Key innovations in integrated health and social care models: Instruments and methods

The chapter is aimed at analysing which are main care instruments adopted by selected countries, their main characteristics, how do they work, main strengths and weaknesses of each one. By comparing models, we will also try to point out lessons to be learned across countries and main open questions for further discussions. Our point of departure is the assumption that the presence of organizational solutions and formal tools to support the whole process of integrated care is crucial to develop coherent and users’ oriented strategies. Instruments, in facts, by introducing some degree of formalization within the care process, provide a support to professionals in order to plan the care project, to define clear and valuable goals. They are also a strategic resource in promoting the dialogue among different key workers. In analysing and comparing integrated care model ways of working, a relevant dimension is the presence of an overall person-centred approach. This does mean that models should be organized according a holistic method, bearing in mind how users perceive the process as seamless or not Taken as a whole, all categories show interesting common organizational patterns: almost every service uses the multidimensional assessment, collecting data with a valid and reliable assessment form, generally including personal data, health assessment, social assessment, cognitive and functional evaluation (IADLs, PADLs). Multi-dimensional teams and/or the case manager, are in charge of making the assessment using personal interviews and, in some cases, home visits. The assessment represents the point of departure to define the individual care plan. Data are then collected into a user’s personal file, usually archived via computer.