Integrated Care Activities Research Articles

Implementing new forms of collaboration and participation in primary health care: leveraging past learnings to inform future initiatives

Introduction Within primary health care policy, there is an increasing focus on enhancing involvement with secondary health care, social care services and communities. Yet, translating these expectations into tangible changes frequently encounters significant obstacles. As part of an investigation into the progress made in achieving primary health care reform in Aotearoa New Zealand, realist research was undertaken with those charged with responsibility for national and local policies. The specific analysis in this paper probes primary health care leaders’ assessments of progress towards more collaboration with other health and non-health agencies, and communities. Aim This study aimed to investigate how ideas for more integration and joinedup care have found their way into the practice of primary health care in Aotearoa New Zealand. Methods Applying a realist logic of inquiry, data from semi-structured interviews with primary health care leaders were analysed to identify key contextual characteristics and mechanisms. Explanations were developed of what influenced leaders to invest energy in joined-up and integrated care activities. Results Our findings highlight three explanatory mechanisms and their associated contexts: a willingness to share power, build trusting relationships and manage task complexity. These underpin leaders’ accounts of the success (or otherwise) of collaborative arrangements. Discussion Such insights have import in the context of the current health reforms for stakeholders charged with developing local approaches to the planning and delivery of health services.

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.

Optimising Integrated Stroke Care in Regional Networks: A Nationwide Self-Assessment Study in 2012, 2015 and 2019.

Background:To help enhance the quality of integrated stroke care delivery, regional stroke services networks in the Netherlands participated in a self-assessment study in 2012, 2015 and 2019.Methods:Coordinators of the regional stroke services networks filled out an online self-assessment questionnaire in 2012, 2015 and 2019. The questionnaire, which was based on the Development Model for Integrated Care, consisted of 97 questions in nine clusters (themes). Cluster scores were calculated as proportions of the activities implemented. Associations between clusters and features of stroke services were assessed by regression analysis.Results:The response rate varied from 93.1% (2012) to 85.5% (2019). Over the years, the regional stroke services networks increased in ‘size’: the median number of organisations involved and the volume of patients per network increased (7 and 499 in 2019, compared to 5 and 364 in 2012). At the same time, fewer coordinators were appointed for more than 1 day a week in 2019 (35.1%) compared to 2012 (45.9%). Between 2012 and 2019, there were statistically significantly more elements implemented in four out of nine clusters: ‘Transparent entrepreneurship’ (MD = 18.0% F(1) = 10.693, p = 0.001), ‘Roles and tasks’ (MD = 14.0% F(1) = 9.255, p = 0.003), ‘Patient-centeredness’ (MD = 12.9% F(1) = 9.255, p = 0.003), and ‘Commitment’ (MD = 11.2%, F(1) = 4.982, p = 0.028). A statistically significant positive correlation was found for all clusters between implementation of activities and age of the network. In addition, the number of involved organisations is associated with better execution of implemented activities for ‘Transparent entrepreneurship’, ‘Result-focused learning’ and ‘Quality of care’. Conversely, there are small but negative associations between the volume of patients and implementation rates for ‘Interprofessional teamwork’ and ‘Patient-centredness’.Conclusion:This long-term analyses of stroke service development in the Netherlands, showed that between 2012 and 2019, integrated care activities within the regional stroke networks increased. Experience in collaboration between organisations within a network benefits the uptake of integrated care activities.

EHOME for an integrated care approach for drug-related problems in home-living older people

