Showing papers on "Integrated care published in 2006"
TL;DR: It is demonstrated that a standardised integrated care intervention, based on shared care arrangements among different levels of the system with support of information technologies, effectively prevents hospitalisations for exacerbations in chronic obstructive pulmonary disease patients.
Abstract: Hospital admissions due to chronic obstructive pulmonary disease (COPD) exacerbations have a major impact on the disease evolution and costs. The current authors postulated that a simple and well-standardised, low-intensity integrated care intervention can be effective to prevent such hospitalisations. Therefore, 155 exacerbated COPD patients (17% females) were recruited after hospital discharge from centres in Barcelona (Spain) and Leuven (Belgium). They were randomly assigned to either integrated care (IC; n565; age meaniSD 70i9 yrs; forced expiratory volume in one second (FEV1) 1.1i0.5 L, 43% predicted) or usual care (UC; n590; age 72i9 yrs; FEV1 1.1i0.05 L, 41% pred). The IC intervention consisted of an individually tailored care plan upon discharge shared with the primary care team, as well as accessibility to a specialised nurse case manager through a web-based call centre. After 12 months' follow-up, IC showed a lower hospitalisation rate (1.5i2.6 versus 2.1i3.1) and a higher percentage of patients without re-admissions (49 versus 31%) than UC without differences in mortality (19 versus 16%, respectively). In conclusion, this trial demonstrates that a standardised integrated care intervention, based on shared care arrangements among different levels of the system with support of information technologies, effectively prevents hospitalisations for exacerbations in chronic obstructive pulmonary disease patients.
446 citations
TL;DR: Integrated systems appear to be feasible and have the potential to reduce hospital and nursing home utilization without increasing costs.
Abstract: Background. Care for elderly persons with disabilities is usually characterized by fragmentation, often leading to more intrusive and expensive forms of care such as hospitalization and institutionalization. There has been increasing interest in the ability of integrated models to improve health, satisfaction, and service utilization outcomes. Methods. A program of integrated care for vulnerable community-dwelling elderly persons (SIPA [French acronym for System of Integrated Care for Older Persons]) was compared to usual care with a randomized control trial. SIPA offered community-based care with local agencies responsible for the full range and coordination of community and institutional (acute and long-term) health and social services. Primary outcomes were utilization and public costs of institutional and community care. Secondary outcomes included health status, satisfaction with care, caregiver burden, and out-of-pocket expenses. Results. Accessibility was increased for health and social home care with increased intensification of home health care. There was a 50% reduction in hospital alternate level inpatient stays (‘‘bed blockers’’) but no significant differences in utilization and costs of emergency department, hospital acute inpatient, and nursing home stays. For all study participants, average community costs per person were C$3390 higher in the SIPA group but institutional costs were C$3770 lower with, as hypothesized, no difference in total overall costs per person in the two groups. Satisfaction was increased for SIPA caregivers with no increase in caregiver burden or out-of-pocket costs. As expected, there was no difference in health outcomes. Conclusions. Integrated systems appear to be feasible and have the potential to reduce hospital and nursing home utilization without increasing costs.
261 citations
TL;DR: There is a growing evidence base of rigorous evaluations of organizational strategies, but the evidence underlying some strategies is limited and for no strategy can the effects be predicted with high certainty.
Abstract: Changing the organization of patient care should contribute to improved patient outcomes as functioning of clinical teams and organizational structures are important enablers for improvement. To provide an overview of the research evidence on effects of organizational strategies to implement improvements in patient care. Structured review of published reviews of rigorous evaluations. Published reviews of studies on organizational interventions. Searches were conducted in two data-bases (Pubmed, Cochrane Library) and in selected journals. Reviews were included, if these were based on a systematic search, focused on rigorous evaluations of organizational changes, and were published between 1995 and 2003. Two investigators independently extracted information from the reviews regarding their clinical focus, methodological quality and main quantitative findings. A total of 36 reviews were included, but not all were high-quality reviews. The reviews were too heterogeneous for quantitative synthesis. None of the strategies produced consistent effects. Professional performance was generally improved by revision of professional roles and computer systems for knowledge management. Patient outcomes was generally improved by multidisciplinary teams, integrated care services, and computer systems. Cost savings were reported from integrated care services. The benefits of quality management remained uncertain. There is a growing evidence base of rigorous evaluations of organizational strategies, but the evidence underlying some strategies is limited and for no strategy can the effects be predicted with high certainty.
