Implementation Of Integrated Care Pathways Research Articles

Impact of standardizing care for agitation in dementia using an integrated care pathway on an inpatient geriatric psychiatry unit.

This study examined the effectiveness of an integrated care pathway (ICP), including a medication algorithm, to treat agitation associated with dementia. Analyses of data (both prospective and retrospective) collected during routine clinical care. Geriatric Psychiatry Inpatient Unit. Patients with agitation associated with dementia (n = 28) who were treated as part of the implementation of the ICP and those who received treatment-as-usual (TAU) (n = 28) on the same inpatient unit before the implementation of the ICP. Two control groups of patients without dementia treated on the same unit contemporaneously to the TAU (n = 17) and ICP groups (n = 36) were included to account for any secular trends. ICP. Cohen Mansfield Agitation Inventory (CMAI), Neuropsychiatric Inventory Questionnaire (NPIQ), and assessment of motor symptoms were completed during the ICP implementation. Chart review was used to obtain length of inpatient stay and rates of psychotropic polypharmacy. Patients in the ICP group experienced a reduction in their scores on the CMAI and NPIQ and no changes in motor symptoms. Compared to the TAU group, the ICP group had a higher chance of an earlier discharge from hospital, a lower rate of psychotropic polypharmacy, and a lower chance of having a fall during hospital stay. In contrast, these outcomes did not differ between the two control groups. These preliminary results suggest that an ICP can be used effectively to treat agitation associated with dementia in inpatients. A larger randomized study is needed to confirm these results.

Adapting an integrated care pathway for implementing electronic patient reported outcomes assessment in routine oncology care: Lessons learned from a case study.

Details of the development and implementation of integrated care pathways (ICPs) in the context of electronic collection of patient reported outcomes (ePROs) for cancer patients are largely lacking in the literature. This study describes what, why and how decisions were made to adapt and implement an ePROs ICP for patients with lung cancer. A consensus process was utilized, with the implementation advisory group including multidisciplinary representation from three participating hospitals, to identify local champions and adapt and incorporate the ePRO ICP into the local contexts. Engagement meetings were documented via meeting transcripts, and detailed notes from October 2019 to November 2020 were content-analysed to identify decision-making themes based on the Consolidated Framework for Implementation Research; workflows and process maps were reviewed and modified to integrate ePROs. In total, 55 engagement activities were held (24 meetings, 20 workshops11 educational sessions), with n = 96 staff from multiple disciplines participating in the ePROs implementation through advisory meetings, process mapping, change management and staff education. Decisions were made regarding eligible patient cohorts to include, the process for onboarding patients onto the ePRO system, and follow-up and referral pathways. Rationales for decisions included alignment with existing workflows, utilizing available staff, minimizing staff and patient burdenand maximizing patient engagement. Existing resources, staff inputand technical and logistical reasons often guided the ICP decisions, highlighting the need for in-depth engagement across all stakeholders for optimal implementation of ePRO ICPs. The ePRO implementation required substantial dialogue and systematic resolution to reach agreement on the final processes. Adapting the local ICP through rigorous engagement facilitated the successful implementation of ePROs as business-as-usual at all three cancer centres. Involving all relevant stakeholders is critical to the successful adaptation of ICPs before their introduction into routine care.

The Exponential Phase of the Covid-19 Pandemic in Central Italy: An Integrated Care Pathway

The Coronavirus Disease (Covid-19) pandemic is rapidly spreading across the world, representing an unparalleled challenge for health care systems. There are differences in the estimated fatality rates, which cannot be explained easily. In Italy, the estimated case fatality rate was 12.7% in mid-April, while Germany remained at 1.8%. Moreover, it is to be noted that different areas of Italy have very different lethality rates. Due to the complexity of Covid-19 patient management, it is of paramount importance to develop a well-defined clinical workflow in order to avoid the inconsistent management of patients. The Integrated Care Pathway (ICP) represents a multidisciplinary outline of anticipated care to support patient management in the Sant’Andrea Hospital, Rome. The main objective of this pilot study was to develop a new ICP evaluated by care indicators, in order to improve the COVID-19 patient management. The suggested ICP was developed by a multi-professional team composed of different specialists and administrators already involved in clinical and management processes. After a review of current internal practices and published evidences, we identified (1) the activities performed during care delivery, (2) the responsibilities for these activities, (3) hospital structural adaptation needs and potential improvements, and (4) ICP indicators. The process map formed the basis of the final ICP document; 160 COVID-19 inpatients were considered, and the effect of the ICP implementation was evaluated over time during the exponential phase of the COVID-19 pandemic. In conclusion, a rapid adoption of ICP and regular audits of quality indicators for the management of COVID-19 patients might be important tools to improve the quality of care and outcomes.

