Community Health Care Services Research Articles

Bridging Health and Social Care – An Innovative Framework

Introduction: There is broad consensus that patient –centered care demands that health and social care be viewed as a single, interdependent system, taking into account all of the individual’s needs. In most countries, barriers must be overcome to achieve this. In Israel, Assuta Medical Centers, a private hospital network now building a new public hospital in the city of Ashdod, initiated the development of an integrated care system for Ashdod with Maccabi Healthcare Services, the second largest non-profit HMO with an integrated community healthcare system, the Municipality of Ashdod Social Services department, and the National Insurance Institute's Southern Region (NII), responsible for domiciliary care as well welfare subsidies system. The challenges faced included different organizational cultures, a lack of work processes to support integration and separate IT systems that do not ‘speak’ to each other. Methodology: A multidisciplinary task force, representing all four organizations, has been working together for over a year to develop a comprehensive, integrated-care model wherein municipality social services, the NII, the hospital and community healthcare services will work together to meet the needs of Ashdod citizens. Sub-task forces have been set up to address four target populations: Complex elderly patients Oncology patients Children with juvenile diabetes Maternity and newborns, including premature births The task forces are multidisciplinary, with representatives from all four organizations, and are in advanced stages of delineating work processes and interventions. Results: The task force has successfully established an ongoing collaborative dialogue and has agreed to create the necessary interfaces among the IT systems of all four organizations. They have established what information will be shared, conditional upon signed consent of the patient. Interfaces have been defined and are in the process of development. The Assuta Ashdod hospital will begin operation mid-2017 and the interfaces with the social services department and NII will be completed by February 2017. The interfaces with Maccabi exist and are being upgraded. A major structural change will be the creation of a case manager function in the hospital for each target group to assure full integration. Maccabi already has a multidisciplinary unit to assure integration of community services for newly discharged complex patients. To improve integration, a care manager in the community will be assigned to coordinate ongoing care for the complex elderly. For oncology patients, a joint Assuta-Maccabi care manager will be assigned to assure full integration between hospital, community healthcare and social services. For children with diabetes, the municipality's department of education has become a full partner. Discussion: The process of collaboration has already made major changes in the organizational cultures of the participating organizations. The commitment to full implementation of integrated care processes is very high at all levels of the organizations. While this has been a bottom-up innovation, the relevant Ministries are closely following developments and other parts of the country are eager to follow suit. Multi-national research is already underway to assess the impact of these processes on the quality and cost of care for the target populations, as well as transferability to other countries.

From Connected Care to Integrated Care – A work in Progress

One of the most problematic interfaces is the hospital-community care interface.[1] Older persons discharged from acute care hospitals are at risk of 30-day hospital readmission and death.[2] purports to address the problem, although, to date, a comprehensive solution has not yet been achieved.[3] A new H2020 project – aims to develop and evaluate a new organisational model for Integrated Care for complex patients enabled by ICT tools. Some of the building blocks for the new integrated care model are in advanced stages of implementation by some of the consortium partners. An example of this is Assuta Medical Centers and its mother organization, Maccabi Healthcare Services (Israel): Maccabi has an integrated community care system with a central Electronic Medical Record, used by all healthcare professionals, with patients' access to their record through a patient portal. The clinical decision support system facilitates integration among providers in the community and their patients. Assuta's hospital network has a central EMR and there is two-way access to patient records between community and hospital In May 2015, Maccabi implemented a nationwide Continuity of Care program that provides integrated follow up care for all complex patients discharged from the hospital, supported by a digital platform that defines each provider’s tasks and enables follow up to assure that tasks are completed through seamless interface with the patient’s EMR. A preliminary evaluation based on the first 6 months of operation (July-December 2015) found that: Patients who received integrated care had a 4% reduction in hospital readmissions compared with those who did not receive coordinated care. There was a reduction in hospital care costs of 32% for Maccabi members identified as complex co-morbid patients due to the intensity of the intervention in the community i.e. homecare visits, or visits to primary care Patients expressed high levels of satisfaction with their care. Assuta is building an integrated health and care system in Ashdod in partnership with Maccabi and the Municipality that will begin in Spring, 2017, with dedicated Care Managers responsible for integrating the care for the patient in the hospital, and with community healthcare services and the Municipality's Social Services. As consortium partners in CONNECARE, the Assuta/Maccabi processes will be supported by the CONNECARE model for complex patients with additional digital tools including a platform for care coordination and a Self-Management System for patients and carers. The CONNECARE digital platform will be ready for implementation by Autumn 2017, coinciding with the implementation of the Assuta Ashdod Integrated care system. The CONNECARE pilots will enable a robust evaluation of this integrated care model, not only in Israel but in Spain and the Netherlands, thus providing a foundation for a potentially transferable solution.

