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Showing papers in "International Journal of Integrated Care in 2019"


Journal ArticleDOI
TL;DR: Systematic review of studies comprising older adults assessing hospital admission, length of hospital stay, hospital readmission, patient satisfaction and mortality in integrated care settings shows that integrated care tends to have a positive impact on hospital admission rates, some positive effect on length of stay and possibly also on readmission and patient satisfaction but not on mortality.
Abstract: Introduction: The growing number of older adults with multiple needs increases the pressure to reform existing healthcare systems. Integrated care may be part of such reforms. The aim of this systematic review was to identify important patient-related outcomes of integrated care provided to older adults. Methods: A systematic search of 5 databases to identify studies comprising older adults assessing hospital admission, length of hospital stay, hospital readmission, patient satisfaction and mortality in integrated care settings. Retrieved literature was analysed employing a narrative synthesis. Results: Twelve studies were included (2 randomised controlled trials, 7 quasi-experimental design, 2 comparison studies, 1 survey evaluation). Five studies investigated patient satisfaction, 9 hospital admission, 7 length of stay, 3 readmission and 5 mortality. Findings show that integrated care tends to have a positive impact on hospital admission rates, some positive impact on length of stay and possibly also on readmission and patient satisfaction but not on mortality. Conclusions: Integrated care may reduce hospital admission rates and lengths of hospital stay. However due to lack of robust findings, the effectiveness of integrated care on patient-related outcomes in later life remain largely unknown. Further research is needed to establish the effect of integrated care on these patient-related outcomes. Prospero registration number: CRD42018110491.

48 citations


Journal ArticleDOI
TL;DR: The impact of NDPs providing integrated care can be explained by the specific expertise NDPs bring into general practice and the tailored solutions they offer for individual patients, including deviation from medical protocols when necessary.
Abstract: Background: Data on medication-related hospital admissions suggest that there is an opportunity for improved pharmaceutical care. Hence, concerns about medication-related hospital admissions is a driver to extend and integrate the role of community pharmacists in general practice. Aim: The aim of this paper is to give a systematic description of 1) what integrating a non-dispensing pharmacist (NDP) in general practice entails and 2) how this integrated care model is expected to contribute to patients’ medication therapy management. Methods: Based on ethnographic data collected by NDPs in general practices in the Netherlands, we conducted a theory evaluation. Results: The impact of NDPs providing integrated care can be explained by 1) the specific expertise NDPs bring into general practice and the tailored solutions they offer for individual patients, including deviation from medical protocols when necessary, 2) the reconciliation of interprofessional tensions caused by overlapping tasks with practice nurses, which results in a distinct patient population, 3) the conduct of clinical medication reviews aligned to the work processes of the GP practice and 4) the integration of quality management work into clinical work. Conclusion: The success of integrated pharmaceutical care is dependent on how NDPs collaborate with GPs and practice nurses. NDPs need to mobilize clinical pharmaceutical expertise into general practice. Yet, integrating quality management into clinical work is key to integrate pharmaceutical care. Paradoxically, full integration requires from NDPs to develop a distinct role in general practice.

45 citations


Journal ArticleDOI
TL;DR: In this paper, the authors describe attributes of care that are important to older adults and their caregivers, including feeling heard, appreciated and comfortable, having someone to count on; easily accessing health and social care; knowing how to manage health and what to expect; feeling safe; and being independent.
Abstract: Introduction: Health systems are striving to design and deliver care that is ‘person centered’—aligned with the needs and preferences of those receiving it; however, it is unclear what older people and their caregivers value in their care. This paper captures attributes of care that are important to older people and their caregivers. Methods: This qualitative descriptive study entailed 1–1 interviews with older adults with multimorbidity receiving community based primary health care in Canada and New Zealand and caregivers. Data were analyzed to identify core attributes of care, important to participants. Findings: Feeling heard, appreciated and comfortable; having someone to count on; easily accessing health and social care; knowing how to manage health and what to expect; feeling safe; and being independent were valued. Each attribute had several characteristics including: being treated like a friend; having contact information of a responsive provider; being accompanied to medical and social activities; being given clear treatment options including what to expect; having homes adapted to support limitations and having the opportunity to participate in meaningful hobbies. Conclusions: Attributes of good care extend beyond disease management. While our findings include activities that characterize these attributes, further research on implementation barriers and facilitators is required.

40 citations


Journal ArticleDOI
TL;DR: Development of integrated and population health-oriented systems of care requires the redesign of how services are organized and delivered, and how organizations and care systems operate, which can be supported by a set of cohesive strategies and interventions.
Abstract: Background and aim: Many health systems attempt to develop integrated and population health-oriented systems of care, but knowledge of strategies and interventions to support this effort is lacking. We aimed to identify specific redesign strategies and interventions, and to present evidence of their effectiveness. Method: A modified scoping review process was carried out. Fifteen relevant examples of integrated care organizations that incorporated a broad population health approach in countries of the Organization for Economic Cooperation and Development described in 57 articles and reports were included in analysis. Results: Seven key redesign strategies and multiple redesign interventions have been identified and are described. Most commonly used redesign strategies included focusing on health and wellness, embracing intersectoral action and partnerships, addressing health in vulnerable groups, and addressing a wide range of determinants of health, including making improvements in health services. Redesign interventions included creative and innovative ways of addressing clinical and non-clinical issues such as establishing housing surgeries in primary care, establlishing vast social and provider networks to support patients with complex needs and also broadening of the scope of services, workforce redesign and other. Potential reductions in the utilization of care and costs could be derived by the wider adoption of these strategies and interventions. Conclusion: Development of integrated and population health-oriented systems of care requires the redesign of how services are organized and delivered, and how organizations and care systems operate. Combining integration of care with the population health approach can be supported by a set of cohesive strategies and interventions aimed at preventing disease, addressing social determinants of health and improving health equity at both population- and individual-level.

