Integrated Care Education Research Articles

Workforce Development in Integrated Care: An International Framework

Introduction: Integrated care aims to improve access, quality, and continuity of services for ageing populations and people experiencing chronic conditions. There are several descriptions in the literature recommending training in integrated care for health and social care professionals. One underdeveloped area is a global consensus of the key competencies and a global framework describing what these competencies and models of training look like. This study utilized a consensus building approach (Modified Delphi Study) with global experts with experience in delivering and designing workforce training in integrated care to ascertain which competencies are important to include in the framework and the best ways to implement these competencies. 
 Aims, Objectives, and Methods: The purpose of this study was to analyze the interactions between integrated care education leaders globally to explore what competencies are needed to practice integrated care across a broad range of health and social care settings and to identify the most effective models to implement these competencies. Meticulous and well-informed planning, and the development and implementation of an international competency framework will allow education providers and curriculum developers to incorporate these competencies and proposed models into existing training and curricula.
 A four-step methodological process was used. First, a potential list of competencies and key features of education and training in integrated care were identified based on a systematic scoping review. Second predefined criteria were used to identify the global panelists with experience in delivering or research in education in integrated care to reach consensus on the level of importance of the competencies and key themes. Thirdly, two anonymous iterative Delphi rounds were conducted followed by analysis and consensus of the results. A key focus of the study was determining how the experts engaged people and community in the delivery and design of the education program.
 Results and key findings: Components of training needs to include active involvement of people with lived experience of care in the design, delivery, and evaluation of the training. Other components include incorporating models to train health and social care professionals together to work within and across teams. Incorporating advanced collaboration and shared decision-making skills; a focus on comprehensive assessment of patient and family needs and a focus on primary and community care were some of the key findings of this study. 
 Conclusion: Existing competencies and models of training to build capacity for integrated care are not comprehensive and none has been developed through a formal global expert consensus technique. Higher education providers and workplaces may use the results of our study to highlight areas where they need to seek additional expertise, to develop and incorporate new and more advanced competencies into workforce training. Further work is needed to refine and test the competencies to ensure feasibility and usefulness, and to ensure curriculum developers and workplaces are appropriately supported and trained to implement them. The competencies can be used to shape job descriptions, orientation programmes, supervision, performance reviews and to design curricula and training on integrated care.

Integrated Care Education for General Psychiatry Residents in the US: a Review of the Literature.

The purpose of this review was to synthesize published literature describing integrated care education available to general psychiatry residents in the United States (US) in order to better understand curricular models and summarize curriculum barriers and facilitators. The authors searched electronic databases for articles describing integrated care education for general psychiatry residents. Minimum inclusion criteria were focus on an ambulatory integrated care curriculum, description of the study population and training program, publication in English, and program location in the US. Data extracted included trainee, faculty, or collaborator evaluations, educational model, level of care integration, and barriers or facilitators to implementation. The literature search identified 18 articles describing curricula at 26 residency programs for inclusion. Most programs offered clinical and didactic curricula to advanced trainees across a variety of care integration levels. Common barriers included fiscal vulnerability and difficulties identifying team members or clarifying team member roles. Common facilitators included institutional and interdepartmental support, dedicated space, and faculty supervision. No statistical analysis was able to be performed due to study heterogeneity. This review found a relatively small number of articles written about integrated care education for psychiatry residents. Resident evaluation suggests this training is valuable regardless of curriculum structure, training years, or level of care integration. Dedicated funding, staff, and space were crucial for successful curricula. This review highlights a need for more rigorous research characterizing and evaluating integrated care education.

Integrated care and interprofessional education.

Integrated care and interprofessional education.

Investing in integrated care education in health and social care. Development of a framework to facilitate education and reflection on integrated care in primary and community care

