How has the impact of 'care pathway technologies' on service integration in stroke care been measured and what is the strength of the evidence to support their effectiveness in this respect?

Implications for practice There is some evidence that ICPs may support certain elements of service integration in the context of stroke care. This seems to be as a result of their ability to support the timely implementation of clinical interventions and the mobilisation of resources around the patient without incurring additional increases in length of stay. ICPs appear to be most successful in improving service coordination in the acute stroke context where patient care trajectories are predictable. Their value in the context of rehabilitation settings in which recovery pathways are more variable is less clear. There is some evidence that ICPs may be effective in bringing about behavioural changes in contexts where deficiencies in service provision have been identified. Their value in contexts where inter-professional working is well established is less clear. While earlier before and after studies show a reduction in length of stay in ICP-managed care, this may reflect wider healthcare trends, and the failure of later studies to demonstrate further reductions suggests that there may be limits as to how far this can continue to be reduced. There is some evidence to suggest that ICPs bring about improvements in documentation, but we do not know how far documented practice reflects actual practice. It is unclear how ICPs have their effects and the relative importance of the process of development and the artefact in use. (ABSTRACT TRUNCATED)

How has the impact of ‘care pathway technologies’ on service integration in stroke care been measured and what is the strength of the evidence to support their effectiveness in this respect?

Background Integrated Care Pathways (ICPs) are management technologies which formalise multi-disciplinary team-working and enable professionals to examine and address how they articulate their respective roles, responsibilities and activities. They map out a patient’s journey and aim to have: ‘the right people, doing the right things, in the right order, at the right time, in the right place, with the right outcome’. Initially introduced into the health care context in the 1980s in the US, enthusiasm for ICPs now extends across the world. They have been promoted as a means to realise: evidence based practice, clinical governance, continuity of care, patient empowerment, efficiency gains, service re-engineering, role realignment and staff education. While ICPs are now being developed and implemented across international health care arena, evidence to support their use is equivocal and understanding of their ‘active ingredients’ is poor. Reviews of evidence of ICP effectiveness have focused on their use in specific patient populations. However, ICPs are ‘complex interventions’ and are increasingly being implemented for a variety of purposes in a range of organisational contexts. Identification of the circumstances in which ICPs are effective is the first step towards developing hypotheses about their active ingredients and the generative mechanisms by which they have their effects. This review was designed to address a slightly different set of questions to those that typify systematic reviews of ICP effectiveness. Rather than simply asking: ‘Are ICPs effective?’, our concern was to identify the circumstances in which ICPs are effective, for whom and in what contexts. In addition to identifying evidence of ICP effectiveness, the review therefore required attention to the contexts in which ICPs are utilised, the purposes to which they are put and the factors critical to their success. In framing the review in this way we are drawing on the insights afforded by Pawson and Tilley’s realistic evaluation methodology. The underlying rationale for this approach is that if we know and understand how different interventions produce varying effects in different circumstances, we are better able to decide what policies/services to implement in what conditions. Objectives To identify the purposes for which ICPs are effective, for whom and in what contexts; To identify the purposes for which ICPs are not effective, for whom and in what contexts; To produce recommendations on how ICPs should be used in the full range of health care settings. Inclusion Criteria Types of participants The review focused on adults and children that accessed health care settings in which ICPs are used. Types of intervention(s)/phenomena of interest For the purposes of the review, the ICP had to meet the defining characteristics set by the European Pathway Association (EPA): An explicit statement of the goals and key elements of care based on evidence, best practice and patient expectations; Facilitation of communication, coordination of roles, and sequencing of activities of the multidisciplinary care team, patients and their relatives; The documentation, monitoring, and evaluation of variances and outcomes; The identification of the appropriate resources. Here multidisciplinary is taken to refer to the involvement of two or more disciplines. Types of outcomes Outcome measures were determined by the purposes of the studies selected for review and the type of study participant. Specific clinical outcomes were determined by the group of patients for which the ICP was developed. Types of studies To address the aims of the review it was necessary to examine evidence of ICP effectiveness across the full spectrum of contexts in which they are in use. In order to keep the study to a manageable scale we limited its scope to randomised controlled trials (RCTs). All RCTs reported TRUNCATED AT 600 WORDS.