Introduction: Home-living older peoples often use many medications and the majority routinely take more than five prescription drugs, and are therefore prone to drug-related problems DRPs. For the management of DRPs, integrated primary care by the homecare, general practice and pharmacy is desired. The Homecare Observation of Medication-related problems by homecare Employees HOME-instrument is paper-based and assists homecare workers in reporting potential DRPs. To facilitate integrated multi professional consultation in primary care a digital report of DRPs from the HOME-instrument and digital monitoring and consulting of DRPs between homecare and general practices and/or pharmacies is desired. The objective of this study was to develop and evaluate the usability of eHOME, a mobile version of the HOME-instrument consisting of a report, monitoring and consulting system for primary care and to evaluate the type of DRPs revealed by eHOME, integrated care activities and the impact of DRPs on discomfort and clinical deterioration in homecare patients. Theory/Methods: The development phase of the Medical Research Council Framework was followed in which an iterative human-centered design approach was applied.The approach involved a Delphi-round for context of use and user requirements analysis of eHOME, followed by two series of pilots for testing the usability and redesign. The study was performed in 18 homecare teams n18, general practices 7 and pharmacies n10 in several settings in the Netherlands. Subsequently, a pilot study with one-year follow up was carried out in one primary care setting in the Netherlands consisting of 7 home care teams, 7 general practices and 6 pharmacies. Outcomes are: 1 types of DRPs in homecare patients, 2 integrated care activities and 3 classification of the clinical impact of DRPs on patients’ discomfort and deterioration unlikely to cause discomfort/clinical deterioration, potential to cause moderate discomfort/clinical deterioration and potential to result in severe discomfort/clinical deterioration. Results: The human-centered design study resulted in eHOME including a report, monitoring and consulting system for the primary care. The results of the pilot study will be expected in May 2018. Conclusion: The eHOME-instrument was found as convenient, clear and easy to use. eHOME can also be used by informal caregivers and professionals caregivers in other settings. Suggestions for future research: Future research on the cost-effectiveness of eHOME in primary care on patient related outcomes e.g. patient satisfaction, quality of life and care related outcomes e.g. changes in care program, consultation moments with the general practitioner, admission to nursing homes and hospitals is needed.

Using Information Communication Technology in Models of Integrated Community-Based Primary Health Care: Exploring ICT in the iCOACH Study

Introduction: Information and communication technology (ICT) is a promising enabler to support delivery of integrated care by inter-disciplinary teams by supporting information sharing across professional and organizational boundaries; arguably a crucial aspect of successful models of integrated care. The literature suggests that there are core components of ICT functionality such as interoperability between systems, supported chronic disease management functions and patient and caregiver access to ICT, are required to support the delivery of integrated models of care. While suggestions on what ICT for integrated care should look like abound in the literature, few studies have explored how ICT is used in practice in the implementation of integrated community-based primary health care. Theory and Methods: We draw on data from interviews with front-line staff and management collected from 2 cases in Canada (one in Ontario and one in Quebec) and 3 case studies in New Zealand collected as part of the iCOACH project. Interview data was thematically coded around three core themes: 1) types of ICT systems adopted; 2) the role ICT plays in the model of care with regard to central activities of integrated care, and 3) perceived value of systems from the perspective of health care providers and organizational managers and leaders. Results: All case sites had some form of ICT system in place (most often electronic medical records), however variation occurs within and across jurisdictions in terms of which integrated care activities were supported by ICT, the level of adoption, and the sophistication of systems. Most models faced significant challenges with regard to between-system interoperability to allow for effective information sharing. There was additional diversity in terms of healthcare provider use and acceptance of available technology. Where systems were lacking, sites would use workarounds, for example co-locating providers who could access multiple systems at a single site. Discussion: Preliminary analyses of case study data suggest that ICT was used to support a range of integrated care activities. Interoperability remains an important, and often elusive, requirement. Front-line providers and organizations showed the ability to creatively work around limitations of ICT, but did not see these as sustainable solutions. Conclusion: ICT systems across the cases varied in terms of maturity and functionality. There was a consensus across sites regarding the importance of ICT to support integrated care, however many cases did without robust systems. Providers and leaders identified the need to adopt ICT systems that supported information sharing across teams to sustain and grow programs. Lessons Learned: Adoption of ICT systems into models of integrated care can occur at different stages of implementation, with many models reaching a point at which integrated ICT systems are required to support effective sustainable growth. Limitations: Case study findings offer unique and in-depth perspective on the adoption of ICT in 9 different models of integrated care. Findings may not be generalizable to all of models of integrated care. Suggestions for future research: Further exploration is required to determine at exactly which point in the implementation process (early vs. sustained adoption) ICT is required.

Reducing Hospitalisations for Ambulatory Care-sensitive Conditions in Integrated Care Systems

