Integrated Care Initiatives Research Articles

Does an Inpatient Rehabilitation Admission Via the Community Prevent Hospital Readmissions in Older Adults? An Integrated Care Initiative

Abstract Background Rehabilitation interventions are essential in supporting frail older adult’s recovery following periods of decompensation and preventing future hospitalizations. Previously patients (age > 65 years) could only access inpatient rehabilitation via an inpatient stay in an acute hospital. Within the ICT (Integrated Care Team) in Dublin North West (DNW) a community rehabilitation pathway to two inpatient rehabilitation units exists. We retrospectively evaluated patients that were admitted to rehabilitation units via this pathway and measured their 90-day readmission rate to their local acute hospital. Methods 17 referrals were received from three pathways: Primary Care, the Holly Day clinic and the Frailty Intervention Team (FITT). Clinical frailty score’s (CFS), Falls risk (as per the world falls guidelines) and sarcopenia status as per the European Consensus on the definition of sarcopenia (EWGSOP) were recorded prior to admission. Readmissions within 90 days were collected from the hospital electronic database. Results CFS scores ranged from 5 to 7. All patients were identified as a high risk of falls and sarcopenic. The 90-day readmission rate was 11%. 5.5% of these were due to falls and the other 5.5% was due to the exacerbation of a pre-existing condition. All had CFS score of >6. Conclusion Readmission to acute care is not common in our patient cohort and shows the involvement of the ICT Geriatrician and Physiotherapist in identifying and referring frail older adults for inpatient rehab is successful. Ongoing development of interagency pathways and further referrals is needed to further progress this pathway and measure its efficacy in preventing readmission to an acute hospital. A 90 day and 180 day follow up and falls risk outcome measure pre and post admission would further demonstrate the success of this initiative and help measure the efficacy of this initiative in reducing the risk of preventable hospitalizations in older adults.

Evaluating the impacts of integrating health and social care systems on social care use among older adults with chronic diseases in China

Health and social care systems often operate in silos and cannot meet the complex needs of older adults with multiple chronic conditions. Since 2016, China has been implementing an integrated care initiative in some cities. This study aimed to evaluate the impacts of integrating health and social care in China on social care use among older adults with chronic conditions. Using panel data from the China Health and Retirement Longitudinal Study (N = 5,259), I employed a difference-in-differences analysis to evaluate the effects of the integrated care initiative. The initiative reduced social care use by 4.5 percentage points, primarily through a decreased receipt of informal care rather than formal care. The reduction in social care use was primarily due to a delayed increase in care levels, rather than a substitution with outpatient or inpatient services. The integration of health and social care was found to delay the progression of instrumental activities of daily living (IADL) by 8.8 percentage points but had no impact on activities of daily living (ADL). Heterogeneity analysis showed that the effects of the integrated care initiative on social care receipt and IADL limitation were weaker among those living in the Eastern region of China compared to other regions, indicating additional benefits of the initiative in mitigating geographical disparities. My findings suggest that integrating health and social care can effectively reduce the likelihood of older adults with chronic diseases receiving assistance for daily living tasks from family carers and delay the decline in their functional capabilities.

The Proposed Model for Pharmacy Led Med-to-bed Discharge Service in Tertiary Care Hospital

Introduction: The pharmacy-led discharge medication delivery to bedside (Med-to-bed) service in a tertiary care Johns Hopkins Aramco Healthcare (JHAH) hospital aims to optimize medication management during patient transitions from admission to discharge, especially for those with chronic conditions. The service entails the direct delivery of discharge medications to patients at the pharmacy following their discharge from inpatient wards, accompanied by comprehensive medication counseling. The pharmacy-led Med-to-Bed service aims to reduce patient wait times and improve overall clinical outcomes. Methods: This article highlights common challenges in medication reconciliation and post-discharge prescription fulfillment, highlighting the need for standardized protocols and improved hospital adherence to ensure seamless care transitions. It also discusses future considerations for optimizing the Med-to-Bed service, including proposed pharmacy renovations, installing a dedicated robotic dispensing system, and providing private spaces for patient counseling during medication pickup. Additionally, the proposal suggests deploying more pharmacy staff to address delayed discharge orders and making systemic enhancements to the EHR system to streamline prescription pickup. Result: The successful implementation of the proposed pharmacy-led Med-to-Bed service demonstrates the efficacy of interdisciplinary collaboration among nurses, physicians, and pharmacists. Through this collaborative approach, the Med-to-Bed service has shown tangible improvements in operational efficiency and patient outcomes, underscoring its potential to transform healthcare delivery models. Conclusion: Overall, this proposed model provides valuable insights into the transformative impact of integrated care initiatives like the Med-to-bed service in tackling complex medication management and enhancing quality patient care in hospitals.

