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Showing papers in "International Journal of Integrated Care in 2003"


Journal ArticleDOI
TL;DR: The efficacy of PRISMA has been tested in a pilot project that showed a decreased incidence of functional decline, a decreased burden for caregivers and a smaller proportion of older people wishing to be institutionalised.
Abstract: Purpose: PRISMA is an innovative co-ordination-type Integrated Service Delivery System developed to improve continuity and increase the efficacy and efficiency of services, especially for older and disabled populations. Description: The mechanisms and tools developed and implemented by PRISMA include: (1) co-ordination between decision-makers and managers, (2) a single entry point, (3) a case management process, (4) individualised service plans, (5) a single assessment instrument based on the clients' functional autonomy, and (6) a computerised clinical chart for communicating between institutions for client monitoring purposes. Preliminary results: The efficacy of this model has been tested in a pilot project that showed a decreased incidence of functional decline, a decreased burden for caregivers and a smaller proportion of older people wishing to be institutionalised. Conclusion: The on-going implementation and effectiveness study will show evidence of its real value and its impact on clienteles and cost.

149 citations



Journal ArticleDOI
TL;DR: Although one of the main purposes is to make health care more patient-focused, patients in general seem to have limited impact on the development work, so the challenge is to design Chains of Care, which regards patients as partners instead of objects.
Abstract: Chains of Care are today an important counterbalance to the ever-increasing fragmentation of Swedish health care, and the ongoing development work has high priority. Improved quality of care is the most important reason for developing Chains of Care. Despite support in the form of goals and activity plans, seven out of ten county councils are uncertain whether they have been quite successful in the development work. Strong departmentalisation of responsibilities between different medical professions and departments, types of responsibilities and power still remaining in the vertical organisation structure, together with limited participation from the local authorities, are some of the most commonly mentioned reasons for the lack of success. Even though there is hesitation regarding the development work up to today, all county councils will continue developing Chains of Care. The main reason is, as was the case with Chain of Care development up to today, to improve quality of care. Although one of the main purposes is to make health care more patient-focused, patients in general seem to have limited impact on the development work. Therefore, the challenge is to design Chains of Care, which regards patients as partners instead of objects.

75 citations


Journal ArticleDOI
TL;DR: This policy paper explores the rationale and models of consumer-directed services at home, reviews developments, designs and outcomes of programs in the Austria, Germany, The Netherlands, and the US, and discusses how this experience could be helpful in shaping better and more responsive integrated models of care for vulnerable long term care populations.
Abstract: Over the past decade, policy makers in developed countries have begun to pay increasing attention to reform of the long-term care system for the frail elderly and younger people with disabilities. A continuum of strategies have generated interest, including integrated systems of care with agency/professionally managed service packages on the one end, and programs offering cash benefits along with the flexibility to decide how to best use these funds to meet individual needs and preferences, on the other. The latter approach, known as “consumer-directed care,” is found in various forms and degrees in Europe and North America. Primarily organised around the provision of home and community care, consumer-directed services are aimed at empowering clients and family carers, giving them major control over the what, who and when of needed care. Consumer-directed care appears to be the antithesis of integrated care. However, it actually holds important lessons and implications for the latter. This policy paper explores the rationale and models of consumer-directed services at home, reviews developments, designs and outcomes of programs in the Austria, Germany, the Netherlands, and the US. It also discusses how this experience could be helpful in shaping better and more responsive integrated models of care for vulnerable long term care populations.

69 citations


Journal ArticleDOI
TL;DR: It is argued that the collective sense of professions involved should be integrated into the guideline, for example in relation to goal differentiation, and that multidisciplinary guidelines must also offer a hierarchy between those goals, i.e. a vision of the appropriate type of care and the order in which the various care components should be administered.
Abstract: Purpose: This article describes the Dutch ‘Multidisciplinary Guidelines in Mental Health Care’ project and its first products (multidisciplinary guidelines on depressive and anxiety disorders). Context of case: In the early 1990s, disciplines in Dutch mental health care formulated their first monodisciplinary guidelines, which disagreed on essential features. In 1998, the Dutch government invited representatives of the five core disciplines in mental health care (psychiatrists, general practitioners, psychotherapists (clinical), psychologists and psychiatric nurses) to start a joint project aimed at the development of new integrated multidisciplinary guidelines. Data sources: The vision document, presented in 2000 by the five core disciplines, describes the directions for the development of new guidelines. The guidelines on depressive and anxiety disorders will appear in 2004. Case description: The first draft guidelines were presented in May 2003, in line with the vision document (2000). However, it is still not certain whether they will be authorised by all professional groups. Some disciplines do not recognise themselves in these guidelines. It is argued that these problems can be attributed at least in part to the evidence-based method that was used in drafting the guidelines. Interventions are compared on the basis of their ‘level of evidence’, the consequence of which is that cognitive behavioural therapy and drug treatment are almost always seen as the only appropriate interventions. Other interventions are excluded because of their lower level of evidence. Conclusions and discussion: The conclusion is that guidelines cannot be based on empirical evidence alone. It is argued that the collective sense of professions involved should also be integrated into the guideline, for example in relation to goal differentiation. It is finally argued that multidisciplinary guidelines must also offer a hierarchy between those goals, i.e. a vision of the appropriate type of care and the order in which the various care components should be administered.

