Integrated Care Pathways

We solved half the problem & thought we bridged the gap. Ever worked on a solution that looked perfect on paper… but ended up creating more problems than it solved? That’s exactly what happened when I was called in to review a telehealth solution. It was well-designed, checked all the cybersecurity boxes, & allowed patients to consult doctors remotely. The project requirement was clear: enable remote consultations. And the solution delivered exactly that. But here’s the thing: While healthcare systems often operate in silos, patients experience their care as one continuous journey. And this solution missed critical parts of that journey: 🔸 No easy way to book follow-ups. Patients had to call, leading to missed care. 🔸 Medication collection still required hours of travel, making the platform’s convenience meaningless. 🔸 Administrative staff were overloaded, causing delays in care coordination. We solved one problem & unintentionally created three more. The solution was designed for the system’s convenience, not the patient’s journey. To shift the perspective, we expanded the conversation to include voices we hadn’t considered: 🔸 Pharmacists: To integrate medication delivery into the process 🔸 Community Health Workers: To provide local, hands-on support 🔸 Family Caregivers: To highlight logistical & emotional challenges at home 🔸 IT Teams: To automate follow-ups & reduce administrative burden 🔸 Local Transport Providers: To enable last-mile delivery of medications With these insights, we redesigned the solution into a comprehensive care experience: ✅ Patients could book follow-ups easily & get automated reminders ✅ Medications were delivered directly to their homes ✅ Caregivers & community workers ensured patients didn’t fall through the cracks I later learned that: 🔸 Missed follow-ups dropped by 40%. 🔸 Medication adherence & health outcomes improved significantly. The redesigned platform didn’t just connect patients to doctors, it completed the care journey. Next time you’re working on a solution, consider these points: 1️⃣ Patients see one journey While systems operate in silos, patients experience care as a unified process. 2️⃣ Identify all stakeholders Both direct & indirect voices like caregivers, pharmacists & community workers, are essential to closing gaps. 3️⃣ Design for continuity Address every touchpoint in the patient’s journey, ensuring nothing falls through the cracks. Have you worked on solutions where overlooked stakeholders made all the difference? What’s one gap you discovered that changed everything? #DigitalHealth #Innovation #HealthcareTransformation #PatientExperience #Collaboration 💡This post is part of 'Rethinking Digital Health Innovation' (RDHI), empowering professionals to transform digital health beyond IT and AI myths. 💡Find the ongoing series and resources on our companion website (URL in comments). 💡 Repost if this message resonates with you!

Transforming Diabetic Foot Care: Insights from the DEFINITE Care Program Diabetic foot ulcers (DFUs) are among the most debilitating complications of diabetes, significantly impacting patients’ quality of life and healthcare systems globally. Recognizing this, Singapore’s Diabetic Foot in Primary and Tertiary (DEFINITE) Care program offers a beacon of hope. A recent study published in BMJ Open Diabetes Research & Care evaluated the clinical and economic outcomes of this multidisciplinary, integrated care model. The findings are compelling: A 9% reduction in mortality and a 5% increase in amputation-free survival within 1 year. Significant reductions in hospital admissions (0.98 fewer episodes) and length of stay (5.5 fewer days). Long-term cost-effectiveness, with an incremental cost-effectiveness ratio (ICER) of USD $22,707 per quality-adjusted life year (QALY), well within Singapore's healthcare thresholds. The program's strengths lie in its integrated approach, spanning primary to tertiary care, and leveraging patient-centered digital tools. By focusing on proactive, limb-salvaging strategies, DEFINITE Care not only improves clinical outcomes but also demonstrates financial sustainability—a critical consideration for healthcare systems worldwide. This study underscores the transformative potential of multidisciplinary care models. As healthcare leaders, policymakers, and clinicians, we must explore how such integrated programs can be scaled and adapted to different healthcare settings globally. For those in public health, healthcare management, or clinical research, this is a case study worth reviewing. It reinforces the power of collaboration, innovation, and patient-centered care in tackling complex chronic conditions. Let’s continue the conversation: How can we implement similar models in our regions to improve outcomes for patients with diabetes? Share your thoughts! #HealthcareInnovation #DiabetesCare #HealthEconomics #IntegratedCare #PublicHealthLeadership

