Showing papers on "Integrated care published in 2014"

Unit Costs of Health and Social Care 2014

Abstract: This is the latest updated volume in a well-established series bringing together information from a variety of sources to estimate national unit costs for a wide range of health and social care services. This report consists of tables for more than 130 types of service which, as well as providing the most detailed and comprehensive information possible, also quotes sources and assumptions so users can adapt the information for their own purposes. This year we have included a guest editorial on ‘Big Data’: increasing productivity while reducing costs in health and social care and three short articles on The cost of integrated care; Shared lives – improving understanding of the costs of family-based support and the costs of providing a group intervention to people with dementia and their family carers:SHIELD: RYCT & CSP intervention costs (Remembering Yesterday Caring Today and Carer Support Programme). There are also several new schema providing the costs of: advocacy for people with learning disabilities; a hospice rapid response service; the early years classroom management programme; residential parenting assessments; independent review officers; time banks; dentists and care home costs for people with dementia. The 2014 edition is also available in full, free of charge, at the PSSRU website www.pssru.ac.uk/unit-costs/2014/ as an Acrobat file.

Italy: Health System Review

Abstract: Italy is the sixth largest country in Europe and has the second highest average life expectancy, reaching 79.4 years for men and 84.5 years for women in 2011. There are marked regional differences for both men and women in most health indicators, reflecting the economic and social imbalance between the north and south of the country. The main diseases affecting the population are circulatory diseases, malignant tumours and respiratory diseases. Italy's health care system is a regionally based national health service that provides universal coverage largely free of charge at the point of delivery. The main source of financing is national and regional taxes, supplemented by copayments for pharmaceuticals and outpatient care. In 2012, total health expenditure accounted for 9.2 percent of GDP (slightly below the EU average of 9.6 percent). Public sources made up 78.2 percent of total health care spending. While the central government provides a stewardship role, setting the fundamental principles and goals of the health system and determining the core benefit package of health services available to all citizens, the regions are responsible for organizing and delivering primary, secondary and tertiary health care services as well as preventive and health promotion services. Faced with the current economic constraints of having to contain or even reduce health expenditure, the largest challenge facing the health system is to achieve budgetary goals without reducing the provision of health services to patients. This is related to the other key challenge of ensuring equity across regions, where gaps in service provision and health system performance persist. Other issues include ensuring the quality of professionals managing facilities, promoting group practice and other integrated care organizational models in primary care, and ensuring that the concentration of organizational control by regions of health-care providers does not stifle innovation.

Germany: Health system review

Abstract: This analysis of the German health system reviews recent developments in organization and governance, health financing, health care provision, health reforms and health system performance. In the German health care system, decision-making powers are traditionally shared between national (federal) and state (Land) levels, with much power delegated to self-governing bodies. It provides universal coverage for a wide range of benefits. Since 2009, health insurance has been mandatory for all citizens and permanent residents, through either statutory or private health insurance. A total of 70 million people or 85% of the population are covered by statutory health insurance in one of 132 sickness funds in early 2014. Another 11% are covered by substitutive private health insurance. Characteristics of the system are free choice of providers and unrestricted access to all care levels. A key feature of the health care delivery system in Germany is the clear institutional separation between public health services, ambulatory care and hospital (inpatient) care. This has increasingly been perceived as a barrier to change and so provisions for integrated care are being introduced with the aim of improving cooperation between ambulatory physicians and hospitals. Germany invests a substantial amount of its resources on health care: 11.4% of gross domestic product in 2012, which is one of the highest levels in the European Union. In international terms, the German health care system has a generous benefit basket, one of the highest levels of capacity as well as relatively low cost-sharing. However, the German health care system still needs improvement in some areas, such as the quality of care. In addition, the division into statutory and private health insurance remains one of the largest challenges for the German health care system, as it leads to inequalities.

Effects of person-centred and integrated chronic heart failure and palliative home care. PREFER: a randomized controlled study.

Abstract: AimsWe evaluated the outcome of person-centred and integrated Palliative advanced home caRE and heart FailurE caRe (PREFER) with regard to patient symptoms, health-related quality of life (HQRL), a ...

Integrated care programmes for adults with chronic conditions: a meta-review

Abstract: Objective. To review systematic reviews and meta-analyses of integrated care programmes in chronically ill patients, with a focus on methodological quality, elements of integration assessed and effects reported.

