Showing papers on "Integrated care published in 2009"

All together now: a conceptual exploration of integrated care.

Abstract: Integrated care is a key strategy in reforming health systems around the world. Despite its importance, the concept's polymorphous nature and lack of specificity and clarity significantly hamper systematic understanding, successful application and meaningful evaluation. This article explores the many definitions, concepts, logics and methods found in health system and service integration. In addition to framing this evolving, albeit imprecise field, the article summarizes the main elements or building blocks of integrated care and suggests a way to address its various complexities and unknowns in a real-world sense.

Frailty: an emerging concept for general practice.

Abstract: Ageing of the population in western societies and the rising costs of health and social care are refocusing health policy on health promotion and disability prevention among older people. However, efforts to identify at-risk groups of older people and to alter the trajectory of avoidable problems associated with ageing by early intervention or multidisciplinary case management have been largely unsuccessful. This paper argues that this failure arises from the dominance in primary care of a managerial perspective on health care for older people, and proposes instead the adoption of a clinical paradigm based on the concept of frailty. Frailty, in its simplest definition, is vulnerability to adverse outcomes. It is a dynamic concept that is different from disability and easy to overlook, but also easy to identify using heuristics (rules of thumb) and to measure using simple scales. Conceptually, frailty fits well with the biopsychosocial model of general practice, offers practitioners useful tools for patient care, and provides commissioners of health care with a clinical focus for targeting resources at an ageing population.

Proactive integrated care improves quality of life in patients with COPD

Abstract: Self-management strategies improve a variety of health-related outcomes for patients with chronic obstructive pulmonary disease (COPD). These strategies, however, are primarily designed to improve chronic disease management and have not focused on early detection and early treatment of exacerbations. In COPD, the majority of exacerbations go unreported and treatment is frequently delayed, resulting in worsened outcomes. Therefore, a randomised clinical trial was designed to determine whether integration of self-management education with proactive remote disease monitoring would improve health-related outcomes. A total of 40 Global Initiative for Chronic Obstructive Lung Disease stage 3 or 4 COPD patients were randomised to receive proactive integrated care (PIC) or usual care (UC) over a 3-month period. The primary and secondary outcomes were change in quality of life, measured by the St George's Respiratory Questionnaire (SGRQ), and change in healthcare costs. PIC dramatically improved SGRQ by 10.3 units, compared to 0.6 units in the UC group. Healthcare costs declined in the PIC group by US$1,401, compared with an increase of US$1,709 in the UC group, but this was not statistically significant. PIC uncovered nine exacerbations, seven of which were unreported. Therefore, proactive integrated care has the potential to improve outcomes in chronic obstructive pulmonary disease patients through effects of self-management, as well as early detection and treatment of exacerbations.

Promoting effective self-management programmes to improve COPD.

Abstract: The recent priority focus on integrated chronic care is not surprising given the burden of chronic disease. This focus has led to the development of integrated care programmes for chronically ill patients. Despite important heterogeneity in these programmes, there is a commonality of objectives i.e. to reduce fragmentation of care, and to increase continuity and coordination of care 1. Self-management interventions are an important component of integrated chronic care and the most commonly mentioned 2. An increasing number of healthcare professionals agree that patients with chronic disease should receive support to help them self-manage their disease as effectively as possible. Current evidence in chronic diseases suggests that patients with effective self-management skills make better use of healthcare professionals’ time and have enhanced self-care 3, 4. Through their daily decisions about medication, self-measurements and exercise, people with chronic diseases play a central role in determining the course of their disease. Unfortunately, what is already common practice in other chronic diseases is not yet applied in chronic obstructive pulmonary disease (COPD). We now urgently need to tackle COPD and ensure that effective self-management interventions, as an important part of integrated chronic care, are implemented when present. We now have sufficient scientific evidence to recommend self-management interventions for patients with COPD. Two recent systematic reviews have shown positive outcomes for patients with COPD 5, 6. In the most recent update of the Cochrane Database of Systematic Reviews , it was demonstrated that self-management programmes reduce the probability of COPD-related hospital admissions 6. Another systematic review demonstrated a significant reduction in healthcare utilisation (unscheduled/emergency centre visits, number of hospitalisations and length of hospital stay) in trials that implemented self-management with other components of the chronic care model compared to trials with self-management alone 5. Self-management also …

Systematic review of the effectiveness of integrated care pathways: what works, for whom, in which circumstances?

