Showing papers in "International Journal of Integrated Care in 2012"
191 citations
TL;DR: Qualitative analyses from a three-year multi-method evaluation to identify barriers and facilitators to successful integration of care are reported, illustrating questions that providers may wish to consider when planning interventions to improve the Integration of care.
Abstract: Background . In 2008, the English Department of Health appointed 16 'Integrated Care Pilots' which used a range of approaches to provide better integrated care. We report qualitative analyses from a three year multi-method evaluation to identify barriers and facilitators to successful integration of care. Theory and methods. Data were analysed from transcripts of 213 in-depth staff interviews, and from semi-structured questionnaires (the 'Living Document') completed by staff in pilot sites at six points over a two-year period. Emerging findings were therefore built from 'bottom up' and grounded in the data. However, we were then interested in how these findings compared and contrasted with more generic analyses. Therefore after our analyses were complete we then systematically compared and contrasted the findings with the analysis of barriers and facilitators to quality improvement identified in a systematic review by Kaplan et al (2010) and the analysis of more micro-level shapers of behaviour found in Normalisation Process Theory (May et al 2007). Neither of these approaches claims to be full blown theories but both claim to provide mid-range theoretical arguments which may be used to structure existing data and which can be undercut or reinforced by new data. Results and discussion . Many barriers and facilitators to integrating care are those of any large scale organisational change. These include issues relating to leadership, organisational culture, information technology, physician involvement, and availability of resources. However, activities which appear particularly important for delivering integrated care include personal relationships between leaders in different organisations, the scale of planned activities, governance and finance arrangements, support for staff in new roles, and organisational and staff stability. We illustrate our analyses with a 'routemap' which identifies questions that providers may wish to consider when planning interventions to improve the integration of care.
176 citations
TL;DR: Interventions at the individual caregivers’ level can be beneficial in reducing or stabilizing depression, burden, stress and role strain, and technology-based interventions can reduce caregiver burden, depression, anxiety and stress and improve the caregiver’s coping ability.
Abstract: Introduction: Informal caregivers are important resources for community-dwelling frail elderly. But caring can be challenging. To be able to provide long-term care to the elderly, informal caregivers need to be supported as well. The aim of this study is to review the current best evidence on the effectiveness of different types of support services targeting informal caregivers of community-dwelling frail elderly. Methods: A systematic literature search was performed in Medline, PsychINFO, Ovid Nursing Database, Cinahl, Embase, Cochrane Central Register of Controlled Trials and British Nursing Index in september 2010. Results: Overall, the effect of caregiver support interventions is small and also inconsistent between studies. Respite care can be helpful in reducing depression, burden and anger. Interventions at the individual caregivers’ level can be beneficial in reducing or stabilizing depression, burden, stress and role strain. Group support has a positive effect on caregivers’ coping ability, knowledge, social support and reducing depression. Technology-based interventions can reduce caregiver burden, depression, anxiety and stress and improve the caregiver’s coping ability. Conclusion: Integrated support packages where the content of the package is tailored to the individual caregivers’ physical, psychological and social needs should be preferred when supporting informal caregivers of frail elderly. It requires an intense collaboration and coordination between all parties involved.
161 citations
TL;DR: The definition of a (care) pathway is addressed, and a description of theories since the fifties of the last century is followed, which ends with a discussion of theoretical advantages and disadvantages of care pathways for patients and professionals.
Abstract: This article addresses first the definition of a (care) pathway, and then follows a description of theories since the 1950s. It ends with a discussion of theoretical advantages and disadvantages of care pathways for patients and professionals. The objective of this paper is to provide a theoretical base for empirical studies on care pathways. The knowledge for this chapter is based on several books on pathways, which we found by searching in the digital encyclopedia Wikipedia. Although this is not usual in scientific publications, this method was used because books are not searchable by databases as Pubmed. From 2005, we performed a literature search on Pubmed and other literature databases, and with the keywords integrated care pathway, clinical pathway, critical pathway, theory, research, and evaluation. One of the inspirational sources was the website of the European Pathway Association (EPA) and its journal International Journal of Care Pathways. The authors visited several sites for this paper. These are mentioned as illustration of a concept or theory. Most of them have English websites with more information. The URLs of these websites are not mentioned in this paper as a reference, because the content of them changes fast, sometimes every day.