Integrated Care Pathway and personalised care at the heart of Lombardy Region’s strategy for tackling chronic care: lessons learnt from the CreG (Chronic Related Group) model

Lombardy Region launched a three years’ plan (2016-2018) for tackling chronic care and frailty through a redesign of the health and social care delivery system that hinges on a population health management (PHM) perspective for programme planning interventions and resources and Integrated Care Pathways (ICPs) for organising the provision of personalised care. The reform strategy relies on the Regional piloting experience with the CReG (Chronic Related Group) model that started in 2011. The latter represents a prospective payment system based on a clinical-risk adjustment model. The model is built on three steps: the classification of diseases, a grouping system, and a bundle tariff accounting for a one-year period of care (including pharmacy and outpatient services). The pilot programme has been managed in the Primary Care setting, through GP-cooperatives with several tools and services (Service Centre) to support care planning activities and the actual implementation of ICPs, based on prospective and flexible Personalized Care Plans (PCP). The paper presents the most significant results of the CReG model, comparing data from the patients’ enrolled in 2012 (first year) and in 2015 (latest available), at the population level (chronic cohorts) and at individual one (impacts of PCP and GPs’ behaviors). A statistical analysis is performed on quantitative data retrieved from different administrative databases (diagnostic and outpatient services, hospital discharge report, pharmaceutical consumption, PCP register, GP patients’ register, Service Centres’ activities). The discussion highlights the lessons learnt and the challenges to exploit the CReG model yet to the overall Regional population yet to other settings, like intermediate and acute care, broadening the mean of PCPs, as foreseen by the Regional policy.

Integrated care pathway for rectal cancer treatment: health care resource utilization, costs, and outcomes.

Managed Flow C20 (MFC20) is an integrated care pathway (ICP) for rectal cancer implemented at a public teaching hospital. This study aims to quantify resource utilization and estimate direct costs and outcomes associated with the use of this ICP. We evaluated consecutive rectal cancer patients treated with neoadjuvant chemoradiotherapy (nCRT) followed by surgery, comparing the period before the ICP implementation (Pre-MFC20 group) and after (MFC20 group). We assessed times between treatment steps and quantified the resources utilized, as well as their costs. There were 112 patients in the Pre-MFC20 group and 218 in the MFC20 group. The mean treatment intervals were significantly shorter in the MFC20 group - from the first medical consultation to nCRT (48.3 vs. 87.5 days; P < 0.001); and from nCRT to surgery (14.8 vs. 23.0 weeks; P < 0.001) - as was the mean total treatment time (192.0 vs. 290.2 days; P < 0.001). Oncology consultations, computed tomography, MRI, and radiotherapy sessions were utilized more frequently in the Pre-MFC20 group (P < 0.001). The median per-patient cost was US$11 180.92 in the Pre-MFC20 group, compared with US$10 412.88 in the MFC20 group (P = 0.125). Daily hospital charges and consultations were the major determinants of the total cost of the treatment. There was no statistical difference in overall survival in the time periods examined. Implementation of a rectal cancer ICP reduced all treatment intervals and promoted rational utilization of oncology consultations and imaging, without increment in per-patient costs or detrimental effects in overall survival.