66 citations


Journal ArticleDOI
TL;DR: Similar outcomes were achieved regardless of the level of service integration or differentiation within Maryland hospitals and service differentiation across the hospital system or network and its affect on heart failure patient clinical and economic outcomes.
Abstract: Objective: To examine the level of service integration within Maryland hospitals and service differentiation across the hospital system or network and its affect on heart failure patient clinical and economic outcomes Data sources/Study setting: Maryland Health Services Cost Review Commission Inpatient Data for 1997 and 1998 were used for secondary data analysis Study design: Retrospective cross sectional Independent variables were the level of service integration and differentiation created from the 1998 American Hospital Association Annual Survey based on the work of Bazzoli et al [1] The primary dependent variables were readmission, in-hospital mortality, length of stay and costs Data collection/Extraction methods: Patients discharged from Maryland hospitals with a diagnosis that grouped to DRG 127 (heart failure) were extracted Multivariate linear and logistic models clustered by hospital were used to analyse results at the patient level Principal findings: A higher likelihood of readmission was found as the level of Community Differentiation increased Although costs were higher as Total Differentiation increased in 1998, these results were not validated by 1997 data No significant relationship was found between integration of services and outcomes Conclusions: Similar outcomes were achieved regardless of the level of service integration or differentiation Community hospitals produce similar patient outcomes at the same cost for this diagnosis

41 citations



Journal ArticleDOI
TL;DR: Policy issues involving end-of-life care, especially involving the hospice benefit, are assessed, and model programs of integrated care for people who are dying are analysed to analyse.
Abstract: Background: End-of-life care financing and delivery in the United States is fragmented and uncoordinated, with little integration of acute and long-term care services. Objective: To assess policy issues involving end-of-life care, especially involving the hospice benefit, and to analyse model programs of integrated care for people who are dying. Methods: The study conducted structured interviews with stakeholders and experts in end-of-life care and with administrators of model programs in the United States, which were nominated by the experts. Results: The two major public insurance programs—Medicare and Medicaid—finance the vast majority of end-of-life care. Both programs offer a hospice benefit, which has several shortcomings, including requiring physicians to make a prognosis of a six month life expectancy and insisting that patients give up curative treatment—two steps which are difficult for doctors and patients to make—and payment levels that may be too low. In addition, quality of care initiatives for nursing homes and hospice sometimes conflict. Four innovative health systems have overcome these barriers to provide palliative services to beneficiaries in their last year of life. Three of these health systems are managed care plans which receive capitated payments. These providers integrate health, long-term and palliative care using an interdisciplinary team approach to management of services. The fourth provider is a hospice that provides palliative services to beneficiaries of all ages, including those who have not elected hospice care. Conclusions: End-of-life care is deficient in the United States. Public payers could use their market power to improve care through a number of strategies.

27 citations


Journal ArticleDOI
TL;DR: The nature of the services actually offered to the elderly in Greece by an institution of integrated care is described, as opposed to those that should be offered according to the relevant law, and the factors influencing the supply of those services are investigated.
Abstract: Purpose: To describe the nature of the services actually offered to the elderly in Greece by an institution of integrated care, as opposed to those that should be offered according to the relevant law, and to investigate the factors influencing the supply of those services. Background: By the year 2020 about 20 million people will be aged 80 and over in the European Union. People of third age consist 16.9% of the total Greek population. Population aging has major implications on health services, employment and society as a whole. “Open Care Centres for the Elderly” (KAPI) is a rapidly developing and expanding institution providing integrated care for the elderly. Methods: A questionnaire to be completed by the staff was sent to all 370 KAPI. Response rate reached 66%. For the analysis of the data multiple logistic regression analysis was performed using SPSS 10.0. Results: Both medical and social care is provided by the KAPI to the elderly with different magnitude all over the country. Factors such as number of members, medical, paramedical and non-medical staff and fund availability in the KAPI mainly influence the supply of services. Conclusions: Integrated care services are offered by the KAPI. However, more steps need to be taken towards the direction of other European countries' integrated care schemes, in order to improve both quality and quantity of the services provided.

