Showing papers on "Integrated care published in 2016"
TL;DR: Specific barriers to medication adherence in T2D, especially those that are potentially modifiable, need to be more clearly identified and strategies that target poor adherence should focus on reducing medication burden and addressing negative medication beliefs of patients.
Abstract: At least 45% of patients with type 2 diabetes (T2D) fail to achieve adequate glycemic control (HbA1c <7%). One of the major contributing factors is poor medication adherence. Poor medication adherence in T2D is well documented to be very common and is associated with inadequate glycemic control; increased morbidity and mortality; and increased costs of outpatient care, emergency room visits, hospitalization, and managing complications of diabetes. Poor medication adherence is linked to key nonpatient factors (eg, lack of integrated care in many health care systems and clinical inertia among health care professionals), patient demographic factors (eg, young age, low education level, and low income level), critical patient beliefs about their medications (eg, perceived treatment inefficacy), and perceived patient burden regarding obtaining and taking their medications (eg, treatment complexity, out-of-pocket costs, and hypoglycemia). Specific barriers to medication adherence in T2D, especially those that are potentially modifiable, need to be more clearly identified; strategies that target poor adherence should focus on reducing medication burden and addressing negative medication beliefs of patients. Solutions to these problems would require behavioral innovations as well as new methods and modes of drug delivery.
428 citations
TL;DR: It is argued that integrated care cannot be narrowly defined, but should be seen as an overarching term for a broad and multi-component set of ideas and principles that seek to better co-ordinate care around people’s needs.
Abstract: Introduction Integrated care is a concept that is now commonly accepted across the world yet there remains a persistent and enduring ‘confusion of languages’ when it comes to understanding it [1] This perspective paper seeks to bring a degree of clarity to the meaning of integrated care It argues that integrated care cannot be narrowly defined, but should be seen as an overarching term for a broad and multi-component set of ideas and principles that seek to better co-ordinate care around people’s needs
188 citations
TL;DR: The case for integration is reviewed, but also provides real practical examples of how it has been achieved, and both the barriers to and facilitators of its successful implementation are described on the basis of interviews of those involved.
173 citations
TL;DR: Analysis of boundaries that affect collaboration and care integration in newly created multidisciplinary teams in hospitals shows that disciplinary boundaries hinder both intra-professional and inter-professional collaboration.
143 citations
TL;DR: There is some evidence that integrated care for people with multimorbidity can create efficiency gains and improve health outcomes, but the evidence is limited, and may only be applicable to high-income countries with relatively strong and well-resourced health systems.
Abstract: Multimorbidity, which is defined as the co-occurrence of two or more chronic conditions, has moved onto the priority agenda for many health policymakers and healthcare providers. Patients with multimorbidity are high utilizers of healthcare resources and are some of the most costly and difficult-to-treat patients in Europe. Preventing and improving the way multimorbidity is managed is now a key priority for many countries, and work is at last underway to develop more sustainable models of care. Unfortunately, this effort is being hampered by a lack of basic knowledge about the aetiology, epidemiology, and risk factors for multimorbidity, and the efficacy and cost-effectiveness of different interventions. The European Commission recognizes the need for reform in this area and has committed to raising awareness of multimorbidity, encouraging innovation, optimizing the use of existing resources, and coordinating the efforts of different stakeholders across the European Union. Many countries have now incorporated multimorbidity into their own healthcare strategies and are working to strengthen their prevention efforts and develop more integrated models of care. Although there is some evidence that integrated care for people with multimorbidity can create efficiency gains and improve health outcomes, the evidence is limited, and may only be applicable to high-income countries with relatively strong and well-resourced health systems. In low- to middle-income countries, which are facing the double burden of infectious and chronic diseases, integration of care will require capacity building, better quality services, and a stronger evidence base.
141 citations
TL;DR: Evidence for the effectiveness of comprehensive care programs targeting multimorbid and/or frail patients remains insufficient, and more good-quality studies and/ or studies allowing meta-analysis are needed to determine which specific target groups at what moment will benefit from comprehensive care.
137 citations
TL;DR: This review aimed to assess the effects on symptom severity and quality of life of people who are dying, or those related to the care, such as families, carers and health professionals, or a combination of these, across all healthcare settings.
