Showing papers in "Journal of Integrated Care in 2018"

Transforming primary care: scoping review of research and practice

Abstract: Purpose The purpose of this paper is to reflect on research evidence and practice experience of transforming primary care to a more integrated and holistic model. Design/methodology/approach It is based on a scoping review which has been guided by primary care stakeholders and synthesises research evidence and practice experience from ten international case studies. Findings Adopting an inter-professional, community-orientated and population-based primary care model requires a fundamental transformation of thinking about professional roles, relationships and responsibilities. Team-based approaches can replicate existing power dynamics unless medical clinicians are willing to embrace less authoritarian leadership styles. Engagement of patients and communities is often limited due to a lack of capacity and belief that will make an impact. Internal (relationships, cultures, experience of improvement) and external (incentives, policy intentions, community pressure) contexts can encourage or derail transformation efforts. Practical implications Transformation requires a co-ordinated programme that incorporates the following elements – external facilitation of change; developing clinical and non-clinical leaders; learning through training and reflection; engaging community and professional stakeholders; transitional funding; and formative and summative evaluation. Originality/value This paper combines research evidence and international practice experience to guide future programmes to transform primary care.

Co-production in integrated health and social care programmes: a pragmatic model

Abstract: The purpose of this paper is to outline the current thinking on co-production in health and social care, examine the challenges in implementing genuine co-production and argue for a pragmatic version of co-production that may assist programme managers in deciding which type of co-production is most suitable for which programme.,A discussion paper based on the professional and academic knowledge and insights of the authors. A focus group interview schedule was used to guide discussions between authors.,The authors argue for a pragmatic approach to co-production within integrated care programmes. The authors set out the basic parameters of such an approach containing procedural rather than substantive standards for co-production activities leaving sufficient room for specific manifestations of the practice in particular contexts.,The authors put forward a pragmatic model of co-production that defines the essential elements of a process for ensuring services are designed to meet with the needs of patients yet allowing the process itself to be adapted to different circumstances.,The paper summarises the discussion on co-production in relation to integration programmes. It formulates a pragmatic model of co-production that may assist programme managers in establishing good practice co-production frameworks when designing or implementing integrated health and social care services.

Delivering primary health care as envisioned: A model of health and well-being guiding community-governed primary care organizations

Abstract: Purpose For over 40 years, Canadian and international bodies have endorsed comprehensive primary health care (PHC), yet very little work has been done to describe how services and programs are delivered within these organizations. Because health equity is now of greater interest to policy makers and the public, it is important to describe an evidence-informed framework for the delivery of integrated and equitable PHC. The purpose of this paper is to describe the development of a “Model of Health and Well-being” (MHWB) that provides a roadmap to the delivery of PHC in a successful network of community-governed PHC organizations in Ontario, Canada. Design/methodology/approach The MHWB was developed through an iterative process that involved members of community-governed PHC organizations in Ontario and key stakeholders. This included literature review and consultation to ensure that the model was evidence informed and reflected actual practice. Findings The MHWB has three guiding principles: highest quality health and well-being for people and communities; health equity and social justice; and community vitality and belonging. In addition, there are eight attributes that describe how services are provided. There is a reasonable evidence base underpinning the all principles and attributes. Originality/value As comprehensive, equitable PHC organizations become increasingly recognized as critical parts of the health care system, it is important to have a means to describe their approach to care and the values that drive their care. The MHWB provides a blueprint for comprehensive PHC as delivered by over 100 Community Governed Primary Health Care (CGPHC) organizations in Ontario. All CGPHC organizations have endorsed, adopted and operationalized this model as a guide for optimum care delivery.