23 citations


Journal ArticleDOI
TL;DR: From an illustrative case of an older patient with pneumonia and atrial fibrillation, potential breaks in continuity of care are catalogued.
Abstract: Continuity of care, defined as the patient experiencing coherent care over time and place, is challenged when a rural senior with multiple medical problems is transferred to a regional hospital for acute care. From an illustrative case of an older patient with pneumonia and atrial fibrillation, we catalogue potential breaks in continuity of care. Optimal continuity of care is characterised not only by regular contact with the providers who establish collaboration with patients and their caregivers, but also by communication, co-ordination, contingency, convenience, and consistency. Because it is not possible to have the same providers continuously available (relational continuity), for continuity of care, there is a need for integrative system approaches, such as: (1) policy and standards, disease management programs, integrated clinical pathways (management continuity), (2) electronic health information systems and telecommunications technology (communication continuity). The evaluation of these approaches requires measures that account for the multi-faceted nature of continuity of care.

20 citations


Journal ArticleDOI
TL;DR: This book is a slim, easily digestible practical guide for health professionals and it is written in a clear, almost simple, accessible style with lots of lists and boxes to break up the text as well as examples to illustrate key points.
Abstract: A side effect of the evidence-based movement in medicine has been mounting pressure to make policy and management evidence-based. This book by Rosemary Stewart, a respected international teacher and researcher in management, is therefore timely. It is not an academic text in that it does not advance theory or provide a critical analysis of evidence-based management. It is a slim, easily digestible practical guide for health professionals and it is written in a clear, almost simple, accessible style with lots of lists and boxes to break up the text as well as examples to illustrate key points.

Journal ArticleDOI
TL;DR: A comprehensive evaluation of NHS walk-in centres in England against criteria of improved access, quality, user satisfaction and efficiency illustrates many of the issues described in a recent WHO reflective paper on Integrated Care.
Abstract: Purpose: To undertake a comprehensive evaluation of NHS walk-in centres against criteria of improved access, quality, user satisfaction and efficiency. Context: Forty NHS walk-in centres have been opened in England, as part of the UK governments agenda to modernise the NHS. They are intended to improve access to primary care, provide high quality treatment at convenient times, and reduce inappropriate demand on other NHS providers. Care is provided by nurses rather than doctors, using computerised algorithms, and nurses use protocols to supply treatments previously only available from doctors. Data sources: Several linked studies were conducted using different sources of data and methodologies. These included routinely collected data, site visits, patient interviews, a survey of users of walk-in centres, a study using simulated patients to assess quality of care, analysis of consultation rates in NHS services near to walk-in centres, and audit of compliance with protocols. Conclusion & discussion: The findings illustrate many of the issues described in a recent WHO reflective paper on Integrated Care, including tensions between professional judgement and use of protocols, problems with incompatible IT systems, balancing users' demands and needs, the importance of understanding health professionals' roles and issues of technical versus allocative efficiency.

Journal ArticleDOI
TL;DR: The results of the study had some influence on the political health agenda in The Netherlands, leading to greater emphasis on innovations and quality of care.
Abstract: Research Question: Innovations in health care are slowly disseminated in The Netherlands and elsewhere. That's why the researchers defined their research question: What is the quickest way of disseminating health care innovations? Research method: The design was a comparative, qualitative case study. The researchers invited a group of 52 authors to describe their 21 health care innovations. All case descriptions were published in a book of 261 pages [2]. Results: Six types of innovations were distinguished. Most innovations simultaneously improved quality from the patient's point of view (18 out of 21 cases), professional pride (18/21) and speed of introduction (16/21). Clinical outcomes were better or comparable in 13 of the 21 cases. Brainstorm sessions took place with the innovators and the 22 experts on the quickest way to disseminate the innovations more widely in The Netherlands. These sessions looked for the critical success factors for the dissemination of the 21 projects and identified nine. The following factors were identified: 1. A clear distribution of responsibilities between professionals within the innovation (20/21) 2. Enough educational programs about the innovations for the professionals (18/21) 3. Adequate ICT support for the running of the innovations (15/21) 4. Suitable publicity for the innovations (12/21) 5. An adequate payment system for innovative care providers (7/21) 6. The right size of catchment's area for the innovations (6/21) 7. Enough professional freedom to adopt the innovation (5/21) 8. Fast managerial and public decision-making about the adoption of the innovation (3/21) 9. The embedding of the innovations in quality management assurance policy (1/21). Discussion: The results of the study had some influence on the political health agenda in The Netherlands, leading to greater emphasis on innovations and quality of care.