Abstract: Background In many clinical areas, integrated care pathways are utilised as structured multidisciplinary care plans which detail essential steps in caring for patients with specific clinical problems. Particularly, care pathways for the dying have been developed as a model to improve the end-of-life care of all patients. They aim to ensure that the most appropriate management occurs at the most appropriate time and that it is provided by the most appropriate health professional. Clinical pathways for end-of-life care management are used widely around the world and have been regarded as the gold standard. Therefore, there is a significant need for clinicians to be informed about the utilisation of end-of-life care pathways with a systematic review. Objectives To assess the effects of end-of-life care pathways, compared with usual care (no pathway) or with care guided by another end-of-life care pathway across all healthcare settings (e.g. hospitals, residential aged care facilities, community). Search strategy The Cochrane Register of controlled Trials (CENTRAL), the Pain, Palliative and Supportive Care Review group specialised register,MEDLINE, EMBASE, review articles and reference lists of relevant articles were searched. The search was carried out in September 2009. Selection criteria All randomised controlled trials (RCTs), quasi-randomised trial or high quality controlled before and after studies comparing use versus non-use of an end-of-life care pathway in caring for the dying. Data collection and analysis Results of searches were reviewed against the pre-determined criteria for inclusion by two review authors. Main results The search identified 920 potentially relevant titles, but no studies met criteria for inclusion in the review. Authors’ conclusions Without further available evidence, recommendations for the use of end-of-life pathways in caring for the dying cannot be made. RCTs or other well designed controlled studies are needed for evaluating the use of end-of-life care pathways in caring for dying people.
127 citations
TL;DR: Although all outcomes showed some significant reductions, and a number of potentially effective interventions were found, interventions rarely demonstrated unequivocally positive effects and questions remain about whether the magnitude of potentially achievable gains is enough to satisfy national targets for reductions in hospital activity.
Abstract: Objective To summarise the evidence regarding the effectiveness of integrated care interventions in reducing hospital activity.
Design Umbrella review of systematic reviews and meta-analyses.
Setting Interventions must have delivered care crossing the boundary between at least two health and/or social care settings.
Participants Adult patients with one or more chronic diseases.
Data sources MEDLINE, Embase, ASSIA, PsycINFO, HMIC, CINAHL, Cochrane Library (HTA database, DARE, Cochrane Database of Systematic Reviews), EPPI-Centre, TRIP, HEED, manual screening of references.
Outcome measures Any measure of hospital admission or readmission, length of stay (LoS), accident and emergency use, healthcare costs.
Results 50 reviews were included. Interventions focused on case management (n=8), chronic care model (CCM) (n=9), discharge management (n=15), complex interventions (n=3), multidisciplinary teams (MDT) (n=10) and self-management (n=5). 29 reviews reported statistically significant improvements in at least one outcome. 11/21 reviews reported significantly reduced emergency admissions (15–50%); 11/24 showed significant reductions in all-cause (10–30%) or condition-specific (15–50%) readmissions; 9/16 reported LoS reductions of 1–7 days and 4/9 showed significantly lower A&E use (30–40%). 10/25 reviews reported significant cost reductions but provided little robust evidence. Effective interventions included discharge management with postdischarge support, MDT care with teams that include condition-specific expertise, specialist nurses and/or pharmacists and self-management as an adjunct to broader interventions. Interventions were most effective when targeting single conditions such as heart failure, and when care was provided in patients’ homes.
Conclusions Although all outcomes showed some significant reductions, and a number of potentially effective interventions were found, interventions rarely demonstrated unequivocally positive effects. Despite the centrality of integrated care to current policy, questions remain about whether the magnitude of potentially achievable gains is enough to satisfy national targets for reductions in hospital activity.
Trial registration number CRD42015016458.
126 citations
TL;DR: This paper describes the methodology of a study seeking to validate the Rainbow Model of Integrated Care measurement tool within and across the Singapore Regional Health System, with the results allowing insights in making recommendations for improving the Regional Health system and supporting international comparison.
