Indian Model of Integrated Healthcare (IMIH): a conceptual framework for a coordinated referral system in resource-constrained settings

Despite constant improvement in the Socio-demographic Index, there is still enough scope in the Indian healthcare system. This is because certain health indicators of India depict significant disparities from the economically advanced Organization for Economic Cooperation and Development (OECD) countries and are concerning. For instance, India's average life expectancy is around 70.8 years compared to 80.4 years in OECD countries. Indian maternal mortality ratio (103 per 100,000 live births) and infant mortality rate (25.5 per 1,000 live births) are way higher than that of the OECD (9.8 and 4.1) [1]. Further, approximately 122 Indians per 100,000 lose their lives due to poor quality of care and accessibility each year, and the estimates are poorer than many other countries [2, 3], The improvement in the quality of the healthcare delivery system (HDS) was envisaged through the Bhore Committee Report (1946) using the existing 3-tier system (Sub Centres (SC), and Primary Health Centres (PHCs) in villages, community blocks as Community Health Centres (CHCs), district hospitals, and tertiary care hospitals) [4]. Despite substantial progress, there were 157935 and 3894 SCs, 24935 and 6118 PHCs and 5480 and 584 CHCs functional in Indian rural and urban areas by March 2022 [5]. The HDS is further supported by a total of 134224, 184175, 109937, 162749 and 224679 hospital beds at the level of PHC, CHC, Sub District Hospitals, District Hospitals and Medical Collages [5]. However, the 2019–20 Rural Health Statistics depicts very low adherence to standards as mandated by the Indian Public Health Standards (IPHS) at all three levels of HDS throughout the country [6, 7]. This is attributed to the modest 2.1% of the Gross Domestic Product (GDP) allocated to the healthcare sector, leading to a lower density of medical practitioners (1.34 doctors per 1,000 population), lesser number of hospital beds (5.3 beds per 10,000 population) and higher Out-of-pocket healthcare expenditure (OOPE) (50.60% of health spendings) [1]. With the escalating burden of chronic disease and multimorbidity in India, owing to its ageing population and overwhelming health needs, the Indian HDS is under constant pressure due to rising public expectations and ambitious new health goals.

We constantly need to manage the patients requiring acute and immediate interventions appropriately to decrease the overall disease burden. Such management may not be possible at lower levels of HDS that call for referral to higher centres. However, the lack of accountability and monitoring mechanisms for the referral process has led to uncoordinated self-referrals, resulting in overused and overburdened tertiary care facilities (which could be managed in primary care), thus compromising the quality of care [8, 9]. The unwarranted fragmentation in HDS has also increased medical errors, misdiagnoses, and provider burnout, accounting for nearly 60% of the cross-regional variation in care, with substantial economic implications [10, 11]. Poor access to qualified care only represents the tip of the iceberg, and poor health promotion, patient education and prevention of chronic disease through timely lifestyle interventions are other deprivations attributed to inadequate quality of care that ultimately lead to increased disease burden and overwhelmed health systems. While health promotion, patient education and prevention of chronic disease through lifestyle interventions remain the mainstay of the primary healthcare system, tertiary care is rather about ‘disease control’. Therefore, the primary, secondary and tertiary care centres must work in coherence to ensure continuity of care, thus calling for optimising health care through Integrated care (IC).

The IC has been defined by the World Health Organization (WHO) as the “management and delivery of health services such that people receive a continuum of health promotion, health protection, and disease prevention services, as well as diagnosis, treatment, long-term care, rehabilitation, and palliative care services through the different levels and sites of care within the health system and according to their needs.” [12]. The IC enhances the patient experience and achieves greater efficiency and value in HDS [13]. For this, IC must demonstrate two fundamental characteristics. First, it must unite the fragmented HDS in its design and execution. Second, it should enhance the coordinated and continuous care for those in need [14]. This reiterates the concept of person-centred coordinated care that puts the control of decision-making in the hands of recipients to plan their care and works in bringing together services to achieve the outcomes crucial to them [15]. Previous studies analysed existing IC models and highlighted the need for change at the system and governance level. Developing and rapidly implementing IC models requires resources, expertise, and policy changes. The known barriers to implementing changed systems include a lack of clarification of roles and responsibilities, competition for funding, and challenges in engaging primary care providers [16]. Another critical challenge is to develop a sense of ownership and create an environment of collaboration between all the stakeholders [17]. The National Health Service (NHS) vanguard sites have been encouraged to develop new IC models after considering and adapting to the local and regional context [18]. The WHO’s global strategy for adopting people-centred IC services outlines a five-point plan emphasising health awareness, improving governance, reorienting the existing models, integrating the services, and providing an enabling environment for all stakeholders [19]. Based on these requirements, the WHO has proposed many critical forms of ICs, including horizontal integration, vertical integration, sectoral integration, people-centred integration, and whole-system integration [20]. However, there is evidence that the more severe the patient’s demand, the more suitable it may be to create a customised “fully integrated” model to manage their complex needs [21]. In the existing literature, IC models have been mainly developed and adopted in developed nations rather than low-middle-income countries (LMICs), including India [22]. Despite an organised 3-Tier HDS, India has not successfully developed or adopted any existing IC models. With this background, the present study attempts to review the applicability of existing models of IC and frame a customised IC model for developing countries like India that can fit and augment the existing healthcare delivery system.

