Showing papers in "International Journal of Integrated Care in 2016"
TL;DR: It is argued that integrated care cannot be narrowly defined, but should be seen as an overarching term for a broad and multi-component set of ideas and principles that seek to better co-ordinate care around people’s needs.
Abstract: Introduction Integrated care is a concept that is now commonly accepted across the world yet there remains a persistent and enduring ‘confusion of languages’ when it comes to understanding it [1] This perspective paper seeks to bring a degree of clarity to the meaning of integrated care It argues that integrated care cannot be narrowly defined, but should be seen as an overarching term for a broad and multi-component set of ideas and principles that seek to better co-ordinate care around people’s needs
188 citations
TL;DR: This paper describes the methodology of a study seeking to validate the Rainbow Model of Integrated Care measurement tool within and across the Singapore Regional Health System, with the results allowing insights in making recommendations for improving the Regional Health system and supporting international comparison.
Abstract: Introduction: The conceptual ambiguity of the integrated care concept precludes a full understanding of what constitutes a well-integrated health system, posing a significant challenge in measuring the level of integrated care. Most available measures have been developed from a disease-specific perspective and only measure certain aspects of integrated care. Based on the Rainbow Model of Integrated Care, which provides a detailed description of the complex concept of integrated care, a measurement tool has been developed to assess integrated care within a care system as a whole gathered from healthcare providers’ and managerial perspectives. This paper describes the methodology of a study seeking to validate the Rainbow Model of Integrated Care measurement tool within and across the Singapore Regional Health System. The Singapore Regional Health System is a recent national strategy developed to provide a better-integrated health system to deliver seamless and person-focused care to patients through a network of providers within a specified geographical region. Methods: The validation process includes the assessment of the content of the measure and its psychometric properties. Conclusion: If the measure is deemed to be valid, the study will provide the first opportunity to measure integrated care within Singapore Regional Health System with the results allowing insights in making recommendations for improving the Regional Health System and supporting international comparison.
114 citations
TL;DR: The results confirm the significant terminological variance in case management which produces role confusion, ambiguity and hinders comparability across different health conditions and contexts and the urgent need for an internationally agreed taxonomy for the coordination, navigation and management of care.
Abstract: The description of case management in research and clinical practice is highly variable which impedes quality analysis, policy and planning. Case management makes a unique contribution towards the integration of health care, social services and other sector services and supports for people with complex health conditions. There are multiple components and variations of case management depending on the context and client population. This paper aims to scope and map case management in the literature to identify how case management is described in the literature for key complex health conditions (e.g., brain injury, diabetes, mental health, spinal cord injury). Following literature searches in multiple databases, grey literature and exclusion by health condition, community-based and adequate description, there were 661 potential papers for data extraction. Data from 79 papers (1988–2013) were analysed to the point of saturation (no new information) and mapped to the model, components and activities. The results included 22 definitions, five models, with 69 activities or tasks of case managers mapped to 17 key components (interventions). The results confirm the significant terminological variance in case management which produces role confusion, ambiguity and hinders comparability across different health conditions and contexts. There is an urgent need for an internationally agreed taxonomy for the coordination, navigation and management of care.
88 citations
TL;DR: This thesis operationalized the concept of integrated care from a primary care perspective and described the collaboration mechanisms among integrated care projects that were part of a national integrated primary care study in The Netherlands.
Abstract: This thesis aimed to contribute to a better understanding of what integrated primary care is, and how it can be achieved by focussing on the collaboration processes that underlie the development of integrated primary care. The first part of this thesis operationalized the concept of integrated care from a primary care perspective. The second part of this thesis described the collaboration mechanisms among integrated care projects that were part of a national integrated primary care study in The Netherlands.
64 citations
TL;DR: Focusing on the different perspectives and the inequality in power between patients and healthcare providers and between different providers might contribute to a better environment for achieving appropriate collaboration.
Abstract: Introduction: This article summarizes and synthesizes the findings of four separate but inter-linked empirical projects which explored challenges of collaboration in the Norwegian health system from the perspectives of providers and patients. The results of the four projects are summarised in eight articles. Methods: The eight articles constituted our empirical material. Meta-ethnography was used as a method to integrate, translate, and synthesize the themes and concepts contained in the articles in order to understand how challenges related to collaboration impact on clinical work. Results: Providers’ collaboration across all contexts was hampered by organizational and individual factors, including, differences in professional power, knowledge bases, and professional culture. The lack of appropriate collaboration between providers impeded clinical work. Mental health service users experienced fragmented services leading to insecurity and frustration. The lack of collaboration resulted in inadequate rehabilitation services and lengthened the institutional stay for older patients. Conclusion: Focusing on the different perspectives and the inequality in power between patients and healthcare providers and between different providers might contribute to a better environment for achieving appropriate collaboration. Organizational systems need to be redesigned to better nurture collaborative relationships and information sharing and support integrated working between providers, health care professionals and patients.
62 citations
TL;DR: The overall effects of inter professional interventions for elderly are positive, but based on heterogeneous outcomes, and more research is needed to gain insight in the process of interprofessional collaboration and so to learn to work interprofessionally.
