Integrated Care Initiatives Research Articles

What do senior management staff members consider to be “interagency collaboration”? From the perspectives of these individuals, an exploration of the context and extent of enablers and barriers to interagency collaboration within their organisations

Introduction: The Sydney Local Health District (SLHD) integrated care initiative, Healthy Homes and Neighbourhoods (HHAN), provides long term care coordination to vulnerable families. The spectrum of care required to optimise the health and social care outcomes for these families well exceeds the capacity of the public healthcare system alone. The HHAN clinicians recognise that needs such as housing, finance, and social supports often preclude these families from addressing physical and mental health issues and as such, work directly with clients to coordinate holistic interagency collaboration to suit each family’s needs. As part of the evaluation of HHAN, this project looks to understand how these endeavours on the “front line” align with the strategic directions of agencies across the network. Theory/Methods: The perspectives as well as the power to influence interagency collaboration will depend in part on an individual’s formal role within an organisation. Using a semi-structured, qualitative interview approach, this aspect of the HHAN evaluation will specifically focus on senior management staff from 12 separate organisations, all of which are networked with the HHAN program in some capacity. The interviews will focus on exploring the participant’s individual definition of “interagency collaboration”, followed by exploring their opinion on context and extent of enablers and barriers to interagency collaboration. Results: Interviews are expected to commence in early September, 2017. Preliminary findings will be presented. We will compare the definitions held by senior level management staff in different organisations and focus on what they believe to be enablers and barriers to interagency collaboration. Discussions: The project will discuss how the definition of interagency collaboration manifests as/or translates to barriers or enablers to engagement and cooperation in practice. Conclusions: We believe perspectives of and definitions held by senior management staff are influenced by their position within an organisation and their formal role which in turn affects interagency collaboration on multiple levels. This study will provide further insights into this concept.

Social Capital and Migrant Maternal Depression. A Multilevel Bayesian Latent Variable Spatial Logistic Regression in South Western Sydney, Australia

Introduction : We take as our starting point the proposition that antenatal and postnatal maternal stress and depression adversely impact on the developmental origins of health and disease. We cannot yet be certain of the biological level mechanisms that alter the genotypic and phenotypic response to perinatal adversity but the triggering of genetic, neuroendocrine and physiological mechanisms but psychological and nutritional stress are regarded as strong contenders. Little is known, however, of the role played by ecological constructs such as social capital. Theory/Methods : In the study reported here we use multilevel Bayesian hierarchical spatial logistic regression to examine relationships between those ecological latent constructs and depressive symptoms among migrant mothers, while controlling for individual level co-variants. Migrant mothers (n=7256) delivering in 2002 and 2003 were assessed at 2-3 weeks after delivery for risk factors for depressive symptoms. The individual-level binary outcome variables were Edinburgh Depression Scale (EDS) >9 and >12. The association between social, demographic and ecological factors and aggregated outcome variables were investigated using exploratory factor analysis and Bayesian methods Results : Migrant mothers had higher rates of depressive symptoms in communities with higher concentration of mothers born in Australia. The reverse was also true. The exploratory factor analysis identified six latent constructs: neighbourhood adversity, social cohesion, health behaviours, housing quality, social services, and social capital. Migrant mothers were at higher risk of depressive symptoms if they were living in communities with strong group-level social capital. . Conclusions : These findings suggest that bonding capital may be a health liability rather than [the] force for health promotion that it is often assumed to be. The finding have implications for the distribution of health services including early nurse home visiting, which has recently been confirmed to be effective in preventing postnatal depression. Lessons Learned : The study reported here was used to design and integrated care initiative in South Western Sydney The paradoxical findings with respect to minority groups and social capital were used to inform intervention design. The methods used here can readily inform critical realist informed intervention designs. Limitations : There were methodological limitations in that the latent variables were developed using frequentist rather than Bayesian methods. Suggestions for future research : Analysis using multilevel spatial latent class analysis will add to our understanding of our population groups are influenced by population level social capital.

Enacting a model of integrated care for people with complex health needs

Introduction : Improving health care through integrated care has been a goal for governments and policymakers internationally for three decades. However, it is still unclear how integrated care can be achieved in practice. This doctoral study examined how a model of integrated care evolved as an approach to caring for people with complex health needs. The case is HealthOne, a NSW government initiative, located in primary health care. Theory / Methods : Drawing on resources from actor-network theory, practice theory and integrated care literatures, this study explored how a model of integrated care was enacted in practice. The multi-sited, mobile ethnographic fieldwork extended from 2011 to 2013. Data was collected from shadowing HealthOne liaison nurses, observing meetings, semi-structured interviews and documents. The focus was on work practices associated with care of HealthOne clients carried out by a range of health and social care professionals. Results : The enactment of integrated care emerged as a relatively unstructured form of integration, understood as linkage. While embedded practices such as working in silos and protecting client confidentiality reacted uneasily to the model of care, practices including engaging clients and working with general practitioners fostered change. This enactment of integrated care was an approach to new ways of working reliant on relational practices encouraging engagement with the model of care. HealthOne liaison nurses and case conferences held together shifting relations and emerging practices. Care was individualised and attuned to the client’s immediate needs and the realities of the local context. Discussion : Policy positioned HealthOne as a new model of care that would encompass primary care and community-based services, with integrated patient-centred care provided by multidisciplinary teams. The absence of adequate structural arrangements for shared care and lack of supportive technologies were matters of concern. Practice change evolved in uneasy tension with stability, rather than as a straightforward replacement of old with new. The policy did not work in practice entirely as envisaged, however, a form of integrated care was accomplished in practice as an ongoing, fluid process of negotiation and adaptation. Conclusions : Since there were no funding incentives, formal agreements or shared care arrangements organising practice, enacting integrated care relied on creating flexible informal partnerships across professional and organisational silos with individual clinicians and services. The HealthOne approach to integrated care became cooperative care management facilitated through liaison nurses and case conferences acting as mechanisms of integration. Lessons learned : Engagement of practitioners and clients are key dependencies. Future initiatives should establish partnership agreements with private practitioners and social care services involved in integrated care. Clinical integration should be supported by systems and structures to facilitate multidisciplinary care management and care planning. Limitations : The data and findings may not be representative of all HealthOne sites, or of a different timepoint in HealthOne’s evolution. Suggestions for future research : Future studies are recommended that foreground the clients' experiences and outcomes from integrated care initiatives. Investigation of how the HealthOne model of integrated care has been embedded in practice and further evolved would produce valuable and complementary findings to this study.