Care-managers\u2019 professional choices: ethical dilemmas and conflicting expectations

BackgroundCare-managers are responsible for the public administration of individual healthcare decisions and decide on the volume and content of community healthcare services given to a population. The purpose of this study was to investigate the conflicting expectations and ethical dilemmas these professionals encounter in their daily work with patients and to discuss the clinical implications of this.MethodsThe study had a qualitative design. The data consisted of verbatim transcripts from 12 ethical reflection group meetings held in 2012 at a purchaser unit in a Norwegian city. The participants consist of healthcare professionals such as nurses, occupational therapists, physiotherapists and social workers. The analyses and interpretation were conducted according to a hermeneutic methodology. This study is part of a larger research project.ResultsTwo main themes emerged through the analyses: 1. Professional autonomy and loyalty, and related subthemes: loyalty to whom/what, overruling of decisions, trust and obligation to report. 2. Boundaries of involvement and subthemes: private or professional, care-manager or provider and accessibility.ConclusionsUnderlying values and a model illustrating the dimensions of professional responsibility in the care-manager role are suggested. The study implies that when allocating services, healthcare professionals need to find a balance between responsibility and accountability in their role as care-managers.

Increasing the provision of preventive care by community healthcare services: a stepped wedge implementation trial

BackgroundAlthough clinical guidelines recommend the provision of care to reduce client chronic disease risk behaviours, such care is provided sub-optimally by primary healthcare providers. A study was undertaken to determine the effectiveness of an intervention in increasing community-based clinician implementation of multiple elements of recommended preventive care for four risk behaviours.MethodsA three-group stepped-wedge trial was undertaken with all 56 community-based primary healthcare facilities in one health district in New South Wales, Australia. A 12-month implementation intervention was delivered sequentially in each of three geographically and administratively defined groups of facilities. The intervention consisted of six key strategies: leadership and consensus processes, enabling systems, educational meetings and training, audit and feedback, practice change support, and practice change information and resources. Client-reported receipt of three elements of preventive care: assessment; brief advice; referral for four behavioural risks: smoking, inadequate fruit and/or vegetable consumption, alcohol overconsumption, and physical inactivity, individually, and for all such risks combined were collected for 56 months (October 2009–May 2014). Segmented logistic regression models were developed to assess intervention effectiveness.ResultsA total of 5369 clients participated in data collection. Significant increases were found for receipt of four of five assessment outcomes (smoking OR 1.53; fruit and/or vegetable intake OR 2.18; alcohol consumption OR 1.69; all risks combined OR 1.78) and two of five brief advice outcomes (fruit and/or vegetable intake OR 2.05 and alcohol consumption OR 2.64). No significant increases in care delivery were observed for referral for any risk behaviour, or for physical inactivity.ConclusionsThe implementation intervention was effective in enhancing assessment of client risk status but less so for elements of care that could reduce client risk: provision of brief advice and referral. The intervention was ineffective in increasing care addressing physical inactivity. Further research is required to identify barriers to the provision of preventive care and the effectiveness of practice change interventions in increasing its provision.Trial registrationAustralian Clinical Trials Registry ACTRN12611001284954. Registered 15 December 2011. Retrospectively registered.

Exploring the relationship between frequent internet use and health and social care resource use in a community-based cohort of older adults: an observational study in primary care

ObjectivesGiven many countries’ ageing populations, policymakers must consider how to mitigate or reduce health problems associated with old age, within budgetary constraints. Evidence of use of digital technology in delaying...

