Fragmentation of chronic care: a call for clarity

Purpose: To clarify the concept of fragmentation of chronic care and contribute to the international debate on how to reform systems to better address the needs of people with a chronic disorder. Theory: In a system wherein care of health and cure of disease get managed, differentiation or the division of work is its very essence and strength. If reducing differentiation is not a realistic option, the level of integration shall have to be increased to reduce unwanted fragmentation. However, with significantly less attention in the scientific literature for fragmentation of chronic care, we have found ourselves implementing solutions before sufficiently understanding the problem. Methods: Twenty experts from the US (9), the UK (3), Australia (2), Canada (2), the Netherlands (2), Denmark (1), Germany (1) were interviewed by phone or face-to-face between November 2008 and February 2009. The proceedings were audio-taped and transcribed and transcripts were examined by authors to identify emergent themes. These were agreed by discussion and the data were categorized independently by both authors, who subsequently agreed an overall classification. Results: Fragmentation of chronic care was referred to as ‘a disconnection that has to matter for a particular person on an individual level’. Experts addressed fragmentation from two perspectives: user of care and provider of care. For each perspective various forms of fragmentation were mentioned (e.g. professional, organizational, financial, informational). Fragmentation was characterized as a multifactorial problem having a mixture of consequences ranging from less severe to very severe. Experts mentioned various drivers of fragmentation on multiple levels. In minimizing fragmentation needs of patients should be taken as a starting point when addressing the drivers in a coordinative and/or integrative fashion. This should be done by a multi-stakeholder coalition. Measures should be selected from a predefined set to assess the impact on fragmentation. Conclusion: From the interviews with experts a framework was derived which aims to enable stakeholders in chronic care to: more structurally assess fragmentation, indentify areas for improvement, and select measures to assess the impact on fragmentation of chronic care. Support for this research was provided by The Commonwealth Fund. The views presented here are those of the authors and should not be contributed to The Commonwealth Fund or its directors, officers, or staff.