Factors that promote and hinder joint and integrated working between health and social care services: a review of research literature

Abstract: This article reports the results of a review of the research evidence related to joint working in the field of adult health and social care services in the UK. It explores whether recent reforms to joint working have met the objectives set by policy-makers. The review followed an established methodology: electronic databases were searched using predetermined terms, abstracts were screened against inclusion criteria, studies that met the criteria were read in full and assessed for inclusion and data were extracted systematically. The findings of the review suggest that there is some indication that recent developments, in particular the drive to greater integration of services, may have positive benefits for organisations as well as for users and carers of services. However, the evidence consistently reports a lack of understanding about the aims and objectives of integration, suggesting that more work needs to be done if the full potential of the renewed policy agenda on integration is to be realised. Additionally, while the review acknowledges that greater emphasis has been placed on evaluating the outcome of joint working, studies largely report small-scale evaluations of local initiatives and few are comparative in design and therefore differences between 'usual care' and integrated care are not assessed. This makes it difficult to draw firm conclusions about the effectiveness of UK-based integrated health and social care services.

Integrated care pathways for airway diseases (AIRWAYS-ICPs).

Abstract: The objective of Integrated Care Pathways for Airway Diseases (AIRWAYS-ICPs) is to launch a collaboration to develop multi-sectoral care pathways for chronic respiratory diseases in European countries and regions. AIRWAYS-ICPs has strategic relevance to the European Union Health Strategy and will add value to existing public health knowledge by: 1) proposing a common framework of care pathways for chronic respiratory diseases, which will facilitate comparability and trans-national initiatives; 2) informing cost-effective policy development, strengthening in particular those on smoking and environmental exposure; 3) aiding risk stratification in chronic disease patients, using a common strategy; 4) having a significant impact on the health of citizens in the short term (reduction of morbidity, improvement of education in children and of work in adults) and in the long-term (healthy ageing); 5) proposing a common simulation tool to assist physicians; and 6) ultimately reducing the healthcare burden (emergency visits, avoidable hospitalisations, disability and costs) while improving quality of life. In the longer term, the incidence of disease may be reduced by innovative prevention strategies. AIRWAYS-ICPs was initiated by Area 5 of the Action Plan B3 of the European Innovation Partnership on Active and Healthy Ageing. All stakeholders are involved (health and social care, patients, and policy makers).

Schizophrenia—Time to Commit to Policy Change

Abstract: Care and outcomes for people with schizophrenia have improved in recent years, but further progress is needed to help more individuals achieve an independent and fulfilled life. This report sets out the current need, informs policy makers and all relevant stakeholders who influence care quality, and supports their commitment to creating a better future. The authors recommend the following policy actions, based on research evidence, stakeholder consultation, and examples of best practice worldwide. (1) Provide an evidence-based, integrated care package for people with schizophrenia that addresses their mental and physical health needs. (2) Provide support for people with schizophrenia to enter and to remain in their community, and develop mechanisms to help guide them through the complex benefit and employment systems. (3) Provide concrete support, information, and educational programs to families and carers on how to enhance care for an individual living with schizophrenia in a manner that entails minimal disruption to their lives. (4) All stakeholders, including organizations that support people living with schizophrenia, should be consulted to regularly revise, update, and improve policy on the management of schizophrenia. (5) Provide support, which is proportionate to the impact of the disease, for research and development of new treatments. (6) Establish adequately funded, ongoing, and regular awareness-raising campaigns that form an integral part of routine plans of action. Implementation of the above recommendations will require engagement by every stakeholder, but with commitment from all, change can be achieved.

The past, present, and future of telemedicine for Parkinson's disease.

Abstract: Travel distance, growing disability, and uneven distribution of doctors limit access to care for most Parkinson's disease (PD) patients worldwide. Telemedicine, the use of telecommunications technology to deliver care at a distance, can help overcome these barriers. In this report, we describe the past, present, and likely future applications of telemedicine to PD. Historically, telemedicine has relied on expensive equipment to connect single patients to a specialist in pilot programs in wealthy nations. As the cost of video conferencing has plummeted, these efforts have expanded in scale and scope, now reaching larger parts of the world and extending the focus from care to training of remote providers. Policy, especially limited reimbursement, currently hinders the growth and adoption of these new care models. As these policies change and technology advances and spreads, the following will likely develop: integrated care networks that connect patients to a wide range of providers; education programs that support patients and health care providers; and new research applications that include remote monitoring and remote visits. Together, these developments will enable more individuals with PD to connect to care, increase access to expertise for patients and providers, and allow more-extensive, less-expensive participation in research.