252 citations
TL;DR: The relation between age, frailty, comorbidity, and disability is elaborated further, a method to detect frail patients quickly is introduced, and its relation to complexity is explored.
177 citations
TL;DR: The survey showed that clinical pathways were predominantly viewed as a multidisciplinary tool to improve the quality and efficiency of evidence-based care and were also used as a communication tool between professionals to manage and standardize outcome-oriented care.
Abstract: ObjectivesTo give an overview on the use and prevalence of clinical pathways.DesignCross-sectional descriptive study.Study participantsEuropean Pathway Association (E-P-A) contact persons in 23 countries.ResultsClinical pathways, also known as critical pathways or integrated care pathways, have been used in health care for 20 years. Although clinical pathways are well established, little information exists on their use and dissemination around the world. The E-P-A has performed their first international survey on the use and dissemination of clinical pathways in 23 countries. At present, pathways are used with a minority of patients, mainly in acute hospital trusts. Our survey showed that clinical pathways were predominantly viewed as a multidisciplinary tool to improve the quality and efficiency of evidence-based care. Pathways were also used as a communication tool between professionals to manage and standardize outcome-oriented care.ConclusionsThere is a future for the use of clinical pathways, but the...
173 citations
TL;DR: A somewhat positive pattern of results is found in terms of service access, utilisation, costs, care provision, quality, health status and client/carer satisfaction, and a call for further research to understand the relationships between whole-system models, services and outcomes in integrated care for elderly people is called for.
Abstract: Irrespective of cross-national differences in long-term care, countries confront broadly similar challenges, including fragmented services, disjointed care, less-than-optimal quality, system inefficiencies and difficult-to-control costs. Integrated or whole-system strategies are becoming increasingly important to address these shortcomings through the seamless provision of health and social care. North America is an especially fertile proving ground for structurally oriented whole-system models. This article summarises the structure, features and outcomes of the Program of All-Inclusive Care for Elderly People (PACE) programme in the United States, and the Systeme de soins Integres pour Personnes Agees (SIPA) and the Programme of Research to Integrate Services for the Maintenance of Autonomy (PRISMA) in Canada. The review finds a somewhat positive pattern of results in terms of service access, utilisation, costs, care provision, quality, health status and client/carer satisfaction. It concludes with the identification of common characteristics which are thought to be associated with the successful impact of these partnership initiatives, as well as a call for further research to understand the relationships, if any, between whole-system models, services and outcomes in integrated care for elderly people.
147 citations
TL;DR: The Veterans Health Study had as its overarching goal the development, testing, and application of patient-centered assessments for monitoring patient outcomes in ambulatory care in large integrated care systems such as the Department of Veterans Affairs.
Abstract: The Veterans Health Study (VHS) had as its overarching goal the development, testing, and application of patient-centered assessments for monitoring patient outcomes in ambulatory care in large integrated care systems such as the Department of Veterans Affairs (VA). Unlike other previous studies, the VHS has capitalized on rich administrative databases restricted to the VA and linked to patient-centered outcomes. The VHS has developed a comprehensive set of general and disease-specific measures for use by systems of care for ambulatory patients. Chief among these assessments is the Veterans SF-36 Health Survey for measuring health-related quality of life in veteran ambulatory populations. The Veterans SF-36 Health Survey provides the cornerstone for this study and historically has been extensively disseminated and used in the VA with close to 2 million administrations nationally as part of its quality management system. National surveys administered by the VA since 1996 using the Veterans SF-36 Health Survey indicate important regional differences with implications for varying resource needs. Based upon the rich foundation provided by the VHS methodology, the VA has implemented some of these approaches as part of its quality monitoring system and can serve as a model for other large integrated systems of care.
144 citations
TL;DR: Whether clinical/care pathway audit tools can identify the characteristics of well-organized care processes and the Integrated Care Pathway Appraisal Tool is the most appropriate audit tool to assess clinical pathway documents is investigated.
