Showing papers on "Integrated care published in 2005"

Integrated care programmes for chronically ill patients: a review of systematic reviews

Abstract: Objective. To investigate effectiveness, definitions, and components of integrated care programmes for chronically ill patients on the basis of systematic reviews. Design. Literature review from January 1996 to May 2004. Main measures. Definitions and components of integrated care programmes and all effects reported on the quality of care. Results. Searches in the Medline and Cochrane databases identified 13 systematic reviews of integrated care programmes for chronically ill patients. Despite considerable heterogeneity in interventions, patient populations, and processes and outcomes of care, integrated care programmes seemed to have positive effects on the quality of patient care. No consistent definitions were present for the management of patients with chronic illnesses. In all the reviews the aims of integrated care programmes were very similar, namely reducing fragmentation and improving continuity and coordination of care, but the focus and content of the programmes differed widely. The most common components of integrated care programmes were self-management support and patient education, often combined with structured clinical follow-up and case management; a multidisciplinary patient care team; multidisciplinary clinical pathways and feedback, reminders, and education for professionals. Conclusion. Integrated care programmes seemed to have positive effects on the quality of care. However, integrated care programmes have widely varying definitions and components and failure to recognize these variations leads to inappropriate conclusions about the effectiveness of these programmes and to inappropriate application of research results. To compare programmes and better understand the (cost) effectiveness of the programmes, consistent definitions must be used and component interventions must be well described.

Evaluating integrated health care: a model for measurement

Abstract: Purpose: In the development of integrated care, there is an increasing need for knowledge about the actual degree of integration between different providers of health services. The purpose of this article is to describe the conceptualisation and validation of a practical model for measurement, which can be used by managers to implement and sustain integrated care. Theory: The model is based on a continuum of integration, extending from full segregation through intermediate forms of linkage, coordination and cooperation to full integration. Methods: The continuum was operationalised into a ratio scale of functional clinical integration. This scale was used in an explorative study of a local health authority in Sweden. Data on integration were collected in self-assessment forms together with estimated ranks of optimum integration between the different units of the health authority. The data were processed with statistical methods and the results were discussed with the managers concerned. Results: Judging from this explorative study, it seems that the model of measurement collects reliable and valid data of functional clinical integration in local health care. The model was also regarded as a useful instrument for managers of integrated care. Discussion: One of the main advantages with the model is that it includes optimum ranks of integration beside actual ranks. The optimum integration rank between two units is depending on the needs of both differentiation and integration.

Improving the rates of quitting smoking for veterans with posttraumatic stress disorder

Abstract: OBJECTIVE: Smoking is highly prevalent and refractory among people with posttraumatic stress disorder (PTSD). This study aimed to improve the rate of quitting smoking for veterans with PTSD by integrating treatment for nicotine dependence into mental health care. METHOD: Smokers undergoing treatment for PTSD (N=66) were randomly assigned to 1) tobacco use treatment delivered by mental health providers and integrated with psychiatric care (integrated care) versus 2) cessation treatment delivered separately from PTSD care by smoking-cessation specialists (usual standard of care). Seven-day point prevalence abstinence was the primary outcome, measured at 2, 4, 6, and 9 months after random assignment. Data were analyzed by using a generalized estimating equations approach following the intent-to-treat principle. RESULTS: Subjects assigned to integrated care were five times more likely than subjects undergoing the usual standard of care to abstain from smoking across follow-up assessment intervals (odds ratio=...

ICT and Integrated Care: Some Dilemmas of Standardising Inter-Organisational Communication

Abstract: There is a growing interest in the issues of how to organise healthcare work along individual patient cases rather than along the demarcation lines of healthcare organisations. Health information systems, such as electronic patient records, are seen as important change agents, since they are asserted to help the coordination of care across organisations through fast and accurate exchange of clinical data. The paper explores how a semi-standardised discharge letter is employed to communicate about the patient between two organisational settings, the hospital and the general practitioner. It is shown that the discharge letter plays a double role as informational tool and accounting device. And it is argued that further standardisation of the discharge letter content -- in order to facilitate electronic exchange -- is likely to strengthen the letter's role as a tool for organisational accountability and weaken it as a clinical tool. The paper concludes that this finding adds to the theoretical understanding of how computers support cooperative work, and that understanding how healthcare professionals present themselves as accountable and trustworthy should be of major concern when designing healthcare ICTs.