Abstract: Background: Geriatric care increasingly needs more multidisciplinary health care services to deliver the necessary complex and continuous care. The aim of this study is to summarize indicators of effective interprofessional outcomes for this population. Method: A systematic review is performed in the Cochrane Library, Pubmed (Medline), Embase, Cinahl and Psychinfo with a search until June 2014. Results: Overall, 689 references were identified of which 29 studies met the inclusion criteria. All outcome indicators were summarized in three categories: collaboration, patient level outcome and costs. Seventeen out of 24 outcome indicators within the category of ‘collaboration’ reached significant difference in advantage of the intervention group. On ‘patient outcome level’ only 15 out of 32 outcome parameters met statistical significance. In the category of ‘costs’ only one study reached statistical significance. Discussion and conclusion: The overall effects of interprofessional interventions for elderly are positive, but based on heterogeneous outcomes. Outcome indicators of interprofessional collaboration for elderly with a significant effect can be summarized in three main categories: ‘collaboration’, patient level’ and ‘costs’. For ‘collaboration’ the outcome indicators are key elements of collaboration, involved disciplines, professional and patient satisfaction and quality of care. On ‘patient level’ the outcome indicators are pain, fall incidence, quality of life, independence for daily life activities, depression and agitated behaviour, transitions, length of stay in hospital, mortality and period of rehabilitation. ‘Costs’ of interprofessional interventions on short- and long-term for elderly need further investigation. When organizing interprofessional collaboration or interprofessional education these outcome indicators can be considered as important topics to be addressed. Overall more research is needed to gain insight in the process of interprofessional collaboration and so to learn to work interprofessionally.
60 citations
TL;DR: A conceptual framework of organizational capabilities for integrating care is developed and validates, identifying which of these capabilities may be most important, and explores the mechanisms by which they influence integrated care efforts.
Abstract: Background: Interventions aimed at integrating care have become widespread in healthcare; however, there is significant variability in their success. Differences in organizational contexts and associated capabilities may be responsible for some of this variability. Purpose: This study develops and validates a conceptual framework of organizational capabilities for integrating care, identifies which of these capabilities may be most important, and explores the mechanisms by which they influence integrated care efforts. Methods: The Context and Capabilities for Integrating Care (CCIC) Framework was developed through a literature review, and revised and validated through interviews with leaders and care providers engaged in integrated care networks in Ontario, Canada. Interviews involved open-ended questions and graphic elicitation. Quantitative content analysis was used to summarize the data. Results: The CCIC Framework consists of eighteen organizational factors in three categories: Basic Structures, People and Values, and Key Processes. The three most important capabilities shaping the capacity of organizations to implement integrated care interventions include Leadership Approach, Clinician Engagement and Leadership, and Readiness for Change. The majority of hypothesized relationships among organizational capabilities involved Readiness for Change and Partnering, emphasizing the complexity, interrelatedness and importance of these two factors to integrated care efforts. Conclusions: Organizational leaders can use the framework to determine readiness to integrate care, develop targeted change management strategies, and select appropriate partners with overlapping or complementary profiles on key capabilities. Researchers may use the results to test and refine the proposed framework, with a focus on the hypothesized relationships among organizational capabilities and between organizational capabilities and performance outcomes.
59 citations
TL;DR: Together with other indicators, IEXPAC can determine the quality of care provided according to the Triple Aim framework, facilitating health systems reorientation towards integrated patient-centred care.
Abstract: Introduction: The experience of chronic patients with the care they receive, fuelled by the focus on patient-centeredness and the increasing evidence on its positive relation with other dimensions of quality, is being acknowledged as a key element in improving the quality of care. There are a dearth of accepted tools and metrics to assess patient experience from the patient’s perspective that have been adapted to the new chronic care context: continued, systemic, with multidisciplinary teams and new technologies. Methods: Development and validation of a scale conducting a literature review, expert panel, pilot and field studies with 356 chronic primary care patients, to assess content and face validities and reliability. Results: IEXPAC is an 11+1 item scale with adequate metric properties measured by Alpha Chronbach, Goodness of fit index, and satisfactory convergence validity around three factors named: productive interactions, new relational model and person’s self-management. Conclusions: IEXPAC allows measurement of the patient experience of chronic illness care. Together with other indicators, IEXPAC can determine the quality of care provided according to the Triple Aim framework, facilitating health systems reorientation towards integrated patient-centred care.
52 citations
TL;DR: This umbrella review aims to clarify the critical attributes that shape cross-sector service provision by presenting the current state of the literature and building on the findings of the 2004 review by Sloper.