Abstract: Aim: Integrated care pathways (ICP) are management technologies which formalise multidisciplinary team-working and enable professionals to examine their roles and responsibilities. ICPs are now being implemented across international healthcare arena, but evidence to support their use is equivocal. The aim of this study was to identify the circumstances in which ICPs are effective, for whom and in what contexts. Methods: A systematic review of high-quality randomised controlled trials published between 1980 and 2008 (March) evaluating ICP use in child and adult populations in the full range of healthcare settings. Results: 1.For relatively predictable trajectories of care ICPs can be effective in supporting proactive care management and ensuring that patients receive relevant clinical interventions and/or assessments in a timely manner. This can lead to improvements in service quality and service efficiency without adverse consequences for patients.2.ICPs are an effective mechanism for promoting adherence to guidelines or treatment protocols thereby reducing variation in practice.3.ICPs can be effective in improving documentation of treatment goals, documentation of communication with patients, carers and health professionals.4.ICPs can be effective in improving physician agreement about treatment options.5.ICPs can be effective in supporting decision-making when they incorporate a decision-aide.6.The evidence considered in this review indicates that ICPs may be particularly effective in changing professional behaviours in the desired direction, where there is scope for improvement or where roles are new.7.Even in contexts in which health professionals are already experienced with a particular pathway, ICP use brings additional beneficial effects in directing professional practice in the desired direction.8.ICPs may be less effective in bringing about service quality and efficiency gains in variable patient trajectories.9.ICPs may be less effective in bringing about quality improvements in circumstances in which services are already based on best evidence and multidisciplinary working is well established.10.Depending on their purpose, the benefits of ICPs may be greater for certain patient subgroups than others.11.We do not know whether the costs of ICP development and implementation are justified by any of their reported benefits.12.ICPs may need supporting mechanisms to underpin their implementation and ensure their adoption in practice, particularly in circumstances in which ICP use is a significant change in organisational culture.13.ICP documentation can introduce scope for new kinds of error.Conclusions ICPs are most effective in contexts where patient care trajectories are predictable. Their value in settings in which recovery pathways are more variable is less clear. ICPs are most effective in bringing about behavioural changes where there are identified deficiencies in services; their value in contexts where inter-professional working is well established is less certain. None of the studies reviewed included an economic evaluation and thus it is not known whether their benefits justify the costs of their implementation.

Health in South Africa 4 The burden of non-communicable diseases in South Africa

Abstract: 15 years after its fi rst democratic election, South Africa is in the midst of a profound health transition that is characterised by a quadruple burden of communicable, non-communicable, perinatal and maternal, and injury-related disorders. Non-communicable diseases are emerging in both rural and urban areas, most prominently in poor people living in urban settings, and are resulting in increasing pressure on acute and chronic health-care services. Major factors include demographic change leading to a rise in the proportion of people older than 60 years, despite the negative eff ect of HIV/AIDS on life expectancy. The burden of these diseases will probably increase as the roll-out of antiretroviral therapy takes eff ect and reduces mortality from HIV/AIDS. The scale of the challenge posed by the combined and growing burden of HIV/AIDS and non-communicable diseases demands an extraordinary response that South Africa is well able to provide. Concerted action is needed to strengthen the district-based primary health-care system, to integrate the care of chronic diseases and management of risk factors, to develop a national surveillance system, and to apply interventions of proven cost-eff ectiveness in the primary and secondary prevention of such diseases within populations and health services. We urge the launching of a national initiative to establish sites of service excellence in urban and rural settings throughout South Africa to trial, assess, and implement integrated care interventions for chronic infectious and non-communicable diseases.

Addressing the workforce crisis in integrated primary care.

Abstract: Training and education in integrated primary care is limited. We see a need for addressing the looming workforce shortage as behavioral health services in primary care become more widely implemented. Bringing mental health clinicians straight from specialty mental health settings into primary care often results in program failure due to poor skills fit, assumptions about services needed, and routines of practice these clinicians bring from their specialty settings. Health psychology graduate programs tend to prepare graduates for specialty research and practice in medical settings rather than preparing them for the pace, culture and broad spectrum of needs in primary care. Family medicine residency programs provide an underutilized resource for training primary care psychologists and family physicians together. Even if comprehensive graduate training programs in integrated primary care were developed, they could not begin to meet the need for behavioral health clinicians in primary care that the present expansion will require. In response to the demand for mental health providers in primary care, new initiatives have emerged which attempt to provide training for the preexisting mental health workforce to enable their successful integration into primary care settings.

