Health System Design Research Articles

7.H. Round table: Advancing societal goals through health systems: Insights from the Renewed HSPA Framework

Abstract The purpose of this workshop, entitled ‘Advancing societal goals through health systems: Insights from the renewed HSPA framework,’ is to take a deeper look at the intricate relationships between health systems and broader societal objectives. We will dissect the contributions of health systems to societal well-being, a concept that stretches beyond mere economic growth to include social cohesion, environmental sustainability, and economic development. The session will examine the renewed global Health System Performance Assessment Framework, which serves as a tool for policymakers to better understand how health systems fit together and explains how they perform. This framework allows for a clearer interpretation of health data and provides a pathway to pinpoint health system issues and design that are most likely to enhance performance and resilience. The workshop will delve into the three dimensions of societal well-being-social cohesion, economic development, and environmental sustainability-nested within the HSPA framework. We will explore the health system’s role in advancing these dimensions, such as fostering community bonds, supporting economic growth through a healthy workforce, and contributing to the sustainable management of environmental resources. Integrating health system performance into societal goals is a practical obligation to create a resilient, cohesive, and economically robust society. This workshop will engage stakeholders in a discourse to translate this integration into multisectoral and actionable policies, aligning health system goals with societal aspirations for a sustainable future. This workshop will focus on: How health system assessments can capture contributions to societal goals, underpinning sustainable economic and environmental practices. Real-world case studies showcasing health systems’ role in fostering societal well-being and advancing public health policies. Interactive discussions will shed light on how health systems can be pivotal in achieving the Sustainable Development Goals, particularly in the face of modern challenges such as climate change, demographic shifts, and economic pressures. Key messages • Health systems play a pivotal role in advancing societal well-being beyond traditional health outcomes. • The renewed HSPA framework is a robust tool for policymakers to align health system performance with broader societal goals. Speakers/Panelists Scott Greer University of Michigan, European Observatory on Health Systems and Policies, Ann Arbor, USA Andrea Schmidt Austrian Public Health Institute, Vienna, Austria

10.A. Round table: Transforming public health systems at large scale: no pain, no gain

Abstract The COVID-19 pandemic, acceleration of climate change, and geopolitical turmoil have triggered discussions about how public health systems in Europe need to transform to be adequately equipped for the so-called “permacrisis”. The challenges to policy makers, health institutions and health services have become so multifaceted, that single solutions from the health sector alone no longer work. Yet, despite the complexity, countries seek to get its own house in order whilst building on inter-sectoral and European approaches in parallel. Germany, Ireland, and Ukraine have all embarked upon ambitious public health services and institutional reforms, leading to transformative change in public health systems. WHO has been accompanying these reforms. The workshop will provide a platform to draw insights and lessons on transforming public health systems from all three countries, although their population size, their socioeconomic and political situation and their public health system design is so different. As the smallest of the three countries in population, Ireland created coherence and is aligning public health actors within “Healthy Ireland” and the Sláintecaire and the Crowe Horwath public health reforms. Germany’s “Pact for the Public Health Services” has been one of the greatest public health investment programs in Europe that was initiated following lessons from the COVID-19 pandemic. And Ukraine has undertaken important legal steps to adopt a Public Health System Law, in the middle of a war of aggression on its territory. The workshop will exhibit the process of large-scale public health system transformation in each of the three countries. The purpose is to identify the enablers that make large scale system transformation possible and addressing some of the pains and gains. The workshop will have three parts. Part one consists of three presentations on large scale system reforms from each of the participating countries. Part two consists of a moderated Q&A session. Part three will focus on the synthesis of enablers for large scale public health system reforms through interaction with the workshop participants, using a digital white board. Key messages • Disruptive times can create enabling conditions for large scale public health system transformation. • Designing and implementing large scale public health system reforms is complex, requiring passion, resilience, and collaborative leadership.