Governing body nurses’ experiences of clinical commissioning groups: an observational study of two clinical commissioning groups in England

Clinical commissioning groups were set up under the Health & Social Care Act (2012) in England to commission healthcare services for local communities. Governing body nurses provide nursing leadership to commissioning services on clinical commissioning groups. Little is known about how nurses function on clinical commissioning groups. We conducted observations of seven formal meetings, three informal observation sessions and seven interviews from January 2015 to July 2015 in two clinical commissioning groups in the South of England. Implicit in the governing body nurse role is the enduring and contested assumption that nurses embody the values of caring, perception and compassion. This assumption undermines the authority of nurses in multidisciplinary teams where authority is traditionally clinically based. Emerging roles within clinical commissioning groups are not based on clinical expertise, but on well-established new public management concepts which promote governance over clinically-based authority. While governing body nurses claim an authority located in clinical and managerial expertise, this is contested by members of the clinical commissioning group and external stakeholders irrespective of whether it is aligned with clinical knowledge and practice or with new forms of management, as both disregard the type of expertise nurses in commissioning embody.

Ensuring Operational Continuity of Community Healthcare Services During Disasters

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Pårørendes erfaringer med bruk av frivillige ved alvorlig sykdom i hjemmet

Next-of-kins’ experiences when using volunteers for palliative patients living at homeThe aim of this study was to illuminate next-of-kins’ experiences when using volunteers supplementing community health care services for palliative patients living at home. The study has a qualitative approach. Nine individual interviews were conducted with next of kin from a municipality in Southern Norway. Use of volunteers for palliative care in the home was a relief for next-of-kin, especially prominent for families who had limited social network. Planned volunteering resulted in the best results. Use of volunteer was also found helpful for families as they were given a "breathing space" and a certain normalization of everyday life. The volunteers followed up activities related to the patient that the next-of-kin to a limited extent managed to attend. This affected the next-of-kin’s conscience in a positive way. The next-of-kin experienced the volunteers to be empathetic, they could inspire confidence and showed good characteristics to assist ill people and their next-of-kin. The next-of-kin needed regular relief from volunteers as a supplement to the community health care services. The volunteers were well suited to meet people, who were in a difficult situation, and with their approach they had strong confidence in the next-of-kin and gave them relief in a challenging environment. The coordinator for palliative care was a key person in relation to the link between families, patients in palliative care and the volunteers.

Does Telehealth Monitoring Identify Exacerbations of Chronic Obstructive Pulmonary Disease and Reduce Hospitalisations? An Analysis of System Data.

BackgroundThe increasing prevalence and associated cost of treating chronic obstructive pulmonary disease (COPD) is unsustainable. Health care organizations are focusing on ways to support self-management and prevent hospital admissions, including telehealth-monitoring services capturing physiological and health status data. This paper reports on data captured during a pilot randomized controlled trial of telehealth-supported care within a community-based service for patients discharged from hospital following an exacerbation of their COPD.ObjectiveThe aim was to undertake the first analysis of system data to determine whether telehealth monitoring can identify an exacerbation of COPD, providing clinicians with an opportunity to intervene with timely treatment and prevent hospital readmission.MethodsA total of 23 participants received a telehealth-supported intervention. This paper reports on the analysis of data from a telehealth monitoring system that captured data from two sources: (1) data uploaded both manually and using Bluetooth peripheral devices by the 23 participants and (2) clinical records entered as nursing notes by the clinicians. Rules embedded in the telehealth monitoring system triggered system alerts to be reviewed by remote clinicians who determined whether clinical intervention was required. We also analyzed data on the frequency and length (bed days) of hospital admissions, frequency of hospital Accident and Emergency visits that did not lead to hospital admission, and frequency and type of community health care service contacts—other than the COPD discharge service—for all participants for the duration of the intervention and 6 months postintervention.ResultsPatients generated 512 alerts, 451 of which occurred during the first 42 days that all participants used the equipment. Patients generated fewer alerts over time with typically seven alerts per day within the first 10 days and four alerts per day thereafter. They also had three times more days without alerts than with alerts. Alerts were most commonly triggered by reports of being more tired, having difficulty with self-care, and blood pressure being out of range. During the 8-week intervention, and for 6-month follow-up, eight of the 23 patients were hospitalized. Hospital readmission rates (2/23, 9%) in the first 28 days of service were lower than the 20% UK norm.ConclusionsIt seems that the clinical team can identify exacerbations based on both an increase in alerts and the types of system-generated alerts as evidenced by their efforts to provided treatment interventions. There was some indication that telehealth monitoring potentially delayed hospitalizations until after patients had been discharged from the service. We suggest that telehealth-supported care can fulfill an important role in enabling patients with COPD to better manage their condition and remain out of hospital, but adequate resourcing and timely response to alerts is a critical factor in supporting patients to remain at home.Trial RegistrationInternational Standard Randomized Controlled Trial Number (ISRCTN): 68856013; http://www.isrctn.com/ISRCTN68856013 (Archived by WebCite at http://www.webcitation.org/6ofApNB2e)

Participants' perceptions of an intervention implemented in an Action Research Nursing Documentation Project.