155 citations
TL;DR: It is concluded that integrating care requires policies and management practices that promote system awareness, relationship-building and information-sharing, and that recognize change as an evolving learning process rather than a series of programmatic steps.
Abstract: Introduction: Despite over two decades of international experience and research on health systems integration, integrated care has not developed widely. We hypothesized that part of the problem may lie in how we conceptualize the integration process and the complex systems within which integrated care is enacted. This study aims to contribute to discourse regarding the relevance and utility of a complex-adaptive systems (CAS) perspective on integrated care. Methods: In the Canadian province of Ontario, government mandated the development of fourteen Local Health Integration Networks in 2006. Against the backdrop of these efforts to integrate care, we collected focus group data from a diverse sample of healthcare professionals in the Greater Toronto Area using convenience and snowball sampling. A semi-structured interview guide was used to elicit participant views and experiences of health systems integration. We use a CAS framework to describe and analyze the data, and to assess the theoretical fit of a CAS perspective with the dominant themes in participant responses. Results: Our findings indicate that integration is challenged by system complexity, weak ties and poor alignment among professionals and organizations, a lack of funding incentives to support collaborative work, and a bureaucratic environment based on a command and control approach to management. Using a CAS framework, we identified several characteristics of CAS in our data, including diverse, interdependent and semi-autonomous actors; embedded co-evolutionary systems; emergent behaviours and non-linearity; and self-organizing capacity. Discussion and Conclusion: One possible explanation for the lack of systems change towards integration is that we have failed to treat the healthcare system as complex-adaptive. The data suggest that future integration initiatives must be anchored in a CAS perspective, and focus on building the system's capacity to self-organize. We conclude that integrating care requires policies and management practices that promote system awareness, relationship-building and information-sharing, and that recognize change as an evolving learning process rather than a series of programmatic steps.
132 citations
TL;DR: Hospital-at-home has proved to be a safe alternative for hospital care for selected patients, and should be considered as a treatment option for COPD exacerbations in the Netherlands.
Abstract: Introduction: A remarkable difference in care delivery pathways for Chronic Obstructive Pulmonary Disease (COPD) is the presence of hospital-at-home for COPD exacerbations in England and its absence in the Netherlands. The objective of this paper is to explain this difference. Methods: Descriptive COPD statistics and care delivery pathways on all care levels within the institutional context, followed by a comparison of care delivery pathways and an explanation of the difference with regard to hospital-at-home. Results: The Netherlands and England show broad similarities in their care delivery pathways for COPD patients. A major difference is the presence of hospital-at-home for COPD exacerbations in England and its absence in the Netherlands. Three possible explanations for this difference are presented: differences in the urgency for alternatives (higher urgency for alternative treatment models in England), the differences in funding (funding in England facilitated the development of hospital-at-home) and the differences in the substitution of tasks to nurses (substitution to nurses has taken place to a larger extent in England). Discussion and Conclusion: The difference between the Netherlands and England regarding hospital-at-home for COPD exacerbations can be explained in three ways. Hospital-at-home has proved to be a safe alternative for hospital care for selected patients, and should be considered as a treatment option for COPD exacerbations in the Netherlands.
109 citations
TL;DR: The research supports a broader notion of collaborative practice that extends beyond specific care settings and includes an appropriate, informed role for patients and informal caregivers and can help guide system-level and setting-specific interventions designed to promote high-quality, patient-centred care during care transitions.
Abstract: Introduction: Complex older adults, such as those with hip fracture, frequently require care from multiple professionals across a variety of settings. Integrated care both between providers and across settings is important to ensure care quality and patient safety. The purpose of this study was to determine the core factors related to poorly integrated care when hip fracture patients transition between care settings. Methods: A qualitative, focused ethnographic approach was used to guide data collection and analysis. Patients, their informal caregivers and health care providers were interviewed and observed at each care transition A total of 45 individual interviews were conducted. Interview transcripts and field notes were coded and analysed to uncover emerging themes in the data. Results: Four factors related to poorly integrated transitional care were identified: confusion with communication about care, unclear roles and responsibilities, diluted personal ownership over care, and role strain due to system constraints. Conclusions: Our research supports a broader notion of collaborative practice that extends beyond specific care settings and includes an appropriate, informed role for patients and informal caregivers. This research can help guide system-level and setting-specific interventions designed to promote high-quality, patient-centred care during care transitions.
