Publications from ODSW Social Insights: Letters by DSW (Vol 1) | Seite 36

Integration 2

Dear Students of Social Work,
A Continuation on Integrated Care
The subject of integrated care continues to be an active issue for discussion
after my earlier letter on this topic. I had reiterated the importance of social
and health integration in service delivery for vulnerable adults and in particular
older persons who are frail. There are several issues that are common in all
countries that are focusing on integrating the health and social care systems
or service providers. These often start from who should ‘own’ the patient
and her problems. As there is often no clear ownership, the information gets
lost as she navigates the systems. With the pressure of time and urgency
in discharging a patient, there is limited involvement of the user or patient
and her family in the management and strategy of care. Other issues have
to do with the challenge of effectively treating patients for often more than
one condition. This often lands the patient in the community without a good
handing off to a service provider in the community, if there is to be one.
Yet another challenge for providers is to focus attention on how to treat the
multiple conditions of users in a coordinated fashion.
A common lament from the formal provider system is the lack of home care
and informal support for a patient. This stems from the fact that we do not
spend sufficient resources to cultivate the informal care support system, when
in fact the system is critical in providing the appropriate combination of social
and home care that recognises the interdependence of health and social care
outcomes. So what results is the focus on acute care with ‘a cliff effect’ in
managing the patient when she is discharged from the hospital as there is a
lag in informal care and home care. Increasing attention should be given to
supporting the expansion of the informal care network and integrating this
into the care management process and to providing appropriate respite and
support for informal carers. This is urgent as we face a larger number of older
persons in the community and in need of care.

Thoughts on what Integrated Care looks like
Integrated care may improve the quality and continuity of care. Yet there is no
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