Implementation Of Integrated Care Research Articles

Development of a Qualitative Data Analysis Codebook for Arterial Hypertension and Type-2-Diabetes Integrated Care Evaluation.

Non-communicable diseases, such as arterial hypertension (HTN) and type-2 diabetes (T2D), pose a global public health problem. Integrated care with focus on person-centred principles aims to enhance healthcare quality and access. Previous qualitative research has identified facilitators and barriers for scaling-up integrated care, however the lack of standardized terms and measures hinder cross-country comparisons. This paper addresses these gaps by presenting a generic codebook for qualitative research on integrated care implementation for HTN and T2D. The codebook serves as a tool for deductive or deductive-inductive qualitative analysis, organizing concepts and themes from qualitative data. It consists of nine first level and 39 second level themes. First level codes cover core issues; and second level codes provide detailed insights into facilitators and barriers. This codebook is more widely applicable than previously developed tools because it includes a broader scope of stakeholders across micro, meso, and macro levels, and the themes being derived from highly diverse health systems across high- and low-income countries. The codebook is a useful tool for implementation research on integrated care for HTN and T2D at global scale. It facilitates cross-country learning, contributing to improved implementation, scale-up and outcomes.

Cost-effectiveness of system-level mental health strategies for young people in the Australian Capital Territory: a dynamic simulation modelling study

Regional mental health planning is a key challenge for decision makers because mental health care is a complex, dynamic system. Economic evaluation using a system dynamics modelling approach presents an opportunity for more sophisticated planning and important evidence on the value of alternative investments. We aimed to investigate the cost-effectiveness of eight systems-based interventions targeted at improving the mental health and wellbeing of children, adolescents, and young adults in the Australian Capital Territory (ACT). We assessed eight interventions for children and young people (aged ≤25 years) with low, moderate, and high-to-very-high psychological distress: technology-enabled integrated care, emergency department-based suicide prevention, crisis response service, family education programme, online parenting programme, school-based suicide prevention programme, trauma service for youths, and multicultural-informed care. We developed a system dynamics model for the ACT through a participatory process and calibrated the model with historical data, including population demographics, the prevalence of psychological distress, and mental health services provision. We calculated incremental cost-effectiveness ratios compared with business as usual for cost (AU$) per: quality-adjusted life-year (QALY), suicide death avoided, self-harm related hospital admissions avoided, and mental health-related emergency department presentation, using a 10-year time horizon for health-care and societal perspectives. We investigated uncertainty through probabilistic sensitivity analysis and deterministic sensitivity analysis, including using a 30-year timeframe. From a societal perspective, increased investment in technology-enabled integrated care, family education, an online parenting programme, and multicultural-informed care were expected to improve health outcomes (incremental QALYs 4517 [95% UI -3135 to 14 507] for technology-enabled integrated care; 339 [91 to 661] for family education; 724 [114 to 1149] for the online parenting programme; and 137 [88 to 194] for multicultural-informed care) and reduce costs ($-91·4 million [-382·7 to 100·7]; $-12·8 million [-21·0 to -6·6]; $-3·6 million [-6·3 to 0·2]; and $-3·1 million [-4·5 to -1·8], respectively) compared with business as usual using a 10-year time horizon. The incremental net monetary benefit for the societal perspective for these four interventions was $452 million (-351 to 1555), $40 million (14 to 74), $61 million (9 to 98), and $14 million (9 to 20), respectively, compared with business as usual, when QALYs were monetised using a willingness to pay of $79 930 per QALY. Synergistic effects are anticipated if these interventions were to be implemented concurrently. The univariate and probabilistic sensitivity analyses indicated a high level of certainty in the results. Although emergency department-based suicide prevention and school-based suicide prevention were not cost effective in the base case (41 QALYs [0 to 48], incremental cost $4·1 million [1·2 to 8·2] for emergency department-based suicide prevention; -234 QALYs [-764 to 12], incremental cost $90·3 million [72·2 to 111·0] for school-based suicide prevention) compared with business as usual, there were scenarios for which these interventions could be considered cost effective. A dedicated trauma service for young people (9 QALYs gained [4 to 16], incremental cost $8·3 million [6·8 to 10·0]) and a crisis response service (-11 QALYs gained [-12 to -10], incremental cost $7·8 million [5·1 to 11·0]) were unlikely to be cost effective in terms of QALYs. Synergistic effects were identified, supporting the combined implementation of technology-enabled integrated care, family education, an online parenting programme, and multicultural-informed care. Synergistic effects, emergent outcomes in the form of unintended consequences, the capability to account for service capacity constraints, and ease of use by stakeholders are unique attributes of a system dynamics modelling approach to economic evaluation. BHP Foundation.