99 citations
TL;DR: Case management may result in improvements in some aspects of care and has the potential to reduce secondary care costs, however, to improve patient experience, case management approaches need to be introduced in a way which respects patients’ wishes.
Abstract: Introduction: In 2009, the English Department of Health appointed 16 integrated care pilots which aimed to provide better integrated care. We report the quantitative results from a multi-method evaluation of six of the demonstration projects which used risk profiling tools to identify older people at risk of emergency hospital admission, combined with intensive case management for people identified as at risk. The interventions focused mainly on delivery system redesign and improved clinical information systems, two key elements of Wagner’s Chronic Care Model. Methods: Questionnaires to staff and patients. Difference-in-differences analysis of secondary care utilisation using data on 3646 patients and 17,311 matched controls, and changes in overall secondary care utilisation.
75 citations
TL;DR: This investigation investigated whether a text message programme targeted at changing patients’ illness and medication beliefs would improve adherence in young adult asthma patients.
Abstract: Objective. While effective preventative medication is readily available for asthma, adherence is a major problem due to patients’ beliefs about their illness and medication. We investigated whether a text message programme targeted at changing patients’ illness and medication beliefs would improve adherence in young adult asthma patients. Methods. Two hundred and sixteen patients aged between 16 and 45 on asthma preventer medication were recruited from pamphlets dispensed with medication and e-mails sent to members of a targeted marketing website. Participants were randomized to receive individually tailored text messages based on their illness and medication beliefs over 18 weeks or no text messages. Illness and medication beliefs were assessed at baseline and at 18 weeks. Adherence rates were assessed by phone calls to participants at 6, 12, and 18 weeks and at 6 and 9 months. Results. At 18 weeks, the intervention group had increased their perceived necessity of preventer medication, increased their belief in the long-term nature of their asthma, and their perceived control over their asthma relative to control group (all p’s < .05). The intervention group also significantly improved adherence over the follow-up period compared to the control group with a relative average increase in adherence over the follow-up period of 10% (p < .001). The percentage taking over 80% of prescribed inhaler doses was 23.9% in the control group compared to 37.7% in the intervention group (p < .05).
74 citations
TL;DR: A development model of 89 elements of integrated care, which are clustered in nine themes, has the potential to serve as a generic quality management model for integrated care services and can be used for monitoring, self evaluation or benchmarking of integratedCare services.
Abstract: textThe thesis adresses the phenomenon of integrated care. The implementation of integrated care for patients with a stroke or dementia is studied. Because a generic quality management model for integrated care is lacking, the study works towards building a development model for integrated care. Based on a systematic approach in which a literature study, a delphi study, a concept mapping study and questionnaire research are combined, a development model for integrated care is created. The model exists of 89 elements of integrated care, which are clustered in nine themes. Also the model describes four phases of development which integrated care services can experience. The model is succesfully empirically validated in 84 integrated care services for stroke, acute myocardial infarct or dementia patients. The model has the potential to serve as a generic quality management model for integrated care services and can be used for monitoring, self evaluation or benchmarking of integrated care services. Also insurers or policy makers could use the model to stimulate integrated care services to further improve and develop their integrated care.
66 citations
TL;DR: The results suggest that even in the early stages of implementation, DMPs for COPD may significantly improve care.
