Considerations about public health within integrated care in Denmark

Background
The epidemiological transition, sociodemographic changes, an aging population, and the increasedprevalence of chronic diseases are changing the demands placed upon health care systems. Citizens, aswell as patients with chronic diseases, drive the need for broad, coordinated, long-term services for healthpromotion, disease prevention, treatment, and rehabilitation. The future challenge for many health caresystems, including the Danish one, is to address health broadly, including public health, rather thanremaining within the confines of traditional health care services. There is a risk that health care willbecome fragmented and deliver poor outcomes if we do not envision integrated care as part of a broadershift toward community and population health. The notion of integrated care has evolved over the yearsand has begun to recognize the need to take a more population-oriented approach to promoting publichealth, preventing ill-health, and securing the well-being of the population. Yet, for the most part, publichealth has remained somewhat separate from the planning and purchasing of health and social care servicesand, as a result, public health interventions have often tended to operate in silos separate from traditionalcare provision. When integrated care services with a public health perspective are inadequatelycoordinated, not delivered at the right time, or duplicated there is a significant risk that quality, healthoutcomes, and patient satisfaction will be negatively affected. 

Aim and research questions
The overall aim of the thesis is to examine and understand how public health is incorporated withinintegrated care. The idea is to identify and describe existing concepts of integrated care and their elementsfrom a public health perspective and to propose a synthesized approach that can be applied to explore thepublic health orientation of integrated care. The specific objectives of the thesis are:

• To explore and understand integrated care from a public health perspective by systematicallymapping and analyzing the existing concepts and frameworks and revealing the gaps.Furthermore, based on the findings, to propose an approach that can be applied to analyze apublic health orientation of integrated care (Paper I). (Submitted, in peer review).
• To explore the content of the Danish health agreements texts and to reflect on how theseagreements may have facilitated public health orientation in integrated care (Paper II)(submitted, in peer review).
• To investigate the users’ and providers’ views and perspectives of integrated care in Denmark(Paper III) (Published)

Methods
A scoping review approach has been applied. A literature search has been conducted in Embase, Medline, CINAHL, Scopus, and Web of Science for the period 2000–2020, which has yielded 16 studies for inclusion. Across the papers, 16 frameworks have been identified. The literature review focuses on exploring existing concepts of integrated care and their key elements from a public health perspective and on proposing a synthesized approach that can be applied to analyze the public health orientation of integrated care (Paper I). The scoping review is followed by an analysis of the Danish health agreements applying the proposed approach from Paper I. A directed, deductive approach to qualitative content analysis has been utilized to analyze the Danish health agreements from the five regions (Capital Region of Denmark, Region Zealand, Region of Southern Denmark, Central Denmark Region, Region of Northern Denmark) for the period 2019–2023 (Paper II). The final empirical part of the study (Paper III) focuses specifically on providers’ and users’ perspectives on integrated care in Denmark. I have interviewed the following health professionals and health directors: health department consultants from eight municipalities, four GPs, three representatives of the Region of Southern Denmark, two hospital doctors, one nurse, and one representative of the National Board of Health. The informants’ areas of work include health policies, health promotion, disease prevention, diagnosis, treatment, nursing, and rehabilitation. Two focus group interviews have also been conducted with users (patients, n=18): 6 females and 12 males aged 45–83 with one or more chronic diseases. Qualitative interviews with 19 providers and 18 users have been conducted and analyzed through inductive content analysis.

Results
The scoping review (Paper I) indicates that most of the identified elements of integrated care fall outsidethe focus of the public health perspective, as they focus primarily on clinical processes and treatment ofdiseases rather than the wider determinants of population health. A synthesized approach is proposed thatcan be applied to analyze integrated care from a public health perspective. The suggested approach considers the unique needs and characteristics of the populations it aims to serve by combining the socialdeterminants approach with empowerment, health literacy, identifying community health needs, andreorienting health care delivery and services to address these needs. The findings of the analysis of theDanish health agreements (Paper II) reveal that the text dealing with or emphasizing the contribution ofpublic health elements is limited, except for a few initiatives associated with public health that arepresented. In the qualitative study (Paper III), providers’ and stakeholders’ point out deficits in systemlevel factors, a lack of organizational culture, weaknesses in communication, a need to consider equity inaccess to health services, and a need to focus on person-centeredness. Participants suggest fundamentalchanges to the system, including better sharing of information and knowledge, a stronger focus on trustbuilding, efforts to make communication more effective, and changes in incentive structures. Usersexperience poor navigation in the health care system, frustration when services are not based on theirneeds, and a lack of support for improving their health literacy. The study shows challenges in the healthcare system in terms of improving coordination, user involvement in decision-making, the user–providerrelationship, and access to services.

Conclusion
The three papers together address the complexity of promoting public health within integrated care in thehealth care system. Despite the significant interest in integrated care, the study shows that integrated effortshave rarely included a broader perspective on the health of local populations. Integrated health careencompassing public health or community health remains a neglected area in many European settings,including Denmark. Improving integrated care requires cooperation and coordination on national,regional, and municipal decision-making levels. Sectors, organizations, health providers, and communitieswill need to work with a common purpose and in partnership to focus on community health needs and thepeople with the greatest need for support. Furthermore, enabling different sectors and levels of the healthcare system to work more effectively together will improve service efficiency, patient experience, healthoutcomes, and address inequalities in access. Our study shows that the health care system is challenged bypoor user experiences. This can be helped by promoting integrated care through increased userinvolvement in decision-making, enhanced user–provider relationships, strengthened coordination, andeasier access to services. Public health within integrated care requires policies and management practicesthat promote system awareness, relationship-building, information-sharing, and incentive structures thatsupport a public health perspective within integrated care.