An integrated care programme in London: qualitative evaluation

Abstract: Purpose A well-funded, four-year integrated care programme was implemented in south London. The programme attempted to integrate care across primary, acute, community, mental health and social care. The purpose of this paper is to reduce hospital admissions and nursing home placements. Programme evaluation aimed to identify what worked well and what did not; lessons learnt; the value of integrated care investment. Design/methodology/approach Qualitative data were obtained from documentary analysis, stakeholder interviews, focus groups and observational data from programme meetings. Framework analysis was applied to stakeholder interview and focus group data in order to generate themes. Findings The integrated care project had not delivered expected radical reductions in hospital or nursing home utilisation. In response, the scheme was reformulated to focus on feasible service integration. Other benefits emerged, particularly system transformation. Nine themes emerged: shared vision/case for change; interventions; leadership; relationships; organisational structures and governance; citizens and patients; evaluation and monitoring; macro level. Each theme was interpreted in terms of “successes”, “challenges” and “lessons learnt”. Research limitations/implications Evaluation was hampered by lack of a clear evaluation strategy from programme inception to conclusion, and of the evidence required to corroborate claims of benefit. Practical implications Key lessons learnt included: importance of strong clinical leadership, shared ownership and inbuilt evaluation. Originality/value Primary care was a key player in the integrated care programme. Initial resistance delayed implementation and related to concerns about vertical integration and scepticism about unrealistic goals. A focus on clinical care and shared ownership contributed to eventual system transformation.

Values, interests and power: the politics of integrating services

Abstract: Differences in professional values, organisational interests and access to resources are key issues to be addressed when integrating services. They are widely seen by service planners and commissioners to be matters of governance. However, they also inform critical debates in political science. In essence they revolve around the question of distribution, or (how to decide) who gets what. The purpose of this paper is to re-frame the subject of inter-organisational governance in integration by conceptualising it through the lens of three prominent politico-theoretical approaches: the liberal, the authoritarian and the radical-utopian.,A discussion paper that proceeds by utilising political science terms of reference and applying it to a public management problem.,All three theories provide particular insights into the way in which service planners and commissioners may think about the inescapable plurality of values and interests in integration programmes. Where the liberal perspective places particular emphasis on the purpose and utility of organisational autonomy and self-direction, the authoritarian model highlights the need to produce results within tight timescales. It also accords with the manner in which integration policy is normally implemented, top down. The radical-utopian model is built on the least realistic assumptions but offers researchers a useful framework to assess the rationale and effectiveness of value-based policy in integration programmes wherever robust inter-organisational structures fail to materialise.,Whilst there has been significant research on how to conceptualise integration programmes, scholars have usually championed a public management approach. The potential insights of political thought have not been explored until now. The paper demonstrates that the wider conceptual framework of political theory has significant purchase in the field of integration studies and can help us understand the benefits and limitations of an interdisciplinary approach.

An evaluation of the reablement service programme on physical ability, care needs and care plan packages.

Abstract: Purpose In response to an aging population and rising prevalence of disability, reablement initiatives have been introduced yet the evidence base concerning the long-term effects remains inconclusive. The purpose of this paper is to examine the impact of reablement on physical independence, care plans and care packages post-discharge for older adults. Design/methodology/approach A retrospective cohort design was used to examine patient records who had completed a reablement programme. Measures on internationally renowned and psychometrically strong tools, completed by trained healthcare professionals, were examined pre-and post-intervention with a consecutive sample (n=416) of participants since the introduction of the reablement programme. Findings Reablement had a significant impact on physical independence living scores and a corresponding reduction in care needs and care plans post-discharge enabling the person to stay at home. Originality/value The study’s findings present empirical evidence on the value of reablement health service programme developed to promote independent living at home following a short illness, for older people. While no examination of financial data was recorded in this study, the increase in physical ability and corresponding reduction in care needs and care plans post-discharge indicates a reduction in costs and a better standard of living.