Abstract: Introduction: The conceptual ambiguity of the integrated care concept precludes a full understanding of what constitutes a well-integrated health system, posing a significant challenge in measuring the level of integrated care. Most available measures have been developed from a disease-specific perspective and only measure certain aspects of integrated care. Based on the Rainbow Model of Integrated Care, which provides a detailed description of the complex concept of integrated care, a measurement tool has been developed to assess integrated care within a care system as a whole gathered from healthcare providers’ and managerial perspectives. This paper describes the methodology of a study seeking to validate the Rainbow Model of Integrated Care measurement tool within and across the Singapore Regional Health System. The Singapore Regional Health System is a recent national strategy developed to provide a better-integrated health system to deliver seamless and person-focused care to patients through a network of providers within a specified geographical region. Methods: The validation process includes the assessment of the content of the measure and its psychometric properties. Conclusion: If the measure is deemed to be valid, the study will provide the first opportunity to measure integrated care within Singapore Regional Health System with the results allowing insights in making recommendations for improving the Regional Health System and supporting international comparison.
114 citations
TL;DR: ‘Horizontal’ care using care plans for older people with complex problems can be a valuable tool in general practice, however, no direct beneficial effect was found for older persons.
Abstract: Background: older people often experience complex problems. Because of multiple problems, care for older people in general practice needs to shift from a ‘problem-based, disease-oriented’ care aiming at improvement of outcomes per disease to a ‘goal-oriented care’, aiming at improvement of functioning and personal quality of life, integrating all healthcare providers. Feasibility and cost-effectiveness of this proactive and integrated way of working are not yet established.
Design: cluster randomised trial.
Participants: all persons aged ≥75 in 59 general practices (30 intervention, 29 control), with a combination of problems, as identified with a structured postal questionnaire with 21 questions on four health domains.
Intervention: for participants with problems on ≥3 domains, general practitioners (GPs) made an integrated care plan using a functional geriatric approach. Control practices: care as usual.
Outcome measures: (i) quality of life (QoL), (ii) activities of daily living, (iii) satisfaction with delivered health care and (iv) cost-effectiveness of the intervention at 1-year follow-up.
Trial registration: Netherlands trial register, NTR1946.
Results: of the 11,476 registered eligible older persons, 7,285 (63%) participated in the screening. One thousand nine hundred and twenty-one (26%) had problems on ≥3 health domains. For 225 randomly chosen persons, a care plan was made. No beneficial effects were found on QoL, patients' functioning or healthcare use/costs. GPs experienced better overview of the care and stability, e.g. less unexpected demands, in the care.
Conclusions: GPs prefer proactive integrated care. ‘Horizontal’ care using care plans for older people with complex problems can be a valuable tool in general practice. However, no direct beneficial effect was found for older persons.
97 citations
TL;DR: Given the thematic range of the identified barriers, the diagnostic process of non-specific, functional, and somatoform disorders in primary care is highly complex and individual or practice-level interventions are needed to help address the diagnostic challenges.
TL;DR: The results confirm the significant terminological variance in case management which produces role confusion, ambiguity and hinders comparability across different health conditions and contexts and the urgent need for an internationally agreed taxonomy for the coordination, navigation and management of care.
Abstract: The description of case management in research and clinical practice is highly variable which impedes quality analysis, policy and planning. Case management makes a unique contribution towards the integration of health care, social services and other sector services and supports for people with complex health conditions. There are multiple components and variations of case management depending on the context and client population. This paper aims to scope and map case management in the literature to identify how case management is described in the literature for key complex health conditions (e.g., brain injury, diabetes, mental health, spinal cord injury). Following literature searches in multiple databases, grey literature and exclusion by health condition, community-based and adequate description, there were 661 potential papers for data extraction. Data from 79 papers (1988–2013) were analysed to the point of saturation (no new information) and mapped to the model, components and activities. The results included 22 definitions, five models, with 69 activities or tasks of case managers mapped to 17 key components (interventions). The results confirm the significant terminological variance in case management which produces role confusion, ambiguity and hinders comparability across different health conditions and contexts. There is an urgent need for an internationally agreed taxonomy for the coordination, navigation and management of care.
TL;DR: The MHCP focused on improving demand and access at the community level, inclusive care at the facility level and sustainability at the organisation level, and may be a useful template for similar LMIC.
Abstract: Background Developing evidence for the implementation and scaling up of mental healthcare in low- and middle-income countries (LMIC) like Ethiopia is an urgent priority. Aims To outline a mental healthcare plan (MHCP), as a scalable template for the implementation of mental healthcare in rural Ethiopia. Method A mixed methods approach was used to develop the MHCP for the three levels of the district health system (community, health facility and healthcare organisation). Results The community packages were community case detection, community reintegration and community inclusion. The facility packages included capacity building, decision support and staff well-being. Organisational packages were programme management, supervision and sustainability. Conclusions The MHCP focused on improving demand and access at the community level, inclusive care at the facility level and sustainability at the organisation level. The MHCP represented an essential framework for the provision of integrated care and may be a useful template for similar LMIC.