A literature review to explore integrated care for older people

Abstract: Purpose: This paper reports on some of the findings of a literature review commissioned to explore integrated care for older people. Methods: The process of revising included finding and selecting literature from multidisciplinary sources, and encompassed both published papers and ‘grey’ literature, i.e. material which had not been reviewed for publication. Results: The study found that thinking has moved on from a focus on the problems of accessing services to exploring ways in which they may function in an integrated way. Conclusions: The study shows how thinking on integrated care for older people has developed, and knowledge of micro, mezzo and macro strategies is now more available.

Integrated care for patients with a stroke in the Netherlands: results and experiences from a national Breakthrough Collaborative Improvement project

Abstract: Purpose: This article considers the question if measurable improvements are achieved in the quality of care in stroke services by using a Breakthrough collaborative quality improvement model. Context of case: Despite the availability of explicit criteria, evidence based guidelines, national protocols and examples of best practices; stroke care in the Netherlands did not improve substantially yet. For that reason a national collaborative started in 2002 to improve integrated stroke care in 23 self selected stroke services. Data sources: Characteristics of sites, teams, aims and changes were assessed by using a questionnaire and monthly self-reports of teams. Progress in achieving significant quality improvement has been assessed on a five point Likert scale (IHI score). Case description: The stroke services (n=23) formed multidisciplinary teams, which worked together in a collaborative based on the IHI Breakthrough Series Model. Teams received instruction in quality improvement, reviewed self reported performance data, identified bottlenecks and improvement goals, and implemented “potentially better practices” based on criteria from the Edisse study, evidence based guidelines, own ideas and expert opinion. Conclusion and discussion: Quality of care has been improved in most participating stroke services. Eighty-seven percent of the teams have improved their care significantly on at least one topic. About 34% of the teams have achieved significant improvement on all aims within the time frame of the project. The project has contributed to the further development and spread of integrated stroke care in the Netherlands.

Promoting end-of-life care in nursing homes using an ‘integrated care pathway for the last days of life’

Abstract: The purpose of this study was to promote quality end-of-life care in eight independent nursing homes using an ‘integrated care pathway (ICP) for the last days of life’ document. Action research methodology underpinned the design of this study in order to promote collaboration between staff in the nursing homes and the research team, empower staff in the practice of quality end-of-life care, and promote sustainable development of end-of-life care once the study finished. Considerable barriers within the nursing home context highlighted initial difficulties. This is reported elsewhere (Watson et al., in press) (Bridges Initiative, 2004). However, key champions appointed in each nursing home and their subsequent support was a major part of facilitating the ICP implementation. This paper reports the qualitative analysis from the summative evaluation of the study. One overarching pattern of ‘dying being more central to care in the nursing homes’ emerged as a result of the study; five themes that contributed to...

Processes for effective communication in primary care.

Abstract: Communication in the delivery of health care services occurs along 2 axes: between providers and patients and among several providers. In primary care, a principle objective in the provider-patient relationship is facilitating whole-person care, which is care provided in the context of family and community. In addition, primary care emphasizes communication between the primary care physician and other providers with the goal of integrated care, or care provided in the context of a patient's overall health care needs. However, considering both the U.S. health care delivery system and medical education programs, several obstacles interfere with the necessary processes of communication. This paper addresses those obstacles with a conceptual framework for effective communication in primary care. Recommendations propose formalizing requirements for the exchange of information among providers, enhancing communication training, disseminating information technology, and mitigating external factors that disrupt communication in primary care.

Integrating care for patients with infectious, psychiatric, and substance use disorders: concepts and approaches.

