When life looks like easy street, there’s danger at your door: Why the respiratory therapy profession should evolve

BackgroundFamilies with preterm infants find life after hospital discharge challenging and need tailored support to thrive. The “Transition to Home (TtH)”-model offers structured, individual support for families with preterm infants before and after hospital discharge. TtH improves parental mental health and competence, promotes child development and fosters interprofessional collaboration (IPC).AimEvaluate the TtH-models’ structure and implementation process and its associated interprofessional collaboration from the healthcare professional’s (HCP) perspective.MethodsThis qualitative explorative study thematically analyzed four focus group interviews (n=28 HCP) and an open-ended questionnaire with general pediatricians (n=8).ResultsThe main themes of the thematic analysis were the benefits of the TtH-model, tailored parental support, the challenges of changing interprofessional collaboration, facilitators and barriers to successfully implementing the model, and feasibility and health economic limits. HCP acknowledge that continuous family-centered care led by an advanced practice nurse (APN) supports, strengthens, and relieves families with preterm infants in the transition from hospital to home. Families in complex situations benefit most. The TtH-model incorporates key aspects of integrated care like shared decision-making, considering family preferences, and defining the APN as the family’s main contact. HCP want network collaboration but found communication, cooperation, and reorganization challenging in the new IPC process. IPC challenges and involving many HCP in family care can create parental oversupply, negatively affect treatment outcomes, and raise health care costs.ConclusionThese challenges need to be addressed to ensure sustainable implementation of the model. The roles and tasks of HCP should be clearly distinguished from each other, and HCP must have time to learn this new form of IPC. Learning requires time, effective communication strategies, and leadership support. Political action is also required to implement new models of care, including regulating advanced practice roles and developing new financing models.

BackgroundA new model of complex diabetes care is provided by a multidisciplinary team which incorporates general practitioner (GP) Clinical Fellows supported by an Endocrinologist and diabetes educator within a community-based general practice setting. This study evaluates the health and clinical benefits of the new model of care, assesses the acceptability of the model to patients, GPs and other health professionals, and examines the cost-effectiveness of the model.Methods/DesignThe study is an open, non-inferiority randomised controlled trial with data collected at baseline, 6 and 12 months. Participants are identified from new patients on hospital-based diabetes outpatient clinic waiting lists and new GP referrals. Eligible consenting patients are randomised to either a community practice site (intervention) or a hospital site (usual care). In the intervention model, medical care is led by a GP Clinical Fellow in partnership with an Endocrinologist. Quantitative measures include clinical indicators with HbA1c as the primary outcome; patient-reported outcomes include health-related quality of life, mental health and satisfaction with care. Qualitative methods will be used to explore the perspectives and experiences of patients and providers regarding the new model of care. An economic evaluation will also be undertaken.DiscussionThis model of care seeks to improve the quality and safety of healthcare at the interface between the hospital and primary care sectors for patients with complex diabetes. The study will provide empirical evidence about the impact of the model of care on health outcomes, patient and clinician satisfaction, as well as any economic impacts.Trial registrationClinical Trials Registry Number:ACTRN12612000380897

Research on new models of care in health service provision is complex, as is the introduction and embedding of such models, and positive research findings are only one factor in whether a new model of care will be implemented. In order to understand why this is the case, research design must not only take account of proposed changes in the clinical encounter, but the organisational context that must sustain and normalise any changed practices. We use two case studies where new models of maternity care were implemented and evaluated via randomised controlled trials (RCTs) to discuss how (or whether) the use of theory might inform implementation and sustainability strategies. The Normalisation Process Model is proposed as a suitable theoretical framework, and a comparison made using the two case studies – one where a theoretical framework was used, the other where it was not. In the maternity sector there is considerable debate about which model of care provides the best outcomes for women, while being sustainable in the organisational setting. We explore why a model of maternity care – team midwifery (where women have a small group of midwives providing their care) – that was implemented and tested in an RCT was not continued after the RCT’s conclusion, despite showing the same or better outcomes for women in the intervention group compared with women allocated to usual care. We then discuss the conceptualisation and rationale leading to the use of the ‘Normalisation Process Model' as an aid to exploring aspects of implementation of a caseload midwifery model (where women are allocated a primary midwife for their care) that has recently been evaluated by RCT. We demonstrate how the Normalisation Process Model was applied in planning of the evaluation phases of the RCT as a means of exploring the implementation of the caseload model of care. We argue that a theoretical understanding of issues related to implementation and sustainability can make a valuable contribution when researching complex interventions in complex settings such as hospitals. Application of a theoretical model in the research of a complex intervention enables a greater understanding of the organisational context into which new models of care are introduced and identification of factors that promote or challenge implementation of these models of care.