TL;DR: This study has demonstrated that a complex multi-strategy intervention led by nursing staff can successfully reduce hospital admissions for older people living in Residential Aged Care Facilities.
Abstract: Older people living in Residential Aged Care Facilities (RACF) are a vulnerable, frail and complex population. They are more likely than people who reside in the community to become acutely unwell, present to the Emergency Department (ED) and require admission to hospital. For many, hospitalisation carries with it risks. Importantly, evidence suggests that some admissions are avoidable. A new collaborative model of care, the Aged Care Emergency Service (ACE), was developed to provide clinical support to nurses in the RACFs, allowing residents to be managed in place and avoid transfer to the ED. This paper examines the effects of the ACE service on RACF residents’ transfer to hospital using a controlled pre-post design. Four intervention RACFs were matched with eight control RACFs based on number of total beds, dementia specific beds, and ratio of high to low care beds in Newcastle, Australia, between March and November 2011. The intervention consisted of a clinical care manual to support care along with a nurse led telephone triage line, education, establishing goals of care prior to ED transfer, case management when in the ED, along with the development of collaborative relationships between stakeholders. Outcomes included ED presentations, length of stay, hospital admission and 28-day readmission pre- and post-intervention. Generalised estimating equations were used to estimate mean differences in outcomes between intervention and controls RACFs, pre- and post-intervention means, and their interaction, accounting for repeated measures and adjusting for matching factors. Residents had a mean age of 86 years. ED presentations ranged between 16 and 211 visits/100 RACF beds/year across all RACFs. There was no overall reduction in ED presentations (OR = 1.17, p = 0.56) with the ACE intervention. However, when compared to the controls, the intervention group reduced their ED length of stay by 45 min (p = 0.0575), and was 40 % less likely to be admitted to hospital, . The latter was highly significant (p = 0.0012). Transfers to ED and admission to hospital are common for residents of RACFs. This study has demonstrated that a complex multi-strategy intervention led by nursing staff can successfully reduce hospital admissions for older people living in Residential Aged Care Facilities. By defining goals of care prior to transfer to the ED, clinicians have the opportunity to better deliver care that patients require. Integrated care requires accountability from multiple stakeholders. The Australian New Zealand Clinical Trials Registration number is ACTRN12616000588493
It was registered on 6th May 2016.
TL;DR: There is great unrealised opportunity for integration in developing new approaches to mental health within primary care in England, and part of the high stress and dissatisfaction levels experienced by GPs relates to managing these patients effectively.
Abstract: Reducing fragmentation between different parts of the health system is a key priority for the National Health Service (NHS) and for health systems internationally, if they are to meet the challenges they face. One of the deepest fault-lines in the NHS is the disconnection of mental healthcare from the rest of the system; this has to be addressed as part of efforts to improve integrated care. Developing integrated approaches towards mental and physical health is increasingly becoming a policy priority; the report of the independent mental health taskforce to the NHS identified this as one of the top three priorities for the next five years. There has been recent investment in integrating mental and physical health within secondary care, for example, liaison psychiatry in acute general hospitals and perinatal mental healthcare. While such investment is also crucial, we believe that there is great unrealised opportunity for integration in developing new approaches to mental health within primary care. Mental health problems are very common in the community; 90%of adults with mental health problems are supported largely or exclusively by primary care. Mental health problems often co-exist with physical health problems; the King’s Fund highlighted that 12–18%of NHS expenditure on long-term conditions is linked to anxiety, depression or other mental health problems. Furthermore, as the UK population ages, we will see an increase in the number of people with co-existing physical and mental health problems. Alongside diagnosable mental health problems, subthreshold symptoms are common in primary care and often co-exist with high levels of complexity and challenging social circumstances, such as unemployment and poor housing.Medically unexplained symptoms and substance abuse disorders are also highly prevalent in primary care. Unfortunately, these kinds of problems are often poorly managed through current arrangements. Clear referral pathways exist for people suffering severe mental illnesses and, in England, the Improving Access to Psychological Therapies (IAPT) programme has recently improved availability of psychological therapies for non-complex cases of mild to moderate depression or anxiety. However, for more complex presentations, current arrangements are often poor in terms of clinical and costeffectiveness. In addition, monitoring of