Training General Practice Registrars on conducting child health and developmental surveillance. Evaluation of a blended eLearning Program

Introduction: Community-based integrated care initiatives for children and families had been developed in Sydney Australia over five years. One of those is the Healthy Homses and Neighbourhoods Integrated Care (HHAN) Initiative. The HHAN design includes several sector workforce capacity building initiatives. A partnership was formed with: primary health networks (PHN), child and family nurses, practice nurses, a general practice training organisation, Sydney Children's Hospita Network and the local health district. Child health checks are conducted by Child and Family Nurses in Australia. Due to many reasons, most families do not return for their checks. However they still frequent their GPs for a range of health needs, a setting where follow up checks can be implemented and an opportunity for postgraduate learning. Theory/Methods: GP registrars were invited to participate in an eLearning program followed by a clinical skills workshop. A curriculum blueprint mapping to learning objectives underpinned the program. Content was extracted from well child check resources and developed into individual learning objects, multimedia and interactive quizzes within a blended learning platform. Results: Eighty-eight percent felt that the online program was useful, 66% felt learning objectives were fully met with 100% at least partially met. An overwhelming majority felt that the workshop reinforced knowledge gained from online modules and improved confidence in applying learnt content. More results will be presented at the conference. Discussion: Development of eLearning for general practice is a growing field. GPs are busy and often bombarded with many requirements for CPD. Ensuring that there are adequate incentives as well as instructional design that is interesting, relevant and time efficient is the mainstay of GP education. Conclusion: Learning to conduct child health checks can occur in an online setting. Blended learning opportunities should be provided where possible to consolidate specific clinical skills. There is potential for learning to occur in more remote geographical regions and for busy clinicians. Lessons learned: Designing an eLearning program for GPs need to take into consideration their work practices, IT setup and convenience in order to achieve program completion. Embedding eLearning within a CPD context provides incentives and endorsement of education standards. Limitation: The evaluation numbers were constrained by web site technical matters. Suggestions for future research Further e-Learning modules are planned as part of the district integrated care initiative. Qualitative research projects are planned to assess impact.

A qualitative study into health and social needs and barriers to service access for families residing in a suburb of Sydney with high rates of disadvantage

Introduction: Healthy Homes and Neighbourhoods (HHAN) Integrated Care Program utilises a long-term care coordination model to enhance vulnerable family engagement with and access to appropriate health and social services. HHAN services vulnerable families across inner west Sydney, with a particular focus on two areas of clustered family disadvantage identified by a geospatial epidemiological study. Riverwood was identified as a suburb of heightened vulnerability. The study aims to identify barriers and enablers to service access and engagement in order to inform the delivery of HHAN’s Riverwood place-based initiative. Both service providers and community members were consulted in order to identify the health and social needs and current gaps in service provision in this area. The study also aims to encourage consumer participation in the health service planning process through community consultation. Theory/methods: This qualitative project will utilise informal interviews, community forums and focus groups. The first round of consultation involved informal interviews with stakeholders from which key themes and issues were identified. In the second round of consultation Riverwood community members were recruited via a variety of methods including through schools, community organisations, and letterbox drops in order to attract a varied range of participants to a community forum and follow-up focus groups. Emerging key themes and issues were identified, summarised and analysed. NVivo was used for coding and thematic analysis. Results: Preliminary results from consultation with service providers identified both intrinsic and extrinsic factors. The major extrinsic factors include issues with health district and local boundaries, unclear referral pathways, and a lack of targeted local services. Service provider consultation also suggested that intrinsic factors such as attitudes towards health and historic mistrust of services were significant barriers to accessing and engaging with health services. Discussions: The health and social service system is complex and difficult for both service providers and clients to navigate. Examining the issue of service access requires consideration of a broad range of factors including the perspective of service providers and the community and also reviewing systemic and process factors. This assessment of the service landscape will enable HHAN to establish a place-based initiative that adequately responds to community and service needs in this suburb of significant family disadvantage. Conclusions: Multiple extrinsic and intrinsic factors complicate access to and engagement in services in the Riverwood area. This highlights the need for place-based integrated care initiatives such as Healthy Homes and Neighbourhoods to target the needs of disadvantaged communities. Lessons learned: A broad framework is required to gain a comprehensive understanding of access to and engagement with services that examines the interplay of individual factors, social issues, process and systemic factors. Limitations: The transferability of these findings outside of the Riverwood context is unknown, however, learnings may assist with planning of place-based initiatives in similar areas. Suggestions for future research: Further research will focus on evaluation of the Riverwood place-based initiative in order to determine if identified needs and gaps are being adequately addressed.