ObjectiveResearch on new models of care in health service provision is complex, as is the introduction and embedding of such models, and positive research findings are only one factor in whether a new model of care will be implemented. In order to understand why this is the case, research design must not only take account of proposed changes in the clinical encounter, but the organisational context that must sustain and normalise any changed practices. We use two case studies where new models of maternity care were implemented and evaluated via randomised controlled trials (RCTs) to discuss how (or whether) the use of theory might inform implementation and sustainability strategies. The Normalisation Process Model is proposed as a suitable theoretical framework, and a comparison made using the two case studies – one where a theoretical framework was used, the other where it was not.Context and approachIn the maternity sector there is considerable debate about which model of care provides the best outcomes for women, while being sustainable in the organisational setting. We explore why a model of maternity care – team midwifery (where women have a small group of midwives providing their care) – that was implemented and tested in an RCT was not continued after the RCT’s conclusion, despite showing the same or better outcomes for women in the intervention group compared with women allocated to usual care. We then discuss the conceptualisation and rationale leading to the use of the ‘Normalisation Process Model' as an aid to exploring aspects of implementation of a caseload midwifery model (where women are allocated a primary midwife for their care) that has recently been evaluated by RCT.DiscussionWe demonstrate how the Normalisation Process Model was applied in planning of the evaluation phases of the RCT as a means of exploring the implementation of the caseload model of care. We argue that a theoretical understanding of issues related to implementation and sustainability can make a valuable contribution when researching complex interventions in complex settings such as hospitals.Conclusion and implicationsApplication of a theoretical model in the research of a complex intervention enables a greater understanding of the organisational context into which new models of care are introduced and identification of factors that promote or challenge implementation of these models of care.

Introduction: North West London (NWL) has a population of over 2 million people and an annual health and social care spend of over £4bn. We have a diverse, growing and ageing population and need to make best use of resources in order to respond to changing needs. Change implemented: In 2013 partners from across the health and social care system began a journey towards Whole Systems Integrated Care (WSIC) that, when completed, will see us delivering new person-centred models of care, jointly commissioned and delivered across organisational boundaries. During the initial 8 month ‘co-design phase’ over 200 stakeholders from health, social care, service users and carers co-produced a framework - the Integrated Care Toolkit - for the delivery of integrated care in NWL. Following the publication of the Toolkit, 9 collaborative ‘Early Adopter’ partnerships began to translate the Toolkit into local delivery models, initially focussing people aged over 65. A number of these new service models have begun to go live in 2015. New models addressing the needs of further population groups will be implemented from 2016 onwards with the ambition of fully comprehensive coverage by 2018. Key findings: The Integration Toolkit, which is freely available on-line at http://integration.healthiernorthwestlondon.nhs.uk , has proved a useful starting point for the development of new models of care locally and has been viewed widely both nationally and internationally. Once local implementation got underway, the need for more detailed guidance about financial flows, governance and shared data became clear and a new set of handbooks were developed to provide specific support on operational, legal and delivery considerations and were consolidated into a ‘Toolbox’. An evaluation of the design phase was carried out by the Nuffield Trust and London School of Economics. Their report identified some of the themes below. Highlights: - The importance of co-design; building a common vision and framework grounded in the needs of the service user provides a strong foundation for transformation but takes time and can be challenging. The principle of co-design continues to be relevant passed the initial production of the framework however its role and focus needs to adapt and change. - Maintaining a balance between local and system-level focus; whilst there is clear value in working at scale to build momentum, reduce duplication and ensure consistency and stability at system level, there is a need to embed ownership locally to make changes relevant and sustainable - Integrated data is critical to integrated care; shared data is necessary for both the commissioning and delivery of effective person-centred integrated care. The multiplicity of systems and the information governance that underpins them has provided a considerable challenge. Developing the right capabilities and capacity in the system to utilise the data produced is a critical consideration as we move into implementation. - New ways of working; underpinning our programme are new models of care that require systemic behaviour change. We have developed a ‘Change Academy’ that brings teams together alongside service users to innovate new ways of working, break down organisational and professional barriers and ensure that the patient is at the centre of their care. - System-wide transformation takes time; the in-year ‘invest to save’ approach of most statutory change programmes does not take into account the time it takes to embed new models of care. Our initial timelines were ambitious and implementation has not happened as quickly as initially anticipated. The management of expectations with regards to timelines and benefits realisation is critical so that stakeholders (both local and national) do not become disillusioned with the ambitious work being undertaken. Conclusion: As one of 25 integrated care ‘Pioneers’ in England we are part of a community that shares challenges and the approaches being taken to address them. There is a striking commonality to the problems we face in implementing integrated care including; defining an organising principle for commissioning and delivering care; the operationalization of accurate and timely information sharing; the development of commissioning and contracting methodologies that embed joint accountability and the mainstreaming of new ways of working that bring teams of people together to meet the needs of the populations they serve. The ways in which we are addressing these challenges are not necessarily right or appropriate outside of NWL but they provide a case study for the design and delivery of integrated care at scale from which it is hoped there are lessons that may be valuable and applicable elsewhere.