30 citations


Journal ArticleDOI
TL;DR: The authors don’t really have enough knowledge on what or how to implement things, nor on what really makes a difference to the outcomes they observe – the very practicalities that managers and professionals need if they are to replicate or adopt new ways of working effectively.
Abstract: have yet to make any significant breakthrough to understand the implementation and sustainability of complex service innovations that so characterise the development of integrated care programmes [1]. Without such knowledge we might be able to explain the core building blocks of integrated care systems, but we cannot adequately explain the intricacies of effective implementation nor fully understand the causes of the outcomes we observe. This is not simply a methodological problem but reflects a more deep-rooted challenge in the lack of value that is placed both in the commissioning of such research and the findings that are produced. Last month I attended a one-day seminar in London, attended by a ‘who’s who’ of health service researchers, examining the Challenges of Evaluating Integrated Care Programmes. This was hosted by the Health Foundation and the Nuffield Trust and was a chance to reflect on the evidence for integrated care following the recent conclusion of the three-year New Care Models programme funded by NHS England [2, 3, 4]. This itself built on earlier and well evaluated programmes such as the Integrated Care Pilots [5] and Integrated Care Pioneers [6]. Specifically, the seminar asked why all this research had yet not been able to reach any definitive conclusion to how the impact (positive, negative or neutral) of different integrated care strategies could be explained? For example, evidence was presented at the meeting that multi-speciality community providers (MCPs) – one of the new care models in England that sought to promote specialist care in the community – had had a collective impact in the lowering of emergency hospital admissions (if not overall bed days) [4]. However, given the significant variation in ‘the what and the how’ of implementation in practice, it has been impossible to really understand what interventions or processes have been able to make the difference, how these should be balanced in practice, or indeed at what cost [4]. This means we don’t really have enough knowledge on what or how to implement things, nor on what really makes a difference to the outcomes we observe – the very practicalities that managers and professionals need if they are to replicate or adopt new ways of working effectively. The upshot of the discussion was that we needed research which allowed for a deeper dive into the ‘black box’ of complexities that integrated care initiatives present. However, it was also noted that evaluations, even those of the highest technical quality, rarely have been given the opportunity to use an implementation science approach to examine what happens at the operational level. Moreover, because such qualitative research is both timeand resource-intensive (for example, requiring ethnographic and observational methods) such investigations are often based on surveys and/or case study approaches of limited design. The consequence is that this results in a list of ‘truisms’ – e.g. ‘teamwork is essential’, ‘effective leadership matters’, or ‘success depended on a positive organisational culture’. Such findings give you an understanding of the outcome domains that matter when evaluating the difference between success and failure, but don’t solve the problem of the practical tools and approaches that might be used in specific contexts to build or replicate such capabilities (if required, of course, since some things happen naturally or even by fluke). If we are serious about understanding the ‘black box’ of complexities, then we need to take social science seriously. Unfortunately, the value of an implementation science approach is under-appreciated, rarely commissioned and often not published in the ‘high impact’ journals as they are seen as lower on the evidence hierarchy from which decisions are made. This is despite the overwhelming evidence that it is the ‘softer’ issues such as leadership and management, effective teams and networks, and positive cultures and behaviours that are the most likely to be deciding factors in whether innovations in integrated care succeed or fail. Investigations, therefore, need to become much more granular in understanding how behaviours are influenced and the practical tools and approaches required to do so. To take a step forward in the development of practical tools to support the implementation of integrated care in practice, a cross-European project called SUSTAIN EDITORIAL

28 citations


Journal ArticleDOI
TL;DR: This paper critically reflects on the need to reconcile the professional, organizational and institutional frameworks by which care work is structured with the diversity and diffuseness that is inherent to pursuits of active user and citizen participation and raises questions about whose knowledge counts, who is in control, who participates and whose interests matter.
Abstract: Policy makers, practitioners and academics often claim that care users and other citizens should be ‘at the center’ of care integration pursuits. Nonetheless, the field of integrated care tends to approach these constituents as passive recipients of professional and managerial efforts. This paper critically reflects on this discrepancy, which, we contend, indicates both a key objective and an ongoing challenge of care integration; i.e., the need to reconcile (1) the professional, organizational and institutional frameworks by which care work is structured with (2) the diversity and diffuseness that is inherent to pursuits of active user and citizen participation. By identifying four organizational tensions that result from this challenge, we raise questions about whose knowledge counts (lay/professional), who is in control (local/central), who participates (inclusion/exclusion) and whose interests matter (civic/organizational). By making explicit what so often remains obscured in the literature, we enable actors to more effectively address these tensions in their pursuits of care integration. In turn, we are able to generate a more realistic outlook on the opportunities, limitations and pitfalls of citizen participation.

27 citations


Journal ArticleDOI
TL;DR: This book presents a meta-politics of language that aims to explain the human experience through the lens of language, as well as some examples of examples from the literature.
Abstract: Amelung, V.E., Stein, V., Goodwin, N., Balicer, R., Nolte, E., Suter, E. (Eds.), Publisher: Sprinter International Publishing. DOI: 10.1007/978-3-319-56103-5

24 citations


Journal ArticleDOI
TL;DR: Upscale of the C-EYE-C model should be considered to further improve capacity of public eye services in Australia.
Abstract: Introduction: Glaucoma, a chronic eye disease requires regular monitoring and treatment to prevent vision-loss. In Australia, most public ophthalmology departments are overburdened. Community Eye Care is a ‘collaborative’ care model, involving community-based optometrist assessment and ‘virtual review’ by ophthalmologists to manage low-risk patients. C-EYE-C was implemented at one Australian hospital. This study aims to determine whether C-EYE-C improves access to care and better utilises resources, compared to hospital-based care. Methods: A clinical and financial audit was conducted to compare access to care and health system costs for hospital care and C-EYE-C. Attendance, wait-time, patient outcomes, and the average cost per encounter were calculated. A weighted kappa assessed agreement between the optometrist and ophthalmologist decisions. Results: There were 503 low-risk referrals, hospital (n = 182) and C-EYE-C (n = 321). C-EYE-C had higher attendance (81.6% vs 68.7%, p = 0.001); and shorter appointment wait-time (89 vs 386 days, p Discussion: C-EYE-C showed higher attendance, and reduced wait-times and health system costs. Conclusions: Upscale of the C-EYE-C model should be considered to further improve capacity of public eye services in Australia.