Effectiveness of joint specialist case conferences for building general practice capacity to enhance diabetes care: A pilot study in Western Sydney, Australia

Abstract: Purpose Type 2 diabetes mellitus has become a major concern of Australian healthcare providers. From rates of barely more than 1 percent in the mid-90s, diabetes is now the leading cause of morbidity in the country. To combat the growing diabetes epidemic, Western Sydney Local Health District created the Western Sydney Diabetes (WSD) initiative. One of the key components of the WSD initiative since 2014 has been joint specialist case conferencing (JSCC). The purpose of this paper is to evaluate the JSCC service including both individual- and practice-based changes. Design/methodology/approach The authors evaluated the JSCC program by conducting an analysis of patient-level data in addition to a discrete practice-level study. The study aim was to examine both the effect on individual patients and the practice, as well as acceptability of the program for both doctors and their patients. The evaluation included data collection and analysis of primary patient outcomes, as well as a survey of GPs and patients. Patient data on primary outcomes were obtained by accessing and downloading them through GP practice management software by GP practice staff. Findings The authors found significant improvements at both the patient levels, with reductions in BMI, HbA1c and blood pressure sustained at three years, and at the practice level with improvements in markers of patient management. The authors also found high acceptability of the program from both patients and GPs. Originality/value This paper provides good evidence for the use of a JSCC program to improve diabetes management in primary care through capacity building with GPs.

The health care home in New Zealand: rolling out a new model of primary health care

Abstract: Purpose The purpose of this paper is to report on the origins, development and early impacts of a Health Care Home (HCH) model of care being rolled out around New Zealand (NZ). Design/methodology/approach This paper draws on a literature review on HCHs and related developments in primary health care, background discussions with key players, and a review of significant HCH implementation documents. Findings The HCH model of care is emerging from the sector itself and is being tailored to local needs and to meet the needs of local practices. A key focus in NZ seems to be on business efficiency and ensuring sustainability of general practice – with the assumption that freeing up general practitioner time for complex patients will mean better care for those populations. HCH models of care differ around the world and NZ needs its own evidence to show the model’s effectiveness in achieving its goals. Research limitations/implications It is still early days for the HCH model of care in NZ and the findings in this paper are based on limited evidence. Further evidence is needed to identify the model’s full impact over the next few years. Originality/value This paper is one of the first to explore the HCH model of care in NZ.

Diffusion theory and multi-disciplinary working in children’s services

Abstract: Purpose: The purpose of this paper is to explore how innovation in children’s services is adopted and developed by staff within new multi-disciplinary children’s safeguarding teams. It draws on diffusion of innovations (DOI) theory to help us better understand the mechanisms by which the successful implementation of multi-disciplinary working can be best achieved. Design/methodology/approach: It is based on interviews with 61 frontline safeguarding staff, including social workers, substance misuse workers, mental health workers and domestic abuse workers. Thematic analysis identified the enablers and barriers to implementation. Findings: DOI defines five innovation attributes as essential for rapid diffusion: relative advantage over current practice; compatibility with existing values and practices; complexity or simplicity of implementation; trialability or piloting of new ideas; and observability or seeing results swiftly. Staff identified multi-disciplinary team working and group supervision as advantageous, in line with social work values and improved their service to children and families. Motivational interviewing and new ways of case recordings were less readily accepted because of the complexity of practicing confidently and concerns about the risks of moving away from exhaustive case recording which workers felt provided professional accountability. Practical implications: DOI is a useful reflective tool for senior managers to plan and review change programmes, and to identify any emerging barriers to successful implementation. Originality/value: The paper provides insights into what children’s services staff value about multi-disciplinary working and why some aspects of innovation are adopted more readily than others, depending on the perception of diffusion attributes.

Mapping the "housing with care" concept with stakeholders: insights from a UK case study.