A cost-effectiveness study of a patient-centred integrated care pathway.

Abstract: Title. A cost-effectiveness study of a patient-centred integrated care pathway. Aim. The aim of the study was to compare costs and consequences for an integrated care pathway intervention group with those of a usual care group for patients admitted with hip fracture. Background. Rehabilitation for patients with hip fracture consists of training in hospital and/or in a rehabilitation unit, and on their own at home with assistance from community care staff. It is important for hospitals to provide methods of care that can safeguard these older patients’ physical function and potential for independent living. Methods. A consecutive sample of 112 independently living participants, aged 65 years or older and admitted to hospital with a hip fracture, were included in the study. Data were collected over an 18-month period in 2003–2005. A costeffectiveness analysis was performed to compare an integrated care pathway intervention (treatment A) with usual care (treatment B). Results. There was a 40% reduction for each participant in the average total cost of treatment A of €9685 vs. €15,984 for treatment B. Moreover, clinical effectiveness was much improved. The cost-effectiveness ratio for treatment A was €14,840 vs. €31,908 for treatment B. In addition, 75% of the participants in treatment A were successfully rehabilitated vs. 55% in treatment B. Conclusions. The recovery trajectory for hip fracture surgery may be shortened if nurses pay more attention to the individual patient’s resources and motivation for rehabilitation. The application of an integrated care pathway with individualized care appears to enhance both rehabilitation outcomes and cost-effectiveness.

Dying in an acute hospital setting: the challenges and solutions.

Abstract: More than half of all UK deaths occur in hospital, yet evidence suggests that the quality of inpatient end of life care is suboptimal at best. Over half of all NHS complaints pertain to problems with care in the dying phase, particularly with regard to poor communication. This is a hugely topical area following the recent publication of the Department of Health's End of Life Care Strategy. With reference to current literature, we seek to investigate the challenges associated with providing 'a good death' in hospital and construct a framework of strategies for improvement; including communication skills training, use of integrated care pathways, advance planning, educational initiatives and the role of the palliative care team.

Integrated care improves risk-factor modification after stroke: initial results of the Integrated Care for the Reduction of Secondary Stroke model

Abstract: Objective: Despite evidence demonstrating that risk-factor management is effective in reducing recurrent cerebrovascular disease, there are very few structured care programmes for stroke survivors. The aim was to implement and evaluate an integrated care programme in stroke. Methods: 186 patients with stroke were randomised to either the treatment (integrated care) or control (usual care) group and were followed up over 12 months. The Integrated Care for the Reduction of Secondary Stroke (ICARUSS) model of integrated care involved collaboration between a specialist stroke service, a hospital coordinator and a patient’s general practitioner. The primary aim was to promote the management of vascular risk factors through ongoing patient contact and education. Results: In the 12 months poststroke, systolic blood pressure (sBP) decreased in the treatment group but increased in controls. The group difference was significant, and remained so when age, sex, disability and sBP at discharge were accounted for (p = 0.04). Treatment patients also exhibited better modification of body mass index (p = 0.007) and number of walks taken (p Conclusions: Through an integrated system of education, advice and support to both patient and GP, the ICARUSS model was effective in modifying a variety of vascular risk factors and therefore should decrease the likelihood or recurrent stroke or vascular event.

A Health Care Cooperative Extension Service: Transforming Primary Care and Community Health