Use of the Project Integrate Framework for situational analysis and benchmarking of progress towards care integration in the Central Coast NSW

Background: The Project Integrate[i] conceptual framework began with a literature review on conceptual frameworks and relevant aspects of integrated care, from which a new conceptual framework, was built iteratively. This framework provides a standard set of dimensions and sub-elements which can be used to describe any integrated care initiative. As part of the formative evaluation of the Central Coast Integrated Care Program (CCICP), we have employed the Project Integrate Framework to map the integration efforts of the program, provide a consistent and common language, to enable supported self-assessment of progress towards integrated care and to allow for international benchmarking. Methods: An online survey of key stakeholders was undertaken mapping the degree of agreement on progress towards the Project Integrate dimensions. The survey results were used as a support tool in a workshop to assist CCICP team reflection and assessment and build a situational analysis of care integration progress within the program. This exercise was used as the basis to support agreement of future priorities and strategies within the program. Results: The survey results indicated where progress towards care integration had been achieved in the Central Coast. It was then used as a support tool in a workshop setting to assist the CCICP team to reflect and self-assess progress towards integrated care. Reflections regarding international comparators were made, stimulating further discussion, this led to the recognition of progress made to date and a realistic review of where progress should be given the maturity of the intervention. Achievements and opportunities were identified, with priority areas mapped out. A key priority was communication, in particular, building a common and consistent language for integrated care. Workforce and upskilling regarding data warehousing and analysis was also identified as an opportunity for future work. Discussion: The survey tool alone was inadequate since many answers reflected uncertainty regarding progress (Neither Disagree nor Agree), thus the data required review and further consideration by the team to contextualise the uncertainty, particularly given the formative stage of assessment. The power of the survey results was in the group analysis and the contextualized discussion which ensued and added greatly to the understanding of progress in care integration on the Central Coast. The Project Integrate Framework and its nomenclature was identified by the CCICP team as a key communication tool, to build a consistent terminology for integrated care and its use in reporting, communication and stakeholder engagement. As with international case studies, progress towards system integration was regarded as poor, with substantial structural barriers beyond the control of the CCICP team. However, the intervention appears to be tracking more favourably in the dimension of patient-centred care. Conclusion: Use of the Project Integrate framework has enabled the CCICP team to reflect on progress and spread of integrated care within the Central Coast Local Health District and where their next steps should be for spreading and building sustainability.

Designing an Integrated Care Initiative for Vulnerable Families: Operationalization of realist causal and programme theory, Sydney Australia

Designing an Integrated Care Initiative for Vulnerable Families: Operationalization of realist causal and programme theory, Sydney Australia

Developing new pathways to Health and Social Care for vulnerable clients in targeted Primary Schools

Introduction: Healthy Homes and Neighbourhoods (HHAN) is an integrated care program that supports families in inner west Sydney where adults have complex health and social needs, often impacting on the parent’s ability to provide a safe and supportive environment for their children. HHAN provides care coordination and activities that promote inter- and intra-agency integration. Referral pathways from local schools are targeted in one suburb with significant family disadvantage. Practice change implemented: Following a service provider consultation with schools and other agencies to identify community barriers and enablers, the HHAN social worker established a preferred pathway relationship with target schools. This prioritised clinical pathway featured service delivery of long term care coordination, whole of family focus, flexible home and community visits, fast track Paediatric outreach clinic and consistent collaboration with the schools. Aim and theory of change: To establish new service partnerships that facilitate whole-of-family access to health and social services and result in improved outcomes for families with complex needs who are disconnected from key services. Targeted population and stakeholders: Children and families with complex health and social needs who attend either of two public primary schools in a suburb of significant family disadvantage are targeted in this initiative. Important stakeholders who need to be engaged to ensure success of the pathway include school staff, health service staff, local social service providers, and the broader community. Timeline: Stakeholder engagement commenced in October 2015 and is ongoing. The referral pathway commenced in late 2015. Highlights: This is a unique care coordination pathway linking professionals from the health, social and education sectors to provide whole-of-family care to families with complex needs. Data from Patient Reported Outcome Measures provide a baseline description of the issues that families are facing. Independentqualitative interviews conducted with referred families have shown that the intervention enabled the families to make improvements in their access to services and health and wellbeing outcomes. Trust between service providers, particularly education and healthcare providers, has developed over time. Sustainability: HHAN is a permanently funded program and the pathways established enable health and other community partners to better “join up” and access this target group. Transferability: Other community agencies are exploring similar models where education and social care services are partnered. Key lessons from the evaluation of this pathway could be applied to other models. Conclusion: Qualitative and quantitative data collected demonstrate improvements in families’ health experience, independence and quality of life following referral to HHAN care coordination via this pathway. Discussion: Establishing this pathway successfully has challenged partners to develop a new model using creative, non-standard methods of intervention. The families seen have multiple complex needs and face many barriers to care. The qualitative findings and case studies indicate the importance of integrated care initiatives such as HHAN. Lessons Learned: The establishment of this pathway has created a bridge between Health and Department of Education leaders and the broader service system to assist vulnerable families. Enabling systems now exist which encourage ongoing integration and communication between professionals.