BackgroundThe sustainability of Australian rural maternity services is under threat due to current workforce shortages. In July 2019, a new midwifery caseload model of care was implemented in rural South Australia to provide midwifery continuity of care and promote a sustainable workforce in the area. The model is unique as it brings together five birthing sites connecting midwives, doctors, nurses and community teams. A critical precursor to successful implementation requires those working in the model be ready to adopt to the change. We surveyed clinicians at the five sites transitioning to the new model of care in order to assess their organizational readiness to implement change.MethodsA descriptive study assessing readiness for change was measured using the Organizational Readiness for Implementing Change scale (ORIC). The 12 item Likert scale measures a participant’s commitment to change and change efficacy. All clinicians working within the model of care (midwives, nurses and doctors) were invited to complete an e-survey.ResultsOverall, 55% (56/102) of clinicians participating in the model responded. The mean ORIC score was 41.5 (range 12–60) suggesting collectively, midwives, nurses and doctors began the new model of care with a sense of readiness for change. Participants were most likely to agree on the change efficacy statements, “People who work here feel confident that the organization can get people invested in implementing this change and the change commitment statements “People who work here are determined to implement this change”, “People who work here want to implement this change”, and “People who work here are committed to implementing this change.ConclusionResults of the ORIC survey indicate that clinicians transitioning to the new model of care were willing to embrace change and commit to the new model. The process of organizational change in health care settings is challenging and a continuous process. If readiness for change is high, organizational members invest more in the change effort and exhibit greater persistence to overcome barriers and setbacks. This is the first reported use of the instrument amongst midwives and nurses in Australia and should be considered for use in other national and international clinical implementation studies.

APA's Education Council Issues Report on Need for Integrated Care Training

Introduction : In times of a demographic change many Western countries experience a scarcity of general practitioners in rural and remote areas. These hard to serve regions show a high proportion of older people and, hence, a higher morbidity, while at the same time general practitioners are of higher age and plan on retiring in the near future. While integrated care is primarily applied in a regular care setting, it can even develop a higher potential in hard to serve regions. New models of care, such as an enhanced delegation of service provision to non-medical professionals, can help to ensure the availability of primary healthcare services. In order to guarantee the people-centeredness of these approaches and to improve the people’s acceptance of these new models of care, their preferences for the specific design of these models and their willingness to take use of the models should be known. Thus, the people’s preferences can be taken into account when designing and introducing the new models of care. Methods : A discrete choice experiment (DCE) and a survey were designed in order to evaluate the preferences for and ratings of a variety of new models of care: delegation of services to advanced nurses or to pharmacists, remote treatment by a physician via telemedicine, a mobile practice and a bus taking patients from their villages to a practice. These models of care have not been introduced into the regular care setting in Germany yet. The attributes for the DCE and the aspects for the survey were derived from focus group interviews and, additionally, from the literature. The two postal elicitation instruments were sent to 2,000 people each between June and August 2015 in Germany. Results : The response rates were 46.1% (n = 904) for the DCE and 51% (n = 996) for the survey. The DCE showed that the attributes “opening hours”, “home visit”, “practice facilities”, “distance to GP’s practice” and “treatment by one single doctor” had all significant impact on choosing a supply situation. The survey showed that people are willing to take use of these new models of care. Among the new models of care, the delegation of medical tasks to advanced nurses, followed by the treatment in a mobile practice are the ones which are most highly accepted. Out of all respondents, 60.3% and 56.5% would make use of these models of care in the primary healthcare setting, respectively. On the other hand, only 32.3% of the respondents would accept to be treated by a remote doctor via telemedicine. Furthermore, the survey showed that there are conditions connected to the use of these models. For example, it is important to people that the nurses’ qualification is guaranteed or that the telemedical doctor is already known to them from previous treatments. If people were able to decide on which of the presented new models of care should be introduced in their regions, they would prefer the mobile practice followed by delegation to an advanced nurse. Discussion and Conclusion : Even though these models are not widely implemented in Germany until now, they will gain in importance in the near future in order to guarantee a sufficient provision of healthcare services to the rural population. If tailored to the needs and preferences of the population, they have the potential to overcome physician shortages and satisfy the patients’ needs. Overall, the two studies show that a large part of the population is willing to take use of new models of care. The results indicate which aspects are of significance to the population and which of the models are the preferred ones. Thus, the results of the DCE and the survey can inform policy makers how new models of care should be designed to guarantee a wide acceptance among the population.