Abstract: RIMARY CARE IS THE ESSENTIAL FOUNDATION FOR AN effective, efficient, and equitable health care system.Callstorebuildthecrumblingprimarycareinfrastructure in the United States are reaching receptive ears, with public and private advisory groups includingtheMedicarePaymentAdvisoryCommissionand the National Business Group on Health recommending increased payments for primary care. 1 The American RecoveryandReinvestmentAct(ARRA) 2 of2009appropriated$19 billion for the purchase of health information technology (HIT), with primary care physicians’ offices slated to be among the beneficiaries. Policy makers expect that new investments will transform primary care by creating more effective and efficient patient-centered medical homes. The primary care physician community acknowledges the need for new practice models that provide accessible, comprehensive, integrated care based on healing relationships over time. 3 New investment in primary care is necessary but not sufficienttorevitalizeprimarycareunlesscombinedwithastrategy for disseminating and implementing innovations and best practices. Acquiring an electronic health record (EHR) will not create a highly functioning medical home unless it can be used to create functional patient registries. Receivingenhancedpaymentsforcarecoordinationwithoutaworkable plan for hiring and training health coaches for patient self-management leaves a gap between expectations and reality. Large, organized delivery systems such as Geisenger, Kaiser Permanente, and the Veterans Administration have theinstitutionalwherewithalandeconomiesofscaletoimplement practice redesign in a systematic and successful manner. However, two-thirds of office-based physicians work in practices of 4 or fewer physicians. 4 These clinicians oftenhavelittleornotechnicalassistancetodeployandmaintain new practice improvements like EHRs. To successfully redesign practices requires knowledge transfer, performance feedback, facilitation, and HIT support provided by individuals with whom practices have established relationships over time. The farming community learned these principles a century ago. Primary care practices are like small farms of that era, which were geographically dispersed, poorly resourced for change, and inefficient in adopting new techniques or technology but vital tothenation’swell-being.Practicingphysiciansneedsomething akin to the agricultural extension agent who was so transformativeforfarming. 5,6 AnationwidePrimaryCareCooperative Extension Service, modeled after the US Department of Agriculture’s Cooperative State Research, Education,andExtensionService(CooperativeExtension),which so successfully accelerated farm transformation, should be created.County-basedhealthextensionorganizationswould supportprimarycarecliniciansinthesamemannerthatthe agricultural model assists family farmers, providing infrastructureforlocallearningcommunitiesandpracticetransformation. ARRA establishes a Health Information Technology Extension Program 2 to “assist health care providers toadopt,implement,andeffectivelyusecertifiedEHRtechnology,” which could serve as the nidus for a broader program to revitalize primary care and community health.

A quality management model for integrated care: results of a Delphi and Concept Mapping study.

Abstract: Objective. The objective of this study is to identify the elements and clusters of a quality management model for integrated care. Design. In order to develop the model a combination of three methods were applied. A literature study was conducted to identify elements of integrated care. In a Delphi study experts commented and prioritized 175 elements in three rounds. During a half-a-day session with the expert panel, Concept Mapping was used to cluster the elements, position them on a map and analyse their content. Multi-dimensional statistical analyses were applied to design the model. Participants. Thirty-one experts, with an average of 8.9 years of experience working in research, managing improvement projects or running integrated care programmes. Results. The literature study resulted in 101 elements of integrated care. Based on criteria for inclusion and exclusion, 89 unique elements were determined after the three Delphi rounds. By using Concept Mapping the 89 elements were grouped into nine clusters. The clusters were labelled as: ‘Quality care’, ‘Performance management’, ‘Interprofessional teamwork’, ‘Delivery system’, ‘Roles and tasks’, ‘Patient-centeredness’, ‘Commitment’, ‘Transparent entrepreneurship’ and ‘Result-focused learning’. Conclusion. The identified elements and clusters provide a basis for a comprehensive quality management model for integrated care. This model differs from other quality management models with respect to its general approach to multiple patient categories, its broad definition of integrated care and its specification into nine different clusters. The model furthermore accentuates conditions for effective collaboration such as commitment, clear roles and tasks and entrepreneurship. The model could serve evaluation and improvement purposes in integrated care practice. To improve external validity, replication of the study in other countries is recommended.

The psychiatric reform in Brazil: a (re)view.

Abstract: This paper aims at contextualizing the Brazilian Psychiatric Reform by reviewing theoretical and practical milestones in the country's policies. Theses, dissertations, papers published in a database (Scielo), books on the theme, and official documents (conference reports, laws, bills) published between 1990 and 2007 were studied. The results show the advances and challenges of the Psychiatric Reform and point to the immediate need of a program for qualifying personnel; the need to use primary care, mainly the Family Health Program; the need to finance primary care; the adoption of the principles of the psychiatric reform; the need to individualize treatment, psychosocial rehabilitation; integrated care; and therapeutic project constructed collectively through the use of interdisciplinary and trans-disciplinary approaches, as well as constant assessment of the current practices. It is also pointed out that Reform projects are not homogeneous, i. e., practices happen according to the professionals' theoretical conception. This means that there are general guidelines, but that they are subordinated to the specific settings where the practices are carried out.