Abstract: Objective: We investigated whether patients with chronic obstructive pulmonary disease (COPD) who were enrolled in disease-management programmes (DMPs) felt that they received a better quality of care than non-enrolled COPD patients. Methods: Our cross-sectional study was performed among patients (n=665) enrolled in four DMPs in the Netherlands. We also evaluated COPD patients (n=227) not enrolled in such programmes. Patients’ assessment of chronic-illness care (PACIC) was measured with a 20-item questionnaire. The instrument had five pre-defined domains: patient activation (three items), delivery-system/practice design (three items), goal setting/tailoring (five items), problem solving/contextual (four items), and follow-up/coordination (five items). Results: The mean overall PACIC score (scale: 1–5) of enrolled DMP patients was 2.94, and that of non-enrolled DMP patients was 2.73 (p≤0.01). Differences in the same direction were found in the subscales of patient activation (p≤0.01), delivery-system/practice design (p≤0.001), and problem solving/contextual (p≤0.001). Conclusions: Our results suggest that even in the early stages of implementation, DMPs for COPD may significantly improve care.
TL;DR: Integrated care models have the potential to improve care for patients with chronic diseases and concurrently have a positive impact on health care expenditure, and policy-makers are suggested to improve the incentives for patientsWith chronic diseases within the existing regulations providing further potential for cost-efficiency of medical care.
Abstract: Introduction: This study investigates the efficiency gains of integrated care models in Switzerland, since these models are regarded as cost containment options in national social health insurance. These plans generate much lower average health care expenditure than the basic insurance plan. The question is, however, to what extent these total savings are due to the effects of selection and efficiency. Methods: The empirical analysis is based on data from 399,274 Swiss residents that constantly had compulsory health insurance with the Helsana Group, the largest health insurer in Switzerland, covering the years 2006 to 2009. In order to evaluate the efficiency of the different integrated care models, we apply an econometric approach with a mixed-effects model. Results: Our estimations indicate that the efficiency effects of integrated care models on health care expenditure are significant. However, the different insurance plans vary, revealing the following efficiency gains per model: contracted capitated model 21.2%, contracted non-capitated model 15.5% and telemedicine model 3.7%. The remaining 8.5%, 5.6% and 22.5% respectively of the variation in total health care expenditure can be attributed to the effects of selection. Conclusions: Integrated care models have the potential to improve care for patients with chronic diseases and concurrently have a positive impact on health care expenditure. We suggest policy makers improve the incentives for patients with chronic diseases within the existing regulations providing further potential for cost-efficiency of medical care.
TL;DR: Six out of six studies provided evidence that the costs of early-supported discharge are less than for conventional care, at similar health outcomes, and cost-effectiveness studies on integrated stroke services suggest that they can reduce costs.
Abstract: Introduction: Given the high incidence of stroke worldwide and the large costs associated with the use of health care resources, it is important to define cost-effective and evidence-based services for stroke rehabilitation. The objective of this review was to assess the evidence on the relative cost or cost-effectiveness of all integrated care arrangements for stroke patients compared to usual care. Integrated care was defined as a multidisciplinary tool to improve the quality and efficiency of evidence-based care and is used as a communication tool between professionals to manage and standardize the outcome-orientated care. Methods: A systematic literature review of cost analyses and economic evaluations was performed. Study characteristics, study quality and results were summarized. Results: Fifteen studies met the inclusion criteria; six on early-supported discharge services, four on home-based rehabilitation, two on stroke units and three on stroke services. The follow-up per patient was generally short; one year or less. The comparators and the scope of included costs varied between studies. Conclusions: Six out of six studies provided evidence that the costs of early-supported discharge are less than for conventional care, at similar health outcomes. Home-based rehabilitation is unlikely to lead to cost-savings, but achieves better health outcomes. Care in stroke units is more expensive than conventional care, but leads to improved health outcomes. The cost-effectiveness studies on integrated stroke services suggest that they can reduce costs. For future research we recommend to focus on the moderate and severely affected patients, include stroke severity as variable, adopt a societal costing perspective and include long-term costs and effects.
TL;DR: An overview of new forms of contracting that have been introduced in the German healthcare system are given and recommendations for the further development of integrated care are provided.
Abstract: German healthcare provides a very comprehensive benefits catalogue, high quality standards, low access barriers and in particular healthcare which is independent from one's income. But at the same time it is one of the most expensive systems in the world. Reasons for the high costs of care are mainly due to the separation of the outpatient, inpatient and rehabilitation sectors, the poor information flow between the service providers and insufficient competition in healthcare provision. In the last 15 years the German government has introduced various reform acts and in doing so has followed a continual path of development: more competition for care concepts between health insurances, more options for the insured and more leeway for players in the various sectors of healthcare. The following article gives an overview of new forms of contracting that have been introduced and provides recommendations for the further development of integrated care in the German healthcare system.