Experiences and preliminary effects of the Comprehensive chrOnic caRe outpatiEnt (CORE) clinic for patients with multimorbidity in the hospital setting.

Healthcare systems remain disease oriented despite growing sustainability concerns caused by inadequate management of patients with multimorbidity. Comprehensive care programmes (CCPs) can play an important role in streamlining care delivery, but large differences in setup and results hinder firm conclusions on their effectiveness. Many elements for successful implementation of CCPs are identified, but strategies to overcome barriers and embed programmes within health systems remain unknown. To address this knowledge gap through a detailed study of implementing a CCP in a Dutch hospital setting, including patient experiences, facilitators, barriers and ways to overcome those barriers. Additionally, this study aims to explore effects on patient satisfaction and healthcare use. A qualitative study design with 39 semistructured interviews and focus groups between July 2020 and February 2023 with 16 patients and 17 involved professionals. Additionally, effects on quantitative outcomes for patient satisfaction (PACIC-20) and healthcare use were explored. Professionals expressed a wide range of topics related to implementation and ways to overcome barriers at hospital and system level. Alterations in the design to accommodate varying care demands, focus on inclusions through referrals, and lack of long-term support and appropriate financing were key topics. Patients expressed varying experiences, stated a strong desire for comprehensive information, and emphasised the importance of trust in caregivers. Patient satisfaction showed no effects, while healthcare use showed slight decreases in trends, but patient numbers were limited. The introduction of a CCP is feasible, and exploratory analysis on effectiveness shows lower hospital care use without decreasing patient satisfaction. However, this is accompanied by several challenges that show current fragmented systems still do not support implementation of integrated care initiatives. Overcoming those comes with substantial costs and may require a strong bottom-up implementation within a motivated team and actions on all levels of healthcare systems.

Spatio-temporal modelling of referrals to outpatient respiratory clinics in the integrated care system of the Morecambe Bay area, England

BackgroundPromoting integrated care is a key goal of the NHS Long Term Plan to improve population respiratory health, yet there is limited data-driven evidence of its effectiveness. The Morecambe Bay Respiratory Network is an integrated care initiative operating in the North-West of England since 2017. A key target area has been reducing referrals to outpatient respiratory clinics by upskilling primary care teams. This study aims to explore space-time patterns in referrals from general practice in the Morecambe Bay area to evaluate the impact of the initiative.MethodsData on referrals to outpatient clinics and chronic respiratory disease patient counts between 2012-2020 were obtained from the Morecambe Bay Community Data Warehouse, a large store of routinely collected healthcare data. For analysis, the data is aggregated by year and small area geography. The methodology comprises of two parts. The first explores the issues that can arise when using routinely collected primary care data for space-time analysis and applies spatio-temporal conditional autoregressive modelling to adjust for data complexities. The second part models the rate of outpatient referral via a Poisson generalised linear mixed model that adjusts for changes in demographic factors and number of respiratory disease patients.ResultsThe first year of the Morecambe Bay Respiratory Network was not associated with a significant difference in referral rate. However, the second and third years saw significant reductions in areas that had received intervention, with full intervention associated with a 31.8% (95% CI 17.0-43.9) and 40.5% (95% CI 27.5-50.9) decrease in referral rate in 2018 and 2019, respectively.ConclusionsRoutinely collected data can be used to robustly evaluate key outcome measures of integrated care. The results demonstrate that effective integrated care has real potential to ease the burden on respiratory outpatient services by reducing the need for an onward referral. This is of great relevance given the current pressure on outpatient services globally, particularly long waiting lists following the COVID-19 pandemic and the need for more innovative models of care.

The ART of Readiness: A Practical Tool for Implementation Tailoring at the Activity Level

The field of implementation science has made notable strides to enhance the practice of tailoring through the development of implementation strategy taxonomies (e.g., Expert Recommendations for Implementation Change; Waltz et al., In Implement Sci 10:109, 2015) and numerous tailoring methodologies (e.g., concept mapping, conjoint analysis, group model building, and intervention mapping; Powell et al., In J Behav Health Serv Res 44:177–194, 2017). However, there is growing concern about a widening gap between implementation science research and what is practical in real-world settings, given resource and time constraints (Beidas et al., In Implement Sci 17:55, 2022; Lewis et al., In Implement Sci 13:68, 2018). Overly complex implementation strategies and misalignment with practitioner priorities threaten progress in the field of implementation science. As solutions to the burgeoning threats, implementation science thought leaders have suggested using rapid approaches to contextual inquiry; developing practical approaches to implementation strategy design, selection, and tailoring; and embracing an embedded implementation science researcher model that prioritizes partner needs over researcher interests (Beidas et al., In Implement Sci 17:55, 2022). Aligned with these recommendations, we introduce the Activity Readiness Tool (ART)—a brief, practitioner-friendly survey that assesses discrete determinants of practice through an implementation readiness lens. We illustrate how the tool can be used as a rapid approach to facilitate implementation efforts in a case example involving a national integrated care initiative. The ART can serve as a quick, user-friendly companion to an array of existing evidence-based tailoring methods and tools.