Access to primary care for homeless veterans with serious mental illness or substance abuse: a follow-up evaluation of co-located primary care and homeless social services.

Abstract: To examine the hypothesis that a demonstration clinic integrating homeless, primary care, and mental health services for homeless veterans with serious mental illness or substance abuse would improve medical health care access and physical health status. A quasi-experimental design comparing a ‘usual VA care’ group before the demonstration clinic opened (N = 130) and the ‘integrated care’ group (N = 130). Regression models indicated that the integrated care group was more rapidly enrolled in primary care, received more prevention services and primary care visits, and fewer emergency department visits, and was not different in inpatient utilization or in physical health status over 18 months. The demonstration clinic improved access to primary care services and reduced emergency services but did not improve perceived physical health status over 18 months. Further research is needed to determine generalizability and longer term effects.

Integrated primary health care in Greece, a missing issue in the current health policy agenda: a systematic review.

Abstract: Background: Over the past years, Greece has undergone several endeavors aimed at modernizing and improving national health care services with a focus on PHC. However, the extent to which integrated primary health care has been achieved is still questioned. Purpose: This paper explores the extent to which integrated primary health care (PHC) is an issue in the current agenda of policy makers in Greece, reporting constraints and opportunities and highlighting the need for a policy perspective in developing integrated PHC in this Southern European country. Methods: A systematic review in PubMed/Medline and SCOPUS, along with a hand search in selected Greek biomedical journals was undertaken to identify key papers, reports, editorials or opinion letters relevant to integrated health care. Results: Our systematic review identified 198 papers and 161 out of them were derived from electronic search. Fifty-three papers in total served the scope of this review and are shortly reported. A key finding is that the long-standing dominance of medical perspectives in Greek health policy has been paving the way towards vertical integration, pushing aside any discussions about horizontal or comprehensive integration of care. Conclusion: Establishment of integrated PHC in Greece is still at its infancy, requiring major restructuring of the current national health system, as well as organizational culture changes. Moving towards a new policy-based model would bring this missing issue on the discussion table, facilitating further development.

Quality of integrated chronic care measured by patient survey: identification, selection and application of most appropriate instruments.

Abstract: Objective To identify the most appropriate generic instrument to measure experience and/or satisfaction of people receiving integrated chronic care. Background Health care is becoming more user-centred and, as a result, the experience of users of care and evaluation of their experience and/or satisfaction is taken more seriously. It is unclear to what extent existing instruments are appropriate in measuring the experience and/or satisfaction of people using integrated chronic care. Methods Instruments were identified by means of a systematic literature review. Appropriateness of instruments was analysed on seven criteria. The two most promising instruments were translated into Dutch, if necessary, and administered to a convenience sample of 109 people with a chronic illness. Data derived from respondents were analysed statistically. Focus-group interviews were conducted to assess the semantic and technical equivalence as well as opinions of people about the applicability and relevance of the translated instruments. Results From 37 instruments identified, the Patients’ Assessment of Care for chronIc Conditions (PACIC) and the short form of the Patient Satisfaction Questionnaire III (PSQ-18) were selected as most promising instruments. Both instruments produced similar median scores across people with different chronic conditions. The overall PACIC and its subscales and the overall PSQ-18 were highly internally consistent, but not the PSQ-18 subscales. Overall, the PACIC demonstrated better psychometric characteristics. PACIC and PSQ-18 scores were found to be moderately correlated. Whereas more respondents preferred the PSQ-18, focus-group participants regarded the PACIC to be more applicable and relevant. The technical and semantic equivalence of both instruments were sufficient. Conclusions Because of its psychometric characteristics, perceived applicability and relevance, the PACIC is the most appropriate instrument to measure the experience of people receiving integrated chronic care

The financial dimension of integrated behavioral/primary care.

Abstract: There are two reasons why mental health, now more appropriately termed behavioral healthcare, is declining: (a) a lack of understanding among psychotherapists of healthcare economics, particularly the intricacies of medical cost offset, and (b) our failure as a profession to see the importance of behavioral interventions as an integral part of the healthcare system inasmuch as the nation pays for healthcare, not psychosocial care. This paper will briefly describe the rapid changes in the economics of healthcare during the past 75 years, including the post World War II enthusiastic espousal of psychotherapy by the American public which was followed by a precipitous decline as our outcomes research in behavioral care remained ignorant of financial outcomes, leaving it to the government and managed care to arbitrarily curtail escalating mental health costs. At the present time psychology is on the cusp of becoming part of the healthcare system through integrated behavioral/primary care, renewing the primacy of financial considerations such as return on investment (ROI) and medical cost offset, as well as an urgency that we avoid the mistakes that are emerging in some flawed implementations of integrated care.

