Showing papers in "International Journal of Integrated Care in 2018"
TL;DR: A systematic literature review of forty studies summarising and categorising the barriers to integrated care in inter-organisational settings as reported in previous studies allows for a better understanding of the characteristics and reasons for the occurrence of barriers that impede collaboration aiming for the integration of care.
Abstract: Introduction: In recent years, inter-organisational collaboration between healthcare organisations has become of increasingly vital importance in order to improve the integration of health service delivery. However, different barriers reported in academic literature seem to hinder the formation and development of such collaboration. Theory and methods: This systematic literature review of forty studies summarises and categorises the barriers to integrated care in inter-organisational settings as reported in previous studies. It analyses how these barriers operate. Results: Within these studies, twenty types of barriers have been identified and then categorised in six groups (barriers related to administration and regulation, barriers related to funding, barriers related to the inter-organisational domain, barriers related to the organisational domain, barriers related to service delivery, and barriers related to clinical practices). Not all of these barriers emerge passively, some are set up intentionally. They are not only context-specific, but are also often related and influence each other. Discussion and conclusion: The compilation of these results allows for a better understanding of the characteristics and reasons for the occurrence of barriers that impede collaboration aiming for the integration of care, not only for researchers but also for practitioners. It can help to explain and counteract the slow progress and limited efficiency and effectiveness of some of the inter-organisational collaboration in healthcare settings.
129 citations
TL;DR: There is a need for improved communication among professionals and better information technology to support them, greater clarity about who is responsible and accountable for physical health care, and greater awareness of the effects of stigmatisation on the wider culture and environment in which services are delivered.
Abstract: People with mental health conditions have a lower life expectancy and poorer physical health outcomes than the general population. Evidence suggests this is due to a combination of clinical risk factors, socioeconomic factors, and health system factors, notably a lack of integration when care is required across service settings. Several recent reports have looked at ways to better integrate physical and mental health care for people with severe mental illness (SMI). We built on these by conducting a mapping review that looked for the most recent evidence and service models in this area. This involved searching the published literature and speaking to people involved in providing or using current services. Few of the identified service models were described adequately and fewer still were evaluated, raising questions about the replicability and generalisability of much of the existing evidence. However, some common themes did emerge. Efforts to improve the physical health care of people with SMI should empower staff and service users and help remove everyday barriers to delivering and accessing integrated care. In particular, there is a need for improved communication among professionals and better information technology to support them, greater clarity about who is responsible and accountable for physical health care, and greater awareness of the effects of stigmatisation on the wider culture and environment in which services are delivered.
89 citations
TL;DR: A set of underlying values of integrated care has been developed and defined, which enable better understanding of the behaviours and collaboration in integrated care and may also be used to develop guidance or governance in this area.
Abstract: Introduction: Although substantial generic knowledge about integrated care has been developed, better understanding of the factors that drive behaviour, decision-making, collaboration and governance processes in integrated care networks is needed to take integrated care forward. To gain more insight into these topics and to understand integrated care in more depth, a set of underlying values of integrated care has been developed and defined in this study. Theory and methods: A systematic literature review was conducted to identify the underlying values of integrated care. Values theory was used as a theoretical framework for the analysis. Results: This study identified 23 values in the current body of knowledge. The most frequently identified values are ‘collaborative’, ‘co-ordinated’, ‘transparent’, ‘empowering’, ‘comprehensive’, ‘co-produced’ and ‘shared responsibility and accountability’. Discussion and conclusion: The set of values is presented as a potential basis for a values-driven approach to integrated care. This approach enables better understanding of the behaviours and collaboration in integrated care and may also be used to develop guidance or governance in this area. The practical application of the values and their use at multiple levels is discussed. The consequences of different stakeholder perceptions on the values is explored and an agenda for future research is proposed.
79 citations
TL;DR: The overall structure and approach of the SUSTAIN project is presented, which aims to generate evidence on how to improve integrated care, and apply and transfer the knowledge gained to other health and social care systems, and regions in Europe.
Abstract: Introduction: Integrated care programmes are increasingly being put in place to provide care to older people who live at home. Knowledge of how to further develop integrated care and how to transfer successful initiatives to other contexts is still limited. Therefore, a cross-European research project, called Sustainable Tailored Integrated Care for Older People in Europe (SUSTAIN), has been initiated with a twofold objective: 1. to collaborate with local stakeholders to support and monitor improvements to established integrated care initiatives for older people with multiple health and social care needs. Improvements focus on person-centredness, prevention orientation, safety and efficiency; 2. to make these improvements applicable and adaptable to other health and social care systems, and regions in Europe. This paper presents the overall structure and approach of the SUSTAIN project. Methods: SUSTAIN uses a multiple embedded case study design. In three phases, SUSTAIN partners: (i) conduct interviews and workshops with stakeholders from fourteen established integrated care initiatives to understand where they would prefer improvements to existing ways of working; (ii) collaborate with local stakeholders to support the design and implementation of improvement plans, evaluate implementation progress and outcomes per initiative, and carry out overarching analyses to compare the different initiatives, and; (iii) translate knowledge and experience to an online roadmap. Discussion: SUSTAIN aims to generate evidence on how to improve integrated care, and apply and transfer the knowledge gained to other health and social care systems, and regions. Lessons learned will be brought together in practical tools to inform and support policy-makers and decision-makers, as well as other stakeholders involved in integrated care, to manage and improve care for older people living at home.