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

Adaptation of Adult Pathways to Improve the Care of Adult Patients at Pediatric Hospitals.

Critical pathways, also known as critical paths, clinical pathways, or care paths, are management plans that display goals for patients and provide the sequence and timing of actions necessary to achieve these goals with optimal efficiency.1 As competition in the healthcare industry has increased, managers have embraced critical pathways as a method to reduce variation in care, decrease resource utilization, and potentially improve healthcare quality. Cardiovascular medicine in particular is an area in which critical pathways have been embraced. This is due in part to the high volume and high cost associated with cardiovascular diseases and procedures. In addition, the relatively mature guideline process has also contributed to the growth in use of critical pathways in cardiology. Although anchored in clinical guidelines, the critical pathway is a distinct tool that details processes of care and highlights inefficiencies regardless of whether there is evidence to warrant changes in those processes. Clinical guidelines, on the other hand, are consensus statements that are systematically developed to assist practitioners in making patient management decisions related to specific clinical circumstances.2 Although clinical guidelines can and should be used in pathway development, the majority of processes included in a pathway have not been rigorously tested and are generally not addressed in guidelines. Another term that should also be distinguished from critical pathways is clinical protocols. Protocols are treatment recommendations that are often based on guidelines. Like the critical pathway, the goal of the clinical protocol may be to decrease treatment variation. However, protocols are most often focused on guideline compliance rather than the identification of rate-limiting steps in the patient care process. In further contrast to critical pathways, protocols may or may not include a continuous monitoring and data-evaluation component. Critical pathway techniques were first developed for use in industry as a tool to …

Objectives 1. To systematically review all high quality studies which have evaluated the effectiveness of care pathway technologies on ‘service integration’ and its derivatives, i.e. seamless care, joined up working etc in stroke care. 2. To examine how elements of service integration are defined in such studies. 3. To examine the type of evidence utilised to measure service integration. 4. To analyse the weight of evidence used to support claims about the impact of care pathways on service integration. 5. To produce guidelines for the users of care pathways and researchers for evaluation purposes. Criteria for considering studies for this review Types of participants This review is concerned with the effects of care pathway technologies on service integration across the spectrum of stroke care and will not be restricted to a particular care setting. Only adult patients will be included in the review. Types of Interventions There is no explicit definition of care pathways in the literature and the problems in describing care pathways are caused by the many similar terms that exist. Examples of synonyms of care pathways include care maps, care protocols, critical paths, collaborative plan of care and multi-disciplinary action plans. For the purpose of this review, a “care pathway technology”, must meet the broad definition set out in the background section. Types of outcome measures Any impact on ‘service integration’ that is attributable to a care pathway technology. Due to the complex nature of service integration, we predict that some of these effects may warrant further unpacking, as the outcomes we are interested in may be embedded within the data. One aim of the review is to contribute to conceptual refinement in this area.