Abstract: Aim To determine whether clinical/care pathway audit tools can identify the characteristics of well-organized care processes.
Background Although pathways are used worldwide, confusion exists about the concept and impact.
Evaluation Search of OVID-Medline, Cinahl, British Nursing Index; manual search of the Journal of Integrated Care Pathways; contact with Smartgroup on Clinical Pathways and board members of the European Pathway Association and Google® search.
Key issues We selected seven of 15 clinical pathway audit tools for this review. Through content analysis, we identified 17 characteristics and grouped them using the realistic evaluation paradigm. The Integrated Care Pathway Appraisal Tool is the most appropriate audit tool to assess clinical pathway documents.
Conclusions It is astonishing that so little research on clinical pathway audit tools has been underwent, given the prevalent use of clinical pathways. Because the concept of clinical pathways remains unclear, a variety of audit tools are needed to help clarify the concept. Further research on the construct and criter- ion validity of pathway audit tools is necessary to fully understand why and under which circumstances pathways lead to improved care.
121 citations
TL;DR: It cannot be presumed that the implementation of a care pathway for the last days of life in nursing homes is straightforward, and this study suggests that an action research framework was extremely useful in highlighting and overcoming some obstacles when developing evidence-based practice.
Abstract: Aim: This paper explores the barriers that needed to be overcome during the process of implementing an integrated care pathway for the last days of life as a way of developing quality end-of-life care in nursing homes. Methods: An action research methodology underpinned the study. Qualitative and quantitative data were collected in eight nursing homes before, during and after the implementation of the care pathway. Findings: Six main barriers were identified: a lack of knowledge of palliative care drugs and control of symptoms at the end of life; lack of preparation for approaching death; not knowing when someone is dying or understanding the dying process; lack of multidisciplinary team working in nursing homes; lack of confidence in communicating about dying; some nursing homes are not ready or able to change. These findings highlight a functional ‘rehabilitative’ culture that may not be so appropriate in the current context of nursing home care, and one that makes implementing an integrated care pathwa...
102 citations
TL;DR: Six-month outcomes for older primary care patients with depression who received different models of treatment were comparable for the two models, but rates of remission and change in function did not differ across models of care for major depression.
Abstract: OBJECTIVE: This study, entitled Primary Care Research in Substance Abuse and Mental Health for the Elderly, examined six-month outcomes for older primary care patients with depression who received different models of treatment. METHODS: Clinical outcomes were compared for patients who were randomly assigned to integrated care or enhanced specialty referral. Integrated care consisted of mental health services co-located in primary care in collaboration with primary care physicians. Enhanced specialty referral consisted of referral to physically separate, clearly identified mental health or substance abuse clinics. RESULTS: A total of 1,531 patients were included; their mean age was 73.9 years. Remission rates and symptom reduction for all depressive disorders were similar for the two models at the three- and six-month follow-ups. For the subgroup with major depression, the enhanced specialty referral model was associated with a greater reduction in depression severity than integrated care, but rates of remission and change in function did not differ across models of care for major depression. CONCLUSIONS: Six-month outcomes were comparable for the two models. For the subgroup with major depression, reduction in symptom severity was superior for those randomly assigned to the enhanced specialty referral group. Language: en
97 citations
01 Jan 2006
TL;DR: Experience of integrated care so far is limited but promising, and further research and evaluation is needed to ensure that implementation of proposed models is feasible sustainable and results in better health outcomes.
Abstract: Integrated care seeks to close the traditional division between health and social care. In doing so it may: address the changing demand for care arising from the ageing of the population offer care that is person-centred recognising that health and social care outcomes are interdependent facilitate the social integration of societys more vulnerable groups through better access to flexible community services lead to better system efficiency through better coordination of care. Putting models of integrated care into practice poses substantial challenges. These occur at the political organisational and service delivery level. Experience of integrated care so far is limited but promising. Further research and evaluation is needed to ensure that implementation of proposed models is feasible sustainable and results in better health outcomes. Policies need to be adapted to local realities. (excerpt)
01 Jan 2006
TL;DR: In this paper, the authors review progress that has been made, identify current challenges, and point to promising directions for the future, including the development and dissemination of integrated clinical intervention approaches and states' activities to reduce the administrative and philosophical divisions be- tween the two treatment systems.
