Integrated Care Arrangements Research Articles

More long‐term care for better healthcare and vice versa: investigating the mortality effects of interactions between these public sectors

AbstractPublic healthcare (HC) and long‐term care (LTC) sectors coexist in several OECD countries. Economic interactions between these two sectors have been found to occur even in the absence of formal integrated care arrangements. We investigate whether and how interactions between the HC and LTC sectors impact mortality. We analyse data on English local authorities in 2014–15 and employ a sequence of cross‐sectional econometric specifications based on instrumental variables to identify the effect that LTC expenditure has on mortality through its interactions with HC services, and vice versa. Our findings suggest that any effect of LTC expenditure on mortality is likely to run through the HC sector by allowing the latter to reallocate resources from less to more effective services. A 10 per cent increase in LTC expenditure per user can indirectly save, on average, about three lives per million individuals. In addition, on top of the known HC direct mortality effects, we find that investing an extra £42 million in the HC sector – equivalent to a 10 per cent increase in HC expenditure per capita for the average local authority – can decrease the use of LTC services, producing around £7.8 million of savings. These can generate mortality effects if invested in services having an impact on mortality.

Association of Primary and Behavioral Health Integrated Care Upon Pediatric Mental Disorder Treatment.

The objective of this study was to examine whether linkage with mental health (MH) treatment differed across 3 different integrated care arrangements (ICAs), following incident attention deficit hyperactive disorder (ADHD) and major depressive disorder (MDD) diagnoses given by primary care providers (PCPs) in the pediatric setting. Using claims linking with multiple public data sources, we examined the treatment initiation among children receiving an incident diagnosis of ADHD or MDD from PCPs working in practices with various ICAs. ICAs were categorized as PCP practiced alone (non-co-located), PCP practiced with specialist outside the practice but co-located at the practice site (co-located), and employed specialists who were co-located (co-located and co-affiliated). A total of 4203 incident ADHD and 298 incident MDD cases diagnosed by PCPs were identified, of which 3123 (74%) with ADHD and 200 (67%) with MDD received treatment within 90 days since the diagnosis. Children diagnosed with ADHD by co-located and co-affiliated PCPs were twice as likely to receive treatment as those diagnosed by non-co-located PCPs (odds ratio [OR]=1.93; 95% confidence interval [CI], 1.24-2.78). Of those treated, children diagnosed by co-located and co-affiliated PCPs were 2 times more likely to receive guideline recommended psychotherapy (OR=2.15; 95% CI, 1.35-3.44). These patients were also more likely to be treated at the diagnosing site versus elsewhere. Similar beneficial effects were not observed in those first diagnosed by co-located but non-affiliated PCPs. Service co-location between co-affiliated PCPs and MH specialists was associated with significant higher ADHD treatment rate and the receipt of guideline-recommended psychotherapy.

Complex care needs and devolution in Greater Manchester: a pilot study to explore social care innovation in newly integrated service arrangements for older people.

Objective The aim of this study was to describe emergent approaches to integrated care for older people with complex care needs and investigate the viability of measuring integrated care. Methods A case study approach was used. Sites were recruited following discussion with senior staff in health and social care agencies. Service arrangements were categorised using a framework developed by the researchers. To investigate joint working within the sites, the development model for integrated care was adapted and administered to the manager of each service. Data were collected in 2018. Results Six case study sites were recruited illustrating adult social care services partnerships in services for older people with home care providers, mental health and community nursing services. Most were established in 2018. Service arrangements were characterised by joint assessment and informal face-to-face discussions between staff. The development of an infrastructure to promote partnership working was evident between adult social care and each of the other services and most developed with home care providers. There was little evidence of a sequential approach to the development of integrated working practices. Conclusion Components of partnerships promoting integrated care have been highlighted and understanding of the complexity of measuring integrated care enhanced. Means of information sharing and work force development require further consideration. What is known about the topic? The devolution of health and social care arrangements in Greater Manchester has aroused considerable interest in much wider arenas. Necessarily much of the focus in available material has been upon strategic development, analysis of broader trends and mechanisms and a concern with changes in the healthcare system. What does this paper add? The findings from this study will enable emerging approaches to be described and codified, and permit the specific social care contribution to the new arrangements to be discerned. The findings are relevant beyond the immediate context of Greater Manchester to wider integrated care. The evidence can be used by commissioners and services, providing a sound basis for further work as service systems develop. What are the implications for practitioners? This research is important because it is one of the first pieces of work to examine the new integrated care arrangements in Greater Manchester. By providing guidance to promote evidence-based practice, this study contributes to service development in Greater Manchester and the achievement of the broad national service objectives of improving user and carer experiences and ensuring value for money.