Abstract: Introduction: Meeting the complex health needs of people often requires interaction among numerous different sectors. No one service can adequately respond to the diverse care needs of consumers. Providers working more effectively together is frequently touted as the solution. Cross-sector service provision is defined as independent, yet interconnected sectors working together to better meet the needs of consumers and improve the quality and effectiveness of service provision. Cross-sector service provision is expected, yet much remains unknown about how it is conceptualised or its impact on health status. This umbrella review aims to clarify the critical attributes that shape cross-sector service provision by presenting the current state of the literature and building on the findings of the 2004 review by Sloper. Methods: Literature related to cross-sector service provision is immense, which poses a challenge for decision makers wishing to make evidence-informed decisions. An umbrella review was conducted to articulate the overall state of cross-sector service provision literature and examine the evidence to allow for the discovery of consistencies and discrepancies across the published knowledge base. Findings: Sixteen reviews met the inclusion criteria. Seven themes emerged: Focusing on the consumer, developing a shared vision of care, leadership involvement, service provision across the boundaries, adequately resourcing the arrangement, developing novel arrangements or aligning with existing relationships, and strengthening connections between sectors. Future research from a cross-organisational, rather than individual provider, perspective is needed to better understand what shapes cross-sector service provision at the boundaries. Conclusion: Findings aligned closely with the work done by Sloper and raise red flags related to reinventing what is already known. Future researchers should look to explore novel areas rather than looking into areas that have been explored at length. Evaluations of out-comes related to cross-sector service provision are still needed before any claims about effectiveness can be made.
47 citations
TL;DR: The project aimed to shift health professionals’ focus on the geographic variation issue, promote the Population Medicine approach, and engage professionals in a community of practice to stimulate an improvement process towards integration.
Abstract: Introduction and Background: As diabetic foot (DF) care benefits from integration, monitoring geographic variations in lower limb Major Amputation rate enables to highlight potential lack of Integrated Care. In Tuscany (Italy), these DF outcomes were good on average but they varied within the region. In order to stimulate an improvement process towards integration, the project aimed to shift health professionals’ focus on the geographic variation issue, promote the Population Medicine approach, and engage professionals in a community of practice. Method: Three strategies were thus carried out: the use of a transparent performance evaluation system based on benchmarking; the use of patient stories and benchmarking analyses on outcomes, service utilization and costs that cross-checked delivery- and population-based perspectives; the establishment of a stable community of professionals to discuss data and practices. Results: The project enabled professionals to shift their focus on geographic variation and to a joint accountability on outcomes and costs for the entire patient pathways. Organizational best practices and gaps in integration were identified and improvement actions towards Integrated Care were implemented. Conclusion and Discussion: For the specific category of care pathways whose geographic variation is related to a lack of Integrated Care, a comprehensive strategy to improve outcomes and reduce equity gaps by diffusing integration should be carried out.
47 citations
TL;DR: The patient profiles resulting from this project must be tested in practice to investigate the effects of tailored management on patient experience, population health and costs.
Abstract: Background: This article presents the design of PROFILe, a study investigating which (bio)medical and non-(bio)medical patient characteristics should guide more tailored chronic care. Based on this insight, the project aims to develop and validate ‘patient profiles’ that can be used in practice to determine optimal treatment strategies for subgroups of chronically ill with similar healthcare needs and preferences. Methods/Design: PROFILe is a practice-based research comprising four phases. The project focuses on patients with type 2 diabetes. During the first study phase, patient profiles are drafted based on a systematic literature research, latent class growth modeling, and expert collaboration. In phase 2, the profiles are validated from a clinical, patient-related and statistical perspective. Phase 3 involves a discrete choice experiment to gain insight into the patient preferences that exist per profile. In phase 4, the results from all analyses are integrated and recommendations formulated on which patient characteristics should guide tailored chronic care. Discussion: PROFILe is an innovative study which uses a uniquely holistic approach to assess the healthcare needs and preferences of chronically ill. The patient profiles resulting from this project must be tested in practice to investigate the effects of tailored management on patient experience, population health and costs.
TL;DR: The paper proposes that accountability for the consolidation of competencies of the health workforce lies with executives of health services and shows how competencies are the responsibility of a range of stakeholders - service managers, policy makers, regulatory bodies, and patient and professional associations- and how they can work more closely with each other.