We initiated the process of model development following a narrative review. IC models were broadly categorised into Individual models of integrated care, Group and disease-specific models, and Population-based models (Table 1). Each model was reviewed in terms of country of origin, funding resource, salient features, and limitations were framed. Individual IC models mainly originated in the USA, England, and other countries under the OECD. The models were funded by government and non-government organisations. The individual IC models have been criticised for being time-consuming and costly [24‐27]. Group and disease-specific models like the Chronic Care Model (CCM) and Program of Research to Integrate the Services for the Maintenance of Autonomy were adopted in developed countries like the USA, Sweden, Scotland, and Germany and were funded by the government. The limitation in the implementation of group and disease-specific models concerns the need to reorganise the entire healthcare system and prolonged delivery time focusing on specific age groups, thus affecting the program's application [28‐30]. Population-based models like Kaiser Permanente are non-government and financers-based models which need to be enrolled by opting out of tax-based government coverage health system [31]. Based on the review, it was seen that the levels of HDS are planned per the complexity of the health conditions but have no physical or virtual integration to track the patients in terms of continuity of care that is sustainable at the same time and within the scope of existing infrastructure.

The proposed IMIH provides a framework to eliminate HDS fragmentation by providing a controlled and coordinated patient movement between the levels of care using a patient-centric approach. Our model has some key features which ensures its utility and acceptability. First, the patient’s movement is based on routing (referral system) and flow of data within digital platforms which are already in place. Second, the only entry point into the IMIH is primary care gateway, where decision is made by the ‘gatekeeper’ doctor to either keep the patient at primary HDS or refer him/her to a higher center. Third, the patient’s physical movement is paralleled by referrals and movement of data between primary, secondary and tertiary HDS. Fourth, the secondary care HDS are physically designed to enable optimal integration and continuity of care right from its entry to exit. Lastly, The IMIH also focuses on patient’s education and preventive measures during the follow-up at its nearest peripheral HDS using updated online health records, thus limiting the excessive load on tertiary care institutions.

Our review depicted that the existing IC models adopted by the developed countries were customised for their countries with limitations of having prolonged delivery time, focussed only on chronic diseases, or were economically expensive for LMICs. Also, most of the IC models were unsuitable for Indian Healthcare system as they require massive revamping of the healthcare system. Resource constraints call for planning a patient-centric IC model that can fit in the existing HDS and utilise the existing resources and infrastructure. The proposed IMIH is based on the pillars of the existing HDS developed over the years and can complement the system. The IMIH envisages improved continuity of care, better access to specialists and management timeliness, care through existing government schemes and packages by coordinated services, and improved patient flow. From a service provider’s perspective, better communication minimises work duplication, reduces staff time, and enhanced accessibility to information, which helps offer standardised care.

The IMIH introduces the Gatekeeper physicians as a primary contact point to enter the referral system. A study from California conducted to determine patients’ perception of the role of primary care physicians as first-contact care providers and coordinators of referrals and whether primary care physicians impede access to specialists depicted that almost all patients valued the role of a primary care physician as a source of first-contact care and coordinator of referrals and 75% to 91% of patients preferred to seek care initially from their primary care physicians rather than specialists [54]. Another study from Egypt narrates the problem of overuse of hospital outpatient clinics due to the lack of an effective gatekeeper system, where the price of direct hospital outpatient visits was increased, thus indirectly encouraging to visit primary care through the gatekeeper system, which resulted in a 63% decrease in direct hospital outpatient visits [55]. Although the existing healthcare delivery system in India is based on the level of care framework, the role of a Primary care physician is not based on a gatekeeper model to coordinate the referral. Once the process is in place, IMIH will help uplift the status of primary health care physicians and their role in disease management over the time, but it should be supported by adequate capacity building and standardised protocols, and continuous medical education.