Abstract: Patients with chronic viral infections such as HIV/AIDS or hepatitis C often have multiple co-existing problems such as psychiatric and addictive disorders, as well as social problems such as lack of housing, transportation and income that present challenging obstacles to successful management. Because services for these different problems are usually provided by different disciplines in varying locations, fragmentation of care can lead to treatment dropouts, lack of adherence, and poor outcomes. Integration strategies, ranging from simple efforts to improve communication and coordinate care to fully integrated multidisciplinary teams have been used to improve disease management. Although evidence for effectiveness is comprised primarily of observational studies of demonstration programmes, integration may be desirable on a pragmatic basis alone. Quality improvement strategies are attractive vehicles for implementing care integration and measuring its impact. Careful assessment of the problem to be solved and the development of targeted strategies will maximize chances of a successful outcome.

Introducing an integrated care pathway for the last days of life

Abstract: Integrated care pathways (ICPs) are multiprofessional documents designed to enable the implementation of evidence-based care and support the practical delivery of clinical governance. However, the implementation of care pathways is resource intensive and few evaluations have been conducted with respect to these areas or to the efficacy of care pathways to change practice and improve outcomes in care. This project sought to address these issues and the report outlines the approach taken by a palliative care team in South Wales, UK, to implement a care pathway for the dying throughout a district general hospital and six community hospitals. Dying can be a complex area of care and changing practice can be challenging, therefore a PRINCE Project management approach was taken and a full-time project nurse employed for the life of the project. This paper describes the strategies used to approach implementing a care pathway and provides a template for other teams who may embark on similar projects. At the end of the project, the care pathway was successfully implemented and provided demonstrable outcomes of care for those dying from cancer and nonmalignant diseases. Strikingly, a large number of patients dying from nonmalignant disease were cared for via the pathway, which was not expected.

Addressing chronic pain in primary care settings

Abstract: Preface. Byrd, O'Donohue, Cummings, Introduction: The Case for Integrated Care: Coordinating Behavioral Healthcare with Primary Care Medicine. Strosahl, Training Behavioral Health and Primary Care Providers for Integrated Care: A Core Competencies Approach. Robinson, Adapting Empirically Supported Treatments to the Primary Care Setting: A Template for Success. Callaghan, Gregg, The Role of the Behavioral Health Care Specialist in the Treatment of Depression in Primary Care Settings. Campbell, Grisham, Brown, Anxiety Disorders in Primary Care. Mosco, Fruzzetti, Suicide and Parasuicide Management in the Primary Care Setting. Leskin, Morland, Keane, Integrating PTSD Services: The Primary Care Behavioral Health Model. Cummings, Identification and Treatment of Substance Abuse in Primary Care Settings. Cummings, Identifying and Treating the Somatizer: Integrated Care's Penultimate Behavioral Intervention. Pelham, Jr., Meichenbaum, Fabiano, Treating Attention Deficit Hyperactivity Disorder and Oppositional Defiant Disorder in the Primary Care Setting. Gifford, Palm, Providing Integrated Care for Smoking Cessation. Jacobs, Infertility. Kovacs, Houts, The Integration of Psychosocial Interventions into the Oncology Practice. Conrad, Poston, Foreyt, Managing Obesity in Primary Care. Kessler, As Precise as the Scalpel's Cut... Sort of: Psychological and Self-regulation Treatments in Preparation for Surgery and Invasive Medical Procedures. Arena, Blanchard, Assessment and Treatment of Chronic Benign Headache in the Primary Care Setting. Robinson, Gardea, Maddrey, Gatchel, Addressing Chronic Pain in Primary Care Settings. Callaghan, Ortega, Berlin, Psychosocial Interventions with Type 1 and 2 Diabetic Patients. Levensky, Increasing Medication Adherence in Chronic Illnesses: Guidelines for Behavioral Healthcare Clinicians Working in Primary Care Settings. Byrd, Ferguson, Henderson, Oksol, O'Donohue, The Integrated Management of Adult Asthma.