Introduction: The reduction of unnecessary hospital admissions is one of the key success factors for integrated care systems. Not least the development of country-specific lists of diagnoses which have been classified and validated by medical experts to be ambulatory care sensitive [1] - meaning that these conditions usually do not need to be treated in the hospital setting - has boosted the attention for this field of intervention. Policy context and objective: In Germany previous studies estimated an amount of 3.7 million hospital admissions which were classified as avoidable which corresponds about 20% of all cases per year [2]. Twenty-two diagnosis groups were worked out as a core list and for each of them medical actions were proposed to reduce correspondent hospital admissions. Strengthening the continuity of ambulatory treatment and providing better access to appropriate professionals in the outpatient sector were considered the most important systemic changes necessary to reduce ambulatory care sensitive hospitalisations. Integrated care systems seem to be the best setting to foster the activities necessary for change whereby the expected efficiency gains can help to partly regain the necessary investments [3]. The results of a comparative analysis of hospitalisation rates for ambulatory care sensitive conditions between Germany (GER) and the integrated care system Gesundes Kinzigtal (GK) give an impression of possible reductions in cases and the corresponding amount of savings on health system level. Targeted population: The regional population which is included in the integrated care contracts of GK and which potentially benefits from the different integrated care activities comprises nearly 33,000 individuals in the southwest of Germany. Although their age and gender distribution is already comparable to the mean in Germany (2011: O-Age GER: 43.8 vs. GK: 43.9; Amount of females GER: 51.2% vs. GK: 51.6%) age-standardized rates of ambulatory care sensitive hospitalisations were calculated to compare the groups more precisely. The results were afterwards projected on the 80.3 million lives of the German Standard Population 2011. Highlights: In GK lower mean hospitalisation rates for 18 of the 22 diagnosis groups of the ambulatory care-sensitive conditions could be observed between 2012 and 2015. This shows that there is a potential for reductions in unnecessary admissions which could partly already be achieved by strengthening ambulatory care in GK. If the same age-standardized rates like in GK are applied to Germany about 950,000 cases would have been avoided per year. Valuating each diagnosis group with the mean costs of these hospital cases in Kinzigtal, 2.7 billion Euro could thereby have been saved in Germany's health system per year. And comparing this difference of 950,000 with the overall estimated potential of 3.7 million preventable cases [2] it seems, that even more can be reached. The biggest difference between Germany and the GK projection was found in back pain (-161,000 cases), ischemic heart diseases (-151,000 cases) and hypertension (-97,000 cases) whereas only in these three diagnosis groups about one billion Euro could have been saved on health system level. In contrast there are also diagnosis groups for which the GK projection would result in slightly higher numbers on system level, e.g. for preventable mental and behavioral disorders (+31,000 cases), depressive disorders (+18,000 cases) and heart failure (+18,000 cases) which should in turn trigger the development of appropriate reactions in GK. Transferability: The results of the comparative analysis prove that efficiency gains by focusing on improvements in the outpatient sector in integrated care systems are possible. Some of the actions of GK related to this issue will be demonstrated and their potential contribution to the largely lower rates of ambulatory care-sensitive hospitalisations will be discussed. Conclusions: If integrated care activities like in GK were provided for all citizens of Germany and similar results could be achieved, nearly one million of hospital cases might already have been prevented and about 17,350 hospital beds would not have been needed. The urgently needed workforce could transfer into the ambulatory and preventive services. Efficiency gains in integrated care systems need more nurses, community workers as well as other health professionals and care coordination between all sectors must be improved. This is recently still hindered by certain factors like especially fragmented remuneration systems. Without changes towards value-based regional care systems it seems impossible to make use of the full potential of the concept of ambulatory care sensitive conditions and to define clear responsibilities for certain treatments.

Conducting a Health Needs Assessment to Identify Potentials for Population-based Integrated Care Models in Socially Deprived Urban Regions – The Example of the Integrated Care Project “Billstedt-Horn” in Hamburg, Germany