Abstract: Separate public financing and regulation of substance (SA) abuse treatment distinct from mental health (MH) treatment preserves a focus on the special needs of those with substance abuse but creates challenges to providing appropriate care for the large number of people with co-occurring conditions. This paper reviews recent efforts to over- come these challenges through clinical and systems approaches that better integrate care. Although much progress has been made for some subgroups of people with co-occurring disorders, further efforts to develop and sustain clinically integrated service delivery ap- proaches within separate systems, particularly in SA treatment settings, are needed. linical a nd s ystems b arr i ers often stand in the way of care for co- occurring mental health (MH) and substance abuse (SA) disorders. In the past decade there has been much effort to overcome these barriers, includ- ing development and dissemination of integrated clinical intervention approaches, and states' activities to reduce the administrative and philosophical divisions be- tween the two treatment systems. In this paper we review progress that has been made, identify current challenges, and point to promising directions for the future.
TL;DR: Although much progress has been made for some subgroups of people with co-occurring disorders, further efforts to develop and sustain clinically integrated service delivery approaches within separate systems, particularly in SA treatment settings are needed.
Abstract: Separate public financing and regulation of substance (SA) abuse treatment distinct from mental health (MH) treatment preserves a focus on the special needs of those with substance abuse but creates challenges to providing appropriate care for the large number of people with co-occurring conditions. This paper reviews recent efforts to overcome these challenges through clinical and systems approaches that better integrate care. Although much progress has been made for some subgroups of people with co-occurring disorders, further efforts to develop and sustain clinically integrated service delivery approaches within separate systems, particularly in SA treatment settings, are needed.
TL;DR: It is suggested that older persons with at-risk drinking can substantially modify their drinking over time and the magnitude of reduction in alcohol use was comparable with other intervention studies.
Abstract: Objective: This study was part of the Primary Care Research in Substance Abuse and Mental Health for the Elderly study (PRISM-E) and determined the relative effectiveness of two different models of care for reducing at-risk alcohol use among primary care patients aged 65 and older. Methods: This multisite study was a randomized clinical trial comparing integrated care with enhanced specialty referral for older primary care patients screened and identified to have at-risk drinking. Results: Before the study, the 560 participants consumed a mean of 17.9 drinks per week and had a mean of 21.1 binge episodes in the prior three months. At six months, both treatment groups reported lower levels of average weekly drinking (p<.001) and binge drinking (p<.001), despite low levels of treatment engagement. However, the declines did not differ significantly between treatment groups. Conclusions: These results suggest that older persons with at-risk drinking can substantially modify their drinking over time. Although no evidence suggested that the model of care was important in achieving this result, the magnitude of reduction in alcohol use was comparable with other intervention studies. (Psychiatric Services 57: 954–958, 2006)
TL;DR: Various aspects of the INTERMED, such as its relevance, description, scoring, the related patient interview and treatment planning, scientific evaluation, implementation, and support for the method are presented.
TL;DR: The conclusion recommends the use of the Iso-SMAF profiles for planning, managing and predicting LTC service needs in an integrated care system.
TL;DR: This article is a follow-up to the discussion started in the April issue with Beland and colleagues' article "A System of Integrated Care for Older Persons with Disabilities in Canada: Results From a Randomized Controlled Trial" and invites short position articles that contribute to this same argumentation.
Abstract: This article is a follow-up to the discussion started in the April issue with Beland and colleagues' article "A System of Integrated Care for Older Persons with Disabilities in Canada: Results From a Randomized Controlled Trial" (p. 367), complemented by the Reuben guest editorial (p. 365). The Editor invites short position articles that contribute to this same argumentation.
TL;DR: Regression results showed that patients who used the IC model, attended the treatment service twice or more, or showed clinical improvement were more likely to express greater satisfaction, and older adults are more likely than younger adults to have greater satisfaction with mental health services integrated in primary care settings.
