Process Evaluation of the North York CARES (Community Access to Resources Enabling Support) Integrated Care Program for Complex Older Adults

Background:Health care delivery is often poorly coordinated and fragmented. Integrated care (IC) programs represent one solution to improving continuity of care. The aim of this study was to understand experiences and reported outcomes of patients and caregivers in an IC Program that coordinates hospital and home care for thoracic surgery.Methods:A process evaluation was undertaken using qualitative methods. We conducted semi-structured interviews with 10 patients and 8 caregivers who received IC for thoracic surgery and were discharged between June 2019 and April 2020. A phenomenological approach was used to understand and characterize patient and caregiver experiences. Thematic analysis began with a deductive approach complemented by an inductive approach.Results:Four major themes evolved from patient and caregiver interviews, including 1) coordination and timeliness of patient care facilitated by an IC lead; 2) the provision of person-centred care and relational continuity fostered feelings of partnership with patients and caregivers; 3) clear communication and one shared digital record increased informational continuity; and 4) impacts of IC on patient and caregiver outcomes.Conclusions:Patients and caregivers generally reported this IC Program met their health care needs, which may help inform how future IC programs are designed.

BACKGROUND. Over the last decade, few randomized controlled trials of high methodological quality have been carried out to evaluate the effectiveness of interventions for patients with hand eczema. Little to no attention has been paid to the feasibility of these interventions. This process evaluation was carried out to gain insight in the barriers to and facilitators for implementation of an intervention for hand eczema. The aims of this process evaluation were to examine the feasibility and the satisfaction of the patients and the professionals with the integrated care programme, and the perceived barriers to and facilitators for the use of the programme. Eligible for this study were patients with moderate to severe chronic hand eczema who completed the integrated care programme. This programme is an intervention provided by a multidisciplinary team, consisting of a dermatologist, a specialized nurse, and a clinical occupational physician. Data were collected from the patients and the healthcare professionals, by means of semistructured telephone interviews, questionnaires, and a patient tracking system. Implementation, satisfaction and expectations were investigated. Ninety-three patients completed the integrated care programme. Compliance with the integrated care programme was good. The results indicate good satisfaction of both patients and healthcare professionals with the integrated care programme. However, with regard to the process and feasibility of the integrated care programme, there is room for improvement. The clinical occupational physician was only involved in a very limited number of cases, the protocol was not flexible, and the intervention period was too compact. Most of the perceived barriers in the present study are at the organizational level. Satisfaction with the integrated care programme was high among both patients and healthcare professionals. The involvement of the clinical occupational physician in the treatment, when indicated, should be optimized. With the multidisciplinary approach and good communication as a basis for the programme, and a more flexible protocol to avoid unnecessary consultations by the healthcare professionals, integrated care could be a useful treatment from a process evaluation perspective.