Abstract: Finding more efficient, innovative and responsive ways of engaging the health workforce to manage patients is key to ensuring integrated care. Systems that are transforming their services to be more integrated must ensure that health professionals are ready to fill the new roles assigned to them in prevention and pro-active patient management, manage health and care rather than disease and cure, work in teams across professions and sectors, work along a continuum of care, protect and advocate the most vulnerable, ensure equitable service delivery, optimize communication that has an emphasis on compassion and empathy and develop more than one vertical expertise. Securing a health workforce that “wants and feels” and has the theoretical knowledge and skills to work more efficiently and effectively is not enough in ensuring integrated health services. What is needed is a guarantee that health professionals who enter the workplace will apply their knowledge and skills with sound judgment (i.e. that they will have competencies) and that they will refine and maintain these over the course of their career (consolidate competencies). To date the focus on competencies has been limited to looking at education institutions (i.e. college and universities) where initial exposure to competencies takes place. Indeed important strides have been taken since the Lancet review on transforming health professional education to be more competency-oriented. The lack of a clear definition on what competencies are, how they are governed and strengthened beyond initial training settings has however resulted in misplacing competencies of the health workforce as merely a problem for training institutions. Without a deeper exploration into what competencies are and how they can be strengthened at both the service and systems level important conversations on the relevance of competencies to health systems have been missed. This has been explored in our paper for the World Health Organization Regional Office for Europe "Strengthening a competent health workforce for the provision of coordinated/ integrated health services" (http://www.euro.who.int/en/health-topics/Health-systems/health-service-delivery/publications/2015/strengthening-a-competent-health-workforce-for-the-provision-of-coordinated-integrated-health-services). A systematic review of the literature was conducted resulting in the identification of 5 core competencies for integrated care. Their consolidation over the course of a health professional's career is conceptualized and a framework proposed that addresses actors and their responsibilities at both the service delivery level and the systems level. 13 important entry points for the assurance and improvement of competencies. Having done this, the paper shows how competencies are the responsibility of a range of stakeholders - service managers, policy makers, regulatory bodies, and patient and professional associations- and how they can work more closely with each other. Most notably the paper proposes that accountability for the consolidation of competencies of the health workforce lies with executives of health services. Without such clarity of roles and responsibilities, governance of the health workforce will continue to be challenged by poor accountability, corruption, limited involvement of communities in policy-making, ineffective management strategies and ultimately poor health outcomes. A workshop is proposed to discuss: - what participants think of the five proposed integrated care competencies listed; - what the participant's experiences with the five proposed integrated care competencies in their individual countries are; - the proposed conceptual framework for competency consolidation and the identified 13 entry points; and - experiences with barriers/facilitators and opportunities for implementation of the competencies and the entry points. The workshop will take a particular focus on the service delivery level and discuss examples and tools for the service-specific entry points for governing competency consolidation.
TL;DR: The unique nature of integrated care as a topic for economic evaluation is described, the obstacles to perform economic evaluation are explored, methods and techniques that can be used to address them are discussed, and the basis to develop a research agenda for health economics in integrated care is set.
Abstract: Health economists are increasingly interested in integrated care in order to support decision-makers to find cost-effective solutions able to tackle the threat that chronic diseases pose on population health and health and social care budgets. However, economic evaluation in integrated care is still in its early years, facing several difficulties. The aim of this paper is to describe the unique nature of integrated care as a topic for economic evaluation, explore the obstacles to perform economic evaluation, discuss methods and techniques that can be used to address them, and set the basis to develop a research agenda for health economics in integrated care. The paper joins the voices that call health economists to pay more attention to integrated care and argues that there should be no more time wasted for doing it.
TL;DR: The findings of this review can be used in the evaluation of integrated healthcare delivery systems and can be integrated into quality- and patient-oriented reimbursement of care providers in the design of healthcare contracts.
Abstract: Introduction: Effective risk adjustment is an aspect that is more and more given weight on the background of competitive health insurance systems and vital healthcare systems. The objective of this review was to obtain an overview of existing models of risk adjustment as well as on crucial weights in risk adjustment. Moreover, the predictive performance of selected methods in international healthcare systems should be analysed. Theory and methods: A comprehensive, systematic literature review on methods of risk adjustment was conducted in terms of an encompassing, interdisciplinary examination of the related disciplines. Results: In general, several distinctions can be made: in terms of risk horizons, in terms of risk factors or in terms of the combination of indicators included. Within these, another differentiation by three levels seems reasonable: methods based on mortality risks, methods based on morbidity risks as well as those based on information on (self-reported) health status. Conclusions and discussion: After the final examination of different methods of risk adjustment it was shown that the methodology used to adjust risks varies. The models differ greatly in terms of their included morbidity indicators. The findings of this review can be used in the evaluation of integrated healthcare delivery systems and can be integrated into quality- and patient-oriented reimbursement of care providers in the design of healthcare contracts.
TL;DR: This paper examines the provision of integrated advanced dementia care within seven European countries and critically reviews the potential contribution of the Prudent Healthcare perspective as a starting point for reform, arguing that for successful implementation, both require practitioners to be equipped with knowledge and skills and be empowered to deliver high quality care often within impoverished care environments.
Abstract: This paper examines the provision of integrated advanced dementia care within seven European countries and critically reviews the potential contribution of the Prudent Healthcare perspective as a starting point for reform. Progressive efforts to innovate, promote quality and integrate care are tempered with the reality of resource constraints. Some policy makers in Europe and North America have turned their attention to the principles of Prudent Healthcare as a potential mechanism to maximise benefits for patients within available resources. As dementia progresses, living well requires increasing levels of support and care, people living with advanced dementia have complex health and social care needs, are highly dependent on others but are not yet at the terminal end stage of the condition. People with advanced dementia can benefit from a dementia specific palliative approach to care (Palliare), that helps them to live the best life possible for the months and often years they live with advanced dementia. It is also highly desirable to align policy innovations with integrated palliative care practice models and the education of the dementia workforce to accelerate informed improvements in advanced dementia care. There may be some coherence, at least superficially between Prudent Healthcare and integrated palliative care models such as Palliare. It is argued that for successful implementation, both require practitioners to be equipped with knowledge and skills and be empowered to deliver high quality care often within impoverished care environments. Adoption of the prudent perspective will however require development of a repertoire of approaches to hear the voice or proxy voice of people living with advanced dementia and to commit to the development and implementation of new evidence for advanced dementia practice. Evidence informing this policy debate draws upon contemporary literature and policy and the findings from research activities undertaken by the Palliare project supported through the Erasmus+ K2 Strategic Partnerships funding programme.