57 citations
TL;DR: Work by the ADVANTAGE Joint Action (JA), co-funded by the European Union and 22 Member States, to develop a common European approach to the prevention and management of frailty is described.
Abstract: Frailty is increasingly recognised as a public health priority due to the associated demand for acute and longer term health and social care support, and the impact on the lives of individuals, caregivers and families. Integrated care is widely considered to be most effective when applied to an older population, but there is limited data on outcomes and costs from studies of integrated care to prevent and manage frailty. This paper describes work by the ADVANTAGE Joint Action (JA), co-funded by the European Union and 22 Member States, to develop a common European approach to the prevention and management of frailty. The authors reflect on the emerging evidence and experience of implementing integrated care for frailty, and invite readers to participate in ongoing dialogue on this topic through the ADVANTAGE JA website and IFIC Academy activities.
56 citations
TL;DR: An innovative model for integrated care for cancer survivors, the “Personalized Cancer Survivorship Care Model”, which has been developed as a universal model of care that will work for all cancer survivors in different health care systems is developed.
Abstract: Survivors of childhood and adult-onset cancer are at lifelong risk for the development of late effects of treatment that can lead to serious morbidity and premature mortality. Regular long-term follow-up aiming for prevention, early detection and intervention of late effects can preserve or improve health. The heterogeneous and often serious character of late effects emphasizes the need for specialized cancer survivorship care clinics. Multidisciplinary cancer survivorship care requires a coordinated and well integrated health care environment for risk based screening and intervention. In addition survivors engagement and adherence to the recommendations are also important elements. We developed an innovative model for integrated care for cancer survivors, the “Personalized Cancer Survivorship Care Model”, that is being used in our clinic. This model comprises 1. Personalized follow-up care according to the principles of Person Centered Care, aiming to empower survivors and to support self management, and 2. Organization according to a multidisciplinary and risk based approach. The concept of person centered care is based on three components: initiating, integrating and safeguarding the partnership with the patient. This model has been developed as a universal model of care that will work for all cancer survivors in different health care systems. It could be used for studies to improve self efficacy and the cost-effectiveness of cancer survivorship care.
53 citations
TL;DR: The identification and classification of the elements from this literature review provide a basis to develop a comprehensive framework enabling standardized descriptions and benchmarking of integrated care initiatives carried out in different contexts.
Abstract: Objective: As part of the EU-funded Project INTEGRATE, the research sought to develop an evidence-based understanding of the key dimensions and items of integrated care associated with successful implementation across varying country contexts and relevant to different chronic and/or long-term conditions. This paper identifies the core dimensions of integrated care based on a review of previous literature on the topic. Methodology: The research reviewed literature evidence from the peer-reviewed and grey literature. It focused on reviewing research articles that had specifically developed frameworks on integrated care and/or set out key elements for successful implementation. The search initially focused on three main scientific journals and was limited to the period from 2006 to 2016. Then, the research snowballed the references from the selected published studies and engaged leading experts in the field to supplement the identification of relevant literature. Two investigators independently reviewed the selected articles using a standard data collection tool to gather the key elements analyzed in each article. Results: A total of 710 articles were screened by title and abstract. Finally, 18 scientific contributions were selected, including studies from grey literature and experts’ suggestions. The analysis identified 175 items grouped in 12 categories. Conclusions: Most of the key factors reported in the literature derive from studies that developed their frameworks in specific contexts and/or for specific types of conditions. The identification and classification of the elements from this literature review provide a basis to develop a comprehensive framework enabling standardized descriptions and benchmarking of integrated care initiatives carried out in different contexts.
51 citations
TL;DR: The results from this review suggest that the patient satisfaction of shared care is higher than usual care, and the effectiveness of share care is similar to usual care in cancer survivorship.
Abstract: Objectives: To determine whether the shared care model during the follow-up of cancer survivors is effective in terms of patient-reported outcomes, clinical outcomes, and continuity of care.
Methods: Using systematic review methods, studies were searched from six electronic databases—MEDLINE (n = 474), British Nursing Index (n = 320), CINAHL (n = 437), Cochrane Library (n = 370), HMIC (n = 77), and Social Care Online (n = 210). The review considered all health-related outcomes that evaluated the effectiveness of shared care for cancer survivors.
Results: Eight randomised controlled trials and three descriptive papers were identified. The results showed the likelihood of similar effectiveness between shared care and usual care in terms of quality of life, mental health outcomes, unmet needs, and clinical outcomes in cancer survivorship. The reviewed studies indicated that shared care overall is highly acceptable to cancer survivors and primary care practitioners, and shared care might be cheaper than usual care.
Conclusions: The results from this review suggest that the patient satisfaction of shared care is higher than usual care, and the effectiveness of shared care is similar to usual care in cancer survivorship. Interventions that formally involve primary care and improve the communication between primary care and hospital care could support the PCPs in the follow-up.
Keywords: shared care , survivors , follow-up , cancer
48 citations
TL;DR: Care coordination must be done, however, it is not consistently being done in the way policymakers imagine, and in the real world of work can be done differently.