Innovating Health Governance in Australian Integrated Care

Background: Australia is one of many countries implementing integrated care initiatives to facilitate the Quadruple Aim (the improvement of health outcomes, patient experience, provider experience and health system sustainability). These initiatives can be complex while working within a fragmented and siloed health system. NSW Health has created the Patient Centred Collaborative Commissioning Groups (PCCGs) program facilitating Local Health Districts (LHDs) and Primary Health Networks (PHNs) to co-commission health initiatives targeting local populations and their specific health needs. These PCCGs are unique as they are comprised of stakeholders involved at all levels of government in addition those from the community and private sectors. The LHDs and PNHs collaborate with additional relevant and local stakeholders to co-design new service pathways and ensure collaboration within one local health system.
 The literature evaluating integrated care aims at advancing knowledge of patient and provider experiences. Both areas are vital to understanding the successes and failures of integrated care but are insufficient to understand the ‘how’ and ‘why’ of successful system integration. This study therefore focuses on the under-researched question of ‘is it possible to govern integrated care?’
 In the Australian context, the governance of integrated care needs significant attention. In the context of this research, health system governance is defined as “the norms, structures, actors, institutions, and formal and informal relationships that shape authority and action in a health system”.
 Methods: This qualitative study involves semi-structured interviews with key stakeholders involved in the PCCGs and reviewing the governance documents of each local program. Data collected is thematically analysed and compared to existing governance models to draw out aspects of the individual PCCG governance mechanisms. This is part of a larger study that aims to understand the stakeholders, partnerships, and governance in integrated care in Australia.
 Implications for the future: This study will provide an in-depth understanding of the decision-making processes involved in the development (and subsequent use) of the governance models, as well as determining which actors have what roles and accountabilities within the PCCG. It is vital to determine what contributes to and facilitates each domain of health system governance (as defined above) to truly understand how we can achieve sustainable health care system reform. Traditional governance models are not sufficient to regulate the dynamic nature of integrated care initiatives, so they cannot facilitate the sustainability of these initiatives. As such, the overarching aim of this research is to create an ideal governance framework that can be replicated and applied across various integrated care initiatives.

The Evolution of Ontario Health Teams: A Developmental Evaluation

Background: Ontario, Canada’s most populous province, is no stranger to integrated care initiatives. However, none have been as ambitious and far-reaching as the Ontario Health Team (OHT) initiative, announced by its Ministry of Health (MOH) in 2019. Its eventual objective is population health management – every Ontarian will belong to an OHT providing them with seamlessly coordinated care across the hospital-community continuum. Our team conducted a Developmental Evaluation (DE) that sought to understand and guide the development of 6 OHTs over the course of a year. 
 Methods: Six OHTs were chosen, based on their representation of a range of geographies and readiness and willingness to participate. DE employs embedded research and collaboration between researchers and participants to understand and guide development. Findings are co-constructed and shared with participants continuously. DE was paired with ethnography which employs multiple methods and prioritizes close engagement with participants over time. Data collection took place from Spring 2021-2022, led by a team of five embedded researchers. Approximately 275 OHT development meetings were observed and 30 interviews conducted. Key participants were also invited to periodically journal about their experience of working together on OHT development. While analysis was guided by existing frameworks (Context and Capabilities for Integrated Care Framework & the MOH’s 8 “building blocks”), a ground-up inductive approach was privileged. 
 Results: We identified 9 key areas of development: a) developing vision, b) establishing governance, c) strategic planning, d) designing and implementing integrated models, e) advancing digital health, f) engaging primary care, g) partnering with patients, families and caregivers, h) establishing funding and incentive structures, and i) enhancing performance measurement, quality improvement and continuous learning. 
 Discussion & Impact: 
 Local 
 Analysis of our results yielded the following insights: a) OHTs were evolving at different paces, each at a different stage of progress in relation to key areas of development, b) despite differences in evolutionary trajectory, there were shared contexts, structures and cultures that both forwarded and frustrated progress across OHTs, and c) while findings largely overlapped with the MOH’s eight building blocks for OHT maturity, there were key differences. These differences suggest the need for change management that supports the translation of macro-level expectations into local realities, while ensuring on-the-ground realities are reflected in expectations. Recommendations were generated to guide OHT development across the province.
 International 
 This research contributes to scholarship on the context-bound practice of integrated care - its constant negotiation of both local and systemic contexts. It also provides an important example of how an initiative that is similar in purpose to population health and integrated care initiatives such as the Integrated Care System (ICS) in the UK and Accountable Care Organizations (ACO) in the US, may be differently implemented and experienced across an entire health system. 
 Next Steps: While we have an understanding of OHT struggles with the system and policy environment, we know less about policymakers’ perspectives on these issues. Our next phase of research will therefore explore how policymakers respond to systemic gaps identified by OHTs and where their own concerns lie.

