Integrated Care Network Research Articles

Leadership in integrated care networks: A literature review and opportunities for future research

The International Journal of Integrated Care (IJIC) is an online, open-access, peer-reviewed scientific journal that publishes original articles in the field of integrated care on a continuous basis.IJIC has an Impact Factor of 5.120 (2020 JCR, received in June 2021)

Towards Integrated Care for Chronic Patients in Belgium: The Pilot Project, an Instrument Supporting the Emergence of Collaborative Networks

In 2015, the Belgian Health Ministers launched a plan intended to evolve towards an integrated care system for chronic patients. This plan is implemented through pilot projects involving local actors. Therefore, the researcher raised the following research question: how does the use of pilot projects as implementation instruments structure the collaboration between parties involved in a pilot project? The term “pilot project” refers to a collaborative work method coupled with an experimentation purpose. This is further developed in the paper via a literature study. This qualitative research draws on interviews, focus groups, direct observation, and a documentary analysis. During the two first phases of the process, field workers had to create multidisciplinary local consortia and write an application file describing the project they would implement during the third phase, which raised challenging collaboration issues. Many people learned to work together over time, progressively overcoming the traditional fragmentation of care. They met regularly, understood their respective roles, and dealt with controversies through negotiation to reach an agreement on a common project. In conclusion, the researcher shows that, thanks to its characteristics, the pilot project instrument supports the development of collaborative care networks; in this example of community-based integrated care networks.

A Study on the Countermeasure of the Integrated Care Network for the Elderly to Promote Community Cooperation and Connectio

A Study on the Countermeasure of the Integrated Care Network for the Elderly to Promote Community Cooperation and Connectio

Abstract P6-16-08: Using continuing professional development (CPD) as an investigative tool to improve clinical practice and interdisciplinary team treatment

Abstract Background: Continued and rapid evolution of diagnosis and staging methods along with the development of new treatments has changed the decision-making process for cancer patients into a more complex task. In breast cancer, quality measures related to sentinel lymph node biopsy (SLNB), axillary dissection (AD), HER2 testing and use of HER2-targeted therapy, provide parameters for assessing care quality. We assessed the influence of quality improvement education (QIE) on alignment with BC quality indicators. Methods: 39 members of the interprofessional team at Inova (an integrated care network of 5 hospitals) participated in the QIE components. For a baseline Inova provided deidentified electronic medical records (EMR) data that included a total of 67 breast cancer patients treated between 12/1/16 – 2/28/17. The patients diagnosed with HER2+ breast cancer records were retrospectively reviewed for adherence to quality measures pertaining to HER2 testing, SLNB, AD, and treatment. Follow-up reviews were completed 6 months after the launch of the online component, which included 142 patients. Results: Patient and disease characteristics were generally similar across the 2 cohorts. At baseline, treatment selection for patients with advanced stage cancer was consistent. The original goal of the activity was to assess adherence to quality measures in breast cancer treatment, in our assessment stage the team discovered potential undersampling of sentinel lymph nodes in patients who underwent neoadjuvant chemotherapy for clinically node-positive, with 3 of 8 patients (37.5%) having only 1 or 2 lymph nodes sampled. The educational programming improved recognition of the risk of false negative rates of sampling under 2 lymph nodes in this setting. In addition, the Inova team recommended that the triage protocol be changed to include the medical oncologist earlier in the treatment decision making process in tandem with the surgeon. In the post-program patient data, 26 patients with clinically N1/N2 disease had neoadjuvant therapy and a SLN biopsy. Of these, 3 (11.5%) had only 1 lymph node sampled, suggesting an increased adherence to recommended sampling. The educational program also improved participant knowledge of the phase III APHINITY trial efficacy findings, which was consistent with an increase in the use of pertuzumab-containing adjuvant therapy for early breast cancer (use of TCHP, 0% vs 46% in the pre-program and post-program charts, respectively). In addition, participants in the educational programming increased awareness of the need for reflex testing in the event of an equivocal HER2 IHC result. In the post-program follow-up, no cases of equivocal HER2 IHC staining lacked reflex testing with FISH. Taken together, these findings are consistent with practice change following interventional medical education for incorporating best practices and emerging clinical data in the management of HER2-positive breast cancer. Citation Format: Harnden K, Hester D. Using continuing professional development (CPD) as an investigative tool to improve clinical practice and interdisciplinary team treatment [abstract]. In: Proceedings of the 2018 San Antonio Breast Cancer Symposium; 2018 Dec 4-8; San Antonio, TX. Philadelphia (PA): AACR; Cancer Res 2019;79(4 Suppl):Abstract nr P6-16-08.