Policy, system and service design influence on healthcare inequities for people with end-of-life chronic obstructive airways disease, their support people and health professionals

BackgroundPeople with end-of-life chronic obstructive pulmonary disease (COPD) experience debilitating physical limitations, with a high mortality rate. Our research has shown health system design and delivery leads to inequitable outcomes. Enabling people with end-of-life COPD, their support people, and health professionals to partner in setting the agenda for resource allocation may inform health service improvement.DesignQualitative methodology utilising focus groups including patients, family, friends, informal support people, health care workers and professionals.MethodsThe analysis, utilising critical theory and Actor-Network theory, positioned people with severe COPD, their support people and health professionals as experts in end-of-life care. Analyses triangulated these perspectives, and were reviewed by the research investigators and an expert reference group.ResultsParticipants (n=74) in seven focus groups reported their experiences of inequity within the healthcare system. Equity was an overarching phenomenon identified by participants, with three specific themes being described: policy design, system design, and service design.ConclusionExperiences of patients, their support people and health professionals as experts in end-of-life COPD care can inform health systems and health service design to address current inequities in funding and delivery of care for end-of-life COPD.

The Impact of Public Health on Health Planning

This study investigates the complex relationship between public health and health planning, specifically how public health influences the design of health systems and services. It looks into the use of public health data and frameworks in health planning to address health inequities, socioeconomic factors, and community-level health issues. Case studies demonstrate effective models in which public health initiatives influence health planning, stressing stakeholder involvement, interdisciplinary methods, and policy frameworks. The study continues by discussing the obstacles and potential for better integrating public health into comprehensive health planning. Keywords: Public health, health planning, socio-economic determinants, health disparities, community health, policy integration.

Equity in practice: Integrating cross cultural health brokers for culturally safe primary care for immigrants and refugees in British Columbia.

Umbrella Multicultural Health Co-op is a community health centre serving cultural communities of immigrants/refugees in British Columbia. It uses Cross Cultural Health Brokers (CCHBs), multicultural workers bridging patients and the healthcare system, to better meet the primary care needs of immigrant/refugee populations. Through the Team Primary Care initiative, Umbrella Co-op: (1) added new CCHBs alongside allied health practitioners; and (2) implemented team workshops and evaluation for quality improvement. The learning health system framework guided project activities. Comprehensive, culturally responsive primary care for immigrants and refugees benefits from a team-based approach that includes the integration of CCHBs. Team development activities improved team function. Co-developing evaluation with the interprofessional team enabled meaningful participation. Health system design for equity-oriented team-based primary care for immigrants and refugees should include resources for CCHBs and team development infrastructure.

Design of Health and Elderly Care Intelligent Monitoring System Based on IoT Wireless Sensing and Data Mining

Design of Health and Elderly Care Intelligent Monitoring System Based on IoT Wireless Sensing and Data Mining

Telehealth development in the WHO European region: Results from a quantitative survey and insights from Norway

BackgroundThe COVID-19 pandemic sent shock waves through societies, economies, and health systems of Member States in the WHO European Region and beyond. During the pandemic, most countries transitioned from a slow to a rapid adoption of telehealth solutions, to accommodate the public health and social measures introduced to mitigate the spread of the disease. As countries shift to a post-pandemic world, the question remains whether telehealth’s importance as a mode of care provision in Europe continues to be significant. ObjectiveThis paper aims to present, synthesize, and interpret results from the Telehealth Programmes section of the 2022 WHO Survey on Digital Health (2022 WHO/Europe DH Survey). We specifically analyze the implementation and use of teleradiology, telemedicine, and telepsychiatry. Norwegian telehealth experiences will be used to illustrate survey findings, and we discuss some of the relevant barriers and facilitators that impact the use of telehealth services. MethodsThe survey tool was revised from the 2015 WHO Global Survey on eHealth, updated to reflect recent progress and policy priorities.The 2022 WHO/Europe DH Survey was conducted by WHO and circulated to Member States in its European Region from April to October 2022. ResultsThe data analysis revealed that teleradiology, telemedicine, and telepsychiatry are the telehealth services most commonly used in the WHO European Region in 2022. Funding remains the most significant barrier to the implementation of telehealth in the Region, followed by infrastructure and capacity/human resources. The survey results highlighted in this study are presented in the following sections: (1) telehealth strategies and financing, (2) telehealth programmes and services offered by Member States of the WHO European Region, (3) barriers to implementing telehealth services, and (4) monitoring and evaluation of telehealth. ConclusionBased on WHO’s 2022 survey, the use of telehealth in the WHO European Region is on the rise. However, merely having telehealth in place is not sufficient for its successful and sustained use for care provision. Responses also uncovered regional differences and barriers that need to be overcome. Successful implementation and scaling of telehealth requires rethinking the design of health and social care systems to create robust, trustworthy, and person-centred digital health and care services.