Designing an Integrated Care Initiative for Vulnerable Families: Operationalisation of Realist Causal and Programme Theory, Sydney Australia.

Introduction:In July 2015 Sydney Local Health District (SLHD) implemented an integrated care initiative for vulnerable families in the Inner West region of Sydney, Australia. The initiative was designed as a cross-agency care coordination network that would ensure that vulnerable families: had their complex health and social needs met; kept themselves and their children safe; and were connected to society. We will describe the development of the design that drew on earlier realist causal and program theoretical work.Methods:Realist causal and program theory were used to inform the collaborative design of an initiative for vulnerable families. The collaborative design process included: identification of desirable and undesirable outcomes and contextual factors, stakeholder consultation, interagency planning, and development of a service proposal.Results:The design elements included: identification of vulnerable family cohorts; care coordination; evidence-informed intervention(s); general practice engagement and support; family health improvement; placed-based neighbourhood initiatives; interagency system change and collaborative planning; monitoring of individual and family outcomes; and evaluation.Conclusions:The design study described advances toward the implementation of a whole-of-government integrated health and social care initiative. The initiative was designed as a cross-agency care coordination network that would ensure that vulnerable families: had their complex health and social needs met; kept themselves and their children safe; and were connected to society. In so doing we aim to break intergenerational cycles of poverty, violence and crime, poor education and employment opportunities, psychopathology, and poor lifestyle and health behaviours, through strengthening family resilience, improving access to services, and addressing the social determinants of health and wellbeing.

Integrated palliative care is about professional networking rather than standardisation of care: A qualitative study with healthcare professionals in 19 integrated palliative care initiatives in five European countries

Background: Integrated palliative care aims at improving coordination of palliative care services around patients’ anticipated needs. However, international comparisons of how integrated palliative care is implemented across four key domains of integrated care (content of care, patient flow, information logistics and availability of (human) resources and material) are lacking. Aim: To examine how integrated palliative care takes shape in practice across abovementioned key domains within several integrated palliative care initiatives in Europe. Design: Qualitative group interview design. Setting/participants: A total of 19 group interviews were conducted (2 in Belgium, 4 in the Netherlands, 4 in the United Kingdom, 4 in Germany and 5 in Hungary) with 142 healthcare professionals from several integrated palliative care initiatives in five European countries. The majority were nurses (n = 66; 46%) and physicians (n = 50; 35%). Results: The dominant strategy for fostering integrated palliative care is building core teams of palliative care specialists and extended professional networks based on personal relationships, shared norms, values and mutual trust, rather than developing standardised information exchange and referral pathways. Providing integrated palliative care with healthcare professionals in the wider professional community appears difficult, as a shared proactive multidisciplinary palliative care approach is lacking, and healthcare professionals often do not know palliative care professionals or services. Conclusion: Achieving better palliative care integration into regular healthcare and convincing the wider professional community is a difficult task that will take time and effort. Enhancing standardisation of palliative care into education, referral pathways and guidelines and standardised information exchange may be necessary. External authority (policy makers, insurance companies and professional bodies) may be needed to support integrated palliative care practices across settings.

The SUSTAIN Project: A European Study on Improving Integrated Care for Older People Living at Home.

Introduction:Integrated care programmes are increasingly being put in place to provide care to older people who live at home. Knowledge of how to further develop integrated care and how to transfer successful initiatives to other contexts is still limited. Therefore, a cross-European research project, called Sustainable Tailored Integrated Care for Older People in Europe (SUSTAIN), has been initiated with a twofold objective: 1. to collaborate with local stakeholders to support and monitor improvements to established integrated care initiatives for older people with multiple health and social care needs. Improvements focus on person-centredness, prevention orientation, safety and efficiency; 2. to make these improvements applicable and adaptable to other health and social care systems, and regions in Europe. This paper presents the overall structure and approach of the SUSTAIN project.Methods:SUSTAIN uses a multiple embedded case study design. In three phases, SUSTAIN partners: (i) conduct interviews and workshops with stakeholders from fourteen established integrated care initiatives to understand where they would prefer improvements to existing ways of working; (ii) collaborate with local stakeholders to support the design and implementation of improvement plans, evaluate implementation progress and outcomes per initiative, and carry out overarching analyses to compare the different initiatives, and; (iii) translate knowledge and experience to an online roadmap.Discussion:SUSTAIN aims to generate evidence on how to improve integrated care, and apply and transfer the knowledge gained to other health and social care systems, and regions. Lessons learned will be brought together in practical tools to inform and support policy-makers and decision-makers, as well as other stakeholders involved in integrated care, to manage and improve care for older people living at home.