TL;DR: Analysis revealed indications of an emerging shift from the patient and carer ‘perspectivist’ paradigm of the Freeman model towards a new ‘partnership” paradigm where continuity is recognised to be co-constructed by patients, families and professionals, all of whom have an active part to play in its accomplishment.
Abstract: Introduction: A Continuity of Care Research Programme was undertaken in England in 2000-9. The Programme was informed by a conceptual framework proposed by Freeman and colleagues in an earlier scoping study. At the end of the Programme, a conceptual synthesis was carried out in order to confirm or refine the 'Freeman model' of continuity of care. Methods: A conceptual synthesis of the outputs of the Programme, using Critical Interpretive Synthesis. Results: The conceptual framework underpinning the Freeman model of continuity of care, which prioritises the perspectives of service users and carers, was variously utilised in the Programme. Analysis revealed indications of an emerging shift from the patient and carer 'perspectivist' paradigm of the Freeman model towards a new 'partnership' paradigm where continuity is recognised to be co-constructed by patients, families and professionals, all of whom have an active part to play in its accomplishment. Conclusions: The projects in the Programme have advanced understanding of patients' perspectives on continuity of care and on the complex nature of this concept. At the same time, they have raised issues and reported findings which may be indicative of an emergent paradigm shift in this area of research, towards a more dynamic partnership model.
TL;DR: Child mental health professionals’ Individual Interprofessional Collaboration scores from the PINCOM-Q individual aspects subscale were better than that of other child professionals and these scales may be interesting instruments to measure the quality of partnership in child mental health collaborative care settings.
Abstract: Objective: This pilot study examines the potential utility of the Perception of Interprofessional Collaboration Model and the shared decision-making scales in evaluating the quality of partnership in child mental health collaborative care. Methods: Ninety-six primary care professionals working with children and youth responded to an internet survey which included the Perception of Interprofessional Collaboration Model scale (PINCOM-Q) and an adapted version of a shared decision-making scale (Echelle de confort decisionnel, partenaire—ECD-P). The perceptions of child mental health professionals were compared with those of other professionals working with children. Results: The PINCOM-Q and the ECD-P scales had an excellent internal consistency and they were moderately correlated. Child mental health professionals’ Individual Interprofessional Collaboration scores from the PINCOM-Q individual aspects subscale were better than that of other child professionals. Conclusion: These scales may be interesting instruments to measure the quality of partnership in child mental health collaborative care settings. Research needs to replicate these findings and to determine whether the quality of collaboration is a predictor of mental health outcome.
TL;DR: The 2011 Growing Older with a Disability (GOWD) Conference as discussed by the authors was a part of the Festival of International Conferences on Caregiving, Disability, Aging and Technology (FICCDAT), held in Toronto, Canada June 5-8, 2011.
Abstract: We, as organizers and participants of the 2011 Growing Older with a Disability (GOWD) Conference, a part of the Festival of International Conferences on Caregiving, Disability, Aging and Technology (FICCDAT), held in Toronto, Canada June 5–8, 2011 forward this declaration and invite governmental, non-governmental, professional, and consumer stakeholders to join us in supporting and implementing this plan of action.
TL;DR: It is suggested that published studies of transitional care interventions do not often include older adults at highest risk of rehospitalization, raising concerns about the generalizability of their results.