Enhanced Medical Image Segmentation using Transfer Learning with Res101_UNet: Experimental Insights and Comparative Performance Analysis

Throughout the past few decades, artificial intelligence and machine learning have seen a lot of active research in areas such as computer vision, natural language processing, and speech processing. As a result, deep learning models became state-of-the-art for computer vision tasks such as object detection, classification, segmentation, and other allied tasks. Of course, the fruits of this research are extended to the design of robust and reliable digital health systems as well as other applications in the healthcare sector. Many clinical applications require the automatic segmentation of medical images. Recent deep learning-based approaches have demonstrated state-of-the-art performance in medical image segmentation tasks. In addition to their ability to automatically extract features and generalize over large amounts of data, transfer learning based deep learning models have proven to be handy for data scared areas like medical domains. In this research, we investigate and demonstrate the efficacy of a DCNN-based transfer learning model -Res101_Unet, which has been trained and/or fine-tuned to execute tumor tissue segmentation tasks in MRI, CT, PET, and X-RAY pictures of medical organ scans with little data. For our experimental study, we employed two image datasets: 'Liver Tumor' and 'Gland Colon Cancer', both obtained from the Kaggle portal. This experimental setup includes an Open-Source segmentation model API. Our findings indicate that domain similarity-based transfer learning can be used to data-scarce sectors. We achieved 98.47% accuracy and a IoU score of 0.9891 on Liver Tumor data and 0.6956 accuracy and a IoU score of 0.7043 on gland colon dataset.

Attention Among Health Care Professionals : A Scoping Review.

The concept of attention can provide insight into the needs of clinicians and how health systems design can impact patient care quality and medical errors. To conduct a scoping review to 1) identify and characterize literature relevant to clinician attention; 2) compile metrics used to measure attention; and 3) create a framework of key concepts. Cumulated Index to Nursing and Allied Health Literature (CINAHL), Medline (PubMed), and Embase (Ovid) from 2001 to 26 February 2024. English-language studies addressing health care worker attention in patient care. At least dual review and data abstraction. Article information, health care professional studied, practice environment, study design and intent, factor type related to attention, and metrics of attention used. Of 6448 screened articles, 585 met inclusion criteria. Most studies were descriptive (n = 469) versus investigational (n = 116). More studies focused on barriers to attention (n = 387; 342 descriptive and 45 investigational) versus facilitators to improving attention (n = 198; 112 descriptive and 86 investigational). We developed a framework, grouping studies into 6 categories: 1) definitions of attention, 2) the clinical environment and its effect on attention, 3) personal factors affecting attention, 4) relationships between interventions or factors that affect attention and patient outcomes, 5) the effect of clinical alarms and alarm fatigue on attention, and 6) health information technology's effect on attention. Eighty-two metrics were used to measure attention. Does not synthesize answers to specific questions. Quality of studies was not assessed. This overview may be a resource for researchers, quality improvement experts, and health system leaders to improve clinical environments. Future systematic reviews may synthesize evidence on metrics to measure attention and on the effectiveness of barriers or facilitators related to attention. None.