22 citations


Journal ArticleDOI
TL;DR: Mandated system-wide integration appears to have structural, organizational, functional, and normative transformations, but its clinical changes are more uncertain in view of the observed divergent perspectives of actors.
Abstract: Introduction: Integrated care models for older adults are increasingly utilised in healthcare systems to overcome fragmentations. Several groups of stakeholders are involved in the implementation of integrated care. The aim of this study is to identify the main concerns, convergences and divergences in perspectives of stakeholders involved in the implementation of a centralised system-wide integrated care model for older adults in Quebec. Theory and methods: Qualitative multiple-case study. Semi-structured interviews of key stakeholders: policymakers (n = 11), providers (n = 29), managers (n = 34), older adult patients (n = 14) and caregivers (n = 9), including document analysis. Thematic analysis of the views of stakeholders along the lines of the six dimensions of the Rainbow Model of Integrated Care. Results: While patients/caregivers were mostly concerned by their unmet individual needs, policymakers, managers and providers were concerned by structural barriers to integrating care. Stakeholders’ diverse perspectives indicated implementation gaps in a top-down implementation context. Conclusion: Mandated system-wide integration appears to have structural, organizational, functional, and normative transformations, but its clinical changes are more uncertain in view of the observed divergent perspectives of actors. It will be interesting to explore if the systemic changes are precursors of clinical changes or, on the contrary, explains the lack of clinical changes.

21 citations


Journal ArticleDOI
TL;DR: Patient navigation programs can contribute to decreasing fragmentation, improving access, and promoting integrated care across disciplines, settings, and sectors for individuals across the lifespan.
Abstract: Children and youth with complex care needs require more and varied healthcare services than the average population, as well as a high degree of coordinated care. Evidence has shown that these individuals and their families have better outcomes if they have access to integrated care. Patient navigation can serve as a novel approach to improve the integration of care for individuals with complex care needs in an increasingly fragmented system. NaviCare/SoinsNavi is an example of a navigation centre for children and youth with complex care needs, their families, and the care team. This research-based service is aimed at facilitating more convenient and integrated care using a personalized family-centred approach. NaviCare/SoinsNavi employs two patient navigators who work with clients to formulate and prioritize goals based on their unmet needs. The centre serves as a living laboratory, which provides researchers, knowledge users, and clients a real life setting where innovative ideas can be explored, evaluated, modified as needed throughout the research process, and moved into policy in an efficient manner. Patient navigation programs can contribute to decreasing fragmentation, improving access, and promoting integrated care across disciplines, settings, and sectors for individuals across the lifespan.

20 citations


Journal ArticleDOI
TL;DR: Collaborations of care providers, (representatives of) people with multiple chronic conditions and researchers need to develop appropriate methods and measures to include users’ experiences in quality assessment of integrated care.
Abstract: In response to growing populations of citizens with multiple chronic conditions, integrated care models are being implemented in many countries. Based on our experiences from three EU co-funded actions (ICARE4EU, SUSTAIN, JA-CHRODIS), we notice that users’ experiences are not always taken into account when assessing the quality of integrated care, whereas research shows that it is in this particular domain that quality improvement is most evident. The greatest value of integrated care for people with multiple chronic conditions may not lie in its potential to improve their health or reduce their use of services, but in its potential to improve their care experience, by strengthening person-centred decision-making and delivering care and support accordingly. Collaborations of care providers, (representatives of) people with multiple chronic conditions and researchers need to develop appropriate methods and measures to include users’ experiences in quality assessment of integrated care.

Journal ArticleDOI
TL;DR: Organisational improvements should be considered a priority when implementing IPC within integrated care initiatives since patient care improvements due to IPC can be expected mainly when organisational aspects are improved.
Abstract: Introduction: Interprofessional collaboration (IPC) is a key ingredient of integrated care. Nevertheless, IPC benefits remain unclear and its implementation within integrated care initiatives is not straightforward. In this study, we first explored whether IPC was associated with organisational and patient care improvements in Swiss integrated care initiatives; we then investigated the effect of various barriers faced by these initiatives, on these associations. Methods: Self-reported data from 153 integrated care initiatives included in the Swiss Integrated Care Survey was used. We conducted moderated mediation analyses in which patient care improvements were the outcome, the degree of IPC implementation was the predictor, organisational improvements were the mediator, and professional, patient and financial barriers to integrated care, the moderators. Results: IPC implementation within integrated care was associated with organisational improvements, which in turn were associated with patient care improvements; this path no longer existed when financial barriers to integrated care were considered. Conclusion: Organisational improvements should be considered a priority when implementing IPC within integrated care initiatives since patient care improvements due to IPC can be expected mainly when organisational aspects are improved. More importantly, the role of financial barriers should be acknowledged, and actions taken to reduce their impact on integrated care.