Abstract: OBJECTIVE : Older adults are at risk of rehospitalization if their care transitions from hospital-to-home are not properly managed. The objective of this review was to determine if older patient populations recruited for randomized controlled trials of transitional care interventions represented those at greatest risk of rehospitalization following discharge. Relevant risk factors examined were cognitive impairment, depression, polypharmacy, comorbidity, length of stay, advanced non-malignant diseases, and available social support. DESIGN: Systematic Review. SETTING: Hospital to home. PARTICIPANTS: Older hospitalized adults. MEASUREMENTS: For inclusion, articles were required to focus on hospital-to-home transitions with a self-care component, have components occurring both before and after discharge, and a randomized controlled trial design. Articles were excluded if participants had a mean age under 55 years, or if interventions focused on developmental disabilities, youth, addictions, or case management, or were solely primary-care based. RESULTS: Following title, abstract, and full review by two authors, 17 articles met inclusion criteria. Risk factors for rehospitalization were often listed either as exclusion criteria or were not reported at baseline by the studies. One study included patients with all identified risk factors for rehospitalization. CONCLUSIONS: These data suggest that published studies of transitional care interventions do not often include older adults at highest risk of rehospitalization, raising concerns about the generalizability of their results. Studies are needed that evaluate interventions that explicitly address the needs and characteristics of these patients.
TL;DR: Evaluating parents’ experiences regarding the system’s contribution to their communication with professionals during a six-months pilot in three Dutch care regions found all users indicated a contribution of the system to parent-professional communication, although the extent of the experienced contribution varied considerably.
Abstract: Introduction: To improve communication in the integrated care setting of children with cerebral palsy, we developed a web-based system for parent-professional and inter-professional communication. The present study aimed to evaluate parents’ experiences regarding the system’s contribution to their communication with professionals during a six-months pilot in three Dutch care regions. In addition, factors associated with parents’ system use and non-use were analyzed. Theory and methods: The system’s functional specifications were based on key elements of the Chronic Care Model and quality dimensions formulated by the Institute of Medicine. At baseline, parents completed a T0-questionnaire on their experiences regarding sufficiency of contact, accessibility of professionals, timeliness of information exchange, consistency of information and parents’ role as messenger of information and/or care coordinator. After the pilot, parents completed a T1-questionnaire on their experiences regarding the system’s contribution to each of these aspects.
TL;DR: This report comprises four case studies of different integrated care projects all over the world and displays “integration in action”, which aims to find a superior structure of advices on what is necessary to help integration to be successful.
Abstract: As the title says, this report comprises four case studies of different integrated care projects all over the world and displays “integration in action”. The report gives a broad view of how integrated care can work and aims to find a superior structure of advices on what is necessary to help integration to be successful. It defines “key ingredients for progress with integration” on the example of four actual integrated care programs.
TL;DR: The PACIC+ is preferred because it also includes multidisciplinary coordination and cooperation—one of the central pillars of chronic care management—with good psychometric quality.
Abstract: Background: The patient assessment of chronic illness care (PACIC) is a promising instrument to evaluate the chronic care experiences of patients, yet additional validation is needed to improve its usefulness. Methods: A total of 1941 patients with diabetes completed the questionnaire. Reliability coefficients and factor analyses were used to psychometrically test the PACIC and PACIC+ (i.e. PACIC extended with six additional multidisciplinary team functioning items to improve content validity). Intra-class correlations were computed to identify the extent to which variation in scores can be attributed to GP practices. Results: The PACIC and PACIC+ showed a good psychometric quality (Cronbach’s alpha’s >0.9). Explorative factor analyses showed inconclusive results. Confirmative factor analysis showed that none of the factor structures had an acceptable fit (RMSEA>0.10). In addition, 5.1 to 5.4% of the total variation was identified at the GP practice level. Conclusion: The PACIC and PACIC+ are reliable instruments to measure the chronic care management experiences of patients. The PACIC+ is preferred because it also includes multidisciplinary coordination and cooperation—one of the central pillars of chronic care management—with good psychometric quality. Previously identified subscales should be used with caution. Both PACIC instruments are useful in identifying GP practice variation.
TL;DR: Having someone at home upon return from hospital and having adequate formal home-care services are significantly associated with patient-reported success in managing well.
Abstract: Introduction and background: The early post-discharge period is a vulnerable time for older patients with complex care requirements. This paper identifies factors predicting a self-reported successful post-discharge outcome for patients aged 80 years and over by exploring factors related to the discharge process, the provision of formal home-care services, informal care and characteristics of the patients. Methods: The study reports results from survey interviews with patients admitted from home to 14 hospitals in Norway and later discharged home. Logistic regression analysis was performed to assess the impact of a number of factors on the likelihood that the patients would report that they managed well after discharge. Results: The odds of managing well after discharge were more than four times higher (OR=4.75, p=0.022) for patients reporting that someone was present at homecoming than for those who came home to an empty house. Patients who reported receiving adequate help from the municipality had an odds four times (OR=4.18, p=0.006) higher of reporting that everything went well after discharge than those who stated the help was inadequate. Conclusions: Having someone at home upon return from hospital and having adequate formal home-care services are significantly associated with patient-reported success in managing well.