physical health among people with severe mental illnesses remains inconsistent. General practice is currently under extreme pressure in England and elsewhere; part of this pressure relates to complex cases with superimposed mental health, physical health and social challenges, associated with frequent service use and attendance in general practice. This is compounded by significant pressures in specialist mental health services, which in some cases lead to raised eligibility thresholds and more complex patients being managed in primary care. GPs have expressed concern over the level of risk they carry in the absence of specialist support. Furthermore, despite the introduction of the IAPT programme, there remains considerable variation in availability of psychological therapies for adults with common mental health problems, which meet only 15% of current need. Overall, part of the high stress and dissatisfaction levels experienced by GPs relates to managing these patients effectively. We believe that a new approach towards mental health in primary care could alleviate some of this pressure. There is no simple solution that can be implemented everywhere, but we can learn from examples of real-life innovations. In the UK, there is a ‘Primary Care Psychotherapy Consultation Service’ in City and Hackney, London, where a multidisciplinary team of mental health professionals help GPs manage complex patients (e.g. medically unexplained symptoms, co-morbidity, personality
TL;DR: A generic framework for integrated PC in cancer and chronic disease in Europe is proposed, which fosters integration of PC in the disease trajectory concurrently with treatment and identifies the importance of employing a PC-trained multidisciplinary team with a threefold focus: treatment, consulting and training.
Abstract: Integrated Palliative Care (PC) strategies are often implemented following models, namely standardized designs that provide frameworks for the organization of care for people with a progressive life-threatening illness and/or for their (in)formal caregivers. The aim of this qualitative systematic review is to identify empirically-evaluated models of PC in cancer and chronic disease in Europe. Further, develop a generic framework that will consist of the basis for the design of future models for integrated PC in Europe. Cochrane, PubMed, EMBASE, CINAHL, AMED, BNI, Web of Science, NHS Evidence. Five journals and references from included studies were hand-searched. Two reviewers screened the search results. Studies with adult patients with advanced cancer/chronic disease from 1995 to 2013 in Europe, in English, French, German, Dutch, Hungarian or Spanish were included. A narrative synthesis was used. 14 studies were included, 7 models for chronic disease, 4 for integrated care in oncology, 2 for both cancer and chronic disease and 2 for end-of-life pathways. The results show a strong agreement on the benefits of the involvement of a PC multidisciplinary team: better symptom control, less caregiver burden, improvement in continuity and coordination of care, fewer admissions, cost effectiveness and patients dying in their preferred place. Based on our findings, a generic framework for integrated PC in cancer and chronic disease is proposed. This framework fosters integration of PC in the disease trajectory concurrently with treatment and identifies the importance of employing a PC-trained multidisciplinary team with a threefold focus: treatment, consulting and training.
TL;DR: This article proposes a framework for population strategies in integrated care-whole populations, subpopulations, and high-risk populations-and shows how patient segmentation can support these strategies.
Abstract: Integrated care aims to organize care around the patient instead of the provider. It is therefore crucial to understand differences across patients and their needs. Segmentation analysis that uses big data can help divide a patient population into distinct groups, which can then be targeted with care models and intervention programs tailored to their needs. In this article we explore the potential applications of patient segmentation in integrated care. We propose a framework for population strategies in integrated care—whole populations, subpopulations, and high-risk populations—and show how patient segmentation can support these strategies. Through international case examples, we illustrate practical considerations such as choosing a segmentation logic, accessing data, and tailoring care models. Important issues for policy makers to consider are trade-offs between simplicity and precision, trade-offs between customized and off-the-shelf solutions, and the availability of linked data sets. We conclude th...
TL;DR: The results suggest that the quality of measurement properties of instruments measuring integrated care is in need of improvement with the less-studied constructs and domains to become part of newly developed instruments.
Abstract: Policy Points:
Investigations on systematic methodologies for measuring integrated care should coincide with the growing interest in this field of research.
A systematic review of instruments provides insights into integrated care measurement, including setting the research agenda for validating available instruments and informing the decision to develop new ones.
This study is the first systematic review of instruments measuring integrated care with an evidence synthesis of the measurement properties.