The S20 Brazilian Mental Health Report for Building a Just World and a Sustainable Planet: Part II.

This is the second part of the Brazilian S20 mental health report. The mental health working group is dedicated to leveraging scientific insights to foster innovation and propose actionable recommendations for implementation in Brazil and participating countries. In addressing the heightened mental health challenges in a post-pandemic world, strategies should encompass several key elements. This second part of the S20 Brazilian Mental Health Report will delve into some of these elements, including: the impact of climate change on mental health, the influence of environmental factors on neurodevelopmental disorders, the intersection of serious mental illness and precision psychiatry, the co-occurrence of physical and mental disorders, advancements in biomarkers for mental disorders, the utilization of digital health in mental healthcare, the implementation of interventional psychiatry, and the design of innovative mental health systems integrating principles of innovation and human rights. Reassessing the treatment settings for psychiatric patients within general hospitals, where their mental health and physical needs are addressed should be prioritized in mental health policy. As the S20 countries prepare for the future, we need principles that stand to advance innovation, uphold human rights, and strive for the highest standards in mental health care.

Explore the practice and barriers of collaborative health policy and system research-priority setting exercise in Ethiopia

IntroductionCollaboration is gaining prominence in the priority setting of Health Policy And System Research (HPSR). However, its practice and challenges are not well explored in Ethiopia. Understanding the practice and barriers of collaborative Health Policy and System Research will help design approaches and platforms for setting inclusive and participatory policy and system-level health research topics. This paper explores the practice and barriers of collaborative HPSR-priority setting exercise in Ethiopia.MethodsThis study investigates the practice and barriers of collaborative health policy and system research priority-setting exercises in Ethiopia. Utilizing a mixed-methods approach, we conducted Key Informant Interviews (KIIs) and an online self-administered survey with open-ended questionnaires to capture diverse perspectives from stakeholders involved in the research priority-setting process. Through conventional content analysis, we identified key contents related to current practices, challenges, and opportunities for enhancing collaboration in health policy and system research prioritization.ResultsOur findings reveal a complex landscape characterized by varying levels of stakeholder engagement, institutional capacity constraints, and competing priorities within the health research ecosystem. Despite notable efforts to foster collaboration, stakeholders identified persistent challenges such as limited resources, institutional fragmentation, and inadequate coordination mechanisms as barriers to effective priority-setting processes. The implications of our research extend beyond academic discourse, with direct relevance to health policy and system research practice in Ethiopia. By shedding light on the dynamics of collaborative priority-setting exercises, our findings offer valuable insights for policymakers, researchers, and practitioners seeking to enhance the effectiveness and inclusivity of health research prioritization processes. Addressing the identified barriers and leveraging existing strengths in the research ecosystem can contribute to more evidence-informed health policies and programs, ultimately improving health outcomes for Ethiopian populations.ConclusionsMost institutions do not apply health policy and system research-priority setting to conduct informed decision-making. The barriers explored were weak integration, lack of knowledge, system, and platforms for the priority setting of Health Policy and System Resreach. So, it is recommended to build skills of different actors in the Health Policy and System Research-priority setting exercise and design a system and platform to integrate different stakeholders for collaborative research topics priority setting.

Exploring indicators of system-of-systems resilience: outcomes of a health systems design workshop at an international conference

AbstractThis contribution departs from an existing model, the Design Framework for Systems-of-Systems Resilience, to explore systems resilience issues across the health, environmental, and economic domains. The reported research activities include 1) a rapid review to collect a set of systems indicators and 2) a design workshop employing causal loop diagramming to map expected causal influences between indicators. Through this exercise, we examine key themes in this research domain and outline directions for further enquiry, while involving members of the design research community in an open dialogue.

Enablers and barriers to a quaternary prevention approach: a qualitative study of field experts

ObjectiveThere is a growing concern about the sustainability of healthcare and the impacts of ‘overuse’ on patients and systems. Quaternary prevention (P4), a concept promoting the protection of patients from...