TL;DR: Progress in developing LTC systems can be identified today in all European countries and it will depend on whether new societal approaches to long-term care are created that meet the demands of ageing societies.
Abstract: As a researcher and consultant I have coordinated local pilots and European research projects to analyse and improve long-term care for older people by better integrating health and social care systems. One of my conclusions from the wide range of initiatives that have been taken over the past two decades in Europe has been the need to treat long-term care as a system in its own right. Long-term care systems require a discernable identity; specific policies, structures, processes and pathways; and the leadership and resources that can underpin expectations, drive performance and achieve better outcomes for people that are living with (and working for those with) long-term care needs. Progress in developing LTC systems can be identified today in all European countries. Integrated care solutions at the interface between health and social care, and between formal and informal care, have appeared. These have been achieved partly by means of (slow) political reforms, partly as a response to market-oriented governance, and in many cases through pioneering community and civil society initiatives. It will depend on such initiatives, and their ability to convince both citizens and policy-makers, whether new societal approaches to long-term care are created that meet the demands of ageing societies.
TL;DR: The findings call for attention to be paid to older people’s opportunities to receive care and services according to their individual needs and their potential for influencing their day-to-day provision of care and service.
Abstract: Introduction: Care-planning meetings represent a common method of needs assessment and decision-making practices in elderly care. Older people’s influence is an important and required aspect of these practices. This study’s objective was to describe and analyse older people’s influence on care-planning meetings at home and in hospital. Methods: Ten care-planning meetings were audio-recorded in the older people’s homes and nine were recorded in hospital. The study is part of a project including a comprehensive continuum-of-care model. A qualitative content analysis was performed. Results: Care-planning meetings at home appeared to enable older people’s involvement in the discussions. Fewer people participated in the meetings at home and there was less parallel talking. Unrelated to the place of the care-planning meeting, the older people were able to influence concerns relating to the amount of care/service and the choice of provider. However, they were not able to influence the way the help should be provided or organised. Conclusion: Planning care at home indicated an increase in involvement on the part of the older people, but this does not appear to be enough to obtain any real influence. Our findings call for attention to be paid to older people’s opportunities to receive care and services according to their individual needs and their potential for influencing their day-to-day provision of care and service.
TL;DR: The Quality and Outcomes Framework (QOF) was introduced as part of the new GP contract in 2004 in order to meet the increasing pressure of health services to provide cost-effective high-quality care in times of an ever rising number of patients with various chronic conditions.
Abstract: The Quality and Outcomes Framework (QOF) was introduced as part of the new GP contract in 2004 in order to meet the increasing pressure of health services to provide cost-effective high-quality care in times of an ever rising number of patients with various chronic conditions. The idea of linking physician’s pay to quality of care is to change the status quo by encouraging not only immediate but also long-term improvements in performance [2]. Practice participation in QOF is voluntary but most GPs participate in the pay-for-performance scheme [3]. GP practices score points according to their level of achievement based on indicators for how well the practice is organized, how patients view their experience, whether extra services are offered, and how well common chronic diseases are managed, and practice payments are calculated accordingly.
TL;DR: A complex picture of barriers, dilemmas and benefits emerges, both internal and external to an organisation as well as at a personal level that need to be taken into consideration in forthcoming implementation processes to increase the rate of success.