Impact of Generalist Care Managers on Patients with Diabetes

Abstract: Diabetes mellitus and its complications comprise one of the most expensive categories of chronic disease in the United States, contributing to at least 213,062 deaths in 2000 and $132 billion in costs in 2002. There is significant potential for improvement when appropriate medical care is provided (American Diabetes Association 2003). The highest potential for improvement comes from the capability to prevent the deadly complications of this disease; careful control of blood pressure, control of glycoslylated hemoglobin (HbA1c) and low density lipoprotein (LDL) level, and administration of appropriate medications (including ACE inhibitors, statins, aspirin, and β-blockers) have been shown to slow, and, in many cases, stop the progression of microvascular disease in people with diabetes (Matthews 1999; Nicollerat 2000). However, the United States' success in achieving tight control of HbA1c levels and appropriate medication administration in these patients has been limited at best (Toth et al. 2003). Despite implementation efforts at over half of the major health systems in the United States, compliance with management guidelines remains low. In a recent study, only 10.4 percent of patients met HbA1c, blood pressure, and LDL goals and only 13 percent met medication standards after guideline implementation (Toth et al. 2003). Clearly, people with diabetes and those caring for them have difficulty adhering to these guidelines. Guideline compliance can be increased through improved processes of care or disease management. One heavily studied approach involves an additional team member called a care manager who facilitates changes in clinic processes and patient knowledge and behaviors. Several studies have shown that interventions involving care managers can help patients and other care providers improve the quality of care and outcomes in diabetes (Pan et al. 1997; Tuomilehto et al. 2001; Knowler et al. 2002; New et al. 2003; Taylor et al. 2003; The California Medi-Cal Type 2 Diabetes Study Group 2004) and other diseases (Bond et al. 1988; Allen 1994; McGrew et al. 1995; Crystal, Lo Sasso, and Sambamoorthi 1999; Naylor et al. 1999; Bull, Hansen, and Gross 2000). These studies focus almost entirely on specific diseases or conditions and are mostly efficacy-style trials of disease management, or “a coordinated system … for a specific chronic illness” (AHM 2001), as opposed to a more broadly defined vision of care management, e.g., “a collaborative process of assessment, planning, facilitation and advocacy” (CMSA 2003). Disease management programs frequently create specialized clinics, which represent a highly focused setting where providers have in-depth training in a single disease whether they are specialists or trained primary care providers. In these specialized clinics or disease-specific clinic sessions, processes can be more easily controlled than in a general clinic where a multitude of acute and chronic illnesses are treated. In contrast, we studied the impact when care management was used to help treat a patient population with multiple chronic and acute illnesses and needs; care management was characterized by generalist care managers and specially developed information technology to support collaboration during the general primary care workflow. As persons with multiple chronic illnesses are known to suffer higher rates of complications and mortality, the generalist approach has the theoretical advantage of treating the whole person with one or more chronic disease rather than focusing on one disease (Rothman and Wagner 2003; Norris and Olson 2004). In practice, however, this approach is challenging. One study in which a broader patient population was treated demonstrated increases in adherence to guidelines and patient satisfaction, but did not find reductions in HbA1c in the patients with diabetes (Wagner et al. 2001). In other studies, it was found that care management programs increased the use of resources (D'Ercole et al. 1997). This finding is of special concern for overworked primary care clinics that frequently only receive a fraction of the savings that result from improving the health of their patients (Casalino 2003). Thus, it is important that implementation of such programs be carried out carefully, especially in real-world settings with diverse patient populations and limited resources. Given these concerns, we hypothesized that specialized care could be generalized into a multidisease care management model. To do so, we implemented Wagner's Chronic Care Model (CCM) (Bodenheimer, Wagner, and Grumbach 2002a, Bodenheimer, Wagner, and Grumbach 2002b) in a way different from many of the previous studies. At Intermountain Health Care (IHC) in Salt Lake City, we adopted a team approach (with the patient at the center) to encourage patient self-management and improved connection to community resources, and created core health care organization goals as part of a model to improve the care of chronic illness; these interventions are all standard parts of Wagner's CCM. Two major capabilities from the CCM were implemented to address the need to integrate the care management program into primary care workflow. Care managers were placed in the clinics and trained to facilitate team collaboration and general patient education, a more central role than advocated for in the CCM. In addition, existing information technology was leveraged and new applications were created to enable the primary care teams (including the care manager) to adopt many different guidelines at once. We hypothesized that the use of computerized alerts, summarized patient information, and electronic communication would allow an integrated approach to successfully meet the needs of patients with chronic illnesses without the need for specialized clinics for each disease or patient population. This information technology would aid the care manager, who would also work with the patient to assess their readiness to change and create a specific care plan based on any of the patient's particular chronic illness(es) (Spencer et al. 2002; Duran 2003). The generalist care manager, with support of the information system, can then act as a catalyst in each clinic, creating and then helping enact the care plan with the patient. We also hypothesized that the care of patients with diabetes would especially improve in our multidisease, collaborative care management model as patients with diabetes have a very high rate of co-occurring conditions that can worsen disease outcomes (Rothman and Wagner 2003). Improvement was measured by assessing changes in processes (such as timely testing for disease markers), and outcomes (changes in the levels of these markers indicating control) as defined by current diabetes guidelines (AACE 2000; ADA 2003; Goldstein et al. 2004; Haffner 2004). The demands and benefits of successful multidisease care management programs that can be implemented in the workflow of primary care clinics need to be defined, especially in diseases where they have the most impact. When one attempts to integrate multidisease care management systems into primary care, one may dilute the benefit, that might accrue to patients who are treated in a specialized setting. Integrated care management systems offer the promise to improve quality in a cost-effective manner. By examining the changes in adherence and outcomes in a generalist implementation within diabetes, we hoped to determine whether positive effects can be substantial when examining the impact on a single disease.