Identifying target groups for person-centred integrated care among multi-morbid populations

Background The growing populations of people with multi-morbidity pose a new challenge to health systems. As multi-morbidity is not a clearly demarcated condition, chronic disease management programs may be unable to meet the needs of persons with multi-morbidity. This requires health systems to shift to more person-centred care models. Developing person-centred care for people with multi-morbidity asks for knowledge about their needs. Methods We conducted four studies (within the EU funded JACHRODIS and ICARE4EU project, and in a recent project funded by the Netherlands MoH) to gain insight in the needs of primary care patients with multi-morbidity. We distinguished subgroups based on their use of health services and quality of life by cluster analyses, and described their medical characteristics and resources (e.g., social support, health literacy, self-management abilities). Next, we predicted adverse outcomes, i.e., a poor quality of life and suboptimal use of services, from patients’ illness perceptions and resources by logistic regression analysis. Results In all studies, we found half of the study sample to report a relatively good quality of life and/or a low use of health services. The other half consists of various subgroups: with a poor QoL (physical and mental or social), a high or suboptimal use of health services or a combination of these outcomes. Adverse outcomes relate to medical characteristics, but also to persons’ perceptions of their conditions and resources. Conclusions Among multi-morbid populations, subgroups of high-need patients can be distinguished based on their medical complexity, illness perceptions and resources (e.g., health literacy, mastery). These subgroups differ in their needs for care and support, and thus require different integrated care arrangements, for instance, horizontal integration of primary care and social care, and/or vertical integration of primary and secondary care services. (aut. ref.)

APA Registry May Advance Early Detection of Psychosis

Back to table of contents Previous article Next article Professional NewsFull AccessAPA Registry May Advance Early Detection of PsychosisMark MoranMark MoranSearch for more papers by this authorPublished Online:14 Nov 2016https://doi.org/10.1176/appi.pn.2016.11b9AbstractAPA’s patient registry, if it includes integrated care systems that are also linked to local educational systems, may be useful for identifying children and adolescents who display signs of prodromal psychosis.A national mental health registry—such as the one under development by APA to help psychiatrists meet quality reporting and Maintenance of Certification (MOC) requirements—may also help to reduce duration of untreated psychosis by enhancing early detection, referral of patients, tracking of symptoms over time, and treatment effects at the psychiatrist, clinic, and national levels.“In order to achieve this goal, a registry needs to include psychiatrists involved in integrated care arrangements with primary care, and especially the inclusion of health systems that are integrated with educational systems,” said APA Deputy Director of Research Diana E. Clarke, Ph.D., M.Sc. “It may also require interoperability between mental health and primary care registries and be open to modifications as knowledge improves.” Clarke spoke last month at APA’s fall meeting, IPS: The Mental Health Services Conference, in Washington, D.C. (During the symposium, panelist Carol Tamminga, M.D., was presented with APA’s Research Award. See box.)Throughout the symposium—and during other lectures and symposia at the IPS—clinicians and researchers emphasized the importance of early detection of psychosis and, especially, the need to shorten the duration of untreated psychosis (DUP) to improve the long-term trajectory of illness. The patient registry being developed by APA may prove to be a critical tool in these efforts. “Nationally, the registry can allow participating clinicians to track their patients’ symptom profiles and changes in severity over time and easily identify individuals at risk for psychosis by providing measures that indicate presence of psychotic symptoms and biomarkers, such as any lag in neurocognitive development,” Clarke said. “It can also help clinicians monitor prescriptions and medication use. Ideally, the registry can help clinicians engage patients and families in the treatment process.”APA President-elect Anita Everett, M.D, who was the discussant at the symposium, agreed. “There is growing strength in the evidence that if we can identify high-risk cases early and provide psychosocial support and treatment, we can shorten the duration of untreated mental illness and psychosis, keep a person on track, and ultimately change the trajectory of a person’s life who otherwise might track into a long-term disabling condition such as schizophrenia and severe bipolar disorder,” she said in comments to Psychiatric News following the meeting. “Multiple components are coming together that now support this. These include increasing knowledge about our brain’s plasticity or ability to change biochemically and structurally coupled with the demonstrated value of coordinated specialty care that includes specific interventions such as education coaching, psychotherapy, and pharmacotherapy. APA began exploring the possibility of creating a patient registry in 2014, and last year the Board of Trustees formally approved a pilot project. In the discussion leading up to that vote, Gregory Dallack, M.D., chair of the APA Registry Work Group, told trustees the registry could help improve health outcomes for patients served by APA members, identify effective patterns of care and best practices on a national basis. A registry can assist members with meeting quality-reporting requirements for Medicare and MOC requirements, he said.At the IPS symposium, Clarke emphasized the importance of including in the registry integrated care networks that are also integrated with local educational systems, where teachers and school administrators can identify children and adolescents in need of mental health treatment. Integrated care practice administrators can then register individuals with early symptoms of psychosis and trigger a referral for care when appropriate. “The registry manager can identify, on an aggregate level, sites with groups of patients with symptoms of psychosis, especially those with no indicated follow-up care,” Clarke said. “And the registry manager can also identify treatments that work or don’t work.” ■More information about the APA registry can be accessed here or available from Philip Wang, M.D., Dr.P.H., at [email protected]. ISSUES NewArchived