Background: Over the last 20 years, the NHS has introduced multiple changes in the commissioning structures, aiming at promoting integrated care in England. The Health and Care Bill 2021 is the latest and farthest-reaching reform, under which local commissioners from the emerging Integrated Care System (ICSs) are expected to accelerate the implementation of ‘integrated care programmes’. This overhaul demands local commissioners to develop approaches to robustly monitor and assess ‘integrated care programmes’ when making investment decisions. This research project aims to develop a framework to support the local commissioning of integrated care in England. Methods: To understand the decision-context and identify the most relevant monitoring and assessment criteria, we conducted 26 semi-structured interviews with local stakeholders. To supplement the criteria and inform the development of the evaluation component, we conducted a systematic literature review on the use of multi-criteria decision analysis (MCDA) in healthcare. The monitoring component of the framework is based on key performance indicators. A system-adjusted time-trend is used to identify ‘integrated care programmes’ that underperform and consequently should be re-assessed. For the evaluation component, we develop a value-measurement MCDA. To define the relative importance of the assessment criteria on the basis of public values, we conducted a discrete choice experiment (DCE) with members from the public in England. In the DCE, participants are presented with two hypothetical care programmes, described by six attributes (assessment criteria), and are asked to state their choice. The design of this experiment was informed by the literature, local stakeholders, and representatives from the Oxford & Thames Valley Patient and Public Involvement group. Standardised performance scores will be estimated using routinely collected data and quasi-experimental methods. Preliminary results: The emerging ICSs open an opportunity for local decision-makers to strengthen the commissioning process, and the proposed framework can potentially contribute to this end. In the interviews, stakeholders indicated that health outcomes, quality of care, cost and equity should be the main drivers of investment decisions. Similar criteria were used in 55 MCDA studies developed to guide priority-setting decisions in high-income countries, with most of these studies using the value-measurement approach. Intermediate health outcomes, compliance with national guidelines, quality of care and equity in access are defined as the monitoring criteria. The assessment criteria are six: final health outcomes, health-related quality of life, patient experience, size of the target population, equity and cost. According to the DCE conducted with 440 members from the public, the six attributes are statistically significant. Next steps: The structure of the framework has been presented to local stakeholders. Based on the data available and how ICSs are starting to operate, it seems that the framework could be applied to support the local commissioning of integrated care. We will demonstrate the framework’s applicability with an evaluation of integrated mental health services in Oxfordshire. We also aim to incorporate social care into the framework and, with this, identify potential data gaps. Afterwards, we will develop a user-friendly software to facilitate the use of the framework by other ICSs across England.

Introduction: In Ireland, an Integrated Care Programme for the Prevention and Management of Chronic Disease was established with the goal of treating patients at the lowest level of complexity that is safe, timely, efficient and as close to home as possible. An outline document by the Integrated Care Programme describes the spectrum of services needed and the levels of service delivery required to implement the Programme. National Clinical Programmes have also been established to improve specific clinical service areas including chronic disease. Doctors, nurses, allied health professionals and hospital managers with expertise in that clinical service area work together to develop standardised care pathways, clinical guidelines and models of care for the patient journey. It is important that documents produced by the Integrated Care Programme and National Clinical Programmes for Chronic disease complement each other. A key target of the Integrated Care Programme is the completion of standardised models of care for each chronic disease programme to reflect all aspects of the Integrated Care Programme. Objective: A gap analysis was undertaken between the Integrated Care Programme Outline Document and draft models of care of four major chronic conditions type 2 diabetes, asthma, COPD, heart failure. The objective was to facilitate alignment of the documents. Targeted Population: The targeted population was all healthcare professionals, policy-makers and other parties interested in the prevention and management of chronic disease. As an introductory step, four main chronic conditions were chosen. Consultations with relevant stakeholders were undertaken and included clinical leads of the Integrated Care Programme, clinical leads and programme managers of the National Clinical Programmes for each of the four main chronic diseases, GPs and representatives from academia. Highlights: A model of care is concerned with the delivery of services; clinical guidelines are concerned with treatment. Lesser detail on specific treatments is required for a model of care as readers can be referred to clinical guidelines as necessary. To support effective integration, each model of care needs referral pathways between each level of service, which reflect the current healthcare organisational units of that country. Transferability: The methods and findings from this gap analysis are applicable to models of care for all chronic diseases. Lessons learned from this exercise are informing current work with other chronic diseases. Conclusions: This work involved professionals from many different backgrounds and the importance of a glossary of terms became quickly obvious. Clear definitions of terms such as ‘model of care’ were required from the outset to ensure everyone was speaking the same language. Early face-to-face engagement with stakeholders proved important for later implementation of the findings of the gap analysis. Face-to-face meetings were valuable in conjunction with email correspondence. In view of the diverse range of stakeholders interested in the area of chronic disease, the executive summary of all documents are important resources for many professionals and need to be targeted appropriately. Finally, a national template for the development of future models of care would be useful to ensure a standardised approach by all.

