Showing papers on "Integrated care published in 2004"

Improving access to geriatric mental health services: a randomized trial comparing treatment engagement with integrated versus enhanced referral care for depression, anxiety, and at-risk alcohol use.

Abstract: Objective: The authors sought to determine whether integrated mental health services or enhanced referral to specialty mental health clinics results in greater engagement in mental health/substance abuse services by older primary care patients. Method: This multisite randomized trial included 10 sites consisting of primary care and specialty mental health/substance abuse clinics. Primary care patients 65 years old or older (N=24,930) were screened. The final study group consisted of 2,022 patients (mean age=73.5 years; 26% female; 48% ethnic minority) with depression (N=1,390), anxiety (N= 70), at-risk alcohol use (N=414), or dual diagnosis (N=148) who were randomly assigned to integrated care (mental health and substance abuse providers co-located in primary care; N=999) or enhanced referral to specialty mental health/substance abuse clinics (i.e., facilitated scheduling, transportation, payment; N=1,023). Results: Seventy-one percent of patients engaged in treatment in the integrated model compared with 49% in the enhanced referral model. Integrated care was associated with more mental health and substance abuse visits per patient (mean=3.04) relative to enhanced referral (mean=1.91). Overall, greater engagement was predicted by integrated care and higher mental distress. For depression, greater engagement was predicted by integrated care and more severe depression. For at-risk alcohol users, greater engagement was predicted by integrated care and more severe problem drinking. For all conditions, greater engagement was associated with closer proximity of mental health/substance abuse services to primary care. Conclusions: Older primary care patients are more likely to accept collaborative mental health treatment within primary care than in mental health/substance abuse clinics. These results suggest that integrated service arrangements improve access to mental health and substance abuse services for older adults who underuse these services.

Developing integrated health and social care services for older persons in Europe.

Abstract: Purpose: This paper is to distribute first results of the EU Fifth Framework Project ‘Providing integrated health and social care for older persons—issues, problems and solutions’ (PROCARE—http://www.euro.centre.org/procare/). The project's first phase was to identify different approaches to integration as well as structural, organisational, economic and social-cultural factors and actors that constitute integrated and sustainable care systems. It also served to retrieve a number of experiences, model ways of working and demonstration projects in the participating countries which are currently being analysed in order to learn from success—or failure—and to develop policy recommendations for the local, national and European level. Theory: The paper draws on existing definitions of integrated care in various countries and by various scholars. Given the context of an international comparative study it tries to avoid providing a single, ready-made definition but underlines the role of social care as part and parcel of this type of integrated care in the participating countries. Methods: The paper is based on national reports from researchers representing ten organisations (university institutes, consultancy firms, research institutes, the public and the NGO sector) from 9 European countries: Austria, Denmark, Finland, France, Germany, Greece, Italy, the Netherlands, and the UK. Literature reviews made intensive use of grey literature and evaluation studies in the context of at least five model ways of working in each country. Results: As a result of the cross-national overview an attempt to classify different approaches and definitions is made and indicators of relative importance of the different instruments used in integrating health and social care services are provided. Conclusions: The cross-national overview shows that issues concerning co-ordination and integration of services are high on the agenda in most countries. Depending on the state of service development, various approaches and instruments can be observed. Different national frameworks, in particular with respect to financing and organisation, systemic development, professionalisation and professional cultures, basic societal values (family ethics), and political approaches have to be taken into account during the second phase of PROCARE during which transversal and transnational analysis will be undertaken based on an in-depth analysis of two model ways of working in each country. Discussion: Far from a European vision concerning integrated care, national health and social care systems remain—at best—loosely coupled systems that are facing increasing difficulties, given the current challenges, in particular in long-term care for older persons: increasing marketisation, lack of managerial knowledge (co-operation, co-ordination), shortage of care workers and a general trend towards down-sizing of social care services continue to hamper the first tentative pathways towards integrated care systems.

The clinician's perspective on electronic health records and how they can affect patient care.