We found 209 index instruments measuring different constructs related to integrated care; the strength of evidence on the adequacy of the majority of their measurement properties remained largely unassessed.
Context
Integrated care is an important strategy for increasing health system performance. Despite its growing significance, detailed evidence on the measurement properties of integrated care instruments remains vague and limited. Our systematic review aims to provide evidence on the state of the art in measuring integrated care.
Methods
Our comprehensive systematic review framework builds on the Rainbow Model for Integrated Care (RMIC). We searched MEDLINE/PubMed for published articles on the measurement properties of instruments measuring integrated care and identified eligible articles using a standard set of selection criteria. We assessed the methodological quality of every validation study reported using the COSMIN checklist and extracted data on study and instrument characteristics. We also evaluated the measurement properties of each examined instrument per validation study and provided a best evidence synthesis on the adequacy of measurement properties of the index instruments.
Findings
From the 300 eligible articles, we assessed the methodological quality of 379 validation studies from which we identified 209 index instruments measuring integrated care constructs. The majority of studies reported on instruments measuring constructs related to care integration (33%) and patient-centered care (49%); fewer studies measured care continuity/comprehensive care (15%) and care coordination/case management (3%). We mapped 84% of the measured constructs to the clinical integration domain of the RMIC, with fewer constructs related to the domains of professional (3.7%), organizational (3.4%), and functional (0.5%) integration. Only 8% of the instruments were mapped to a combination of domains; none were mapped exclusively to the system or normative integration domains. The majority of instruments were administered to either patients (60%) or health care providers (20%). Of the measurement properties, responsiveness (4%), measurement error (7%), and criterion (12%) and cross-cultural validity (14%) were less commonly reported. We found <50% of the validation studies to be of good or excellent quality for any of the measurement properties. Only a minority of index instruments showed strong evidence of positive findings for internal consistency (15%), content validity (19%), and structural validity (7%); with moderate evidence of positive findings for internal consistency (14%) and construct validity (14%).
Conclusions
Our results suggest that the quality of measurement properties of instruments measuring integrated care is in need of improvement with the less-studied constructs and domains to become part of newly developed instruments.
TL;DR: In this systematic literature review, predominantly positive economic impacts of integrated care models for patients with chronic diseases were found.
07 Apr 2016
TL;DR: It is argued that a culture change is needed to make person-centred care the norm and that patients can help deliver this through a more meaningful involvement in medical research, training and education, service reconfiguration and commissioning.
Abstract: This edition of Future Hospital Journal has a focus on person-centred care and explores the dimensions to partnership working at three different levels - consultation, service and system levels. In this introduction, the authors explain what they consider to be the essential components of person--centred care and what needs to be done to embed it at all levels of healthcare delivery. The changing attitudes of patients and the desire of most of them to receive personalised care based on their individual needs, preferences and lifestyles are explored. It is argued that a culture change is needed to make person-centred care the norm and that patients can help deliver this through a more meaningful involvement in medical research, training and education, service reconfiguration and commissioning.
TL;DR: This thesis operationalized the concept of integrated care from a primary care perspective and described the collaboration mechanisms among integrated care projects that were part of a national integrated primary care study in The Netherlands.
Abstract: This thesis aimed to contribute to a better understanding of what integrated primary care is, and how it can be achieved by focussing on the collaboration processes that underlie the development of integrated primary care. The first part of this thesis operationalized the concept of integrated care from a primary care perspective. The second part of this thesis described the collaboration mechanisms among integrated care projects that were part of a national integrated primary care study in The Netherlands.
TL;DR: Focusing on the different perspectives and the inequality in power between patients and healthcare providers and between different providers might contribute to a better environment for achieving appropriate collaboration.
Abstract: Introduction: This article summarizes and synthesizes the findings of four separate but inter-linked empirical projects which explored challenges of collaboration in the Norwegian health system from the perspectives of providers and patients. The results of the four projects are summarised in eight articles. Methods: The eight articles constituted our empirical material. Meta-ethnography was used as a method to integrate, translate, and synthesize the themes and concepts contained in the articles in order to understand how challenges related to collaboration impact on clinical work. Results: Providers’ collaboration across all contexts was hampered by organizational and individual factors, including, differences in professional power, knowledge bases, and professional culture. The lack of appropriate collaboration between providers impeded clinical work. Mental health service users experienced fragmented services leading to insecurity and frustration. The lack of collaboration resulted in inadequate rehabilitation services and lengthened the institutional stay for older patients. Conclusion: Focusing on the different perspectives and the inequality in power between patients and healthcare providers and between different providers might contribute to a better environment for achieving appropriate collaboration. Organizational systems need to be redesigned to better nurture collaborative relationships and information sharing and support integrated working between providers, health care professionals and patients.