A 360<sup>0</sup> scan of primary care in Flanders: what is needed and how to address challenges to build a strong primary care.

The primary care (PC) in Flanders is going through a transition to realize integrated care (IC).
 Artevelde University of Applied Sciences (AUAS), as knowledge institution, wants to contribute to a strong PC and undertook a needs analysis incorporating the problems PC-actors are facing and the support AUAS could offer.
 A stakeholder mapping (e.g. care, welfare actors at micro-, meso- and macrolevel) was executed. 44 in dept interviews were conducted. After data-analyze, a member check (n=17) took place, followed by validation by the Flemish Patient Organization representing the person with care and support need, the Flemish Institute for PC, and the King Baudouin Foundation, a philanthropy organization.
 Key is the paradigm shift from supply-led care to person-centered care. Transformation towards IC encompasses various dimensions of integration: clinical, service, functional and organizational (Lewis et al.). Our findings showed obstacles on those dimensions. At the clinical level, care professionals and providers stressed the need for shared guidelines and protocols. At the service level, implementation of IC-services through interdisciplinary teams is hampered. Professionals do not know each other or what to expect, since they are mainly organized in ad hoc or fluid teams, hampering good collaboration. Participants indicated at the functional level the lacking of an integrated, patient-centered electronic record.Integration of organizations is still ongoing. Different obstacles within and without the sphere of influence of an organization were brought up, e.g., the current legal and financial framework.
 The participants indicated that both the PC- sector as well as education, research and policy hold a piece of the puzzle to facilitate the different forms of cooperation. 
 They reached out to educational institutions to coordinate their educational and lifelong learning programs more co-creatively and flexible. Basic courses should work on interdisciplinary courses to promote cooperation later in the field. There is a need for further development of the so-called t-shaped professional, a professional with skills and expertise in a single field, but the ability to collaborate across disciplines with experts in other areas and to apply knowledge in areas of expertise other than one's own.
 Lifelong learning should work out multidisciplinary education courses targeting broad topics and develop a tailor-made offer, including coaching of PC actors, organizations, and networks. 
 They also called for more cooperation between PC and research. Research must be tailor-mode and needs to speed-up. Support in all forms and phases of research is wanted. A willingness to work together as equal partners from scratch is formulated. Co-creation and transfer of research competence are key. In addition, mandate is given to researchers to report results to policy.
 Based on those findings AUAS is working together with PC to develop an ""academic collaborative center (ACC)"" a sustainably funded collaboration between end users, science, care practice and education with complete equality between partners. Central is co-creation with intensive and equal collaboration between various stakeholders, creating scientific knowledge in which the perspectives of the end users are central (f.i. implementation of IC in PC) and creating societal impact (improve quality of care) are ambitions that are intertwined.
 
 

Maturity of Integrated Care in Belgium

Introduction: As integrated care (IC) has been on the Belgian policy agenda for almost a decade, it was requested by the federal minister of health to perform a maturity check of IC, as perceived by the stakeholders and patients. To serve as input for a new inter-federal plan, we were asked to identify actions for further implementation of IC.
 Methods: The perception of the professionals was assessed using the Scirocco tool, which gauges the maturity of twelve dimensions of IC on a scale from 0 to 5. Professionals considered were healthcare professionals, social workers, project coordinators of pilot projects, patient representatives, policy makers or advisers, and researchers. Sixteen discussion groups (140 stakeholders) and 6 world cafés (82 experts) were then organised to identify potential actions for implementation of integrated care in Belgium.
 The experience of the chronic patients was surveyed via the PACIC instrument, an instrument with 20 items scored on a five-point scale from ‘never’ to ‘always’ created to assess whether provided care is congruent with the Chronic Care Model.
 Since data collection took place during the COVID-19 pandemic, all data collection was done online.
 Results: The Scirocco assessment of 865 professionals showed that for 9 dimensions the maturity was rated low (median score 1), and for the other three the median score was 2 ("Populational approach", "Evaluation methods" and "Process coordination"). Small differences were observed between regions.
 A convenience sample of 1 298 chronic patients completed the PACIC questionnaire online. For 16 items out of the 20, “never”, “generally not” or “sometimes” were scored. However, more than 60% of the respondents were, most of the time or always, satisfied with the organisation of care. 
 More than 500 action points were identified by the stakeholders suggesting the need for a phased approach instead of formulating a number of isolated, stand-alone actions. Experts highlighted the need for a clear framework shared by the relevant policy levels to be able to formulate actionable policy measures. The framework must be clear in terms of targeted population and sectors, including coherent territories, defining roles and tasks of governance structures, the legislative and financial initiatives/reforms as well as the possibilities on the availability of data. An incremental financial reform towards a mixed model financing system including fee-for-service with alternative methods of payment is needed to stimulate the patient-centred and population approach as it was perceived as a large barrier towards more IC. Moreover, education is seen as an important lever and extra research is needed to identify relevant measurable indicators (including patient-reported). 
 Conclusion: Integrated Care in Belgium is perceived to be in an early phase, explaining the need for a stepped approach of an agreed upon framework/plan by all relevant policy levels. As it is not easy to define the framework, scenario-analyses including budget impact is recommended to make political choices about further implementation of integrated care.