According to the WHO 1 It is essential to match health workers’ knowledge and skills to population needs. Therefore it is important to educate and support future health and social workers on these competences and on how to put integrated care in practice. As delivering integrated care is very complex and influenced by a variety of variables, it is a challenge to provide a useful practical framework for this purpose. The aim of this study is to explore how integrated care is accomplished in practice by professionals working in interdisciplinary community care teams, in order to conceptualize a comprehensible framework that can be used for education and reflection. This exploratory study, consisting of document analysis, participant observations, interviews and focus groups, primarily took place in 3 Community Health Centers CHCs in Ghent Belgium. Those settings were selected because they distinguish from other primary care settings by factors known as facilitators for integrated care. First of all there is the interdisciplinary approach by at least 3 disciplines: a general practitioner, a nurse and a third discipline at the primary care level, for example a social worker. A second facilitating principle is the accessibility and the low financial threshold. Finally, the CHCs devote a lot of attention to prevention, health promotion and detection of local health needs. Often these centers are situated in areas with a lot of welfare problems. Based on the research, a two-step approach for implementing integrated care was designed. The first step is to assess current and future needs of a person. In this assessment it is crucial that every social and health professional picks up health and wellbeing, and takes in account different relevant life domains. The second step is to deeply reflect on 5 dimensions, starting from the needs of the person, situated in his/her social context: shift between health and social care, and between life domains, shift between formal and informal care, shift between professionals both inside as outside the organisation, shift between the supply of organisations, and shift between the perception of a problem as an individual problem or as a collective problem. There is a sequence between those dimensions, but no hierarchy. All these dimensions need consideration. However, it is possible that in one particular case or setting, one dimension is more important or explicit. As the model is mainly built on the results of research in CHCs, and is tested until now with professionals of the CHCs and with bachelor students in social and healthcare, further research and testing is needed to explore if this model can be adopted in other primary and community care teams.

Education for Integration

The Public Bodies Joint Working Scotland Act 2014 and the World Health Organisation’s document Strengthening a Component HealthWorkforce for the Provision of Coordinated / Integrated Health Services Langins and Borgermans, 2015, position the integration of health and social care services as the principal means of transforming the delivery of services. In relation to staff, the Scottish Government’s 2017 National Health and Social Care workforce plan, acknowledge that the planning for the future workforce within NHS Scotland will require a broad range of professionals who will recognise inter-dependence, the importance of ‘whole of workforce’ and that a distributed model of professional leadership will support the provision of more sustainable services. From an international perspective, the World Health Organization’s 2015 Strengthening a Component Workforce for the Provision of Coordinated / Integrated Health Provision Langins and Borgermans, 2015 highlights that, “all health professionals in all countries to be educated to mobilize knowledge and to engage in critical reasoning and ethical conduct so they are competent to participate in patient and population-centred health systems as members of locally responsive and globally connected teams” Frenk et al 2010. This highlights that delivering integrated care across the globe requires that the workforce are appropriately educated. At the University of West of Scotland UWS we have responded to this need by developing undergraduate and post graduate programmes in integrating health and social care. These have been developed to address the educational needs of a cross-sectoral health and social care workforce in cultural transformation focusing on educating for enablement and empowerment through co-production and an asset based approach. The programmes we deliver at UWS are the BA Hons Integrated Health and Social Care programmes, which have been successfully running since 2011 and the recently validated MSc in Leading People-centred Integrated Care at the University of the West of Scotland. These programmes are reflective of 3 stages of education as identified by Frenk et al 2010, informative education, formative education and transformative education. The undergraduate programme is focused on informative education and the post graduate on transformative education, the ethos behind both are to enable and empower the students to deliver, develop and lead integrated services to promote and enhance quality, effective and efficient people-centred services. A key feature of the programmes are through the multi-professional and multi-sectoral nature of shared co-productive learning to Integrated Care education students can explore the complexities and challenges of delivering and leading system integration. This is advocated as a way of breaking down professional boundaries and in developing a more cohesive approach to professional practice. The principle of co-production is evident throughout both the ongoing developments in the undergraduate programme and in the development of the Masters programme. Both programme teams have been commended for the co-productive approach taken, which has included Subject specialists in Integrated Care, students and programme staff. Delivering and developing programmes relating to integration cannot be done in isolation and must up hold the very principles of integration it is aiming to achieve.

Advancing Integrated Care through Psychiatric Workforce Development: A Systematic Review of Educational Interventions to Train Psychiatrists in Integrated Care.

Integrated or collaborative care is a well-evidenced and widely practiced approach to improve access to high-quality mental health care in primary care and other settings. Psychiatrists require preparation for this emerging type of practice, and such training is now mandatory for Canadian psychiatry residents. However, it is not known how best to mount such training, and in the absence of such knowledge, the quality of training across Canada has suffered. To guide integrated care education nationally, we conducted a systematic review of published and unpublished training programs. We searched journal databases and web-based 'grey' literature and contacted all North American psychiatry residency programs known to provide integrated care training. We included educational interventions targeting practicing psychiatrists or psychiatry residents as learners. We critically appraised literature using the Medical Education Research Study Quality Instrument (MERSQI). We described the goals, content, and format of training, as well as outcomes categorized according to Kirkpatrick level of impact. We included 9 published and 5 unpublished educational interventions. Studies were of low to moderate quality and reflected possible publication bias toward favourable outcomes. Programs commonly involved longitudinal clinical experiences for residents, mentoring networks for practicing physicians, or brief didactic experiences and were rarely oriented toward the most empirically supported models of integrated care. Implementation challenges were widespread. Similar to integrated care clinical interventions, integrated care training is important yet difficult to achieve. Educational initiatives could benefit from faculty development, quality improvement to synergistically improve care and training, and stronger evaluation. Systematic review registration number: PROSPERO 2014:CRD42014010295.

