Showing papers in "International Journal of Integrated Care in 2005"

Evaluating integrated health care: a model for measurement

Abstract: Purpose: In the development of integrated care, there is an increasing need for knowledge about the actual degree of integration between different providers of health services. The purpose of this article is to describe the conceptualisation and validation of a practical model for measurement, which can be used by managers to implement and sustain integrated care. Theory: The model is based on a continuum of integration, extending from full segregation through intermediate forms of linkage, coordination and cooperation to full integration. Methods: The continuum was operationalised into a ratio scale of functional clinical integration. This scale was used in an explorative study of a local health authority in Sweden. Data on integration were collected in self-assessment forms together with estimated ranks of optimum integration between the different units of the health authority. The data were processed with statistical methods and the results were discussed with the managers concerned. Results: Judging from this explorative study, it seems that the model of measurement collects reliable and valid data of functional clinical integration in local health care. The model was also regarded as a useful instrument for managers of integrated care. Discussion: One of the main advantages with the model is that it includes optimum ranks of integration beside actual ranks. The optimum integration rank between two units is depending on the needs of both differentiation and integration.

A literature review to explore integrated care for older people

Abstract: Purpose: This paper reports on some of the findings of a literature review commissioned to explore integrated care for older people. Methods: The process of revising included finding and selecting literature from multidisciplinary sources, and encompassed both published papers and ‘grey’ literature, i.e. material which had not been reviewed for publication. Results: The study found that thinking has moved on from a focus on the problems of accessing services to exploring ways in which they may function in an integrated way. Conclusions: The study shows how thinking on integrated care for older people has developed, and knowledge of micro, mezzo and macro strategies is now more available.

Integrated care for patients with a stroke in the Netherlands: results and experiences from a national Breakthrough Collaborative Improvement project

Abstract: Purpose: This article considers the question if measurable improvements are achieved in the quality of care in stroke services by using a Breakthrough collaborative quality improvement model. Context of case: Despite the availability of explicit criteria, evidence based guidelines, national protocols and examples of best practices; stroke care in the Netherlands did not improve substantially yet. For that reason a national collaborative started in 2002 to improve integrated stroke care in 23 self selected stroke services. Data sources: Characteristics of sites, teams, aims and changes were assessed by using a questionnaire and monthly self-reports of teams. Progress in achieving significant quality improvement has been assessed on a five point Likert scale (IHI score). Case description: The stroke services (n=23) formed multidisciplinary teams, which worked together in a collaborative based on the IHI Breakthrough Series Model. Teams received instruction in quality improvement, reviewed self reported performance data, identified bottlenecks and improvement goals, and implemented “potentially better practices” based on criteria from the Edisse study, evidence based guidelines, own ideas and expert opinion. Conclusion and discussion: Quality of care has been improved in most participating stroke services. Eighty-seven percent of the teams have improved their care significantly on at least one topic. About 34% of the teams have achieved significant improvement on all aims within the time frame of the project. The project has contributed to the further development and spread of integrated stroke care in the Netherlands.

Integrating services for older people: a resource book for managers

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Quebec mental health services networks: models and implementation

Abstract: Purpose: In the transformation of health care systems, the introduction of integrated service networks is considered to be one of the main solutions for enhancing efficiency. In the last few years, a wealth of literature has emerged on the topic of services integration. However, the question of how integrated service networks should be modelled to suit different implementation contexts has barely been touched. To fill that gap, this article presents four models for the organization of mental health integrated networks. Data sources: The proposed models are drawn from three recently published studies on mental health integrated services in the province of Quebec (Canada) with the author as principal investigator. Description: Following an explanation of the concept of integrated service network and a description of the Quebec context for mental health networks, the models, applicable in all settings: rural, urban or semi-urban, and metropolitan, and summarized in four figures, are presented. Discussion and conclusion: To apply the models successfully, the necessity of rallying all the actors of a system, from the strategic, tactical and operational levels, according to the type of integration involved: functional/administrative, clinical and physician-system is highlighted. The importance of formalizing activities among organizations and actors in a network and reinforcing the governing mechanisms at the local level is also underlined. Finally, a number of integration strategies and key conditions of success to operationalize integrated service networks are suggested.