Mental health in post-communist countries

Abstract: Massive political, economic, and social changes in eastern and central Europe since the 1990s have created conditions of instability and stress, which are associated with troubling trends in health. Severe economic constraints after the collapse of the former Soviet Union followed by patchy economic growth have contributed to marked inequalities in income1 and social upheaval. These changes have been associated with increased physical morbidity, mortality, and mental illness in the population of such transitional countries,2 including high suicide rates, high mortality from alcohol and tobacco related diseases, and rapidly rising HIV rates.3 Compounding the recent changes are the political and social legacies of communism. These include the massive over-institutionalisation of people with mental disorders and intellectual disabilities4 that still occurs in the health and social protection sectors and leaves many in mental hospitals and internats (social asylums). These top heavy systems of mental health care are coupled with relatively underdeveloped systems of primary care. Primary care services are not generally expected to manage common mental disorders, and most simply refer patients to specialist services. While access to essential medicines is usually possible, access to evidence based psychological interventions is still limited. This arises from isolation from the west and poor awareness of the international evidence base on diagnosis, effective services, and interventions. Partly as a result of the hierarchical structures inherited from the communist era, intersectoral joint collaborative working between systems for health, social care, education, housing, employment, and criminal justice is still extremely difficult to achieve. There is little joint working between programmes for mental health and those for preventing HIV infection and substance misuse, for reducing harms, and for promoting health. There are, however, many levers for change. A situation appraisal (a detailed formal assessment) of social, political, and geographic context; of populations' needs; and of the structures, processes, and outcomes of services is crucial to inform subsequent policy and planning.5-9 The transitional countries of central and eastern Europe must develop and implement comprehensive policies for mental health and integrate these policies with wider reforms in health care and other sectors and with plans for economic recovery.10 Schools in the region should offer integrated education on physical and mental health, and societies should make comprehensive efforts to reduce social stigma and discrimination associated with mental illness.10 In addition, legislation on mental health is needed to protect the human rights of people subject to compulsory admission and treatment. Several countries in the region—for example Russia11—now have such progressive legislation, but this is not widely implemented because professionals working in courts, prisons, the police, and services for health and social protection have not been trained to use the new laws. Improvements in mental health will depend greatly on effective working between public sectors. Some countries, including Georgia, Bulgaria, Lithuania, and Slovenia, have developed comprehensive strategies for improving mental health and preventing suicide, but, again, implementation of these policies is limited. The development of local comprehensive services that are socially inclusive and based in the community is hindered by inherent financial disincentives. These include the way disability benefits are allocated (creating disincentives to return to work) and the funding of mental hospitals and internats by the number of inpatients. When attention and resources shift from such institutions to the community, conditions for patients in the institutions that are still open often worsen, paradoxically exacerbating inpatients' loss of human rights. Non-governmental organisations can play an important part in advocating better services, setting up pilot services to test new models of care, and conducting research and audits of provision, range, and quality of services. For example, the US Open Society Institute has supported non-governmental organisations providing community based services and advocacy to promote social inclusion and the human rights of people with mental disabilities. Such investment by donors has allowed a variety of demonstration projects in health, social, educational, and employment services in the region, but community based models of care have not yet been disseminated nationally in any systematic way.12 Fully integrated care has also been tested successfully—for example, in a project to reform services for adult mental health in Russia, funded by the UK Department for International Development (Jenkins et al, in preparation). Such combined approaches, developed through projects funded by donor organisations, can provide an effective model and can accelerate subsequent national dissemination.