An integrated care program was set up in China to improve the collaboration between primary healthcare centers and hospitals on diabetes management. This study aims to evaluate the economic value of this program with real-world data and to examine whether it can be promoted in primary healthcare settings in China. This integrated diabetes care program was implemented in Yuhuan City, China, to coordinate primary care and specialty care, treatment and prevention services, as well as the responsibilities of doctors and nurses. Cost-effectiveness analysis was used to compare the short-term economic value of this program (intervention group) versus usual diabetes management (control group). The cost data were collected from a societal perspective, while the effectiveness indicators pointed to the improvement of control rates of fasting blood glucose (FBG), systolic blood pressure (SBP), and diastolic blood pressure (DBP) levels after the 1 year intervention. In addition, cost-utility analysis was applied to evaluate the long-term value of the two groups. Patients' long-term diabetes management costs and quality-adjusted life years (QALYs) were simulated by the United Kingdom Prospective Diabetes Study Outcomes Model 2. The results showed that for 1% FBG, SPB, and DBP control rate improvement, the costs for the intervention group were 290.53, 124.39, and 249.15 Chinese Yuan (CNY), respectively, while the corresponding costs for the control group were 655.19, 610.43, and 1460.25 CNY. Thus, the intervention group's cost-effectiveness ratios were lower than those of the control group. In addition, compared to the control group, the intervention group's incremental costs per QALY improvement were 102.67 thousand CNY, which means that the intervention was cost-effective according to the World Health Organization's standards. In conclusion, this study suggested that this integrated diabetes care program created short-term and long-term economic values through patient self-management support, primary care strengthening, and care coordination. As this program followed the principles of integrated care reform, it can be promoted in China. Also, its elements can provide valuable experience for other researchers to build customized integrated care models.

Introduction: Integrated healthcare models are increasingly being implemented to reduce health system fragmentation and costs related to high service utilization through increased community intervention (e.g., home care) for populations with complex care needs like older adults. These models are intended to increase coordination of the healthcare system, and improve the patient and caregiver experience. However, these models have returned mixed results and the context and mechanisms of integrated care programs have not yet been established. We conducted a realist review of the evaluative evidence on integrated care programs for older adults to identify key processes that lead to the success or failure of these programs in achieving outcomes such as reduced healthcare utilization, improved patient health, and improved patient and caregiver experience. Theory and Methods: The realist review method sought to identify the relationship between program mechanism, context and outcomes, through processes of initial theory-building, literature search, extraction, quality appraisal and synthesis. Initial theories guiding the review included trust in multidisciplinary team relationships, organizational readiness, and the role of leadership to establish an organizational culture receptive to integrated care programs. We searched for international academic literature in 12 indexed, electronic databases and grey literature through internet searches, to identify evaluative studies on integrated care programs for older adults, published between January 1980 and July 2015, in English. Results: A total of 65 articles, representing 28 integrated care programs, were included in the review. We identified two context-mechanism-outcome configurations (CMOcs): 1) trusting multidisciplinary team relationships, and 2) provider commitment to and understanding of the model. Discussion and Lessons Learned: The review emphasizes the importance of trusting multi-disciplinary team relationships for processes of effective communication and knowledge sharing, and for program success. Contextual factors such as strong leadership that sets clear goals and establishes an organizational culture in support of the program, along with joint governance structures, supported team collaboration and subsequent successful implementation. Furthermore, provider commitment to and understanding of the model (organizational readiness), as fostered by strong leadership, clear governance, time to build an infrastructure to implement and flexibility in implementation, emerged as key processes instrumental to success of these programs. Limitations: In general, published evaluations do not provide detailed information on mechanisms and contextual factors that drive program success or failures, which limits reviewers’ ability to fully identify these processes. Suggestions for future research: This review included a wide range of international evidence, and identified key processes for successful implementation of integrated care programs that should be considered by program planners, leaders and evaluators.

