Open access Original research BMJ Open: first published as 10.1136/bmjopen-2019-036182 on 3 June 2020. Downloaded from Impact of integrated care on trends in the rate of emergency department visits among older persons in Stockholm County: an interrupted time series analysis Megan Doheny ,1 Janne Agerholm,2 Nicola Orsini ,1 Pär Schön,2 Bo Burström1 To cite: Doheny M, Agerholm J, ABSTRACT Strengths and limitations of this study Orsini N, et al. Impact of Objective To investigate the association between the integrated care on trends implementation of an integrated care (IC) system in ► The study used a long time series of population- in the rate of emergency Norrtälje municipality and changes in trends of the rate of department visits among based data and could adjust for changes in compo- emergency department (ED) visits. older persons in Stockholm sition of the population, using robust methods. Design Interrupted time series analysis from 2000 to County: an interrupted time ► The geographic setting of Norrtälje made it difficult 2015. series analysis. BMJ Open to find an appropriate control community. 2020;10:e036182. doi:10.1136/ Setting Stockholm County. ► Other contextual changes during the study period Participants All inhabitants 65+ years in Stockholm bmjopen-2019-036182 may have impacted the results. County on 31 December of each study year. Prepublication history and ► Intervention IC was established by combining the additional material for this paper are available online. To funding, administration and delivery of health and social associated with old age.2 Older persons often view these files, please visit care for older persons in Norrtälje municipality, within have complex health and social care needs due Stockholm County. the journal online (http:// dx. doi. to multimorbidity, functional and cognitive org/ 10. 1136/ bmjopen- 2019- Outcome Rates of hospital- based ED visits. 036182). Results IC was associated with a decrease in the rate impairments and frailty, therefore, frequently http://bmjopen.bmj.com/ of ED visits (incidence rate ratio: 0.997, 95% CI 0.995 need health and social care services from 3 Received 04 December 2019 to 0.998) among inhabitants 65+ years in Norrtälje. multiple providers. Older persons can expe- Revised 02 March 2020 However, the rate of ED visits remained higher in Norrtälje rience reduced quality of care and adverse Accepted 06 May 2020 than the rest of Stockholm in the preintervention and health outcomes due to uncoordinated and postintervention periods. Stratified analyses showed that fragmented delivery of care services. Hence, IC was associated with a decline in the trend of the rate it is important that the health and social care of ED visits among those 65–79 years, the lowest income systems adapt to the needs of an ageing popu- group and born outside of Sweden. However, there was no lation, who could benefit from better align- significant decrease in the trend among those 80+ years. ment between and within health and social on October 2, 2021 by guest. Protected copyright. Conclusion The implementation of IC was associated care services.4 5 with a modest change in the trend of ED visits in Norrtälje, though the rate of ED visits remained higher than in the The Swedish health and social care system rest of Stockholm. Changes in the composition of the is tax- funded and universal for all citizens, population and contextual changes may have impacted our however, it is highly decentralised. The findings. Further research, using other outcome measures responsibility of provision, management is needed to assess the impact of IC on healthcare and financing of services has three levels of utilisation. governance. At the national level, the govern- © Author(s) (or their ment sets policy, aims and directives, through employer(s)) 2020. Re- use permitted under CC BY. legislation and economic incentives, while Published by BMJ. INTRODUCTION the 21 regions are responsible for the provi- 1Global Public Health, Karolinska The population of Sweden is rapidly ageing, sion of health and medical care, and the Institute, Stockholm, Sweden those 80+ years represent the fastest growing 290 municipalities provide the social care 2Aging Research Center, group and are expected to double within 25 services (ie, home- help including both house- Karolinska, Stockholm, Sweden years.1 However, coupled with a longer life hold and personal care services) needed by 6 Correspondence to expectancy, there is an increased likelihood older persons. Regions and municipalities Ms Megan Doheny; of older persons experiencing long-term are independent, as they both collect taxes megan. doheny@ ki. se health problems and functional disabilities to finance the majority of care services, set Doheny M, et al. BMJ Open 2020;10:e036182. doi:10.1136/bmjopen-2019-036182 1 Open access priorities and make decisions at the regional and local is, from primary, secondary to tertiary care. Horizontal BMJ Open: first published as 10.1136/bmjopen-2019-036182 on 3 June 2020. Downloaded from level.6 