Journal ArticleDOI
TL;DR: This framework can be used as a stand-alone or combined tool to guide managers to plan and evaluate the care process design of people-centred integrated care services and future work should apply this tool to other settings.
Abstract: Background: People-centred integrated care is an acknowledged approach to improve the quality and effectiveness of health systems in delivering care around people’s needs and preferences. Nevertheless, more guidance on how to effectively design, implement and evaluate the care process of people-centred integrated care services is needed. Under Project INTEGRATE, a framework was developed to guide managers in the assessment, transformation and delivery of these health service innovations. Methods: The framework is a product of the synthesis of operations, service and project management literature, relevant health care literature, and the analysis of four good practice integrated care case studies analysed under Project INTEGRATE. A first iteration of the framework was developed and then applied to one of the integrated care case studies to test its validity and utility. Results and Discussion: The tool combines a number of important considerations and criteria that have not been previously included in integrated care assessment frameworks, allowing for a pragmatic and comprehensive analysis of the care process. Conclusion: This framework can be used as a stand-alone or combined tool to guide managers to plan and evaluate the care process design of people-centred integrated care services; future work should apply this tool to other settings.

Journal ArticleDOI
TL;DR: The CCFE in the Netherlands is an exemplary initiative to integrate care for the frailest elderly living at home and its innovative components and critical success factors are likely to be transferable to other settings when providers can take on similar roles and work closely with payers who provide integrated funding.
Abstract: Introduction: Increasingly, frail elderly need to live at home for longer, relying on support from informal caregivers and community-based health- and social care professionals. To align care and avoid fragmentation, integrated care programmes are arising. A promising example of such a programme is the Care Chain Frail Elderly (CCFE) in the Netherlands, which supports elderly with case and care complexity living at home with the best possible health and quality of life. The goal of the current study was to gain a deeper understanding of this programme and how it was successfully put into practice in order to contribute to the evidence-base surrounding complex integrated care programmes for persons with multi-morbidity. Methods: Document analyses and semi-structured interviews with stakeholders were used to create a ‘thick description’ that provides insights into the programme. Results: Through case finding, the CCFE-programme targets the frailest primary care population. The person-centred care approach is reflected by the presence of frail elderly at multidisciplinary team meetings. The innovative way of financing by bundling payments of multiple providers is one of the main facilitators for the success of this programme. Other critical success factors are the holistic assessment of unmet health and social care needs, strong leadership by the care groups, close collaboration with the healthcare insurer, a shared ICT-system and continuous improvements. Conclusion: The CCFE is an exemplary initiative to integrate care for the frailest elderly living at home. Its innovative components and critical success factors are likely to be transferable to other settings when providers can take on similar roles and work closely with payers who provide integrated funding.

Journal ArticleDOI
TL;DR: Professional identity was viewed as a dynamic structural element of social life recursively related to professionals’ collaborative actions through sensemaking processes and became meaningful through a complex net of organizational and institutional features, and patients’ nosological profiles.
Abstract: Purpose: The purpose of this paper was to help answer two persistent calls in the literature: the first asks to strengthen the understanding of medical collaboration across levels of healthcare delivery; the second one requests paying more attention to the individual experience of different forms of professional work. Accordingly, the study was guided by the following research question: How do family physicians and specialists working at different levels of healthcare delivery enact their professional identity when interacting in their situated clinical contexts? Methodology: This was a multiple interpretive case study in which, based on Giddens’ ideas, professional identity was viewed as a dynamic structural element of social life recursively related to professionals’ collaborative actions through sensemaking processes. The study involved 57 participants. Face-to-face individual semi-structured interviews and organizational documents were the main sources of data. Deductive-inductive thematic analysis was adopted as strategy for data analysis. Findings: Three prevailing physicians’ identity roles were elicited: medical expert, care coordinator, and team member. These professional identities, not mutually exclusive, were instantiated in three specific modalities of collaboration: quasi-inexistent, restrained, and extended. The entanglement of a particular identity role and a specific collaborative practice became meaningful through a complex net of organizational and institutional features, and patients’ nosological profiles.