BackgroundIn the past decade, a considerable amount of research has been carried out to evaluate the effectiveness of innovative low back pain (LBP) interventions. Although some interventions proved to be effective, they are not always applied in daily practice. To successfully implement an innovative program it is important to identify barriers and facilitators in order to change practice routine. Because usual care is not directly aimed at return to work (RTW), we evaluated an integrated care program, combining a patient-directed and a workplace-directed intervention provided by a multidisciplinary team, including a clinical occupational physician to reduce occupational disability in chronic LBP patients. The aims of this study were to describe the feasibility of the implementation of the integrated care program, to assess the satisfaction and expectations of the involved stakeholders and to describe the needs for improvement of the program.MethodsEligible for this study were patients who had been on sick leave due to chronic LBP. Data were collected from the patients, their supervisors and the involved health care professionals, by means of questionnaires and structured charts, during 3-month follow-up. Implementation, satisfaction and expectations were investigated.ResultsOf the 40 patients who were eligible to participate in the integrated care program, 37 patients, their supervisors and the health care professionals actually participated in the intervention. Adherence to the integrated care program was in accordance with the protocol, and the patients, their supervisors and the health care professionals were (very) satisfied with the program. The role of the clinical occupational physician was of additional value in the RTW process. Time-investment was the only barrier for implementation reported by the multidisciplinary team.ConclusionThe implementation of this program will not be influenced by any flaws in its application that are related to the program itself, or to the adherence of patients with chronic LBP and their health care professionals.This program is promising in terms of feasibility, satisfaction and compliance of the patients, their supervisors and the health care professionals. Before implementation on a wider scale, the communication and the information technology of the program should be improved.Trials Registration[ISRCTN28478651]

Hospital admissions due to exacerbations of chronic obstructive pulmonary disease (COPD) have a major impact on disease progression and costs. We hypothesized that a 1-year integrated care (IC) programme comprising two components (patient-centred education+case management) would be effective in preventing COPD-related hospitalizations. This was a retrospective longitudinal cohort study. Data were retrieved both from an administrative database in the province of Quebec (Canada), and from the medical records at two hospitals in Montreal. One hundred and eighty-nine COPD patients were randomly selected from registers at these centres, from 2004 to 2006. Patients in the intervention group underwent a programme comprising two components: patient -centred education-involving three group sessions of self-management education that included one motivational interview and instruction in the use of a written action plan; and case management-involving scheduled follow-up visits with access to a call centre. The intervention group was compared with a group receiving usual care (UC). The main outcome was COPD-related re-hospitalizations, with length of hospital stay and emergency department (ED) visits being secondary outcomes. Logistic regression analysis with adjustment for covariates showed that there was a lower probability of re-hospitalization over the follow-up year in the IC group compared with the UC group (odds ratio 0.44; 95% confidence interval 0.23-0.85). Subgroup analyses revealed that the IC programme prevented more COPD-related hospitalizations in women compared with men. There were no significant between-group differences in length of hospital stay or number of ED visits. An IC programme combining self-management education and case-management can decrease rates of COPD-related hospitalizations, particularly among women.