Individual Budgets: Transforming the allocation of resources for care

Abstract: This article challenges local authorities, Primary Care Trusts and other funding bodies to reflect on the efficacy, and on the justice, of the way they allocate funds for individual care. It describes how greater cost effectiveness is being combined with better care in a number of authorities where a new approach is being piloted. The article follows up a contribution to the Special Issue of Journal of Integrated Care in December 2004 which focussed on user empowerment, and it aims to take thinking beyond the implementation of Direct Payments.

Treatment for dual diagnosis patients in the psychiatric and substance abuse systems.

Abstract: The purpose of this study was to describe and compare the extent to which psychiatric and substance abuse programs treating dual diagnosis patients in the residential and outpatient modalities offered the components recommended for this client group. Surveys were completed by managers of 753 programs in the Department of Veterans Affairs that had a treatment regimen oriented to dual diagnosis patients. Programs within both the psychiatric and substance abuse systems had some of the key services of integrated treatment (e.g., assessment and diagnosis, crisis intervention, counseling targeted at psychiatric and at substance use problems, medications, patient education, HIV screening and counseling, family counseling and education). However, compared to psychiatric programs, substance abuse programs were more likely to offer some of these services and other critical components (e.g., a cognitive-behavioral treatment orientation, assignment of a single case manager to each patient). Outpatient psychiatric programs were particularly lacking on key management practices (e.g., use of clinical practice guidelines, performance monitoring of providers) and services (e.g., detoxification, 12-step meetings) of integrated treatment. Generally, differences between psychiatric and substance abuse programs appeared to involve difficulties in developing treatment that is fully oriented toward the co-occurring diagnosis. To improve the provision of high-quality dual-focused care, we recommend planners' use of cross-system teams and applications of recently produced tools designed to increase programs' ability to deliver integrated care to dually disordered individuals.

Informal and formal caregivers' involvement in nursing home care activities: impact of integrated care.

Abstract: Aims. This paper reports a study to investigate the relationships between informal and formal care, changing relationships over time, impact of integrated care, and theoretical and methodological lessons that can be drawn from research on this topic. Background. The ratio of informal to formal care provided in nursing homes varies. In many countries the predominance of traditional, formal care is being challenged by the emergence of integrated care models in which formal and informal caregivers co-operate and co-ordinate their activities to deliver tailor-made care. This move towards integrated care is likely to result in changes in the degree and nature of involvement of formal and informal caregivers in care activities. However, very little research has investigated this. Previous research is restricted to one point in time, as opposed to focussing on the changing relationships between formal and informal caregivers over time. Methods. The quasi-experimental design encompassed a traditional care comparison setting and an experimental setting with an integrated care intervention. At three measurement points, one before the intervention in May/June 2000 and two at 6 and 14 months after the intervention, informal and formal caregivers recorded their care activities. Informal care relationships were determined by calculating contribution rates and informal/formal care ratios for 14 activities. Results. Integrated care did not bring about the expected major changes. There was a limited amount of substitution of formal care with informal care. There were limited changes in the extent of dual specialization, in which informal and formal caregivers perform separate activities. There was little supplementation of formal care with informal care. Furthermore, relationships changed over time, resulting in a complex pattern of linkages at the level of separate activities. Conclusions. Informal caregivers contribute to many activities. The impact of integrated care on the degree and nature of involvement, however, was moderate. A possible explanation is the contextual situation for nursing home care. These findings point to the need for further research into the (changing) relationship between formal and informal carers in residential care activities and the evolution of this relationship over time.