Journal ArticleDOI
TL;DR: VBHC calls for a measuring of health outcomes from a broad, plural perspective, and not merely from a health economics, primary care or other narrow scope, and incorporates measuring health outcomes that matter to the patient as essential, i.e. patient-defined outcomes and patient-reported outcome measures.
Abstract: in healthcare management and policy [1]. Value is defined as the outcomes that matter to patients related to the costs required to achieve those outcomes [2]. VBHC is thus yet another strategy that promises to “fix” health care [3]. Although it is uncertain if this purpose will be achieved, it is clear that VBHC incorporates some very relevant elements that have been hitherto absent or neglected in the daily management of organizations and health systems. To start with, a core aspect of the proposal must be highlighted here: VBHC calls for a measuring of health outcomes from a broad, plural perspective, and not merely from a health economics, primary care or other narrow scope. Not only that, but it also incorporates measuring health outcomes that matter to the patient as essential, i.e. patient-defined outcomes and patient-reported outcome measures [4]. This proposal and its instruments are not new, however it does constitute the definitive commitment to standardizing, systematizing and incorporating value-based thinking and functioning into the clinical and management routine. It involves breaking with the usual complacency of measuring activity, average stays, process indicators and resources, etc. and neglecting the true effects of healthcare interventions. Thus, the widespread acceptance of VBHC would place us in scenarios involving organizational innovation, benchmarking and benchlearning, value-based purchasing, comparative effectiveness analysis and competition for value creation – the impact of which is not yet easy to foresee, but will lead to a disruption of the business model in health regardless of the type of health system prevailing in each country. Following on from Porter and Teisberg’s proposals [1], other experts have also proposed their own theoretical models based on the underlying idea of value. For instance, there is the OECD’s Expert Panel on effective ways of investing in Health [5] defined in terms of valuebased healthcare as a comprehensive concept founded on four value-pillars: appropriate care in order to achieve patients’ personal goals (personal value), achievement of best possible outcomes with available resources (technical value), fair resource distribution across all patient groups (allocative value) and contribution of healthcare to social participation and connectedness (societal value). This definition can be useful at a macro level to ensure the financial sustainability of universal healthcare – a long-term strategy geared towards the reallocation of low-value and high-value care resources. However, it is not very actionable in clinical and management practice and, unlike Porter’s proposals, is not sufficiently nurtured by the advances made over the last few decades in Organization Theory, Strategy or Integrated Care. From a care integration perspective, Porter’s proposals already incorporate a system integration vision [6] and anticipate three key changes: horizontal integration based on units of excellence that concentrate volume according to medical condition, moving non-acute care out of hospitals and multidisciplinary work into Integrated Practice Units (IPUs). The concept of IPUs was introduced in the book Redefining Health Care [1]. The term IPU was chosen to highlight the fact that whenever an organization is doing something complicated, it should organize itself around overall customer needs being met. IPUs are multidisciplinary teams organized around meeting the needs of groups of patients with a shared clinical condition. Ultimately, at the core of VBHC there are already the seeds of a Value-Based Integrated Care vision (VBIC), but does it capture the theoretical and empirical advances of integrated care in recent decades? We believe there is a great path of conceptual and empirical progress between VBHC and integrated care that can eventually converge on a VBIC paradigm for both individuals and populations, as has been previously proposed by Valentijn and colleagues [7, 8], although their concept of value is based on Berwick and colleagues’ Triple Aim model [9]. Therefore, Valentijn and Vrijhoef defined VBIC [8] as “patients’ achieved outcomes and experience of care in combination with the amount of money spent by providing accessible, comprehensive and coordinated services to a targeted population”. Anyway, we can see that both proposals put forward by Porter and Berwick foster the implementation of integrated care delivery and new payment models that are key for transformation towards an era of value-based EDITORIAL

Journal ArticleDOI
TL;DR: This study shows how normative integration among health care professionals and employment consultants is feasible in co-located intersectoral teams, with positive implications for the delivery of coherent support.
Abstract: Introduction: Intersectoral integration is recommended in vocational rehabilitation, though difficult to implement. We describe barriers to and strategies for the development of normative integration in an intersectoral, team-based vocational rehabilitation intervention. Method: Attitudes and behaviours regarding the development of shared culture, norms, and goals in the collaboration between health care professionals and employment consultants were investigated through 30 semi-structured interviews, participant observation of 12 intersectoral meetings, and document analysis of 12 joint plans. Results: Organisational factors and unsettled power balance between professionals constituted barriers to the development of a shared culture. These issues were resolved by establishing smaller work teams, and through health care professionals’ gradual acceptance of employment consultants’ control in their capacity as administrators of legislation. Some barriers to shared norms were resolved explicitly, whereas implicit diverging norms were continuously negotiated. The development of shared goals was supported by clarifying the fit between individual, professional, and organisational goals, though the alignment of goals required a paradigmatic change of mindset among the health care professionals. Conclusion: This study shows how normative integration among health care professionals and employment consultants is feasible in co-located intersectoral teams, with positive implications for the delivery of coherent support.

Journal ArticleDOI
TL;DR: An integrated electronic health record is needed to improve accessibility of care information from within all the organisations, facilitating handovers between professionals and levels of care, and involving patients in the information flow.
Abstract: Introduction: Integrated care is believed to provide support to patients with multiple long-term and complex conditions. Transparency in information delivery is key for shared decision-making, and co-production of care. This study aimed to explore information pathways within an integrated healthcare and social care organisation and describe how information continuity was delivered for an older patient with complex care needs. Methods: An explorative single-case study conducted in a Swedish healthcare organization where municipality and the county council have integrated their services. One focus group discussion and six individual interviews were conducted. Results: Information flow to partners in care was obstructed, with compensatory double documentation, complementary information channels, and information loss. A heavy burden was on the patient and relatives to keep track of and communicate information between different caregivers. Patients were expected to be active partners in their own care, but were largely excluded from the information flow. Discussion: Even integration of care organisations does not imply that integrated care is delivered at the sharp end of practice. An integrated electronic health record is needed to improve accessibility of care information from within all the organisations, facilitating handovers between professionals and levels of care, and involving patients in the information flow.

Journal ArticleDOI
TL;DR: A translational social epidemiology protocol for confirming a critical realist “Theory of Neighbourhood Context, Stress, Depression, and the Developmental Origins of Health and Disease” to break intergenerational cycles of disadvantage and poor life outcomes is described.
Abstract: Background: We will describe here a translational social epidemiology protocol for confirming a critical realist “Theory of Neighbourhood Context, Stress, Depression, and the Developmental Origins of Health and Disease (DOHaD)”. The approach will include the concretising and contextualising of the above causal theory into programme theories for child and adolescent interventions that aim to break intergenerational cycles of disadvantage and poor life outcomes. In undertaking this work we seek to advance realist translational methodology within the discipline of applied perinatal and paediatric social epidemiology. Theory and Methods: The research settings are in metropolitan Sydney. The design will be a longitudinal, multi-level, mixed method realist evaluation of applied programme interventions that seek to break the intergeneration cycle of social disadvantage and poor child health and developmental outcomes. The programme of research will consist of three components: 1) Operationalisation of the theory and designing of programme initiatives for implementation; 2) Evaluation of the translated programme and implementation theory using Theory of Change and critical realist evaluation; and 3) Theory Testing of realist hypotheses using both intensive and extensive critical realist research methods including realist structural modelling. Discussion: The proposed programme of research will assist in translating empirical explanatory theory building to theory driven interventions. The research will be situated in socially disadvantaged regions of Sydney where the local child and family inter-agencies will collaborate to design and implement new initiatives that address significant disparities in childhood development and adolescent outcomes attributed to neighbourhood circumstances, family stress and intergenerational cycles of disadvantage and poor mental health.