Moving improvement research closer to practice: the Researcher-in-Residence model

Abstract: The traditional separation of the producers of research evidence in academia from the users of that evidence in healthcare organisations has not succeeded in closing the gap between what is known about the organisation and delivery of health services and what is actually done in practice. As a consequence, there is growing interest in alternative models of knowledge creation and mobilisation, ones which emphasise collaboration, active participation of all stakeholders, and a commitment to shared learning. Such models have robust historical, philosophical and methodological foundations but have not yet been embraced by many of the people working in the health sector. This paper presents an emerging model of participation, the Researcher-in-Residence. The model positions the researcher as a core member of a delivery team, actively negotiating a body of expertise which is different from, but complementary to, the expertise of managers and clinicians. Three examples of in-residence models are presented: an anthropologist working as a member of an executive team, operational researchers working in a front-line delivery team, and a Health Services Researcher working across an integrated care organisation. Each of these examples illustrates the contribution that an embedded researcher can make to a service-based team. They also highlight a number of unanswered questions about the model, including the required level of experience of the researcher and their areas of expertise, the institutional facilitators and barriers to embedding the model, and the risk that the independence of an embedded researcher might be compromised. The Researcher-in-Residence model has the potential to engage both academics and practitioners in the promotion of evidence-informed service improvement, but further evaluation is required before the model should be routinely used in practice.

Integrated Telehealth Care for Chronic Illness and Depression in Geriatric Home Care Patients: The Integrated Telehealth Education and Activation of Mood (I‐TEAM) Study

Abstract: Objectives: To evaluate an integrated telehealth intervention (Integrated Telehealth Education and Activation of Mood (I-TEAM)) to improve chronic illness (congestive heart failure, chronic obstructive pulmonary disease) and comorbid depression in the home healthcare setting. Design: Randomized controlled trial. Setting: Hospital-affiliated home healthcare setting. Participants: Medically frail older homebound individuals (N = 102). Intervention: The 3-month intervention consisted of integrated telehealth chronic illness and depression care, with a telehealth nurse conducting daily telemonitoring of symptoms, body weight, and medication use; providing eight weekly sessions of problem-solving treatment for depression; and providing for communication with participants' primary care physicians, who also prescribed antidepressants. Control participants were allocated to usual care with in-home nursing plus psychoeducation (UC+P). Measurements: The two groups were compared at baseline and 3 and 6 months after baseline on clinical measures (depression, health, problem-solving) and 12 months after baseline on health utilization (readmission, episodes of care, and emergency department (ED) visits). Results: Depression scores were 50% lower in the I-TEAM group than in the UC+P group at 3 and 6 months. Those who received the I-TEAM intervention significantly improved their problem-solving skills and self-efficacy in managing their medical condition. The I-TEAM group had significantly fewer ED visits (P = .01) but did not have significantly fewer days in the hospital at 12 months after baseline. Conclusion: Integrated telehealth care for older adults with chronic illness and comorbid depression can reduce symptoms and postdischarge ED use in home health settings.

What is the evidence on the economic impacts of integrated care

Abstract: This new policy summary reviews the existing evidence on the economic impact of integrated care approaches. Whereas it is generally accepted that integrated care models have a positive effect on the quality of care, health outcomes and patient satisfaction, it is less clear how cost effective they are. As the evidence-base in this field is rather weak, the authors suggest that we may have to revisit our understanding of the concept and our expectations in terms of its assessment. Integrated care should rather be seen as a complex strategy to innovate and implement long-lasting change in the way services in the health and social-care sectors are delivered. This policy summary (number 11) is based on a report for the European Commission to inform the discussions of the EU’s Reflection process on modern, responsive and sustainable health systems on the objective of integrated care models and better hospital management. Both authors are affiliated to RAND Europe.