Case management as a tool for integrated care

Introduction: Résinam and Chronicopôle are two pilot projects implemented in the Namur and Liège areas. They are part of a larger plan of 12 integrated care initiatives targeting chronically ill people. The “Case management” is a central action within the two pilot projects. Its main specificity is that it meets with a number of components of integrated care as well as needs arising from the field experience.
 Policy Context And Objective: Each territory has its own specificities. For example, we can identify home nursing coordination, integrated home care services, P3 protocols... The “case manager” is not an additional initiative. He/She intervenes up when the missions of the different structures do not allow a sufficient offer of care to the patient. His/Her intervention is therefore ad hoc and characterized by a period of crisis. His/Her main objective is to stabilize patient care while offering a treatment path that corresponds with their needs. His/Her intervention requires acting in coherence with the operating mode of the network. He/She must be able to target his/her strengths and limits of action in order to adapt his/her missions. 
 Target population: Chronically ill people in a situation of polyfragility (mental health problem and/or social insecurity)
 Highlights (innovation, impact, outcomes): The implementation of case management has been evolving (since 2018, 3 case managers have taken care of 171 patients in the Namur region) according to the specificities of the areas and to the projects that have developed the mission. 
 Nethertheless, we can identify a common process to facilitate the development of this action. It is necessary to co-construct the profile with the various stakeholders (in Namur, a working group with home care coordination and a Be-Hive researcher has been set up) in order to identify the existing processes and the unmet needs among patients.
 On the other hand, we can mention an added value for the patient namely the reactivation of available services, the networking of the various stakeholders (which goes beyond simple multidisciplinary consultation). This approach invites social interventions (CPAS, humanitarian aid centers and the social and housing services) to interact, focusing on the patient and his health.
 Conclusion: The implementation process as described is an added value in terms of change management. The action highlights the different processes of patient care and allows an improvement of the situations encountered in the most complex situations. This process requires flexibility from stakeholders and openness in terms of integrated care.
 The process of network activation and patient support requires stakeholders to be open in the process and innovative in the segmentation of services to provide quality outpatient service.
 The outpatient service also allows to work from the patient’s perspective, using communication tools that allow case managers and protagonists to work on requests while respecting the person's choice.
 This co-construction system allows the needs of each stakeholder (subsidizing power-service providers-patients) to be met and is therefore a reference as a methodology for implementing other integrated care initiatives.

Using Population Segmentation to Identify Opportunities for Integrated Care in Ontario, Canada.

Ontario, Canada has introduced Ontario Health Teams (OHTs) to advance integrated care and population health management. There are currently 54 OHTs covering a population of nearly 14 Million individuals. The teams are expected to plan and implement new care models that improve quadruple aim goals of patient and provider experience, health outcomes and cost efficiency. The Health System Performance Network (HSPN) is funded by the Ontario Ministry of Health to provide evaluation and research to support OHTs. The HSPN is using population segmentation alongside performance measurement to support OHTs to identify populations for improvement. OHTs are using the data provided by HSPN to target opportunities for improvement. This presentation summarizes the performance measures and population segmentation approach used in Ontario to advance integrated care and population health. 
 HSPN is using the British Columbia Health System Matrix (BCHSM), based on the Bridges to Health model to segment the population for each OHT. HSPN has identified 10 overall indicators of performance for OHTs ranging from premature mortality to continuity of physician care. There are also 5 measures respectively in several specific populations including older adults, mental health, and end of life. Indicators are also examined according to socioeconomic strata. This presentation will overview the population segmentation methodology, the ways that performance indicators vary according to population segments, and the ways that OHTs receive the data and are coached in the use of data to target and advance integrated care initiatives. 
 The BCHSM provides 14 different population segments ranging from non-users to low-users to frail older adults in the community to people at the end of life. Increasing frailty and clinical complexity is strongly related to the population segments/groups and premature mortality and total system costs correspond as well to increasing patient complexity. The BCHSM has high face-validity. Improvement indicators for mental health and health system priorities such as emergency presentations for mental health reasons and delayed discharge from acute hospital are also more common in specific population groups which helps to prioritize and target interventions. These data are supporting the development of specific integrated care programs to address health needs in underserved populations.