Abstract: Many attempts to get clinicians to use electronic health records have failed, often because of difficulties with data entry.1–4 Technology should complement and improve clinical care, not impose extra burdens on already overloaded medical staff. The clinical “usability” of electronic records systems is particularly relevant with the recent appointment of service providers to implement the national Integrated Care Record Service for the NHS as usability also affects patient care. I examine important lessons learned from previous attempts to get clinicians to use computers in health care; discuss how clinicians actually work; make recommendations on designing or selecting clinical computer systems; and explore how the use of electronic health records might affect patient care. ### Use of narratives in clinical reasoning Patient documentation systems that try to reproduce previously accepted models of clinical reasoning (pattern recognition, algorithms, or hypothetico-deductive models) have achieved limited acceptance. According to Greenhalgh, the medical encounter consists of stories within stories.5 Kay and Purves maintain that narratives are at the heart of clinical decision making and refers to this concept as “narrative reasoning.”6 They argue that “every patient tells a story (narrative) and clinicians intuitively use narrative devices in relation to the delivery of patient care.” The patient is seen as “a page from the book of nature, a text to be read,” and the doctor becomes the author of “stories within the medical record.” Kay and Purves make a strong case for retaining information in a conceptual framework and maintain that this is best accomplished by means of narratives rather than “reducing the semantic richness and degrading the story to limited codes and weakly connected phrases.” Van Ginneken also states that many computerised medical record systems are rejected by clinicians because they are not based on a story metaphor.7 Frisse and colleagues state that “using conversations as …

In‐hospital care pathways for stroke

Abstract: Background Care within a stroke unit reduces death or dependency after stroke. However, studies have found significant variations in clinical practice, access to stroke unit care, organisation of patient care, and clinical outcome. Stroke care pathways have been introduced as a method to promote organised and efficient patient care that is based on best evidence and guidelines. Objectives We aimed to assess the effects of care pathways, as compared to standard medical care, among patients with acute stroke who had been admitted to hospital. Search strategy We searched the Cochrane Stroke Group Specialised Trials Register (last searched in May 2001), the Cochrane Controlled Trials Register (Issue 4, 2000), MEDLINE (1975-2000), EMBASE (1980-2000), CINAHL (1982-2000), the Index to Scientific and Technical Proceedings (ISTP, May 2001), and HealthSTAR (May 2001). We also handsearched the Journal of Managed Care (1997 to 1998), which was later renamed the Journal of Integrated Care (1998 to 2001). Reference lists of articles were searched. Selection criteria We considered randomised controlled trials and non-randomised studies (quasi-randomised trials, comparative studies, controlled and uncontrolled before and after studies, and interrupted time series) that compared care pathway care with standard medical care. Data collection and analysis One reviewer selected studies for inclusion and the other independently checked the decisions. Two reviewers independently assessed the methodological quality of the studies. One reviewer extracted the data and the other checked the extracted data. Data from randomised and non-randomised studies were analysed separately. We found significant statistical heterogeneity in the analysis of two outcomes (computed tomography brain scanning and duration of stay). Main results There were three randomised controlled trials (total of 340 patients) and seven non-randomised studies (total of 1673 patients) that compared care pathway care with standard medical care. We found no difference between care pathway and control groups in terms of death, dependency, or discharge destination. Evidence from mainly non-randomised studies suggests that patients managed using a care pathway may be: a) less likely to suffer a urinary tract infection (OR 0.38, CI 0.18 to 0.79), b) less likely to be readmitted (OR 0.11, CI 0.03 to 0.39), and c) more likely to have a computed tomography brain scan (OR 3.66, CI 1.45 to 9.27) or carotid duplex study (OR 2.45, CI 1.3 to 4.61). Evidence from randomised trials suggests that patient satisfaction and quality of life may be significantly lower in the care pathway group (P=0.02 and P<0.005 respectively). Reviewers' conclusions The use of care pathways to manage stroke patients in hospital may be associated with both positive and negative effects on the process of care and clinical outcomes. Since most of the results have been derived from non-randomised studies, they are likely to be influenced by potential biases and confounding factors. There is currently insufficient supporting evidence to justify routine implementation of care pathways for acute stroke management or stroke rehabilitation.

Primary care clinicians evaluate integrated and referral models of behavioral health care for older adults: results from a multisite effectiveness trial (PRISM-e).