Supportive Care Network: Evaluation of Its Impact on the Performance of a Urology Department.

Hospitals are dealing with patients who may have clinical discharge but cannot return to their home due to non-medicalissues. Cross-sectional analysis of all the cases referred to the Integrated Care Network during the year 2016.Evaluation of waiting times, typology, reason for referral and clinical parameters. IBM SPSS 24.0 software was used for all statisticalanalyses. In the evaluated period, 2294 patients were discharged from our department. Of these, 55 were referred to Integrated CareNetwork. The mean length of hospitalization of the patients referred to the network was 20.6 ± 11.4 days, and the mean overall lengthof hospital stay in the period analyzed was 4.8 ± 0.9 days. The mean time between hospitalization and referral for continuing carewas 10.7 ± 7.2 days. The time between referral and discharge of the hospital was 10.0 ± 8.7 days. Thirty-nine (70.9%) patients werehospitalized for oncological diseases. The most common referral was to Palliative Care units (n = 16; 29.1%). Patients referred toPalliative Care units showed the largest waiting times between the referral for the network and the hospital discharge, 12.2 ± 10.51days. We observed 289 hospitalization days with patients who had no need of specialized urological care. In order to reduce time between referral to the network and hospital discharge, there is a need for enhanced cooperationand coordination among doctors, nurses and social workers. Early identification by physicians and nurses of patients who will require care after discharge will provide a better responsefrom social workers and increased hospital performance.

Innovation of the governance of integrated care

Aim: Interest in integrated care is growing. This is reflected in the rising numbers of scientific publications, IJIC’s increased impact factor and the increasing number of participants at IFIC’s international conferences. It is stimulating to see that organizations like the World Health Organisation are developing conceptual frameworks that embrace integrated care [1,2]. At the same time we know that integrated care does not become reality automatically; it takes a long timeframe. That can be conflicting with ambitions like ‘implementing good practices as fast as possible’ and with the pressure to deliver results in politically set tight time frames. Governance of integrated care: For future directions, the governance of integrated care and interorganisational collaboration on a local level needs more attention, more innovative thinking and more knowledge. We define governance as the total package of leadership, accountability and supervision in the local setting in an area or region [3]. In the Netherlands, a huge number of networks of collaborating organisations in a certain area, for instance for dementia care, stroke care, elderly care or palliative care, have been set up in the last decade. Too less is known about the governance of these networks. In the workshop we discuss how the governance of integrated care and these networks works and what doesn’t work and could be innovated. An inventory among 130 integrated care networks in the Netherlands will be presented. It showed that although in most cases the collaboration is signed up in a collaborative agreements commitment towards the network is not automatically present. Organizational interests predominate and often one of the partners is dominant in the network that may often result in reduced levels of cooperation [4]. Although the aim of these networks is to serve clients better, results showed that in one-third of the networks the interests of clients are not taken into account. If clients are involved this is often via the professionals. Overall, the inventory shows that these networks explore and also struggle with how to organise integrated care and on what scale population, target group, geographical area. Traditional governance within organisations often does not match the needed governance between organisations. Network governance is more horizontal, non-hierarchic, and focuses on trust as a basic value. The quality of the relationship between involved people, organizations and underlying values is a crucial factor to focus on in this type of governance [5, 6]. In the workshop also the results of a session with 30 CEO’s of Dutch health care organisations from all domains are shared that demonstrate the themes for the future regarding the needed innovation in governance that suits integrated care. Themes are for instance accountability, ownership, legal issues, collaborative models but also uniformity in language. Network session or workshop: In the session insights about local governance leadership, accountability and supervision of integrated care are discussed, the results of the inventory among 130 networks. Expertise from other domains like legislation is present, including a representative CEO from an integrated care network. Reference list: see remarks 7 references included.