Perspectives of Technology Users on the Eve of Innovation Deployment: the Case of Integrated Care Pathways (ICPs)

Background: Over the last 10 years or so, integrated service networks (ISNs) for older people have been implemented throughout the Province of Quebec in Canada. The main instruments used in the ISNs are the Multiclientele Assessment Tool (OEMC; French acronym), including the Functional Autonomy Measurement System (SMAF); the Iso-SMAF profile classification system; and the Individualized service and allocation plan. All of these instruments are included in the computerized clinical and management solution (French acronym: RSIPA) of Quebec’s Ministry of Health and Social Services and used by more than 15,000 professionals. Despite the advantages offered by RISPA—such as the adoption of common vocabulary used by professionals and the use of the same instruments throughout the entire service continuum—it could be improved to support professionals in making decisions when assessing and planning services as well as to take into account the values and preferences of the elderly and their families in delivering services. In response to this shortcoming, our team developed integrated care pathways (ICPs), which were designed to use the instruments mentioned above in fulfilling the needs of frail and disabled older adults and to constitute the core decision-support system providing guidance on appropriate actions for specific clinical circumstances. Before being implemented throughout Quebec, the ICPs were developed as an electronic prototype with a local home-care-service organization. The purpose of this presentation is to provide an initial picture of clinical practices prior to the implementation of the ICPs and described the efforts in deploying them.Method: Qualitative research was conducted with ISNs users. Semi-structured interviews were carried out with professionals in order to assess clinical practices that is, use of the existing OEMC instruments and the Individualized service and allocation plan as well as to determine the state of mind of professionals on the verge of the implementation. The interview guide was based on the Consolidated Framework for Implementation Research (CFIR). The interviews were recorded, transcribed, and analyzed according to CFIR themes. NVivo software was used to code and classify data.Results: A total of nine professionals from a home-care-service organization took part in the interviews, which lasted 45 minutes. Most of the interviewees were trained in social work. Their comments about RSIPA instruments were essentially positive, except in the case of the Individualized service and allocation plan. The responses indicate that the OEMC is a good instrument for service continuity. It provides a great deal of information that provides an overview and makes it possible to grasp the situation of the elderly person and his or her family. On the other hand, it is long to complete and certain information must be duplicated in other instruments. The Individualized service and allocation plan was introduced in 2014. The interviewees' perception was that this instrument responded to institutional needs and detected shortcomings in existing services rather than supporting the planning process conducted by care providers. The training on its use was deemed inadequate as was clinical and technical support. Faced with the imminent implementation of ICPs, several of the interviewees indicated that they didn't have much information about its content or implementation methods. They maintained that they had not been involved in the consultation process or even consulted about more technical issues. Moreover, a number of interviewees that they were curious and excited to find out more about the ICPs and that the ICPs could save time and yield higher-quality interventions.Discussion: It is interesting to draw relationships between interviewee criticisms related to training and support subsequent to the introduction of the Individualized service and allocation plan and what they hoped to have as training for ICP implementation. There appears to be a clear association between the lack of information and the degree of fear and apprehension. Certain interviewees stated that there was a climate of insecurity and stress in the teams and among care providers, which could be very fertile ground for the development of negative scenarios. Several care providers asked managers to approach productivity during ICP implementation with open minds and understanding. Some suggested that managers should also take the ICP training in order to better understand what it demanded of teams in terms of adaptation and learning.Conclusion: The comments made by the professionals demonstrate that the support strategy adopted when the ICPs were on the verge of being implemented could be optimized.

Understanding context for quality improvement: Artefacts, affordances and socio-material infrastructure

Against a backdrop of growing concern for patient safety and service quality, modern health-care systems are witnessing a proliferation of improvement initiatives. The impact is often variable, however, and a key theme to emerge from evaluations of these efforts is a recognition of the effects of local context on the success or otherwise of an intervention. However, the 'context' tends to be understood in terms of higher order issues such as structure, culture and leadership. This article explores a dimension of context not typically taken into account in the health-care improvement literature: the infrastructural context. Many quality improvement interventions hinge on the introduction of artefacts to support behavioural change in the workplace. Despite calls from scholars of technology in practice for a greater acknowledgement of the role of such mundane artefacts in supporting the organisation of health-care work, they are rarely considered in these terms in evaluations of improvement efforts. In this article, I argue that understanding the potential generative effects of artefacts for quality improvement purposes requires an understanding of their 'affordances' and how these relate to the socio-material infrastructure into which they are to be introduced, and/or the technologies they are designed to replace. Integrated care pathway implementation is examined to illustrate this position. Drawing on qualitative case studies of integrated care pathway development processes undertaken in the UK National Health Service and ethnographic research on the international care pathway community, I consider the infrastructural reasons behind the challenges of making pathways work in organising health care, and why, contrary to the aspirations of their proponents, they often appear to increase rather than decrease paperwork.