Financing for equity for women's, children's and adolescents' health in low- and middle-income countries: A scoping review.

Over the past few decades, the world has witnessed considerable progress in women's, children's and adolescents' health (WCAH) and the Sustainable Development Goals (SDGs). Yet deep inequities remain between and within countries. This scoping review aims to map financing interventions and measures to improve equity in WCAH in low- and middle-income countries (LMICs). This scoping review was conducted following Joanna Briggs Institute (JBI) guidance for conducting such reviews as well as the PRISMA Extension for Scoping Reviews (PRISMA-ScR) for reporting scoping reviews. We searched Medline, PubMed, EMBASE and the World Health Organization's (WHO) Global Index Medicus, and relevant websites. The selection process was conducted in duplicate and independently. Out of 26 355 citations identified from electronic databases, relevant website searches and stakeholders' consultations, 413 studies were included in the final review. Conditional cash transfers (CCTs) (22.3%), health insurance (21.4%), user fee exemptions (18.1%) and vouchers (16.9%) were the most reported financial interventions and measures. The majority were targeted at women (57%) and children (21%) with others targeting adolescents (2.7%) and newborns (0.7%). The findings highlighted that CCTs, voucher programs and various insurance schemes can improve the utilization of maternal and child health services for the poor and the disadvantaged, and improve mortality and morbidity rates. However, multiple implementation challenges impact the effectiveness of these programmes. Some studies suggested that financial interventions alone would not be sufficient to achieve equity in health coverage among those of a lower income and those residing in remote regions. This review provides evidence on financing interventions to address the health needs of the most vulnerable communities. It can be used to inform the design of equitable health financing policies and health system reform efforts that are essential to moving towards universal health coverage (UHC). By also unveiling the knowledge gaps, it can be used to inform future research on financing interventions and measures to improve equity when addressing WCAH in LMICs.

Post-acute care in China: development, challenges, and future prospects

Introduction: Post-acute care has been proved to be a crucial component of the health care system which promotes autonomous living functions, reduce unnecessary hospitalization, prevent unnecessary placement in a long-term care facility, and coordinate care between different levels of care.Different countries have built various forms of a PAC systems for decades. In light of the ongoing payment reform and population aging, PAC is becoming increasingly important as a part of the integrated health system in China. Based on comprehensive literature review, this paper summarizes Chinese health policies and progress that addressed PAC system in recent decades and provides outlook for future development.
 Methods: We based our review on published work and grey literature, including reports (international and domestic) and government policy documents. We searched PubMed, Google Scholar, EconLit, MEDLINE, Social Science Research Network, Wiley Online Library, and China Knowledge Resource Integrated Database for relevant research published since January 2009, until June 2022. We restricted our search to works published in English or Chinese and used the search terms “post-acute care”, “rehabilitation”, “nursing care”, “intermediate/transitional care”, “continuous medical/healthcare”, AND “China”, and combinations of these terms.
 Results: In the past decade, China has released various policies to support and regulate the development of rehabilitative and nursing facilities, in order to meet the increasing demand for PAC, including the building of rehabilitation and nursing facilities, strengthening PAC at the primary care level, constructing a tiered rehabilitative network, and experimenting innovative payment methods. However, the challenges and gaps remain. China lacks clinical consensus for PAC delivery and continues to face a severe shortage of PAC resources, both in terms of facilities and professionals. Moreover, quality of PAC at the primary level health facilities needs improvement for the hierarchical care system to function well. The development of a sound financing and payment mechanism for PAC services is still at the initial stage.
 Conclusions: This is the first paper comprehensively examining the current development progress of PAC as a whole, and point direction for future PAC system development in China.In its overall health system design, although the name of PAC is not explicitly stated in domestic policy documents, it is considered as an integral part towards a more continuous system, and a preliminary framework of the PAC system has been established through various efforts. To promote the further development of China’s PAC system, attention should be given to setting up of official definition and clinical guidelines, development of sound financing and payment models, increasing public and private investment in PAC infrastructures, establishing health provider requirements, strengthening the training and retaining of professionals and development of unified information system for PAC based on functional assessment. 
 