Values of Integrated Care: A Systematic Review.

Introduction:Although substantial generic knowledge about integrated care has been developed, better understanding of the factors that drive behaviour, decision-making, collaboration and governance processes in integrated care networks is needed to take integrated care forward. To gain more insight into these topics and to understand integrated care in more depth, a set of underlying values of integrated care has been developed and defined in this study.Theory and methods:A systematic literature review was conducted to identify the underlying values of integrated care. Values theory was used as a theoretical framework for the analysis.Results:This study identified 23 values in the current body of knowledge. The most frequently identified values are ‘collaborative’, ‘co-ordinated’, ‘transparent’, ‘empowering’, ‘comprehensive’, ‘co-produced’ and ‘shared responsibility and accountability’.Discussion and conclusion:The set of values is presented as a potential basis for a values-driven approach to integrated care. This approach enables better understanding of the behaviours and collaboration in integrated care and may also be used to develop guidance or governance in this area. The practical application of the values and their use at multiple levels is discussed. The consequences of different stakeholder perceptions on the values is explored and an agenda for future research is proposed.

Governing integrated care networks through collaborative inquiry

PurposeThe purpose of this paper is to develop a theory of governing in integrated care networks. Asking how and why the governance of these networks emerges and evolves over time, it responds to calls for more innovative thinking in this field.Design/methodology/approachData result from a rare longitudinal qualitative case study conducted with the Healthcare Centre Lower Engadin, the lead organisation of pioneering health and social care network in a rural Swiss region.FindingsActors governed the network through repetitive sequences of collaborative inquiry, a practice through which they defined and addressed recurrent problems of network governance and joint network action in creative and experimental ways.Research limitations/implicationsExplaining how and why the governance of integrated care networks emerges and evolves, this study adds a dynamic theory to previous research, which has studied the determinants of effective network governance without considering their temporal evolution. It also contributes to the wider network literature, drawing attention to the pivotal role of meaning making, creativity and experimentation for understanding network governance dynamics.Practical implicationsThe study invites practitioners to reflect on how they want to design collaborative inquiry in their own contexts. Important design levers include the creation of communication forums, trust and information transparency.Originality/valueThe study adds a rare longitudinal perspective on the governance of integrated care networks.

Implementation of Integrated Care in Singapore: A Complex Adaptive System Perspective.

Background:Integrated care that focuses on organising healthcare services around people and their communities rather than their diseases is promoted as the strategy to overcome the challenges associated with growing complexity in healthcare needs, demand for healthcare services and inadequate supply of services due to fragmentation in the provision of services. While conceptually appears to be simple, integrated care is made up of multicomponent delivery strategies targeting various levels of the healthcare system while engaging various stakeholders in their execution.Methods:We applied the complex adaptive system (CAS) perspective to two different initiatives that exemplify approaches towards integrating care in Singapore: the Regional Health System (RHS) model, implemented across healthcare institutions at the national level, and CARITAS Integrated Dementia Care implemented in the northern region of Singapore. We adopted an inductive approach in our analysis in which we studied the RHS and CARITAS Integrated Dementia Care according to the components of the CAS. We applied the typical characteristics of CAS: (i) diverse, interdependent and semi-autonomous actors (ii) self-organizing capacity and simple rules (iii) relationship with the bigger system, emergent behaviour and non-linearity in our analysis of key drivers behind the implementation of both the RHS and CARITAS integrated dementia care.Results:By considering the RHS and CARITAS as whole networks each comprising of interacting and adaptive components instead of separate entities within a bigger system, the CAS provided a new mind-set in surfacing issues associated to the implementation of these integrated care networks. In addition to important actors, systems, it informed understanding of relationships and dependencies between different parts of the network – revealing the lack of homogeneity, conformity and difficulties in designing any optimal system in advance given the many moving parts.Conclusions:Drawing on the two examples of integrated care networks, this paper highlights the significance of effective collaboration built on a common focus, responsiveness to emergent behaviours, simple rules, the ability to self-organize and adapt in response to unexpected situations in further development of integrated care in the Singapore context and beyond.