A.C.T. like a champion: Primary care providers' responses to an integrated care initiative

Background: Primary care and mental/behavioral health (MBH) integration is designed to improve patient outcomes and enhance access to care. To achieve system-level change, embedded integrated care champions are needed; however, no known conceptual model for identifying champion PCPs of integrated care has been articulated. To address this gap, we propose that PCP championship consists of greater: (i) Awareness of patients’ MBH needs, (ii) Comfort assessing patients’ MBH needs, and (iii) dedication to MBH Training (A.C.T.). Method: A provider survey was administered yearly (n = 4 time points, 2013-2016) at a large multi-site Federally Qualified Health Center (FQHC) actively working to achieve MBH integration. The survey assessed PCPs’ Awareness of a variety of MBH needs, Comfort diagnosing MBH disorders, and interest in MBH Training. Results: As expected, the cohort of PCPs demonstrated significantly increased Awareness of MBH needs, greater Comfort diagnosing MBH disorders, and increased interest in MBH Training over time. Overall prevalence of champions, indicated by both high levels of comfort and an expressed interest in training, decreased initially and then consistently increased across time (37%, 19%, 22%, 52%). Conclusions: The A.C.T. model may aid in future MBH integration efforts by providing a framework for assessing and facilitating PCP integrated care championship.

Population-level impact of diabetes integrated care on commissioner payments for inpatient care among people with type 2 diabetes in Cambridgeshire: a postintervention cohort follow-up study

ObjectivesFew studies have estimated the effect of diabetes integrated care at a population level. We have assessed the impact of introducing a community service-led diabetes integrated care programme on commissioner...

SUSTAIN: what have we learned so far and how to move forward?

Introduction : In an increasing number of EU countries, integrated care initiatives are being put in place as new models to support older people with complex problems living in the community. Evidence of the effectiveness of integrated care is, however, inconclusive. Also there is little knowledge of what is the best way to practice integrated care, how to successfully implement it and how to transfer successful initiatives to other regions and health systems. Aim : SUSTAIN is a European-wide project in which thirteen organizations from nine European countries collaborate to work towards the following aims: 1. improve established integrated care initiatives for older people living at home with multiple health and social care needs and 2. ensure that improvements to the integrated care initiatives are applicable and adaptable to other health systems and regions in Europe. Targeted population and stakeholders : The SUSTAIN project is currently 18 months underway. We have established working relationships with thirteen integrated care initiatives spread across seven European countries. These initiatives vary in terms of e.g. type of care services being offered, involved stakeholders and organizations, and targeted populations of older people (e.g. older people discharged from hospital, older people with cognitive impairment, frail older people in primary care). Practice change implemented : Despite their differences, these sites encounter quite similar bottlenecks to coordination and integration of care, and as such aim to improve in similar areas. Areas of improvement include clearer agreements on tasks and responsibilities of stakeholders involved, better collaboration between professionals from health and social care, better information exchange and more intense engagement of older people and their informal carers. Theory of change : SUSTAIN research partners are collaborating with local stakeholders (e.g. health and social care professionals, managers, older people, policy-makers) attached to the different sites to change the current way of working; all intended to move towards more person-centred, prevention-oriented, safe, and efficient care. Time line and highlights : Improvement projects will be rolled-out and outcome and progress will be monitored during an 18 month period (approx. October 2016-April 2018). This process is underpinned by the Evidence Integration Triangle, an approach targeted at effective implementation of scientific evidence in daily practice. Sustainability and transferability : Overarching analyses will be undertaken to compare and integrate data from the different integrated care initiatives to robustly identify what works for whom, in what context and with what outcome. As such, we will obtain EU evidence on the applicability and adaptability of integrated care initiatives for older people living at home with multiple health and social care needs in relation to different European health systems and regions. Equally importantly, we will identify the steps that are necessary to realise improvement of existing initiatives. Project results will be translated to a roadmap targeted at policy-makers and decision-makers in care systems tasked with designing, establishing and maintaining systems of integrated care that focus on older people with complex needs. Conclusion, discussion and lessons learned : During this workshop, we will share the lessons that we have learned so far during the SUSTAIN project. During the first presentation, we will provide a general overview of the project. The second presentation focusses on our overall methodological approach and the methodological challenges that we have encountered. During the third and fourth presentation, we will provide insights in the participating integrated care sites from the Netherlands and Catalonia respectively and their experiences with the roll-out of their improvement projects so far. The fifth presentation is dedicated to the development process of the roadmap. We will discuss with the audience what will be important elements of the roadmap and inform them how we aim to move forward.

Distributed versus centralized leadership in the implementation of a Canadian integrated care initiative