Abstract: BACKGROUND Recent studies have shown that integrated behavioral health services for older adults in primary care improves health outcomes. No study, however, has asked the opinions of clinicians whose patients actually experienced integrated rather than enhanced referral care for depression and other conditions. METHOD The Primary Care Research in Substance Abuse and Mental Health for the Elderly (PRISM-E) study was a randomized trial comparing integrated behavioral health care with enhanced referral care in primary care settings across the United States. Primary care clinicians at each participating site were asked whether integrated or enhanced referral care was preferred across a variety of components of care. Managers also completed questionnaires related to the process of care at each site. RESULTS Almost all primary care clinicians (n = 127) stated that integrated care led to better communication between primary care clinicians and mental health specialists (93%), less stigma for patients (93%), and better coordination of mental and physical care (92%). Fewer thought that integrated care led to better management of depression (64%), anxiety (76%), or alcohol problems (66%). At sites in which the clinicians were rated as participating in mental health care, integrated care was highly rated as improving communication between specialists in mental health and primary care. CONCLUSIONS Among primary care clinicians who cared for patients that received integrated care or enhanced referral care, integrated care was preferred for many aspects of mental health care.

Supporting informality: team working and integrated care records

Abstract: This paper reports findings from an ethnographic study of the work of Adult and Care of the Elderly Community Mental Health Teams in the context of the deployment of an Electronic Medical Record. Our findings highlight the importance of informal discussions and provisional judgments as part of the process by which teams achieve consensual clinical management decisions over time. We show how paper-based documentation supports this collaborative work by affording both the revision of preliminary clinical management options and the accretion of contributions by team members with different clinical perspectives and expertise. Finally, we consider the implications both for teamwork and the Integrated Care Record (ICR) as clinical documentation becomes increasingly held and distributed electronically.

Integrated care and the working record

Abstract: By default, many discussions and specifications of electronic health records or integrated care records often conceptualize the record as a passive information repository. This article presents data from a case study of work in a medical unit in a major metropolitan hospital. It shows how the clinicians tailored, re-presented and augmented clinical information to support their own roles in the delivery of care for individual patients. This is referred to as the working record: a set of complexly interrelated clinician-centred documents that are locally evolved, maintained and used to support delivery of care in conjunction with the more patient-centred chart that will be stored in the medical records department on the patient’s discharge. Implications are drawn for how an integrated care record could support the local tailorability and flexibility that underpin this working record and hence underpin practice.

Joint working in community mental health teams: implementation of an integrated care pathway

Abstract: Integration of community mental health services is a key policy objective that aims to increase quality and efficiency of care. Integrated care pathways (ICPs) are a mechanism designed to formalise multi-agency working at an operational level and are currently being applied to mental health services. Evidence regarding the impact of this tool to support joint working is mixed, and there is limited evidence regarding the suitability of ICPs for complex, community-based services. The present study was set in one primary care trust (PCT) in Scotland that is currently implementing an ICP for community mental health teams (CMHTs) across the region. The aim of the study was to investigate professionals' experiences and views on the implementation of an ICP within adult CMHTs in order to generate learning points for other organisations which are considering developing and implementing such systems. The study used qualitative methods which comprised of individual interviews with three CMHT leaders and two service development managers, as well as group interviews with members of four adult CMHTs. Data was analysed using the constant comparison method. Participants reported positive views regarding joint working and the role of an ICP in theory. However, in practice, teams were not implementing the ICP. Lack of integration at higher organisational levels was found to create conflicts within the teams which became explicit in response to the ICP. Implementation was also hindered by lack of resources for ongoing support, team development and change management. In conclusion, the study suggests that operational systems such as ICPs do not address and cannot overcome wider organisational barriers to integration of mental health services. Integrated care pathways need to be developed with strategic input as well as practitioner involvement and ownership. Team development, education about integration and change management are essential if ICPs are to foster and support joint working in integrated teams.

Literature on integrated HIV care: a review.

Abstract: With a significant proportion of HIV-infected patients now presenting with co-occurring substance abuse disorders and mental disorders, interest in integrated HIV care is growing. However, no review of integrated HIV care has been conducted. Using relevant key word searches of the Medline and Psychlit databases, the authors identified about 450 publications. The few evaluations of integrated models tended to focus on measurements of engagement and retention in medical care, and their findings indicated an association between integrated HIV care and increased service utilization. No random assignment controlled studies were identified, except in the peripheral area of integrated care (without HIV primary care) for persons with co-occurring substance abuse disorders and mental disorders. The majority of reviewed articles described integrated models operating in the field and various aspects of implementation and sustainability. Overall, they supported use of a wide range of primary and ancillary services delivered by a multidisciplinary team that employs a 'biopsychosocial' approach. Despite the lack of scientific knowledge regarding the effects of integrated HIV care, those wanting to optimize treatment for patients with multiple interacting disorders can gain useful and practical knowledge from this literature.