Training for coordinating professionals as part of Dutch integrated care for childhood overweight and obesity – a mixed-methods evaluation

Introduction: Healthcare professionals (HCPs) play an important role in childhood overweight and obesity care, yet they often feel ill-equipped to manage this complex and sensitive health problem. As part of Dutch integrated care for childhood overweight and obesity, a training for coordinating professionals (CPs) was designed and carried out. This study evaluates the training based on the four levels of Kirkpatrick’s model of training evaluation: (1) reaction, (2) learning, (3) behaviour, and (4) results.
 Method: Eleven CPs who completed the training participated in this mixed-methods study. First, completed questionnaires on the four levels were analysed with Qualtrics. Next, the transcripts of semi-structured interviews on levels 1, 3 and 4 were analysed in MAXQDA using thematic analysis. 
 Results: On level 1, participants were satisfied with the training as it stimulated their professional and personal development, for instance awareness of prejudices about people with overweight and obesity. Barriers, improvements and needs from the training varied between participants based on their background. On level 2, CPs improved perceived knowledge about integrated care and its practice, skills for providing overweight and obesity care, coaching attitudes, and trust and commitment towards local integrated care. On level 3, the extent to which the learnings were practised depended on the experience and local context of the CP. Last, on level 4 CPs mentioned noticing post-training practical results for themselves, the child and the family, integrated care partners, and the participants’ organisation.
 Conclusion: This study evaluated a training for CPs for the support and care they provide to children with overweight and obesity and their families as part of Dutch integrated care. The training contributed to improve perceived knowledge, skills and attitudes of CPs. This study recommends sufficient implementation of local integrated care, to optimally practise what was learned during the training. More on-time evaluations of the training and taking the perspective of the organisation into account is needed. This would improve the training and give CPs confidence to adequately provide support and care to children with overweight and obesity and their families.
 Keywords: Pediatric obesity, education, health care providers, primary health care, mixed-methods appraisal

Creating a global learning environment to promote integrated care.

Introduction: While the concept of integrated care has evolved considerably, there is general agreement that the competences necessary to co-create, implement, work in, and evaluate integrated care are only taught and practiced piecemeal. There is a hunger for more information, training and exchange of knowledge and experiences. In general, performance and outcome measurement is lacking, resulting in gaps between implementation in theory and practice. This workshop will discuss how we can bring community members, professionals and policymakers together in a meaningful way to learn and grow together.
 Why are you conducting a workshop? The existing offers of degree and certificate programmes, targeted training by organisations or learning by doing, do not foster sustainable change in competences of the workforce, system leaders or the wider communities. Often that is because the focus is still on a specific context, competence, or profession. But evidence and experience underline how important it is for everyone to understand the principles of integrated care, including e.g. social determinants of health, co-creation or cross-sectoral, inter-organisational team work. In this workshop, we want to build on our collective intelligence to discuss, define and design a global learning platform, which complements and builds on existing offers to connect people on different levels and in different languages. The key questions to answer are:
 •What the key barriers for learning and practicing integrated care?
 •How we can foster the next generation to become true integrated care proponents?
 •What are current performance and outcome measures that can be implemented immediately?
 •What are gaps in outcome assessment that must be prioritized to ensure equity and health justice for all?
 •Who is missing from training discussion/ forums that would help advance integrated care?
 Who is it for? The workshop is for people with lived experience of health and social care (including family carers) and professionals, policy makers, evaluation and performance experts, managers and academics who are committed to joint learning as the basis of integrated care implementation.
 10 minutes introduction & collaborative definition of aims and outcomes of the workshop
 5 minutes explanation of the fish bowl discussion and introduction to the starting discussants
 20 minutes fish bowl discussion round 1
 20 minutes small-group discussions
 20 minutes fish bowl discussion round 2
 10 minutes summary and wrap-up
 Participants will have the opportunity to participate in the fish bowl discussions and in the following small-group discussions they can move around from topic to topic. A facilitator will remain at each flip chart to encourage discussion and foster actionability of ideas. The discussion will be visually recorded to enable participants to build on what has come before to enable a rich and diverse conversation.
 How are you going to summarize the take home messages?There will be a short feedback from each flip chart facilitator on main points discussed – the facilitation team will then write up the discussions into a short and accessible summary which will be shared through social media, integrated care networks and relevant organisational routes.