Abstract: Objective This study examines whether older adult primary care patients are satisfied with two intervention models designed to ameliorate their behavioral health problems Methods A total of 1,052 primary care patients aged 65 and older with depression, anxiety, or at-risk drinking were randomly assigned to and participated in either integrated care (IC) or enhanced specialty referral (ESR) model and completed the Client Satisfaction Questionnaire (CSQ) administered at three-month follow-up assessment Results Older adult patients' satisfaction with IC (mean: 34, standard deviation [SD]: 060) was significantly higher than that with ESR (mean: 32, SD: 078), but the absolute difference was modest Regression results showed that patients who used the IC model, attended the treatment service twice or more, or showed clinical improvement were more likely to express greater satisfaction Stigma toward mental illness was negatively associated with satisfaction with mental health services Conclusions Older adults are more likely to have greater satisfaction with mental health services integrated in primary care settings than through enhanced referrals to specialty mental health and substance abuse clinics
TL;DR: In this paper, the authors proposed that the opportunity to invest in integrated care may open up innovative processes, which generate considerable productivity gains and serve as a gateway for the introduction of more widespread selective contracting.
TL;DR: In this paper, the authors discuss the provision of pharmaceutical care in community pharmacies in Germany including community pharmacy, organization and delivery of health services, pharmacy education, community pharmacy services, research in community pharmacy and future plans for community pharmacists.
Abstract: Objective:To discuss the provision of pharmaceutical care in community pharmacies in Germany including community pharmacy, organization and delivery of health services, pharmacy education, community pharmacy services, research in community pharmacy, and future plans for community pharmacy services.Findings:In Germany, cognitive pharmaceutical services have been developed for more than 12 years. Several studies and programs have shown that pharmaceutical care and other pharmaceutical services are feasible in community pharmacy practice and that patients benefit from these services. In 2003, a nationwide contract was established between representatives of the community pharmacy owners and the largest German health insurance fund. In this so-called family pharmacy contract, remuneration of pharmacists for provision of pharmaceutical care services was successfully negotiated for the first time. In 2004, a trilateral integrated care contract was signed that additionally included general practitioners, combinin...
TL;DR: This work analysed the development of an integrated network from a learning perspective to see how care givers from different organisations were able to cross the professional and organisational boundaries that existed between them to make sure patients receive the right care.
TL;DR: Education which embeds essential attributes to integrated working is needed to advance nursing practice for interprofessional working and its impact on integrated provision is essential to ensure that evidence-based services are provided.
Abstract: Aim. This paper reports a systematic review to identify the education needs of the workforce within primary care to promote the effective delivery of integrated health and social care services.
Background. The need for different professionals to work more closely dominates global health policy. The drive to develop a workforce prepared for the future is crucial to the success of integrated services. However, some have argued that nurses are ill-equipped to meet the challenges of integrated service provision. The ability to work interprofessionally is an important skill which needs to be developed to support integrated working.
Methods. Structured searches were undertaken on organizational websites and the Caredata, CINAHL, Cochrane Library, MEDLINE, Sociofile databases between December 2002 and April 2004 to identify policy documents and primary research studies. The robustness of identified research studies were appraised using recognized appraisal tools.
Findings. Six themes were identified which indicate essential elements needed for integrated care. The need for effective communication between professional groups within teams and an emphasis on role awareness are central to the success of integrated services. In addition, education about the importance of partnership working and the need for professionals to develop skills in relation to practice development and leadership through professional and personal development is needed to support integrated working.
Conclusion. Education which embeds essential attributes to integrated working is needed to advance nursing practice for interprofessional working. Further research exploring this and its impact on integrated provision is essential to ensure that evidence-based services are provided. The reinforcement of partnerships between higher education institutions and health and social care organizations should ensure that the workforce is educated to manage continuous change in service delivery. Innovative ways of teaching and learning which promote inter-professional working need to be explored.
TL;DR: For the first time, a framework of leadership domains including vision, alignment, relationships, values and process is reported to facilitate priority setting practices in health services' organizations to facilitate good leadership practices for health reform.
TL;DR: It was found that unmet need was significantly related to burden, suggesting that meeting patient needs could reduce carer burden.
Abstract: Objective
To identify patients’ and carers’ perceptions of need in inpatient and community settings and investigate the relationship between need and caregiver burden.