Effects of Clinical Pathways: Do They Work?

Abstract: Objective:Evaluation of the effect of implementing clinical pathways is a relatively new field in health care research. Little is known about the way in which practice is influenced by the implementation of clinical pathways, and to what degree. This review takes significant steps in answering these questions by describing the parameters that are used in literature as indicators to evaluate clinical pathways.Methods:A Medline-based review of literature published between 2000 and 2002 was carried out using the keywords ‘clinical pathway’, ‘critical pathway’, ‘care map’, ‘care pathway’ and ‘integrated care pathway’. Articles were selected if they contained any form of evaluation, outcome or indicator concerning the use of clinical pathways. This included all types of research design and sample size. A total of 200 articles were selected. Relevant data were summarized using the following characteristics: country of origin, clinical field of expertise, research design, sample size, clinical outcome indicators...

Effects of introducing an integrated care pathway in an acute stroke unit

Abstract: Background and purpose: integrated care pathways are often implemented to guide acute stroke therapy and improve organisation of care, but there is not sufficient evidence to support their routine use. We sought to evaluate the effects of introducing an integrated care pathway for acute stroke. Methods: we performed a before-and-after study. The ‘before’ (control) group comprised 154 consecutive stroke patients admitted to the acute stroke unit over a 9-month period. The ‘after’ (intervention) group comprised 197 consecutive patients admitted to the same unit over a 9-month period in the year after the introduction of the integrated care pathway. Effectiveness was assessed with a variety of measures: quality of documentation; process of care; occurrence of complications; death and discharge destination. Results were adjusted for case mix using a validated model. Results: the baseline characteristics of the two groups were similar, although there were more total anterior circulation strokes (29% versus 18%, P = 0.005) and fewer partial anterior circulation strokes (30% versus 42% P = 0.04) in the intervention group. In the intervention group, we found that urinary tract infections were significantly less frequent (OR 0.37, CI 0.15–0.91) and the quality of several aspects of care (e.g. CT scanning <48 hours) and documentation were significantly better. However, there were no significant differences in deaths, discharge destination, or length of stay between the two groups. Conclusion: this before-and-after study has provided further evidence that introducing an integrated care pathway for acute stroke may improve the quality of documentation and process of care, and reduce the risk of certain post-stroke complications.

Cost-Benefit Analysis of a Case Management Project for the Community-Dwelling Frail Elderly in Hong Kong:

Abstract: This randomized, controlled trial evaluates the cost-benefit of a case management project for older persons in HongKong. Case managers provided integrated care to participants in an intervention gr...

Patterns of admissions for children with special needs to the paediatric assessment unit

Abstract: Background: Children with special needs present a challenge to those involved in their care. Aims: To determine the role of the acute assessment unit for these children. Methods: Case notes and other records were reviewed for information on referrals, admissions, readmission within 7 and 28 days, length of stay, and management of 86 children registered for special needs. The study covered five years between January 1997 and December 2001. Results: Of the 86 children, 48 (58%) were boys; 62 children had cerebral palsy and 52 learning disability. There were 914 episodes, with 44% of these being self referrals and 35% from general practitioners; 35.5% of the episodes were managed in the assessment unit. The average length of stay in hospital was 5 days, ranging from Conclusion: Children with special needs tend to have a predictable pattern of conditions requiring inpatient care. One third of the inpatients episodes did not need a prolonged stay in hospital. This latter group of children could be managed at home with support of community nurses. Integrated care pathways need to be developed to minimise disruption to their lives. Appropriate resources should be made available to achieve these goals.

Economic evaluation of integrated care: an introduction

Abstract: Background: Integrated care has emerged in a variety of forms in industrialised countries during the past decade. It is generally assumed that these new arrangements result in increased effectiveness and quality of care, while being cost-effective or even cost-saving at the same time. However, systematic evaluation, including an evaluation of the relative costs and benefits of these arrangements, has largely been lacking. Objectives: To stimulate fruitful dialogue and debate about the need for economic evaluation in integrated care, and to outline possibilities for undertaking economic appraisal studies in this relatively new field. Theory: Key concepts, including e.g. scarcity and opportunity costs, are introduced, followed by a brief overview of the most common methods used in economic evaluation of health care programmes. Then a number of issues that seem particularly relevant for economic evaluation of integrated care arrangements are addressed in more detail, illustrated with examples from the literature. Conclusion and discussion: There is a need for well-designed economic evaluation studies of integrated care arrangements, in particular in order to support decision making on the long-term financing of these programmes. Although relatively few studies have been done to date, the field is challenging from a methodological point of view, offering analysts a wealth of opportunities. Guidance to realise these opportunities is provided by the general principles for economic evaluation, which can be tailored to the requirements of this particular field.

