A fundamental transformation in Qatar’s healthcare system is needed in order to develop strategic and sustainable solutions to meet current and future challenges.

This transformation cannot be achieved unless Qatar’s healthcare system shifts from a reactive, provider-centric model to a proactive, patient-centric model that designs and delivers coordinated and integrated services wrapped around individual patient needs. 

In order to support the sustainable solutions developed by Qatar’s national healthcare strategies, continuing care must be approached as a system-wide framework driving the identification, assessment, planning and coordination processes for patients with ongoing needs, regardless of when and where they interact with the healthcare system. The rebalanced and connected healthcare system is presented below.

This model places the needs of the patient and their family at the center of the healthcare system and stresses the need for comprehensive, coordinated and integrated care. 

The model focuses strongly on supporting care delivery closer to home and offers solutions for driving step-up and step-down care, which avoid admission to secondary care facilities when appropriate and support timely discharge when an inpatient admission is necessary. In addition, the model has been designed to support and maintain the patient’s level of independence, flexibly transitioning between levels of care as their needs change. 

The key features of the national continuing care model can be summarized as follows:

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​A Comprehensive Care Continuum with Expanded Levels of Care	​The National Continuing Care Model proposes a health system built on expanded and defined levels of care that will establish a comprehensive care continuum. Patient acuity, clinical service needs, care environment and healthcare provider competencies and in turn length of stay and costs vary from one level of care to another. The model recommends the significant expansion of intermediate levels of care to support patient transitions and rebalance demand across the healthcare system. The model also recommends the expansion of community-based levels of care to address a broader range of patient acuity levels. A description of the recommended levels of care is presented in Appendix A.
​Use of Predictive Risk Stratification and Patient Assessment Tools	​At patient level, risk assessment and decision support tools, based on comprehensive evidence-based clinical criteria, facilitate identification of patients with ongoing care needs and allocation to the most appropriate level of care while proactively driving care closer to home. This ensures that everyone who would benefit from a care plan gets one, and that the complexity of the care plan is proportionate. Risk stratification also recognizes that people are not static in their level of risk so the model of care flexes as their level of risk changes. At health system level, data from evidence-based tools can be aggregated to understand population health needs, and support the design and expansion of services and care settings to meet the demand for each level of care.
​Care Coordination	​Patient and family centered assessments are the focus of care coordinators utilizing a range of validated and reliable tools. Assessment by a care coordinator can occur at any level of care, and in any facility or environment and facilitates the development of a plan for care, transitions to alternate levels of care within an organization and early discharge planning.  One of the main tools to support care coordination is the Comprehensive Clinical Assessment InterRAI suite, which includes several instruments designed for application in acute and community care.
​Health System Navigation	​The newly developed national integrated continuing care system will have a mandate to establish a health system navigation and coordination  function. This national function includes; a central point of access to a comprehensive needs assessment performed by specially trained national health system navigators. These national system navigators utilize predictive tools, cross-organizational pathways, health and social funding options and a system-wide menu of public and private provider services in order to commission personalized packages of ongoing care.  National health system navigators work closely with organization-based care coordinators to ensure seamless patient transitions to the most appropriate level of care.
​Integrated Care Delivery	​Care integration is a desirable outcome in contemporary health system design. The model supports a systematic approach to achieving integration through the use of standardized system-wide tools, pathways in order to support the development of a single, shared and integrated plan of care.
​Support of Community-based Care Activities​	​The model introduces holistic patient and family centered assessment tools to support the identification and planning of health and social care. More expanded levels of care support the targeted development and expansion of community-based services to meet local population needs, rebalance demand across the system and drive care closer to home.
​Use of Technology to Enable Service Delivery	​The model recognizes the significant potential offered by health technologies in enabling continuing care service delivery. A sustainable, integrated national continuing care system adopts the development of robust information, telehealth and mobile technology infrastructure across healthcare organizations and at a national level. Such an infrastructure will support shared record systems, evidence-based assessment tools, smart sensors, community workforce management systems and system level analytics.

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