What do we mean by skill-mix innovations?

Many countries in Europe have started to reorganize the delivery of health and social care services in response to the increasing numbers of patients with chronic conditions and multimorbidity, recognizing the importance of moving away from a fragmented and disease-centred approach to a holistic, patient-centred one. The emerging integrated and coordinated care models often require changes to the skills, competencies, roles or tasks within and across health professionals, subsumed under “skill-mix changes”. These skill-mix changes aim to better meet the increasing and changing demands of patients with complex needs and improve coordination and collaboration between various professionals within the health sector but also across the health and social care sectors. These changes take place in a context of technological advances, new treatment options, growing workloads and shortages of primary care providers. The COVID-19 pandemic has further highlighted the importance of flexibility in the health workforce and the necessity of reskilling and distributing tasks and roles differently. This experience has shown the potential of skill-mix innovations to surge capacities of health systems, and that these are fundamental for implementing new ways of health services provision.

Which skill-mix innovations can improve integrated delivery of care for individuals with chronic conditions and multimorbidity?

This policy brief identified six skill-mix interventions as most promising to tackle current and emerging challenges in primary and ambulatory care and in improving the integration of care of patients with chronic conditions and multimorbidity:

1. Shifting tasks and roles centres on re-allocating tasks and results in a new division of work. Most commonly, nurses or pharmacists in advanced practice roles perform tasks such as management of medication adherence, disease management and patient education that were traditionally provided by physicians or other health professionals. They lead and coordinate the treatment and care process for patients with (multiple) chronic conditions in close collaboration with physicians.
2. Relocation of care to other settings involves moving the provision of chronic care from usual settings (e.g. GP practices, hospitals) to patients’ homes or other outpatient care settings such as nurse-led clinics. Nurse-led clinics are run by nurses under the supervision of physicians and typically focus on chronic disease management. In Sweden, nurse-led heart failure clinics have been widely established. Another example is a nurse-run general practice in London that is operated by nurse practitioners and employs a GP on a sessional basis.
3. Introduction of care coordination roles aims to explicitly improve the coordination of care for patients with chronic diseases. Care coordination roles were established in virtually all European countries under different names such as case managers or transition coordinators, often as part of integrated care models. Care coordination roles may be taken up by different health professions. They usually arrange care and develop shared care plans, often at the intersection of care settings, and monitor patients’ health and well-being.
4. New roles were also implemented with the aim of empowering patients and caregivers. These roles focus on providing information and training to strengthen a patient’s self-management and support behavioural change. They are primarily taken up by nurses, pharmacists or lay health workers with lived experience of the disease. The most known example implemented in many European countries is the role of the peer educator who supports patients with mental illness. Patient navigators and community health workers are also becoming increasingly relevant in providing patient education and assistance in accessing services and support.
5. New dedicated prevention roles in primary care, such as among nurses, pharmacists, community health workers or patient navigators, were introduced to improve health literacy and access to preventive care for patients with (multiple) chronic conditions. They provide general health advice, disease-specific counselling, motivational interviewing and promote a healthy lifestyle to slow the progression of the disease.
6. Establishment of teamwork and collaboration in multi-professional teams is a major skill-mix change and is key for organizing and coordinating health and care services. The most common approaches to facilitating teamwork in chronic care include the introduction of consultation liaison, joint care coordination and shared care. The composition of teams depends on delivery models and care settings. They usually consist of very different professions which may include GPs, specialists, nurses, therapists, social workers, psychotherapists, nutritionists, pharmacists, community health workers and front desk staff as well as housing staff who work together across sectoral boundaries.

What is the evidence on the impact of skill-mix innovations on health outcomes and resource use?

Evidence on skill-mix innovations for patients with single chronic conditions and multimorbidity shows overall positive impact or at least equivalent results on patient outcomes compared to routine care. Many systematic reviews on advanced practice roles of nurses and pharmacists reported improved medication adherence, blood glucose levels and blood pressure control. Reviews on nurse-led clinics also pointed towards better health outcomes, although the majority of results suggest comparable effects. Evidence on care coordinators, peer educators, community health workers and patient navigators indicate that these roles are associated with an improvement in physical health, adherence to screenings, and patient engagement in treatment and social relationships, although results for patients with mental illness were mixed. Teamwork and collaboration appear to have a moderate impact on physical health but collaborative care in mental health is associated with a positive impact on depressive symptoms and patient satisfaction. Overall, evidence on the impact of skill-mix innovations on resources use is mixed and remains insufficient to draw clear conclusions.

What are the levers and barriers for implementing skill-mix innovations within integrated care?

Implementation of skill-mix innovations is most effective when it is part of a system-wide process of integration and involves changes at the system (macro), organizational (meso) and professional and patient level (micro level). Evidence on implementation experiences has revealed various barriers and facilitators for developing skill-mix innovations for integrated care at these three levels. Important levers for successful implementation are regulatory frameworks around (new) professional roles, scope of practice and educational standards and curricula of training. The availability of sufficient and multiannual funding can incentivize or disincentivize the implementation of new roles. For example, reimbursement rates may not be sufficient to cover additional training for professionals to take up new roles. Another major barrier for skill-mix changes at the organizational level is the lack of qualified health professionals and joint workforce planning. Coordinated governance structures, leadership, stakeholder involvement and pre-existing working relationships, as well as sufficient support for implementation, are also key for driving skill-mix innovations within integrated care.

Implementation of skill-mix innovations is highly context-specific, thus recommendations on how changes can be scaled-up and sustained can only be general. However, consideration of the macro, meso and micro context levers and barriers can offer guidance on what key aspects should be taken into account when designing and implementing skill-mix innovations to foster sustained change for more integrated care. Monitoring and evaluation are also central for learning for implementation and policy support.