Revolutionising management of chronic disease: the ParkinsonNet approach

Abstract: Patients with Parkinson’s disease need long term support to manage their condition. Bastiaan Bloem and Marten Munneke describe the benefits of a model of integrated care provided by a network of specialists and suggest it has promise for other long term conditions

Effectiveness of integrated disease management for primary care chronic obstructive pulmonary disease patients: results of cluster randomised trial

Abstract: Objective To investigate the long term effectiveness of integrated disease management delivered in primary care on quality of life in patients with chronic obstructive pulmonary disease (COPD) compared with usual care Design 24 month, multicentre, pragmatic cluster randomised controlled trial Setting 40 general practices in the western part of the Netherlands Participants Patients with COPD according to GOLD (Global Initiative for COPD) criteria Exclusion criteria were terminal illness, cognitive impairment, alcohol or drug misuse, and inability to fill in Dutch questionnaires Practices were included if they were willing to create a multidisciplinary COPD team Intervention General practitioners, practice nurses, and specialised physiotherapists in the intervention group received a two day training course on incorporating integrated disease management in practice, including early recognition of exacerbations and self management, smoking cessation, physiotherapeutic reactivation, optimal diagnosis, and drug adherence Additionally, the course served as a network platform and collaborating healthcare providers designed an individual practice plan to integrate integrated disease management into daily practice The control group continued usual care (based on international guidelines) Main outcome measures The primary outcome was difference in health status at 12 months, measured by the Clinical COPD Questionnaire (CCQ); quality of life, Medical Research Council dyspnoea, exacerbation related outcomes, self management, physical activity, and level of integrated care (PACIC) were also assessed as secondary outcomes Results Of a total of 1086 patients from 40 clusters, 20 practices (554 patients) were randomly assigned to the intervention group and 20 clusters (532 patients) to the usual care group No difference was seen between groups in the CCQ at 12 months (mean difference –001, 95% confidence interval –010 to 008; P=08) After 12 months, no differences were seen in secondary outcomes between groups, except for the PACIC domain “follow-up/coordination” (indicating improved integration of care) and proportion of physically active patients Exacerbation rates as well as number of days in hospital did not differ between groups After 24 months, no differences were seen in outcomes, except for the PACIC follow-up/coordination domain Conclusion In this pragmatic study, an integrated disease management approach delivered in primary care showed no additional benefit compared with usual care, except improved level of integrated care and a self reported higher degree of daily activities The contradictory findings to earlier positive studies could be explained by differences between interventions (provider versus patient targeted), selective reporting of positive trials, or little room for improvement in the already well developed Dutch healthcare system Trial registration Netherlands Trial Register NTR2268

A Taxonomy of Accountable Care Organizations for Policy and Practice

Abstract: The Affordable Care Act (ACA) granted the Centers for Medicare and Medicaid Services (CMS) the authority to create accountable care organizations (ACOs) with the intent that this new payment and delivery model might help achieve the triple aim goals of better quality of care, greater population health, and lower growth in health care cost (Berenson and Devers 2009; Shortell and Casalino 2010; Colla et al. 2012; Fisher et al. 2012). Private insurers and Medicaid programs have also begun to contract with ACOs (Larson et al. 2012; McGinnis and Small 2012; Lewis et al. 2014). ACOs are entities that take responsibility for both the cost and quality of care for a defined population of patients. Although there are a variety of different payment arrangements, the key idea is that the ACO has financial incentives to improve quality based on predefined criteria and keep overall costs within a target budget. But given the historical difficulty of bringing together hospitals, physicians, and other delivery organizations to provide integrated care, the ACO concept has met with skepticism (Burns and Pauly 2012; Mathews 2012; Christensen, Flier, and Vijayaraghavan 2013). Yet today, there are an estimated over 600 ACOs, both federal and private, with diverse organizational attributes (Larson et al. 2012; Lewis et al. 2014; Muhlestein, Crowshaw, and Pena 2014). With so much activity under way and so little known about the ACO model (Fisher et al. 2012), there is a great need to understand these new organizations; identify some of the characteristics that may be associated with their success or failure; help target needs for technical assistance and support; and measure their progress in achieving performance goals (Fisher et al. 2012; Kroch et al. 2012; Larson et al. 2012). With these objectives in mind, we develop a conceptually based exploratory taxonomy of ACOs that policy makers, practitioners, and researchers can use to achieve the above objectives.

Integrated Care Experiences And Outcomes In Germany, The Netherlands, And England

Abstract: Care for people with chronic conditions is an issue of increasing importance in industrialized countries. This article examines three recent efforts at care coordination that have been evaluated bu...

