Community-oriented Integrated Care Research Articles

Evaluating case studies of community-oriented integrated care.

This paper summarises a ten-year conversation within London Journal of Primary Care about the nature of community-oriented integrated care (COIC) and how to develop and evaluate it. COIC means integration of efforts for combined disease-treatment and health-enhancement at local, community level. COIC is similar to the World Health Organisation concept of a Community-Based Coordinating Hub – both require a local geographic area where different organisations align their activities for whole system integration and develop local communities for health. COIC is a necessary part of an integrated system for health and care because it enables multiple insights into ‘wicked problems’, and multiple services to integrate their activities for people with complex conditions, at the same time helping everyone to collaborate for the health of the local population. The conversation concludes seven aspects of COIC that warrant further attention.

Reorganising health and social care in Québec: a journey towards integrating care through mergers.

ContextTwo reforms (2014, 2015) characterised by the merger of public health care establishments profoundly shaped the current organisation of Quebec’s healthcare system. In 2015, 22 megastructures called Integrated Health and Social Services Centres/Integrated University Health and Social Services Centres (IHSSC/IUHSSC), were created and mandated to organise care delivery to their local populations.ObjectiveTo describe the service configuration of the 2015 healthcare system reforms, emphasising on how it shaped the organisation of primary health care (PHC) in Quebec.ResultsWith the creation of IHSSCs/IUHSSCs, Quebec’s healthcare system passed from three to two levels of governance, leading to a centralisation of decision-making powers. Most health services are delivered by the new organisations, while most PHC is delivered by semi-private medical practices, mainly Family Medicine Groups (FMGs). The FMG model is the preferred strategy to develop interdisciplinary team-work and inter-organizational collaborations with other PHC services.Conclusionmechanisms through which centralised healthcare systems achieve community oriented integrated care (COIC) need to be properly understood in order to improve meaningful clinical outcomes. Mergers may not sufficiently achieve integration of services in all its dimensions. These reforms should be monitored and evaluated on their capacity to mobilise all providers as well as physicians to participate in COIC.

Collaborating sites for community-oriented integrated care and health promotion.

London Journal of Primary Care wishes to develop a network of collaborating sites to better understand how to achieve community-oriented integrated care and health promotion in different contexts. A collaborating site can do more than submit papers. It can develop its own domain on the LJPC website, contribute to the development of LJPC policy, and stimulate discussions with other collaborating sites. At any time a collaborating site can opt out. In addition to securing papers for publication, a site might nurture a network of supporters, teach people to use multiple research and quality improvement methods, develop a system of governance for locally led inquiries, develop case studies of community-oriented integrated care and health promotion and facilitate within-site and between-site learning and change.

A network of activists for community-oriented integrated care.

A network of activists for community-oriented integrated care.

Community-oriented integrated care and health promotion - views from the street.

On the 1st and 2nd May 2015, participants at the RCGP London City Health Conference debated practical ways to achieve integrated care at community level. In five connected workshops, participants reviewed current work and identified ways to overcome some of the problems that had become apparent. In this paper, we summarise the conclusions of each workshop, and provide an overall comment. There are layers of complexity in community-oriented integrated care that are not apparent at first sight. The difficult thing is not persuading people that it matters, but finding ways to do it that are practical and sustainable. The dynamic and complex nature of the territory is bewildering. The expectation of silo-operating and linear thinking, and the language and models that encourage it, pervade health and social care. Comprehensive integration is possible, but the theory and practice are unfamiliar to many. Images, theories and models are needed to help people from all parts of the system to see big pictures and focused detail at the same time and oscillate between them to envision-integrated whole systems. Infrastructure needs to enable this, with coordination hubs, locality-based multidisciplinary meetings and cycles of inter-organisational improvement to nurture relationships across organisational boundaries.

How do we make community-oriented integrated care work?