A managed clinical network for cardiac services: set-up, operation and impact on patient care

Abstract: Purpose: To investigate the set up and operation of a Managed Clinical Network for cardiac services and assess its impact on patient care. Methods: This single case study used process evaluation with observational before and after comparison of indicators of quality of care and costs. The study was conducted in Dumfries and Galloway, Scotland and used a three-level framework. Process evaluation of the network set-up and operation through a documentary review of minutes; guidelines and protocols; transcripts of fourteen semi-structured interviews with health service personnel including senior managers, general practitioners, nurses, cardiologists and members of the public. Outcome evaluation of the impact of the network through interrupted time series analysis of clinical data of 202 patients aged less than 76 years admitted to hospital with a confirmed myocardial infarction one-year pre and one-year post, the establishment of the network. The main outcome measures were differences between indicators of quality of care targeted by network protocols. Economic evaluation of the transaction costs of the set-up and operation of the network and the resource costs of the clinical care of the 202 myocardial infarction patients from the time of hospital admission to 6 months post discharge through interrupted time series analysis. The outcome measure was different in National Health Service resource use. Results: Despite early difficulties, the network was successful in bringing together clinicians, patients and managers to redesign services, exhibiting most features of good network management. The role of the energetic lead clinician was crucial, but the network took time to develop and ‘bed down’. Its primary “modus operand” was the development of a myocardial infarction pathway and associated protocols. Of sixteen clinical care indicators, two improved significantly following the launch of the network and nine showed improvements, which were not statistically significant. There was no difference in resource use. Discussion and conclusions: The Managed Clinical Network made a difference to ways of working, particularly in breaching traditional boundaries and involving the public, and made modest changes in patient care. However, it required a two-year “set-up” period. Managed clinical networks are complex initiatives with an increasing profile in health care policy. This study suggests that they require energetic leadership and improvements are likely to be slow and incremental.

Functional status measures for integrating medical and social care

Abstract: Purpose: Identify standard self-report questions about functioning suitable for measuring disability across integrated health and social services. Theory: Functional activities can be validly grouped according to the International Classification of Functioning, Disability and Health (ICF) chapters of mobility, self-care, and domestic life. Methods: Cross-sectional analysis using information on 112,601 persons interviewed as part of the United States National Health Interview Survey on Disability. We combined related sets of questions and tested the appropriateness of their groupings through confirmatory factor analyses. Construct validity was addressed by seeking to confirm clinically logical relationships between the resulting functional scales and related health concepts, including number of physician contacts, number of bed days, perception of illness, and perception of disability. Results: Internal consistency for the summed scales ranged from 0.78 to 0.92. Correlations between the functional scales and related concepts ranged from 0.12 to 0.52 in directions consistent with expectations. Conclusions: Analyses supported the 3 ICF chapters.

Integrated mental health services in England: a policy paradox

Abstract: Purpose: The purpose of this paper is to examine the effects of health care policy on the development of integrated mental health services in England. Data sources: Drawing largely from a narrative review of the literature on adult mental health services published between January 1997 and February 2003 undertaken by the authors, we discuss three case studies of integrated care within primary care, secondary care and across the primary/secondary interface for people with serious mental illness. Conclusion: We suggest that while the central thrust of a raft of recent Government policies in England has been towards integration of different parts of the health care system, policy waterfalls and implementation failures, the adoption of ideas before they have been thoroughly tried and tested, a lack of clarity over roles and responsibilities and poor communication have led to an integration rhetoric/reality gap in practice. This has particular implications for people with serious mental health problems. Discussion: We conclude with suggestions for strategies that may facilitate more integrated working.

Nurses’ information management at patients’ discharge from hospital to home care

Abstract: Purpose: The purpose of this paper is to explore and compare hospital and home care nurses’ assessment of their information management at patients’ discharge from hospital to home care before and after the hospital implemented an electronic nursing discharge note. Theory: This paper draws on the concept of inter-organizational continuity of care, and specifically addresses the contribution of the implementation of an electronic patient record (EPR). Methods: The study has a prospective descriptive design. A questionnaire addressing the information that hospital and home care nurses exchange when patients need continuing care after hospitalization was developed and used. Results: Hospital and home care nurses differed in the way they assessed the structures and content of the information they exchanged, both before and after the EPR implementation. Conclusion and discussion: There is a need to take account of the different organizational contexts within which the two nursing groups work. The organizational context (hospital versus home care) has implications for the nurses’ assessment of the information they exchange. In further development of EPR, it is therefore essential to clarify the context-related information needs of the various health care provider groups as part of the commitment to patient safety.