Chronic diseases and multi-morbidity - a conceptual modification to the WHO ICCC model for countries in health transition

Abstract: The burden of non-communicable diseases is rising, particularly in low and middle-income countries undergoing rapid epidemiological transition. In sub-Saharan Africa, this is occurring against a background of infectious chronic disease epidemics, particularly HIV and tuberculosis. Consequently, multi-morbidity, the co-existence of more than one chronic condition in one person, is increasing; in particular multimorbidity due to comorbid non-communicable and infectious chronic diseases (CNCICD). Such complex multimorbidity is a major challenge to existing models of healthcare delivery and there is a need to ensure integrated care across disease pathways and across primary and secondary care. The Innovative Care for Chronic Conditions (ICCC) Framework developed by the World Health Organization provides a health systems roadmap to meet the increasing needs of chronic disease care. This framework incorporates community, patient, healthcare and policy environment perspectives, and forms the cornerstone of South Africa’s primary health care re-engineering and strategic plan for chronic disease management integration. However, it does not significantly incorporate complexity associated with multimorbidity and CNCICD. Using South Africa as a case study for a country in transition, we identify gaps in the ICCC framework at the micro-, meso-, and macro-levels. We apply the lens of CNCICD and propose modification of the ICCC and the South African Integrated Chronic Disease Management plan. Our framework incorporates the increased complexity of treating CNCICD patients, and highlights the importance of biomedicine (biological interaction). We highlight the patient perspective using a patient experience model that proposes that treatment adherence, healthcare utilization, and health outcomes are influenced by the relationship between the workload that is delegated to patients by healthcare providers, and patients’ capacity to meet the demands of this workload. We link these issues to provider perspectives that interact with healthcare delivery and utilization. Our proposed modification to the ICCC Framework makes clear that healthcare systems must work to make sense of the complex collision between biological phenomena, clinical interpretation, beliefs and behaviours that follow from these. We emphasize the integration of these issues with the socio-economic environment to address issues of complexity, access and equity in the integrated management of chronic diseases previously considered in isolation.

Toward Culturally Centered Integrative Care for Addressing Mental Health Disparities among Ethnic Minorities

Abstract: Despite decades of research, recognition and treatment of mental illness and its comorbidities still remain a significant public health problem in the United States. Ethnic minorities are identified as a population that is vulnerable to mental health disparities and face unique challenges pertaining to mental health care. Psychiatric illness is associated with great physical, emotional, functional, and societal burden. The primary health care setting may be a promising venue for screening, assessment, and treatment of mental illnesses for ethnic minority populations. We propose a comprehensive, innovative, culturally centered integrated care model to address the complexities within the health care system, from the individual level, which includes provider and patient factors, to the system level, which includes practice culture and system functionality issues. Our multidisciplinary investigative team acknowledges the importance of providing culturally tailored integrative health care to holistically concentrate on physical, mental, emotional, and behavioral problems among ethnic minorities in a primary care setting. It is our intention that the proposed model will be useful for health practitioners, contribute to the reduction of mental health disparities, and promote better mental health and well-being for ethnic minority individuals, families, and communities.

The adverse consequences of unmet need among older persons living in the community: dual-eligible versus Medicare-only beneficiaries.

