Lindner S, et al. Can Integrated Care Help in Meeting the Challenges Posed on Our Health Care Systems by COVID-19? Some Preliminary Lessons Learned from the European VIGOUR Project. International Journal of Integrated Care, 2020; 20(4): 4, 1–5. DOI: https://doi.org/10.5334/ijic.5596 PERSPECTIVE PAPER Can Integrated Care Help in Meeting the Challenges Posed on Our Health Care Systems by COVID-19? Some Preliminary Lessons Learned from the European VIGOUR Project Sonja Lindner*, Lutz Kubitschke†, Christos Lionis‡, Marilena Anastasaki‡, Ursula Kirchmayer§, Simona Giacomini‖, Vincenzo De Luca¶, Guido Iaccarino**, Maddalena Illario††, Antonio Maddalena‡‡, Antonio Maritati§§, Diego Conforti‖‖, Isabella Roba¶¶, Daniele Musian¶¶, Antonio Cano***, Monica Granell†††, Ana M. Carriazo‡‡‡, Carmen M. Lama‡‡‡, Susana Rodríguez‡‡‡, Agnieszka Guligowska§§§, Tomasz Kostka§§§, Annemieke Konijnendijk‖‖‖, Maria Vitullo¶¶¶, Alejandro García-Rudolph****,††††,‡‡‡‡, Javier Solana Sánchez****,††††,‡‡‡‡, Marcello Maggio§§§§, Giuseppe Liotta‖‖‖‖, Chariklia Tziraki‡ and Regina Roller-Wirnsberger*, on behalf of the VIGOUR consortium The COVID-19 pandemic puts health and care systems under pressure globally. This current paper highlights challenges arising in the care for older and vulnerable populations in this context and reflects upon possible perspectives for different systems making use of nested integrated care approaches adapted during the work of the EU-funded project VIGOUR (“Evidence based Guidance to Scale-up Integrated Care in Europe”, funded by the European Union’s Health Programme 2014–2020 under Grant Agreement Number 826640). Keywords: integrated care; COVID-19; pandemic management; vulnerable patients; health care; social care Context and aim older and/or vulnerable people and patients with pre- The spread of the new coronavirus SARS-CoV-2 is chal- existing medical conditions being at risk for severe out- lenging many health and care systems around the globe comes [2]. This new challenge puts care systems in need [1]. Its onset constitutes a critical issue, especially for of answers: how can vulnerable populations be protected * Medical University of Graz, Department of Internal INCLIVA, University of Valencia, Valencia, ES Medicine, Graz, AT ††† Department of Pediatrics, Obstetrics and Gynecology, † Empirica GmbH, Bonn, DE University of Valencia, Valencia, ES ‡ Clinic of Social and Family Medicine, School of Medicine, ‡‡‡ Regional Ministry of Health and Families of Andalusia, University of Crete, GR Seville, ES § Department of Epidemiology ASL Roma 1, Lazio Regional §§§ Department of Geriatrics, Healthy Ageing Research Centre, Health Service, IT Medical University of Lodz, PL ‖ ASL Viterbo, Lazio Regional Health Service, IT ‖‖‖ University of Twente, Department of Biomedical Signals and ¶ Research and Development Unit, Federico II University Systems, Enschede, NL Hospital, Naples, IT ¶¶¶ Santobono-Pausilipon Hospital, Naples, IT ** Department of Advanced Biomedical Sciences, Federico II University and Hospital, Naples, IT **** Department of Research and Innovation, Institut Guttmann, Institut Universitari de Neurorehabilitació adscrit a la UAB, †† Campania Region Health Innovation Unit, and Federico II Badalona, Barcelona, ES University Department of Public Health, Naples, IT †††† Universitat Autònoma de Barcelona, Bellaterra (Cerdanyola ‡‡ Local Health Agency Naples 1 Department for Home Care Services, Naples, IT del Vallès), ES §§ ProMIS Coordination, Health Committee and Social & Health ‡‡‡‡ Fundació Institut d’Investigació en Ciències de la Salut Relations Organization Unit Social and Health Area, Veneto Germans Trias i Pujol, Badalona, Barcelona, ES Region, IT §§§§ University of Parma, Department of Medicine and Surgery, IT ‖‖ Department of Health and Social Policies, Autonomous Prov- ‖‖‖‖ University of Rome Tor Vergata, Department of Biomedicine ince of Trento, IT and Prevention, Rome, IT ¶¶ ALISA Liguria Region, Genoa, IT Corresponding author: Prof. Regina Roller-Wirnsberger, MME *** Department of Pediatrics, Obstetrics and Gynecology – (Regina.Roller-Wirnsberger@medunigraz.at) Art. 4, page 2 of 5 Lindner et al: Can Integrated Care Help in Meeting the Challenges Posed on Our Health Care Systems by COVID-19? Some Preliminary Lessons Learned from the European VIGOUR Project from becoming infected while also getting the best care in cerns the fact that integrated care represents a “nested” this exceptional situation, also considering that the attri- concept rather than a pre-defined organisational model of bution of vulnerability may need to be redefined within care delivery [10]. In practice, integrated care is strongly this pandemic [3]. In addition, how can care systems be context bound, can take different forms [7, 11] and there equipped to continue providing complex care manage- is a strong processual element in its implementation, e.g. ment in times of social isolation and containment? when it comes to enabling cooperation and coordination Prior to the outbreak, care authorities from six European processes involving different parties across care settings countries have joined forces in the VIGOUR project funded [8, 12]. Such processes can take different forms depending under the 3rd European Health Programme in order to on the given care contexts [12–15]. systematically review current practices in the health and Against this background, a multi-staged process was care sector to see how existing services could be improved developed by the VIGOUR project [16] to support