Introduction : Against the background of regional differences in morbidity and social determinants of health small-scale health services research is becoming increasingly relevant, particularly for planners of population-based integrated care models. Despite of longstanding research of regional variation especially by John Wennberg neither are there scientifically or practically accepted standards on how to identify regions which are in a special need for integrating health services nor is there a precisely defined set of methods which could be used to identify and prioritize problems in health services delivery. Policy context and objective : Based on discussions with the health authority of Hamburg the two neighbouring districts of Billstedt and Horn were predefined as a potential region for integrated care activities due to their comparable situation in terms of social deprivation as indicated by several social and demographical indicators. Having focussed on this region the health-related characteristics should be systematically analysed in more detail to develop a comprehensive concept of intervention. Therefore quantitative data analysis of several data sources (statutory health insurance claims data, data of the local health authority, reports of statistical offices and urban planning) as well as qualitative interviews with regional providers were conducted to better understand the health needs of the population living in this area and problems in the way healthcare is provided. Targeted population : The population living in Billstedt or Horn is socially disadvantaged compared to the general population in Hamburg as well as in Germany overall. For example higher unemployment rates, a higher amount of unskilled workers and lower average incomes can be observed which among other indicators is the cause of very low status indexes of these districts [1]. People living in Billstedt or Horn are indeed about four years younger than the population in Hamburg but the older they get the more health related problems they have compared to the average [2]. Highlights : Calculating mean ages at the time of death and comparing residents living near chosen subway stations showed mean ages between 71 to 74 for the stations in Billstedt and Horn and for example mean ages between 82 to 87 in socially much more advantaged regions in Hamburg. The claims data analysis moreover indicates that several chronic morbidities like e.g. backpain, depression and diseases of the coronary system occur five to ten years earlier in Billstedt and Horn than averagely in Hamburg. For the region of Billstedt and Horn four key areas for potential interventions were proposed based on the claims data analyses: 1. Improving care for multimorbid elderly patients, 2. Prevention of the metabolic syndrome, 3. Better access to psychiatric care and 4. Improving child health. The qualitative interviews furthermore highlighted problems of unnecessary utilization like e.g. preventable hospital cases which occur due to existing or expected speech barriers in ambulatory care respectively a general unconsciousness of adequate ambulatory health institutions or problems of access to specialist care due to an observable unwillingness of several providers to open a practice in this region which is even exacerbated by a unwillingness of a certain amount of resident patients to leave their district to use health services. The establishment of a multilingual “retail clinic” in a large mall in Billstedt led by a nurse practitioner or a physician assistant who is in charge of offering care coordination consulting was proposed subsequently. Transferability : The methodology of this mixed-methods health services research as a starting point could be used in other settings where an integrated care model is planned. The identified problem fields and the thereupon developed intervention strategies might guide integrated care managers or policy makers on how to systematically plan, implement and/or further develop integrated care systems. Conclusions : The analysis of the regional social and health characteristics enabled the preparation of a comprehensive concept of planned integrated care strategies and first specific interventions. Because of the systematic approach several providers and health insurances finally could be convinced to participate in a proposal to the German Ministry of Health to give a start up funding for this integrated care project in course of a so called “innovation fund”. The proposal was finally chosen to be granted with the funding amount of about 6.3 million Euros over three years starting in 2017. 1- Pohlan, J./Dafateri-Moghaddam, N. Sozialmonitoring Integrierte Stadtteilentwicklung. Bericht 2012. Hamburg: HafenCity Univiversity Department Stadtplanung Stadt- und Regionalokonomie. 2015 2- Erhart, M./Hering, R./Schulz, M./Graf von Stillfried, D. Morbiditatsatlas Hamburg. Berlin: Zentralinstitut fur die kassenarztliche Versorgung in Deutschland. 2013

The development of integrated diabetes care in the Netherlands: a multiplayer self-assessment analysis

BackgroundSince recent years Dutch diabetes care has increasingly focused on improving the quality of care by introducing the concept of care groups (in Dutch: ‘zorggroepen’), care pathways and improving cooperation with involved care professionals and patients. This study examined how participating actors in care groups assess the development of their diabetes services and the differences and similarities between different stakeholder groups.MethodsA self-evaluation study was performed within 36 diabetes care groups in the Netherlands. A web-based self-assessment instrument, based on the Development Model for Integrated Care (DMIC), was used to collect data among stakeholders of each care group. The DMIC defines nine clusters of integrated care and four phases of development. Statistical analysis was used to analyze the data.ResultsRespondents indicated that the diabetes care groups work together in well-organized multidisciplinary teams and there is clarity about one another’s expertise, roles and tasks. The care groups can still develop on elements related to the management and monitoring of performance, quality of care and patient-centeredness. The results show differences (p < 0.01) between three stakeholders groups in how they assess their integrated care services; (1) core players, (2) managers/directors/coordinators and (3) players at a distance. Managers, directors and coordinators assessed more implemented integrated care activities than the other two stakeholder groups. This stakeholder group also placed their care groups in a further phase of development. Players at a distance assessed significantly less present elements and assessed their care group as less developed.ConclusionsThe results show a significant difference between stakeholder groups in the assessment of diabetes care practices. This reflects that the professional disciplines and the roles of stakeholders influence the way they asses the development of their integrated care setting, or that certain stakeholder groups could be less involved or informed.