Abstract: One of the most disadvantaged subgroups of older Americans is the population of persons who are covered by both Medicare and Medicaid health insurance, often referred to as the “dual eligible” population. A recent report reveals them to be significantly poorer, less educated, and to have lower levels of social support than their “Medicare only” counterparts (Congressional Budget Office, 2013). The social and economic disadvantage of dual eligibles relative to Medicare-only beneficiaries is mirrored in disparities in both physical and cognitive health status. Compared to older adults who are eligible for Medicare only, dual eligible persons have a higher prevalence of physical and cognitive impairments, including mental illness, are more likely to have multiple chronic conditions, and are more likely to have qualified for Medicare due to disability or kidney disease before the age of 65 (Congressional Budget Office, 2013; Meyer, 2012). Rates of potentially preventable hospitalization and rehospitalization are high in this population, suggesting problems of access to and quality of care (Jiang, Wier, Potter, & Burgess, 2010; Konetzka, Karon, & Potter, 2012; Walsh et al., 2012; Wysocki, Kane, Dowd, et al., 2014). Utilization of both institutional and community-based long-term services and supports (LTSS) is also high among dual eligibles. In 2009, more than half of dual eligible persons over the age of 65 used home and community-based services (HCBS), and one-quarter lived in an institution (Congressional Budget Office, 2013). Considerable research indicates that dual eligible beneficiaries are served in poorer quality nursing homes, both for short term and permanent placement (Harrington, Zimmerman, Karon, Robinson, & Beutel, 2000; Rahman et al., 2014; Rahman, Grabowski, Gozalo, Thomas, & Mor, 2014), with higher rates of hospitalization (Carter & Porell, 2003) than is the case for nursing homes in which Medicare-only residents are predominant. Despite rapidly growing emphasis on the development of HCBS and recent policies to encourage discharge of nursing home residents who can manage in the community with HCBS (Reinhard, 2010; Watts, Reaves, & Musumeci, 2014), little is known about the adequacy of such care to meet the disability-related assistance needs of dual eligible persons given lower levels of family support and financial resources in comparison to persons covered by Medicare only (Congressional Budget Office, 2013). However, given the complex care needs of persons eligible for both Medicare and Medicaid, and in light of poor coordination between acute and long-term care systems, adequate assistance may be lacking for a substantial proportion of this population (Gold, Jacobson, & Garfield, 2012; Meyer, 2012). Prior research has demonstrated that unmet need for assistance among adults with disabilities can result in a range of adverse consequences that can compromise health status (Allen & Mor, 1997; Desai, Lentzner, & Weeks, 2001; LaPlante, Kaye, Kang, & Harrington, 2004). More recent research indicates an increased risk of preventable hospitalizations among dual eligibles receiving Medicaid HCBS than among comparable dual eligible nursing home residents (Wysocki, Kane, Golberstein, et al., 2014), and among dual eligibles following transition from the nursing home to the community, likely due to situations in which available HCBS are inadequate to meet these older persons’ assistance needs (Wysocki, Kane, Dowd, et al., 2014). The purpose of this article is to estimate and compare the prevalence of need for assistance and selected adverse consequences associated with unmet need for assistance among older adults who are dually eligible for Medicare and Medicaid with those who are eligible for Medicare only. Implications for current and emerging care models that integrate health care and LTSS are discussed. Conceptual Framework The Commission on the Social Determinants of Health (CSDH) clearly delineates the mechanisms by which low socioeconomic position in a given nation, indicated in the United States by one’s education, income, occupation, gender, and ethnicity, has implications for their living and working conditions, food adequacy, health behaviors, and psychosocial factors that lead to population differences in both exposure to, and vulnerability to, health compromising conditions. Unhealthy exposures and high vulnerability to illness and injury, in turn, lead to disparities in health, disabilities, and well-being (World Health Organization, 2010). We extend CSDH’s framework to incorporate the impact of the greater severity of illness and impairment experienced by disadvantaged social groups on the level of need for assistance required to perform everyday tasks. More severe impairment necessarily requires a higher level of need for assistance than lower levels of impairment (Figure 1). In the case of dual eligibles, a group that is characterized by a composite of factors indicating socioeconomic and health status disadvantage, with a resulting high burden of disease and impairment, levels of need for assistance are higher than are those experienced by the Medicare only population. Whether or not needs for assistance are adequately met is dependent on the availability of adequate family care and/or access to sufficient LTSS, a moderating effect. The challenge of adequately meeting the assistance needs of dual eligibles is compounded by the low levels of social support available to them, resulting in disparities in unmet need and their adverse consequences relative to the Medicare only population. It is this challenge that emerging models of care that integrate health care and LTSS are attempting to meet. Figure 1. Pathway to unmet need and its adverse consequences.

Implementation process and challenges for the community-based integrated care system in Japan.

Abstract: Background : Since 10 years ago, Japan has been creating a long-term vision to face its peak in the number of older people that will be reached in 2025 when baby boomers will turn 75 years of age. In 2003, the government set up a study group called “Caring for older people in 2015” which led to a first reform of the Long-Term Care Insurance System in 2006. This study group was the first to suggest the creation of a community-based integrated care system. Reforms : Three measures were taken in 2006: ‘Building an active ageing society: implementation of preventive care services’, ‘Improve sustainability: revision of the remuneration of facilities providing care’ and ‘Integration: establishment of a new service system’. These reforms are at the core of the community-based integrated care system. Discussion : The socialization of long-term care that came along with the ageing of the population, and the second shift in Japan towards an increased reliance on the community can provide useful information for other ageing societies. As a super ageing society, the attempts from Japan to develop a rather unique system based on the widely spread concept of integrated care should also become an increasing focus of attention.