Trial and error, together: divergent thinking and collective learning in the implementation of integrated care networks

Hybrid networks that link disparate professionals and organizations are a common approach to deliver integrated care to patients. Recent literature argues that successful implementation of these networks demands a socio-cognitive perspective in which stakeholder mental frames and thought processes are prioritized, investigated, and compared. The aims of this article are to identify where mindsets diverge among clinical and managerial stakeholders involved in the implementation of integrated care networks known as ‘Health Links’ (HLs) in Ontario, Canada, and to describe strategies to support stakeholders’ capacity to collectively learn and develop more convergent views. Drawing from shared mental model theory and practice-based learning theory, a secondary analysis was conducted of interview data with 55 healthcare professionals and managers involved in the implementation of HLs. We identified examples of divergences in stakeholders’ conceptualization of the HL design and approach (‘strategy mental model’) and their perceptions of each other and how they work together (‘relationship mental model’). We also identified four strategies that facilitate learning and possibly mental model convergence. The results of the study may help guide stakeholder dialogue towards collective learning and coordinated action for integrated care delivery. Points for practitioners The findings suggest that in the implementation of large-scale change involving multiple stakeholder groups, there are predictable areas where divergent views are likely to occur and may have a negative impact on coordinated action. An awareness of these potential divergences can guide practitioners to examine them explicitly and regularly, and to proactively develop strategies to support practice-based learning and the development of a convergent perspective.

Unique Digital Care Interactions of Diabetes Patients with Remote Health Coach through Apollo Sugar App to Achieve Positive Glycemic Control Outcomes

Aim: To evaluate the quality and meaningful interactions of patients with type 2 diabetes mellitus (T2DM) with health coach through Apollo Sugar App and its effects on clinical outcomes. Methods: Apollo Sugar Clinics is a pan-India chain of state of art, integrated care network of diabetes specialty clinics. The current analysis includes digital data of health interactions captured through a novel, unique and well-designed Apollo Sugar App. of great utility value. These live health interactions were between Sugar health coaches and 10,000 patients with T2DM, registered at Apollo Sugar Clinics who downloaded the Apollo Sugar App from Google Play store for the last 6 months. Meaningful health interactions with health coach were identified in 317 patients which were categorized into medication, diet, exercise, and self-monitoring blood glucose (SMBG). Descriptive statistics was applied to analyze the data, to assess clinical outcomes. Results: A total of 10800 health interactions were captured, of which 2000 quality interactions were categorized as meaningful interactions. Among these interactions 29% on diet, 21% on exercise, 19% on medication change, 4% on insulin dose, 2% on hypoglycemia and 25% on meaningful use of SMBG data. SMBG was performed >2times/week by 65% of study population. Pre-meal and post-meal SMBG target were achieved in 35% and 24% of patients, respectively. 28% achieved control reductions in <2 weeks and no hypoglycemic episodes occurred in any of the patients. There was a considerable reduction in mean HbA1c (-0.7%), fasting plasma glucose (-41.5mg/dL) and post-prandial glucose (-100.7mg/dL) at 3 months follow-up. Conclusions: The current analysis indicates that patient interactions with health coach through an Apollo Sugar app is a modern improved method of behavioral and clinical care, to achieve long term continuity of care for change in outcome of hard end points. Disclosure S. Shah: None. R. Mehrotra: None. S. Das: None. R.S. Erukulapati: None. S.P. Reddy: None. J. Jayaprakashsai: None. K. Dash: None. B. Jaganmohan: None. U. Ayyagari: None. S. Tippisetty: None. V.K. Kolukula: None. S. Joshi: None.

Realist evaluation of a complex integrated care programme: protocol for a mixed methods study

IntroductionThe lack of understanding of how complex integrated care programmes achieve their outcomes due to the lack of acceptable methods leads to difficulties in the development, implementation, adaptation and scaling...