From paper to practice: implementing integrated care for youth-at risk

Background: At present, professionals experience difficulties applying known facilitators and barriers of integrated care in practice [1]. This is particularly intricate when working with youth at-risk and their families. These families have a diversity of problems in different life-areas, that often do not seek or accept care, and with a continuing risk of crisis situations occurring. To improve integrated care for youth at-risk, we aimed at deepening insights into how to enable facilitators or overcome barriers when implementing integrated care for youth at risk.
 Targeted population and stakeholders: The overall study design comprises practice-based action research. The primary focus of this study is on the perspective of Youth Care professionals, policymakers and youth at-risk in the Dutch Youth Care system. This study is designed and monitored in co-creation with professionals, policymakers and youth representatives. By organizing learning sessions based on the results of the study, professionals and other stakeholders are stimulated to learn and improve the quality of care for youth at-risk. 
 Method: For the aim of this study, we conducted 31 semi-structured interviews, observations with different stakeholders and one learning session with a youth and parent representative, professionals, and policymakers within a network of an integrated care initiative for youth at-risk. To analyse the transcripts, learning session and observation reports, we conducted a thematic analysis both deductively and inductively.
 Results: The implementation of integrated care for youth at risk seemed to be influenced by three underlying mechanisms: mandate, care coordination, and professional autonomy. Neither mandate, nor care coordination, nor professional autonomy was reported as lying with one person or organization and shifted between them depending on the specific case. When there was a lack of, or insufficient agreement on professional autonomy, mandate, or care coordination, it became extremely difficult for the professionals involved to provide integrated care in practice. Specifically in crisis situations, when clarity on mandate, care coordination, and professional autonomy was urgent but often lacking in practice. This led to indecisiveness and inappropriate support or no care provision at all. At the same time when these mechanisms were present: integrated care for youth at-risk was more easily realized. 
 Conclusions: Providing integrated care for youth at-risk is a joint effort. The different organizations need to specify with every new case who is involved and what their role and responsibility is, in order to offer youth at-risk the care they need. Therefore, professionals and organizations need to realize, understand and act on the underlying mechanisms mandate, care coordination and professional autonomy when providing integrated care for youth at-risk. Future studies are needed to establish whether and if so, what, other underlying mechanisms are crucial when providing integrated care for youth at risk in practice and how these mechanisms are successfully implemented. 
 Reference: 1.Nooteboom LA, Mulder EA, Kuiper CH, Colins OF, Vermeiren RRJM. Towards integrated youth care: A systematic review of facilitators and barriers for professionals. Administration and Policy in Mental Health and Mental Health Services Research. 2020;48(1):88–105.

First Phase of Integrated Care Initiative PAIK in Estonia: Lessons Learned

Background: Patients with chronic conditions often experience fragmented care and suboptimal health outcomes. Therefore, initiatives to improve the care-continuum of high-risk patients have emerged in Estonia. PAIK project was the first which tried to integrate social-services sector, specialist care and primary healthcare to co-ordinate the care for high-risk elderly patients with social health determinants. Although we measured improved perception of quality of care and level of integration, pragmatic analysis with matched controls failed to improve health outcomes and reduce costs.
 Aim: To analyse and describe lessons learned from PAIK initiative and if intervention or implementation failure explains the negative results of the project.
 Method: A qualitative analysis using focused interviews and expert opinion was used.
 Results: Firstly, the PAIK project was more a pragmatic service design and feasibility exercise than a full-fledged study designed to demonstrate better health outcomes. It was started without power analysis and analytical components were added later. No control arm was used and having social health determinants as inclusion criteria prevented retrospectively finding an unbiased propensity matched control group. Analysis showed that majority of the patients included, belonged to a very high-risk stratum (top 1%), where care-management is less effective. Also we found that not all components of the intervention were aligned with reducing hospitalisations and ER-visits.
 Another factor was that the healthcare sector lacked any prior experience with integrated care practice implementation and scaling, so the lack of existing workforce resulted in training activities continuing well into the duration of the project. Mid-study there was a change in clinical leadership, which also resulted in target population adjustment and process redesign.
 Thirdly we failed to identify and recruit champions from the primary care and social services sides, therefore engagement of these sectors was modest and the service was dominantly specialist care focused. The Covid pandemia also coincided causing resource conflicts in the sector both on hospital and primary care side. 
 Despite these above mentioned shortcomings, we consider the study generally a success, as we feel that focusing on social health determinants is important in such services and was very welcomed by both the social service providers and GP nurses. Also due to our project the role of care managers was defined in Estonia and educational programs implemented. Also, a functional care-management software module was developed and tested during the service. Finally our experience has been seen as valuable and has attracted specialist in several other counties to invest in integrated care efforts and there is greater readiness to change.
 Conclusions: Despite the PAIK intervention in Viljandi being well received by the patients and showed better patient reported outcomes, it failed to convincingly reduce health resource utilisation and hospitalisations. Both components of intervention failure and implementation failure are probably responsible. Experience from the project however might improve the success of future initiatives and be part of the foundation for care-delivery model innovation in Estonia.