Abstract: Introduction Care coordination is intended to ensure needs are met and integrated services are provided. Formalised processes for the coordination of mental health care arrived in the UK with the introduction of the care programme approach in the early 1990s. Since then the care coordinator role has become a central one within mental health systems. Theory and methods This paper contrasts care coordination as work that is imagined with care coordination as work that is done. This is achieved via a critical review of policy followed by a qualitative analysis of interviews, focusing on day-to-day work, conducted with 28 care coordinators employed in four NHS organisations in England and two in Wales. Findings Care coordination is imagined as a vehicle for the provision of collaborative, recovery-focused, care. Those who practise care coordination are concerned with the quality of their relationships with service users and the tailoring of services, but limits exist to collaboration and open discussion. Care coordinators describe doing necessary work connecting people and the system of care. However, this work also brings significant administrative demands, is subject to performance management which distorts its primary purpose, and in a context of scarce resources promotes generic professional roles. Conclusion Care coordination must be done. However, it is not consistently being done in the way policymakers imagine, and in the real world of work can be done differently.
45 citations
TL;DR: It is shown that PROMs can show meaningful outcomes in older subjects’ patient journeys and may improve patient-physician relationship, quality of care and prediction of future outcomes in geriatric care, if they are valid, reliable and responsive, but still short and simple.
Abstract: Introduction: Patient reported outcome measures (PROMs) have been introduced as standardised outcomes, but have not been implemented widely for disease targeted pathways of care, nor for geriatric patients who prefer functional performance and quality of life. Discussion: We describe innovative multipurpose implementation of PROMs as evidenced by two best practices of PROMs application in geriatric and physiotherapy practice. We show that PROMs can show meaningful outcomes in older subjects’ patient journeys, which can at the same time serve individuals and groups of both patients and professionals. Key lesson: PROMs can deliver generic outcomes relevant for older patients, may improve patient-physician relationship, quality of care and prediction of future outcomes in geriatric care, if they are valid, reliable and responsive, but still short and simple. A precondition to make the hard tip from research to practice is that PROMs are carefully positioned in the clinical encounters and in electronic health records.
43 citations
TL;DR: The added value of the present study lies in its provision of information on which factors might mitigate the success of an intervention, which helps to prevent premature conclusions of ineffectiveness for complex interventions.
Abstract: Introduction: The aim of the study is to investigate the barriers and facilitators to the implementation of workforce changes implemented as part of integrated chronic care interventions. Methods: We used a qualitative multimethod design that combined expert questionnaires, a systematic literature review, and secondary analysis of two case reports. Twenty-five experts, twenty-one studies and two case reports were included in the study. Results: Most barriers related to problematic delivery structures, health professionals’ skills and enthusiasm, IT, funding, culture and cooperation and communication. Most facilitators related to health professionals’ motivation and enthusiasm, good delivery structures, communication and cooperation, IT, patients, leadership and senior management. Overall, similar categories of barriers and facilitators were found. Discussion: We recommend that future research focusses on more complex designs including multiple data sources, as these are better able to capture the complexity of interventions such as integrated care. We recommend that health managers and policy-makers should invest in delivery structures and skills and motivation of health professionals to improve the implementation of workforce changes in integrated chronic care interventions. Conclusion: The added value of the present study lies in its provision of information on which factors might mitigate the success of an intervention, which helps to prevent premature conclusions of ineffectiveness for complex interventions.
TL;DR: The home-based individualized care plan aimed at substituting hospitalization and implementing a transitional care strategy for optimal discharge showed health value generation, as well as potential for synergies with community-based Integrated Care Services.
Abstract: Home Hospitalization has proven efficacy, but its effectiveness and potential as an Integrated Care Service in a real world setting deserves to be explored. Objective: To evaluate implementation and 10 years follow-up of Home Hospitalization and Early Discharge as an Integrated Care Service in an urban healthcare district in Barcelona. Methods: Prospective study with pragmatic assessment. Patients: Surgical and medical acute and exacerbated chronic patients requiring admission into a highly specialized hospital, from 2006 to 2015. Intervention: Home-based individualized care plan, administered as a hospital-based outreach service, aiming at substituting hospitalization and implementing a transitional care strategy for optimal discharge. Main measurements: Emergency Department, readmissions and mortality. Patients’ and professionals’ perspectives, technologies and costs were evaluated. Results: 4,165 admissions (71 ± 15 yrs; Charlson Index 4 ± 3). In-hospital stay was 1 (0–3) days and the length of home-based stay was 6 (5–7) days. The 30-day readmission rate was 11% and mortality was 2%. Patients, careers and health professionals expressed high levels of satisfaction (98%). At the start, the service was reimbursed at a flat rate of 918€ per patient discharged, significantly lower than conventional hospitalization (2,879€) but still allowing the hospital to keep a balanced budget. At present, there is no difference in the payment schemes for both types of services. Conclusions: The service freed an average of 6 in-hospital days per patient. The program showed health value generation, as well as potential for synergies with community-based Integrated Care Services.
TL;DR: The study demonstrates that although the focus of integration across sectors is often on social services and health care, other arrangements are also frequently in place and shows that integration may be either tailored to a particular target group or designed for communities in general.