TL;DR: This work proposes governmentality as a valuable perspective for analysing and understanding power in integrated care and addresses the need for more finely tuned theoretical frameworks that can be used to guide empirical work.
Abstract: Integrated care occurs within micro, meso and macro levels of governance structures, which are shaped by complex power dynamics. Yet theoretically-led notions of power, and scrutiny of its meanings and its functioning, are neglected in the literature on integrated care. We explore an alternative approach. Following a discussion on governance, two streams of theorising power are presented: mainstream and second-stream. Mainstream concepts are based on the notion of power-as-capacity, of one agent having the capacity to influence another—so the overall idea is ‘power over ’. Studies on integrated care typically employ mainstream ideas, which yield rather limited analyses. Second-stream concepts focus on strategies and relations of power—how it is channelled, negotiated and (re)produced. These notions align well with the contemporary shift away from the idea that power is centralised, towards more fluid ideas of power as dispersed and (re)negotiated throughout a range of societal structures, networks and actors. Accompanying this shift, the notion of governance is slowly being eclipsed by that of governmentality. We propose governmentality as a valuable perspective for analysing and understanding power in integrated care. Our contribution aims to address the need for more finely tuned theoretical frameworks that can be used to guide empirical work.
TL;DR: This study explores barriers to and facilitators of interorganisational integration as perceived by healthcare professionals caring for patients with chronic obstructive pulmonary disease within the Danish healthcare system.
Abstract: Introduction: Despite many initiatives to improve coordination of patient pathways and intersectoral cooperation, Danish health care is still fragmented, lacking intra- and interorganisational integration. This study explores barriers to and facilitators of interorganisational integration as perceived by healthcare professionals caring for patients with chronic obstructive pulmonary disease within the Danish healthcare system. Methods: Seven focus groups were conducted in January through July 2014 with 21 informants from general practice, local healthcare centres and a pulmonary department at a university hospital in the Capital Region of Denmark. Results and discussion: Our results can be grouped into five influencing areas for interorganisational integration: communication/information transfer, committed leadership, patient engagement, the role and competencies of the general practitioner and organisational culture. Proposed solutions to barriers in each area hold the potential to improve care integration as experienced by individuals responsible for supporting and facilitating it. Barriers and facilitators to integrating care relate to clinical, professional, functional and normative integration. Especially, clinical, functional and normative integration seems fundamental to developing integrated care in practice from the perspective of healthcare professionals.
TL;DR: The Service User Technology Acceptability Questionnaire (SUTAQ) was initially translated, culturally adapted and pretested and subsequently used to assess patients’ perception of telemedicine and was perceived as a viable addition to usual care.
Abstract: Introduction: The purpose of this paper is to assess if similar telemedicine services integrated in the management of different chronic diseases are acceptable and well perceived by patients or if there are any negative perceptions Theory and methods: Participants suffering from different chronic diseases were enrolled in Veneto Region and gathered into clusters Each cluster received a similar telemedicine service equipped with different disease-specific measuring devices Participants were patients with diabetes (n = 163), chronic obstructive pulmonary disease (n = 180), congestive heart failure (n = 140) and Cardiac Implantable Electronic Devices (n = 1635) The Service User Technology Acceptability Questionnaire (SUTAQ) was initially translated, culturally adapted and pretested and subsequently used to assess patients’ perception of telemedicine Data were collected after 3 months and after 12 months from the beginning of the intervention Data for patients with implantable devices was collected only at 12 months Results: Results at 12 months for all clusters are similar and assessed a positive perception of telemedicine The SUTAQ results for clusters 2 (diabetes), 5 (COPD) and 7 (CHF) after 3 months of intervention were confirmed after 12 months Conclusions: Telemedicine was perceived as a viable addition to usual care A positive perception for telemedicine services isn’t a transitory effect, but extends over the course of time
TL;DR: By defining the differences between knowledge, skills and attitudes, and outlining the key ingredients for a competent workforce, this paper brings to light one of the most neglected topics in integrated care.
Abstract: Summary Reflecting on the knowledge, skills and attitudes necessary to work in integrated care, this perspectives paper explores the competencies required to implement and deliver integrated care and analyses how current education and training approaches fall short of conveying these competencies on all levels By defining the differences between knowledge, skills and attitudes, and outlining the key ingredients for a competent workforce, this paper brings to light one of the most neglected topics in integrated care Why is building a competent workforce not a priority yet? Nobody would ever question the necessity of having a competent workforce to deliver high quality services Equally, everyone keeps reaffirming the challenges and complexities associated with designing, managing, implementing and delivering integrated care Yet, there are few examples of integrated care initiatives, which invest in the education and training of their people or which have adequate programmes available to build the skills and attitudes necessary to change service delivery towards integrated, people-centred care While the focus remains on implementing a plethora of tools and instruments to support and foster integration of health and social services, little thought is given to the people who need to implement and utilize these tools on a day-to-day basis Having started my professional career as a PhD and PostDoc at the Medical University of Vienna, I have been actively involved in the education and training of students and professionals from the outset I have designed and delivered courses from the undergraduate to the professional training level, and for uni- as well as multidisciplinary audiences around the world And as a health economist with a background in organisational development and project management, I have always been fascinated by how our health and social systems are organised with a seeming disregard for an overall understanding and alignment of activities Combining my passion for teaching with my long-standing involvement in integrated
TL;DR: The main conclusion to be reached is that the successful implementation of integrated care requires an effective composition of a complex set of interventions at the micro- and macro-levels, and effective implementation is as much relational as it is technical.