Abstract: Purpose The purpose of this paper is to present the findings of an early stage, exploratory case study of a proposed housing with care initiative (the Crichton Care Campus (CCC)). This sought the perspectives of a range of key stakeholders on the proposed model and how it might be best realised. The analyses of these findings show their relevance to debates on integrated housing with care, and reflect on the methodology used and its potential relevance to similar projects. Design/methodology/approach The study used a transactive planning approach, where grounded views are sought from a variety of stakeholders. A purposive sample identified informants from relevant health, social care and housing organisations and nine semi-structured interviews were conducted. These were transcribed and data analysis was undertaken on an “interactive” basis, relating care theory to empirical expressions. Findings The authors identify two contrasting orientations – inclusive “community-oriented” and professional “service-oriented”. This distinction provides the basis for a rudimentary conceptual map which can continue to be used in the planning process. Two significant variables within the conceptual map were the extent to which CCC should be intergenerational and as such, the degree to which care should come from formalised and self-care/informal sources. The potential to achieve an integrated approach was high with stakeholders across all sectors fully supporting the CCC concept and agreeing on the need for it to have a mixed tenure basis and include a range of non-care amenities. Originality/value This paper offers originality in two respects. Methodologically, it describes an attempt to undertake early stage care planning using a needs led transactive methodology. In more practical terms, it also offers an innovative environment for considering any approach to care planning that actively seeks integration – based on an acknowledgement of complexity, a variety of perspectives and possible conflicts. The authors propose that the concepts of “community-orientation” and “service-orientation” are used as a helpful basis for planning negotiations, making implicit divergences explicit and thus better delineated.

Study of the Local Health Integration Network: impact of Ontario’s Regionalization Policy

Abstract: Purpose The purpose of this paper is to undertake an examination of the Local Health Integration Network (LHIN) Health Policy proposal. This policy established a decentralized approach to health system management in the province of Ontario, Canada by creating 14 crown agencies, LHINs. Design/methodology/approach This policy is examined against the five policy stages of the Stages Model: agenda setting, formulation, legitimation, implementation and evaluation. The examination was based on a review of grey literature, including key government reports and briefs. Findings This policy did not follow the Stages Model sequentially: the policy was implemented while it was still undergoing its legitimacy phase. Formal reviews were undertaken following implementation and found areas for improvement: poor integration amongst all the LHINs; poor patient navigation persists; LHINs lack the capacity and competency to engage in regional capacity planning; and planning and integration is not centered around patient needs. As a result, a decade after the introduction of LHINs, the Ontario HealthCare System has not achieved systems improvement when measured against accepted government indicators of performance. Originality/value This integration policy highlights the context and evolution of Ontario’s healthcare system governance in the past decade and contributes to the body of knowledge on the impact of regionalization on health systems and patient care.

The business of integrated care: implementing new models of care in a fee-for-service setting

Abstract: Purpose The Western New South Wales Integrated Care Strategy (ICS) was rolled out from November 2014 across three rural sites. The purpose of this paper is to assess its impact on general practices, and examine the feasibility of implementing an ICS, within a predominantly fee-for-service delivery model. Design/methodology/approach Mixed methods were used to analyse the implementation of the ICS, including practice-level patient data on changes in service provision. This includes unit-record data on 130 enroled patients across three rural sites, as well as qualitative data collection from providers. Findings There were significant increases in both revenue-generating and non-revenue-generating activities (primarily care coordination activities) associated with implementing the ICS. Each occasion of service involved greater contact time with practice staff other than GPs, as well as greater administration time. There is evidence that ICS activities such as case conferencing and team care planning substitute for traditional GP consultations. Overall, the study found that a significant investment of resources – namely staff time devoted to a range of activities – was required to support the implementation of the ICS. Such an investment was supported both externally and through revenue-generating practice-level activities. Research limitations/implications The data collection and evaluation project is ongoing, with analysis based on the first wave of data from three sites. Practical implications At the practice level, a substantial commitment of resources is required to invest in, and sustain, a new model of integrated care (IC). This commitment can currently be supported both through higher revenue generation at the practice level, and externally by health system stakeholders, but changes in financial settings could impact on financial viability. Originality/value This paper provides evidence on the role of blended payment mechanisms in facilitating the implementation of IC in a rural setting where there are medical workforce constraints.