A Practical Guide to Building, Evaluating and Refining a Multi-Sector Community-Based Integrated Care Model for Seniors

Background: Integrated care models that bring together health and social care services in the communities where people live are necessary to meet people’s needs in an effective, person-centred, and sustainable manner. However, designing, implementing, and evaluating these models remain challenging particularly given the complexity of need, services, and partnerships.
 Objectives: Over the last three years, we utilized a learning health system approach to design, implement, evaluate, and revisit our integrated care model that aims to integrate health and social care for seniors, with a focus on those facing socioeconomic or other challenges. The Community Wellness Hub is an alliance of health and social service providers that coordinate and deliver services to seniors. The Hub is located in affordable housing buildings and provides services to individuals who reside in the building and surrounding area. The aim is to enable members to lead healthy and fulfilling lives in the community by proactively addressing health and wellness needs and reducing health crises requiring acute care. Services provided are an intersection of three systems: health care, housing, and social care, spanning 15 organizations. 
 In this workshop, we share the journey of the Community Wellness Hub from inception to date. We will reflect on facilitators, challenges, and learnings in three main areas: building and implementing the hub, evaluating the implementation, and enacting the results of the evaluation.
 Proposed Audience: Proposed participants include policy makers, program designers, evaluators, quality improvement specialists, patients, and caregivers as well as researchers interested in designing and evaluating complex integrated care initiatives.
 Structure: 
 •The first 5-10 minutes of the workshop will be a round table introduction
 •Then 5 minutes for introducing the Community Wellness Hub and the agenda of the workshop to the participants 
 •The last 10 minutes will be for summarizing the lessons learned and take-home messages. Similarities and variations amongst jurisdictions will be reflected on based on the participants
 •Then the rest of the time will be divided into three equal parts. The first will cover the creation of the hub, then the evaluation and finally enacting of the evaluation results into actionable steps. Each of the three sections will start by an open question inviting the audience to work in small groups to answer this question. These questions are: what are the key elements when creating a hub model via a partnership that spans health, social and community care? How to evaluate the implementation of an integrated hub model? How to enact the evaluation results?
 •After each group discussion, we will connect to reflect on the various approaches. Following that the presenters will share the approach they used within the hub highlighting resources, methods, tools, and practical tips.
 Outcome: By the end of the workshop, participants are expected to have learned some practical tips around designing, implementing, evaluating and utilizing the evaluation results in the context of integrating health and social care that may be applied to their local programs or initiatives.

The Tyrolean Federal Institute for Integrated Care (LIV Tyrol)

A constantly increasing life expectancy of society leads to an increase in severe chronic diseases, which are accompanied by negative effects on the quality of life for patients and an increasing number of hospital admissions as well as long hospital stays. This poses major challenges for the healthcare system and requires innovative and integrated approaches in order to provide high quality healthcare.
 Therefore, the Tyrolean Federal Institute for Integrated Care (LIV Tyrol) was founded from a joint initiative of the federal state government of the Province of Tyrol and the social insurance institutions to target the above mentioned challenges and reduce burdens for the health care system by developing and implementing integrated care approaches and programs for different chronic diseases. Integrated care is understood to be patient-oriented, continuous, cross-sectoral, interdisciplinary and/or multiprofessional care based on standardized care concepts.
 LIV Tyrol aims for optimal care for patients – especially patients suffering from chronic diseases – at their homes in order to increase their quality of life on the one hand and, on the other hand, to relieve the healthcare system through innovative approaches. As a result, different disease management programs are developed, implemented, coordinated, operated and evaluated.
 They include disease management programs for patients with heart failure (HerzMobil Tirol), dementia (Demenz Tirol), patients who suffered a stroke (Schlaganfallpfad Tirol) or in need of palliative care (Hospiz- und Palliativversorgung). LIV Tyrol also coordinates the care management for the Province of Tyrol, Austria and the post-Covid care. Some of these programs are supported by telemedical solutions including telemonitoring systems to provide a secure framework for patient care outside the hospital and to allow for immediate measures when needed. Furthermore, different registries, such as the Austrian birth registry, the Tyrolean cancer registry, the Tyrolean arthroplasty registry, or the Tyrolean diabetes registry are located and operated at the Institute of Clinical Epidemiology, which is part of LIV Tyrol. LIV Tyrol also supports data management and analytics for (clinical) problems but also provides an important contribution to quality assurance within the Tyrolean healthcare system.
 In order to implement such disease management programs, a close collaboration of different stakeholders is needed. Stakeholders of LIV Tyrol include but are not limited to health-policy makers, social insurance institutions, healthcare providers (hospitals, resident practitioners, other health-related professions), research institutions, and patients. 
 An institution like LIV Tyrol is unique in the Austrian health care system and contributes to optimal care security for patients in Tyrol and poses hub for new, innovative and flexible integrated care models.
 To make the health care system fit for the future, the federal and state governments have agreed to expand integrated care. The federal government of Tyrol has therefore commissioned the Tyrolean Federal Institute for Integrated Care to implement these targets and to design, organize and coordinate integrated care initiatives throughout the province of Tyrol.