TL;DR: The range of in- and outpatient options for integrating medicine and psychiatry as currently practiced is illustrated, and qualifications for practicing in each model are described, the settings, the patient populations, the relevant financial issues, and the advantages and disadvantages of practicing ineach model.
TL;DR: This article proposes that these health system deficiencies will persist unless behavioral health services become an integral part of medical care (ie, integrated) and creates a win-win situation for virtually all parties involved.
TL;DR: Compared with referral care, providing primary care within a VA addiction clinic increased primary care access and initial SUD treatment retention but showed no effect on overall health status or costs.
Abstract: Background: Patients presenting for treatment of substance use disorders (SUDs) often exhibit medical comorbidities that affect functional health status and healthcare costs. Providing primary care within addictions clinics (onsite care) may improve medical and SUD treatment outcomes in this population. Objective: The objective of this study was to compare outcomes among Veterans’ Administration (VA) patients who receive medical care within the SUD clinic and those referred to a general medicine clinic at the same facility. Methods: Veterans entering SUD treatment with a chronic medical condition and no current primary care were randomized to receive primary medical care: 1) onsite in the VA SUD clinic (n = 358), or 2) in the VA general internal medicine clinic (n = 362). Subjects were assessed at baseline and at 3, 6, and 12 months postrandomization. Intention-to-treat analyses used random-effects regression. Measures: Measures included SF-36 Physical and Mental Component Summaries (PCS, MCS), VA service utilization, SUD treatment retention, Addiction Severity Index (ASI) scores, 30-day abstinence, and total VA healthcare costs. Results: Over the study year, patients assigned to onsite care were more likely to attend primary care (adjusted odds ratio [OR] = 2.20; 95% confidence interval [CI] = 1.53–3.15) and to remain engaged in SUD treatment at 3 months (adjusted OR = 1.36; 1.00–1.84). Overall, outcomes on the MCS (but not the PCS) and the ASI improved significantly over time but did not differ by treatment condition. Total VA healthcare costs did not differ reliably across conditions. Conclusions: Compared with referral care, providing primary care within a VA addiction clinic increased primary care access and initial SUD treatment retention but showed no effect on overall health status or costs.
TL;DR: Just for Us is becoming a financially sustainable way of creating a "system within a nonsystem" for low-income elderly persons in clustered housing.
Abstract: Purpose: To promote health and maintain independence, Just for Us provides financially sustainable, in-home, integrated care to medically fragile, low-income seniors and disabled adults living in subsidized housing. Design and Methods: The program provides primary care, care management, and mental health services delivered in patient's homes by a multidisciplinary, multiagency team. Results: After 2 years of operation, Just for Us is serving nearly 300 individuals in 10 buildings. The program is demonstrating improvement in individual indices of health. Medicaid expenditures for enrollees are shifting from ambulances and hospital services to pharmacy, personal care, and outpatient visits. The program is not breaking even, but it is moving toward that goal. The program's success is based on a partnership involving an academic medical center, a community health center, county social and mental health agencies, and a city housing authority to coordinate and leverage services. Implications: Just for Us is becoming a financially sustainable way of creating a "system within a nonsystem" for low-income elderly persons in clustered housing.
TL;DR: Several organizational attributes, caseload characteristics, and service provision patterns were associated with the availability of integrated care within public and private-sector addiction treatment programs.
Abstract: The co-occurrence of psychiatric conditions and substance abuse presents significant challenges for behavioral healthcare providers. The need for integrated care has received substantial recent attention from clinical, research, and funding entities. However, the availability of integrated care has been low, carrying potential adverse implications for quality of care and treatment outcomes. This article describes the prevalence and key correlates of the availability of integrated care for co-occurring conditions within public and private-sector addiction treatment programs. Several organizational attributes, caseload characteristics, and service provision patterns were associated with the availability of integrated care.
TL;DR: The NHS focus on memory clinics driven by drugs that slow cognitive decline is taking resources away from services offering long term integrated care.
Abstract: The NHS focus on memory clinics driven by drugs that slow cognitive decline is taking resources away from services offering long term integrated care. The role of these clinics needs reconsideration alongside availability of the drugs