The aim of this study is to describe healthcare professionals' experiences and perceptions of an intervention implemented in an action research project conducted to improve nursing documentation practices in four municipalities in Norway. Documentation of individualized patient care is a continuing concern in healthcare services and could impacts the quality and safety of healthcare. Use of electronic systems has made some aspects of documentation more comprehensive, but creation of an individualized care plan remains a pressing issue. A qualitative descriptive design was used. An action research project was conducted between 2010-2012 to improve the content and quality of nursing documentation in community healthcare services in four municipalities. One year after the project was completed four focus group interviews were conducted with healthcare professionals, one for each involved municipality. Two unit managers were interviewed individually. Qualitative content analysis was used. Three themes emerged: healthcare professionals perceived competing interest; they experienced that they had to manage complexity and changes; and they highlighted a clear and visible leader as important for success. Quality improvement activities are essential. Healthcare professionals experience a complicated situation when electronic health record systems do not support workflow. Further research is recommended to focus on the functionality and user interface of electronic health record systems, and on the role of leadership when implementing changes in clinical practice. Stronger cooperation among policymakers, electronic health record system vendors, and healthcare professionals is essential for improving electronic health record systems and documentation practices. Involvement of end-users in these improvements can make a difference in the way the systems are perceived in the clinical workflow.

The Development of a Telemedicine Planning Framework Based on Needs Assessment

Providing equitable access to healthcare services in rural and remote communities is an ongoing challenge that faces most governments. By increasing access to specialty expertise, telemedicine may be a potential solution to this problem. Regardless of its potential, many telemedicine initiatives do not progress beyond the research phase, and are not implemented into mainstream practice. One reason may be that some telemedicine services are developed without the appropriate planning to ascertain community needs and clinical requirements. The aim of this paper is to report the development of a planning framework for telemedicine services based on needs assessment. The presented framework is based on the key processes in needs assessment, Penchansky and Thomas's dimensions of access, and Bradshaw's types of need. This proposed planning framework consists of two phases. Phase one comprises data collection and needs assessment, and includes assessment of availability and expressed needs; accessibility; perception and affordability. Phase two involves prioritising the demand for health services, balanced against the known limitations of supply, and the implementation of an appropriate telemedicine service that reflects and meets the needs of the community. Using a structured framework for the planning of telemedicine services, based on need assessment, may help with the identification and prioritisation of community health needs.

To be a trained and supported volunteer in palliative care \u2013 a phenomenological study

BackgroundIt has been found that including volunteers in palliative care is a positive contribution to seriously ill patients. It is, however, recommended that the volunteers are trained and supported. The aim of this study was to describe a group of trained and supported volunteers’ lived experiences as volunteers in palliative care within the community health care services.MethodsThis study adopted a descriptive phenomenological approach featuring individual interviews with nine volunteers. The interviews were analysed using the descriptive phenomenological research method according to Giorgi.ResultsBeing a volunteer in palliative care was both a positive and meaningful experience. It was a privilege being able to help those in need, which yielded positive returns. As a volunteer, it was important to be present for the ill persons and to follow them in their various physical and psychical states, which also implied that the volunteer had to face and deal with challenging situations. However, volunteers stated it was crucial to possess knowledge and life experience, as well as a clarified role, and they stressed the importance of being followed up by a mentor.ConclusionsThe findings showed that trained and supported volunteers among seriously ill or dying people within the realm of community health care services play an independent and important role in the palliative care team. A coordinator in palliative care is especially suitable for training and supporting the volunteers.

Before the bombing: High burden of traumatic injuries in Kunduz Trauma Center, Kunduz, Afghanistan.