Towards a flexible, process-oriented IT architecture for an integrated healthcare network

Abstract: Healthcare information systems play an important role in improving healthcare quality. As providing healthcare increasingly changes from isolated treatment episodes towards a continuous medical process involving multiple healthcare professionals and institutions, there is an obvious need for an information system to support processes and span the whole healthcare network. A suitable architecture for such an information system must take into account that it has to work as an integral part of a complex socio-technical system with changing conditions and requirements. We have surveyed the core requirements of healthcare professionals and analysed the literature for known problems and information needs. We consolidated the results to define use cases for an integrated information system as communication patterns, from which general implications on the required properties of a helathcare network information system could be derived. Key issues are flexibility, adaptability, robustness, integration of existing systems and standards, semantic compatibility, security and process orientation. Based on these results an IT architecture is being designed that is capable of addressing the requirements mostly on the basis of well-established standards and concepts.

Providing integrated health and social care for older persons: a European overview of issues at stake

Abstract: Telomere length homeostasis is a prerequisite for the generation and growth of cancer. In 485% cancer cells, telomere length is maintained by telomerase that add telomere repeats to the end of telomere DNA. Because the G-rich strand of telomere DNA can fold into G-quadruplex that inhibits telomerase activity, stabilizing telomere quadruplex by small molecules is emerging as a potential therapeutic strategy against cancer. In these applications, the specificity of small molecules toward quadruplex over other forms of DNA is an important property to ensure no processes other than telomere elongation are interrupted. The evaluating assays currently available more or less have difficulty identifying or distinguishing quadruplex-irrelevant effect from quadruplex stabilization. Here, we describe an exonuclease I hydrolysis assay that evaluates quadruplex stabilization by DNA-interacting compounds, discriminates inhibitory effect from different sources and helps determine the optimal compound concentration.

Teaching integrated care: CAM familiarisation courses.

Abstract: ○ As the use of CAM grows, CAM familiarisation offers educational opportunities for undergraduates to understand CAM, their attitudes to medical change and the process of evidence-based medicine. ○ Such courses also offer the opportunity to integrate patient care and improve the relationship between medical and CAM practitioners. ○ CAM familiarisation courses are available in many medical schools in the United States and the United Kingdom. ○ The multiprofessional model which we have developed at the University of Southampton (UK) offers valuable experience to those thinking of establishing such courses.

Social work, general practice and evidence‐based policy in the collaborative care of older people: current problems and future possibilities

Abstract: While collaborative (or joint) working between social services and primary healthcare continues to rise up the policy agenda, current policy is not based on sound evidence of benefit to either patients or the wider community. Both sets of practitioners report benefits for their own work from adopting new arrangements for collaboration. The underlying assumption behind much of this activity is that a greater degree of integration provides benefits to both users and their carers, a perspective that at times obscures the issue of resource availability, especially in the form of practical community services such as district nursing and home help. At the present time there is insufficient evidence to demonstrate that formal arrangements for collaborative working (CW) are better than those forged informally between committed individuals or teams. Furthermore, arrangements for CW have not hitherto been widely evaluated in systematic studies with a comparative design and focus on outcomes for users and carers rather than on processes. In this paper we propose a number of process measures for future evaluation of CW: (1) study populations must be comparable; (2) details of how services are actually delivered must be obtained and colocation should not be assumed to mean collaboration; (3) care packages in areas of comparable resources should be examined; (4) both destinational outcomes and user-defined evaluations of benefit should be considered; (5) possible disadvantages of integrated care also need to be actively considered; (6) evaluations should include an economic analysis. Those implementing new policies in Primary Care Trusts have, at present, little sound evidence to guide them in their innovative work. However, they should take the opportunity to rigorously test the advantages and disadvantages of collaboration.