Accelerating Health System Change and Transformation with the Health System Transformation Playbook: A Work Shop for Practitioners

Introduction: Health systems are complex adaptive systems (CAS) operating within larger socioeconomic contexts. Health system transformation (HST) is a complex endeavour that often results in unintended consequences. Existing methods to drive health system transformation is slow, have intrinsic limitations, and may impede successful implementation in local contexts.
 Yishun Health is a small regional population health system of 320,000 people. In our HST experience, services redesign and transformation projects were initiated continuously through time with transformation actions interacting across all health system sub-systems e.g. governance, manpower, financing, informatics systems, etc. Ensuring synergistic and coherent transformation into a more people-centred, integrated and value-driven health system at scale was extremely challenging.
 We designed a Health System Transformation Playbook (HSTP) as a design-, systems-, and complexity-thinking enabled methodology to systematically design, prioritize and test health system and services transformation actions, anchored on a three-step (1) iterative story-telling, (2) model building and (3) pathfinding process that tackles the scale of socially and technologically complex adaptive systems through time.
 It is hypothesized that the use of HSTP enables stewards of health systems to gain a more systematic and coherent understanding of health systems services planning and organization development, so as to accelerate transformation towards people-centred, integrated and value-driven health systems.
 Workshop: Our experience suggested that any HST method with the hope of accelerating whole system change must address the need to train and gather numerous stakeholders as co-designers, it must enable a continual series of innovations that remain synergistic despite their introduction at different time points and into different sub-systems of a CAS, and it must guard against incremental-only innovations, premature convergence and lock-in into HST paths that are less transformative or with potential negative effects.
 We hope to engage with health system leaders, designers, organization development and change management practitioners across the world through a facilitated workshop that encourages participant sharing and group discussion on how we lead and accelerate HST in our own organizational and cultural contexts. The session aims to co-create new knowledge on HST methodologies that can accelerate whole health systems change and transformation.
 
 Outline of Workshop (90 minutes) 
 
 Introduction to Health System Transformation (5min)
 Presentation on Health System Transformation Playbook (15min)
 Table Discussions (25min):
 
 - Group Story Telling: Each participant to share own experiences in leading and facilitating large scale or whole health systems change and transformation. Highlight valuable lessons, especially what didn’t work, counter-intuitive results and reasons.
 - Pathfinding: Generate questions or recommendations for accelerating HST. 
 
 Table Read Back & Facilitated Q&A (25min)
 Invitation to Share Personal Takeaways (15min)
 Closing (5min)
 
 Facilitators: A/Prof Ng Yeuk Fan & Dr Teo Ken Wah

Building a Better System to Support Family Caregivers: Engaging Multi-level Interdisciplinary Stakeholders in Micro, Meso, and Macro Level Learning Health System Design.  