Integrated dementia care in The Netherlands: a multiple case study of case management programmes

Abstract: The number of dementia patients is growing, and they require a variety of services, making integrated care essential for the ability to continue living in the community. Many healthcare systems in developed countries are exploring new approaches for delivering health and social care. The purpose of this study was to describe and analyse a new approach in extensive case management programmes concerned with long-term dementia care in The Netherlands. The focus is on the characteristics, and success and failure factors of these programmes. A multiple case study was conducted in eight regional dementia care provider networks in The Netherlands. Based on a literature study, a questionnaire was developed for the responsible managers and case managers of the eight case management programmes. During 16 semistructured face-to-face interviews with both respondent groups, a deeper insight into the dementia care programmes was provided. Project documentation for all the cases was studied. The eight programmes were developed independently to improve the quality and continuity of long-term dementia care. The programmes show overlap in terms of their vision, tasks of case managers, case management process and the participating partners in the local dementia care networks. Differences concern the targeted dementia patient groups as well as the background of the case managers and their position in the local dementia care provider network. Factors for success concern the expert knowledge of case managers, investment in a strong provider network and coherent conditions for effective inter-organizational cooperation to deliver integrated care. When explored, caregiver and patient satisfaction was high. Further research into the effects on client outcomes, service use and costs is recommended in order to further analyse the impact of this approach in long-term care. To facilitate implementation, with a focus on joint responsibilities of the involved care providers, policy recommendations are to develop incentives for collaborative financial contracts between insurers and providers.

Behavioral Health Consultation and Primary Care: Lessons Learned

Abstract: This article provides an overview of 20 years of professional experiences with developing and implementing a model for integrating behavioral health services into primary care. The Primary Care Behavioral Health (PCBH) model is designed to provide immediate access to behavioral care for a large number of primary care patients by positioning a behavioral health consultant in the exam room area to function as a core member of the primary care team. In an initial era of discovery, the authors were directly involved in developing and testing a variety of new approaches to providing behavioral health services in general medicine. In a second era focused on feasibility, the authors worked with Kaiser Permanente, the United States Air Force and Navy, the Veteran’s Administration, and the Bureau of Primary Care to system test this innovative model of integrated care. Now in an era devoted to dissemination, the authors review the various roles formal research, system level quality improvement initiatives and stakeholder analysis play in promoting integrated care. The authors also describe current efforts to (1) create a tool that helps systems develop integration targets and (2) use the PCBH model as a platform for teaching medical residents and behavioral health providers to work together in a redesigned primary care team model.

Integrated primary care: an inclusive three-world view through process metrics and empirical discrimination.

Abstract: Integrating behavioral health services within the primary care setting drives higher levels of collaborative care, and is proving to be an essential part of the solution for our struggling American healthcare system. However, justification for implementing and sustaining integrated and collaborative care has shown to be a formidable task. In an attempt to move beyond conflicting terminology found in the literature, we delineate terms and suggest a standardized nomenclature. Further, we maintain that addressing the three principal worlds of healthcare (clinical, operational, financial) is requisite in making sense of the spectrum of available implementations and ultimately transitioning collaborative care into the mainstream. Using a model that deconstructs process metrics into factors/barriers and generalizes behavioral health provider roles into major categories provides a framework to empirically discriminate between implementations across specific settings. This approach offers practical guidelines for care sites implementing integrated and collaborative care and defines a research framework to produce the evidence required for the aforementioned clinical, operational and financial worlds of this important movement.