Can we mandate partnership working? Top down meets bottom up in structural reforms in Scotland and Norway

Abstract: Partnership working across health and social care is considered key to manage rising service demand whilst ensuring flexible and high-quality services. Evidence suggests that partnership working is a local concern and that wider structural context is important to sustain and direct local collaboration. “Top down” needs to create space for “bottom up” management of local contingency. Scotland and Norway have recently introduced “top down” structural reforms for mandatory partnerships. The purpose of this paper is to describe and compare these policies to consider the extent to which top-down approaches can facilitate effective partnerships that deliver on key goals.,The authors compare Scottish (2015) and Norwegian (2012) reforms against the evidence of partnership working. The authors foreground the extent to which organisation, finance and performance management create room for partnerships to work collaboratively and in new ways.,The two reforms are held in place by different health and social care organisation and governance arrangements. Room for manoeuvre at local levels has been jeopardised in both countries, but in different ways, mirroring existing structural challenges to partnership working. Known impact of the reforms hitherto suggests that the potential of partnerships to facilitate user-centred care may be compromised by an agenda of reducing pressure on hospital resources.,Large-scale reforms risk losing sight of user outcomes. Making room for collaboration between user and services in delivering desired outcomes at individual and local levels is an incremental way to join bottom up to top down in partnership policy, retaining the necessary flexibility and involving key constituencies along the way.

Retrospective analysis of telemonitoring in Wollondilly, Australia

Abstract: The purpose of this paper is to analyse early findings from telemonitoring data for chronic obstructive pulmonary disease patients, residing in Wollondilly Shire, New South Wales, Australia. The Shire has 19 small scattered and isolated rural communities, which experience undersupply of healthcare providers. Findings are to be used for further research to support wider implementation of telemonitoring by general practitioners (GPs).,Local patients with multiple chronic obstructive pulmonary disease hospital admissions were allocated home telemonitoring equipment, entering readings according to their GP management plan. Demographic, biometric and self-assessment readings were retrospectively collected, from July 2015 to April 2016.,Data for 18 patients aged 44-87, with equal gender representation was analysed. There was a total of 24,545 data points from 2,932 readings. Over half showed high clinical risk; 93 occasions required GP escalation, 23 per cent for respiratory conditions, in 14 patients. Nine were hospitalised, 51 per cent for respiratory conditions.,Home telemonitoring of chronic obstructive pulmonary disease was found to be a promising patient management approach, providing accurate, reliable health indicators. Its use empowered patients to improve symptom control and health outcomes.,Experience in Australian general practice with telemonitoring is limited. High protocol compliance occurred, risk indicators were obtained and the value of home telemonitoring was confirmed.

Care transition types across acute, sub-acute and primary care: case studies of older people with complex conditions and their carers

Abstract: The purpose of the paper is to examine the care transitions of older people who transfer between home, acute and sub-acute care to determine if there were common transition types and areas for improvements.,A longitudinal case study design was used to examine care transitions of 19 older people and their carers as a series of transitions and a whole-of-system experience. Case study accounts synthesising semi-structured interviews with function and service use data from medical records were compared.,Three types of care transitions were derived from the analysis: manageable, unstable and disrupted. Each type had distinguishing characteristics and older people could experience elements of all types across the system. Transition types varied according to personal and systemic factors.,This study identifies types of care transition experiences across acute, sub-acute and primary care from the perspective of older people and their carers. Understanding transition types and their features can assist health professionals to better target strategies within and across the system and improve patient experiences as a whole.

