In our recent blog post (link here), we explored the complexities of multimorbidity and its significant impact on patients and the NHS. We highlighted how fragmented care often leads to inefficiencies, poorer outcomes, and frustration for individuals managing multiple conditions.
Now, we turn our attention to the solutions: what integrated care looks like in practice, global examples of success, and innovative approaches such as community-driven initiatives.
The Case for Integrated Care
As we previously discussed, despite the rise of multimorbidity, most healthcare systems are still designed to address single conditions, one at a time. However, multimorbidity requires a fundamentally different approach—one that prioritises holistic, patient-centred care. Integrated care brings together services across disciplines, ensuring patients receive seamless support tailored to their unique needs.
For example, imagine a patient managing both hypertension and depression. Instead of having separate appointments with a GP for blood pressure checks and a mental health practitioner for depression management, an integrated primary care approach could coordinate their care. A GP, practice nurse, and social prescriber could work together to align treatment plans, offer joint consultations where appropriate, and provide a more holistic approach. This ensures that medication interactions are carefully considered, lifestyle interventions are reinforced across conditions, and the patient receives consistent, accessible support—all within their local primary care setting.
There are several ways to enable integrated care. These include:
- Multidisciplinary teams (MDTs): These teams include GPs, specialists, care coordinators, and mental health professionals collaborating to create unified care plans.
- Shared care records: By enabling providers to access a single, comprehensive view of a patient’s medical history, shared records help avoid duplication and improve decision-making.
- Community health initiatives: These localised approaches bring care closer to patients, reducing barriers such as travel and improving accessibility.
Case Studies: Community-Driven Innovations
In the UK, innovative solutions like the Community Appointment Days developed by Here (a healthcare social enterprise)(1) are leading the way. These appointment days bring together healthcare professionals and services in a single location, allowing patients to attend multiple appointments and access support in one visit. This not only reduces the burden on patients but also improves efficiency for providers. Such initiatives demonstrate the potential of collaborative care models to address the challenges of multimorbidity.
At Appt Health, we’re inspired by these examples. Our AI-driven platform takes a technology-first approach to enabling more integrated care inside the existing primary care frameworks by:
- Identifying patients across multiple conditions: Our system ensures that patients with complex needs are identified and offered the right appointments at the right time, tailored to their specific healthcare requirements.
- Consolidating appointments: Reducing the number of visits needed for patients managing multiple conditions, which in turn minimises administrative burden, saving both time and money.
- Personalised communication: Leveraging behavioural science to deliver messages that resonate with patients, improving engagement.
- Proactive care management: Using AI to identify high-risk patients and tailor care pathways to their needs, ensuring resources are allocated efficiently and outcomes are optimised.
Global Examples of Integrated Care
Countries around the world have embraced integrated care models with promising results. For instance:
- The Netherlands: Their “Care Group Model” involves primary care providers working together under shared contracts to manage chronic diseases. This approach has improved coordination and reduced costs (2).
- New Zealand: The "Health Care Home" initiative combines general practice with wraparound services, providing patients with proactive, coordinated care (3).
- Sweden: Coordinated health and social care programs, particularly for older adults with multimorbidity, have demonstrated improvements in patient satisfaction and reduced hospital admissions(4).
Moving Forward
Multimorbidity is a challenge that demands systemic change. By adopting integrated care models and drawing on global best practices, we can create a healthcare system that works better for patients, providers, and payers alike. Community-driven initiatives like the Community Appointment Days are shining examples of how collaboration and innovation can improve outcomes.
At Appt Health, we’re committed to being part of this transformation. By combining cutting-edge technology with patient-centred care, we aim to reduce the fragmentation of care and make managing multiple conditions simpler for all.