A four phase development model for integrated care services in the Netherlands

Abstract: Multidisciplinary and interorganizational arrangements for the delivery of coherent integrated care are being developed in a large number of countries. Although there are many integrated care programs worldwide, the process of developing these programs and interorganizational collaboration is described in the literature only to a limited extent. The purpose of this study is to explore how local integrated care services are developed in the Netherlands, and to conceptualize and operationalize a development model of integrated care. The research is based on an expert panel study followed by a two-part questionnaire, designed to identify the development process of integrated care. Essential elements of integrated care, which were developed in a previous Delphi and Concept Mapping Study, were analyzed in relation to development process of integrated care. Integrated care development can be characterized by four developmental phases: the initiative and design phase; the experimental and execution phase; the expansion and monitoring phase; and the consolidation and transformation phase. Different elements of integrated care have been identified in the various developmental phases. The findings provide a descriptive model of the development process that integrated care services can undergo in the Netherlands. The findings have important implications for integrated care services, which can use the model as an instrument to reflect on their current practices. The model can be used to help to identify improvement areas in practice. The model provides a framework for developing evaluation designs for integrated care arrangements. Further research is recommended to test the developed model in practice and to add international experiences.

Psychologists and Primary Care Physicians: A Training Model for Creating Collaborative Relationships

Abstract: For over a decade insurance reform, changes in health care delivery, reimbursement policies, and managed care have increased pressure on psychologists to diversify beyond traditional practices. Despite the negative impact of failing to make a transformation, most psychologists have not modified their practice and most training programs do not prepare psychologists to provide integrated care. The current paper describes the importance of primary care and psychology partnering to create integrated care models and makes the case that such partnerships are not only beneficial to patients but to both professions. The paper concludes with a description of a training model that has been implemented at the institution of the authors that provides opportunities for psychologists to learn how to practice in primary care settings.

The impact of integrated HIV care on patient health outcomes.

Abstract: Background—Control of viral replication through combination antiretroviral therapy (cART) improves patient health outcomes. Yet many HIV-infected patients have co-morbidities that pose social and clinical barriers to achieving viral suppression. Integration of subspecialty services into HIV primary care may overcome such barriers. Objective—Evaluate effect of Integrated HIV Care on suppression of HIV replication. Research Design—A retrospective cohort study of HIV patients from five Veterans Affairs healthcare facilities 2000–2006. Subjects—Patients with >3 months of follow-up, sufficient baseline HIV severity, on cART. Measures—We measured and ranked Integrated Care at the facilities. These rankings were applied to patient visits to form an index of Integrated HIV Care utilization. We evaluated effect of Integrated HIV Care utilization on likelihood of achieving viral suppression while on cART, controlling for demographic and clinical factors using survival analysis.

Implementation of integrated care for patients with cancer: a systematic review of interventions and effects

Abstract: Purpose To review integrated care interventions and their effects on the quality of care for patients with cancer. Data sources Search in Medline and Cochrane Library databases from January 1996 to October 2006. Study selection Randomized controlled trials and controlled before–after studies in which the intervention focused on at least one of the three principles of integrated care: patient-centredness, organization of care and multidisciplinary care. Data extraction and results Of the 1397 references, 33 studies were included and analysed. No study focused on all three principles of integrated care: 16 studies focused on patient-centredness (48%), 14 on the organization of care (42%), 1 on multidisciplinary care and 2 on both patient-centredness and organization of care. There was a large variation in interventions reported and in outcomes used for evaluation. Effective interventions to improve patient-centredness are the ‘provision of an audiotape of the consultation to the patient’, ‘provision of information to patients’ and ‘use of a decision aid’. Effective interventions to improve the organization of care can be ‘follow-up’ and ‘case management’, especially by nurses and ‘one-stop clinics’. Conclusion To improve integrated care for patients with cancer, a multicomponent intervention programme is required focusing on patients, professionals and the organization of care. The promising interventions found in this review should be part of this programme. This programme should be evaluated using rigorous methods and unequivocal outcome measures linked to the intervention.

Improving training in spiritual care: a qualitative study exploring patient perceptions of professional educational requirements.

Abstract: Healthcare professionals express difficulties in delivering spiritual care, despite it being a core component of palliative care national policies. The patient perspective on professional training to address difficulties has not previously been sought. The aim of this study is to describe patient suggestions for development of training to deliver spiritual care. Qualitative semi-structured in-depth 'palliative patient' interviews (n = 20) were analysed thematically. Training suggestions encompassed practical care delivery. Patients supported staff who introduced questions about spiritual needs, and they expected opportunities to engage in spiritual care discussions. The 'right' attitude for spiritual care delivery was defined as being non-judgemental, providing integrated care and showing interest in individuals. Training issues included patient perspectives of boundaries between personal and professional roles. This study provides 'palliative patient' perspectives to strengthen recommended models of spiritual care delivery. It shows that user opinions on training can be helpful not only in deciding objectives but also how to achieve them.