Common Experiences of Staff Working in Integrated Health and Social Care Organisations: A European Perspective

Abstract: This paper presents a comparison of the views of staff working in 18 integrated care settings, undertaken as part of the PROCARE study of integrated health and social care. The data reveals some apparent commonalities across the nine European countries. Increased job satisfaction was an advantage of integrated working, but respondents also reported difficulties in working with hospitals or medical professionals, and continued barriers to integrated working generally. Overall, single standalone organisations such as home care teams reported the clearest benefits from integrated working, while cross‐agency models continued to encounter significant barriers to health and social care integration.

Integrated substance use and mental health treatment for adolescents: aligning organizational and financial incentives

Abstract: The high prevalence of the dual diagnosis of mental and substance use disorders (SUD) has been increasingly documented for both adolescents and adults (Crowley and Riggs 1995; Kandel et al. 1999; Whitmore et al. 1997). For more than a decade, the National Institute of Drug Abuse (NIDA) has included integrated treatment of comorbid psychiatric disorders as one of nine core treatment principles (National Institute on Drug Abuse 1999). Despite empirically supported practice guidelines, implementation of integrated treatment has been slow (New Freedom Commission on Mental Health 2003; U.S. Department of Health and Human Services 1999). In response to the growing call for integrated treatments and systems of care, this paper: (1) identifies systemic and economic barriers that have impeded widespread implementation of integrated care for adolescents with co-occurring SUD, specifically the supply of treatment providers, shifting priorities of gatekeepers to specialty care, and financing streams; and (2) describes possibilities for aligning economic incentives in order to facilitate the dissemination and implementation of integrated care for adolescents with co-occurring SUD.

A Comparative Study of Dementia Care in England and the Netherlands Using Neo-Institutionalist Perspectives

Abstract: In this article, the authors compare dementia care in England and the Netherlands. They used qualitative methods to explore recommended standards of service provision and perceived achievements in mainstream care. They found some similarities in recommended standards and in major shortcomings in mainstream services: notably, weaknesses of generic services in supporting patients and carers, and failure to achieve integrated care. Priorities regarding service provision differed. Whereas in England, a social model of care was used to encourage empowerment of both the person with dementia and the carer, Dutch care professionals focused more on "warm care concepts" and on support of the carer rather than the patient. The balance between community care and institutional care also differed. The authors used neo-institutionalist concepts to explore these similarities and differences as embedded in the (historically developed) structural and cultural contexts of the respective health and social care systems.

Integrated mental health services in England: a policy paradox

Abstract: Purpose: The purpose of this paper is to examine the effects of health care policy on the development of integrated mental health services in England. Data sources: Drawing largely from a narrative review of the literature on adult mental health services published between January 1997 and February 2003 undertaken by the authors, we discuss three case studies of integrated care within primary care, secondary care and across the primary/secondary interface for people with serious mental illness. Conclusion: We suggest that while the central thrust of a raft of recent Government policies in England has been towards integration of different parts of the health care system, policy waterfalls and implementation failures, the adoption of ideas before they have been thoroughly tried and tested, a lack of clarity over roles and responsibilities and poor communication have led to an integration rhetoric/reality gap in practice. This has particular implications for people with serious mental health problems. Discussion: We conclude with suggestions for strategies that may facilitate more integrated working.

The effectiveness of quality improvement tools: joint working in integrated community teams

Abstract: Objective. To explore the effectiveness of integrated care pathways in facilitating integration in community-based teams. Design. Case comparison of models of integrated care pathways in two different settings: community mental health teams in one Scottish region and care of the elderly rapid response teams in three Scottish regions. In both settings, an integrated care pathway was used as a tool for integration, but in different ways. Comparison is made by first identifying key factors structuring team-work in both settings, then analysing how the constellation of these factors results in different dynamics of team-work in each setting. The pathway tool used in each setting is then outlined and an analysis presented of how the tool interacts with the organizational dynamics in and around the teams to produce observed outcomes in each setting. Results. In both settings impact of tool was shaped by the same organizational dynamics which produced the nature of teamwork. In neither setting was the tool optimally effective in improving integration. In community mental health teams a prescriptive, management-driven integrated care pathway was introduced. This presumed a degree of task sharing in teams which was absent. It was resisted by the teams. In rapid response teams a flexible, team-driven pathway tool was being introduced to help teams conceptualize and communicate about the service. This approach fitted with autonomy and task sharing in rapid response teams and uptake was good. However, management did not engage. Conclusion. The effectiveness of the tool in both settings requires attention to organizational context.