Care pathways ? the future's bright

BackgroundCervical cancer is a major public health problem. Even though readily preventable, it is the fourth leading cause of death in women globally. Women living with HIV are at increased risk of invasive cervical cancer, highlighting the need for access to screening and treatment for this population. Integration of services has been proposed as an effective way of improving access to cervical cancer screening especially in areas of high HIV prevalence as well as lower resourced settings. This paper presents the results of a systematic review of programs integrating cervical cancer and HIV services globally, including feasibility, acceptability, clinical outcomes and facilitators for service delivery.MethodsThis is part of a larger systematic review on integration of services for HIV and non-communicable diseases. To be considered for inclusion studies had to report on programs to integrate cervical cancer and HIV services at the level of service delivery. We searched multiple databases including Global Health, Medline and Embase from inception until December 2015. Articles were screened independently by two reviewers for inclusion and data were extracted and assessed for risk of bias.Main results11,057 records were identified initially. 7,616 articles were screened by title and abstract for inclusion. A total of 21 papers reporting interventions integrating cervical cancer care and HIV services met the criteria for inclusion. All but one study described integration of cervical cancer screening services into existing HIV services. Most programs also offered treatment of minor lesions, a ‘screen-and-treat’ approach, with some also offering treatment of larger lesions within the same visit. Three distinct models of integration were identified. One model described integration within the same clinic through training of existing staff. Another model described integration through co-location of services, with the third model describing programs of integration through complex coordination across the care pathway. The studies suggested that integration of cervical cancer services with HIV services using all models was feasible and acceptable to patients. However, several barriers were reported, including high loss to follow up for further treatment, limited human-resources, and logistical and chain management support. Using visual screening methods can facilitate screening and treatment of minor to larger lesions in a single ‘screen-and-treat’ visit. Complex integration in a single-visit was shown to reduce loss to follow up. The use of existing health infrastructure and funding together with comprehensive staff training and supervision, community engagement and digital technology were some of the many other facilitators for integration reported across models.ConclusionsThis review shows that integration of cervical cancer screening and treatment with HIV services using different models of service delivery is feasible as well as acceptable to women living with HIV. However, the descriptive nature of most papers and lack of data on the effect on long-term outcomes for HIV or cervical cancer limits the inference on the effectiveness of the integrated programs. There is a need for strengthening of health systems across the care continuum and for high quality studies evaluating the effect of integration on HIV as well as on cervical cancer outcomes.

Integration of community mental health services is a key policy objective that aims to increase quality and efficiency of care. Integrated care pathways (ICPs) are a mechanism designed to formalise multi-agency working at an operational level and are currently being applied to mental health services. Evidence regarding the impact of this tool to support joint working is mixed, and there is limited evidence regarding the suitability of ICPs for complex, community-based services. The present study was set in one primary care trust (PCT) in Scotland that is currently implementing an ICP for community mental health teams (CMHTs) across the region. The aim of the study was to investigate professionals' experiences and views on the implementation of an ICP within adult CMHTs in order to generate learning points for other organisations which are considering developing and implementing such systems. The study used qualitative methods which comprised of individual interviews with three CMHT leaders and two service development managers, as well as group interviews with members of four adult CMHTs. Data was analysed using the constant comparison method. Participants reported positive views regarding joint working and the role of an ICP in theory. However, in practice, teams were not implementing the ICP. Lack of integration at higher organisational levels was found to create conflicts within the teams which became explicit in response to the ICP. Implementation was also hindered by lack of resources for ongoing support, team development and change management. In conclusion, the study suggests that operational systems such as ICPs do not address and cannot overcome wider organisational barriers to integration of mental health services. Integrated care pathways need to be developed with strategic input as well as practitioner involvement and ownership. Team development, education about integration and change management are essential if ICPs are to foster and support joint working in integrated teams.