BackgroundMédecins Sans Frontières (MSF) has been providing healthcare in Afghanistan since 1981 including specialized health services for trauma patients in Kunduz Trauma Center (KTC) from 2011. On October 3rd, 2015, a US airstrike hit the KTC, killing 42 people including 14 MSF staff. This study aims to demonstrate the impact on healthcare provision, after hospital destruction, by assessing the extent of care provided for trauma and injuries by the MSF KTC and to report on treatment outcomes from January 2014 to June 2015, three months prior to the bombing.MethodsThis is a descriptive, retrospective review of hospital records. All patients with traumatic injuries registered in the Emergency Department (ED) or hospitalized in In-Patients Department (IPD) and/or Intensive Care Unit (ICU) of KTC between January 2014 and June 2015 were included in the study.ResultsA total of 35647 patients were registered in KTC during the study period. 3199 patients registered in the ED were children aged <5 years and 310 of them were admitted including 47 to the ICU. 77.5% patients were from Kunduz province and the remaining were from other provinces. The average length of stay was 7.3 days and 3.3 days while the bed occupancy rate was an average 91.1% and 75.8% in IPD and ICU, respectively. Of 4605 IPD patients, 105 (2.3%) developed complications. Among those admitted to the ICU, 12.6% patients died. About one-third surgical interventions were carried out on an urgent basis and the major proportion (45.8%) of surgical procedures was wound surgery followed by orthopedic surgery (27.0%).ConclusionsThis study highlights the high burden of traumatic injuries in Kunduz province and MSF Trauma Center’s contribution to saving lives, preventing disabilities and alleviating suffering among adults and children within the region. The bombing and destruction of KTC has resulted in a specific gap in critical healthcare services for the local communities in the health system of this war-ravaged region. This suggests the urgent need for reconstruction and re-opening of the center.

Helsepersonells erfaringer og tanker om bruk av frivillige i palliativ omsorg

Health care personnel’s experiences and thoughts on the use of volunteers in palliative care in a social perspectiveThe government of Norway is planning for the municipalities’ health care resources, including volunteering. The purpose of this study was to shed light on the experiences and thoughts of a group of health care personnel on the use of volunteers in palliative care in the community health care services, and to discuss the findings in a social perspective. Individual interviews were conducted with seven nurses and three nursing assistants. Using a qualitative content analysis three categories emerged: "The importance of organization, clarification and responsibility," "Qualifications" and "Different types of tasks," with the overarching theme: “Close monitoring and good clarification of roles can contribute to suitable volunteers functioning as an appropriate supplement for patients in palliative care in the community health care services”. The informants stated that trained health care personnel must perform the nursing tasks in palliative care while volunteers can be a positive supplement for the patient.

A Survey on Prediction Using Big Data Analytics

This article describes how nowadays, the growth of big data in bio-medical and healthcare community services is increasing rapidly. The early detection of diseases and patient care are analyzed with the help of accurate analysis of medical data includes diagnosed patients' details. The analysis of accuracy rate is considerably reduced when the quality of medical data is unclear since every part of the body has unique characteristics of certain regional diseases that may suppress the prediction of diseases. This article reviews the detailed survey of different prediction methods developed for analyzing the accuracy rate of disease affected patients in 2015-2016 mainly focuses on choosing the efficient predictions based on the quality of medical data not only provides the overall view of prediction methods but also gives the idea of big data analytics in medical data further discusses the methods, techniques used and the pros and cons of prediction methods.

Perception and Information Seeking Behaviour of Rural Households towards Health Promoting Practices in Maigana District of Kaduna State, Nigeria

Information is valuable, increases understanding and reduces uncertainty. Limited knowledge and access to health promoting and disease prevention programmes are more pronounced in rural than urban areas of Nigeria. Furthermore, the paucity of healthcare services in these rural communities also contributes to the prevalence of health challenges in the rural sector. This study investigated the perception and information seeking behavior of rural households in Maigana District of Kaduna State, Nigeria towards health promoting practices. A random sample of 152 respondents selected from five of eleven wards in the district was interviewed using a pre-tested structured questionnaire. The results, based on a 4-point Likert type scale and benchmark of 2.5 showed a very poor perception of health promoting practices among the respondents. Also, the information needs of the respondents were shown to be enormous. Three of the six socio-demographic variables regressed were found to significantly influence the information seeking behavior of the respondents regarding health promoting practices. Constraints limiting the embracement of health promoting practices were identified and measures aimed at promoting healthier living standards in rural communities were recommended. The study concludes that vast knowledge gaps do exist coupled with the poor perception of HPPs by the respondents.