Integrated care pathways between primary, secondary and tertiary health care for Aboriginal and Torres Strait Islander Australians

Empirical evidence and current policy documents strongly indicate a requirement for greater healthcare integration for Aboriginal and Torres Strait Islander people as an extension of the current coordinated care models. System fragmentation and the documented evidence of inadequate care transitions of many Aboriginal and Torres Strait Islander patients test the adequacy and flexibility of health systems to provide access and effective, efficient and appropriate care. Integration across organisations and sectors in the health system is necessary for coordinated patient-centred care that improves patient experiences and health outcomes and adds value to the system by delivering efficiencies. In this project, we aimed to better understand integrated care as a significant quality improvement approach in delivering care between the primary, secondary and tertiary care systems for Aboriginal and Torres Strait Islander people as the first step to real-world design and implementation. Firstly, we used a ‘participatory’ systematic review methodology to identify care processes and effective components needed to support integrated care models between primary, secondary and tertiary care. We focused on the processes involved in its implementation, delivery, and outcomes and impact to develop a conceptual model. Engagement with healthcare providers and community members grounded the theoretical model in real-world contexts. We then tested the model using a jury approach and wargaming, a soft simulation method. The structural reforms needed to ensure effective multistakeholder, multilevel integrated care implementation were identified and priority setting for implementation considered. We will present the developed integrated care model and discuss the inherent opportunities and challenges for implementation.

The Integrated Care Workforce - why is nobody interested?

Introduction: The health and care workforce was under pressure long before the pandemic, not least because of the constant development of new technologies, policy reforms and dwindling ressources. In recent years, concepts like the Quadruple Aim or the WHO European Framework for Action for integrated health services delivery have helped to highlight the importance of workforce planning, education and training or role definitions for integrated care. If we want the principles of integrated care working to become engrained in the work ethic and culture of health and care, a lot more needs to happen on many levels in order to ensure that the full potential of the individual and the concept as a whole can be fulfilled. However, as the lack of response to a recent call for papers on the subject has shown, there still doesn’t seem to be much interest in the research, practice and planning to support an integrated care workforce.
 Aims and Scope of the workshop: We want to use this workshop therefore to discuss with the integrated care community, why so little is done to support the integrated care workforce. We understand the integrated care workforce to comprise of health and social care professionals, carers, volunteers, etc. but we are open to being challenged on this point. Interesting questions to explore include:
 •Why are there hardly any integrated care cases, which include continuous professional education and training programmes?
 •Why are professionals so seldomly included in research and practice design?
 •What role do patients, service users, volunteers, families, etc. play in the future workforce? Are they a part of it? How formal or informal should their role be? How can we use them more strategically in education and training at the least?
 •What support does the workforce need during the transition process from fragmented to integrated working?
 •How can professional associations become promoters of integrated care?
 •What are some of the good examples which illustrate the development of a resilient, compassionate and integrated workforce? How can digital solutions support them?
 Audience: The workshop is for professionals, policy makers, educators and teachers, managers and academics, as well as people with lived experience of health and social care (including family carers) who are committed to a healthy, integrated workforce as the basis of integrated care implementation.
 Programme:
 5 minutes introduction to the topic
 15 minutes brainstorming world café round 1
 5 minutes change over
 15 minutes world café round 2
 15 minutes plenary discussion on key messages and next steps
 5 minutes wrap-up and personal actions
 Objectives and outcomes: Th objective of this workshop is to identify the reasons, why the workforce is still not recognised as a crucial topic in theory and practice, except for headlines in the media. It will also define the most urgent research questions, and priorities for policy and practice, which should be discussed within the international network of integrated care to support a better prepared workforce for the future.