Journal ArticleDOI
TL;DR: There is still room for improvement in relations between different centres, in particular with regard to the clearer definition of the roles and interdependence of those intermediate-level centres located between the hub centres and basic healthcare facilities.
Abstract: Objective: We analysed the integrated planning model adopted by the Italian region Emilia Romagna in year 2000 to cover the entire range of treatment of cardiovascular disease. This model, called “hub and spoke”, provides for the transfer of patient care and treatment from peripheral units (the spokes) to central units (the hubs) once a certain complexity threshold has been reached. Methods: We examined inter-temporal variations in patients flows for the selection/referral and follow-up phases between cardiac surgery and cardiology units during two periods characterised by different organisational set-ups, in order to reflect on the progress being made in the organisation of the network. The database consisted of regional records of hospital discharges during the 1997–2001 period. Results: The investigation pointed to the achievement of a good degree of coordination between structures at different levels of specialisation in the case of cardiac surgery, for which six centres were selected already in 1996. On the other hand, the more recent introduction of a hierarchical system for interventional cardiology points to the prevalence of operations on patients previously treated within the same centre, to admissions by direct access, and to follow-up mainly conducted within the hub providing the initial service. Conclusions: Despite the progress made towards the more effective rationalisation of the health care network, there is still room for improvement in relations between different centres, in particular with regard to the clearer definition of the roles and interdependence of those intermediate-level centres located between the hub centres and basic healthcare facilities.

Journal ArticleDOI
TL;DR: The age of integration of residential and ambulatory mental health institutions correlates significantly with two subscales of process quality of schizophrenia care, i.e. availability of interventions and treatment and no association was found between the size of the MHO's catchment area and any of the used subscales.
Abstract: Objective: The objective of this study is to investigate the influence of mergers of ambulatory and mental healthcare organisations on the process quality of care for persons suffering from schizophrenia or related psychoses. Theory: On the basis of the theory of Donabedian we assume the relationships between three types of quality in healthcare: structure quality, process quality and outcome quality. This study focuses on the influences of structure quality, i.e. years since merger and catchment area size upon process quality. Methods: Criteria according to Tugwell for evaluating healthcare were used to describe the process quality of schizophrenia care, resulting in a process quality questionnaire with 6 subscales and 21 items. Leading psychiatrists of 31 Dutch mental healthcare organisations, covering 89% of the country, answered the questionnaire. Both programmes and documents from the responding institutions and schizophrenia projects were analysed. Correlations of two determinants, age of the merged organisation and catchment area size, were made with total scale scores and the sub scores of the questionnaire. Results: The response rate was 97% (31/32). Twenty-two organisations (71%) had a score of more than 50% on the used scale, 8 (29%) scored less. Two evidence-based interventions were implemented in more than 50% of the organisations, three in less than 50%. A low degree of implementation occurs in establishing care for people with schizophrenia from ethnic minorities, standardising diagnostic procedures and continuity of care. No significant relationship between the age of the merged organisation (‘age’) and the total process quality of schizophrenia care was found, however, the relationships between age and the subscales availability of interventions and integrated treatment were significant. No association was found between the size of the MHO's catchment area and any of the used subscales. Conclusions: The age of integration of residential and ambulatory mental health institutions correlates significantly with two subscales of process quality of schizophrenia care, i.e. availability of interventions and treatment. Catchment area size is not significantly associated with process quality or any of the subscales. Despite the mentioned positive effects, the overall picture of schizophrenia care is not very positive. Additional forces other than merely integration of ambulatory and residential services are needed for the further implementation of evidence-based interventions, diagnostic standards and continuity of care. The development of a national ‘schizophrenia standard’ (like in other countries) in relation with implementation plans and strategies to evaluate care on a regional level is recommended as well as further research on patient outcomes in relation to mergers of mental healthcare organisations.