A novel integrated care concept (NICC) versus standard care in the treatment of chronic cardiovascular diseases: protocol for the randomized controlled trial CardioCare MV

BackgroundCardiovascular diseases are the major cause of death globally and represent a major economic burden on health care systems. Positive effects of disease management programs have been shown for patients with heart failure (HF). Remote monitoring and telemonitoring with active intervention are beneficial in atrial fibrillation (AF) and therapy-resistant hypertension (TRH), respectively. For these patients, we have developed a novel integrated care concept (NICC) which combines telemedicine with intensive support by a care center, including a call center, an integrated care network including inpatient and outpatient care providers and guideline therapy for patients.MethodsThe aim of the study is to demonstrate the superiority of NICC over guideline therapy alone. The trial is designed as open-label, bi-center, parallel-group design with two groups and a blinded observer. Patients will be included if they are either inpatients or if they are referred to the outpatient clinic of the hospitals by their treating physician. Randomization will be done individually with stratification by cardiovascular disease (AF, HF, TRH), center and admission type. Primary endpoints are based on the 1-year observation period after randomization. The first primary endpoint is the composite endpoint consisting of mortality, stroke and myocardial infarction. The number of hospitalizations form the second primary endpoint. The third primary endpoint is identical to the first primary endpoint plus cardiac decompensation. Adjustments for multiple testing are done using a fall-back strategy. Secondary endpoints include patient adherence, health care costs, quality of life, and safety. A sample size of 2930 gives 80% power at the two-sided 2.5% test level for the first primary endpoint. The power for the second primary endpoint is 99.8% at this sample size, and it is 80% with 1086 patients.DiscussionThis study will inform care providers whether quality of care can be improved by an integrated care concept providing telemedicine through a round-the-clock call center approach. We expect that cost of the NICC will be lower than standard care because of reduced hospitalizations. If the study has a positive result, NICC is planned to be immediately rolled out in the federal state of Mecklenburg-West Pomerania and other federal states in Germany. The trial will also guide additional research to disentangle the effects of this complex intervention.Trial registrationDRKS, ID: DRKS00013124. Registered on 5 October 2017;ClinicalTrials.gov, ID: NCT03317951. Registered on 17 October 2017.

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.

The implementation of personalised supports for people with dementia through multi-stakeholder, integrated care networks

Introduction: It is estimated that 55,000 people have dementia in Ireland. This is projected to increase significantly in Ireland and globally. People with dementia (PWD) have a wide range of health, social, psychological, emotional and other needs which change over time, therefore many health and social care professionals from different settings can be involved in their care. Many PWD wish to remain living at home for as long as possible and maintaining personhood and social connection is key to the person living well with dementia. Resource constraints, gaps in community-based services and a fragmented health and social care system presents a significant challenge to meet the variety of needs of people with dementia in a personalised, responsive way. Policy context and objective of initiative: Ireland’s National Dementia Strategy recognises these challenges and proposes an integrated partnership approach to the development and delivery of services for PWD including all stakeholders in providing a range of person-centred, flexible and responsive services. The HSE & Genio Dementia Programme is a collaborative initiative whose objective is to develop innovative, integrated and personalised services and supports for PWD in their local community so that they can remain living well at home. The target population was PWD, including early onset dementia, family carers as well as the wider health and social care ecosystem. Highlights: The mechanism used to address the integration of services was a Dementia Consortium. This is a locally based, multi-stakeholder group of organisations and individuals who brought together varied expertise and resources to develop innovative and personalised supports to enable PWD to live well at home. Consortia included people with dementia, family carers, health and social care professionals, other statutory organisations, voluntary and community groups, hospitals, nursing homes and others. Nine Dementia Consortia, with 160 members developed a range of personalised supports for PWD and carers to maintain ability and connection, including respite supports and assistive technology (AT). To date, over 74,000 hours of personalised supports have been provided to 1,474 PWD plus carers. Learning points to the need for supports to be responsive and flexible; the importance of timely engagement with the person and carer and the usefulness of tailoring supports to the person and their interests. Evaluation findings indicate a greater degree of integrated working and that personalised supports enable PWD to remain living at home for longer, resulting in significant cost avoidance. Transferability: A Dementia Consortium builds on what is locally available and is an easily localised and transferable model. The learning from this programme is now supporting a further four sites to develop integrated working, with a focus on implementing Intensive Home Care Packages for PWD. Conclusions: This programme has demonstrated that multi-stakeholder consortia are a useful mechanism for supporting a profound change in the development and delivery of dementia services, enabling the central involvement of people with dementia and family carers, a focus on personhood through personalised supports and meaningful integration across a wide range of stakeholders.