What are the health, social and economic benefits of providing public housing and support to formerly homeless people?

This report finds that the provision of stable public housing for people experiencing or at risk of homelessness results in reduced health service use (both in terms of the number of people and the frequency and duration of use), and associated cost savings to the health system and public purse. Providing stable housing with support should be a first priority to improving not only housing outcomes, but health outcomes and consequently reducing health care costs. This is particularly the case for individuals who experience mental health issues. The findings support the role of public housing as a foundation for non-shelter outcomes and, in particular, health outcomes. They also point to the importance of continued support for highly vulnerable entrants to public housing, particularly for those with a history of severe and persistent mental illness who are either homeless or at risk of homelessness. They further support the need for integrated care arrangements and for a holistic approach to health issues that recognises the importance of housing and of support in terms of improved health outcomes. Specifically, the study provides an evidence base for the continuation of NPAH programs focused on the provision of housing with support. It also shows the importance of linked health and housing data in policy-relevant research and impact evaluations and provides the basis for future Australian studies in this area.

Renewing the expertise of health and social care professionals to provide integrated care: Evaluation of an intervention in a deprived Dutch neighbourhood

Rationale, aims and objectives: Multimorbidity in deprived populations is associated with longer hospital stays, more avoidable admissions and complications, higher costs, and lower satisfaction with available services. While integrated care has been proposed as a solution, the expertise of professionals to deliver this type of care has received little attention. Our case study evaluates an intensive intervention in a deprived neighbourhood in the Netherlands, launched in 2008, to tackle multimorbidity and the expertise of health and social care professionals to cater to the population’s health needs.Methods: Mixed-methods evaluation. Between 2009-2012 semi-structured interviews (n= 11), field observations, conversations, dialogue sessions and documentary review. In 2012 and 2013 quantitative before-and-after study with web-based questionnaire in the intervention and two control neighbourhoods (n= 86 at t0 and n=117 at t1).Results: The intervention sought to develop professional expertise in population health orientation, generalism, and coaching. Activities were supported by management that emphasized learning by doing, working bottom-up with direct application in practice, and professionals enjoying discretion to experiment. The intervention’s widely supported mission brought cohesion to its activities. In the interviews, professionals reported becoming more adept at understanding the common causes behind patients’ complaints, unravelling their multiple problems, and encouraging them to be more active in addressing their own health and well-being. But this was not supported by the quantitative data measuring professionals’ attitudes.Conclusion and practice implications: Neighbourhood interventions can strengthen professionals’ expertise in population health orientation, generalism and coaching, and the communication and collaboration skills necessary to employ them. Whether they can lead to more adequate responses to multimorbidity and more effective integrated care arrangements needs to be further researched.