The case for mental health support at a primary care level

Abstract: Severe mental illness affects a significant number of people and, if left untreated, leads to poor quality of life and disability. Many of the aspirations proposed for new models of care assert that better preventative services, closer integration between professionals, and increased access to cognitive behavioural therapy in primary care will bring substantial benefits and improved outcomes. The purpose of this paper is to explore the benefits of integrating mental health services into primary care, and improving collaboration between secondary services and primary care. There is a transition underway in healthcare whereby a focus on illness is being supplemented with, or refocused towards achieving better patient well-being. New approaches to service provision are being proposed that: focuses on more holistic outcomes; integrates services around the user; and employs innovative system techniques to incentivise professional and organisational collaboration. Such a transition must be inclusive of those with mental health needs managed in primary care and for those people with serious mental illness in secondary care.,This paper discusses the issues of professional collaboration and the need to provide mental healthcare in a continuous and coordinated manner and; how this may improve timely access to treatment, early diagnosis and intervention. Importantly, it is essential to consider the limitations and reality of recent integration initiatives, and to consider where the true benefit of better integrating mental health into a more collaborative system may lie.,Identifying and addressing issues of parity is likely to call for a new approach to service provision that: focuses on outcomes; co-designs services integrated around the user; and employs innovative contracting techniques to incentivise provider integration.,There is a transition underway in healthcare whereby a focus on illness is being supplemented with or refocused towards working towards wellness. Such a transition requires primary care mental health services to be provided in a continuous and coordinated manner in order to meet the health needs of people with serious mental illness.,It discusses the issues of professional collaboration and how this may improve timely access to treatment, early diagnosis and intervention. It is essential to consider the limitations and reality of recent integration initiatives, and to consider where the true benefit may lie.

Having a voice: A collaborative research project exploring the challenges and assets of people experiencing homelessness

Abstract: Purpose The purpose of this paper is to understand the lived experience of people who have experienced homelessness and street activity, and professional stakeholders’ views about the challenges faced by this client group. The study sought to identify measures to improve the current situation for both individuals experiencing homelessness and professionals working with them. Design/methodology/approach Peer researchers with lived experience of multiple and complex needs conducted semi-structured interviews/surveys with 18 participants (eight individuals experiencing homelessness and street activity and ten professional stakeholders). The authors of the paper conducted a thematic analysis of the data. Findings This paper offers insights into both the current challenges and assets for people who are or have been homeless in an urban setting. Key findings include the need for a coordinated partnership approach to address pathways to support, and the importance of developing opportunities for meaningful activity and building on local resources including giving homeless people a voice. These findings are discussed within the context of current policy (Housing First) and legislation (Homelessness Reduction Act 2017) and the impact on integrated care for people who have experienced homelessness. Research limitations/implications The views explored in this study are specific to one city centre in the West Midlands; thus, generalisability may be limited. Originality/value This study presents a participatory research approach with peer researchers exploring the perspective of individuals experiencing homelessness and wider stakeholders. The findings of this research are considered with reference to the provisions of the HRA 2017.

Frequent presentations to emergency departments and the collaborative community and emergency response: A case series

Abstract: Purpose Patient dependence on an emergency department (ED) for ongoing, non-urgent health care is a complex issue related to poor mental and physical health, disability, previous trauma, social disadvantage and lack of social supports. Working Together to Connect Care is an innovative program that provides an assertive community case management approach coupled with an ED management plan to support people who frequently attend the Royal Brisbane and Women’s Hospital ED. The program, which is yet to be fully evaluated, currently helps to manage a large number of patients with a wide variety of complex needs. To demonstrate the scope and capabilities of the program, the purpose of this paper is to present a series of case studies of patients who frequently attended the ED and subsequently became program participants. Design/methodology/approach A series of five case studies is used to illustrate the variety of patient characteristics and available management pathways. Outcomes, including rates of ED attendance, at five months after program commencement are also described. Findings The variety of characteristics and experiences of the patients in the case studies is representative of the program cohort as a whole. Program participation has resulted in improved patient outcomes as demonstrated by crisis resolution, housing stability, engagement with primary health care and reduced frequency of ED presentations. Originality/value A personalized, integrated-care management approach is both flexible and effective in responding to the complex needs of five patients who frequently attend EDs.