Polypharmacy and Integrated Care: Identifying synergies in implementation

Introduction : Integrated care has the potential to assist health systems in achieving the triple aims of improving the experiences of individual patients, the health of the population, whilst at the same time increasing efficiencies. Integrated care can impact significantly those with complex needs such as older, multimorbid patients, in whom inappropriate polypharmacy has emerged as a key issue. Unfortunately, the pharmacists’ role within integrated care medicines optimisation is often not explicitly addressed; meaning potential opportunities to achieve the triple aims are being missed. As part of project SIMPATHY (Stimulating Innovative Management of Polypharmacy and Adherence in the Elderly), case studies were conducted in a sample of European Union countries with the aim of identifying components of, and implementation strategies, adopted in polypharmacy management targeting integrated care for the elderly. Objectives : To identify commonalities between integrated care frameworks and polypharmacy case studies to facilitate implementation of polypharmacy management and medicines optimisation into integrated care networks. Methods : Case studies in nine sites in eight countries (Germany (Lower Saxony), Greece, Italy (Campania), Poland, Portugal, Spain (Catalonia), United Kingdom (Northern Ireland and Scotland), and Sweden) have been completed. A narrative literature review identifying commonly used frameworks and taxonomies in integrated care implementation is ongoing. Common elements will be identified within these frameworks and mapped to findings from the case studies. Preliminary results : Core components of polypharmacy initiatives identified in the case studies included: the need to implement multidisciplinary teams; to establish responsibilities of team members; to target specific groups of complex patients; and move beyond the focus on single disease state guidelines. Other key themes related to: change management and implementation strategies, including the importance of developing local solutions; the need to align polypharmacy management with other healthcare priorities and initiatives; the important role of healthcare provider education; the need to align personnel and remuneration with polypharmacy management goals; the need for strategic planning from policy makers and managers together with clinical leadership; and the important role of both information technology and communication systems initiatives within a supportive culture. The role of legislation and high level policies supporting polypharmacy management were also noted. Comparing these results to the initial findings of the literature reviews reveals that there is strong concordance between the case study findings and elements of conceptual frameworks for integrated care. Many elements of systems, organisational, professional, and clinical integration were aligned as well as normative and functional integration. There was also significant agreement with proposed taxonomies of integrated care, although discrepancies, most notably in the areas of professional and functional integration, were identified. Discussion and Future Research : Based on the initial level of concordance, we anticipate the results of this work will inform the development of common approaches to implementing medicines management into integrated care initiatives for multimorbid, older people. Beyond polypharmacy, we also see that the approach developed here will be applicable to the introduction of other specific health services targeting particular populations. Acknowledgements : We would like to acknowledge the significant contributions of the SIMPATHY consortium on the case studies.

Family Carers as Partners in Implementing Integrated Care: Maximising the Impact of Ireland’s National Carers Strategy