Abstract: Introduction: To meet the needs of vulnerable people, the integration of services across different sectors is important. This paper presents a preliminary review of service integration across sectors in Europe. Examples of service integration between social services, health, employment and/or education were studied. A further aim of the study was to improve conceptual clarity regarding service integration across sectors, using Minkman’s Developmental Model for Integrated Care (DMIC) as an analytical framework. Methods: The study methods comprised a literature review (34 articles) and a survey of practice examples across Europe (44 practices). This paper is based on a more comprehensive study published in 2016. Results: The study demonstrates that although the focus of integration across sectors is often on social services and health care, other arrangements are also frequently in place. The review shows that integration may be either tailored to a particular target group or designed for communities in general. Although systems to monitor and evaluate social service integration are often present, they are not yet fully developed. The study also highlights the importance of good leadership and organizational support in integrated service delivery. Discussion: The study shows that the DMIC can work as a conceptual framework for the analysis of service integration across sectors. However, as this is an exploratory study, further in-depth case studies are required to deepen our understanding of the processes involved in service integration across sectors.
TL;DR: The results show that it is preferable to enhance collaborative skills before introducing new professional teams, roles and responsibilities, and that local managers must be supported with infrastructure on a macro level to understand the embedding of practice and look at what professionals actually do and how they work.
Abstract: Introduction: Multi-professional collaboration (MPC) is essential for the delivery of effective and comprehensive care services. As in other European countries, primary care in Norway is challenged by altered patient values and the increased expectations of health administrations to participate in team-based care. This scoping review reports on the organisational, processual, relational and contextual facilitators of collaboration between general practitioners (GP) and other healthcare professionals (HCPs) in primary care. Methods: A systematic search in specialist and Scandinavian databases retrieved 707 citations. Following the inclusion criteria, nineteen studies were considered eligible and examined according to Arksey and O’Malley’s methodological framework for scoping reviews. The retrieved literature was analysed employing a content analysis approach. A group of stakeholders commented on study findings to enhance study validity. Results: Primary care research into MPC is immature and emerging in Norway. Our analysis showed that introducing common procedures for documentation and handling of patient data, knowledge sharing, and establishing local specialised multi-professional teams, facilitates MPC. The results indicate that advancements in work practices benefit from an initial system-level foundation with focus on local management and MPC leadership. Further, our results show that it is preferable to enhance collaborative skills before introducing new professional teams, roles and responsibilities. Investing in professional relations could build trust, respect and continuity. In this respect, sufficient time must be allocated during the working day for professionals to share reflections and engage in mutual learning. Conclusion: There is a paucity of research concerning the application and management of MPC in Norwegian primary care. The work practices and relations between professionals, primary care institutions and stakeholders on a macro level is inadequate. Health care is a complex system in which HCPs need managerial support to harvest the untapped benefits of MPC in primary care. As international research demonstrates, local managers must be supported with infrastructure on a macro level to understand the embedding of practice and look at what professionals actually do and how they work.
TL;DR: The significance of effective collaboration built on a common focus, responsiveness to emergent behaviours, simple rules, the ability to self-organize and adapt in response to unexpected situations in further development of integrated care in the Singapore context and beyond is highlighted.
Abstract: Background: Integrated care that focuses on organising healthcare services around people and their communities rather than their diseases is promoted as the strategy to overcome the challenges associated with growing complexity in healthcare needs, demand for healthcare services and inadequate supply of services due to fragmentation in the provision of services. While conceptually appears to be simple, integrated care is made up of multicomponent delivery strategies targeting various levels of the healthcare system while engaging various stakeholders in their execution. Methods: We applied the complex adaptive system (CAS) perspective to two different initiatives that exemplify approaches towards integrating care in Singapore: the Regional Health System (RHS) model, implemented across healthcare institutions at the national level, and CARITAS Integrated Dementia Care implemented in the northern region of Singapore. We adopted an inductive approach in our analysis in which we studied the RHS and CARITAS Integrated Dementia Care according to the components of the CAS. We applied the typical characteristics of CAS: (i) diverse, interdependent and semi-autonomous actors (ii) self-organizing capacity and simple rules (iii) relationship with the bigger system, emergent behaviour and non-linearity in our analysis of key drivers behind the implementation of both the RHS and CARITAS integrated dementia care. Results: By considering the RHS and CARITAS as whole networks each comprising of interacting and adaptive components instead of separate entities within a bigger system, the CAS provided a new mind-set in surfacing issues associated to the implementation of these integrated care networks. In addition to important actors, systems, it informed understanding of relationships and dependencies between different parts of the network – revealing the lack of homogeneity, conformity and difficulties in designing any optimal system in advance given the many moving parts. Conclusions: Drawing on the two examples of integrated care networks, this paper highlights the significance of effective collaboration built on a common focus, responsiveness to emergent behaviours, simple rules, the ability to self-organize and adapt in response to unexpected situations in further development of integrated care in the Singapore context and beyond.
TL;DR: The B3-MM dimensions, maturity indicators and assessment scale showed satisfactory content validity and is a unique instrument based on existing knowledge and experiences of regions in integrated care, while further testing is needed to explore other measurement properties of B2-MM.