Lessons learned about integrating multisectorial collaboration agreements

This contrubution wil make a cross comparative analysis of research done in innovation strategies in elderly care, mental health care and chronic care in Belgium. The aim of this analysis is to better understand which factors hamper or facilitate multisectorial collabration in order the enhance integrated care (on the organisational level). The added value of a cross comparative analysis of innovation paths in different sectors, is that it allows for identifying idiosyncratic issues in certain care domains, but more importantly, transversal barriers and facilitating or hampering factors regardless of the health or social issue that is being adressed. The contribition is grounded in empirical process evaluation research (realist eveluation) of a number of recent Belgian initiatives to enhance integrated care. Contentwise, the contribution relies on theoretical insights from health system approaches, interorganisational network literature and institutional field studies. The cross comparative analysis will lead to a number of lessons to be taken on board when trying to enhance integrated care activities. thses lessons will be discussed agans the background of exstsing theoretical debates on multisectorial collaborations and integrated care.

Meaningful clinical communication and Integrated Care in Barcelona. Eight years of experience

Context: Public healthcare system in Catalonia is based on yearly contracts stablished among the Public Healtcare Administration (Catsalut) and the different Healthcare Organizations (HCO). Each one has its own Electronic Patient Record (EPR) system.In 2006 a task force group was committed for a radical redesign of the healthcare in an area of Barcelona with a population on 600.000 inhabitants with a focus on the improvement in the relationship between Primary care (PC) and Specialized Care (SC) for a better integrated care for the population. Once the new model was accepted by all the HCO, an specific workgroup was created to develop a ICT-supported system to interchange meaningful clinical information and enable the continuity of care. Twenty-three centers were involved. They belong to nine different HCO: three hospitals, one SC outpatient clinic and six PC organizations. Initial analysis of the departure situation resulted in a high heterogeneity in relation to the degree of technological investment, development and maturity in the use of EPRs by the professionals. Several ICTs options were considered. The decision was to implement an interchange platform using structured xml files with clinical content based on standadrd HL7 v2.5 messages.Results: The solution got the integrated connection of all the EPRs of the different HCOs in spite of their big differences. Also the project has speed-up the process of investment and maturity in the use of EPR in those HCOs with a worse departure situation. The overall system supports the full information cycle of several clinical processes like the patient referral from PC to SC with all the possible circumstances at each step in the workflow and the return of clinical documentation, the request for specific procedures from PC to SC with the return of the report and the related images if it’s the case, the communication to PC of the admission of a patient at the Emergency ward and the return of the discharge reports, as well as new collaboration processes like the teleconsultation in Dermatology. All the messages are completely generated and fully integrated in all the different EPRs of the nine HCOs.Since January 2010 until December 2015 statistics showed a total of 323360 requests from PC to the SC centers, 577.575 professional integrated care activities done over the patients, 839.779 relevant clinical documents and 91374 images done at the hospitals delivered on time at the point of care accessible by the PC centers. All of these transactions are the result of standardize and improve existing workflows using ICTs. Outstanding results have been the start up of Teledermatology, a new service made possible through ICTs. Quality of the images provided by the PC physicians were good enough in 94,3% of the cases. Delay in the SC answer has been reduced to 1,84 days and avoiding more than a half of the SC visits at the hospital (58,2%).Conclusions: Several management and clinical scores demonstrates the benefits of such implementation in the quality of care of the population covered by the HCOs. The other big achievement has been the standardization of the clinical processes in this area of the Barcelona city.A good Governance model of the different IT departments involved as well as the ICT providers, based upont profesionalism, leadership and transparency, is a key point for the successAt this moment we are in the process to evolve to a bigger platform with the capability to connect all the HCO and centers in Catalonia.

Provider status effort engaged on Capitol Hill

Provider status effort engaged on Capitol Hill

Criteria for the selection and evaluation of integrated care priorities

Aims and Objectives: To identify, define and quantify criteria which are common to integrated care models. To build a framework with these criteria which will enable the evaluation of prospective integrated care activities. Methods: Identification and clustering of criteria necessary andyor inherent in integrated care models and projects. Literature review on the development of common criteria and indicators for health. Identification of relevant and applicable quantifiers. Identification and analysis of criteria for success common to projects and programmes internationally. Results: A generalised framework of criteria for the evaluation of integrated care activities. The framework shall function as a decision-finding tool for the selection of projects and shall help to identify key components of integrated care activities. It can then be used to define whether proposed projects are actually integrated care or not. Common criteria for success facilitate the design of ameliorated programmes. Conclusions: There are many prerequisites for integrated care but so far, no framework is available with which to identify, along clear-cut lines, whether an initiative actually is viable for integrated care models or not. Also, there is a need for quantifiable indicators when evaluating integrated care activities. The proposed framework shall provide the basis for further methodological developments.