Abstract: In their 2004 systematic review on the diffusion of innovations in service organizations, Greenhalgh et al concluded that there was a lack of any robust understanding in how complex health service innovations can be implemented and sustained (or not) across contexts and settings [1]. An underlying implication from this work was the need for more 'realistic evaluation' methodologies to help unpick how outcomes may result from the intricate interplay between multi-component interventions in different contexts and settings [2]. One such advance has been the recent development of the COMIC Model for the comprehensive evaluation of integrated care interventions [3]. Derived from work undertaken in the recently concluded EU-funded Project INTEGRATE [4], the COMIC Model (Context, Outcomes and Mechanisms of Integrated Care interventions) uti-lised the realistic synthesis approach to study the interplay between contexts, mechanisms and outcomes across selected case examples of integrated care, including for diabetes in Dutch Care Groups. The authors were able to demonstrate how such an approach brought insights into understanding how, when and why integrated care interventions influenced outcomes in these specific cases. As a conceptual tool, realistic synthesis provides a useful template to provide an in-depth narrative description of the various factors that may influence outcomes and, potentially, to then take the lessons from one evaluation and test them across a range of different contexts. Indeed, other work within Project INTEGRATE formulated a bench-marking tool by creating a set of generic factors influencing the implementation of integrated care that appears to have face validity across condition-specific groups (e.g. diabetes , COPD, geriatric conditions and mental health) and across different contexts and settings of deployment [4]. In this edition of IJIC, a special collection of perspective papers on the building blocks of integrated care has shed further light on some of the more critical components [5–10]. What these amply demonstrate is that the successful implementation of integrated care requires an effective composition of a complex set of interventions at the micro-, meso-and macro-levels. Moreover, effective implementation is as much relational as it is technical. In other words, the influence of pre-existing values, cultures, politics and relationships (both personal and organisational) play as much a significant part in influencing outcomes as the role of technical components such as governance structures, financial incentives, organisational and service models, workforce skills or the ability to engage and empower people in their care. The main conclusion to be reached is that, …
TL;DR: The organisational model of the maternity health clinic does not impact the utilisation of maternity care services or maternal and perinatal health outcomes, and primary maternity care could be provided effectively when integrated with child health services.
Abstract: Introduction: Primary maternity care services are globally provided according to various organisational models. Two models are common in Finland: a maternity health clinic and an integrated maternity and child health clinic. The aim of this study was to clarify whether there is a relation between the organisational model of the maternity health clinics and the utilisation of maternity care services, and certain maternal and perinatal health outcomes. Methods: A comparative, register-based cross-sectional design was used. The data of women (N = 2741) who had given birth in the Turku University Hospital area between 1 January 2009 and 31 December 2009 were collected from the Finnish Medical Birth Register. Comparisons were made between the women who were clients of the maternity health clinics and integrated maternity and child health clinics. Results: There were no clinically significant differences between the clients of maternity health clinics and integrated maternity and child health clinics regarding the utilisation of maternity care services or the explored health outcomes. Conclusions: The organisational model of the maternity health clinic does not impact the utilisation of maternity care services or maternal and perinatal health outcomes. Primary maternity care could be provided effectively when integrated with child health services.
TL;DR: The conceptual framework Integrated Team Effectiveness Model is relevant in developing a practical full-spectrum instrument to facilitate discussing teamwork effectiveness and provides a well-founded basis to self-evaluate teamwork effectiveness in integrated COPD care by healthcare providers.
Abstract: Introduction: Teamwork between healthcare providers is conditional for the delivery of integrated care. This study aimed to assess the usefulness of the conceptual framework Integrated Team Effectiveness Model for developing and testing of the Integrated Team Effectiveness Instrument. Theory and methods: Focus groups with healthcare providers in an integrated care setting for people with chronic obstructive pulmonary disease (COPD) were conducted to examine the recognisability of the conceptual framework and to explore critical success factors for collaborative COPD practice out of this framework. The resulting items were transposed into a pilot instrument. This was reviewed by expert opinion and completed 153 times by healthcare providers. The underlying structure and internal consistency of the instrument were verified by factor analysis and Cronbach’s alpha. Results: The conceptual framework turned out to be comprehensible for discussing teamwork effectiveness. The pilot instrument measures 25 relevant aspects of teamwork in integrated COPD care. Factor analysis suggested three reliable components: teamwork effectiveness, team processes and team psychosocial traits (Cronbach’s alpha between 0.76 and 0.81). Conclusions and discussion: The conceptual framework Integrated Team Effectiveness Model is relevant in developing a practical full-spectrum instrument to facilitate discussing teamwork effectiveness. The Integrated Team Effectiveness Instrument provides a well-founded basis to self-evaluate teamwork effectiveness in integrated COPD care by healthcare providers. Recommendations are provided for the improvement of the instrument.