One of the central challenges in health policy is to ensure nationwide provision of primary healthcare services. However, it is not clear how the general public rates the current primary healthcare provision in their region. Furthermore, there is very little information on whether people are willing to make use of new models of care that could contribute to ensuring a nationwide provision of healthcare services. Thus, the objective of this study was to analyse the general public's ratings of the local primary healthcare provision as well as their acceptance of selected new models of care. Furthermore, potential differences in the ratings of the population between hard to serve regions and normal regions will be analysed. Focus group discussions and a literature review were conducted in order to develop a questionnaire to elicit the expectations of the population concerning the local provision of primary healthcare as well as their acceptance of new models of care. A postal questionnaire was sent to a random sample of 2,000 persons in 8 regions in Lower Saxony. The adjusted response rate of the postal survey was 51% (n=996). 97% of respondents saw a general practitioner regularly, with 5.4 visits per year on average. Patients could reach the practice in 13 min on average. Respondents predominantly rated the current healthcare provision as being good. However, the majority of respondents expected the local primary healthcare provision to deteriorate in the future. New models of care most preferred by the respondents were the delegation of medical tasks to non-medical professionals and mobility-oriented models. On the other hand, the provision of healthcare via telemedicine was rejected. According to the results of this study, respondents believe that new models of care can play an important role in ensuring the nationwide provision of healthcare services. Introducing, at an early stage, those new models of care that people accept could contribute to ensuring a sustainable provision of primary healthcare services. Furthermore, the introduction of these new models of care could reduce the public's concerns regarding a worsening provision of primary healthcare services in their regions. Additionally, pilot projects with those new models of care that are rather rejected might increase acceptance with these models of care if they prove to be successful.

The challenges of the COVID-19 pandemic have led to the development of new hospital design strategies and models of care. To enhance staff safety while preserving patient safety and quality of care, hospitals have created a new model of remote inpatient care using telemedicine technologies. The design of the COVID-19 units divided the space into contaminated and clean zones and integrated a control room with audio-visual technologies to remotely supervise, communicate, and support the care being provided in the contaminated zone. The research is based on semi-structured interviews and observations of care processes that implemented a new model of inpatient telemedicine at Sheba Medical Center in Israel in different COVID-19 units, including an intensive care unit (ICU) and internal medicine unit (IMU). The study examines the impact of the diverse design layouts of the different units associated with the implementation of digital technologies for remote care on patient and staff safety. The results demonstrate the challenges and opportunities of integrating inpatient telemedicine for critical and intermediate care to enhance patient and staff safety. We contribute insights into the design of hospital units to support new models of remote care and suggest implications for Evidence-based Design (EBD), which will guide much needed future research.

