From micro to macro: assessing implementation of integrated care in Australia.
TL;DR: Light is shed on how integrated care is being implemented in Australia, using a new tool to characterise and compare integration strategies at micro, meso and macro levels, and suggests that current integrated care efforts are unevenly weighted towards micro-level strategies.
Abstract: Many countries and health systems are pursuing integrated care as a means of achieving better outcomes. However, no standard approaches exist for comparing integration approaches across models or settings, and for evaluating whether the key components of integrated care are present in different initiatives. This study sheds light on how integrated care is being implemented in Australia, using a new tool to characterise and compare integration strategies at micro, meso and macro levels. In total, 114 staff from a purposive sample of 38 integrated care projects completed a survey based on the Rainbow Model of Integrated Care. Ten key informants gave follow-up interviews. Participating projects reported using multiple strategies to implement integrated care, but descriptions of implementation were often inconsistent. Micro-level strategies, including clinical-professional service coordination and person-centred care, were most commonly reported. A common vision was often described as an essential foundation for joint work. However, performance feedback appeared under-utilised, as did strategies requiring macro-level action such as data linkages or payment reform. The results suggest that current integrated care efforts are unevenly weighted towards micro-level strategies. Increased attention to macro-level strategies may be warranted in order to accelerate progress and sustain integrated care in Australia.
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01 Jan 2010
TL;DR: In this article, the authors explore the many definitions, concepts, logics and methods found in health system and service integration, and summarize the main elements or building blocks of integrated care and suggest a way to address its various complexities and unknowns in a real world sense.
Abstract: Integrated care is a key strategy in reforming health systems around the world. Despite its importance, the concept's polymorphous nature and lack of specificity and clarity significantly hamper systematic understanding, successful application and meaningful evaluation. This article explores the many definitions, concepts, logics and methods found in health system and service integration. In addition to framing this evolving, albeit imprecise field, the article summarizes the main elements or building blocks of integrated care and suggests a way to address its various complexities and unknowns in a real-world sense.
310 citations
TL;DR: Evidence of elements of integrated care for older people focuses particularly on micro clinical care integration processes, while there is a relative lack of information regarding the meso organisational and macro system-level care integration strategies.
Abstract: Objective The World Health Organization (WHO) recently proposed an Integrated Care for Older People approach to guide health systems and services in better supporting functional ability of older people. A knowledge gap remains in the key elements of integrated care approaches used in health and social care delivery systems for older populations. The objective of this review was to identify and describe the key elements of integrated care models for elderly people reported in the literature. Design Review of reviews using a systematic search method. Methods A systematic search was performed in MEDLINE and the Cochrane database in June 2017. Reviews of interventions aimed at care integration at the clinical (micro), organisational/service (meso) or health system (macro) levels for people aged ≥60 years were included. Non-Cochrane reviews published before 2015 were excluded. Reviews were assessed for quality using the Assessment of Multiple Systematic Reviews (AMSTAR) 1 tool. Results Fifteen reviews (11 systematic reviews, of which six were Cochrane reviews) were included, representing 219 primary studies. Three reviews (20%) included only randomised controlled trials (RCT), while 10 reviews (65%) included both RCTs and non-RCTs. The region where the largest number of primary studies originated was North America (n=89, 47.6%), followed by Europe (n=60, 32.1%) and Oceania (n=31, 16.6%). Eleven (73%) reviews focused on clinical ‘micro’ and organisational ‘meso’ care integration strategies. The most commonly reported elements of integrated care models were multidisciplinary teams, comprehensive assessment and case management. Nurses, physiotherapists, general practitioners and social workers were the most commonly reported service providers. Methodological quality was variable (AMSTAR scores: 1–11). Seven (47%) reviews were scored as high quality (AMSTAR score ≥8). Conclusion Evidence of elements of integrated care for older people focuses particularly on micro clinical care integration processes, while there is a relative lack of information regarding the meso organisational and macro system-level care integration strategies.
110 citations
TL;DR: Fourteen essential actions and five important actions are necessary at system and service levels to implement community-based integrated care for older people to implement the World Health Organization Integrated Care for Older People (ICOPE) approach.
Abstract: Background
Integrated care is recognised as an important enabler to healthy ageing, yet few countries have managed to sustainably deliver integrated care for older people. We aimed to gather global consensus on the key actions required to realign health and long-term systems and integrate services to implement the World Health Organization (WHO) Integrated Care for Older People (ICOPE) approach.
Methods
A two-round eDelphi study, including a global consultation meeting, was undertaken to identify, refine and generate consensus on the actions required across high-, middle- and low-income countries to implement the WHO ICOPE approach. In round 1, a framework of 31 actions, empirically derived from previous WHO evidence reviews was presented to panellists to judge the relative importance of each action (numeric rating scale; range:1–9) and provide free-text comments concerning the scope of the actions. These outcomes were discussed and debated at the global consultation meeting. In round 2, a revised framework of 19 actions was presented to panellists to measure their extent of agreement and identify ‘essential’ actions (five-point Likert scale; range: strongly agree to strongly disagree). A threshold of ≥80% for agree/strongly agree was set a priori for consensus.