The burden of chronic disorders on hospital admissions prompts the need for new modalities of care: A cross-sectional analysis in a tertiary hospital

Abstract: Background: Chronic disorders constitute a primary concern because of their burden on healthcare systems worldwide. Integrated care strategies enhancing the interface between tertiary care and primary care are pivotal to improve chronic care. Aim: To asses the prevalence of chronic disorders on hospital discharges and their impact on unplanned admissions and mortality. Design: Cross-sectional analysis of discharge information over 1 year (2004) in one University hospital. Methods: Adoption of an operational definition of chronic disorder based on the WHO. Main outcome: co-morbid conditions, emergency room and hospital admissions, outpatient consultations and mortality. Results: Fifty-eight percent of patients presented at least one chronic condition (19 192 patients, 53% males, 63 ± 18 years) as primary (12 526 patients, 38%) or secondary diagnosis. The Charlson index was 2 ± 3. Each chronic condition was associated with a 30% increase of having had an admission in the previous year. Up to 9% (1 656) of chronic patients showed multiple admissions in the previous year: two (917 patients, 55%), three (360, 22%) and four or beyond (379, 23%), being mostly unscheduled hospitalizations. The three most prevalent chronic disorders were cancer, cardiovascular diseases and chronic obstructive pulmonary disease (COPD). The rate of admissions was associated with co-morbidity ( P < 0.001) and mortality ( P < 0.001). Conclusions: The study shows a high impact of cancer on planned hospitalizations whereas cardiovascular diseases and COPD generates a high percentage of unscheduled admissions. We conclude that integrated care services including patient-oriented guidelines are strongly needed to enhance both health and managerial outcomes.

Integrated primary care in Germany: the road ahead

Abstract: Problem statement: Health care delivery in Germany is highly fragmented, resulting in poor vertical and horizontal integration and a system that is focused on curing acute illness or single diseases instead of managing patients with more complex or chronic conditions, or managing the health of determined populations. While it is now widely accepted that a strong primary care system can help improve coordination and responsiveness in health care, primary care has so far not played this role in the German system. Primary care physicians traditionally do not have a gatekeeper function; patients can freely choose and directly access both primary and secondary care providers, making coordination and cooperation within and across sectors difficult. Description of policy development: Since 2000, driven by the political leadership and initiative of the Federal Ministry of Health, the German Bundestag has passed several laws enabling new forms of care aimed to improve care coordination and to strengthen primary care as a key function in the German health care system. These include on the contractual side integrated care contracts, and on the delivery side disease management programmes, medical care centres, gatekeeping and ‘community medicine nurses’. Conclusion and discussion: Recent policy reforms improved framework conditions for new forms of care. There is a clear commitment by the government and the introduction of selective contracting and financial incentives for stronger cooperation constitute major drivers for change. First evaluations, especially of disease management programmes, indicate that the new forms of care improve coordination and outcomes. Yet the process of strengthening primary care as a lever for better care coordination has only just begun. Future reforms need to address other structural barriers for change such as fragmented funding streams, inadequate payment systems, the lack of standardized IT systems and trans-sectoral education and training of providers.

The challenge of integrated care for mental health: leaving the 50 minute hour and other sacred things.

Abstract: A growing body of research has demonstrated the effectiveness of integrating mental/behavioral healthcare with primary care in improving health outcomes. Despite this rich literature, such demonstration programs have proven difficult to maintain once research funding ends. Much of the discussion regarding maintenance of integrated care has been focused on lack of reimbursement. However, provider factors may be just as important, because integrated care systems require providers to adopt a very different role and operate very differently from traditional mental health practice. There is also great variability in definition and operationalization of integrated care. Provider concerns tend to focus on several factors, including a perceived loss of autonomy, discomfort with the hierarchical nature of medical care and primary care settings, and enduring beliefs about what constitutes “good” treatment. Providers may view integrated care models as delivering substandard care and passively or actively resist them. Dissemination of available data regarding effectiveness of these models is essential (e.g. timeliness of treatment, client satisfaction). Increasing exposure and training in these models, while maintaining the necessary training in traditional mental health care is a challenge for training at all levels, yet the challenge clearly opens new opportunities for psychology and psychiatry.