Abstract: Aim of the study The aim of the study is to explore and describe what hampers and promotes the implementation of 'Individual Plan' - Norway's answer to integrated care, and to discuss the findings according to implementation theory and research. Background 'Individual Plan' is a master-plan intended to increase user-participation and provide better coordination of measures for patients in need of extensive and long-term health-care services. Norwegian Health Authorities used a dissemination strategy to implement 'Individual Plan' but managers within health and social care could chose their own way of implementation in their organisation. Methodology Twenty-two managers from different clinics and organisational levels within mental health care were interviewed with an in-depth semi-structured interview about the implementation process in their organisation. The analysis was primarily made according to Systematic Text Condensation. Findings The findings describe different implementation processes and how the managers identified with the usefulness of 'Individual Plan' as a tool, choice of practical implementation strategies, the manager's own role, characteristics of organisational culture as well as how the manager considered external factors such as administration, lack of time and resources. The evolved implementation themes are discussed within a frame of existing knowledge and theory. Conclusion A complex picture of barriers, dilemmas and benefits emerges, both internal and external to an organisation as well as at a personal level that need to be taken into consideration in forthcoming implementation processes to increase the rate of success.
TL;DR: No wonder two movements described in such similar terms are so often confused, one strives to knit services together, the other to cultivate collaborative practice amongst their workers.
Abstract: No wonder two movements described in such similar terms are so often confused. One strives to knit services together, the other to cultivate collaborative practice amongst their workers. Dedicated though both of them are to the improvement of health and social care, integrated care falters without engaging the workforce actively as partners in change whilst interprofessional care falters without organisational support. Neither stands alone. Each depends on the other.
TL;DR: Using the data from the Children’s Treatment Network, the degree of integration for the CTN agencies in York and Simcoe was measured and the global scores were robust.
Abstract: Background : Integration involves the coordination of services provided by autonomous agencies and improves the organization and delivery of multiple services for target patients. Current measures generally do not distinguish between agencies' perception and expectation. We propose a method for quantifying the agencies' service integration. Using the data from the Children's Treatment Network (CTN), we aimed to measure the degree of integration for the CTN agencies in York and Simcoe. Theory and Methods : We quantified the integration by the agreement between perceived and expected levels of involvement and calculated four scores from different perspectives for each agency. We used the average score to measure the global network integration and examined the sensitivity of the global score. Results: Most agencies' integration scores were less than 65%. As measured by the agreement between every other agency's perception and expectation, the overall integration of CTN in Simcoe and York was 44% (95% CI: 39% - 49%) and 52% (95% CI: 48% - 56%), respectively. The sensitivity analysis showed that the global scores were robust. Conclusion : Our method extends existing measures of integration and possesses a good extent of validity. We can also apply the method in monitoring improvement and linking integration with other outcomes.
TL;DR: The scores obtained in the highly integrated network are better than those of the poorly integrated network on all dimensions of management continuity (coordinator role, role clarity and coordination between clinics, and information gaps between providers) except for experience of care plan.
Abstract: Introduction: Patients increasingly receive care from multiple providers in a variety of settings. They expect management continuity that crosses boundaries and bridges gaps in the healthcare system. To our knowledge, little research has been done to assess coordination across organizational and professional boundaries from the patients’ perspective. Our objective was to assess whether greater local health network integration is associated with management continuity as perceived by patients. Method: We used the data from a research project on the development and validation of a generic and comprehensive continuity measurement instrument that can be applied to a variety of patient conditions and settings. We used the results of a cross-sectional survey conducted in 2009 with 256 patients in two local health networks in Quebec, Canada. We compared four aspects of management continuity between two contrasting network types (highly integrated vs. poorly integrated). Results: The scores obtained in the highly integrated network are better than those of the poorly integrated network on all dimensions of management continuity (coordinator role, role clarity and coordination between clinics, and information gaps between providers) except for experience of care plan. Conclusion: Some aspects of care coordination among professionals and organizations are noticed by patients and may be valid indicators to assess care coordination.
TL;DR: This perspective paper makes a brief conceptual review of continuity and argues that relationship continuity is the most controversial type and urgently needs to be supplemented by studies of causation.
Abstract: This perspective paper makes a brief conceptual review of continuity and argues that relationship continuity is the most controversial type. Plentiful evidence of association with better satisfaction and outcomes urgently needs to be supplemented by studies of causation. The scope of these has been outlined in this paper. Evidence strongly suggests that patients generally want more relationship continuity than they are getting and that relationship continuity is linked with better patient and staff satisfaction. This is reason enough to justify improving relationship continuity for patients.