Healthcare professionals' experiences of the implementation of integrated care pathways

The purpose of this paper is to report on a study that explores healthcare professionals' experiences of the implementation of integrated care pathways (ICPs). This study used a phenomenological research approach with a purposive sample of ten multi-disciplinary healthcare professionals across two acute hospitals in Ireland. Data were collected via semi-structured interviews and analysed using Colazzi's framework. The findings of the study are presented under four themes: buy-in from all disciplines, multidisciplinary communication, service-user involvement, and audit of ICPs. These themes emanated from the questions asked at interview. The limitations of the study include the small sample size and the use of two different interviewers across the sites. The inexperience of the interviewers is acknowledged as a limitation as the probing of some questions could have been improved. In addition the themes of the findings were predetermined by the use of the interview guide. Changes in existing institutional structures and cultures are required when introducing ICPs. It is necessary for senior management in organisations to lead by example. They also need to identify where support can be offered, such as in the provision of an ICP facilitator, education sessions in relation to ICPs and the development of strategies to improve multi-disciplinary buy-in and participation. The findings of this study respond to a gap in the literature in Ireland on the experiences of healthcare professionals who have implemented ICPs. Key findings of the study are the perception that the doctor is pivotal in driving the implementation of ICPs, yet the doctor was not always interested in this responsibility.

An integrated care pathway improves quality of life in Primary Biliary Cirrhosis

Clinical management of the chronic autoimmune liver disease, Primary Biliary Cirrhosis (PBC) involves addressing the underlying liver disease and a range of symptoms independent of liver disease severity. We have formally explored how these two perspectives of chronic disease management can be combined into a clinic consultation and impact upon quality of life (QOL) in PBC. To develop and implement the first Integrated Care Pathway (ICP) for the management of liver disease progression and symptom management in PBC. Process mapping of current practice by a multidisciplinary group developed a flowchart of care from which the clinical record evolved. Symptom assessment is incorporated into the PBC ICP (QOL; PBC-40, autonomic symptoms; Orthostatic Grading Scale, daytime sleepiness; Epworth Sleepiness Scale). All patients were considered who attended clinic between July 2005 and June 2006. Symptom assessment was repeated after 1 year in those participating in the initial clinic cohort. The PBC ICP was successfully introduced into our clinical environment with high levels of patient satisfaction. A total of 225 PBC patients attended over 12 months. Initial QOL assessments were in 195 (87%). Five patients died (3%). Repeat assessment 1 year later occurred in 149 subjects (149/190; 78%). All symptom domains improved after ICP implementation with significant improvements in those with moderate and severe symptoms in all PBC-40 symptom domains (P < 0.02). In those with severe fatigue (n = 38) symptom improvement was even more dramatic (P = 0.002). ICP implementation delivers evidence-based care, leads to improvements in QOL coupled with high levels of patient satisfaction.

Is Everything in the Garden Rosy? An Integrated Care Pathway for Acute Inpatient Mental Health Care, from Development to Evaluation: Part 2

This is the second paper of two, which considers the development, use and evaluation of an integrated care pathway (ICP) for acute inpatient mental health care. This paper reports an evaluation that was carried out to measure the impact of an ICP (described in Part 1) on the interventions it was designed to guide. The methodology used was pre- and post-ICP comparison of activities/care recorded in health-care records using delineating measures. Data were gathered from the notes of 23 service-users who had two inpatient stays within a year, one pre-ICP and one post-ICP. The findings suggested an overall improved provision of interventions, although as the ICP progressed the likelihood of receiving interventions fell. Three specific aspects were not affected by the ICP, these were giving information about observation levels to service-users, care planning and medical interventions. These issues are discussed and the conclusion raise implications for further ICP development and implementation.