TL;DR: A conceptual framework of organizational capabilities for integrating care is developed and validates, identifying which of these capabilities may be most important, and explores the mechanisms by which they influence integrated care efforts.
Abstract: Background: Interventions aimed at integrating care have become widespread in healthcare; however, there is significant variability in their success. Differences in organizational contexts and associated capabilities may be responsible for some of this variability. Purpose: This study develops and validates a conceptual framework of organizational capabilities for integrating care, identifies which of these capabilities may be most important, and explores the mechanisms by which they influence integrated care efforts. Methods: The Context and Capabilities for Integrating Care (CCIC) Framework was developed through a literature review, and revised and validated through interviews with leaders and care providers engaged in integrated care networks in Ontario, Canada. Interviews involved open-ended questions and graphic elicitation. Quantitative content analysis was used to summarize the data. Results: The CCIC Framework consists of eighteen organizational factors in three categories: Basic Structures, People and Values, and Key Processes. The three most important capabilities shaping the capacity of organizations to implement integrated care interventions include Leadership Approach, Clinician Engagement and Leadership, and Readiness for Change. The majority of hypothesized relationships among organizational capabilities involved Readiness for Change and Partnering, emphasizing the complexity, interrelatedness and importance of these two factors to integrated care efforts. Conclusions: Organizational leaders can use the framework to determine readiness to integrate care, develop targeted change management strategies, and select appropriate partners with overlapping or complementary profiles on key capabilities. Researchers may use the results to test and refine the proposed framework, with a focus on the hypothesized relationships among organizational capabilities and between organizational capabilities and performance outcomes.
TL;DR: In conclusion, this cross-sectional study offers important insights into the psychosocial and organizational elements that impact on type 2 diabetes patients' activation in self-management and on their willingness to use mHealth and eHealth devices.
Abstract: eHealth and mHealth interventions for type 2 diabetes are emerging as useful strategies to accomplish the goal of a high functioning integrated care system. However, mHealth and eHealth interventions in order to be successful need the clear endorsement from the healthcare professionals. This cross-sectional study included a sample of 93 Italian-speaking type 2 diabetes patients and demonstrated the role of the perceived ability of healthcare professionals to motivate patients' initiative in improving the level of their engagement and activation in type 2 diabetes self-management. The level of type 2 diabetes patients' activation resulted also in being a direct precursor of their attitude to the use of mHealth and eHealth. Furthermore, patient engagement has been demonstrated to be a mediator of the relationship between the perceived ability of healthcare professionals in motivating type 2 diabetes patients and patients' activation. Finally, type 2 diabetes patients adherence did not result in being a direct consequence of the frequency of mHealth and eHealth use. Patient adherence appeared to be directly influenced by the level of perceived healthcare professionals ability of motivating patients' autonomy. These results offer important insights into the psychosocial and organizational elements that impact on type 2 diabetes patients' activation in self-management and on their willingness to use mHealth and eHealth devices.
TL;DR: It is concluded that close monitoring of ANC and PNC quality and delivery models, health workforce support, appropriate use of electronic technologies, integrated care, a woman‐friendly perspective, and adequate infrastructure are key elements of successful programmes that benefit the health and wellbeing of women, their newborns and families.
TL;DR: Key components of these models are early intervention during the inpatient phase, discharge planning, early postdischarge review and structured follow-up, advanced transition planning, and the involvement of physicians and nurses specialized in heart failure.
Abstract: Despite advances in the treatment of heart failure, mortality, the number of readmissions, and their associated health care costs are very high. Heart failure care models inspired by the chronic care model, also known as heart failure programs or heart failure units, have shown clinical benefits in high-risk patients. However, while traditional heart failure units have focused on patients detected in the outpatient phase, the increasing pressure from hospital admissions is shifting the focus of interest toward multidisciplinary programs that concentrate on transitions of care, particularly between the acute phase and the postdischarge phase. These new integrated care models for heart failure revolve around interventions at the time of transitions of care. They are multidisciplinary and patient-centered, designed to ensure continuity of care, and have been demonstrated to reduce potentially avoidable hospital admissions. Key components of these models are early intervention during the inpatient phase, discharge planning, early postdischarge review and structured follow-up, advanced transition planning, and the involvement of physicians and nurses specialized in heart failure. It is hoped that such models will be progressively implemented across the country.