Integrating Community Health and Social Care Services in Fife

Introduction: Fife is the third largest local government region in Scotland with a growing population of 366,957, of which 18% are over the age of 65, and with a mix of urban communities and sparsely populated rural communities. Social care services are delivered by Fife Council and healthcare services by National Health Service Fife in a partnership working arrangement but with separate workforces, management structures and funding. Unplanned admissions to hospitals and care homes account for nearly 30% of the resources that Fife spends on health and social care for older people. To address these demographic and associated funding pressures, a programme to redesign and integrate community health and social care services was implemented. Description: The Scottish Government introduced a Reshaping Care for Older People programme to create a vision and offer some funding for service change. The programme aims to increase care in community settings resulting in reductions in demand for hospital inpatient and care home facilities. This should allow disinvestment to enable successful community services and projects to be sustained. The Government programme does not prescribe how community services should be redesigned, devolving responsibility and empowering organisations to do that with their local knowledge. In Fife, community service redesign is informed by Stakeholder Events where health and social care professionals are joined by third and independent sector, patient and carer representatives to map existing pathways and identify ways of integrating teams, reducing handovers and avoidable hospital and care home admissions. The aim is to empower teams to encourage patients and their carers to take control of their own health and wellbeing personal outcomes. The redesign has created an Integrated Community Assessment and Support Service (ICASS) combining professionals and blurring roles (nurses, physiotherapists, occupational therapists and care assistants) into multidisciplinary teams with shared care plans, resources and support systems. A number of related projects focus on prevention of admission (Hospital-at-home, day hospital rapid assessment, falls response, re-ablement, third sector capacity building, Local Area services Co-ordinators). Other projects focus on discharge planning and support (hospital discharge planning hubs, Short Term Assessment and Rehabilitation beds, special needs housing, discharge-to-assess, third sector supported discharge) Service managers facilitated integration and scaling up of services, developed a culture of integrated multi-disciplinary working in teams of co-located health and social care workers, created a generic support worker role, introduced performance management measures and consistent delivery processes across Fife. Evaluation is focussed on achieving personal outcomes, including conversations training for staff, and an IT patient management system that records outcomes goals. National tools such as Indicators of Relative Need (IoRNs) are used, and a university research project, PEPPERs, is measuring the effectiveness of proactive community interventions compared with unplanned hospital admissions in a randomised trial. Key findings: Successful integration of multidisciplinary ICASS teams and collocation of professionals has improved communication and empathy resulting in better co-ordinated patient care and more effort on prevention of admission to hospital. Assessing homecare needs at home or in STAR beds is reducing the costs of packages of care or care home admission. However this success is countered by accelerating growth in demand for services and increasing complexity of people living longer with multiple long term conditions. Highlights: Redesign of community services was already underway in 2011 when the Reshaping Care for Older People programme was launched and the process of evolution is continuing. The huge complexity of health and social care service integration needs a structured project management methodology to plan and implement change. Resistance to change in the workforce, and differences in practices between localities is being overcome with ongoing engagement, using reference groups, training needs analysis and upskilling, shadowing and mentoring. Clear communication of vision and change plans, and full engagement of the workforce in the change process is the key to success. Implementing change will take longer and cost more than you expect. Conclusion: Fife is continuously evolving and improving integrated community health and social care services that are focussed on proactively helping older people live safely and independently in their own homes for as long as possible. A new operational management structure for intermediate care that is scalable and transferrable across Fife communities, ensures a consistent service experience for patients across Fife . Community teams’ activities are shifting from responding to crisis to proactively managing frailty and long term conditions. To create a more enabling environment for integrated care, in April 2016 NHS Fife and Fife Council will launch a new Integration Authority with strategic priorities for prevention and early intervention, integrated and co-ordinated care, tackling health inequalities and improving mental health services. The journey continues…..