Long-Term Outcomes of a Randomized Trial of Integrated Skills Training and Preventive Healthcare for Older Adults with Serious Mental Illness

Abstract: Objective This report describes 1-, 2-, and 3-year outcomes of a combined psychosocial skills training and preventive healthcare intervention (Helping Older People Experience Success [HOPES]) for older persons with serious mental illness. Methods A randomized controlled trial compared HOPES with treatment as usual (TAU) for 183 older adults (age ≥ 50 years [mean age: 60.2]) with serious mental illness (28% schizophrenia, 28% schizoaffective disorder, 20% bipolar disorder, 24% major depression) from two community mental health centers in Boston, Massachusetts, and one in Nashua, New Hampshire. HOPES comprised 12 months of weekly skills training classes, twice-monthly community practice trips, and monthly nurse preventive healthcare visits, followed by a 1-year maintenance phase of monthly sessions. Blinded evaluations of functioning, symptoms, and service use were conducted at baseline and at a 1-year (end of the intensive phase), 2-year (end of the maintenance phase), and 3-year (12 months after the intervention) follow-up. Results HOPES compared with TAU was associated with improved community living skills and functioning, greater self-efficacy, lower overall psychiatric and negative symptoms, greater acquisition of preventive healthcare (more frequent eye exams, visual acuity, hearing tests, mammograms, and Pap smears), and nearly twice the rate of completed advance directives. No differences were found for medical severity, number of medical conditions, subjective health status, or acute service use at the 3-year follow-up. Conclusion Skills training and nurse facilitated preventive healthcare for older adults with serious mental illness was associated with sustained long-term improvement in functioning, symptoms, self-efficacy, preventive healthcare screening, and advance care planning.

Clinical Decision Support Systems (CDSS) for preventive management of COPD patients

Abstract: The use of information and communication technologies to manage chronic diseases allows the application of integrated care pathways, and the optimization and standardization of care processes. Decision support tools can assist in the adherence to best-practice medicine in critical decision points during the execution of a care pathway. The objectives are to design, develop, and assess a clinical decision support system (CDSS) offering a suite of services for the early detection and assessment of chronic obstructive pulmonary disease (COPD), which can be easily integrated into a healthcare providers' work-flow. The software architecture model for the CDSS, interoperable clinical-knowledge representation, and inference engine were designed and implemented to form a base CDSS framework. The CDSS functionalities were iteratively developed through requirement-adjustment/development/validation cycles using enterprise-grade software-engineering methodologies and technologies. Within each cycle, clinical-knowledge acquisition was performed by a health-informatics engineer and a clinical-expert team. A suite of decision-support web services for (i) COPD early detection and diagnosis, (ii) spirometry quality-control support, (iii) patient stratification, was deployed in a secured environment on-line. The CDSS diagnostic performance was assessed using a validation set of 323 cases with 90% specificity, and 96% sensitivity. Web services were integrated in existing health information system platforms. Specialized decision support can be offered as a complementary service to existing policies of integrated care for chronic-disease management. The CDSS was able to issue recommendations that have a high degree of accuracy to support COPD case-finding. Integration into healthcare providers' work-flow can be achieved seamlessly through the use of a modular design and service-oriented architecture that connect to existing health information systems.

A Pilot Test of a Peer Navigator Intervention for Improving the Health of Individuals with Serious Mental Illness

Abstract: Individuals with serious mental illness (SMI) are at considerably higher risk for morbidity and mortality than those in the general population. The current pilot trial is a preliminary examination of a peer health navigation intervention for improving health and healthcare utilization called the Bridge. Twenty-four individuals with SMI were randomly assigned to either peer navigation or treatment as usual (TAU). Navigators encouraged development of self-management of healthcare through a series of psychoeducation and behavioral strategies. Outcomes included a range of health consequences, as well as health utilization indices. After 6 months, compared to the TAU group, participants receiving the intervention experienced fewer pain and health symptoms. Participants changed their orientation about seeking care to a primary care provider (44.4 % vs. 83.3 %, χ2 = 3.50, p < .05) rather than the emergency room (55.6 % vs. 0 %, χ2 = 8.75, p < .01). Therefore, the Bridge intervention demonstrated considerable promise through positively impacting health and healthcare utilization.