Abstract: Introduction: Lessons captured from interviews with 12 European regions are represented in a new instrument, the B3-Maturity Model (B3-MM). B3-MM aims to assess maturity along 12 dimensions reflecting the various aspects that need to be managed in order to deliver integrated care. The objective of the study was to test the content validity of B3-MM as part of SCIROCCO (Scaling Integrated Care into Context), a European Union funded project. Methods: A literature review was conducted to compare B3-MM’s 12 dimensions and their measurement scales with existing measures and instruments that focus on assessing the development of integrated care. Subsequently, a three-round survey conducted through a Delphi study with international experts in the field of integrated care was performed to test the relevance of: 1) the dimensions, 2) the maturity indicators and 3) the assessment scale used in B3-MM. Results: The 11 articles included in the literature review confirmed all the dimensions described in the original version of B3-MM. The Delphi study rounds resulted in various phrasing amendments of indicators and assessment scale. Full agreement among the experts on the relevance of the 12 B3-MM dimensions, their indicators, and assessment scale was reached after the third Delphi round. Conclusion and discussion: The B3-MM dimensions, maturity indicators and assessment scale showed satisfactory content validity. While the B3-MM is a unique instrument based on existing knowledge and experiences of regions in integrated care, further testing is needed to explore other measurement properties of B3-MM.
TL;DR: This paper describes a program of research by an international, multi-university, multidisciplinary research team who are seeking to understand how to scale up and spread models of Integrated CBPHC (ICBPHC).
Abstract: Health and social care systems across western developed nations are being challenged to meet the needs of an increasing number of people aging with multiple complex health and social needs. Community based primary health care (CBPHC) has been associated with more equitable access to services, better population level outcomes and lower system level costs. Itmay be well suited to the increasingly complex needs of populations; however the implementation of CBPHC models of care faces many challenges. This paper describes a program of research by an international, multi-university, multidisciplinary research team who are seeking to understand how to scale up and spread models of Integrated CBPHC (ICBPHC). The key question being addressed is "What are the steps to implementing innovative integrated community-based primary health care models that address the health and social needs of older adults with complex care needs?" and will be answered in three phases. In the first phase we identify and describe exemplar models of ICBPHC and their context in relation to relevant policies and performance across the three jurisdictions (New Zealand, Ontario and Quebec, Canada). The second phase involves a series of theory-informed, mixed methods case studies from which we shall develop a conceptual framework that captures not only the attributes of successful innovative ICBPHC models, but also how these models are being implemented. In the third phase, we aim to translate our research into practice by identifying emerging models of ICBPHC in advance, and working alongside policymakers to inform the development and implementation of these models in each jurisdiction. The final output of the program will be a comprehensive guide to the design, implementation and scaling-up of innovative models of ICBPHC.
TL;DR: The medical consortium provides an effective strategy to improve the outcomes of cancer patients in Shanxi, China and bridges the gap in resources and plays a critical role in the quality of care in China.
Abstract: Objective: To assess the effect of the medical consortium policy on the outcomes of cancer patients admitted to secondary hospitals in Shanxi, China. Method: Electronic medical records of lung cancer (n = 8,193), stomach cancer (n = 5,693) and esophagus cancer (n = 2,802) patients hospitalized in secondary hospitals were used. Propensity score matching was used to match each patient enrolled in medical consortium hospitals with a counterpart admitted in nonmedical consortium hospitals. Cox proportional hazard models were used to estimate the hazard ratio of patients enrolled different categories of hospitals. Results: The hazards of lung, stomach and esophageal cancer patients admitted in medical consortium hospitals were consistently and significantly lower than those admitted in non-medical consortium hospitals after adjusting for a number of potential confounders. Lower hazard ratios were associated with lung (hazard ratio (HR) = 0.533, p Conclusion: The medical consortium provides an effective strategy to improve the outcomes of cancer patients in Shanxi, China. The partnerships between top-tier hospitals and grassroots medical services bridge the gap in resources and plays a critical role in the quality of care in China.
TL;DR: The authors' findings emphasize the essential role of the team’s chairperson, who, in addition to technically structuring meetings, should act as a change agent guiding team development.
Abstract: Introduction: Interprofessional teamwork is increasingly necessary in primary care to meet the needs of people with complex care demands. Needs assessment shows that this requires efficient interprofessional team meetings, focusing on patients’ personal goals. The aim of this study was to develop a programme to improve the efficiency and patient-centredness of such meetings. Methods: Action research approach: a first draft of the programme was developed, and iteratively used and evaluated by three primary care teams. Data were collected using observations, interviews and a focus group, and analysed using directed content analysis. Results: The final programme comprises a framework to reflect on team functioning, and training activities supplemented by a toolbox. Training is intended for the chairperson and a co-chair, and aims at organizing and structuring meetings, and enhancing patient-centredness. Our findings emphasize the essential role of the team’s chairperson, who, in addition to technically structuring meetings, should act as a change agent guiding team development. Conclusion: Findings show that the programme should be customizable to each individual team’s context and participants’ learning objectives. Becoming acquainted with new structures can be considered a growth process, in which teams have to find their way, with the chairperson as change agent.