Teaching Integrated Care.

This issue of Academic Psychiatry includes five articles [1–5] focusing on teaching tomorrow’s psychiatrists about integrated care, and the American Psychiatric Association’s Council on Medical Education and Lifelong Learning (CMELL) recently released its report on “Training Psychiatrists for Integrated Behavioral Health Care” [6]. Why is integrated care education important, and what do these reports tell us about how to teach this? Only 1 in 8 people in the USAwith a mental health disorder consults a psychiatrist [7]. Most people who seek care do so in primary care settings. In fact, for decades primary care has been recognized as the “de facto mental health system” [8]. Access to mental health specialty care is poor, and at least half of people referred do not follow up [9]. Integrated care models were designed to close this gap and provide access to mental health care for the maximum number of people. Behavioral health care can be integrated into primary care in a number of different ways, including co-location of a mental health provider or consultant within a primary care setting, telemental health, and collaborative care models, in which psychiatrists collaborate with primary care providers and behavioral health care managers to optimize the mental health of a clinic or care system. Collaborative care, especially for depression, has been shown in multiple studies and metaanalyses to improve access, outcomes, and costs of mental health care, thus accomplishing the “triple aim” of the US health care system [10, 11]. Given the effectiveness of such integrated care models and the increasing focus on patientcentered care, medical homes, and providing integrated behavioral and primary medical care under the Affordable Care Act, many psychiatrists will take on new roles as consultants, educators, and team leaders within interprofessional behavioral health teams working in primary care settings. Psychiatric education needs to prepare tomorrow’s psychiatrists for these roles. At the same time, patients within the mental health system, especially with chronic mental illnesses, have significantly earlier mortality than the general population, primarily due not to suicide but to chronic medical problems exacerbated or caused by low socioeconomic status, poor access to and adherence with primary medical care, and side effects of psychotropic medications [12]. In recent years, there has been increasing focus on the responsibility of psychiatrists to ensure adequate primary medical care for such patients, bringing with it the challenge of determining how psychiatry trainees should be prepared to do this. The reports in this issue focus on integrated care education across the spectrum, from medical students to psychiatry residents, subspecialty fellows, and psychiatrists in practice. The Dube and Verduin paper [1] and their CMELL report section [6] discuss integrated care education for medical students. Currently, medical student education in psychiatry seldom includes integrated care settings or experiences, although some schools provide elective integrated care experiences or longitudinal integrated clerkships that follow the same patients across different specialties and clinical services, which may or may not be integrated. The CMELL report [6] provides a number of recommendations regarding medical student exposure to effective integrated care services and psychiatrist role models, as well as education in interprofessional and interdisciplinary communication. Seeing psychiatrists working at the interface of primary care and mental health may also destigmatize psychiatry as a career choice for some students. * Deborah S. Cowley dcowley@u.wahington.edu

General and Child and Adolescent Psychiatry Resident Training in Integrated Care: a Survey of Program Directors.

Integrated care models are an evidence-based approach for integrating physical and behavioral health services. The American Association of Directors of Psychiatric Residency Training Integrated Care Task Force sought to describe current practices for providing training in integrated care to general and child and adolescent psychiatry residents. Directors of US general and child and adolescent psychiatric residency training programs were anonymously surveyed to examine current practices in educating their residents in integrated care. Based on themes that emerged from the survey, the authors make recommendations for integrated care education of general and child and adolescent psychiatry residents. Fifty-two of 197 (26%) general and 36 of 111 (32%) child and adolescent program directors responded. Results demonstrate that a majority of responding general psychiatry (78%) and child and adolescent psychiatry (CAP) (72%) training programs offer integrated care rotations, many of which are electives for senior residents. The Veterans Health Administration (VA) and Federally Qualified Health Centers are common venues for such rotations. Sustainable funding of these rotations is a concern. Fewer than half of programs offer integrated care didactics. This report is intended to help program directors consider options for starting or optimizing their own integrated care curricula. Future research should examine the educational value, and the overall value to health care systems, of training in the integrated care model.

APA's Education Council Issues Report on Need for Integrated Care Training

APA's Education Council Issues Report on Need for Integrated Care Training

P05.09. "Without it, it would have been much worse": a mixed-method evaluation of clinical reflective practice in integrative care education

P05.09. "Without it, it would have been much worse": a mixed-method evaluation of clinical reflective practice in integrative care education