Introduction: Traditional notions of leadership involve more centralized power at the senior levels, with the expectation that vision and strategy will trickle down to operational levels. This type of leadership may work well in smaller organizations, but the complexity of integrated health models involving large inter-organizational networks may challenge this notion of leadership. To date, the evidence on how traditional centralized leadership impacts the implementation and functioning of integrated care networks is unclear. There is a need to understand different forms of leadership within and across organizations that are involved in integrated care networks. Theory/Methods: We conducted multiple case studies evaluating the implementation of Health Links (HL), a “low-rules”/bottom-up integrated care model in Ontario, Canada. Through an analysis of the qualitative data via semi-structured interviews, this study provides a practical exploration of leadership in the HL context. Our analysis draws on process- or action-oriented theories of leadership that look beyond senior leadership (e.g., distributed and shared leadership, complexity leadership theory). These theories posit that non-formal leaders are critical to the functioning of complex organizations and systems, and consider leadership as an interactive adaptive process, often emergent in nature. Results: Preliminary results show that leadership was highly centralized in implementing HL and concentrated almost exclusively at the senior level, which entailed governance committees involving CEOs and upper management. This centralized leadership seemed to result from a failure to develop capacity for distributed leadership throughout partner organizations, which further impeded front-line workers from understanding the goals of HLs to provide integrated care. That is, due to factors such as insufficient education/communication regarding HLs, lack of delegation of more operational tasks, and failure to meaningfully seek out front-line support, there was limited ability within the organizations to sustain the integrated care effort without an ‘overreliance’ on senior leadership to drive HLs forward. Conclusions: Though senior leadership is critical in setting a vision for integrated care networks, our findings indicate that a centralized leadership approach may not be optimally effective at the stage of implementation and ongoing functioning of these networks. Discussion: In light of these findings, efforts to implement ‘low rules’ integrated care initiatives may require a more proactive approach to leadership, which clearly delineates the possible shared leadership roles throughout organizations. However, in order to develop distributed leadership, senior leadership must facilitate a context (e.g., via knowledge sharing) for informal leaders to take ownership of the implementation project and champion it to those delivering integrated care on the front lines. Lessons Learned: Through the establishment of ‘shared’ or complementary leadership roles across all levels of the organization, distributed leadership may allow for more meaningful clinician buy-in and subsequent spread of the integrated care initiative. Limitations: At this stage, results are still preliminary and limited by the fact that case studies are not generalizable beyond the Ontario, Canada context. Nevertheless, these results help set a foundational groundwork from which to further explore distributed leadership in integrated care. Suggestions for future research: Future research should continue to explore the value of distributed leadership in integrated care, and would particularly benefit by studying contrasting models of leadership and comparing their impact on implementation outcomes.

An Evaluation of the Barriers to Health and Social Care for “Hard to Reach” Groups enrolled in an Integrated Care Initiative in Sydney, Australia

Introduction: Sydney Local Health District's Healthy Homes and Neighbourhoods Integrated Care Initiative (HHAN) seeks to improve the care of families with complex needs and/or inter-generational trauma by providing long-term care coordination and promoting inter- and intra-agency integration. The disadvantage experienced by enrolled individuals is multifaceted, with issues ranging from poor financial and social capital through to adverse health and educational outcomes. This complexity demands multi-agency support but in turn leaves clients vulnerable to fragmented/poorly coordinated care. We explored barriers to attaining health and social care for vulnerable families, as perceived by clients themselves and collaborating professionals. Theory/Methods: A realist CMO (Context, Mechanisms, Outcomes) theoretical approach is being used for program evaluation. Purposive sampling was used to identify 8 clients and 16 professionals (8 healthcare workers and 8 staff from collaborating NGOs/partnering government agencies) who participated in guided interviews. Barriers to care were explored as part of the examination of underlying contexts. All interviews were audio-recorded, transcribed and coded using NVivo v11 software. Results: Both intrinsic and extrinsic barriers were identified. Intrinsic factors included: Trauma affecting families both horizontally and vertically, competing priorities, distrust of services and concerns about confidentiality. Of the extrinsic factors identified, three themes emerged: 1. Accessibility and Economic Barriers including inequitable service coverage geographically, transport issues, strict eligibility criteria, opaque referral systems, lack of financial incentives for seeing vulnerable families, and direct/indirect costs to clients. 2. Misalignment of Service Provision with Client Needs including a perception that needs were assumed not asked, unrealistic care plans given social circumstances, paucity of culturally-appropriate and trauma-informed staff training and short-termism of professionals (resulting in unstable client-service and service-service relationships). 3. Communication Issues including misunderstanding by services or clients of the role, or even existence of other services, trust/territorial issues and technological barriers (e.g. incompatible electronic referral systems). Discussions: It can be challenging for vulnerable clients to navigate health and social care systems. Professionals expressed frustration that attaining appropriate/timely referrals and client care was difficult, even when being undertaken by “high-functioning” individuals on behalf of clients. Conclusions: Families with complex needs face multiple barriers to care. The extrinsic factors identified should be amenable to cultural and structural shifts in health and social care systems. Lessons learned: Disadvantaged families are often characterised as “hard to reach” but this implies that the fault lies solely with these individuals. An examination of the underlying factors for poor engagement illustrates the need for integrated care initiatives such as HHAN, which address the social determinants of health and create enabling systems for integration/communication between professionals. Limitations: The applicability of findings within our health district to other regions is unknown. In recruiting participants for this study, the most vulnerable members of our society may still have been missed; further exploration of their views could enhance our understanding. Suggestions for future research: Integrated care initiatives are attempting to tackle some of the barriers described above. Ongoing data is required to determine which interventions are efficacious, for whom and why, so that optimal service development can be achieved.