Improving inter-organizational care-cure designs: specialization versus integration

Abstract: The purpose of this paper is to investigate inter-organizational designs for care–cure conditions in which low-risk patients are cared for in specialized care organizations and high-risk patients are cared for in specialized cure organizations. Performance impacts of increasing levels of integration between these organizations are analyzed.,Mixed methods were used in Dutch perinatal care: analysis of archival data, clinical research and system dynamics simulation modeling.,Inter-organizational design has an effect on inter-organizational dynamics such as collaboration and trust, and also on the operational aspects such as patient flows through the system. Solutions are found in integrating care and cure organizations. However, not all levels of integrated designs perform better than a design based on organizational separation of care and cure.,A clear split between midwifery practices (care) and obstetric departments (cure) will not work since all pregnant women need both care and cure. Having midwifery practices only works well when there are high levels of collaboration and trust with obstetric departments in hospitals. Integrated care designs are likely to exhibit superior performance. However, these designs will have an adverse effect on organizations that are not part of this integration, since integrating only a subset of organizations will feed distrust, low collaboration and hence low performance.,The originality of this research is derived from its multi-method approach. Archival data and clinical research revealed the dynamic relations between organizations. The caveat of some integrated care models was found through simulation.

The need for care integration across hospital services for adults with sickle cell disease

Abstract: Purpose The purpose of this paper is to examine the risk factors and characteristics that influence the integration of quality care across hospital services by adult Sickle cell disease (SCD) patients. Design/methodology/approach This paper is a systematic review. Findings Painful vaso-occlusive crisis was the major cause of hospital and emergency department admissions in patients with SCD, although high utilizing patients had more diagnoses of acute chest syndrome and sepsis. High utilizers also had more SCD complications (aseptic necrosis) and infections. Patients who were publically insured accounted for 76.5 percent (95% CI: 0.632–0.861) of all patients. Patients aged 18–30 years had the highest rate of utilization, which declined in those over 50. Women were more likely than men to seek hospital services. Research limitations/implications There is a need for prospective studies with a prolonged follow-up, reasonable sample size, objective methods of data collection and similar outcome measures that address characteristics of utilization and integration across different clinical settings for this population. Practical implications There is a small subset of patients with SCD who consume a large percentage of resources. This may lend itself well to targeted collaborative and integrated care management services for these high consumers of healthcare resources. Social implications SCD patients who used hospital services for care, regardless of the frequency of their encounters, were more likely young women who relied heavily on public insurance to seek relief from the pain of vaso-occlusive crises. The majority were from African–American and Hispanic communities. Originality/value This study examines the consumption of resources by a high utilizing group as a necessary step in the development of an integrated care management pathway.

Stroke: the critically neglected first year post-stroke

Abstract: Purpose Stroke is a leading cause of death and disability in the USA and worldwide. While stroke care has evolved dramatically, many new acute approaches to therapy focus only on the first 3-12 hours. Significant treatment opportunities beyond the first 12 hours can play a major role in improving outcomes for stroke patients. The purpose of this paper is to highlight the issues that affect stroke care delivery for patients and caregivers and describe an integrated care model that can improve care across the continuum. Design/methodology/approach This paper details evidence-based research that documents current stroke care and efforts to improve care delivery. Further, an innovative integrated care model is described, and its novel application to stroke care is highlighted. Findings Stroke patients and caregivers face fragmented and poorly coordinated care systems as they move through specific stroke nodes of care, from acute emergency and in-hospital stay through recovery post-discharge at a care facility or at home, and can be addressed by applying a comprehensive, technology-enabled Integrated Stroke Practice Unit (ISPU) Model of Care. Originality/value This paper documents specific issues that impact stroke care and the utilization of integrated care delivery models to address them. Evidence-based research results document difficulties of current care delivery methods for stroke and the impact of that care delivery on patients and caregivers across each node of care. It offers an innovative ISPU model and highlights specific tenets of that model for readers.