TL;DR: A reflective case study used Kuhn’s theory of scientific revolutions to reflect on how an integrated interprofessional shared decision-making approach was developed and implemented over time and offers new approaches to implementing emerging knowledge in the clinical context.
Abstract: Introduction: Healthcare research increasingly focuses on interprofessional collaboration and on shared decision making, but knowledge gaps remain about effective strategies for implementing interprofessional collaboration and shared decision-making together in clinical practice. We used Kuhn’s theory of scientific revolutions to reflect on how an integrated interprofessional shared decision-making approach was developed and implemented over time. Methods: In 2007, an interdisciplinary team initiated a new research program to promote the implementation of an interprofessional shared decision-making approach in clinical settings. For this reflective case study, two new team members analyzed the team’s four projects, six research publications, one unpublished and two published protocols and organized them into recognizable phases according to Kuhn’s theory. Results: The merging of two young disciplines led to challenges characteristic of emerging paradigms. Implementation of interprofessional shared-decision making was hindered by a lack of conceptual clarity, a dearth of theories and models, little methodological guidance, and insufficient evaluation instruments. The team developed a new model, identified new tools, and engaged knowledge users in a theory-based approach to implementation. However, several unresolved challenges remain. Discussion: This reflective case study sheds light on the evolution of interdisciplinary team science. It offers new approaches to implementing emerging knowledge in the clinical context.
TL;DR: A scoping review of literature on community hospitals published from 2005 to 2014 found many examples of collaborative working arrangements between community hospitals and other health care organisations, including colocation of services, shared workforce with primary care and close collaboration with acute specialists.
Abstract: Background: There is no single definition of a community hospital in the UK, despite its long history. We sought to understand the nature and scope of service provision in community hospitals, within the UK and other high-income countries. Methods: We undertook a scoping review of literature on community hospitals published from 2005 to 2014. Data were extracted on features of the hospital model and the services provided, with results presented as a narrative synthesis. Results: 75 studies were included from ten countries. Community hospitals provide a wide range of services, with wide diversity of provision appearing to reflect local needs. Community hospitals are staffed by a mixture of general practitioners (GPs), nurses, allied health professionals and healthcare assistants. We found many examples of collaborative working arrangements between community hospitals and other health care organisations, including colocation of services, shared workforce with primary care and close collaboration with acute specialists. Conclusions: Community hospitals are able to provide a diverse range of services, responding to geographical and health system contexts. Their collaborative nature may be particularly important in the design of future models of care delivery, where emphasis is placed on integration of care with a key focus on patient-centred care.
TL;DR: Identifying essential preconditions in fulfilling the management assignment, its operationalization and impact on provision of sustainable integration of health and social care found co-leadership promoted robust management by providing broader competence, continuous learning and joint responsibility for services.
Abstract: Introduction: Co-leadership has been identified as one approach to meet the managerial challenges of integrated services, but research on the topic is limited. In the present study, co-leadership, practised by pairs of managers – each manager representing one of the two principal organizations in integrated health and social care services – was explored. Aim: To investigate co-leadership in integrated health and social care, identify essential preconditions in fulfilling the management assignment, its operationalization and impact on provision of sustainable integration of health and social care. Method: Interviews with eight managers exercising co-leadership were analysed using directed content analysis. Respondent validation was conducted through additional interviews with the same managers. Results: Key contextual preconditions were an organization-wide model supporting co-leadership and co-location of services. Perception of the management role as a collective activity, continuous communication and lack of prestige were essential personal and interpersonal preconditions. In daily practice, office sharing, being able to give and take and support each other contributed to provision of sustainable integration of health and social care. Conclusion and discussion: Co-leadership promoted robust management by providing broader competence, continuous learning and joint responsibility for services. Integrated health and social care services should consider employing co-leadership as a managerial solution to achieve sustainability.
TL;DR: This work focuses on initiatives that seek to improve outcomes for those with (complex) chronic health problems and needs by overcoming issues of fragmentation through linkage or coordination of services of different providers along the continuum of care.
Abstract: Introduction Chronic conditions are related to 60% of disability adjusted life years and account for 75% of total health care expenditure worldwide The economic burden of chronic conditions is much larger when considering the costs of productivity loss and informal care The threat that chronic conditions pose to population health and economies increase because of increasing prevalence and multi-morbidity, which multiplies the burden of chronic conditions Integrated care is seen as the means to tackle this threat by improving population health and patient experience with care, and reducing costs It includes initiatives that seek to improve outcomes for those with (complex) chronic health problems and needs by overcoming issues of fragmentation through linkage or coordination of services of different providers along the continuum of care In the era of personalized medicine and genomics, integrated care may be characterized by the recently suggested term ‘humanomics’ because it incorporates treatment based on personal need, preferences and capacity, it interacts with the context in which it is implemented, and its success depends highly on human behaviour [1] Financial incentives are one of the main prerequisites for integrating care [2]
TL;DR: The qualitative component of a mixed method study aimed at evaluating an organisational intervention shaped by Appreciative Inquiry to promote integrated working between visiting health care practitioners and care home staff uncovered evidence of both identity mobilisation and context change.