Healthcare Professionals' Perspectives on the Implementation of the Integrated Care Models for Chronic Patients.

Objective This study aimed toassess the understanding, adoption, and barriers to implementing integrated care for chronic diseases among healthcare professionals in Greece. By gathering insights from healthcare professionals directly involved in the care of patients with chronic conditions, this study sought to identify areas for improvement and inform future policy and strategic initiatives to enhance the quality of care and patient outcomes in Greece. Specific objectives included assessing healthcare professionals' knowledge and understanding of integrated care concepts, principles, and components in chronic disease management and exploring healthcare professionals' experiences in providing or participating in integrated care activities for patients with chronic diseases. Methods This study employed a census-based survey design to assess healthcare professionals' understanding, adoption, and barriers to the implementation of integrated care for chronic diseases in the Greek healthcare system. The sampling technique has been used to ensure the representation of different healthcare professions and regions in Greece. The survey questionnaire was structured based on the internationally recognized Chronic Care Model Elements Survey, specifically tailored to capture insights on integrated care for chronic illnesses in Greece. Healthcare professionals from diverse settings, including primary healthcare centers, public and private hospitals, specialty clinics, rehabilitation centers, home-based care services, and private sector practitioners, were targeted to gather comprehensive perspectives. Both urban and rural areas were included to ensure a representative sample, enabling an understanding of integrated care implementation in Greece. Results A total of 246 responses from healthcare professionals in Greece were collected and analyzed. An applicability index was constructed to evaluate the suitability of the integrated care system in Greece, utilizing variables collected during the survey. The reliability of the index was assessed using Cronbach's Alpha coefficient, which demonstrated a high value of 0.940, indicating strong internal consistency and correlation among the questions related to integrated care. However, the data collected for Greece exhibited a departure from a normal distribution using the Shapiro-Wilk test, suggesting the presence of barriers to the implementation of integrated care within the Greek healthcare system. Conclusions The study revealed several obstacles to integrated care implementation, encompassing organizational and individual factors, such as financial constraints, cultural differences, and regulatory challenges. Tackling these barriers will require a collective approach and close collaboration among multiple stakeholders to create an enabling context for adopting integrated care. Possible strategies involve resource allocation, fostering communication and cooperation among healthcare providers, and revising regulatory frameworks to facilitate integrated care practices. In order to achieve the national objectives of improving public health, the survey increases the focus on evidence-based public health.

Information and Communication Technology Based Integrated Care for Older Adults: A Scoping Review.

Integrated care is an important initiative to respond positively to the ageing of society and information and communication technology(ICT) plays an important role in facilitating the integration of functional and normative health and social care. The scoping review aims to synthesize evidence on the experience and practice of ICT-based implementation of integrated care for older adults. This study followed the research framework developed by Arksey and O'malley for the scoping review and systematically searched for relevant studies published between 1 January 2000 and 30 March 2022 from nine electronic databases, three specialist journals, three key institutional websites, 11 integrated care project websites, google scholar and references of the studies to be included. Two reviewers independently screened and extracted data and used thematic analysis to sort out and summarize the core elements, hindrances and facilitators of ICT-based integrated care. A total of 77 studies were included in this study, including 36 ICT-based practice models of integrated care with seven core elements of implementation including single entry point, comprehensive geriatric assessment, personalized care planning, multidisciplinary case conferences, coordinated care, case management and patient empowerment, which generally had a positive effect on improving quality of life, caregiver burden and primary care resource utilization for older adults, but effectiveness evaluations remained Heterogeneity exists. The barriers and facilitators to ICT-based implementation of integrated care were grouped into four themes: demand-side factors, provider factors, technology factors and system factors. The implementation of ICT-based integrated care for the elderly is expected to improve the health status of both the supply and demand of services, but there is still a need to strengthen the supply of human resources, team training and collaboration, ICT systems and financial support in order to promote the wider use of ICT in integrated care.

