Integrated care and disease management as a bridge in ageing and disabilities

Integrated care is provided by professionals with different disciplines, competencies and degree of specialization with the first objective to promote cooperation and with a final objective to promote quality and efficiency of care. Following the degree of integration four models can be distinguished: no integration, linkage, coordination and full integration. An optimal degree exists for integrated care in relation to cost and quality. This optimum depends on local circumstances. Another distinction is horizontal integration (within PHC or hospitals) and vertical integration (between PHC and hospitals). An example of horizontal integration is the one stop shop. Disease management programmes are examples of vertical integration. In integration the use of health information technology is important, for instance for integrated education programs for patients, telemonitoring, telemedicine, work flow management and feedback to patients and professionals. The PMPM (Per Month Per Member) are important indicators for the efficiency of integrated care.