appointment and the number of separate visits to a health facility required. They want health workers to be aware of their health as a whole (not just one clinical aspect) and for health workers from different levels of a system to communicate well. In short, clients want continuity of care.

For providers, integration means that separate technical services (and their management support systems) are provided, managed, financed and evaluated either together, or in a closely coordinated way.

It is also important to understand factors related to HIV prevention, care, and treatment services, including: the kinds of services currently available; whether the services are user-friendly (i.e., appropriate, accessible, and acceptable and affordable to PWUD); and the policy and regulatory context within which drug use and HIV transmission occur and interventions will be implemented.

WHEN ESTABLISHING REFERRAL TO CARE SERVICES IT IS RECOMMENDED TO HAVE A MEMORANDUM OF UNDERSTANDING (MOU) BETWEEN ALL INVOLVED ORGANIZATIONS SIGNED. THE MOU SHOULD PROVIDE CLEAR INFORMATION ABOUT WHAT EACH ORGANIZATION WILL PROVIDE TO THE CLIENTS REFERRED TO THEM.

THE MOU ALSO MIGHT HAVE INFORMATION ABOUT ELIGIBILITY REQUIREMENTS TO REVIVE SERVICES, POINT PERSONS FOR TROUBLESHOOTING, AND AVERAGE WAITING TIME WHEN CLIENT ARRIVES (PWUD WILL NOT WAIT TOO LONG, SO IT IS THE BEST TO INFORM THE PERSON ABOUT THE LENGTH OF THE EXPECTED WAIT SO THAT THEY CAN PLAN AVOID WITHDRAWAL SYMPTOMS).

COMPREHENSIVE SERVICES ACROSS THE CARE CONTINUUM

PWID and their families have emotional, social, physical and spiritual needs that change over time. They often must cope with the effects of stigma and discrimination, poverty, loss, neglect and abandonment. Integrated care may be seen as a response to the fragmented delivery of health and social services. This fragmentation in delivery has become an acknowledged problem in many health systems. The purpose of the Continuum of Care (CoC) is to address illegal drug use as a chronic disease and develop systems that provide humane, effective, high-quality comprehensive and continuous care to PWID and their families. When implementing a testing program, it is fundamental to establish close collaboration and a referral system between clinical centres providing HIV, HCV and TB diagnosis, treatment and care, and other services where testing and/or counselling may be offered.

PATIENT FOCUS

The integrated service delivery system should meet the needs of patients needs rather than the needs of service providers. Organizations that fail to place the patient at the centre of their integration efforts are unlikely to succeed. The provision of health care, social services and related support (e.g. housing) at the right time and place to such individuals can be challenging. Problems typically include difficulties with: conducting needs assessments; putting together comprehensive service packages; co-ordinating multiple providers and services; ensuring continuity; monitoring health and functional status; responding to crises; supporting family carer; and, finally, performing all of these essential activities within existing funding and resource constraints.

Why ask the patient?

Patients are witnesses of and participants in integration.

Patients are sometimes the only connection between providers / sectors / specialties.

Patients have knowledge that will help to establish the baseline that can be used to measure change over time.

Patients’ experiences relate to many, though not all, aspects of integrated care.

Patients must be engaged in making decisions about their own care and support.” - ‘no decision about me without me.’

GEOGRAPHIC COVERAGE

Similarly, integrated services provide the opportunity for people-centred prevention, care and treatment for PWID, who have complex health and social care needs. Such services also facilitate better communication and multidisciplinary care, and are likely to increase efficiency and cost–effectiveness. Thus, wherever feasible, programs should work towards delivering integrated services for PWID in ways that are informed by PWID and that foster trust in service delivery settings and providers. When this is not possible, strong links among health and social services working with PWID should be established and maintained.

STANDARDIZED CARE DELIVERY

PWID commonly experience multiple comorbidities, often in a context of marginalization and deprivation. Rates of TB, HIV, viral hepatitis and other infectious diseases are high among PWID, as are mental health conditions. If the client is not ready to make a medical appointment, the linkage goal then becomes to get the client “as close to comprehensive medical care as possible” through one or more of the following referrals:

• to a case manager at medically-linked site; or
• to a case manager at non-medically linked site.

INFORMATION SYSTEM

Information technology that supports the linkage, especially via the electronic medical record and the use of clinical decision support systems, and through the ability to identify and target ‘at risk’ patients.

LEADERSHIP

There may also be policies that prevent HIV-positive people who use drugs from accessing care. It will be important for program planners to understand which laws exist and which behaviours the laws criminalize (e.g., into potential barriers to implementation and uptake of services. Effective leadership at all levels with a focus on continuous quality improvement is essential.

FINANCIAL MANAGEMENT

Effective linkage to HIV/HCV care and treatment following a positive diagnosis is expected to improve programme effectiveness, support earlier treatment initiation and reduce loss to follow up before treatment initiation, thus resulting in potential cost savings along the continuum of care. The international framework for measuring integrated care encourages:

• coordination within care teams;
• coordination across care teams;
• coordination between care teams and community resources;
• continuous familiarity with patient over time; and
• continuous proactive and responsive action between visits.