Crucial to the success of integrated care networks is the role of family carers in their creation (Leichsenring K. 2004). When networks are poorly integrated, carers suffer; they are often invisible to the system, and have their needs neglected or ignored. The resulting breakdown in care at home increases pressure on formal services (Binstock et al. 1996). A dual challenge now exists EU-wide: to support informal or family carers through integration of formal services for care recipients, and to involve them in formal care systems (Leichsenring K. 2004). The goals of Ireland’s 2012 National Carers’ Strategy (NCS) represented an acknowledgement of the need to integrate family and formal care. Its vision is to recognise and respect family carers as key partners, and to support them to maintain their own health and wellbeing and to care with confidence (Department of Health (IRL), 2012). Drafted and adopted in the midst of economic recession, the NCS had limited resources for delivery on its objectives. The challenges for a cost-neutral strategy were various: how to secure buy-in of carers; how to measure progress from carers’ perspectives; and how to establish and consolidate fruitful collaboration between government ministers, officials and family carers. Health policy that impacts upon integration of care in Ireland, in particular that related to home and community care, suffers from an implementation deficit (Browne M. 2016). A major factor in that deficit is that, where policy and strategy development often proceeds via widespread engagement with stakeholders, subsequent implementation forsakes their further involvement. The NCS sought to address and partially remedy this. Family Carers Ireland (FCI) set up an independent monitoring group composed of family carers and key experts from FCI and Care Alliance Ireland. The Group devised a simple ‘traffic-light’ scoring system to monitor progress in the strategy’s implementation. Scores were assigned based on comparison between stated NCS goals and annual government progress reports. Assessment was further informed by the lived experience of family carers, which often served to confirm or confute elements of the reports. The scoring process took place annually, and finalised scorecards served to inform family carers nationally and the general public, and as the basis for engagement with government ministers and officials. The initiative’s innovative aspect lies in its promotion of carers’ engagement with health and social policy implementation. The approach supported family carers to monitor progress toward stated integrated care objectives, and facilitated their communication with key stakeholders. Positive engagement from government ministers and officials, and receptiveness to the expertise of an external monitoring body of family carers enabled a collaborative, solution-focused approach to implementation of the NCS. Full achievement of the strategy’s goals is still some way off; but this collaborative approach has yielded positive and tangible results. These include establishment of a cross-divisional Health Service Executive working group; marked improvements in how Government engages and communicates with family carers about available supports; extension of the period of a carer’s receipt of key welfare supports after the care recipient’s death or entry into residential care; and an enhanced Annual Carer Forum. In terms of transferability, Government departments have recommended that other interest groups replicate this approach. In other jurisdictions, this approach could enhance the implementation of Integrated Care Policy that requires the active involvement of patients and carers.

Identifying the determinants for attractiveness of interdisciplinary forms of care from the perspective of health care professionals

Since the collaboration between care givers occurs on a voluntary basis in Austria, the development of integrated care initiatives relies primarily on the engagement and commitment of health care professionals. Motivation theory suggests addressing needs and individual goals in order to achieve higher commitment. If health care professionals believe that their personal goals can better be achieved in integrated care models we can expect a growth in interdisciplinary care provision. The aim of the study is to identify motivational factors and determinants of attractiveness in interdisciplinary forms of care. The development of the questionnaire was based on motivational theory, especially Herzberg`s Two-Factor Theory, Mc Clellands Need Achievement Theory, Vroom`s VIE Theory and previous studies on motivational factors in health care settings. In the first part information was collected on the respondent`s professional background, their working experience, age, work-life attitudes and general preferences for interdisciplinary forms of care. The second part addressed motivational factors and determinants of attractiveness of interdisciplinary forms of care. The sample included practicing physicians, nurses and other non-physician health care professions. Statistical methods included frequency distributions, explanatory factor analysis, t-test and regression analysis. The main sources for motivation are the work itself (interesting and meaningful work, working independently and with responsibility) and recognition and feedback. At their current workplace expectations concerning security and social relationships are met to a high degree whereas expectations concerning recognition and feedback are met to a low degree. Respondents were divided on the expected consequences of entering integrated care networks. Nurses and medical-technical staff expected more challenging work and stated that their interests could be better pursued in integrated forms of care. Doctors expected a reduction in autonomy and stated that their interests could not be better pursued in integrated forms of care. Several suggestions for designing attractive workplaces can be drawn from the findings of the survey. Results suggest that health care professionals are highly motivated by the work itself and by recognition and feedback. In order to increase attractiveness the following components have to be considered: working independently and with responsibility, interesting, meaningful and challenging work, performance-based compensation, feedback on performance, career opportunities and job security. A better understanding of motivational factors and attitudes towards interdisciplinary forms of care provides the basis for designing care in a way to meet the needs and interests of all groups involved. Paying attention to the individual goals of the care providers involved can facilitate the dissemination of interdisciplinary forms of care. The results of the study suggest that two factors seem to be crucial in obtaining the commitment of health care professionals: the dedication to the work itself and the desire to remain independent and autonomous. Respondents were students enrolled in postgraduate master programs. Their common interest in continuous education and learning could induce similarities in working motives and attitudes. Further studies, particularly ones using qualitative methods, should concentrate on the process of the formation of work values and attitudes.