Moreover, market-orientated reforms have been integration refers to when different care organisations introduced in both health and social care which promote combine their efforts and resources to develop a seam- competition, freedom of choice and diversity of care less system for delivering care that is, merging health and providers, further contributing to fragmentation in the social care services and pooling resources.13 14 16 17 Swedish care system.7 8 Furthermore, there has been a Healthcare systems are multilayered and complex, reduction in the number of municipal institutional care establishing IC involves consolidation within and between places and in the number of hospital beds, resulting in a many different care providers.14 16 The implementation of change in how long- term care is provided. These trends IC can be considered within three levels: the macro-level, have resulted in a growing number of older persons with that is, the system, the meso-level, that is, organisation complex care needs living in the community.6 9 and the micro- level, that is, the clinical.15 The macro- level Primary healthcare (PHC) is the basis of the Swedish involves establishing structures to merge health and social healthcare system, where most patients with chronic care services across the continuum.15 17 18 The meso- level diseases are treated, and includes home- health care involves the re- organisation of care services targeting services. PHC should also coordinate with and be a those with greater needs. Finally, the micro- level focuses link to social services for older persons. However, other on the care required by individual users, to facilitate the specialist services may be required. The fragmentation coordination of care across the spectrum of providers, in the Swedish system has placed those with complex by involving the patient, their carers’ and families’ in the care needs in a vulnerable position, as the patients must care decision to meet the goals of the patient.17 An IC be able to obtain pertinent information relating to the setting might better meet the needs of older persons as care they need and which provider they should seek care IC promotes better coordination and communication from.8 9 This increases the risk for individuals to experi- between professional groups which should lead to better ence poor continuity and coordination of care between continuity of care.4 19 multiple providers and may result in an increased use of emergency department (ED) care to meet their needs.10 IC: the Norrtälje model The ED serves as an important link between PHC services The Norrtälje model is an example of an IC initiative in and the hospital-based care.11 The staff in EDs are respon- Sweden. Figure 1 provides an overview of the gradual sible for stabilising, diagnosing and treating patients, implementation of IC in Norrtälje. The initiative began and moreover, they act as gatekeepers determining when the local hospital was under threat of closure due to whether an acute patient will be admitted into inpatient financial concerns. This led to a public appeal that gath- care or organising and negotiating their discharge into ered broad political support to save the local hospital. the community.12 However, those with complex needs In 2006, IC was initiated as a shared project between could be better met through coordinated care with long- Norrtälje municipality and Region Stockholm. A joint http://bmjopen.bmj.com/ term support, rather than in an acute and episodic care health and social care board with politicians from Region setting.13 Stockholm and Norrtälje municipality was formed, responsible for the financial and organisation adminis- Integrated care tration as well as the purchasing of care services from a Integrated care (IC) is an approach to organising and jointly owned public company, Vårdbolaget TioHundra delivering care which could potentially provide care with AB and other private care providers.20–22 greater efficiency and improve how patients receive and The Norrtälje model was set- up to provide care to 14 experience care. In theory, IC might be effective at over- the entire population of the municipality. The inter- on October 2, 2021 by guest. Protected copyright. coming fragmentation of care.14–18 The integration of care vention had its base at the hospital and set out to join involves both vertical and horizontal processes. Vertical the efforts of health and social care services, through integration aims to bridge the gaps between different care aligning medical documentation, care planning, reha- services and providers that operate at different levels, that bilitation, preventative care, home- help, home- health Figure 1 Overview of the timeline of the implementation of IC in Norrtälje. IC, integrated care; PHC, primary healthcare. 2 Doheny M, et al. BMJ Open 2020;10:e036182. doi:10.1136/bmjopen-2019-036182 Open access care and PHC services.20 Care teams were created with was used as a measure of socioeconomic position, grouped BMJ Open: first published as 10.1136/bmjopen-2019-036182 on 3 June 2020.