Comprehensive overview of integrated care in Switzerland: Results of the 1st Swiss Survey on Integrated Care

Introduction: Because of the fragmentation of health care delivery, systems are under pressure and integrated care is advocated for. Compared to the numerous initiatives in this field in Europe and elsewhere, Switzerland seems to lag behind. Methods: The objective of the survey was to produce a comprehensive overview of integrated care initiatives in Switzerland. To be included, initiatives needed to meet the following four criteria: some type of formalization, > 2 different groups of healthcare professionals, integration of > 2 levels of care, currently ongoing. We systematically contacted major organizations of the Swiss health system (providers, regulators, financers, educational and research structures, as well as professional and community organizations) at the national, federal, cantonal and local levels. We also approached experts and used the “snow-ball effect” to increase our reach. Between July 2015 and 2016, 172 integrated care initiatives were identified. They were sent self-reported questionnaire in order to collect data on localisation, target groups, professionals involved, services offered, levels integrated, funding sources, etc. Initiatives were empirically divided into six categories: Health centres, Physicians’ networks, Programs focusing on medication, Projects in mental health & psychiatry, Initiatives targeting specific groups of patients, Programs focusing on transition & coordination. Descriptive analyses of the results were performed. Results: Results from the 162 completed questionnaires revealed important differences between the linguistic regions of Switzerland: there were more “Physicians’ networks” and “Health centres” in the German part of Switzerland, whereas “Specific target-groups”, “Medication” and “Transition & Coordination” initiatives were more frequent in the French and Italian regions. Among numerous differences across categories, “Health Centres” reported the broadest integration, while “Medication Programs” indicated the narrowest; “Transition & Coordination” initiatives were mostly funded by public health departments, while “Health centres” and “Physicians’ networks” reported being mostly financed by health insurances. Discussion: The 162 included initiatives presented unexpected high frequency, heterogeneity and diversity. Empirical categorization of initiatives revealed differences in the models available across linguistic regions of Switzerland, as well as differences across categories: in the number of levels of care integrated, and in the funding sources. Conclusion: This survey intended to produce a first comprehensive overview of integrated care initiatives in Switzerland. Despite this country’s federalist structure and limited incentives to develop integrated care, initiatives were shown to be frequent and diverse. The differentiated picture revealed by the empirical categorization of initiatives raises up questions about the potential impact of the context on the implementation of specific models. Such results should be of interest to stakeholders both in Switzerland and elsewhere. Limitations: The strength of this project was the systematic and comprehensive search of initiatives across a whole country. Accuracy and representativeness of the results was reinforced by the 94% response rate achieved. Weaknesses included the fact that initiatives might have been missed and that data remained self-reported and liable to bias. Suggestions for future research: Empirical categorization of Swiss results might be refined to further explore characteristics of contexts enabling the emergence of integrated care initiatives. Similar comprehensive surveys could be replicated to compare findings across various political and health systems.

Participation of patients with chronic diseases in integrated care – a systematic review

Introduction: Integrated care is a valuable approach in creating a health care system that addresses the complex needs of people with chronic diseases. For integrated care to be successful, patient participation, i.e. the involvement of patients in decision making and active participation in care activities in partnership with professionals, is crucial. Patient participation can occur at the micro (i.e., individual), meso (i.e., organizational) and macro (i.e., policy) level of care. At all levels, participation can range from purely one-sided information exchange provided by professionals, to consultation of patients, to collaboration (also labelled as co-creation) where professionals and patients share power and responsibility in making decisions. While integration and patient participation appear to be two guiding principles in reorganizing health care systems, so far little is known on the actual contribution of patients with chronic diseases to the organization of integrated care. Hence, the objective of this study is to systematically review studies on patient participation in the development and evaluation of integrated care. Method: PubMed (Medline) and Web of Science databases were consulted to conduct a systematic literature review. We searched for papers on patient participation, integrated care and chronic diseases that were published between January 2003 and December 2016. After categorizing the general focus of the articles, the levels and degrees of patient participation that were described in the studies were reviewed. Results: As for the focus of the articles, most papers address patient participation in the creation and/or evaluation of integrated care initiatives or ICT facilitators to achieve integrated care. A small group of articles explores the perspectives of patients on integrated services and policies. Regarding the level of care in which patients are involved, most studies refer to patient participation at the meso level. Also, in some studies participation at the macro level is described. Concerning the degree of participation, in the majority of articles patients are consulted to express their views, yet this infrequently leads to the actual co-creation of integrated care initiatives. Discussion: Despite the importance of patient co-creation that has been articulated by the WHO, actual participation activities and practices in integrated care often comprise a limited degree of patient collaboration in decision making. Conclusion: In the field of research into integrated care, current practices of integrated care provide little opportunity for impact of patients with chronic diseases to collaborate in decision making on (re)designing and changing health care systems. Lessons learned: There appears to be a gap between the importance that has been laid on patient participation by current health care policies and the actual implementation of this principle in integrated care initiatives and policies. Limitations: There are a myriad of terminologies that are used to refer to (strategies of) integrated care and patient participation, which impeded clear guidance in the literature search. Further, by broadening the search strategy to the grey literature, additional relevant publications might have been detected. Suggestions for future research: Future studies could focus on detecting facilitators and barriers to achieve patient participation in integrated care.