Introduction: Preparing current and future health care providers to work in integrated care models requires interprofessional learning about working in teams across health sectors and integrated care concepts/principles. Evidence indicates that Interprofessional education (IPE) is essential for training health and social care providers and building workforce capacity for new models of integrated care. Yet how we are preparing current and future health care professionals (HCPs) to work in these models of care is unclear. Therefore, we sought to understand how IPE is implemented in existing hospital-to- home integrated care. We report key informants’ descriptions of IPE in training existing HCPs to work in hospital-to-home integrated care programs in Ontario Canada. Method: Utilizing a qualitative descriptive approach, interviews were conducted with 15 leaders of hospital-to-home integrated care programs across the province. Interviews were audio-recorded and transcribed verbatim. Data analysis employed a thematic analysis approach. Findings were interpreted through the lens of an interprofessional learning continuum model (Institute of Medicine, 2015) and competencies for integrated care (Langins and Borgermans, 2015). Findings: Formal and informal IPE through staff orientation and team processes within the integrated care programs can support competency development (e.g., role clarity, communication, and teamwork) for interprofessional practice within hospital-to-home integrated care programs. Key informants acknowledged the importance of cross sector IPE to understand patient care trajectories and provider roles more fully. Conclusions: The findings provide examples of the need for both formal and informal IPE in these hospital-to-home integrated care programs. Interprofessional teamwork, learning together, and having no room for silos reinforced the importance of continuing interprofessional learning for existing HCPs in the context of hospital-to-home integrated care programs. IPE in integrated care programs is required to meet the changing needs of patient populations, shifting roles of health care providers, and evolving health care systems. Implications for Education and Practice: This work has direct implications for preparing current and future health care professionals to work in new models of integrated care such as hospital-to-home programs where collaborative approaches are critical to support safe, quality patient care within and across health and social care sectors. Education content should include concepts and principles related to IPE, collaborative teamwork, and fundamentals of integrated care. Training should begin in formal academic programs and continue in practice settings. Student placements for health professionals should be considered as a mechanism to develop knowledge and competencies for integrated care. Cross-sector training can help health and social care providers understand the focus of the integrated care program (e.g., patient pathways, referrals) and the roles and responsibilities of various team members. Next steps: We are currently engaging academic and practice leaders to explore the feasibility of creating new nursing student placement opportunities within hospital to home integrated care programs with the aim of building knowledge and competencies for integrated care.

Introduction: Diabetes is acknowledged to be one of the major cardiovascular risk factors, which are the most prevalent cause of death in Poland [1]. As a substudy of implementing integrated care for cardiovascular patients, an integrated care project for diabetic patients was developed.Short description of practice change implemented: In Poland ambulatory healthcare is diffuse, paper-based and limited by lack of information flow. We implemented a program of complex care for patients with diabetes – the program was similar to the cardiovascular diseases one. Standardized care provided by multidisciplinary team, prophylactic, screening and educational programs, implementation of electronic health records and information system for assessments and prediction of resource utilization, simplification of information flow, patient online registration and scheduling coordination were the key new elements of the program in comparison to the previous care.Objectives: to evaluate the impact of an integrated, multidisciplinary diabetic care program on clinical outcomes (glycated hemoglobin (HbA1c), blood pressure, BMI) among patients with poorly controlled diabetes with or without comorbidity attending a large primary care center.Methods: We conducted an uncontrolled quasi-experimental interventional study with pre–post assessment among patients with poorly controlled diabetes mellitus and/or comorbidities requiring more intensive care as assessed by a diabetologist. The intervention – integrated care program - consisted of intensified patient-specific multidisciplinary care. The team included case coordinator, family physician, nurse, dietician, diabetic educator (health educator). Outcomes measured were HbA1c, blood pressure (BP), BMI. Pre-intervention data were assessed by retrospective reviewing of patient charts for at least 2 visits before starting the integrated care program. Post-intervention data were assessed prospectively, following the patients for at least 2 visits after joining the integrated care program.Targeted population and stakeholders: Patients above 18 years old with poor controlled diabetes mellitus and/or comorbidities requiring more intensive care as assessed by a diabetologist, belonging to IC organization - Medical and Diagnostic Centre in Siedlce, Poland. Ca. 68000 patients in mazowieckie and lubelskie voivodeships belong to Medical and Diagnostic Centre in Siedlce, Poland. The detailed diagnoses according to ICD system included were a subject of contract with Polish National Health Fund.Timeline: Implementation: 2011- ongoing.Outcomes: 592 new patients (average age 53.76 years, 52.7% women) were included in the program of integrated care. Diabetes complications such as neuropathy, polyneuropathy, microangiopathy, macroangiopathy, nephropathy, retinopathy, diabetic foot syndrome, coronary artery disease, were present in 243 patients. 64% of patients were treated with insulin. Mean duration of patient`s participation in the program was 18.44 months (2-46; median 22). The mean (median) number of visits during the intervention was 13,63 (8), with a wide range of 2 to 48 visits. Mean HbA1C at the starting and last available visit was 7.852 (4.633-14.247; median 7.594) and 7.429 (min 5.082; max 11.044; median 6.859), respectively. Mean BMI at the starting and last available visit was 30.167 (17.4-54.9, median 29.7) and 30.168 (17.8-54,0, median 30,0), respectively. Mean blood pressure at the starting and last available visit was 137.9/79.7 (median 132/80) and 136.2/76.7 (median 138/76.5), respectively.Conclusions: Our integrated care program had a positive impact on glycemic control (reductions of mean HbA1C from 7.852 to 7.429). The study showed also that integrated care can optimize the distribution of care of diabetic patients between specialists and primary care team without loss of diabetes control.