par- [4]. Taking current service delivery processes as point ticipating stakeholders in identifying and implementing of departure, participating health care authorities had innovative practices with a view to better joining up hith- started to systematically analyse how current processes erto separated care delivery processes (Figure 1). Each can be scaled-up to deliver better joined-up care. However, care authority can build on previous efforts to better align the pandemic has gradually reached all VIGOUR countries care delivery across the care chain, albeit in different ways since the beginning of this year. The aim of this perspec- and to different degrees. The VIGOUR process therefore tive paper is to draw lessons from the VIGOUR partners’ begins with a targeted consolidation of the integration COVID-19 experience to date with regard to improving ambition, which is to be pursued by each care authority current practices by means of better integrating service throughout the project. This is followed by a systematic delivery across health and social care. assessment of the desired integration approach with respect to its appropriateness and feasibility under given Integrated care for older and vulnerable framework conditions. Next, an operational implementa- citizens in Europe and the VIGOUR project tion plan is developed as basis for piloting and evaluating Integration of health and social care is widely advocated the newly developed integration approach under day-to- as way to improve the management and outcomes for day conditions with a view to preparing further upscaling. increasing numbers of older, vulnerable people with vary- This process is further supported by means of knowledge ing and/or complex health and social care needs [5, 6] transfer and mutual learning. with the goal to improve quality of care, quality of life, patient satisfaction and efficiency of care provision [7]. Acute crisis and its implications on integrated However, the implementation of structural changes in care care delivery has often proved difficult in everyday practice The experiences gained during the pandemic so far rein- [8, 9]. One aspect adding complexity in this respect con- force the care integration approach of the VIGOUR project Figure 1: The VIGOUR Process. Legend Figure 1: Figure 1 demonstrates the multi-staged innovation process of the VIGOUR project, accompanying measures such as the consolidation of good practices and twinning actions and how experiences with COVID-19 affect the context-related innovation needs for each pilot site. Lindner et al: Can Integrated Care Help in Meeting the Challenges Posed on Our Health Care Art. 4, page 3 of 5 Systems by COVID-19? Some Preliminary Lessons Learned from the European VIGOUR Project and encourage to build more connected health and care of the COVID-19 infection and on the other hand, isola- systems enabling collaboration across care settings and tion may lead to deeper psychological and mental health disciplines [17, 18]. Effective responses to the COVID-19 issues, especially for older, vulnerable citizens [21, 22]. pandemic require quick, collaborative and large-scale Literature highlights that isolation or loneliness has a reactions; however, the current fragmentation in health detrimental effect on health, with depression and car- and care systems inhibits these requirements. Maybe the diovascular health as outcomes most researched [23]. The present circumstances allow us to perceive the pandemic introduction of dedicated clinical pathways, integrated as a catalyst to redesign and integrate care pathways, also care process management for COVID-19 patients and case equipping us for any disruptive changes that may come managers are seen as reasonable healthcare practices by beyond COVID-19 [17]. VIGOUR partners helping to maintain healthcare capaci- VIGOUR care authorities detected features gaining a ties and guarantee integrated care provision in pandemic higher importance during the pandemic outbreak, evolv- times. Especially the employment of case managers and ing into three major requirements to drive innovation in care coordinators helps to overcome fragmented health- integrated care under emergency situations within health care organization. This fact is getting even more relevant and care systems. First, the increased need for technol- when considering the still existing underrepresentation of ogy related innovation with regard to COVID-19 was case management and care coordination in integrated care recognized. Major aspects that gained momentum were for the management of an ageing population [24] whereas triage and (remote) pre-triage, tele-consulting and tele- integrating primary care with hospital care enables the monitoring of COVID-19 positive patients and suspected establishment of a care continuum for patients [25]. cases, employment of screening or mobile diagnostic Additionally, the role of primary health care in regards applications, contact tracing and monitoring of hospital to the development of an integrated care system has and ICU beds availabilities. Second, VIGOUR pilot sites received prompt attention by VIGOUR partners and detected the requirement for quarantine related inno- is on line with the World Health Organization (WHO) vation during the pandemic outbreak. Social isolation Anniversary Meeting in Astana [26]. and quarantine are required to be managed by means of The pandemic has brought to fragmentation and gaps cross-service guidelines for home isolation, by fostering in our social and health care