TL;DR: The integration process, core strategies and mechanisms of the Luohu model will promote integrated care in urban China and other countries facing the same challenges, and is analyzed.
Abstract: Introduction: Emerging from the epidemiological transition and accelerated aging process, China’s fragmentated healthcare systems struggle to meet the demands of the population. On Sept 1st 2017, China’s National Health and Family Planning Commission encouraged all cities to learn from the Luohu model of integration adopted in Luohu as an approach to meeting these challenges. In this paper, we study the integration process, analyze the core mechanisms, and conduct preliminary evaluations of integrated policy development in the Luohu model. Policy development: The Luohu hospital group was established in Aug 2015, consists of five district hospitals, 23 community health stations and an institute of precision medicine. The group adopted a series of professional, organizational, system, functional and normative strategies for integrated care, which was provided for the residents of Luohu, especially for the elderly population and patients with chronic conditions. According to a preliminary evaluation of the past two years, the Luohu model showed improvement in the structure and process towards integrated care. New preventive programs conducted in the hospital group resulted in changes of disease incidence. Residents were more satisfied with the Luohu model. However, spending exceeded the global budget for health insurance because of short-term increases in the demand for health care. Lessons learned: First, engagement of multiple stakeholders is essential for the design and implementation of reform. Second, organizational integration is a prerequisite for integrated care in China. Third, effective care integration requires alignment with payment reforms. Fourth, normative integration could promote collaboration in an integrated healthcare system. Conclusion: Core strategies and mechanisms of the Luohu model will promote integrated care in urban China and other countries facing the same challenges. However, it is necessary to study the effects of the Luohu model over the long term and continue to strive for integrated care.
TL;DR: The Patient Experience of Integrated Care Scale (PEICS) showed good psychometric properties and could be used in a population with chronic conditions followed in primary care to measure patient experience of integrated care.
Abstract: Introduction: Valid and comprehensive instruments to measure integrated care are required to capture patient experience and improve quality of patient care. This study aimed to validate the Patient Experience of Integrated Care Scale (PEICS), among patients with chronic conditions seen in primary care. Methods: One hundred and fifty-nine (159) French-speaking adults with at least one chronic condition were recruited in two family medicine clinics in Quebec (Canada) and completed the 17-item PEICS (T1). Fifty (50) participants completed it a second time 2 weeks later (T2). The internal consistency of the scale was assessed using Cronbach’s alpha, the test-retest reliability with the intraclass correlation coefficient (ICC), and concurrent validity using three dimensions of the Continuity of Care from Multiple Clinicians (CC-MC), with Spearman’s rank correlation coefficients. Results: Cronbach’s alpha for the questionnaire was 0.88 (95% CI: 0.85 to 0.91). The intraclass correlation coefficient was 0.81 (95% CI: 0.64 to 0.90) and Spearman’s rank correlation coefficient with the three dimensions of the CC-MC varied from 0.44 to 0.54. Conclusions and discussion: The PEICS showed good psychometric properties. This scale could be used in a population with chronic conditions followed in primary care to measure patient experience of integrated care.
TL;DR: In this paper, the authors used qualitative data obtained from semi-structured interviews and quantitative data collected by project pharmacists to analyse the process of the integrating pharmacists is general practice.
Abstract: Introduction: This process evaluation examined the circumstances affecting implementation, intervention design and situational context of the twelve week pilot phase of a project integrating five pharmacists into twelve general practice sites in Western Sydney. Description of Care Practice: This study used a mixed method study design using qualitative data obtained from semi-structured interviews and quantitative data collected by project pharmacists to analyse the process of the integrating pharmacists is general practice. Framework analysis of the interview transcripts was used to align the results with the key process evaluation themes of implementation, mechanism of impact and context. Preliminary quantitative data was used to provide implementation feedback and to support the qualitative findings. Results: The interventional design included three phases, patient recruitment and selection, the pharmacist consultation and the communication and recording of recommendations. A number of barriers and facilitators affecting implementation were identified. Insight into the situational context of the intervention was gained from examining the differences between individual pharmacists and between practice sites. Conclusion: Conducting a process evaluation in the pilot phase of an integrated care project can allow adjustments to be made to the project procedures to improve the effectiveness and reproducibility of the intervention going forward.
TL;DR: In this paper, the authors explored how health meso-level organizations used, or planned to use, the health governance elements and identified several barriers and enablers to the use of these elements.
Abstract: Introduction: Against a paucity of evidence, a model describing elements of health governance best suited to achieving integrated care internationally was developed The aim of this study was to explore how health meso-level organisations used, or planned to use, the governance elements Methods: A case study design was used to offer two contrasting contexts of health governance Semi-structured interviews were conducted with participants who held senior governance roles Data were thematically analysed to identify if the elements of health governance were being used, or intended to be in the future Results: While all participants agreed that the ten elements were essential to developing future integrated care, most were not used Three major themes were identified: (1) organisational versus system focus, (2) leadership and culture, and, (3) community (dis)engagement Discussion: Several barriers and enablers to the use of the elements were identified and would require addressing in order to make evidence-based changes Conclusion: Despite a clear international policy direction in support of integrated care this study identified a number of significant barriers to its implementation The study reconfirmed that a focus on all ten elements of health governance is essential to achieve integrated care
TL;DR: There is agreement among young adult patients and families about what constitutes PFCC in a chronic disease setting, independent of the aetiology of the pathological process.