Scale-up of a chronic care model-based programme for type 2 diabetes in Belgium: a mixed-methods study

BackgroundType 2 diabetes (T2D) is an increasingly dominant disease. Interventions are more effective when carried out by a prepared and proactive team within an organised system — the integrated care (IC) model. The Chronic Care Model (CCM) provides guidance for its implementation, but scale-up of IC is challenging, and this hampers outcomes for T2D care. In this paper, we used the CCM to investigate the current implementation of IC in primary care in Flanders (Belgium) and its variability in different practice types.MethodsBelgium contains three different primary-care practice types: monodisciplinary fee-for-service practices, multidisciplinary fee-for-service practices and multidisciplinary capitation-based practices. Disproportional sampling was used to select a maximum of 10 practices for each type in three Flemish regions, leading to a total of 66 practices. The study employed a mixed methods design whereby the Assessment of Chronic Illness Care (ACIC) was complemented with interviews with general practitioners, nurses and dieticians linked to the 66 practices.ResultsThe ACIC scores of the fee-for-service practices — containing 97% of Belgian patients — only corresponded to basic support for chronic illness care for T2D. Multidisciplinary and capitation-based practices scored considerably higher than traditional monodisciplinary fee-for-service practices. The region had no significant impact on the ACIC scores. Having a nurse, being a capitation practice and having a secretary had a significant effect in the regression analysis, which explained 75% of the variance in ACIC scores. Better-performing practices were successful due to clear role-defining, task delegation to the nurse, coordination, structured use of the electronic medical record, planning of consultations and integration of self-management support, and behaviour-change intervention (internally or using community initiatives). The longer nurses work in primary care practices, the higher the chance that they perform more advanced tasks.ConclusionsBesides the presence of a nurse or secretary, also working multidisciplinary under one roof and a capitation-based financing system are important features of a system wherein IC for T2D can be scaled-up successfully. Belgian policymakers should rethink the role of paramedics in primary care and make the financing system more integrated. As the scale-up of the IC varied highly in different contexts, uniform roll-out across a health system containing multiple types of practices may not be successful.

Multicomponent integrated care for patients with chronic heart failure: systematic review and meta-analysis.

To investigate the effectiveness of multicomponent integrated care on clinical outcomes among patients with chronic heart failure. We conducted a meta-analysis of randomized clinical trials, published in English language from inception to 20 April 2022, with at least 3-month implementation of multicomponent integrated care (defined as two or more quality improvement strategies from different domains, viz. the healthcare system, healthcare providers, and patients). The study outcomes were mortality (all-cause or cardiovascular) and healthcare utilization (hospital readmission or emergency department visits). We pooled the risk ratio (RR) using Mantel-Haenszel test. A total of 105 trials (n=37 607 patients with chronic heart failure; mean age 67.9±7.3years; median duration of intervention 12months [interquartile range 6-12months]) were analysed. Compared with usual care, multicomponent integrated care was associated with reduced risk for all-cause mortality [RR 0.90, 95% confidence interval (CI) 0.86-0.95], cardiovascular mortality (RR 0.73, 95% CI 0.60-0.88), all-cause hospital readmission (RR 0.95, 95% CI 0.91-1.00), heart failure-related hospital readmission (RR 0.84, 95% CI 0.79-0.89), and all-cause emergency department visits (RR 0.91, 95% CI 0.84-0.98). Heart failure-related mortality (RR 0.94, 95% CI 0.74-1.18) and cardiovascular-related hospital readmission (RR 0.90, 95% CI 0.79-1.03) were not significant. The top three quality improvement strategies for all-cause mortality were promotion of self-management (RR 0.86, 95% CI 0.79-0.93), facilitated patient-provider communication (RR 0.87, 95% CI 0.81-0.93), and e-health (RR 0.88, 95% CI 0.81-0.96). Multicomponent integrated care reduced risks for mortality (all-cause and cardiovascular related), hospital readmission (all-cause and heart failure related), and all-cause emergency department visits among patients with chronic heart failure.

Using logic models to support integrated care implementation - lessons from implementation in 9 European integrated care regions

The International Journal of Integrated Care (IJIC) is an online, open-access, peer-reviewed scientific journal that publishes original articles in the field of integrated care on a continuous basis.IJIC has an Impact Factor of 5.120 (2020 JCR, received in June 2021)The IJIC 20th Anniversary Issue was published in 2021.

Identifying the Physical and Mental Healthcare Needs of Opioid Treatment Program Clients

Background: Individuals with opioid use disorder (OUD) often have significant medical and behavioral health needs that are unaddressed. Opioid treatment programs (OTP) are uniquely positioned to provide integrated services for OUD, physical and mental health but are underutilized for this purpose. This study aims to describe the physical and mental healthcare needs of OTP clients in order to inform integrated care implementation in OTPs. Method: OTP clients (n = 1261) in an integrated care program in the Bronx borough of New York City were assessed for mental health symptoms (e.g., anxiety, depression), chronic disease indicators (e.g., blood pressure, cholesterol), and general functioning (e.g., capability of managing healthcare needs). Results: Symptoms of anxiety, post-traumatic stress, and depression were common. Self-reported health status and level of functioning were generally poor. Heavy smoking and obesity were the most frequent physical health risks. Other chronic disease indicators (e.g., blood pressure) showed 25-46% may be at risk. Sixty percent had multiple mental health risks and 85% had multiple physical health risks. Older clients had a higher rate of hypertension and diabetes risk than younger clients. Conclusions: Integrated care programs in OTPs must be prepared to address and coordinate care for chronic mental and physical health conditions in addition to OUD.