Results
After round 1 (n = 80 panellists), median scores across 31 actions ranged from 6 to 9. Based on pre-defined category thresholds for median scores, panellists considered 28 actions (90·3%) as ‘important’ and three (9·7%) as ‘uncertain’. Fifteen additional actions were suggested for inclusion based on free-text comments, creating 46 for consideration at the global consultation meeting. In round 2 (n = 84 panellists), agreement (agree or strongly agree) ranged from 84·6–97·6%, suggesting consensus. Fourteen (73·7%) actions were rated as essential.
Conclusion
Fourteen essential actions and five important actions are necessary at system (macro; n = 10) and service (meso; n = 9) levels to implement community-based integrated care for older people.
58 citations
TL;DR: This review systematically identified and categorized existing care coordination theoretical frameworks in new ways to make the theory-to-practice link more accessible and identified the most comprehensive frameworks and their main emphases for several general practice-relevant applications.
Abstract: Care coordination is crucial to avoid potential risks of care fragmentation in people with complex care needs. While there are many empirical and conceptual approaches to measuring and improving care coordination, use of theory is limited by its complexity and the wide variability of available frameworks. We systematically identified and categorized existing care coordination theoretical frameworks in new ways to make the theory-to-practice link more accessible. To identify relevant frameworks, we searched MEDLINE®, Cochrane, CINAHL, PsycINFO, and SocINDEX from 2010 to May 2018, and various other nonbibliographic sources. We summarized framework characteristics and organized them using categories from the Sustainable intEgrated chronic care modeLs for multi-morbidity: delivery, FInancing, and performancE (SELFIE) framework. Based on expert input, we then categorized available frameworks on consideration of whether they addressed contextual factors, what locus they addressed, and their design elements. We used predefined criteria for study selection and data abstraction. Among 4389 citations, we identified 37 widely diverse frameworks, including 16 recent frameworks unidentified by previous reviews. Few led to development of measures (39%) or initiatives (6%). We identified 5 that are most relevant to primary care. The 2018 framework by Weaver et al., describing relationships between a wide range of primary care-specific domains, may be the most useful to those investigating the effectiveness of primary care coordination approaches. We also identified 3 frameworks focused on locus and design features of implementation that could prove especially useful to those responsible for implementing care coordination. This review identified the most comprehensive frameworks and their main emphases for several general practice-relevant applications. Greater application of these frameworks in the design and evaluation of coordination approaches may increase their consistent implementation and measurement. Future research should emphasize implementation-focused frameworks that better identify factors and mechanisms through which an initiative achieves impact.
53 citations
TL;DR: Evidence is provided for the reliability and validity of the RMIC patient and provider questionnaires as generic tools to assess the experience with or perception of integrated renal care delivery and the instruments are recommended in future applications testing test-retest reliability, convergent and predictive validity, and responsiveness.
Abstract: Introduction Integrated service delivery is considered to be an essential condition for improving the management and health outcomes of people with chronic kidney disease (CKD). However, research on the assessment of integrated care by patients and care providers is hindered by the absence of brief, reliable, and valid measurement tools. Objective The aim of this study was to develop survey instruments for healthcare professionals and patients based on the Rainbow Model of Integrated Care (RMIC), and to evaluate their psychometric properties. Design The development process was based on the US Food and Drug Administration guidelines. This included item generation from systematic reviews of existing tools and expert opinion on clarity and content validity, involving renal care providers and chronic kidney patients. A cross-sectional, multi-centre design was used to test for internal consistency and construct validity. Setting Outpatient clinics in a large renal network. Participants A sample of 30.788 CKD patients, and 8.914 renal care providers. Methods and analysis Both survey instruments were developed using previous qualitative work and published literature. A multidisciplinary expert panel assessed the face and content validity of both instruments and following a pilot study, the psychometric properties of both instruments were explored. Exploratory factor analysis with principal axis factoring and with promax rotation was used to assess the underlying dimensions of both instruments; Cronbach's alpha was used to determine the internal constancy reliability. Results 17.512 patients (response rate: 56.9%) and 8.849 care providers (response rate: 69.5%) responded to the questionnaires. Factor analysis of the patient questionnaire yielded three internally consistent (Cronbach's alpha > 0.7) factors: person-centeredness, clinical coordination, and professional coordination. Factor analysis of the provider questionnaire produced eight internally consistent (Cronbach's alpha > 0.7) factors: person-centeredness, community centeredness, clinical coordination, professional coordination, organisational coordination, system coordination, technical and cultural competence. As hypothesised, care coordination patient and providers scores significantly correlated with questions about quality of care, treatment involvement, reported health, clinics' organisational readiness, and external care coordination capacity. Conclusion This study provides evidence for the reliability and validity of the RMIC patient and provider questionnaires as generic tools to assess the experience with or perception of integrated renal care delivery. The instruments are recommended in future applications testing test-retest reliability, convergent and predictive validity, and responsiveness.
22 citations
Cites methods from "From micro to macro: assessing impl..."