Introduction. The development of innovative high quality care forms is a challenging issue in rapidly aging society of Lithuania. The new shape integrated homecare services for people with chronic conditions have been constructed and have been functioning over the year as the pilot projects in the 21 municipality around Lithuania. In almost all integrated care pilot municipalities except two regions (in Alytus and Sakiai, with primary health care units as integrated care providers) the initiative to develop team based integrated homecare services to persons with chronic conditions has been taken by departments of social services. The purpose of this study is to identify the key contextual elements and related strategic, organizational processes from pilot municipalities as facilitators and obstacles in developing mobile team based integrated homecare services as contrast to traditional institutionalised care. Theory/Methods. Pettigrew and Whipp's context, content and process model of strategic change was used as theoretical framework for the case studies of team based integrated homecare pilots. According this framework the data collection focused on three entities: what external and internal contexts instigated municipalities and service providers to take the challenge to develop the new shape integrated team based homecare services and how service providers perceive, construct and implement integrated team based homecare; and finally, what outcomes have been shaped with new form integrated care. Data were analysed from transcripts of 20 focus groups with administrators, social and health care providers and 12 in depth interviews with care receivers (informal caregivers and patients) in ten purposively sampled municipalities: pilots executed by municipality social provision departments in partnership with private and state agencies, directly by social services departments and by primary health care unit. The findings were compared with factors and dimensions of Normalisation Process Theory (May et al. 2007). Results and discussion. The study revealed the obstacles and facilitators related to individual and different organizational levels in constructing team based integrated homecare. The study 15th International Conference on Integrated Care, Edinburgh, UK, March 25-27, 2015 1 International Journal of Integrated Care – Volume 15, 27 May – URN:NBN:NL:UI:10-1-117127– http://www.ijic.org/ revealed individual level topics such as trust and collaboration building between integrated team care providers and informal caregivers, challenges in building new routines and habits for patient in homecare process, resistance and adaptation to presence of constant changing strangers’ at home. The study exposed the organizational issues related to interaction between team members and administration, tensions issues in status difference between social and health care providers, tasks distributions between team members, perception diversity of team and care, lack of teamwork experience and sense of shared responsibility, issues of staff commitment due to termed pilots. The inter-institutional and intra-institutional hindering tensions between social and health care providers unclosed the competition over the homecare field; new institution as threat to monocracy of health care; lack of skills and early transition from hierarchical to dialog based horizontal structures; inequality of resource distribution between integrated team members uncompensated travel costs for social care providers vs. car with fuel coverage for health care providers. The mentality of monolog culture with highly hierarchic structures in health care system hinders recognition of nursing as separate profession with certain competencies: avoidance by nurses to take decisions on nursing issues without consultation with physician even in areas of their professional competence supremacy as care of bedsores. The important facilitators were the support of municipality in service development and participatory involvement of the unit from the beginning of project planning. The professionally organized integrated homecare services facilitated transition to collaborative relationship between health care and social care providers. The requirement to follow literally description of project activities even the performance of planned activities contradicted the reality in practice hinders development of new service. As study limitation is the administrators gatekeepers’ role in accessing research participants: patients, informal caregivers, health and social care providers. In some municipalities the presence of head of the unit in the focus group suppressed openness of the staff. The study had insufficient data on patients’ experience of care as the integrated care pilots addressed severely ill patients with limited communication abilities. Conclusions. The study revealed micro, mezzo and macro levels obstacles and facilitators in constructing team based integrated homecare. The distinction of developed models of team based integrated homecare services participatory interaction between stakeholders of the care with the traits of patient centred approach and collaborative practices between existing social and health care structures. The move from the tradition of hierarchical model of service development ( i.e. from “above” perspective constructing orders of ministers with limited perception of reality and municipalities as executive committees with resistance performing commandments and shaping service delivery imitation) grounded the participatory practice in service development.

Introduction:The distinctive characteristics of the German health system are medical progress and financial pressure—and this is especially true of the hospitals. These challenges must be met by strategic management instruments for quality assurance, and by reducing costs.Purpose:This article presents the instrument “clinical pathway” (also known as “clinical treatment pathway”) and describes the possibilities it offers, both for quality assurance and risk management, and for cost reduction. The clinical pathway presented here will be that for “multimodal pain therapy”, as used in the context of acute inpatient care in Germany.Methods:A general presentation of the risks in hospital is followed by consideration of the risks associated with core processes. A comprehensive total cost analysis is performed for those patients who meet the pathway entry criteria and who fulfil the requirements for the structure of care provided within multimodal pain therapy.Discussion and Conclusion:Multimodal pain therapy places high demands on the structural, procedural and outcome quality of the medical, nursing and therapeutic services provided, and these demands are reflected in high costs for the provision of this care. The treatment process involves many different professional groups. These complex interfaces can potentially generate risks, which can lead to the possibility of legal liability. A clinical pathway must structure the core process and then combine elements of quality assurance in order to optimise patient care and minimise risk. The examination of costs reveals significant potential savings (patients with clinical pathway: EUR 3086±212; patients without clinical pathway: EUR 3774±460; Mann-Whitney U test; p<0.001). For the managers of a hospital, the clinical pathway represents a strategic management instrument that can serve for continual cost control and cost reduction, and can contribute in the form of quality assurance towards a transparent provision of services.