Abstract: In the United Kingdom, approximately a third of people with dementia live in long-term care facilities for adults, the majority of whom are in the last years of life. Working arrangements between health services and care homes in England are largely ad hoc and often inequitable, yet quality end-of-life care for people with dementia in these settings requires a partnership approach to care that builds on existing practice. This paper reports on the qualitative component of a mixed method study aimed at evaluating an organisational intervention shaped by Appreciative Inquiry to promote integrated working between visiting health care practitioners (i.e. General Practitioners and District Nurses) and care home staff. The evaluation uses a social identity approach to elucidate the mechanisms of action that underlie the intervention, and understand how organisational change can be achieved. We uncovered evidence of both (i) identity mobilisation and (ii) context change, defined in theory as mechanisms to overcome divisions in healthcare. Specifically, the intervention supported integrated working across health and social care settings by (i) the development of a common group identity built on shared views and goals, but also recognition of knowledge and expertise specific to each service group which served common goals in the delivery of end-of-life care, and (ii) development of context specific practice innovations and the introduction of existing end-of-life care tools and frameworks, which could consequently be implemented as part of a meaningful bottom-up rather than top-down process. Interventions structured around a Social Identity Approach can be used to gauge the congruence of values and goals between service groups without which efforts to achieve greater integration between different health services may prove ineffectual. The strength of the approach is its ability to accommodate the diversity of service groups involved in a given area of care, by valuing their respective contributions and building on existing ways of working within which practice changes can be meaningfully integrated.
TL;DR: Evaluated indicators suggest equal or higher quality of care with stable cost in the population in need of psychiatric care in the district.
Abstract: The Regional Psychiatry Budget (RPB), as a special arrangement within the German Federal Hospital Refund Regulation, is based on the capitation principle. A lump sum is allocated to a major inpatient care provider in a large region on a yearly basis. Under this model, the provider is free to offer all forms of treatment and to construct individual models of integrated care that specifically suit the region and the needs of community members. The present study aimed to evaluate selected aspects that represent a change in the psychiatric health status of patients in the covered region under the conditions of the RPB. We performed a secondary data analysis of administrative data of 19,913 cases generated by the hospital in a pre-post comparison of the periods before and under RPB conditions. The average length of an inpatient stay was reduced by approximately 22 % and could be partially replaced by day care. Selected indicators suggest equal or higher quality of care with stable cost in the population in need of psychiatric care in the district.
TL;DR: Assessment of three different collaboration models in three Chinese cities showed that the Direct Management Model in Wuhan exhibited better structure indicators than the other two models and had the highest satisfaction level with respect to patient referral.
Abstract: Objective: In recent years, in order to provide patients with seamless and integrated healthcare services, some models of collaboration between public hospitals and community health centres have been piloted in some cities in China. The main goals of this study were to assess the nature and characteristics of these collaboration models. Methods: Three cases of three different collaboration models in three Chinese cities were selected to analyse using descriptive statistics, Pearson χ 2 and ordinal logistic regression. Results: Results showed that the Direct Management Model in Wuhan exhibited better structure indicators than the other two models. Staff in the Direct Management Model had the highest satisfaction level (77.6%) with respect to patient referral. Communications between hospitals and community health centres and among care providers were generally inadequate. Publicity about hospital–community health centre collaboration was inadequate, resulting in low awareness among patients and even among health professionals. Conclusion: Results can inform health service delivery integration efforts in China and provide crucial information for the assessment of similar collaborations in other countries.
TL;DR: There is a need for greater understanding of the nature and composition of the interaction between care coordinators and families to determine the extent to which appropriate services are being provided.
Abstract: Introduction: This systematic review seeks to identify the intended components of the role of care coordinator for children with complex care needs and the factors that determine its composition in practice. Theory and methods: The initial search identified 1,157 articles, of which 37 met the inclusion criteria. They were quality assessed using the SIGN hierarchy of evidence structure. Results: Core components of the role include: coordination of care needs, planning and assessment, specialist support, emotional support, administration and logistics and continuing professional development. Influencing factors on the role include the external environment (political and socio-economic), the internal environment (organisational structure and funding protocols), the skills, qualifications and experience of the coordinator, the family circumstances and the nature of the interaction between the care coordinator and the family. Discussion: The lack of consistent terminology creates challenges and there is a need for greater consensus on this issue. Organisations and healthcare professionals need to recognise the extent to which contextual factors influence the role of a care coordinator in practice and plan accordingly. Despite evidence that suggests that the role is pivotal in ensuring that care needs are sustained, there remains great variability in the understanding of the role of a care coordinator for this population. Conclusions: As the provision of care increasingly moves closer to home there is a need for greater understanding of the nature and composition of the interaction between care coordinators and families to determine the extent to which appropriate services are being provided. Further work in this area should take into consideration any potential variance in service provision, for example any potential inequity arising due to geographic location. It is also imperative, where appropriate, to seek the views of children with complex care needs and their siblings about their experiences.