The current Canadian healthcare workforce shortage and care crisis demands innovative solutions, yet it takes 17 years for healthcare innovations to reach 50% adoption in clinical practice. Healthcare workforce shortage solutions include expanding team-based care, moving integrated services closer to home[, and including Family Caregivers [FCGs] as partners on the care team, rather than treating them as visitors or patient accompaniments. Integrating FCGs as partners on the healthcare team improves patient care, health, and well-being, reduces the length of hospital stays, supports aging in the right place, promotes effective communication, and reduces healthcare providers’ workload. While FCGs and the people they care for require integrated care and services coordinated around their comprehensive needs, research confirms that FCGs remain invisible, and often marginalized by healthcare systems.
 Aim: Detail the micro-meso-macro-level elements and roles needed for building integrated FCG support systems.
 Results: As FCGs, the people they care for, and their care trajectories are diverse, an integrated system to support FCGs includes: 1) macro-level policy leadership 2) meso-level FCG-friendly communities, community organizations, health and social care systems, and providers trained to support FCGs; 3) micro-level assessment of FCGs needs and supports tailored to needs/goals, and 4) evaluation and practice improvement research. Three critical elements to Health Learning Approaches are: 1) Prioritize service needs and a design improvement approach; 2) Strengthen and link the assets required to operationalize rapid learning and a quality improvement approach, and 3) Establish a network of rapid-learning champions to drive and sustain action. Our Alberta-based Caregiver-Centered Care Research Program works at collaborating with stakeholders interested in enacting a collective impact approach to build a better system of all the essential elements of integrated health and social care programs and services needed to support FCG's well-being and sustain their caregiving. First, we convened a series of consultations to prioritize approaches to support FCGs. Stakeholders prioritized competency-based education for healthcare providers about person-centered care for FCGs. Accordingly, we engaged FCGs, researchers, health and social care providers/leaders, and policymakers to co-design and deliver free, online Foundational and Advanced education about providing person-centered care for FCGs to health and social care providers. Now, we need to strengthen our network and link assets. We convened a series of six webinars designed to raise awareness of FCGs' work, the need for systemic FCGs support, and to consult stakeholders about the next steps to integrate health and social care systems to support FCGs (October 20 – November 29, 2022). The webinars have also built our network of Canadian collaborators.
 Conclusions: The collaboration required to build a better system to support Canadian FCGs takes facilitation and time. The learning health system framework seems appropriate to approach the complex system and culture changes required more efficiently and effectively. 
 Implications: Learning Health Systems and co-design by communities of patients, FCGs, health and social care providers/leaders, and researchers are currently regarded as a superior approach to improving healthcare and health outcomes. A strength of our team is collaborative, trusting relationships. 

The VALUECARE Model for value-based, integrated health and social care services delivery supported by ICT for older adults: participatory research in 6 European countries

Introduction: In 2006, Michael Porter and Elizabeth Teisberg introduced the concept of value-based health care delivery by presenting a new framework for health system design. They proposed a fundamental unifying goal for health care: maximizing value for patients. Value is defined as the health outcomes achieved in response to the needs of a patient relative to the costs of delivering these outcomes. Consequently, understanding patient goals and values is integral to delivering high value. Participatory approaches are a key element in defining the care delivery model according to the patients’ needs and contribute to the sustainability of the care delivery. This study presents the VALUECARE model co-designed with older adults, care team members, health and social service managers and ICT experts to adapt the ValueCare concept supported by technology to the community context and end-users needs.
 Target group: Older people 65 years and older with comorbidity from 6 European countries (Croatia, Ireland, Portugal, Italy, Spain & The Netherlands) facing different health challenges (cardiovascular disease, cognitive decline, frailty, and stroke).
 Participants engaged in the co-design of the value based integrated care: A total of 369 participants were involved in participatory activities with the purpose of co-designing the VALUECARE care model and supportive digital solution (n= 127 older adults, n=86 caregivers, n=109 health and social care practitioners, n=7 ICT experts, n=34 service managers, n=3 policy makers, n=3 municipality providers).
 Co-design activities implemented: Qualitative data was collected using focus groups and interviews, combining face-to-face and online means with the participants trying to adapt the methodology foreseen in the project to the pandemic situation. The eHealth Enhanced Chronic Care Model was used as a heuristic tool to integrate the discourses of the different stakeholders including older adults and those involved in the delivery of health and social care for them and featuring the guiding principles and the core elements for value-based, integrated health and social care for this group supported by ICT solutions. 
 Results: VALUECARE model highlights best practice value-based, integrated care delivery through the application of a set of 6 guiding principles for the model (i.e. quality and safety, technology as supportive tool) across 7 different key core elements (i.e. health and care decision support, comprehensive support and monitoring). Applying these principles and elements, better health outcomes and care experience for older adults are expected and an improvement in the care team wellbeing. 
 Next steps: Based on the co-design sessions, the co-designed VALUECARE model is being implemented and tested in 6 pilot sites. Continuous and periodic feedback is being collected from participants (older people and care team members) to refine the model and ensure quality care delivery, at the end of the project, a validated model of value-based and integrated care supported by technology.