Abstract: Background and Aim: The published literature addressing the nature of patient- and family-centred care (PFCC) among young adults (16–25 years old) living with chronic disease and their family members is diverse. The aim of this systematic review was to collect and interpretatively synthesise this literature to generate a conceptual understanding of PFCC in this age group. Method: From an initial pool of 10,615 papers, 51 were systematically identified as relevant to the research question and appraised using the Critical Appraisal Skills Programme tools. A total of 24 papers passed the quality appraisal and proceeded to a qualitative meta-synthesis. Results: The qualitative meta-synthesis revealed three major elements of PFCC relevant to young adults living with chronic disease and their family members: (1) patients and practitioners felt able to engage with each other on an emotional and social level; (2) patients and families felt empowered to be part of the care process; and (3) patients and families experienced care as effective at addressing their individual needs. Conclusion: There is agreement among young adult patients and families about what constitutes PFCC in a chronic disease setting, independent of the aetiology of the pathological process. Patients and families also have strong feelings about how practitioners can achieve PFCC in practice. These findings have implications for the delivery of health services to young adults living with chronic disease and their family members.
TL;DR: Integrated physical and mental health service models that focus on building local service provider relationships and are responsive to community needs and outcomes may be more beneficial in rural settings than top down approaches that focused on policies, formal structures, and governance.
Abstract: Introduction: The ‘GP Clinic’ provides primary health care to people using community mental health services in a small town in Australia. This article examines the factors that have driven successful integration in this rural location. Methods: A multiple methods case study approach was used comprising service record data for a 24 month period and semi-structured interviews with sixteen staff members associated with the integrated rural service model. Results: Processes and structures for establishing integrated care evolved locally from nurturing supportive professional and organisational relationships. A booking system that maximised attendance and minimised the work of the general practice ensured that issues to do with remuneration and the capacity for the general practitioner to provide care to those with complex needs were addressed. Strong collaborative relationships led to the upskilling of local staff in physical and mental health conditions and treatments, and ensured significant barriers for people with mental illness accessing primary care in rural Australia were overcome. Conclusions: Integrated physical and mental health service models that focus on building local service provider relationships and are responsive to community needs and outcomes may be more beneficial in rural settings than top down approaches that focus on policies, formal structures, and governance.
TL;DR: Information asymmetries are seen as a major obstacle to the efficient operation of integrated care programmes and represent a necessary but not a sufficient condition for further government intervention in the design of selective individual contracts.
Abstract: Introduction: Integrated care systems are advocated as an effective method of improving the performance of healthcare systems. These systems outline a payment and care delivery model that intends to tie provider reimbursements to predefined quality metrics. Little is known about the contractual design and the main challenges of delegating “accountability” to these new kinds of organisations and/or contracts. The research question in this article focuses on how healthcare contracts can look like and which possible problems arise in designing such contracts. In this a special interest is placed on information asymmetries. Methods: A comprehensive literature review on methods of designing contracts in Integrated Care was conducted. This article is the first in a row of three that all contribute to a specific issue in designing healthcare contracts. Starting with the organisation of contracts and information asymmetries, part 2 focusses on financial options and risks and part 3 finally concludes with the question of risk management and evaluation. Results: Healthcare contracting between providers and payers will have a major impact on the overall design of future healthcare systems. If Integrated care systems or any other similar concept of care delivery are to be contracted directly by payers to manage the continuum of care the costs of market utilisation play an essential role. Transaction costs also arise in the course of the negotiation and implementation of contracts. These costs are the reason why it is generally not possible to conclude perfect (complete) contracts. Problems with asymmetric distribution of information can relate to the situation before a contract is concluded (adverse selection) and after conclusion of a contract (moral hazard). Discussion and Conclusions: Information asymmetries are seen as a major obstacle to the efficient operation of integrated care programmes. Coordination and motivation problems cannot be solved at no-costs. The presented problems in the design of selective individual contracts represent a necessary but not a sufficient condition for further government intervention. A state or political failures have to be assumed continuously.
TL;DR: This paper presents the protocol of a qualitative research study to explore factors that facilitate and hinder the implementation of a social prescribing pilot in the East of England, and affect the uptake, adherence, and completion rates by service users.
Abstract: Background: In response to the increasing numbers of people with (multiple) chronic conditions, the need for integrated care is increasing too. Social prescribing is a new approach that aims to integrate the social and healthcare sector to improve the quality of care and user experience. Understanding main stakeholders’ perceptions and experiences is key to the implementation of social prescription and for informing future initiatives. Objectives: This paper presents the protocol of a qualitative research study to explore factors that (i) facilitate and hinder the implementation of a social prescribing pilot in the East of England, and (ii) affect the uptake, adherence, and completion rates by service users. Methods: A qualitative study including semi-structured interviews with managers, health professionals, service providers, navigators, and service users. Iterative thematic analysis will be used to analyse the data. Conclusion: This study will produce evidence on factors that hinder and facilitate the implementation of a social prescribing programme, as well as factors affecting the engagement, and non-engagement, of service users. Findings can contribute to the development of an evidence base for social prescription programmes in the UK, and inform practice, policy, and future research in the field.