Stop chasing the wrong cost drivers in healthcare. You're missing the biggest one. Health plan executives obsess over: ↳ Provider network costs ↳ Pharmaceutical spend   ↳ Administrative overhead Meanwhile, the real cost multiplier hides in plain sight. Untreated behavioral health conditions are silently destroying your medical budgets. And nobody's talking about it. The Milliman research reveals what most miss: ↳ $26-48 billion in potential annual savings from integrating medical and behavioral care ↳ Patients with behavioral health comorbidities cost 2.8 to 6.2 times more in medical spend ↳ Not behavioral health spend, but MEDICAL spend Here's how mental health conditions multiply medical costs: 1/ Medication Non-adherence ↳ Depression and anxiety sabotage treatment compliance ↳ Diabetes, CHF, and hypertension management fails ↳ Your chronic disease programs miss the target 2/ Emergency Department Overutilization   ↳ Patients with untreated mental illness overuse the ER ↳ Chest pain from panic attacks costs thousands per visit ↳ ER spend for behavioral health crises balloons 3/ Extended Inpatient Stays ↳ Co-morbid mental illness extends hospital length of stay ↳ Higher readmission rates tank quality metrics ↳ The capacity problem is actually a mental health problem Here's the insight most health plans miss: It's not about network access. It's about network engagement. Stop building provider directories. Start building integrated care pathways. Embed behavioral health in medical care. The costs you're chasing are symptoms. Mental illness is the disease. ==================== ⁉️ Carving out behavioral health spend makes no sense. ♻️ Reshare to expose the real multipliers of medical spend. 👉 Follow me for more like this (Eric Arzubi, MD). To Learn More: 1) https://lnkd.in/eH5CAvvh 2) https://lnkd.in/eWDcssqp 3) https://lnkd.in/eK-yumYW 4) https://lnkd.in/er6Qncdb

Globally, patients with rare diseases wait an average of 4–6 years for a correct diagnosis. Over 70% of rare diseases are genetic — yet fewer than 10% of patients receive genomic testing early enough to change outcomes. But here’s the opportunity: 🇶🇦 Qatar is uniquely positioned to compress that timeline. With one of the world’s most advanced population genomics initiatives, centralized healthcare delivery, strong tertiary institutions, and high clinical research density — Qatar already has the infrastructure advantage. The gap isn’t technology. It’s system design. That’s why I mapped the Qatar Rare Disease Fast-Diagnosis Stack (see visual 👇). Instead of fragmented excellence, the goal is coordinated flow across four stages: 1️⃣ Symptom Clustering Structured phenotype capture across PHCC, Hamad, Sidra, QBRI, QPHI. When symptoms are encoded longitudinally (HPO, Orphanet, OMIM standards), suspicion flags earlier — especially in pediatrics and primary care. Without this step, genomics never activates at the right time. 2️⃣ Genomic Triage QGP + clinical genomics labs + interpretation platforms. Sequencing alone doesn’t create diagnosis — interpretation + prioritization does. When genomics is operationalized within care pathways, we see: • Faster confirmation of monogenic conditions • Reduced re-testing • Earlier therapeutic decisions 3️⃣ Specialist Routing Centralized referral logic across Hamad, Sidra, Qatar Foundation networks, and regional excellence centers. Diagnosis without engineered routing simply shifts the delay downstream. Automation + guideline alignment = faster intervention windows and lower specialist overload. 4️⃣ Registry Enrolment Where diagnosis becomes national value. When registries connect QGP, Biobank, QPHI analytics, trial infrastructure (TriNetX, IQVIA, Medidata), and international collaboration — every diagnosis strengthens the next one. That’s how you build a learning system. Most countries struggle because their systems are fragmented: • Symptoms captured inconsistently • Genomics too late • Referrals manual • Registries disconnected Qatar doesn’t lack assets. It needs orchestration. - End-to-end process design. - Cross-institution incentives. - Clear KPIs for diagnostic speed and outcomes. This isn’t a vendor problem. It’s a systems architecture opportunity. I break this down in: “Why Rare Disease Diagnosis Still Takes 5 Years — And How Qatar Can Cut It to 12 Months.” And I’m building a Qatar Rare Disease Market Access Simulator to model how faster diagnosis impacts: • Clinical outcomes • Healthcare cost • Trial readiness • Genomic ROI If you’re working in precision health, genomics, or healthcare strategy in the GCC — this is a systems conversation worth having. Comment “RARE QATAR” and I’ll share the full breakdown. #RareDisease #QatarHealth #PrecisionMedicine #Genomics #HealthSystems #QGP #DigitalHealth #HealthcareInnovation #HealthTech #MarketMaps