Economic evidence on integrated care for stroke patients; a systematic review

Given the high incidence of stroke worldwide and the large costs associated with the use of health care resources, it is important to define cost-effective and evidence-based services for stroke rehabilitation. The objective of this review was to assess the evidence on the relative cost or cost-effectiveness of all integrated care arrangements for stroke patients compared to usual care. Integrated care was defined as a multidisciplinary tool to improve the quality and efficiency of evidence-based care and is used as a communication tool between professionals to manage and standardize the outcome-orientated care. A systematic literature review of cost analyses and economic evaluations was performed. Study characteristics, study quality and results were summarized. Fifteen studies met the inclusion criteria; six on early-supported discharge services, four on home-based rehabilitation, two on stroke units and three on stroke services. The follow-up per patient was generally short; one year or less. The comparators and the scope of included costs varied between studies. Six out of six studies provided evidence that the costs of early-supported discharge are less than for conventional care, at similar health outcomes. Home-based rehabilitation is unlikely to lead to cost-savings, but achieves better health outcomes. Care in stroke units is more expensive than conventional care, but leads to improved health outcomes. The cost-effectiveness studies on integrated stroke services suggest that they can reduce costs. For future research we recommend to focus on the moderate and severely affected patients, include stroke severity as variable, adopt a societal costing perspective and include long-term costs and effects.

How to optimize interfaces between care settings for older patients?

Purpose: Integrated care for older people is becoming more and more important. The purpose of this presentation is to detect influencing factors regarding the interface between ambulatory care and a geriatric day hospital. Quality of care: The coordination between different professions in integrated care is a critical success factor for the quality of care. We assume that this quality is, besides other factors, influenced by – Communication skills, – Time for information exchange and – Continuity of therapy and medication. Method: We sent a standardized questionnaire to 476 practitioners and asked about their experiences in cooperation with the local geriatric day hospital in 2006. Eighty-six of the professionals responded (18.1%). Statistical analysis was conducted using SPSS and Excel. Results and discussion: Overall most of the practitioners are satisfied with the cooperation and 90% will continue the interaction. Eightysix percent share the opinion that the interaction is very good concerning time. A weak point is communication between professionals and access by phone. Difficulties exist in the case of an emergency, in evening care and at night. Challenges in the interface are therapy and medication. Because of the different budget systems practitioners discontinue therapy and medication, which was introduced in the day hospital. The results underline the relevance of coordinating interface activities. Communication is a prominent success factor between partners in integrated care arrangements.

A four phase development model for integrated care services in the Netherlands.

BackgroundMultidisciplinary and interorganizational arrangements for the delivery of coherent integrated care are being developed in a large number of countries. Although there are many integrated care programs worldwide, the process of developing these programs and interorganizational collaboration is described in the literature only to a limited extent. The purpose of this study is to explore how local integrated care services are developed in the Netherlands, and to conceptualize and operationalize a development model of integrated care.MethodsThe research is based on an expert panel study followed by a two-part questionnaire, designed to identify the development process of integrated care. Essential elements of integrated care, which were developed in a previous Delphi and Concept Mapping Study, were analyzed in relation to development process of integrated care.ResultsIntegrated care development can be characterized by four developmental phases: the initiative and design phase; the experimental and execution phase; the expansion and monitoring phase; and the consolidation and transformation phase. Different elements of integrated care have been identified in the various developmental phases.ConclusionThe findings provide a descriptive model of the development process that integrated care services can undergo in the Netherlands. The findings have important implications for integrated care services, which can use the model as an instrument to reflect on their current practices. The model can be used to help to identify improvement areas in practice. The model provides a framework for developing evaluation designs for integrated care arrangements. Further research is recommended to test the developed model in practice and to add international experiences.