Background: Children and young people’s (CYP) health outcomes in England are variable and often poor. Health systems throughout high income countries are struggling to adapt to epidemiological transitions, social change, rising demand, and budget cuts. There was a 58% rise in CYP attending EDs between 2007 and 2016, projected to rise 50-60% more by 2030. CYP from the most deprived backgrounds are 60-70% more likely to go to A&E than the least deprived. The majority of ED attendances by CYP are manageable in primary care or integrated models, yet 85% of ED attendances are for minor illnesses, increasing 5% annually. The Children and Young People’s Health Partnership (CYPHP) is a health system strengthening initiative implementing and evaluating a new model of care. Methods: Health system strengthening using the WHO building blocks model included service design by analysis of population need, systematic literature reviews, and extensive patient and public involvement. An evidence-based implementation plan was agreed for a child population of 90,000 in London, and we are evaluating using a cluster randomised control trial (cRCT) design with nested process evaluation and qualitative studies to assess CYP health and wellbeing, healthcare quality, patterns of healthcare use, and cost effectiveness. Results: CYPHP’s comprehensive care includes health promotion and supported self-management, proactive case-finding, biopsychosocial assessment and self-referral via a patient portal, with care delivered by a multidisciplinary team. Services are integrated vertically and horizontally incorporating physical and mental healthcare. Implementation has taken two years longer than anticipated due to technical and cultural challenges of health system strengthening. Early results indicate a reduction of 72 ED contacts per 100 children with asthma, 30 for children with epilepsy, and 15 for children with constipation. We estimate cost savings per 100 asthma patients to be over £15,000, for epilepsy over £6,000, and for constipation over £3,000. Of the first 200 patients, most were from socially deprived areas and 68% were from black and minority ethnic groups. Families report more confidence in managing their child’s condition. Discussion: As a clinical academic partnership, CYPHP combines pragmatic quality improvement and rigorous health services research. CYPHP demonstrates that health system strengthening in high income countries is feasible and effective for implementing and testing new models of care to improve child health. Conclusions: Early results suggest encouraging impact on patterns of healthcare use and potential cost savings. CYPHP’s population health approach provides care for those with greatest health and social need. Lessons learned: Rigorous health services and systems research is feasible in large scale system change in the NHS. Health system strengthening is a new concept in high income countries. It is slow and difficult, but important for effective implementation of new models of care. Fully integrated comprehensive models of care for children may improve health and healthcare outcomes. Limitations: Results are preliminary and reflect early implementation. Suggestions for future research: Rigorously designed health services research for ongoing large-scale health systems changes are an important source of new knowledge. There are few examples of such opportunistic research, representing new avenues for opportunity.

BackgroundMany countries have introduced reforms with the aim of primary care transformation (PCT). Common objectives include meeting service delivery challenges associated with ageing populations and health inequalities. To date, there has been little research comparing PCT internationally. Our aim was to examine PCT and new models of primary care by conducting a systematic scoping review of international literature in order to describe major policy changes including key ‘components’, impacts of new models of care, and barriers and facilitators to PCT implementation.MethodsWe undertook a systematic scoping review of international literature on PCT in OECD countries and China (published protocol: https://osf.io/2afym). Ovid [MEDLINE/Embase/Global Health], CINAHL Plus, and Global Index Medicus were searched (01/01/10 to 28/08/21). Two reviewers independently screened the titles and abstracts with data extraction by a single reviewer. A narrative synthesis of findings followed.ResultsA total of 107 studies from 15 countries were included. The most frequently employed component of PCT was the expansion of multidisciplinary teams (MDT) (46% of studies). The most frequently measured outcome was GP views (27%), with < 20% measuring patient views or satisfaction. Only three studies evaluated the effects of PCT on ageing populations and 34 (32%) on health inequalities with ambiguous results. For the latter, PCT involving increased primary care access showed positive impacts whilst no benefits were reported for other components. Analysis of 41 studies citing barriers or facilitators to PCT implementation identified leadership, change, resources, and targets as key themes.ConclusionsCountries identified in this review have used a range of approaches to PCT with marked heterogeneity in methods of evaluation and mixed findings on impacts. Only a minority of studies described the impacts of PCT on ageing populations, health inequalities, or from the patient perspective. The facilitators and barriers identified may be useful in planning and evaluating future developments in PCT.

As healthcare policy moves from the realms of "treating disease" towards supporting "well-being" there is a natural move from traditional hospital services to community care. Chaplaincy and Spiritual Care services are uniquely placed to understand the language and essence of this paradigm shift and are developing new models of spiritual care to support it. However, such a shift is not without its challenges. This article explores the shift from current healthcare practices to the promotion of communitybased care focused on well-being in NHS Scotland. It introduces the new models of spiritual care that are being developed to embrace the change. In conclusion, it highlights the challenges of change that arise from new models of care while at the same time embraces the recognition of spiritual care as an integral dimension of modern healthcare.

OA21.06 Turning Best Supportive Care into Active Care. A Service Development for Patients with Advanced Lung Cancer in NHS Fife, Scotland

No service is an island: towards an ecosystem approach to mental health service evaluation.