Integrated care programs (ICPs) are meant to make Medicare and Medicaid coverage for dual-eligible beneficiaries work more seamlessly. Evidence is limited on ICP enrollment trends and the characteristics of dual-eligible beneficiaries who enroll in these programs-specifically, the Program of All-Inclusive Care for the Elderly, Medicare Advantage (MA) Fully Integrated Dual-Eligible Special Needs Plans, and state demonstration Medicare-Medicaid plans. Using national data, we evaluated changes in ICP enrollment between 2013 and 2020 and compared the demographic characteristics of beneficiaries in these programs relative to the characteristics of beneficiaries not in them. The proportion of dual-eligible beneficiaries in ICPs increased from 2.0percent in 2013 to 9.4percent in 2020. However, nonintegrated or partially integrated coordination-only MA plans experienced the plurality of growth in enrollment of dual-eligible beneficiaries. Relative to non-ICP fee-for-service Medicare, beneficiaries in ICPs were more likely to be Black and Hispanic versus White and were less likely to be rural, younger, or disabled. Policy makers should diligently monitor growth in ICPs and less integrated dual-eligible plans in MA while also evaluating their impact on equity, spending, and quality of care.

Integrated care programs (ICPs) deliver care that is coordinated across carers, care sites, and support systems; continuous over time and between visits; tailored to clients' expressed needs and preferences; and based on shared responsibility for optimizing health among clients, carers, and the state. This research asks how ICPs combat issues of fragmentation in a home care sector fundamentally reshaped by neoliberalism. Using a post-positivist epistemological approach, I collect and analyze data from government documents, NGO reports, scholarly literature, and 117 interviews with program administrators, paid and unpaid carers, and elderly clients in five Canadian ICPs working in the home care sector. These include Aging in Place in Ottawa, Ontario; SMILE in South Eastern Ontario; Carefirst in Scarborough, Ontario; CHOICE in Edmonton, Alberta; and Hope Home Health in Hope, British Columbia. My central argument is that ICPs are most useful as a policy solution to fragmented home care when they use policy techniques that promote equitable processes and outcomes as opposed to focusing on enhancing cost-efficiencies for the state. To understand the interrelations among fragmentation, efficiency, equality, and equity, I use a Feminist Political Economy theoretical framework to assess the gendered, classed and racialized impacts of the policy techniques used by ICPs. By looking at which groups are affected through their involvement in ICPs, in what ways, and under what conditions, I find that policy techniques aimed at achieving cost savings for the state often increase inequality/inequity between, and among, clients and carers. Increasing inequality/inequity increases fragmentation. In contrast, ICPs that use policy techniques that challenge neoliberal ways of working often promote equality/equity as their primary policy goal. These techniques help mitigate fragmentation. Understanding if, how and why ICPs meet the expressed needs of clients and carers in different contexts is essential for program administrators looking to improve their programs, as well as for the clients and carers involved in the daily relations of home care. Knowing that ICPs are most useful as a policy solution to fragmented home care when they promote equitable processes and outcomes gives a clear direction for future reforms that can benefit clients and carers alike.