Every time #healthcare is delivered in silos, someone pays twice. Patients repeat their stories. Tests get ordered again. Time is lost and money is wasted. Ultimately, people are treated as episodes rather than as human beings with a continuous health journey. That is the hidden tax of fragmented care, and it quietly drains both trust and access from the system. #Integration changes that. When teams share records and referral pathways, people move through the system with purpose. Specialists focus on complex cases. GPs handle what they are trained to manage. Nurses lead screening, #prevention and ongoing care. Everyone works at the top of their scope, and capacity opens up where it matters most. This is why we invest in connected clinics, pharmacy pathways and data that links the journey. The goal is simple. Fewer repeated steps, more first-time right care, and more access for the many. If you manage a network, start with three questions. Do teams see the same data? Do they share a simple playbook for referral and follow up? And are people practising at the top of their scope? Fix those, and cost and access both move in the right direction.

🔬 Co-designing care for early-stage type 1 diabetes: a new model from Western Australia A new paper in Diabetologia describes the first co-designed clinical pathway for children with pre-symptomatic (stage 1 and 2) T1D, developed with families and HCPs at Perth Children’s Hospital. As screening expands globally, most health systems still have no structured pathway for families living between a positive autoantibody result and clinical diagnosis. This work addresses that gap directly. 🤝 How it was built Using experience-based co-design (EBCD) over 12 months, researchers engaged T1D community members and multidisciplinary HCPs through community conversations, focus groups, and a prototype refinement workshop. Both groups independently converged on the same three priorities: 📚 Age-specific education on etiology, progression risk, monitoring, and disclosure 💬 Psychosocial support from the moment of identification, for the whole family 💊 Integrated access to disease-modifying therapies and clinical trials ✅ Guideline alignment The pathway incorporates visit frequency and monitoring from the 2024 international consensus (Phillip et al.) as minimum requirements, stratified by antibody status and age, with flexible opt-in support layers built in by design. The first visit is literally named “Acknowledging Uncertainty” with the whole team present and a clear signpost to ongoing accessible support. That framing came directly from families. ⚠️ Remaining evidence gaps What glycemic monitoring best detects progression while minimizing family burden? How do psychosocial needs differ by age and stage? Implementation of this pathway will help answer these. 💡 This is what guideline adaptation for local context should look like: international recommendations as a foundation, local stakeholder voices shaping what families will actually trust and use. 📖 Black et al. Diabetologia, 2026. https://lnkd.in/eiy8bVuE #Type1Diabetes #EarlyStageT1D #DiabetesCare #ImplementationScience #CoDesign #PediatricDiabetes

What is a pathway in digital health? We often hear the term ‘pathway’ in both clinical and technical spaces, but what does it really mean? Is it a map? A goal? A flowchart? A framework? 🏥 In healthcare, pathways are often misunderstood as rigid process maps. But life, and care, is messy. Linear thinking doesn't fit. A real-world pathway bends, forks, and overlaps. Patients don't follow flowcharts, they live through experiences. 🤖 From a tech perspective, shifting from imperative (step-by-step pathways) to declarative (goal-based pathways) is key. Instead of 'do A, then B', we ask 'what outcome are we aiming for?' and let systems figure out the route based on context. Systems like openEHR and FHIR are enabling this by separating what needs to be done from how, when, and by who, creating adaptable, intelligent digital care environments. I think the reality is, a pathway is not one thing. It’s a fusion of goals, people, processes, information, and systems. It's the dynamic journey a person takes through care, shaped by their unique needs and the evolving decisions of their care teams. A pathway is not a template, it’s a personal, evolving thread that ties together every action, across settings, services, and teams. So from a technology perspective, the future of pathways isn’t about diagrams - it’s about interoperability, shared goals, reusable processes, and agile tech that supports care that is  by nature chaotic and unorganised. A pathway is not linear, so we need to build systems that are not linear, and can navigate complexity, respect individuality, and truly support integrated, human-centred care. #DigitalHealth #HealthIT #Interoperability #openEHR #FHIR #CarePathways #HealthInnovation #HealthTech #PersonCentredCare