The pros and cons of integrated care implementation in Central and Eastern Europe – a perspective from 9 CEE countries

The International Journal of Integrated Care (IJIC) is an online, open-access, peer-reviewed scientific journal that publishes original articles in the field of integrated care on a continuous basis.IJIC has an Impact Factor of 5.120 (2020 JCR, received in June 2021)The IJIC 20th Anniversary Issue was published in 2021.

IDF21-0244 Multicomponent integrated care and clinical outcomes in people with heart failure: A systematic review and meta-analysis

Background: Multicomponent integrated care is associated with sustained improvements in cardiometabolic risk factors among people with type 2 diabetes. However, its effects among people with chronic heart failure are less clear. Aim: To examine the effects of multicomponent integrated care on hard clinical outcomes among people with chronic heart failure. Method: We conducted a meta-analysis involving randomized clinical trials with implementation of multicomponent integrated care for at least 3 months. Eligible trials, published in English language from inception to 1 November 2020, were identified from PubMed, EMBASE, Ovid and the Cochrane Library databases. Multicomponent integrated care was defined as the implementation of at least 2 quality improvement strategies from any 2 domains targeting the healthcare system, healthcare providers or patients. The outcomes of interest were mortality, hospital readmission and emergency department visits, stratified by all-cause, cardiovascular- and heart failure-related, based on available data. We conducted the Mantel-Haenszel test to pool the risk ratio (RR) for the association between multicomponent integrated care and hard clinical outcomes. Results: A total of 104 trials involving 35,376 people with chronic heart failure (mean ± standard deviation age 70.2 ± 3.9 years) were included. The median duration of multicomponent integrated care intervention was 12 months (interquartile range 6-12 months). Compared with usual care, multicomponent integrated care was associated with a reduced risk for all-cause mortality (RR 0.91, 95% confidence interval [CI] 0.86-0.95, p<0.001), cardiovascular mortality (RR 0.70, 95% CI 0.57-0.85, p<0.001), all-cause hospital readmission (RR 0.95, 95% CI 0.91-1.00, p=0.040), heart failure-related hospital readmission (RR 0.82, 95% CI 0.75-0.90, p<0.001) and all-cause emergency department visits (RR 0.89, 95% CI 0.81-0.98, p=0.010) among people with chronic heart failure. However, there was no significant risk reduction for heart failure-related mortality (RR 0.94, 95% CI 0.74-1.18, p=0.580) and cardiovascular-related hospital readmission (RR 0.88, 95% CI 0.77-1.02, p=0.080). The top 3 quality improvement strategies with the largest effect sizes for all-cause mortality were promotion of self-management (RR 0.86, 95% CI 0.79-0.93, p<0.001), facilitated patient-provider communication (RR 0.87, 95% CI 0.82-0.94, p<0.001) and clinician reminder (RR 0.87, CI 95% 0.75-0.99, p=0.040). Discussion: Multicomponent integrated care is an effective approach to reduce risks for mortality and hospital readmission among people with chronic heart failure. Given the growing burden of heart failure, this patient-centred approach should be considered for service planning, tailored to the needs and capacity of the healthcare systems.

Implementing Asset-Based Integrated Care: A Tale of Two Localities.

Background:To date, few studies have examined the implementation of asset-based integrated care in the UK. This paper aims to address this gap in knowledge through examining the implementation of one model of asset-based integrated care, Local Area Coordination (LAC), within two localities in England.Methods:This paper draws upon data collected from two local authorities (site A and site B), which had both implemented LAC. Using a case study approach, qualitative data was collected from interviews with relevant stakeholders both internal and external to the local authorities. Data was analysed thematically.Results:The findings demonstrate the marked differences between the two sites’ approaches to LAC, especially in relation to: the implementation process; impact; and their collaboration with other agencies and communities.Discussion:The evidence presented in this paper demonstrates that the implementation of LAC, as with most complex service innovations, is dependent on the interplay of organisational and people-based components. In particular, successful implementation depends on maintaining a common vision of what an intervention will achieve and how it will work in practice, continual engagement with the political and organisational leaders of influence, positively addressing the anxieties of existing services and professions, and working with community groups.