TL;DR: In this article, the authors explore factors that affect the provision of and access to care in two provinces - Gauteng and Eastern Cape - and illustrate the complex issues surrounding health maintenance and primary care outreach in poor communities, and describe how the intimate interactions between providers and recipients work to build trust.
Abstract: Community health workers (CHWs) affiliated with community-based organisations are central to the implementation of primary health care in district health services in South Africa. Here, we explore factors that affect the provision of and access to care in two provinces - Gauteng and Eastern Cape. Drawing on narratives of care recipients and the CHWs who support them, we illustrate the complex issues surrounding health maintenance and primary care outreach in poor communities, and describe how the intimate interactions between providers and recipients work to build trust. In the study we report here, householders in Gauteng Province had poor access to health care and other services, complicating the impoverished circumstances of their everyday lives. The limited resources available to CHWs hindered their ability to meet householders' needs and for householders to benefit from existing services. CHWs in the Eastern Cape were better able to address the needs of poor householders because of the organisational support available to them. Based on an ethos of integrated and holistic care, this enabled the CHWs to address the recipients' context-related needs, and health and medical needs, while building greater levels of trust with their clients.
TL;DR: After hospital discharge, new parents need practical support, monitoring and care and improving inter-professional networks, implementing supervisors or a centralized coordinating center could help to remedy the current fragmented care.
Abstract: The length of postpartum hospital stay is decreasing internationally. Earlier hospital discharge of mothers and newborns decreases postnatal care or transfers it to the outpatient setting. This study aimed to investigate the experiences of new parents and examine their views on care following early hospital discharge. Six focus group discussions with new parents (n = 24) were conducted. A stratified sampling scheme of German and Turkish-speaking groups was employed. A ‘playful design’ method was used to facilitate participants communication wherein they used blocks and figurines to visualize their perspectives on care models The visualized constructions of care models were photographed and discussions were audio-recorded and transcribed verbatim. Text and visual data was thematically analyzed by a multi-professional group and findings were validated by the focus group participants. Following discharge, mothers reported feeling physically strained during recuperating from birth and initiating breastfeeding. The combined requirements of infant and self-care needs resulted in a significant need for practical and medical support. Families reported challenges in accessing postnatal care services and lacking inter-professional coordination. The visualized models of ideal care comprised access to a package of postnatal care including monitoring, treating and caring for the health of the mother and newborn. This included home visits from qualified midwives, access to a 24-h helpline, and domestic support for household tasks. Participants suggested that improving inter-professional networks, implementing supervisors or a centralized coordinating center could help to remedy the current fragmented care. After hospital discharge, new parents need practical support, monitoring and care. Such support is important for the health and wellbeing of the mother and child. Integrated care services including professional home visits and a 24-hour help line may help meet the needs of new families.
TL;DR: Together with other indicators, IEXPAC can determine the quality of care provided according to the Triple Aim framework, facilitating health systems reorientation towards integrated patient-centred care.
Abstract: Introduction: The experience of chronic patients with the care they receive, fuelled by the focus on patient-centeredness and the increasing evidence on its positive relation with other dimensions of quality, is being acknowledged as a key element in improving the quality of care. There are a dearth of accepted tools and metrics to assess patient experience from the patient’s perspective that have been adapted to the new chronic care context: continued, systemic, with multidisciplinary teams and new technologies. Methods: Development and validation of a scale conducting a literature review, expert panel, pilot and field studies with 356 chronic primary care patients, to assess content and face validities and reliability. Results: IEXPAC is an 11+1 item scale with adequate metric properties measured by Alpha Chronbach, Goodness of fit index, and satisfactory convergence validity around three factors named: productive interactions, new relational model and person’s self-management. Conclusions: IEXPAC allows measurement of the patient experience of chronic illness care. Together with other indicators, IEXPAC can determine the quality of care provided according to the Triple Aim framework, facilitating health systems reorientation towards integrated patient-centred care.