The Cost of Developing and Implementing a Pathway for Congestive Heart Failure: Not an Inexpensive Journey

This article describes the cost of developing and implementing an integrated care pathway (ICP) for Congestive Heart Failure. Costs were tracked prospectively and allocated to either development or implementation. The development took 1,980 hours of staff time at a salary cost of $67,800. The ICP implementation took 2,083 hours of personnel time at a salary cost of $66,900. Even though an available pathway was adapted for local use, a substantial amount of time and money was required. This article may be useful to others who are interested in monitoring costs of pathways.

Is everything in the garden rosy? An integrated care pathway for acute inpatient mental health care, from development to evaluation: Part 1

This paper is the first of two which consider the development, use and evaluation of an integrated care pathway (ICP) for acute inpatient mental health care. The care pathway discussed is in use on seven inpatient wards within a UK mental health trust. Pathway development began in January 2003, and after a pilot period the pathway was fully implemented in June 2003. Since that time the pathway has been revised twice and the current version can be viewed at http://www.nimhe-em.org.uk/pages/integrated_care_pathways/index.shtml. This paper describes ICP development and implementation, with extracts from variance reports, compliance audits and concluding with lessons learnt from the process. Paper 2 of the series, which follows, describes an evaluation of the pathway's impact upon securing interventions.

Is Everything in the Garden Rosy? An Integrated Care Pathway for Acute Inpatient Mental Health Care, from Development to Evaluation: Part 1

This paper is the first of two which consider the development, use and evaluation of an integrated care pathway (ICP) for acute inpatient mental health care. The care pathway discussed is in use on seven inpatient wards within a UK mental health trust. Pathway development began in January 2003, and after a pilot period the pathway was fully implemented in June 2003. Since that time the pathway has been revised twice and the current version can be viewed at http://www.nimhe-em.org.uk/pages/integrated_care_pathways/index.shtml . This paper describes ICP development and implementation, with extracts from variance reports, compliance audits and concluding with lessons learnt from the process. Paper 2 of the series, which follows, describes an evaluation of the pathway's impact upon securing interventions.

Attitudes towards Integrated Care Pathways in the UK NHS: A Pilot Study in One UK NHS Trust

Background: Integrated care pathways (ICPs) offer an increasingly common approach to the standardization and integration of health-care practice in hospitals. The questionnaire study reported here was the final phase in a systematic investigation of the attitudes of health-care professionals towards ICPs in one acute UK NHS Trust. Method: A total of 314 health-care professionals working in a medium-sized NHS hospital in the UK completed a survey questionnaire, representing 34% of those approached. Results: Ten dimensions of attitude to ICPs were uncovered. Junior staff had less positive attitudes than senior staff on all dimensions. Across all professional groups (doctors, nurses, professions allied to medicine), staff were more unhappy with the idea of ICPs than with the evidence they are based on or the quality of the documentation itself. Conclusions: The investigation provided information about how widespread the dislike of ICPs was in the Trust and details of what was giving rise to staff unease. This enabled the authors to make recommendations to the Trust about the future development and implementation of ICPs in the Trust. The most central of these was that investing time and effort in changing the presentation of ICPs will not meet with success until more fundamental aspects of staff unease have been addressed. Overall, respondents from this Trust felt uneasy about ICPs because they do not like the idea of being told what to do. Therefore, if the ICP development programme is to continue at this hospital and be successful, the hearts and minds of those expected to use ICPs must be won over.

Promoting end-of-life care in nursing homes using an ‘integrated care pathway for the last days of life’

The purpose of this study was to promote quality end-of-life care in eight independent nursing homes using an ‘integrated care pathway (ICP) for the last days of life’ document. Action research methodology underpinned the design of this study in order to promote collaboration between staff in the nursing homes and the research team, empower staff in the practice of quality end-of-life care, and promote sustainable development of end-of-life care once the study finished. Considerable barriers within the nursing home context highlighted initial difficulties. This is reported elsewhere (Watson et al., in press) (Bridges Initiative, 2004). However, key champions appointed in each nursing home and their subsequent support was a major part of facilitating the ICP implementation. This paper reports the qualitative analysis from the summative evaluation of the study. One overarching pattern of ‘dying being more central to care in the nursing homes’ emerged as a result of the study; five themes that contributed to this shift were: greater ‘openness’ around death and dying; recognising dying and taking responsibility; better ‘teamwork’; critically using palliative care knowledge to influence practice; more meaningful communication.