...A cross-sectional study design including a convenience sample of 8.421 renal care providers (e.g. nephrologists, nurses, and management) and 30.788 CKD patients within an international collaborative network of 316 dialysis clinics in 19 countries (e.g. Argentina, PLOS ONE | https://doi.org/10.1371/journal.pone.0222593 September 19, 2019 5 / 21 Australia, Chile, France, Germany, Global, Hungary, Italy, Kazakhstan, Lithuania, New Zealand, Poland, Portugal, Romania, Russia, Saudi Arabia, Spain, Sweden, UK, and Uruguay) was used for the validation of the RMIC-MT patient and provider version....
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...The preliminary version of the RMIC-MT was used to develop an improved patient and provider version [12,13]....
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...This preliminary version of the RMIC-MT has been tested in the Netherlands [11], Australia [12], and Singapore [13]....
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References
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TL;DR: The use of interrater reliability (IRR) and intra-arrater agreement (IRA) indices has increased dramatically during the past 20 years as mentioned in this paper, at least in part because of the increased role of multilevel modeling techniques (e.g., hierarchical linear modeling and multi-level structural equation modeling) in organizational research.
Abstract: The use of interrater reliability (IRR) and interrater agreement (IRA) indices has increased dramatically during the past 20 years. This popularity is, at least in part, because of the increased role of multilevel modeling techniques (e.g., hierarchical linear modeling and multilevel structural equation modeling) in organizational research. IRR and IRA indices are often used to justify aggregating lower-level data used in composition models. The purpose of the current article is to expose researchers to the various issues surrounding the use of IRR and IRA indices often used in conjunction with multilevel models. To achieve this goal, the authors adopt a question-and-answer format and provide a tutorial in the appendices illustrating how these indices may be computed using the SPSS software.
2,775 citations
TL;DR: A conceptual framework that combines the concepts of primary care and integrated care, in order to understand the complexity of integrated care is proposed.
Abstract: Introduction: Primary care has a central role in integrating care within a health system. However, conceptual ambiguity regarding integrated care hampers a systematic understanding. This paper proposes a conceptual framework that combines the concepts of primary care and integrated care, in order to understand the complexity of integrated care. Methods: The search method involved a combination of electronic database searches, hand searches of reference lists (snowball method) and contacting researchers in the field. The process of synthesizing the literature was iterative, to relate the concepts of primary care and integrated care. First, we identified the general principles of primary care and integrated care. Second, we connected the dimensions of integrated care and the principles of primary care. Finally, to improve content validity we held several meetings with researchers in the field to develop and refine our conceptual framework. Results: The conceptual framework combines the functions of primary care with the dimensions of integrated care. Person-focused and population-based care serve as guiding principles for achieving integration across the care continuum. Integration plays complementary roles on the micro (clinical integration), meso (professional and organisational integration) and macro (system integration) level. Functional and normative integration ensure connectivity between the levels. Discussion: The presented conceptual framework is a first step to achieve a better understanding of the inter-relationships among the dimensions of integrated care from a primary care perspective.
672 citations
TL;DR: 10 universal principles of successfully integrated healthcare systems that may be used by decision-makers to assist with integration efforts are identified and define key areas for restructuring and allow organizational flexibility and adaptation to local context.
Abstract: Integrated health systems are considered part of the solution to the challenge of sustaining Canada's healthcare system. This systematic literature review was undertaken to guide decision-makers and others to plan for and implement integrated health systems. This review identified 10 universal principles of successfully integrated healthcare systems that may be used by decision-makers to assist with integration efforts. These principles define key areas for restructuring and allow organizational flexibility and adaptation to local context. The literature does not contain a one-size-fits-all model or process for successful integration, nor is there a firm empirical foundation for specific integration strategies and processes.
364 citations
TL;DR: The article summarizes the main elements or building blocks of integrated care and suggests a way to address its various complexities and unknowns in a real-world sense.
Abstract: Integrated care is a key strategy in reforming health systems around the world. Despite its importance, the concept's polymorphous nature and lack of specificity and clarity significantly hamper systematic understanding, successful application and meaningful evaluation. This article explores the many definitions, concepts, logics and methods found in health system and service integration. In addition to framing this evolving, albeit imprecise field, the article summarizes the main elements or building blocks of integrated care and suggests a way to address its various complexities and unknowns in a real-world sense.
322 citations
01 Jan 2010
TL;DR: In this article, the authors explore the many definitions, concepts, logics and methods found in health system and service integration, and summarize the main elements or building blocks of integrated care and suggest a way to address its various complexities and unknowns in a real world sense.
Abstract: Integrated care is a key strategy in reforming health systems around the world. Despite its importance, the concept's polymorphous nature and lack of specificity and clarity significantly hamper systematic understanding, successful application and meaningful evaluation. This article explores the many definitions, concepts, logics and methods found in health system and service integration. In addition to framing this evolving, albeit imprecise field, the article summarizes the main elements or building blocks of integrated care and suggests a way to address its various complexities and unknowns in a real-world sense.
310 citations