Welcome to the first 2015 issue of LJPC, in which we continue the theme of community-oriented integrated care. In particular, how do we make it work? Lord Darzi, in his recent LJPC interview, explained that it is processes of transformation, rather than structural change that will build integrated care. He called for vision, risk taking and innovation to develop models of continuous improvement, building one stage upon another, and uniting practitioners through a shared approach to patient care. In this issue, Professor Ferlie offers a commentary on Lord Darzi's vision. He agrees that the vision is desirable, but also identifies four major questions that may obstruct implementation: Can primary care development and investment be protected in a cold financial climate? Does the current marketisation of health care erode integration? Does the health and social care system in London behave like a real system? Is there really a cultural shift towards empowerment and organizational learning? The UK is in an election year, and strategy for the NHS will be a hot topic. This means that strategy for integrated care will be a hot topic because it is thought to be one way to contain NHS costs without sacrificing quality. What do you think about Lord Darzi's vision and the four questions Professor Ferlie raises? Other papers in this issue include: an HGV driver with non-alcoholic liver disease – a case study arising from the integrated care pilot in West London (Al-Bakir & Devendra); the compelling story of helping your own father to have a ‘good death’ (Powell); Book Review: a career companion to becoming a GP: developing and shaping your career (Papanikitas) RCGP London and LJPC will hold the City Health Conference on 1–2 May 2015. Through workshops, we will continue the discussion about practical ways to make community-oriented integrated care work. Sign up now.

Introducing Volume 6 of London Journal of Primary Caer: community-oriented integrated care.

Introducing Volume 6 of London Journal of Primary Caer: community-oriented integrated care.

Meeting the needs of vulnerable patients: The need for team working across general practice and community nursing services.

General practitioners and district nurses have a long history of providing care outside the hospital setting. With health care increasingly moving out of the hospital setting, there are more opportunities for general practitioners and district nurses to work together to meet the health needs of the local population. However, the reduction in qualified specialist practitioner district nurses over the last decade is concerning. The need for an effective district nursing service has been recognised by the Department of Health in their own model - the nature of district nursing work, often over a long period, enables relationships to develop with the patient, family and informal carers as a basis for anticipatory care to manage long-term conditions. Communication and understanding of the role are central to enhance effective working between general practitioners and district nurses, which can be fostered by engagement in community-oriented integrated care and case management.

Achieving community oriented integrated care through the 2014 England GP contract.

I have been involved in developing different forms of community-oriented integrated care since 1989 when I set up the Liverpool Primary Care Facilitation Project. I never cease to be amazed at how effective and enjoyable it is when primary care practitioners and managers can work together across organisational boundaries to improve healthcare for local populations. I also never cease to be surprised at how hard it seems to be for many to believe that such an approach could be even contemplated, let alone systematically taught, applied and evaluated. In West London, I have seen the valuable effect of the Integrated Care Pilot at providing one of the key ingredients of community-oriented integrated care - geographic clustering of general practices (termed Health Networks) that provide a regular space where people of different disciplines can come together to learn from and with each other, and co-create things that improve the health of local people. I believe that the April 2014 changes to the England GP contract provide an opportunity for these Health Networks to make a quantum leap in achieving community-oriented integrated care and with it a renaissance of the NHS.

Infrastructure to support modern primary care: the NAPCRG debate update.

In December 2012, at the North American Primary Care Research Group (NAPCRG) conference in New Orleans (USA), associates of London Journal of Primary Care (LJPC) from London (UK) and Cleveland Ohio (USA) hosted a forum entitled ‘Local Health Communities for Integrated Care’. The forum was attended by senior practitioners/academics from different countries who debated the infrastructure needed to support collaboration at primary/community care level. They drew on lessons from West London's integrated care pilot1 and Cleveland's ‘Promoting Health across Boundaries’ initiative.2 Participants at the forum recognised international need for case studies of community-oriented integrated care (COIC), including primaryand community-care leadership of collaboration for integrated care, and continuous improvements of whole systems of care. In November 2013, at the NAPCRG conference in Ottawa (Canada), LJPC associates from Quebec (Canada) and London (UK) hosted a second forum to continue this conversation. In preparation for the Ottawa Forum, in October 2013 LJPC invited its readers to rank 11 aspects of integrated care in respect of their importance to research. Table 1 shows the results in order of most ‘votes’ overall (weighted formula). It also shows the first four (of 11) ‘votes’ of 61 respondents. Table 2 shows additional comments made by 30/61 respondents. Table 1 Priority aspects of integrated care to research Table 2 Additional comments made by 30 respondents about researching integrated care While ‘Patient Involvement’ and ‘Extended Multidisciplinary Primary Care Teams’ were perceived to be the most important aspects (and indeed 29/61 respondents gave them their first ‘vote’), the overall ranking pattern is more complicated. There is an argument for saying that all of these aspects are important, and their perceived importance may relate to their perceived neglect at present. Recognising the wide range of qualitative comments offered in Table 2, these initial results illustrate the range of research still needed to understand how the infrastructure of primary care can be developed, and, as discussions at the two conferences elaborated, more progress can be made in developing research that examines primary care in context.