Journal ArticleDOI
TL;DR: This paper provides an example of how an evaluation evolved alongside an initiative designed to better integrate care across primary, community and hospital services in South Auckland, New Zealand.
Abstract: Introduction: Not surprisingly given their multi-component nature, initiatives to improve integrated care often evolve to find the best way to bring about change. This paper provides an example of how an evaluation evolved alongside such an initiative designed to better integrate care across primary, community and hospital services in South Auckland, New Zealand. Theory and methods: Using the explanatory power of a realist evaluative approach, theories of new ways of working that might be prompted by the initiative were explored in: (i) interviews with stakeholders in 2012 and 2015, (ii) online surveys of general practices and local care organisations, and (iii) a purposive sample of ten general practices. Results: The results highlighted the institutional contexts that led to difficulties in implementing population health initiatives. They also revealed that changes in work practices focussed mostly on activities that improved the coordination of care for individuals at risk of hospital admissions. Discussion: Multi-component complex interventions can vary in their delivery and be vulnerable to one or more components not being implemented as originally intended. In the case of this intervention, the move towards strengthening local relationships arose when contractual arrangements stalled. Realist evaluative approaches offer a logic that helps unpick the complexity of the relationships and politics in play, and uncover the assumptions made by those developing, implementing and assessing health service changes. Conclusion: Given the multi-component and evolving nature of initiatives seeking to better integrate care, the realist evaluative emphasis on surfacing early the theories to explain how change is expected to occur helps overcome the challenge of evaluating “a moving target”.

Journal ArticleDOI
TL;DR: Despite stepped care models of integrated mental health service provision being promoted as optimal, there is limited knowledge surrounding the real-world cost-effectiveness of their application and clearly a need for good quality economic evaluations of integrated care that comply with international guidelines of good practice.
Abstract: Since the mid-2000s stepped care, a model of integrated healthcare delivery, has been promoted for offering accessible, effective and efficient services for individuals with mental health conditions. However, adoption of the model has not been widespread warranting additional investment by way of implementation strategies to encourage uptake. These strategies also require funding and their value for money should be assessed to inform decision making and practice. We conducted a review to better understand the extent to which the cost-effectiveness of stepped care has been evaluated (review i) and also to investigate whether economic evaluation has been applied to implementation strategies of stepped care services for anxiety and depression in developed (high income) countries and to chart their methods and outcomes (review ii). The searches were conducted in six electronic databases, grey literature and relevant journals. The search strategies returned two papers for reviews (i) and a single paper for review (ii). Despite stepped care models of integrated mental health service provision being promoted as optimal, there is limited knowledge surrounding the real-world cost-effectiveness of their application and clearly a need for good quality economic evaluations of integrated care that comply with international guidelines of good practice. There is even less information pertaining to the cost-effectiveness and budget impact of strategies designed to increase the uptake of these models.

Journal ArticleDOI
TL;DR: It is essential for evaluators to use best-practice standards when planning and conducting economic evaluations, in order to build a reliable evidence base for decision-making in integrated care.
Abstract: Introduction: The aim of this review is to systematically assess the methodological quality of economic evaluations in integrated care and to identify challenges with conducting such studies. Theory and methods: Searches of grey-literature and scientific papers were performed, from January 2000 to December 2018. A checklist was developed to assess the quality of economic evaluations. Authors’ statements of challenges encountered during their evaluations were qualitatively coded. Results: Forty-four articles were eligible for inclusion. The review found that study design, measurement of cost and outcomes, statistical analysis and presentation of data were the areas with most quality variation. Authors identified challenges mostly related to time horizon of the evaluation, inadequate or lack of comparator group, contamination bias, and a post-hoc evaluation culture. Discussion: Our review found significant differences in quality, with some studies showing poor methodological rigor; challenging conclusions on the cost-effectiveness of integrated care. Conclusion: It is essential for evaluators to use best-practice standards when planning and conducting economic evaluations, in order to build a reliable evidence base for decision-making in integrated care.

Journal ArticleDOI
TL;DR: This case study investigates the legitimacy of the HiAP approach in three Norwegian municipalities and suggests that legitimacy based on the integration of HiAP in planning and management structures and in formal documents seems easier or less complicated to achieve than other types of legitimacy related to personal understanding, values and norms.
Abstract: Introduction: The 2012 Norwegian Public Health Act stipulates that all Norwegian municipalities need to integrate public health concerns in their decision-making processes at all policy levels. Based on a Health in All Policies (HiAP) approach, population health and health equity are seen as whole-of-government responsibilities, making all municipal actors across sectors and professional boundaries responsible for health issues. Although many municipalities are well on their way towards implementing this goal, several experience a lack of legitimacy and inter-sectoral collaboration, as well as encounter conflicting professional identities. Theory and Methods: In this interview-based case study, we investigate the legitimacy of the HiAP approach in three Norwegian municipalities. We use an institutional perspective to analyse legitimacy, and we discuss how professional identities might relate to the implementation of this inter-sectoral collaboration. Results: Our findings suggest that the three municipalities are in the process of legitimising HiAP. Further, that legitimacy based on the integration of HiAP in planning and management structures and in formal documents seems easier or less complicated to achieve than other types of legitimacy related to personal understanding, values and norms. Conclusions and discussion: We argue that these findings may be related to the possible risk of identity conflicts, which could potentially pose challenges to collaborations, such as HiAP, and then again challenge the implementation of integrated care.