Section Editor: Graeme J. Hankey MD, FRCP Care pathways are structured care plans that are used by the different members of the multidisciplinary team and are usually implemented to manage more than one aspect of patient care (eg, diagnosis, investigation, acute stroke treatment). When used within a case management framework, care pathways can assist health care professionals with clinical decision-making, and they aim to promote organized and efficient patient care that is based on the best-available research evidence and clinical guidelines.1,2 A care pathway can take the form of a printed or electronic document, and it often replaces the patient’s case record for the duration of the hospital stay. Many hospitals have adopted this tool, often as one of the components of a continuous quality improvement scheme, with an aim to improve the quality of stroke care, reduce variation of standards, minimize resource utilization, and educate health care staff.3,4 But is there sufficient evidence to support the use of care pathways for the management of stroke patients? The first Cochrane review of in-hospital care pathways for stroke found some evidence that care pathways may increase the use of certain investigations and reduce the likelihood of urinary tract infections and readmission to hospital.5 However, this benefit …

Since 4 major diseases and geriatric diseases require consistent management, individuals with any of these diseases cannot live alone and need caregivers' assistance. Given these characteristics, an integrative medical service model for 4 major diseases and geriatric diseases was developed in Korea, currently. Dementia, one of the typical geriatric diseases, requires caregivers' assistance from the beginning because of its enormous burden. Thus, it is necessary to provide an integrative medical service that can improve the quality of life (QoL) for both patients and caregivers. Therefore, this study aims to collect various feedback by applying an integrative medical service, which was developed to improve the QoL in patients with dementia and their caregivers, to a single case, and to modify and improve the integrative medical service model based on the results. The integrative medical service program, which was developed to improve the QoL in patients with dementia and their caregivers in Korea, will be used for a patient-caregiver pair. This is an observational study with quantitative and qualitative feedback from various viewpoints. The program will be conducted in 8 sessions (twice a week, within 120 minutes). The patient will receive both Western and Korean medicine, and an integrative service will be provided to improve cognitive rehabilitation and QoL. Feedback collected at each session will be reflected on the program of the subsequent session. This study will then modify and improve the program with feedback and provide integrative medical services to a patient with dementia and caregiver. Patients with dementia need a program that would help them maintain cognitive function, and caregivers need a program that would improve their QoL by reducing the caregiving burden. This study is unique because the developed program is performed after modification based on feedback from the previous session. Accordingly, the patient and caregiver can check which program is the most satisfactory and helpful in improving their QoL. We expect that this study can modify the integrative medical service model to the optimized patient-based model. This study can also be used as basic data for a clinical pathway development study that applies the modified model to medical institutes.

Care of stroke patients varies significantly between hospitals.1,2 Implementation of a stroke care pathway may be a method of promoting organized and efficient patient care that is based on the best-available evidence and clinical guidelines. This, in turn, could reduce variations in stroke care. A care pathway can be defined as a plan of care that is developed and used by a multidisciplinary team, and is applicable to more than 1 aspect of care. It can be a printed document or an electronic program, and it usually forms all or part of the patient’s case record. Care pathways are often used in conjunction with other tools such as case management, and they are intended to assist healthcare professionals in clinical decision-making.3,4 Care pathways are also known by other names such as clinical pathway, critical pathway, critical path method, care paths, and CareMaps. Despite the popularity of care pathways, the evidence to support their use is weak. This systematic review aims to assess the effects of care pathways, as compared with standard medical care, among patients admitted to hospital with acute stroke.5 We searched the Cochrane Stroke Group Specialized Trials Register (last searched in May 2001), the Cochrane …