Coordinating health care: lessons from Norway

Abstract: Objective: What influences the coordination of care between general practitioners and hospitals? In this paper, general practitioner satisfaction with hospital—GP interaction is revealed, and related to several background variables. Method: A questionnaire was sent to all general practitioners in Norway (3388), asking their opinion on the interaction and coordination of health care in their district. A second questionnaire was sent to all the somatic hospitals in Norway (59) regarding formal routines and structures. The results were analysed using ordinary least squares regression. Results: General practitioners tend to be less satisfied with the coordination of care when their primary hospital is large and cost-effective with a high share of elderly patients. Together with the degree to which the general practitioner is involved in arenas where hospital physicians and general practitioners interact, these factors turned out to be good predictors of general practitioner satisfaction. Implication: To improve coordination between general practitioners and specialists, one should focus upon the structural traits within the hospitals in different regions as well as creating common arenas where the physicians can interact.

Utilization and costs of home-based and community-based care within a social HMO: trends over an 18-year period

Abstract: Purpose: Our objective was to describe the utilization and costs of services from 1985 to 2002 of a Social Health Maintenance Organization (SHMO) demonstration project providing a benefit for home-based and community-based as well as short-term institutional (HCB) care at Kaiser Permanente Northwest (KPNW), serving the Portland, Oregon area. The HCB care benefit was offered by KPNW as a supplement to Medicare's acute care medical benefits, which KPNW provides in an HMO model. KPNW receives a monthly per capita payment from Medicare to provide medical benefits, and Medicare beneficiaries who choose to join pay a supplemental premium that covers prescription drugs, HCB care benefits, and other services. A HCB care benefit of up to $12,000 per year in services was available to SHMO members meeting requirement for nursing home certification (NHC). Methods: We used aggregate data to track temporal changes in the period 1985 to 2002 on member eligibility, enrollment in HCB care plans, age, service utilization and co-payments. Trends in the overall costs and financing of the HCB care benefit were extracted from quarterly reports, management data, and finance data. Results: During the time period, 14,815 members enrolled in the SHMO and membership averaged 4,531. The proportion of SHMO members aged 85 or older grew from 12 to 25%; proportion meeting requirements for NHC rose from 4 to 27%; and proportion with HCB care plans rose from 4 to 18%. Costs for the HCB care benefit rose from $21 per SHMO member per month in 1985 to $95 in 2002. The HCB care costs were equivalent to 12% to 16% of Medicare reimbursement. The HCB program costs were covered by member premiums (which rose from $49 to $180) and co-payments from members with care plans. Over the 18-year period, spending shifted from nursing homes to a range of community services, e.g. personal care, homemaking, member reimbursement, lifeline, equipment, transportation, shift care, home nursing, adult day care, respite care, and dentures. Rising costs per month per SHMO member reflected increasing HCB eligibility rather than costs per member with HCB care, which actually fell from $6,164 in 1989 to $4,328 in 2002. Care management accounted for about one-quarter of community care costs since 1992. Conclusions: The Kaiser Permanente Northwest SHMO served an increasingly aged and disabled membership by reducing costs per HCB member care plan and shifting utilization to a broad range of community care services. Supported by a disability-based Medicare payment formula and by SHMO beneficiaries willing to pay increasing premiums, KPNW has been able to offer comprehensive community care. The model could be replicated by other HMOs with the support of favorable federal policies.

Making a difference?: exploring the impact of multi-agency working on disabled children with complex health care needs, their families and the professionals who support them

Abstract: Developments in medical technology mean that many disabled children now have complex healthcare needs, on top of the social, financial and emotional stresses that commonly accompany childhood disability. Parents, siblings and children themselves struggle to experience a normal family life whilst time-consuming and sometimes distressing medical and therapeutic routines are regularly carried out in the home. Social support, advice, information and regular breaks from the routines of care are vitally important. However, this help (when it is available) is usually fragmented between different services and professionals —health, education, social welfare and so on. For some families, accessing and co-ordinating these different sources of help are major tasks and additional sources of stress.

