Hospital-Led Integrated Care for High need-High Cost Patients: A review of reviews

Abstract

Introduction: Patients with multiple morbidities and complex needs are putting a strain on the resources of the health system, particularly on hospitals. The current fragmented hospital and disease centric care is unable to cope with the growing healthcare needs facing the modern day health system [1,2]. Therefore, integrated care interventions have been developed to improve the quality and efficiency of care by coordinating healthcare services in a person-centric manner with the aims of reducing health and social burden on the healthcare systems including hospitals [2]. However, the methods and outcomes of interventions used are different and evidence of the effectiveness of the interventions are not consistent. There is also a lack of understanding on why and how integrated care interventions work or do not work under certain circumstances. Based on the CMO (context, mechanism and outcomes) [3] model, we aim to summarise and compare the existing evidence of the context, mechanism and outcomes of hospital-led integrated care interventions from published peer-reviewed systematic reviews. Methods: A review of existing systematic reviews is being conducted to find out what works, for whom, and under what circumstances hospitals can provide effective integrated care interventions. The review will address the following questions: (1) what are the programmes available? (2) Who is the target population? (3) In what respect of integrated care (i.e., patient, system, organisation)? (4) What are the outcomes measured (e.g. healthcare utilizations, healthcare outcomes (QoL, quality of care mortality rates, etc.), costs) and how effective are they? (5) If they are effective, how do they work in different settings and for different populations? (6) What are the underlying mechanisms of these interventions? (7) What causes the heterogeneity in outcomes of hospital-led integrated care programmes? Based on the WHO definition of integrated care [4] and Rainbow Model of Integrated Care (RMIC) definition of system and organisation integration [5], articles are searched through PubMed, Scopus, Web of Science and Cochrane Database of Systematic Reviews for the period 2006-2016 (N=2290). A systematic review is included if it describes hospital-led interventions that involve system or organisation integration, involve an acute care setting as the lead, and have the outcomes of the interventions evaluated. Titles for inclusion are screened independently by three reviewers using predetermined criteria. Data are extracted and quality of review is assessed according to the Joanna-Briggs Institute guidelines.[6] Findings on context and mechanism are analysed to explain about outcomes. Complete findings will be presented during ICIC17. Discussion: The findings from the review will help inform policy-makers and healthcare professionals on the design of integrated care programmes that will most likely yield their desired outcomes, based on their target populations and context of the health system. The review will also provide an overview of how to bridge the gap between the development of interventions and successful implementation of hospital-led integrated care [2]. For researchers, the review will indicate the strength of existing evidence and identify directions for future research.