The Advantages and Disadvantages of Integrated Care Implementation in Central and Eastern Europe - Perspective from 9 CEE Countries.

Introduction:Health and social care systems in Central and Eastern European (CEE) countries have undergone significant changes and are currently dealing with serious problems of system disintegration, coordination and a lack of control over the market environment.Description:The increased health needs related to the ageing society and epidemiological patterns in these countries also require funding needs to increase, rationing to be reformed, sectors to be integrated (the managed care approach), and an analytical information base to be developed if supervision of new technological approaches is to improve. The period of system transitions in CEE countries entailed significant changes in their health systems, including health care financing.Discussion:Large deficits in the public financing of health systems were just one of the challenges arising from the economic downturn of the 1990s, which was coupled with inflation, increasing unemployment, low salaries, a large informal sector and tax evasion in a number of CEE countries. During the communist period, there was universal access to a wide range of health services, proving it difficult to retain this coverage. As a result, many states sought to ration publicly funded health services – for example, through patient cost-sharing or decreasing the scope of basic benefits. Yet, not all of these reform plans were implemented, and in fact, some were rolled back or not implemented at all due to a lack of social or political consensus.Conclusion:CEE health systems had come to practice implicit rationing in the form of under-the-table payments from patients, quasi-formal payments to providers to compensate for lack of funding, and long waiting lists forcing patients to the private sector. All these difficulties pose a challenge to the implementation of integrated care.

Integrated Care in Switzerland: Strengths and Weaknesses of a Federal System.

Introduction:Switzerland’s fragmented healthcare system mirrors its federal structure and mix of cultures and languages. Although the Swiss have a higher life expectancy than most of their neighbours, their healthcare system faces similar challenges that call for more integrated care (IC).Aim/Method:This article aims to provide insight into the specificities of and latest developments in Switzerland’s healthcare system and how they may have influenced the development and implementation of IC there.Description/Discussion:The number of local IC initiatives has been growing steadily for 20 years. With a certain lag, various policies supporting IC have been established. Among them, a recent democratic debate on the federal mandatory health insurance law could either induce a radical move towards centralised support for IC or continue to support scattered local IC initiatives.Conclusion:In the future, Switzerland’s healthcare system will probably navigate between local IC initiatives and centralised, federal support for IC initiatives. This will be the reflection of a very Swiss way forward in a world without clear evidence on whether centralised or decentralised initiatives are more successful at developing IC.

Can integrated care improve the efficiency of hospitals? Research based on 200 Hospitals in China

BackgroundThe shift towards integrated care (IC) represents a global trend towards more comprehensive and coordinated systems of care, particularly for vulnerable populations, such as the elderly. When health systems face fiscal constraints, integrated care has been advanced as a potential solution by simultaneously improving health service effectiveness and efficiency. This paper addresses the latter. There are three study objectives: first, to compare efficiency differences between IC and non-IC hospitals in China; second, to examine variations in efficiency among different types of IC hospitals; and finally, to explore whether the implementation of IC impacts hospital efficiency.MethodsThis study uses Data Envelopment Analysis (DEA) to calculate efficiency scores among a sample of 200 hospitals in H Province, China. Tobit regression analysis was performed to explore the influence of IC implementation on hospital efficiency scores after adjustment for potential confounding. Moreover, the association between various input and output variables and the implementation of IC was investigated using regression techniques.ResultsThe study has four principal findings: first, IC hospitals, on average, are shown to be more efficient than non-IC hospitals after adjustment for covariates. Holding output constant, IC hospitals are shown to reduce their current input mix by 12% and 4% to achieve optimal efficiency under constant and variable returns-to-scale, respectively, while non-IC hospitals have to reduce their input mix by 26 and 20% to achieve the same level of efficiency; second, with respect to the efficiency of each type of IC, we show that higher efficiency scores are achieved by administrative and virtual IC models over a contractual IC model; third, we demonstrate that IC influences hospitals efficiency by impacting various input and output variables, such as length of stay, inpatient admissions, and staffing; fourth, while bed density per nurse was positively associated with hospital efficiency, the opposite was shown for bed density per physician.ConclusionsIC has the potential to promote hospital efficiency by influencing an array of input and output variables. Policies designed to facilitate the implementation of IC in hospitals need to be cognizant of the complex way IC impacts hospital efficiency.