The primary care home: a new vehicle for the delivery of population health in England

Abstract: The purpose of this paper is to consider how the evolving concept of the “primary care home” (PCH) that is developing in England might be an effective vehicle for the delivery of the goals of “population health”. The authors examine evidence from earlier initiatives to achieve similar objectives of primary care-led health system planning and care integration to understand relevant lessons for the PCH.,This paper is based on a descriptive review of the PCH using documentary sources and a non-systematic review of literature relating to primary care commissioning initiatives and recent initiatives to deliver general practice services on a larger scale.,The PCH is likely to bring forth relatively high engagement from general practitioners due to its neighbourhood scale, voluntary nature and its focus on professional partnership, personalisation of care and outcomes. It is important that participants have sufficient autonomy to act and that financial incentives are aligned with the goals of population health. It is also important that, unlike some earlier primary care initiatives, the PCH is given time to develop to maturity.,The PCH is a recent phenomenon that is developing in England and elsewhere. This paper locates the PCH within a historical context and draws conclusions from a relevant evidence base.

Serious gaming as a method for changing stakeholders’ perspectives on integrated care

Abstract: Purpose Serious gaming provides opportunities to harmonize the views of stakeholders regarding integrated care. In order to provide first insights on the effects and stakeholders’ satisfaction of serious gaming, the purpose of this paper is to explore what effects serious gaming has on the perceptions of different stakeholders regarding integrated care, and to evaluate a trial case of serious gaming on integrated care. Design/methodology/approach A pre- and post-test design was used, with two questionnaires. The first questionnaire focused on integrated care, based on the integrated change model, and was given to participants twice, once before and once after the serious game “Long Life Lab” was completed, to assess changes in perception. The second questionnaire focused on the evaluation of serious gaming, and was given to the participants only after the serious game. Findings With nine participants, the results yielded no statistical effects with the exception of three salient beliefs. Despite the small sample, differences in specific beliefs were found for knowledge, attitude and self-efficacy. Furthermore, the game was positively evaluated, but participants indicated that there is room for improvement. Originality/value Participants have positive beliefs toward the use of serious gaming as a tool for changing stakeholders’ perspectives on integrated care. Further studies in greater sample size are needed to confirm the potential value of serious gaming to improve integrated care.

The development of a collaborative framework for commissioning health and social care

Abstract: The purpose of this paper is to present an evaluation of a collaborative commissioning approach to improve quality and experience and reduce cost within integrated health and social care.,A multi-method approach is used involving qualitative interviews, documentary analysis and non-participant observation.,The findings suggest that the approach provides a suitable framework for the collaborative commissioning of integrated health and social care services.,Further research is now needed to provide a definitive evaluation of its value outside of Wales.,With the significant scrutiny on health systems, the approach demonstrates effectiveness in securing quality improvements, achievement of recognised care standards and patient outcomes, while providing scope for financial gains and a goal for stakeholders to engage in effective communication.,This research presents an innovative method for collaborative commissioning and reveals activities that appear to contribute to more effective commissioning processes.

Case study of home care for isolated and frail elderly patients by general practice nurses: A controlled 17-month study, to May 2016

Abstract: Purpose In a novel approach, two part-time “Link Nurses” within an NE Hampshire practice of 16,500 patients were funded by a local charity, to assess and manage unmet needs of isolated frail elderly patients at home. The paper aims to discuss these issues. Design/methodology/approach Patients in this vulnerable group with no recorded healthcare contact for a prolonged period were identified from practice computer records. One group was to be assessed at home, and appropriate interventions effected. Follow-up visits or telephone contacts also offered support to carers as well as isolated individuals. A matching quasi control group was identified but not visited, to assess the overall impact on the patients, GP and other healthcare contacts. Difficulties with the control group were encountered and addressed. Findings Important unmet healthcare needs were found amongst the visited patients, which the nurses were able to address themselves, or refer to the GPs or appropriate agencies. The control group demonstrated greater demand for out-of-hours, GP and district nurse contacts, and more unplanned hospital admissions. Practical implications Besides dealing with unmet needs at home, ongoing support by local GP nurses may reduce bed-blocking by moving away from “crisis management” of patients in this vulnerable group. Originality/value Few other trials have employed practice nurses to see and manage frail elderly patients in their homes.