Operationalizing Patient-Centered Integrated Care: The Gap between Discourse and Action

Introduction: Complex patients have multiple chronic conditions, often compounded by psychosocial challenges They require a mix of services delivered by multiple providers across settings, which are optimally coordinated through integrated care models. A key success factor of these models is patient-centeredness and engagement. In 2012, Ontario, Canada launched Health Links (HL), a patient-centered initiative that aims to better coordinate care for patients with complex needs. This is achieved via individualized, coordinated care plans (CCPs) that are tailored to the needs and preferences of every patient. HL documents had a clear vision about how to put patients front and center and engage them in every step of the intervention, including co-designing the program, engaging in implementation and evaluation of the patients’ experience with HL. This study aimed to explore if the vision of patient-centeredness and engagement was operationalized in the same way it was planned. Theory/Methods: We conducted evaluative case studies of three HLs within one regional health authority in the spring/summer of 2016. Data was collected through semi-structured interviews with leaders and providers working within the three HLs and an in-depth document analysis of business plans, pre-implementation documents, meeting minutes and all publicly available electronic materials. We compared documentation to interview data, conceptualizing documents as the source of the planned view and draw the operationalizing view from the interviews. Results: Our preliminary results show that leaders and providers agree with the HLs’ planned view that patient-centeredness and engagement is the key philosophy behind HL as a program. However, in terms of operationalization participants identified a lack of clarity about the mechanisms of execution especially when working with such complex patients. Although the documents emphasized the importance of the role of patients in managing their own care, leaders and providers found many barriers to this for example the low buy-in from some patients and the lack of access to medical records. While having the voice of the patients on HL committees was acknowledged in all HL documents, leaders and providers highlighted that most of the time the patients do not have a voice and even when they do, a single patient will never represent all patients. Conclusions: (Comprising Key Findings) Patient-centeredness is a primary goal of HLs. However, in practice, participants struggled to clearly incorporate and execute patient-centeredness in the design, implementation, and evaluation of HL. Discussion: Our case studies provide analysis on how operationalization of patient-centeredness and engagement can be a challenge to integrated care models. The results can help inform decision-makers on how to better deliver patient-centered integrated care. Lessons Learned: Successful implementation of complex interventions like HL requires detailed clarity on the operational level alongside the policy level. Limitations: Our findings are limited to three HLs in Ontario, however, the results highlight an important discrepancy between discourse and action that may be relevant for other patient-centered integrated care initiatives. Suggestions for Future Research: Future work can examine the challenges in operationalizing a patient-centered approach to integrated care and test interventions that support the engagement of complex, high-needs patients.

Inter-professional coordination: first step towards a more person-centred approach. Improvement projects in Catalonia within the framework of the SUSTAIN project

Introduction : Established integrated care initiatives around Europe are working within the framework of SUSTAIN project to improve their current practice in four domains: patient centeredness, prevention, efficiency and safety. In Catalonia these initiatives are: 1) PCC/MACA/Geriatrics a regional-level initiative aiming at providing coordinated and integrated care between different health care levels with Social Services from different County Councils in Osona 2) Social and Health Care Integration of Sabadell, seeks for the coordination between three Primary Care Teams with Basic Social Services from Sabadell City Council to provide integrated care to patients with health and social care complexities. Both initiatives have identified barriers for professional coordination and integration, as well as the need of working with a more patient-centred approach Short description of practice change implemented : In both sites similar interventions will be implemented during 18 months, entailing a multidimensional assessment of selected older people (cases) with complex health and social care needs performed in inter-professional meetings with a tailor designed tool. Afterwards, an individualized interview with older people to validate this assessment and to develop a joint care plan for health and social care professionals involved including goals, views and opinions of the cases. From this full written care plan, key information will be selected following a manual specifically developed by the Steering Group members to be included in the Electronic Care Plan (i.e., PIIC) which is shared through the Electronic Medical Record among all health professionals in Catalonia Aim and theory of change : The aim is to improve professional coordination in the delivery of health and social care and to enhance patient’s empowerment by involving them in the development of joint care plans. This process is underpinned by the Evidence Integration Triangle, an approach targeted at effective implementation of scientific evidence in daily practice Targeted population and stakeholders : Patients with multiple health and social care needs older than 65 living at home and cognitively able to participate Main stakeholders are health and social care professionals with different degrees of responsibility in decision making Timeline : Between October 2016 and April 2017 each site will conduct a pilot implementing the intervention with 6 patients. The improvement project will be then rolled out for 12 months including 36 patients in each initiative Highlights: (innovation, Impact and outcomes) Innovations: - The incorporation of the patient in setting a joint care plan - A tailor designed tool for performing joint multidimensional assessments Impacts: - A progressive acknowledgement from health and social professionals of the importance of discussing complex cases in inter-professional meetings and of the benefits of working in a more integrated way - Increasing patient’s empowerment and improving knowledge and perception about the coordination of the care they receive Outcomes: - Full care plans with the inclusion of patient’s opinions, views and beliefs - Key patient-centred information shared in the Electronic Care Plan (PIIC) with all health professionals Comments on sustainability : Both SUSTAIN improvement projects are aligned with the roadmap set by the Inter-departmental Plan of Social and Health Care and Interaction launched in 2014 by the Catalan Government to impulse change towards a more integrated way of working in the country Comments on transferability : Both tailor designed tools can be transferred to other initiatives to assess patients with complex health and social needs Conclusions: (comprising key findings) Improvement projects are being implemented through a fruitful collaboration between different stakeholders and researchers, who are facilitating and bringing evidence to the design and evaluation of the intervention Discussions :To be developed in light of the results of the intervention Lessons learned : Important lessons learned regarding the identification of facilitators and barriers, on the professional side towards new ways of working (e.g., inter-professional meetings) and on the patient’s side, the ability/willingness of developing their own work care plans