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TL;DR: The perspectives of the coordinators on inter-organisational collaboration are a valuable starting point for interventions directed at the stronger integration of palliative care for residents of long term-care facilities.
Abstract: Introduction: Nursing home residents are a vulnerable and frail segment of the population, characterised by their complex and palliative care needs. To ensure an integrated approach to palliative care for this target group, working on a collaborative basis with multiple providers across organisational boundaries is necessary. Considering that coordinators of palliative networks support and coordinate collaboration, the research question is: ‘how do network coordinators perceive the process of collaboration between organisations in Flemish palliative networks?’ Methods: A dual-phase sequential mixed-methods design was applied. First, the coordinators of each of the fifteen palliative networks in Flanders completed a survey in which they evaluated ten aspects of collaboration for two types of cooperation: between nursing homes and home care, and between nursing homes and hospitals. Next, the survey results thus obtained were discussed to improve understanding in a focus group composed of the above coordinators, and which was analysed on the basis of content analysis. Results: In both forms of cooperation, the ‘formalisation’ and ‘governance’ were the aspects that yielded the lowest mean scores. The coordinators in the focus group expressed a need for more formalised interaction among organisations with regard to palliative care, the establishment of formal channels of communication and the exchange of information, as well as the development of shared leadership. Conclusions: The perspectives of the coordinators on inter-organisational collaboration are a valuable starting point for interventions directed at the stronger integration of palliative care for residents of long term-care facilities.

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TL;DR: A pioneering new method of analysis is presented in drawing on theoretical and methodological extensions of two prominent approaches, namely, social network analysis and developmental social ecology, to provide a new innovative approach to the delivery of integrated care.
Abstract: Efforts to address problems such as mental health, poverty, social exclusion, and chronic disease have often proven resistant to traditional policies or interventions. In this paper, we take up the challenge and present a pioneering new method of analysis in drawing on theoretical and methodological extensions of two prominent approaches, namely, social network analysis and developmental social ecology. Considered in combination, these two seemingly disparate approaches frame a powerful new way of thinking about person-centred care, as well as offer a methodologically more rigorous set of analytical tools. The conceptual model developed from this combination offers to bridge the apparent disconnect between service integration levels and patient needs in such a way as to direct optimal effort to interventions at the individual level and to provide a new innovative approach to the delivery of integrated care.

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TL;DR: A multilevel approach is developed that uses mixed-method research to examine not only outcomes, but also what is working for whom and why in Sydney, Australia.
Abstract: Introduction: In March 2014, the New South Wales (NSW) Government (Australia) announced the NSW Integrated Care Strategy. In response, a family-centred, population-based, integrated care initiative for vulnerable families and their children in Sydney, Australia was developed. The initiative was called Healthy Homes and Neighbourhoods. A realist translational social epidemiology programme of research and collaborative design is at the foundation of its evaluation. Theory and Method: The UK Medical Research Council (MRC) Framework for evaluating complex health interventions was adapted. This has four components, namely 1) development, 2) feasibility/piloting, 3) evaluation and 4) implementation. We adapted the Framework to include: critical realist, theory driven, and continuous improvement approaches. The modified Framework underpins this research and evaluation protocol for Healthy Homes and Neighbourhoods. Discussion: The NSW Health Monitoring and Evaluation Framework did not make provisions for assessment of the programme layers of context, or the effect of programme mechanism at each level. We therefore developed a multilevel approach that uses mixed-method research to examine not only outcomes, but also what is working for whom and why.

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TL;DR: Making care more tailored to the needs of patients with multi-morbidity by paying attention to patient-centered care and co-creation of care is expected to contribute to better outcomes.
Abstract: Background: Patients with multi-morbidity have complex care needs that often make healthcare delivery difficult and costly to manage. Current healthcare delivery is not tailored to the needs of patients with multi-morbidity, although multi-morbidity poses a heavy burden on patients and is related to adverse outcomes. Patient-centered care and co-creation of care are expected to improve outcomes, but the relationships among patient-centered care, co-creation of care, physical well-being, social well-being, and satisfaction with care among patients with multi-morbidity are not known. Methods: In 2017, a cross-sectional survey was conducted among 216 (of 394 eligible participants; 55% response rate) patients with multi-morbidity from eight primary care practices in Noord-Brabant, the Netherlands. Correlation and regression analyses were performed to identify relationships among patient-centered care, co-creation of care, physical well-being, social well-being, and satisfaction with care. Results: The mean age of the patients was 74.46 ± 10.64 (range, 47–94) years. 40.8% of the patients were male, 43.3% were single, and 39.3% were less educated. Patient-centered care and co-creation of care were correlated significantly with patients’ physical well-being, social well-being, and satisfaction with care (all p ≤ 0.001). Patient-centered care was associated with social well-being (B = 0.387, p ≤ 0.001), physical well-being (B = 0.368, p ≤ 0.001) and satisfaction with care (B = 0.425, p ≤ 0.001). Co-creation of care was associated with social well-being (B = 0.112, p = 0.006) and satisfaction with care (B = 0.119, p = 0.007). Conclusions: Patient-centered care and co-creation of care were associated positively with satisfaction with care and the physical and social well-being of patients with multi-morbidity in the primary care setting. Discussion/Lessons learned: Making care more tailored to the needs of patients with multi-morbidity by paying attention to patient-centered care and co-creation of care is expected to contribute to better outcomes. Furthermore, the findings of this study demonstrate the importance of separately examining physical and social well-being in future research among multi-morbidity patients. Limitations: The cross-sectional design prevented us from determining the causality of relationships. Suggestions for future research: Research in other regions and/or countries is needed to confirm our study findings.