systems and has accelerated at-home physical activity during quarantine and keeping the need for integration and coordination of health and remote contact with lifestyle coaches. Third, dynamics social care. In order to achieve better integration, a realis- were also facilitated in the field of care pathway related tic perspective is moving forward given the complexity and innovation. A stronger involvement of case managers, variety of culture and socio-political dependant variables. personalized care planning efforts for COVID-19 patients, The framework within VIGOUR project partners takes into the development of dedicated integrated care processes consideration the fact “that one model does not fit all”. and clinical pathways for patients and suspected cases and Thus, the insights and various models developed during an enhancement of advanced care planning in long-term the project will assist the exploration, development and care represent underlying mechanisms anticipated. implementation of different care integration approaches Figure 1 illustrates the project approach and how pre- in distinct systems across Europe [27] as well as in times of liminary experiences with COVID-19 were incorporated the pandemic and beyond [18]. into the process. Reflecting upon the VIGOUR progress so far, some pre- Conclusion liminary lessons learned can be drawn on how envisaged The onset of COVID-19 constitutes a critical issue and forces care integration approaches of the pilot sites were shaped health care systems not to just provide acute care opportuni- within the course of the pandemic. ties for COVID-19 patients, but also to rethink and redesign Not surprisingly, eHealth and digitalization in their vari- care pathways. The VIGOUR project approach seems robust ous characteristics represent a valuable tool for facilitat- to influences evoked by the pandemic and flexible enough ing integrated care processes also during the COVID-19 to take advantage of integrated care initiatives available pandemic. The COVID-19 experiences that the VIGOUR on pilot level and adopt them to specific needs emerging partners have been able to make so far have made par- in pandemic times. eHealth, quarantine management and ticularly clear the potential generally provided by digi- integrated clinical management of COVID-19 patients and tal technologies for the provision of person-centred and suspected cases evolved into promising aspects, leading coordinated integrated care. However, the availability of health and social care systems towards a more integrated practical and safe applications is crucial [19]. This fact has care approach. Further information on this topic may be also been highlighted recently in a report released by the expected from VIGOUR by fall 2021. International Foundation of Integrated Care (IFIC) [17]. Still, it would be a false inverse conclusion to expect that Acknowledgements digital technologies automatically lead to better care [20]. Authors acknowledge the continuous support and con- Indeed, usability and benefit of digital technologies in tribution of partners of the EU-funded VIGOUR project integrated care strongly depend on the context and needs (Grant Agreement Number 826640). of the target populations. Social isolation was discovered as hotspot, as on the one Competing Interests hand, it has proven to be a necessity to avoid transmission The authors have no competing interests to declare. Art. 4, page 4 of 5 Lindner et al: Can Integrated Care Help in Meeting the Challenges Posed on Our Health Care Systems by COVID-19? Some Preliminary Lessons Learned from the European VIGOUR Project References Nuffield Trust; 2012. [cited 2020 July 13]. Available 1. World Health Organization. Reconfiguring from: https://www.kingsfund.org.uk/sites/default/ health systems vital to tackling COVID-19. [webpage files/integrated-care-patients-populations-paper- on the internet]. [cited 2020 April 14]. 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Creating a Culture ble diseases: current gaps and future directions. of Health in Planning and Implementing Innovative Aging Clinical and Experimental Research. 2020; Strategies Addressing Non-communicable Chronic 32(7): 1353–8. DOI: https://doi.org/10.1007/ Diseases. 2019; 4(9). DOI: https://doi.org/10.3389/ s40520-020-01533-z fsoc.2019.00009 How to cite this article: Lindner S, Kubitschke L, Lionis C, Anastasaki M, Kirchmayer U, Giacomini S, De Luca V, Iaccarino G, Illario M, Maddalena A, Maritati A, Conforti D, Roba I, Musian D, Cano A, Granell M, Carriazo AM, Lama CM, Rodríguez S, Guligowska A, Kostka T, Konijnendijk A, Vitullo M, García-Rudolph A, Sánchez JS, Maggio M, Liotta G, Tziraki C, Roller-Wirnsberger R, on behalf of the VIGOUR consortium. Can Integrated Care Help in Meeting the Challenges Posed on Our Health Care Systems by COVID-19? Some Preliminary Lessons Learned from the European VIGOUR Project. International Journal of Integrated Care, 2020; 20(4): 4, 1–5. DOI: https://doi.org/10.5334/ijic.5596 Submitted: 31 July 2020 Accepted: 04 October 2020 Published: 19 October 2020 Copyright: © 2020 The Author(s). This is an open-access article distributed under the terms of the Creative Commons Attribution 4.0 International License (CC-BY 4.0), which permits unrestricted use, distribution, and reproduction in any medium, provided the original author and source are credited. See http://creativecommons.org/licenses/by/4.0/. International Journal of Integrated Care is a peer-reviewed open access journal published by Ubiquity Press. OPEN ACCESS