Developing a whole systems joint outcomes approach to contracting for integrated health and social care for older people

Background : In the climate of service reorganisation and sensitivity surrounding cost, health and social care systems are confronting many pressures. In England for example, most of the funding is tied up in acute and long term social care, current NHS contracts are widely regarded as insufficient for the transformation agenda and stifle innovation, and Payment by Results does not incentivise the reduction in admissions or social care changes but in fact acts as a perverse incentive (Curry et al 2011). As a consequence, commissioners of health and social care must rapidly consider contracting arrangements to drive forward service integration that is person-centred, innovative, sustainable and transferable. The aim of this project was to develop and externally validate a contracting model blueprint for long-term conditions that was integrated care focused, evidence-based, collaborative and based on achievable joint outcomes. The intention of the model was to ensure high quality integrated care for people with long-term conditions to support self-management and end of life care. Literature review, method and outcome: There were three phases to this project: 1. A critical international literature review of contracting models from within health and social care and industry was undertaken, in order to underpin the model with theory and evidence of effectiveness. This identified eight key contracting models (Alliance, Lead Provider, Partnering model, Outcomes-base commissioning, Accountable Care Organisations, value-based healthcare, incomplete contracts and the Alzira model). Overall there is little evidence of effectiveness, but much on values and principles underpinning the models and an equal amount of qualitative and anecdotal data theorising success and failure (Billings & de Weger 2015). 2. A design group of stakeholders from Clinical Commissioning Groups, acute and community health and social care, contracting and legal services, and technologists from industry was convened to develop the model. It met at monthly intervals over a six month period. A set of underlying principles were initially determined upon which a model should be developed that were person-centred (eg promoting self-management and high quality integrated care) and organisational (eg motivate the workforce, be flexible and innovative). These were isolated from best practice aspirations within professional and integrated care literature (eg Goodwin et al 2014). Secondly, relevant aspects identified in the literature review were extracted for inclusion. This included aspirational leadership and incentivisation from Accountable Care Organisation principles, trust and relational embeddedness between organisations from Alliance models, and person-centred values from outcomes-based commissioning approaches. Following the six months of design, the model consisted of two levels of detail with four overarching core elements – a) (joint) outcomes; b) partnership: collaboration and leadership; c) financial: incentives and risk; and d) legal. Each core element then had a series of more detailed contracting criteria, followed by further detailed specifications to guide the contract development. 3. This model was subsequently validated with a wide range of national and international experts to ascertain relevance and applicability across diverse contexts. The model has been assessed through consultation with five national and four international contracting, legal and long term care experts, and with organisations such as Monitor, the European Centre for Social Welfare Policy and Research, and NHS England. In addition it has been presented at webinars, conferences and discussed with professionals. Overall, those experts and bodies consulted expressed favourable opinions and were in agreement that the contracting model had face validity and potential in the field of integrated care. Discussion and Conclusion : This contracting blueprint signals a significant departure from how current contracts are developed, agreed and operationalised in England, tuned as it is towards integrated care and joint outcomes, and potentially can provide a ‘backbone’ for the achievement of the transformation agenda. However, despite the extensive validation and perceived relevance of such a model, it must remain aspirational until tested in the field. This is even more so, in that the strive for evidence to strengthen the conceptual development of the model was largely faulty, weak or absent; hence the literature underlining its development was equally aspirational. However, new agendas require new thinking. Work is underway to explore technological solutions to its application, developing software that will simulate bespoke contracts for localities using the model as a framework for developing joint outcomes.