Transmural care in the rehabilitation sector: implementation experiences with a transmural care model for people with spinal cord injury

Abstract: Purposes: The purpose of this article is first to describe the development and content of a transmural care model in the rehabilitation sector, which aims to reduce the number and severity of health problems of people with spinal cord injury (SCI) and improve the continuity of care. Second, the purpose is to describe the applicability and implementation experiences of a transmural care model in the rehabilitation sector. Methods: The transmural care model was developed in cooperation with the Dutch Association of Spinal Cord Injured Patients, community nurses, general practitioners, rehabilitation nurses, rehabilitation managers, physiatrists and researchers. The core component of the care model consists of a transmural nurse, who ‘liaises’ between people with SCI living in the community, professional primary care professionals and the rehabilitation centre. The transmural care model provides a job description containing activities to support people with SCI and their family/partners and activities to promote continuity of care. The transmural care model was implemented in two Dutch rehabilitation centres. The following three aspects, as experienced by the transmural nurses, were evaluated: the extent to which the care model was implemented; enabling factors and barriers for implementation; strength and weakness of the care model. Results: The transmural care model was not implemented in all its details, with a clear difference between the two rehabilitation centres. Enabling factors and barriers for implementation were found at three levels: 1. the level of the individual professional (e.g. competencies, attitude and motivation), 2. the organisational and financing level (e.g. availability of facilities and finances), and 3. the social context (the opinion of colleagues, managers and other professionals involved with the care). The most important weakness experienced was that there was not enough time to put all the activities into practice. The strength of the care model lies in the combination of support of patients after discharge, support of and cooperation with primary care professionals, and feedback of experiences to the clinical rehabilitation teams. Conclusion: We recommend further improving and implementing the care model and encourage other care professionals and researchers to share their implementation experiences of follow-up care innovations for people with SCI.

Keep primary health care personal

Abstract: In the fifties and sixties a rebirth for primary health care (PHC) took place in the United Kingdom and The Netherlands. New scientific journals started: the Journal of the College of GP’s (now the British Journal of General Practice) in the UK and Huisarts en Wetenschap in The Netherlands. In 1966 in both countries reforms took place to reinforce General Practitioners within the health care system. In Holland, 1966 was the start for the development of the world famous GPstandards and for many multidisciplinary health care centres. Also in that year, the first Dutch chair in general practice was inaugurated [1]. In the UK Richard Scott had been appointed to the first GP chair in the world in Edinburgh in 1963. In 1966, after bitter negotiations, the government and the GP political leaders agreed the so-called GP charter. This notably rewarded GPs for improving their practices (previously this had been at their own personal expense), it also included incentives for GPs to practice together in groups and to undertake postgraduate education. A second key UK landmark was the nationwide introduction of three years compulsory vocational training for GPs in 1979.

Vernetzte Versorgung für ältere Menschen in Deutschland

Abstract: How to translate “Vernetze Versorgung”? Does the term reflect the German vision on the organization of care? Finding the term that covers the essence often leads to confusion, both within countries and internationally. For instance, disease management, chain of care, care networks, case management and care management—each term brings about a specific aspect of all processes and initiatives to enhance continuity, quality and efficiency of care. In this journal (IJIC) the term “Integrated Care” is used.

A cross sectional study of assessed need and multiple service use among a self harm population: informing the development of inter-agency integrated care

Abstract: Purpose: To examine assessed need and wider health and social care service contact for a total Deliberate Self Harm (DSH) population in the UK. Methods: The study first recorded assessed needs and referrals for this population, then used a new method of identifying and describing all other agency contacts for this population by combining the total anonymised DSH population data with total mental health, health and social care agency populations for one geographical area. Results: For a DSH unit population of 427, half (53%) were assessed with mental health and 18% with drug or alcohol problems; two thirds were referred to appropriate services. Wider service contact for a total DSH population (n=2,205 over three years) confirmed that 53% had contacted mental health (compared to 2.9% of the geographical area population (n=646,239) and 7.4% of the total hospital Emergency population (n=91,911). The DSH population was three times more likely to contact social care agencies (21.1%: 7.2%) and ten times more likely to attend drug (7.3%: 0.7%) and alcohol agencies (8.8%: 0.8%) Conclusions: This new method described the wider service use of one vulnerable shared care population, it is suggested that the method could be used to inform the development of integrated care initiatives in different areas.