Too often, “integrated care” is just a buzzword. A primary care doctor screens for depression. The patient screens positive. And the next step? A referral form. A phone number. A hope that someone else will follow up. That’s not integration. That’s outsourcing. True integration means: • Shared systems/documentation so clinicians work from the same data • Warm handoffs where the patient meets their care team before they leave the office • Real-time support when symptoms escalate or needs change • Follow-up that’s built into the workflow, not left to chance Because when behavioral health is bolted on, patients fall through the cracks. But when it’s built in, care gets better. Faster access. Better coordination. Fewer drop-offs. And outcomes that actually move. If you’re serious about integrated care, start by redefining what integration really means.

I’m pleased to share the release of the new WHO #HIV service delivery guidelines, which now include recommendations to integrate #diabetes care into HIV services! The updated guidelines provide guidance on integrating diabetes, #hypertension and #mentalhealth services, along with interventions to support adherence to antiretroviral therapy, marking a shift toward more person-centred, integrated care. With over 800 million people living with diabetes globally, this approach is both timely and necessary. In sub-Saharan Africa, studies show that 5–10% of people living with HIV also have diabetes and 20–25% have #hypertension, highlighting the urgent need to address #noncommunicablediseases alongside HIV. These guidelines are designed for policymakers and programme managers implementing HIV services or integrating #NCDs and #mentalhealth care into #primaryhealthcare systems. The evidence is clear: integration reduces fragmentation, improves access and supports long-term engagement in care. This publication represents an important step toward delivering lifelong, comprehensive care for people living with HIV. Read the full guidelines here: https://lnkd.in/gEahxk8H 🙏 Special thanks to Nathan Ford for his leadership on this and to colleagues at WHO and the many global experts whose contributions shaped this important work Mai Eltigany Meg Doherty Clarice Pinto Elena Vovc Cadi Irvine Alarcos Cieza #Healthforall #Serviceintegration #Integratedcare #WHO #Personcenteredcare 

Important: The New NHS commissioning guide for ICBs has just been published: 'Fit for the future: towards population health delivery models': heralding the NHS "undergoing the biggest change process since its inception". Here's my summary: Commissioners need move away from traditional activity and block contracts to focused on population health. ICBs to commission providers around the needs of defined populations agreed with local authorities. Purpose: To join up fragmented care pathways: creating care that is personalised, preventative & proactive. Providers to have population based contracts to move their focus beyond their organisation. The changes are intended to address the problems with providers not working together to benefit patients. Commissioners need to - Develop a deep understanding of the needs and health risks within their population, alongside the capabilities of providers. - Understand provider demand & ‘optimal costs’ - Use activity and cost data to identify interventions that increase value and reduce health risks - Use real time data to identify people who need help now - Use new national frameworks - Reallocate funds between providers to deliver the most value for patients. This work will be handed over to IHO in future, but ICBs will retain an oversight role. Population-level delivery models Single neighbourhood providers (SNPs) will deliver services, in a neighbourhood, enabling primary care to take on services that are not contracted through existing GP contracts.   Multi-neighbourhood providers (MNPs) will coordinate delivery of services across several neighbourhoods providing services directly at a larger scale. These will gain funds though risk share approaches that prevent urgent hospital admissions. Integrated health organisation (IHO) contracts will give providers a whole population health budget for a geographically defined population which will plan and allocate resources across the whole pathway and be responsible for the needs of their local population. NHS and DHSC will designate which Trusts can hold these contracts. The Future? All areas of the country to have an IHO. IHO will manage general practice contracts, as well as pharmacy, optometry and dentistry, all of which will continue to be determined nationally.  (This is likely to be VERY controversial) Local actions - ICBs to start implementing some outcome based contracts within 3 years - Agree neighbourhood footprints - Look to increase funding out of hospital care using risk sharing agreements. Next Steps: - NHS England’s Strategic Commissioning Development programme will help develop capability - 2026/27 will be a developmental year for all 3 new contracts.   - NHS England is developing new payment models to support neighbourhood services NHS England will announce 1st wave of providers for IHO contracts this Spring! https://lnkd.in/gaDjZABy