Strengthening a Dutch initiative with action research; community involvement one of the key stumbling blocks

Introduction: There is a strong call from integrated care initiatives for practical guidance, including translating existing scientific knowledge into the local context. This covers several themes such as regional governance, adjusting payment models, and community involvement. In the presented project, we used an action research approach to support the team of HealthKIC implementing the ‘Kavelmodel’ in the Netherlands. HealthKIC supports regions that are willing to change using a population health management approach by facilitating the implementation together with stakeholders on all levels. The Kavelmodel focusses on improving the health and wellbeing of the population of the involved regions, ‘Vallei Vitaal & Gezond’ and ‘8terhoek Gezond’ for now. 
 Methods: Together with the HealthKIC-team we co-designed an action research process looking to evaluate the tools and approaches that were used by the HealthKIC-team to enable key themes and issues in the regions and with system-level stakeholders. Working with an emergent paradigm perspective in this complex and dynamic environment, we attempted to balance the flexibility in the process to adapt to emergent circumstances, while still have the ability to validate the findings. The process focussed on exchanging knowledge and lessons learned between science and practice using learning cycles. 
 Results: While all above-mentioned themes were discussed, one key stumbling block was community engagement. Using several learning cycles in different settings, we were able to continuously stress the importance of it, share knowledge and practical examples, and discuss next steps. However, both system-level stakeholders and regional stakeholders remained reluctant to adopt a form of community involvement and haven’t implemented it yet. The actual doing, listening to community members and hand over some control, was perceived the most difficult and crucial aspect for stakeholders on all levels. Reflection sessions about this theme revealed the main reason for not taking action was feeling insecure about how to progress. As was seen with other themes, this hesitation often led to people falling back into old habits and working on other day-to-day tasks. 
 Discussion: As is evidenced by the literature and practice, community involvement often remains theoretical. We tried out a new way of working using learning cycles to provide practical guidance, but it didn’t result in effective implementation of community involvement yet. Having the knowledge of the importance of and how to involve community members proved to be not enough. Therefore, we still need to search for the most effective strategy to include community members successfully in these kind of initiatives. One of the lessons learned is that it is important is to consider the attitude and commitment of the stakeholders involved. The project leaders need to feel supported by them to take action. Next to that, the community involvement needs to fit within the bigger picture of the initiative, supported by a joint vision, sustainable resources, and a learning environment. These are crucial insights into why community involvement is still lacking. Looking forward, having PHM-coaches in the region could bring the necessary assurance for people to work differently and in new and unexpected circumstances.

2.M. Workshop: Fostering integrated care through a large-scale structural health system reform in Finland

Abstract Several countries have introduced health system reforms to foster integrated care within their health systems and in some case also between health and other welfare services such as social care. These integrated care initiatives have included reorganization of the work of professionals, developing patient pathways and removing barriers for organisations to work together. Comprehensive structural reforms to foster integrated care have not been that common. In health systems, like in public policy in general, small, micro-level reforms are common but only seldom large-scale structural reforms are enacted. Also integrated care is often fostered through small-scale reforms which are not always even scaled up from the local or regional level to national level policies. In Finland a large-scale structural reform was introduced in 2023 which can be marked as one of the most comprehensive health system reform in Europe over the past decades. As a result of the reform the responsibility for organizing health care, social services and rescue services was transferred from over 300 municipalities to 22 health and social care authorities which all get funding from the state. A key tool in pursuing the reform has been to implement administrative and financial integration both in terms of vertical integration within health system and horizontal integration between health care and social services. The workshop uses the Finnish health system reform as a case study to present how integrated care can shape the health reform agendas and implementation of the reform. We discuss how structural reformation can foster integrated care at patient level and how the rather radical restructuration of the Finnish health system looks from the wider European perspective. Key messages • One of the most comprehensive health-system reforms in Europe over the past decades was introduced in Finland in 2023. • The radical structural health-system reformation can foster integrated care at patient level and offers a learning opportunity to other European health systems.