Journal ArticleDOI
TL;DR: This paper highlights qualitative data elicited from interviews with health and social care managers and practitioners from Project CHAIN, a project dedicated to improving the quality of life of older people through the creation of integrated networks.
Abstract: Purpose: To report on the development of a project dedicated to improving the quality of life of older people through the creation of integrated networks. Context: The project is set within a post-industrial community and against a backdrop of government re-organisation and devolution within Wales. The immediate research context is determined by utilising an approach to the structure of integration derived theoretically. Case description: Project CHAIN (Community Health Alliances through Integrated Networks) adopts a network perspective as a means of addressing both the determinants of health and service delivery in health and social care. The Project partners are: healthcare commissioners and providers; local authority directorates including community services and transportation; the voluntary and private sectors; and a university institute. Co-opted participants include fora representing older people's interests. Data sources: The Project incorporates an action research method. This paper highlights qualitative data elicited from interviews with health and social care managers and practitioners. Conclusions and discussion: The Project is ongoing and we record progress in building five integrated networks.

Journal ArticleDOI
TL;DR: It is concluded that determination of HBP density in vivo via a specific tracer is a new, simple and reliable approach for the determination of remaining hepatic function in patients with primary or secondary liver cancer.
Abstract: 9'Tc-galactosylated neoglycoalbumin ("mTc-NGA) is a hepatocyte-specific tracer that, after injection into the blood stream, delivers radioactivity selectively to the liver. This is based upon chemical recognition and binding by the hepatic binding protein (HBP), a receptor specific for galactosylated glycoproteins. Liver tissue samples were obtained intraoperatively from patients undergoing surgery for various cancers. The concentration of specific HBP receptors in the liver (normal liver, hepatoma, liver metastasis) was calculated from the in vitro binding of 99mTc-NGA. One week after surgery, the in vivo HBP density was also measured in some of these patients after injection of 3.5 mg (50 nmol per patient) "mTc-NGA (150-200 MBq) for simulation of 9'Tc-NGA kinetics. Comparison of in vitro and in vivo HBP concentration in the liver showed values in the same concentration range. In patients with hepatoma or liver metastasis a significantly (P<0.01) decreased global HBP density was found in vivo compared to controls. The values obtained for in vivo HBP concentration in the liver amounted to 0.38 ± 0.05 gmol 1-' liver for patients with hepatoma, to 0.4 ± 0.1 gAmol 1in patients with liver metastasis and to 94 ± 0.05 timol 1liver in cancer patients without liver malignancy. In vitro investigation of HBP density revealed the malignant liver tissue to have a significantly (P<0.0001) decreased or almost (completely) absent HBP receptor density compared to the normal tissue apart from the cancer area. It is concluded that determination of HBP density in vivo via a specific tracer is a new, simple and reliable approach for the determination of remaining hepatic function in patients with primary or secondary liver cancer.

Journal ArticleDOI
TL;DR: Every country is seeking its way out of these problems, thus preparing the way to adequately develop, introduce, manage and deliver integrated care services, the question arises what the European Union could do to help tackling it.
Abstract: What is gradually becoming clear in all countries of the European Union is, that integration of services is more and more urgently needed in order to deal with the changing needs and demands of the ageing European citizens. Everywhere in Europe older people are more and more faced with smaller social networks, growing dependency, less mobility and psycho-geriatric syndromes. Such problems cannot be adequately dealt with by the current functional and fragmented health care services. What has also become clear, however, is, that such an integration faces many problems, ranging from difficulties of inter-professional working to inadequate financial and legislative structures. Every country is seeking its way out of these problems, thus preparing the way to adequately develop, introduce, manage and deliver integrated care services. Whereas all countries obviously face the same problem, the question arises what the European Union could do to help tackling it.


Journal ArticleDOI
TL;DR: The author singled out the main issues and gives the reader a brief introduction, but the reader discovers quite soon that without following the instructions it does not establish the appropriate reference frame for learning by exploring the fundamentals of research theory and methods.

Journal ArticleDOI
TL;DR: The argument is that shortage of resources should motivate professionals to share these effectively, and this inevitably means integration, and examples include war leading to social cohesion in uniting against a common enemy.