HIV/AIDS and Homelessness, Part 1: Background and Barriers to Care

Abstract: Co-occurrence of homelessness and HIV/AIDS poses a complex and multidimensional challenge to the health care provider's clinical and system integration skills. Existing data support the high prevalence of HIV/AIDS among homeless persons and a high percentage of persons living with HIV/AIDS being either homeless or at imminent risk for homelessness. There are special considerations and challenges health care providers may face in caring for homeless persons with HIV/AIDS. An integrated, flexible, interdisciplinary, community-based system of care addressing the full array of medical, psychiatric/substance abuse, and housing services would optimize clinical care for this population. Areas that deserve particular attention include HIV/AIDS prevention, access to comprehensive HIV and health care, use of antiretroviral therapy, and adherence to treatment. Research is needed to better understand the multifaceted needs of this population and to develop prevention and treatment strategies applicable to daily clinical care.

HIV nursing consultants: patients' preferences and experiences about the quality of care.

Abstract: AIM AND OBJECTIVES: We were interested to find out how human immunodeficiency virus (HIV)-patients judge the quality of care received from their HIV nursing consultants, compared with the care delivered by HIV specialists and general practitioners. Furthermore, we were interested in how the opinions of HIV patients on the HIV nursing consultant compared with the opinions of patients with rheumatic diseases on the care they receive from their specialized nurses. BACKGROUND: The role of nurses has changed over the years. For patients with chronic diseases there seems to be an increasing role for nursing consultants in the delivery of care. In evaluating quality of care, patients' views are considered important especially for the chronically ill who can be seen as experts by experience. METHODS: Between February 1999 and June 2000, 250 patients, receiving care from both general practitioner and specialist, received a questionnaire [Quality of Care Through the Patient's Eyes (QUOTE)-HIV] to assess HIV-related quality of care, as perceived by them. Aspects were formulated as "importance" and "performance" statements. Items were scored on 4-point scales. A ratio score (R(ij) = P(ij)/I(ij)) was calculated by dividing the perceived performance score (P) of an individual patient (i), on a health service (j) by his importance score (I). A comparison was made with patients with rheumatic diseases by using data from the QUOTE-Rheuma. RESULTS: Patients judged the quality of care from the HIV nursing consultant as predominantly good. Five aspects showed an unfavourable ratio score (R < 1.0) which indicates room for improvement. On the dimensions "professional performance" and "attitude of the professional" the HIV nursing consultant scores between the general practitioner and the HIV specialist. Patients with rheumatic diseases seemed to be more satisfied than HIV patients with the care from their nurse consultant. CONCLUSIONS: The HIV nursing consultants have an important role in the care of patients infected with HIV. The HIV nursing consultants are judged as good and are ranked in between the general practitioner and the HIV specialist. Given the orientation towards a more integrated care for chronically ill patients, there should be more attention paid to the position of the HIV nursing consultant. RELEVANCE TO CLINICAL PRACTICE: In the Netherlands and in the United Kingdom there is a tendency to a greater degree of differentiation of tasks in health care. This study shows that there is room for a position like the nursing consultant and that this is highly valued by patients. (aut.ref.)

Sustainable partnerships for integrated care: the role of decision making and its environment.

Abstract: This paper is intended to further the understanding of the role of the characteristics of decision making and its environment in the development of sustainable partnerships in health care, and to illustrate how this subject can be studied from a combined theoretical and methodological perspective. With the aid of a conceptual model covering sensitizing concepts from contingency theory (that refer to environmental characteristics--particularly institutions--the process course of decision making and its outcomes) and the case study methodology (explanation-building, triangulation, document study and interviews), two Dutch cases were analysed. The findings indicate which environmental characteristics are responsible for the differences in the process course and outcomes between the cases.

An Evaluation of the Quality of Integrated Care Pathway Development in the UK National Health Service

Abstract: An integrated care pathway (ICP) is an outline of planned care for a specific patient group. It highlights usual practice that is evidence-based, from which variations occur as health-care professi...