Taking care of integrated care: integration and fragmentation in the development of integrated care arrangements

The aim of this thesis was to study the development of integrated delivery systems (IDSs). An IDS is a form of institutionalised partnership between organisations and health care professionals, aimed at facilitating cooperation at the levels of management, support services and the primary processes. The purpose of developing an IDS is to achieve control, quality and efficiency in health care delivery. To examine the extent to which IDSs enable integration, this study centred on the question ‘‘how do IDSs develop at the level of management, support services and integrated pathways for elderly and stroke?’’.

Angehörigenarbeit in der Gerontopsychiatrischen Tagesklinik Erlangen: Information, Entlastung und konkrete Hilfestellung durch gemeindenahe Zusammenarbeit mit Einrichtungen der Altenhilfe

Providing support for caregivers plays an important role in the day hospital treatment concept. Protocols (during 15 months) of support groups for caregivers of patients with dementia and depression are identifying main causes of caregivers' burden and distress, as well as their expectations regarding day hospital treatment. Aims of the interventions were to support caregivers' positive self-concept and social competence, to inform and to train problem-solving strategies and to develop individual care arrangements. Close cooperation between the day hospital and the community based services is essential for overall positive treatment outcomes, for integrated care arrangements after discharge and to ease the burden of family caregivers.

Economic evaluation of integrated care: an introduction

Integrated care has emerged in a variety of forms in industrialised countries during the past decade. It is generally assumed that these new arrangements result in increased effectiveness and quality of care, while being cost-effective or even cost-saving at the same time. However, systematic evaluation, including an evaluation of the relative costs and benefits of these arrangements, has largely been lacking. To stimulate fruitful dialogue and debate about the need for economic evaluation in integrated care, and to outline possibilities for undertaking economic appraisal studies in this relatively new field. Key concepts, including e.g. scarcity and opportunity costs, are introduced, followed by a brief overview of the most common methods used in economic evaluation of health care programmes. Then a number of issues that seem particularly relevant for economic evaluation of integrated care arrangements are addressed in more detail, illustrated with examples from the literature. There is a need for well-designed economic evaluation studies of integrated care arrangements, in particular in order to support decision making on the long-term financing of these programmes. Although relatively few studies have been done to date, the field is challenging from a methodological point of view, offering analysts a wealth of opportunities. Guidance to realise these opportunities is provided by the general principles for economic evaluation, which can be tailored to the requirements of this particular field.

Integrated care: the impact of governmental behaviour on collaborative networks

Integration of care is necessary to secure the most appropriate match of the individual demands and the organisational and professional supply. Although this is a basic assumption of all the people involved in health and social care, the magnitude and persistence of obstacles to integration is a common problem in most European countries. In this article, we will explore the role of the Dutch government in the complex interplay of forces around the development of integrated care, within networks of collaborating health and social care agencies. By analysing the behaviour of the Dutch government, we will argue that, in principle, the authorities can play a facilitating role here. For several reasons, however, the government appears not to be able to adequately stimulate the establishment of integrated care arrangements. Examples of such ineffective governmental behaviour are measures with contradictory effects and the adoption of a traditional public finance perspective of comprehensive planning. Our conclusion is that, where local networks play a dominant role in integrated care delivery, the most effective governmental steering should be tailored steering, including a mix of specific steering measures suitable to specific local circumstances, combined with more general steering measures, like financial stimuli, based on legislation.

Integrated health care: A curriculum

Integration of care is necessary to secure the most appropriate match of the individual demands and the organisational and professional supply. Although this is a basic assumption of all the people involved in health and social care, the magnitude and persistence of obstacles to integration is a common problem in most European countries. In this article, we will explore the role of the Dutch government in the complex interplay of forces around the development of integrated care, within networks of collaborating health and social care agencies. By analysing the behaviour of the Dutch government, we will argue that, in principle, the authorities can play a facilitating role here. For several reasons, however, the government appears not to be able to adequately stimulate the establishment of integrated care arrangements. Examples of such ineffective governmental behaviour are measures with contradictory effects and the adoption of a traditional public finance perspective of comprehensive planning. Our conclusion is that, where local networks play a dominant role in integrated care delivery, the most effective governmental steering should be tailored steering, including a mix of specific steering measures suitable to specific local circumstances, combined with more general steering measures, like financial stimuli, based on legislation.