The impact of integrated care on health care utilization and costs in a socially deprived urban area in Germany: A difference-in-differences approach within an event-study framework.

We investigated the impact of an integrated care initiative in a socially deprived urban area in Germany. Using administrative data, we empirically assessed the causal effect of its two sub-interventions, which differed by the extent to which their instruments targeted the supply and demand side of healthcare provision. We addressed confounding using propensity score matching via the Super Learner machine learning algorithm. For our baseline model, we used a two-way fixed-effects difference-in-differences approach to identify causal effects. We then employed difference-in-differences analyses within an event-study framework to explore the heterogeneity of treatment effects over time, allowing us to disentangle the effects of the sub-interventions and improve causal interpretation and generalizability. The initiative led to a significant increase in hospital and emergency admissions and non-hospital outpatient visits, as well as inpatient, non-hospital outpatient, and total costs. Increased utilization may indicate that the intervention improved access to care or identified unmet need.

Integrated care models in Swiss primary care: An embedded multiple case study.

Healthcare systems are confronted with a rising number of patients with chronic conditions and complex care needs, requiring the development of new models of coordinated, patient-centred care. In this study, we aimed to describe and compare a range of new models of care recently implemented in primary care in Switzerland, as well as to gain insight into the type of coordination or integration implemented, the strengths and weaknesses of each modeland the challenges they face. We used an embedded multiple case study design to describe in-depth a series of current Swiss initiatives that specifically aim to improve care coordination in primary care. For each model, documents were collected, a questionnaire was administeredand semistructured interviews with key actors were conducted. A within-case analysis followed by a cross-case analysis were performed. Based on the Rainbow Model of Integrated Care framework, similarities and differences between the models were highlighted. Eight integrated care initiatives were included in the analysis, representing three types of models: independent multiprofessional GP practices, multiprofessional GP practices/health centres that are part of larger groupsand regional integrated delivery systems. Recognized effective activities and tools to improve care coordination, such as multidisciplinary teams, case manager involvement, use of electronic medical records, patient educationand use of care plans, were implemented by at least six of the eight initiatives studied. The main obstacles to the implementation of integrated care models were the inadequate Swiss reimbursement policies and payment mechanisms and the desire of some healthcare professionals to protect their territory in a context where new roles are emerging. The integrated care models implemented in Switzerland are promising; nevertheless, financial and legal reforms must be introduced to promote integrated care in practice.

Cooperation Improvement in an Integrated Healthcare Network: A Social Network Analysis.

Cooperation is a core feature of integrated healthcare systems and an important link in their value-creating mechanism. The premise is that providers who cooperate can promote more efficient use of health services while improving health outcomes. We studied the performance of an integrated healthcare system in improving regional cooperation. Using claims data and social network analysis, we constructed the professional network from 2004 to 2017. Cooperation was studied by analyzing the evolution of network properties at network and physician practice (node) level. The impact of the integrated system was studied with a dynamic panel model that compared practices that participated in the integrated system versus nonparticipants. The regional network evolved favourably towards cooperation. Network density increased 1.4% on average per year, while mean distance decreased 0.78%. At the same time, practices participating in the integrated system became more cooperative compared to other practices in the region: Degree (1.64e-03, p = 0.07), eigenvector (3.27e-03, p = 0.06) and betweenness (4.56e-03, p < 0.001) centrality increased more for participating practices. Findings can be explained by the holistic approach to patients' care needs and coordination efforts of integrated healthcare. The paper provides a valuable design for performance assessment of professional cooperation. Using claims data and social network analysis, we identify a regional cooperation network and conduct a panel analysis to measure the impact of an integrated care initiative on enhancing professional cooperation.Physician practices participating in the integrated system became more cooperative and improved their influence in the regional network more than non-participating practices.Integrated healthcare systems effectively incentivize cooperation through a holistic approach to patient care needs and coordination efforts.

Approaches to improving patient safety in integrated care: a scoping review

ObjectivesThis scoping review aimed to establish the approaches employed to improving patient safety in integrated care for community-dwelling adults with long-term conditions.DesignScoping review.SettingAll care settings.Search strategySystematic searches of seven academic...