Integrated Health Care: Improving Client Care while Providing Opportunities for Mental Health Counselors

Abstract: Integrated health care, the co-location of mental health and medical professionals within primary care settings, is an emerging trend In essence, integrated care eases the access such that underserved primary care clients with mental health needs can receive treatment Current models of integrated care are described, and strategies for mental health counselors' involvement within primary care settings are discussed

Role of a clinical facilitator in introducing an integrated care pathway for the care of the dying.

Abstract: Integrated care pathways (ICPs) have been developed as a tool for improving end-of-life care. The Liverpool Care Pathway for the Dying (LCP) is a multidisciplinary and evidence-based approach to caring for the dying person. At Wythenshawe hospital a clinical facilitator was appointed to facilitate the introduction of the LCP. This full time post, which existed for 18 months, involved supporting and educating staff about the pathway. The LCP is now used throughout the general surgical and medical wards and acute and regional coronary care units. This article reflects on the different aspects of the role and the development of the project.

Family medicine in Croatia: past, present, and forthcoming challenges.

Abstract: The aim of this paper is to present the effects of the reform of primary care by privatization and direct contracting between general practitioners/family physicians and the Croatian Institute for Health Insurance, as well as to propose possible improvements. Using the data of the Croatian Institute of Public Health, we analyzed the coverage of population and accessibility of service, management of chronic illnesses, home visits, and preventive check-ups in the family medicine service. In 2001, 2,408 (30.8% vocationally trained) doctors worked in the family medicine service, taking care of 3.759,248 (84.7%) registered inhabitants of Croatia. There was an average of 6 office encounters, 0.1 home visits, 0.05 preventive check-ups and 1.4 referrals per patient per year. Within the Project of Health System Reform a working group of primary care experts proposed the following improvements: 1) the family medicine service should be organized in accordance with the fundamental principles of accessibility, continuity, and integrated care; and 2) a multilayered financing model should be used, containing a capitation fee payment, fee for service payment, and specific program payment. Taking into account the European Union recommendation, a project aimed at ensuring the specialization of family medicine for all doctors working in the family medicine service was started in 2003. This study indicates that there is a gap between proclaimed health system improvements and effects of the reform of primary care. In order to achieve evidence-based health policy, concerted action of all participants in the decision-making process is needed.

Policy framework for integrated care for older people developed by the Carmen Network

Abstract: This policy framework offers a checklist for national and regional governments concerned with improving services to older people so that older people experience integrated care. The Care and Management of Services for Older People in Europe Network (CARMEN) has defined integrated care as ‘a well planned and well organised set of services and care processes, targeted at the multiple needs/problems of an individual, or a category of persons with similar need/problems’ (Vaarama, cited in Nies 2004b). Illustrations of different policies to address different dimensions of the framework are provided within the text.

Activating chronic kidney disease patients and family members through the Internet to promote integration of care

Abstract: Purpose: To describe the potential role of the Internet as a vehicle for improving integration of care through activating chronic kidney disease patients and their family members. Also, to describe how that potential is being developed through a website sponsored by the Medicare program in the United States. Background: The Internet is expanding at a rapid rate, and health-related websites are one of its most popular features. Efforts to promote integration of care have focused mainly on providers up to now, and more emphasis is needed on the potential roles of patients. Chronically ill patients have particular needs for improved education about their conditions and enhanced involvement in care planning and treatment decisions. Medicare developed the Dialysis Facility Compare website to serve those goals for people with chronic kidney disease. Methods: We conducted qualitative research with 140 chronic kidney disease patients and family members, and 130 renal care professionals to evaluate and improve the Dialysis Facility Compare website. A series of 19 focus groups, 13 triads (small focus groups), and 56 individual interviews were conducted in four regions of the United States and by telephone. Results: We found that the Dialysis Facility Compare website has the potential to improve integration of care for people with chronic kidney disease in at least three ways. First: by expanding the roles of patients as members of the multi-disciplinary team of caregivers treating their disease. Second: through better integration of the informal care provided in the home and community with the formal care provided by health professionals. Third: by improving coordination of between care provided in the pre-dialysis and dialysis phases of the disease. Discussion: We developed recommendations for revising and enhancing the Dialysis Facility Compare website in a number of ways to better promote patient activation and integration of care. The unique features of the Internet, such as its different dimensions of interactivity, and applications of behavioural theories for website design should also be further explored.

What is the impact of out-of-home integrated care and education settings on children aged 0-6 and their parents?