Is care moving closer to home? A snapshot in England in 2014

Introduction: In view of the demographic change with its increasing demand for and cost of institutional care, current approaches to health care delivery are not sustainable. To meet future healthcare needs, the National Health Service (NHS) started an extensive transformation following the Health and Social Care Act 2012 in England, changing the structure, accountabilities, funding arrangements and working relationships within the care system. The goal is to improve the integration between different professions and in particular transitions between health and social care.The aim of this transformation is to shift the balance from hospital to the community setting, providing holistic and patient-centric care.The qualitative study described in this abstract examines if and how different stakeholders experience this transformation process.Methods: The study design involved qualitative methods including reflection exercises, individual and focus group interviews, mapping of care network and trigger cards. Patients with a present chronic condition using one or more social and/or community service(s), professionals and representatives from service providers and informal care giver (ICG), were enrolled for this study. Both patients with and without ICG support were included.Data collection and sample: The study involved semi-structured interviews in 22 subjects: six patients (age 70 ± 13; 4 female 4 COPD, 1 HF, 1 mental disorder), five ICG (age 55 ± 10; all female), eight NHS professionals (5 nurses, 1 service commissioner, 1 quality assurance and 1 rapid response team representative) and three representatives from care service (CS) providers.Patients and ICG were asked about the support they received, social and community services they are using and the associated motivation/obstacles, means of communication with different providers and their vision of future care. Professionals and CS providers explained their professional background, tasks and responsibilities, amount and means of interactions with patients and ICG, role in arranging services, coordination, collaboration and follow-up with service providers as well as expected changes in the future.Findings: Insights on integrated care.Community and social service providers lack access to patient information (e.g. health condition). Data sharing and collaboration between health and care organizations is essential to enable holistic care, but currently not sufficiently in place as trust and clear responsibilities need first to be established. As a result, no single care provider oversees the whole picture of a patient.Patients on the other hand interact with different providers, which causes a lot of dissatisfaction as the patient needs to repeat information from one care provider to the other.Shifting care from hospitals into the community: There is a strong incentive to shift care out-of-hospital, closer to the home environment as health professionals are challenged by rising caseloads and limited patient time windows. The coordination of care is therefore shifting to district nurses and community matrons, linking up social services and community resources. However, the landscape of available community health and social care services is region-specific, fragmented and dynamic. As the service offer differs per neighborhood and is rapidly changing, navigating through the service landscape becomes challenging without a currently available up-to-date information supply chain. Care providers rely on their experience and exchange of such information from peers.Empowering patients and ICG: The transformation of the NHS envisions patients to have far greater control of their own care (e.g. by means of shared budgets). However, patients and ICG lack awareness of available resources or benefits they are entitled to, and particularly mental services were mentioned to be lacking. Patients reported the obligation to be proactive and responsible in coordinating their care (e.g. paperwork). They raised concerns that not everybody is willing and/or capable to carry out these tasks. The selection of services should ideally be supported by a guiding professional.Conclusions: Despite the ambition for integrated care, health and social services are still disjoint. This is reflected by limited collaboration, coordination, communication and data exchange between health and care professions. As social and CS are disconnected from the NHS, no professional has the overall picture of which treatment and care a patient can receive and is receiving.Due to the strain on medical professionals, health and care services are increasingly shifted to the community. This process is supported by district and community nurses who coordinate care for patients with chronic conditions. However, these nurses lack information on what services are available.Similar problems were reported by patients, who appreciate having a say in their care, but still need guidance from a medical professional. Patients will be expected to engage more and more in their care, but this may not be suitable for all.

A comparison of the neuropsychological profiles of people living in squalor without hoarding to those living in squalor associated with hoarding.

Squalor affects 1 in 1000 older people and is regarded as a secondary condition to other primary disorders such as dementia, intellectual impairment and alcohol abuse. Squalor frequently is associated with hoarding behaviour. We compared the neuropsychological profile of people living in squalor associated with hoarding to those presenting with squalor only. This study is a retrospective case series of hospital inpatient and community healthcare services of 69 people living in squalor (49 from aged care, 16 from aged psychiatry, 3 from acute medical and 1 from a memory clinic). Forty per cent had co-morbid hoarding behaviours. The main outcomes were neuropsychologists' opinions of domain-specific cognitive impairment. The squalor-hoarding group (M age 75.8, SD = 6.9,) was significantly older (p < 0.05) than the squalor-only group (M age 69.9 years, SD = 13.1), significantly more likely to have vascular or Alzheimer's type neurodegeneration (p < 0.05) and significantly less likely to have alcohol-related impairment (p < 0.05). Chi-square analyses revealed significantly greater rates of impairment for the squalor-only group (p < 0.05) in visuospatial reasoning, abstraction, planning, organisation, problem solving and mental flexibility, compared with the squalor-hoarding group. Logistic regression analysis indicated that impaired mental flexibility was a significant predictor and strongly indicated squalor only (odds ratio = 0.07; 95% confidence interval: 0.01-0.82). Preliminary evidence suggests that squalor associated with hoarding may have distinct neuropsychological features compared against squalor only. Future work should be conducted using a larger sample and a common neuropsychological battery to better understand the deficits associated with hoarding-related squalor. Copyright © 2016 John Wiley & Sons, Ltd.