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TL;DR: When a new healthcare service such as an MAU becomes a part of the clinical pathway in a municipality, it is important to invest a considerable effort in measures designed to strengthen relational and structural collaboration to make the Clinical pathway smooth.
Abstract: Introduction: Since 2016, Norwegian municipalities have been obliged to provide municipal acute 24-hour services representing a service before or instead of hospital treatment. This study explores two municipal acute units (MAUs) as part of the clinical pathway for older patients. Methods: Patients and healthcare providers from MAUs, purchaser offices, home-based nursing, and physicians were interviewed. Interview transcripts were analysed using systematic text condensation. Results: The collaboration between the MAU staff and the GPs, the purchaser offices and the home-based services is described as challenging, mostly due to disagreement regarding patients’ admission and discharge. The providers’ different understanding seems to derive especially from where they are working in a way that suits their own work functions. An exigent collaboration between providers in the MAUs and their collaborative partners hampers the clinical pathway for older patients in the municipal healthcare service. Conclusion and discussion: When a new healthcare service such as an MAU becomes a part of the clinical pathway in a municipality, it is important to invest a considerable effort in measures designed to strengthen relational and structural collaboration to make the clinical pathway smooth.

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TL;DR: The reader will be stimulated by Schrijvers’s arguments on how integrated care contributes to the actualization of the Triple Aim—i.e., enhancing population health and improving quality of care (better), while lowering cost per capita (cheaper).
Abstract: an excellent book for those interested in learning about the foundations of integrated care and how it addresses many challenges in the healthcare industry. While the author suggests that the book is aimed at professionals, managers, and health care policy-makers, I would propose that it can also be an asset in an introductory graduate level course on integrated care. Throughout the book, the reader will be stimulated by Schrijvers’s arguments on how integrated care contributes to the actualization of the Triple Aim—i.e., enhancing population health and improving quality of care (better), while lowering cost per capita (cheaper). Discussing hundreds of articles as evidence that integrated care is, in fact, better and cheaper than traditional non-integrated care, Schrijvers presents the evidence along six dimensions: type of integrated care, patients as partners, quality of integrated care, paying integrated care digitization and integrated e-health, and leadership, innovation and research of integrated care (integrated care policies). The book is divided in parts, each representing one of the dimensions of integrated care cited above. In the introductory chapters, the author presents basic concepts and technical terms used throughout the book, and familiarizes the reader with the basic question of the book: “Is it possible to improve population health, increase quality of care for the individual and lower per capita costs of care using person-centered integrated care?” In each subsequent chapter, Schrijvers describes evidence from research and from his own experience in healthcare in the Netherlands, such that the reader can appreciate how integrated care satisfies the aspirations of the Triple Aim. In part 2, Types of Integrated Care, Schrijvers discusses the benefits of horizontal integration, vertical integration, case management, pharmaceutical care and integration with social services. The evidence points to lower cost per capita associated with each of these different areas of integrated care, as well as improvement in population health and better quality of care for the individual. In part 3, the partnership between patients and providers within integrated care is examined. The author discusses how changes in behavior associated with developments in society, such as improvement in hygiene, have a greater impact on public health than the development of medical science. He argues that the individual is the greatest change agent of his own health, and he postulates that integrated care can enhance the success of self-management and shared decision-making. In part 4, Schrijvers presents different perspectives on quality of integrated care; that of the professional and that of the patient. He proposes variables associated with each perspective, and ways that organizations can measure advances associated with lowering costs and improvements in patient experience. In part 5, financing integrated care is discussed. Schrijvers discusses how behavioral economics concepts can explain decisionmaking processes in the set-up of healthcare programs, and how to use these concepts and strategies for service improvement and lowering costs. He presents the “cappuccino model”, which is essentially a combination of three layers (population-based payment, a low fee-forservice, and a low fee for innovation or pay for performance). In addition, he discusses the use of integrated personal budget funding system. In part 6, advances in digitization and e-health such as changes to the electronic health record (EHR) and practical issues in e-health are examined. Schrijvers proposes that data derived from EHR can help in the design of population health programs. In part 7, the role of leadership in supporting integrated care is explored along with research principles in integrated care. In the conclusion, a summary table is presented with the findings discussed in each chapter as they are applied to the main question of the book, giving the reader a place for quick referencing concepts discussed in the chapters. While these topics are presented separately, the author emphasizes how these concepts are interconnected and directs the reader to related resources introduced in the book. The explicit focus of the book was the Triple Aim, however, the reader can also infer from the book’s examples how integrated care benefits the fourth aim, care of the provider, as well. Those who are beginning their journey in integrated care will find in this book a well-organized BOOK REVIEW

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TL;DR: Central characteristics of leadership in integrated care networks are reviewed, drawing attention to persistent tensions as a core leadership challenge and offering latest scholarly evidence practitioners can use to reflect on and advance their own leadership practice.
Abstract: Introduction: In many countries, elderly patients with chronic conditions require a web of services delivered by several providers collaborating in inter-organisational networks. In view of their global importance, it is surprising how little we know how these networks are led. Like traditional organisations, networks require leadership to function effectively. This paper reviews central characteristics of leadership in integrated care networks and proposes opportunities for future research. Theory and methods: Analysing 73 studies published in leading academic journals, this paper consolidates research on leadership media, practices, activities and outcomes, covering the network, policy and organisation levels of analysis. Results: Findings indicate that the field has focused on leadership media and outcomes at the network level. They also suggest that leadership in integrated care networks faces multiple tensions. Future research could usefully provide a fuller picture by examining leadership practices, activities and outcomes at the policy and organisation level, integrating advances in the wider leadership literature. Discussion and conclusion: These findings contribute to the debate on leadership in integrated care networks. They also inform practice, drawing attention to persistent tensions as a core leadership challenge and offering latest scholarly evidence practitioners can use to reflect on and advance their own leadership practice.