Abstract: In many European countries, it is conceptually problematic to present the care and education of young children as separate because they are simply not distinguished from each other. It might be more appropriate to represent integration of care and education as a continuum, with the UK, where childcare and education have been treated as distinct in policy and in practice, representing one extreme. Childcare in the UK, where it exists, has been 'wrapped around' a standard two-and-a-half hour education offer for 3-4 year-olds. Attempts are now being made to change this situation, and to offer 'integrated' provision in 'children's centres'. However, 'integration' is an umbrella term that encompasses many different meanings. It may refer only to different types of services working alongside one another, in adjacent spaces, loosely coordinated, but without any fundamental change of approach; or it may mean a coherent service equally accessible to all potential users, with a common costing, staffing, health, pedagogic and curricular framework for all provision. It may also mean combining care and health provision, rather than care and education provision. These are the issues that this review set out to clarify.

Developing the Integrated Care Pathway Appraisal Tool (ICPAT): A Pilot Study

Abstract: Integrated Care Pathways (ICPs) are systematically developed tools that set locally agreed standards of care based on the available evidence for managing a specific group of patients, ensuring that multidisciplinary care can be monitored and outcomes measured1. Their use in the NHS is widespread yet no appraisal tool exists to ensure that their development and implementation have been both rigorous and systematic. This shortfall has implications for the clinical governance and modernisation programmes in all NHS organisationsf This paper describes a pilot study that has focused upon the development of such an instrument. Integrated Care Pathways are being introduced as tools to improve the quality of health care for a homogenous group of patients\" \". The development and maintenance of an ICP is important for multi-

The availability of psychiatric programs in private substance abuse treatment centers, 1995 to 2001.

Abstract: OBJECTIVE: The high rate of co-occurrence of substance abuse and mental disorders renders the availability of psychiatric programs, or integrated service delivery, a vital quality-of-care issue for substance abuse clients. This article describes the availability of psychiatric programs and integrated care for clients with severe mental illness in the private substance abuse treatment sector and examines these patterns of service delivery by profit status and hospital status. METHODS: Survey data from the National Treatment Center Study, which is based on a nationally representative sample of privately funded substance abuse treatment centers, were used to identify the proportion of centers that offered psychiatric programs in 1995-1996, 1997-1998, and 2000-2001. Centers reported whether they treated clients with severe mental illness on-site or referred them to external providers. Repeated-measures general linear models were used to test for significant changes over time and to assess mean differences in ...

Reducing discrepancies between MS patients' needs and use of healthcare services by applying a transmural care model.

Abstract: The Dutch healthcare system is effective for patients with acute, uncomplicated health problems but ineffective for patients with complex, chronic health problems such as multiple sclerosis (MS). To tackle these deficits, special working parties and the Dutch Ministry of Health concluded that healthcare professionals from primary and hospital settings should, by mutual agreement, cooperation, and shared responsibility, better coordinate their care and tailor care to meet patients' individual needs. In the Netherlands this approach is called transmural care. A transmural care model for MS (TCMMS) was developed to assist healthcare professionals in different settings cooperate with one another, comprehensively assess the needs of MS patients, and define an integrated care plan for each patient. The overall aim of the TCMMS was to reduce the discrepancies between the patients' needs and use of healthcare services and to test whether the TCMMS is applicable in practice. Outcomes using the TCMMS were measured using Kurtzke's Expanded Disability Status Scale (EDSS), Incapacity Status Scale (ISS), Environmental Status Scale (ESS), and RAND 36-Item Health Survey (RAND-36). In the study period, many different expressed needs were reported. For the total group the expressed needs decreased significantly from 57 needs 5 months before the implementation of the TCMMS to 19 needs at the end of the study. There were no significant changes over time in EDSS, ISS, ESS, and RAND-36. Overall, the TCMMS was applicable to practice and decreased the discrepancies between needs and services.

The British experience of dual diagnosis in the national health service.

Abstract: The co-occurrence of substance misuse and other psychiatric disorder (dual diagnosis) has been increasingly recognized in the UK. Clinical studies of patients with severe mental disorders showed high rates of substance misuse with poor clinical and social outcome. These patients often fall ‘between the cracks’ of the separate general psychiatric and addiction services. This has necessitated the development of a national policy advocating the provision of integrated care within mainstream psychiatric services. There are emergent models of good practice that require evaluation of effectiveness and cost effectiveness.