To investigate effectiveness, definitions, and components of integrated care programmes for chronically ill patients on the basis of systematic reviews. Literature review from January 1996 to May 2004. Definitions and components of integrated care programmes and all effects reported on the quality of care. Searches in the Medline and Cochrane databases identified 13 systematic reviews of integrated care programmes for chronically ill patients. Despite considerable heterogeneity in interventions, patient populations, and processes and outcomes of care, integrated care programmes seemed to have positive effects on the quality of patient care. No consistent definitions were present for the management of patients with chronic illnesses. In all the reviews the aims of integrated care programmes were very similar, namely reducing fragmentation and improving continuity and coordination of care, but the focus and content of the programmes differed widely. The most common components of integrated care programmes were self-management support and patient education, often combined with structured clinical follow-up and case management; a multidisciplinary patient care team; multidisciplinary clinical pathways and feedback, reminders, and education for professionals. Integrated care programmes seemed to have positive effects on the quality of care. However, integrated care programmes have widely varying definitions and components and failure to recognize these variations leads to inappropriate conclusions about the effectiveness of these programmes and to inappropriate application of research results. To compare programmes and better understand the (cost) effectiveness of the programmes, consistent definitions must be used and component interventions must be well described.

Objectives: To review the effectiveness of current clinical interventions and integrated care program, and the cost-effectiveness of currently available pharmaceutical interventions in the management of Type 2 Diabetes Mellitus in Saudi Arabia. Data Sources and Methods: A systematic search of MEDLINE, EMBASE, ScienceDirect, CENTRAL, and Google Scholar was conducted to identify the relevant articles. A detailed inclusion–exclusion criterion was developed and implemented to screen the abstracts and full-texts. We extracted study data from eligible studies into a data extraction form and categorized into various themes to answer our research question. Study Selection and Themes: Seventeen studies categorized into three themes were included in this review. The evidence was compiled to report the effectiveness of current clinical interventions, integrated care program, and cost-effectiveness of pharmaceutical interventions. Conclusions: There is strong evidence of safety and efficacy of BIAsp 30 in T2DM patients. In addition, BIAsp 30 with or without OADs is more cost-effective compared with other pharmaceutical interventions. The integrated care program is more effective in reducing HbA1c in diabetic patients compared with usual care programs; however, the evidence is small and more studies are required. Recommendations: Most of the available studies are small cross-sectional studies. There is a dire need to conduct extensive and high-quality studies, with the sample size representative of Saudi T2DM populations, to generate larger data with high-quality evidence to provide more robust evidence in the future.

Following hospitalization, older adults with complex health and social care needs are often deemed to need an "alternate level of care" (ALC) where care needs are misaligned with resources. Coordinated networks can implement integrated care programs for this group in home settings. Understanding the experiences of providers, caregivers, and patients will inform ongoing implementation efforts. A qualitative case study was undertaken of North York Community Access to Resources Enabling Support (NYCARES), a novel integrated care program implemented during the COVID-19 pandemic. Data collection consisted of semi-structured interviews, document analysis, and observational field notes; data were thematically analyzed. Thirty-six providers, caregivers, and patients were interviewed. Three themes were developed: 1) NYCARES as a lifeline; 2) Experiences tempered by expectations and connection; and 3) The role of integrated care. The NYCARES program was seen as valuable, but implementation posed challenges for each participant group due to varying expectations and perceived degree of connection between patients, families, and providers. The local coordinated network successfully implemented the NYCARES program for ALC patients despite challenges in stakeholder connections. Similar programs should formally support caregivers and forefront multidirectional communication, particularly between providers in different implementation roles.