Joint principles: integrating behavioral health care into the patient-centered medical home

Abstract: The Patient-centered Medical Home (PCMH) is an innovative, improved, and evolving approach to providing primary care that has gained broad acceptance in the United States. The Joint Principles of the PCMH, formulated and endorsed in February 2007, are sound and describe the ideal toward which we

Clinician Roles in Early Integrated Palliative Care for Patients with Advanced Cancer: A Qualitative Study

Abstract: Background: Early palliative care provides better quality of life, increased prognostic awareness, and even improved survival for patients with advanced cancer but how the integrated care model achieves these outcomes has not been completely explained. Methods: To better understand the clinical approach to early outpatient care from the clinicians' perspective, we conducted focus groups with the palliative care clinicians who had participated in a randomized trial of early palliative care for metastatic lung cancer. Results: Clinicians described their role in providing early palliative care as having three distinct roles in the outpatient setting: (1) managing symptoms to improve functional status and as a bridge to other issues; (2) engaging patients in emotional work to facilitate coping, accepting, and planning; and (3) interpreting the oncologist for the patient and the patient for the oncologist. Conclusions: These data lay the foundation for developing training programs for clinicians in ea...

Towards community-based integrated care: trends and issues in Japan’s long-term care policy

Abstract: Introduction: In 2000, Japan implemented a mandatory long-term care insurance system. With the rapid growth of the system, problems became apparent. Several critical alterations were made to the long-term care insurance system, particularly with respect to integrated care. Methods: This paper elucidates the policy trends that led to the reforms of the long-term care insurance system, which included new concepts of ‘integrated care’ and ‘community-based care’, an agenda of cost containment and service streamlining, and coordination with medical care. Results: Community-based integrated care, as envisaged in the long-term care policy, includes not only the integration of medical care into service provision but also the inclusion of the informal mutual aid, oversight of for-profit providers by an administration that ensures users are not exploited and coordination between systems that cover different geographical areas. Conclusions: Japan’s experience in community-based care integration suggests that this project requires multi-faceted care integration in local communities. In the future, it will be necessary to conduct empirical assessments of the effectiveness of these measures.

Stigma and discrimination against people with schizophrenia related to medical services.

Abstract: Objective:To investigate whether people with schizophrenia experience discrimination when using health care services.Methods:A cross-sectional survey in 27 countries in centres affiliated to the INDIGO Research Network, using face-to-face interviews with 777 participants with schizophrenia (62% male and 38% female). We analysed the data related to health issues, including health care, disrespect of mental health staff, and also personal privacy, safety and security, starting a family, pregnancy and childbirth. Discrimination was measured by the Discrimination and Stigma Scale (DISC), which consists of 36 items comprising three sub-scales: positive experienced discrimination; negative experienced discrimination; and anticipated discrimination.Results:More than 17% of patients experienced discrimination when treated for physical health care problems. More than 38% of participants felt disrespected by mental health staff, with higher ratings in the post-communist countries.Conclusions:Mental health service p...

Patient perspectives of an integrated program of medical care and substance use treatment.

Abstract: The benefits of integrating primary care and substance use disorder treatment are well known, yet true integration is difficult. We developed and evaluated a team-based model of integrated care within the primary care setting for HIV-infected substance users and substance users at risk for contracting HIV. Qualitative data were gathered via focus groups and satisfaction surveys to assess patients' views of the program, evaluate key elements for success, and provide recommendations for other programs. Key themes related to preferences for the convenience and efficiency of integrated care; support for a team-based model of care; a feeling that the program requirements offered needed structure; the importance of counseling and education; and how provision of concrete services improved overall well-being and quality of life. For patients who received buprenorphine/naloxone for opioid dependence, this was viewed as a major benefit. Our results support other studies that theorize integrated care could be of significant value for hard-to-reach populations and indicate that having a clinical team dedicated to providing substance use disorder treatment, HIV risk reduction, and case management services integrated into primary care clinics has the potential to greatly enhance the ability to serve a challenging population with unmet treatment needs.