Geographical challenges and inequity of healthcare access for high-risk paediatric heart disease.

Geographical context is an important consideration for health system design to promote equality in access to care for patients with childhood heart disease (CHD), particularly those living in regional, rural, and remote areas. To help inform future policy and practice recommendations, this study aimed to (i) describe the geographic distribution of high-risk CHD patients accessing an Australian state-wide specialist service and (ii) estimate travel time for accessing healthcare via general practitioners (primary), nearest paediatric centre (secondary) and specialist paediatric cardiac centre (tertiary). Participants included a cohort of children (0-18year) who accessed state-wide specialist CHD services over a 3-year period (2019-2021) in Queensland, Australia. Locations for patient residence, general practitioner, closest paediatric centre and tertiary cardiac centre were mapped using geographical information system (GIS) software (ArcGIS Online). Travel distance and times were estimated using a Google Maps Application Programming Interface (API). 1019 patients (median age 3.8 years) had cardiac intervention and were included in the sample. Of this cohort, 30.2% lived outside the heavily urbanised South East Queensland (SEQ) area where the tertiary centre is located. These patients travel substantially further and longer to access tertiary level care (but not secondary or primary level care) compared to those in SEQ. Median distance for patients residing outside SEQ to access tertiary care was 953km with a travel time of 10h 43min. This compares to 5.5km to the general practitioner and 20.6km to a paediatric service (8.9 and 54min respectively). This geographical mapping of CHD services has demonstrated a key challenge inherent in providing specialist cardiac care to children in a large state-based healthcare system. A significant proportion of high-risk patients live large distances from tertiary level care. The greater accessibility of primary care services highlights the importance of supporting primary care physicians outside metropolitan areas to acquire or build the ability and capacity to care for children with CHD. Strengthening local primary and secondary services not only has the potential to improve the outcomes of high-risk patients, but also to reduce costs and burden associated with potentially avoidable travel from regional, rural, or remote areas to access specialist CHD services.

Pediatric Patients Discharged After Transfer to a Pediatric Emergency Department: Opportunities for Telehealth?

Interemergency department pediatric transfers can be costly, involve risk, and may be disruptive to patients and families. Telehealth could be a way to safely reduce the number of transfers. We made an estimate of the proportion of transfers of pediatric patients to our emergency department (ED) that may have been avoidable using telehealth. This was a retrospective analysis of electronic health record data of all pediatric patients (younger than 19 years) who were transferred to a single urban, academic medical center pediatric emergency department (PED) (annual pediatric volume approximately 15,000) between June 1, 2016, and December 29, 2021. We defined transfers as potentially avoidable with telehealth (the primary outcome) when the encounter at the receiving ED resulted in ED discharge and 1) met our definition of low-resource intensity (had no laboratory tests, diagnostic imaging, procedures, or consultations) or 2) could have used initial ED resources with telehealth guidance. Among 4,446 PED patients received in transfer during the study period, 406 (9%) were low-resource intensity. Of the non-low-resource intensity encounters, as many as another 1,103 (24.8%) potentially could have been avoided depending on available telehealth and initial ED resources, ranging from 210 (4.7%) with only telehealth specialty consultation to 538 (7.4%) with imaging and telehealth specialty consultation, and up to 1,034 (23.3%) with laboratory, imaging, and telehealth specialty consultation. Our results suggest that depending on available telehealth and initial ED resources, between 9% and 33% of pediatric inter-ED transfers may have been avoidable. This information may guide health system design and PED operations when considering implementing pediatric telehealth.