TL;DR: High-fidelity implementation of ACT in a sectored service setting is possible, but implementation was hampered by conflicting goals among the involved authorities and a mismatch between the ACT model’s characteristics and existing organisational traditions and regulations.
Abstract: Introduction: There is increasing interest in implementing evidence-based integrated models of care in community-based mental health service systems. Assertive Community Treatment (ACT) is seen as ...
TL;DR: The design study described advances toward the implementation of a whole-of-government integrated health and social care initiative to break intergenerational cycles of poverty, violence and crime, poor education and employment opportunities, psychopathology, and poor lifestyle and health behaviours.
Abstract: Introduction : In July 2015 Sydney Local Health District (SLHD) implemented an integrated care initiative for vulnerable families in the inner West region of Sydney, Australia. That initiative was designed as a cross-agency care coordination network that would ensure that vulnerable families: had their complex health and social needs met; kept themselves and their children safe; and were connected to society. We will describe the development of the integrated care design that drew on earlier realist causal and program theoretical work. Theory/Methods : Realist causal and program theory were used to inform the collaborative design of initiatives for vulnerable families. The collaborative design process included: identification of desirable and undesirable outcomes and contextual factors, consultation forums, interagency planning, and development of a service proposal. Results : The program theory mechanisms identified included: family-provider trust, willingness to share power, co-operation, Information, and building self-help skills. The Design Elements included: Wrap around services, place-based initiatives, care coordination, sustained nurse home visiting, primary care support, family group conferencing, targeted parenting, social media, outcome monitoring, workforce development and realist program evaluation. Discussion : The Design Elements included: identification of vulnerable families; care coordination; evidence-informed intervention(s); general Practice engagement and support; family health improvement; placed-based neighbourhood initiatives; interagency system change and planning; monitoring of individual and family outcomes; and evaluation. Conclusions : The design study described advances our earlier empirical and programme design studies toward the implementation of a full whole-of-government integrated health and social care initiative. That initiative was designed as a cross-agency care coordination network that would ensure that vulnerable families: had their complex health and social needs met; kept themselves and their children safe; and were connected to society. In so doing we aim to break intergenerational cycles of poverty, violence and crime, poor education and employment opportunities, psychopathology, and poor lifestyle and health behaviours, through strengthening family resiliency, improving access to services, and addressing the social determinants of health and well-being. Lessons learned : In undertaking this study we identified the importance of our earlier hierarchal program analysis for identifying the elements for the full design. The application of theory added rigour to the design of integrated care initiatives. The design benefited from the inclusion of elements of population health, primary care, consumer engagement, community engagement and social determinants of health. Limitations : The analysis and design process did not include a full critical realist analysis of pre-existing context. Consequently existing structural, cultural, relationship and agency barriers and enablers were not fully analysed as part of the design process. Suggestions for future research : Further methodological research to develop: 1) tools that can be rapidly applied during the design process to identify pre-existing contextual barriers and enablers; and 2) approaches to build the knowledge of context into the final design.
TL;DR: Although the intervention was not implemented as planned, the intervention empowered healthcare professionals and increased their awareness of the signals of pain and challenging behaviour.
Abstract: Background: A stepwise, multidisciplinary and multicomponent intervention (called STA OP!) was implemented in Dutch nursing home units, which included a comprehensive multidisciplinary team training A cluster-randomised controlled trial showed that the intervention reduced symptoms of pain and challenging behaviour Objective(s): To describe the experiences around the implementation of the intervention; to examine the extent to which the STA OP! intervention was delivered and implemented as intended (at the level of the team, and the individual resident/professional); and to understand factors influencing the implementation process Methods: A process evaluation was performed using a mixed-methods design encompassing several data sources Quantitative data (ie from the written evaluations by healthcare professionals, management, and the research database) were analysed using descriptive statistics Qualitative data (ie semi-structured interviews, notes, completed intervention forms, and written evaluations) were analysed according to the principles of thematic analysis The implementation process and the influencing factors were categorised according to the i) organisational level, ii) the team level, and iii) the level of the individual resident/professional Results: In total, 392% of the residents with pain and/or challenging behaviour were treated following the stepwise approach of the STA OP! intervention The training manual and forms used were found to be relevant and feasible Factors inhibiting the implementation process at the i) organisational level concerned instability of the organisation and the team (eg involvement in multiple projects/new innovations, staff turnover/absence of essential disciplines, and/or high workload) At the team level (ii), we found that presence of a person with a motivational leadership style facilitated the implementation Also, interdisciplinary cooperation through the design/setting of the multidisciplinary training, securing the intervention by use of clear agreements, and written reporting or transfers facilitated implementation At the individual level (iii), perceived value of the stepwise working method, and enhanced awareness facilitated the implementation Conclusion: Although the intervention was not implemented as planned, the intervention empowered healthcare professionals and increased their awareness of the signals of pain and challenging behaviour Future implementation of the intervention should start on units with a motivational leader, and specific features of the organisation and the team should be considered to facilitate implementation, eg stability, support, and shared focus to change