The IMIH introduces a CGCR to address patient surge management centres for load-balancing and diverting patients in a coordinated manner through a gateway between 3 tiers of HDS. The CGCR will create Patient Surge Management (PSM) facilities using principles applied during the pandemic in which a three-tier arrangement of dedicated COVID-19 health facilities, including COVID Care Center (CCC); Dedicated COVID Health Centre (DCHC) and Dedicated COVID Hospital (DCH)] has been implemented in the country [56]. A similar approach was used during the COVID-19 pandemic for oxygen allocation using the oxygen demand aggregation system, Oxygen Digital Tracking System, and OxyCare app that helped coordinate demand and supply [56, 57]. The CGCR will keep a two-way track of patients referred to higher or lower levels of care and guide the patient by specifying the bed availability to the nearest referral centre. The government of West Bengal- an Eastern state of India- has started working on a particular control room at the Swasthya Bhawan to check whether the referral cases made from one medical establishment to another were required [58]. It is stated that smoothing the flow of patients in and out of institutions could help to reduce wide fluctuations in occupancy rates and prevent surges in patient visits that lead to overcrowding, poor handoffs, and delays in care [59]. CGCR is crucial in eliminating fragmentation from the HDS and providing cost-effective, acceptable, lean, and safe healthcare. The CGCR will act on the principles of Identification and Routing of referrals initiated through primary HDS. In addition, the CGCR helps share the electronic medical records with the referral facility even before the patient arrives and will help in planning necessary management. The ABDM already implemented through the National Health Authority (NHA) Government of India, provides a digital framework based on the National Digital Health Ecosystem (NDHE), which supports a continuum of care and adheres to Fast Healthcare Interoperability Resources (FHIR) guidelines of Health Level Seven International (HL7) is already in place and ready for use [60].

We further propose strengthening the secondary level of care to reduce overwhelmed tertiary care centres. In India and other LMICs, the patient load at tertiary care facilities is constantly increasing [61]. IPHS 2022 guidelines narrated the detailed plans for adequate resources in terms of infrastructure [53]. The IMIH will help properly utilise the secondary level through Load-balancing by diverting patients in a coordinated manner through CGCR primarily to secondary care capsules using the bucket overflow model, which allows the optimum utilisation of health resources and reducing pressure at the tertiary care. A study in the USA estimated that 75% to 85% of the general population only needs primary care services; 10% to 12% need referrals to short-term secondary care services. 5% to 10% of patients require specialised tertiary care services [62]. In a resource-constrained country like India, utilising available facilities to their maximum is crucial, as envisaged using the bucket overflow model, a metaphorical term used to describe a condition when all the beds are occupied in SdC, the patients are referred to the next capsule in a controlled manner. Although examples of re-routing are not directly available in healthcare, the principle of re-routing can be found in Vehicular traffic rerouting for better traffic mobility [63]. Then, the Three-Door OPD Concept (TDO) in OPDs at the SdC will provide a one-stop comprehensive patient-centric care in which patients will get all the out-patient care under a single roof without moving from one level to another. Even at a lower level of care, systematic, comprehensive care has been shown to improve outcomes for chronic diseases [64‐66]. However, the better care offered at the secondary and tertiary care level lures patients to practice self-referral, leading to fragmentation of care at the level of general and speciality practitioners. This can, however, be resolved if we enforce the primary care gateway as the only entry point into the IMIH, as previous studies also show that more visits to hospitals and fewer visits to primary care facilities further lead to increased hospitalisations [11].

There are specific policy implications of this model. We visualise reduced OOPE through this model mainly by promoting better utilisation of government healthcare centres. While being patient-centric, direct and indirect, OOPE can still be reduced, firstly, by reducing the duplication of investigations and better utilisation of government facilities and secondarily, by a coordinated healthcare delivery system by ensuring continuity of care and promotion of targeted health education, self-care, and health promotion programs. By engaging the IC model in the existing healthcare delivery system, the goal of increasing utilisation of the public health sector can be achieved without massively disturbing the current framework [67]. Lastly, the model uses a lean healthcare delivery system. Lean healthcare is a management tool that minimises waste in healthcare delivery services by identifying and removing unnecessary steps that waste crucial patient serving time [68]. However, a few other critical components essential to building a successful IC model must be considered for any model to succeed. Commitment starting with solid leadership, updated IT support, and a unified budget to cover joint working between various integrated divisions is the main bottleneck that can restrain the integration. Despite a 3-tier HDS, IC in India is relatively new and has not been much developed and tested. IMIH is mostly in line with the biomedical diagnosis-centered model of care and a step towards a future biopsychosocial patient(person)-centred integration model.

To conclude, the IMIH offers unique features that considers the resource constraints and local context of the LMICs while being economically viable. This model envisages a step toward UHC through the optimum utilisation of resources, ensuring a continuum of care, decreased time to care, and minimal OOPE. Coordinated and Controlled referrals augmented by transferring patient health records through digital health platforms, with standardised treatment protocols across different levels, can help improve the perceived knowledge among the healthcare staff, standardised practices, and adherence to guidelines. However, health being a state subject in India, various socio-political and legal/administrative issues warrant further discussion before implementing the IMIH.