An Urban Partnership for Inner Sydney Social Inclusion, Health and Well-being

Inner City Sydney, the catchment area of St Vincent's Health Networks (SVHN) Inner City Health Programme, is populated by people who represent the highest and lowest social deciles in Australia. In common with other inner city environments around the world, the latter are characterised by high levels of homelessness, addictions and mental illness. Challenges for health and social services to coordinate care and meet the needs of vulnerable people of this demographic is complicated by surges of population relating to the central business district, tourists, backpackers, thrill seekers and those with nefarious intent. The catchment area is well served by a number of excellent general practices and non-government organisations. However as a result of the interweaving psychosocial factors and a lack of formal service coordination between community managed organisations and SVHNs Specialist Services, Housing and Family and Community Services, the SVHN Emergency Department has the highest number of mental health and drug and alcohol presentations, the highest throughput of patients through the lowest number of mental health beds and the lowest average length of stay in the state of New South Wales. Given these presentations are increasing at between 2-4% per year and the health and social care resource base is being reduced, a situation is evolving which is unsustainable in terms of consumer safety and quality of life. To address these issues an initiative to establish an integrated care network, the Inner Sydney Urban Partnership for Health and Well-being (UP) is being developed to jointly assess need, plan and integrate service delivery (especially physical health with psychosocial care), share and increase the resource base, research and evaluate developments and promote person centred, recovery oriented care. The process and challenges of developing the Partnership is described and explored referencing the engagement of providers, consumers and carers, a radical vision for transforming the ethos and practical realities of the existing system, the contextual challenges extant in Australia's and NSW policy and funding framework (including the Roadmap for Mental Health Reform, National Disability Insurance Scheme and Activity Based Funding) and progress made to date with developments. Finally consideration is given to how the Urban Partnership is positioned with regard to other international integrated care initiatives and the 4th wave of deinstitutionalisation.

Promise and Reality of Genomics: Link to Schizophrenia Involves Lots of Unknowns

Back to table of contents Previous article Next article Clinical and Research NewsFull AccessPromise and Reality of Genomics: Link to Schizophrenia Involves Lots of UnknownsMark MoranMark MoranSearch for more papers by this authorPublished Online:15 May 2017https://doi.org/10.1176/appi.pn.2017.5a1AbstractHundreds of possible gene mutations may act alone or with each other to determine phenotypic expression of schizophrenia.Better treatments for schizophrenia rely on a more complete understanding of how genetic mutations alter the activity of neural circuits in patients with the disease. NIMH Director Joshua Gordon, M.D., says extremely large study cohorts are necessary to help prioritize targets for genetic research in schizophrenia. That’s the message National Institute of Mental Health (NIMH) Director Joshua Gordon, M.D., delivered to researchers and clinicians during a plenary lecture at the International Congress of Schizophrenia Research in San Diego in March. Gordon said the path forward for genomics and schizophrenia, though promising, is extraordinarily daunting: hundreds of potential gene mutations act through the same complex chain—genes to molecules to cells to circuits to behavior—resulting in a diversity of possible phenotypes. This wide range of phenotypes accounts for what has traditionally been called the “heterogeneity” of schizophrenia. “There is the promise of genetics, and there is the reality,” Gordon said at the meeting. “The reality is that there are hundreds of genes that contribute to subsyndromal or syndromal schizophrenia, and each one of these mutations has a very small effect size. There is a lot of biology [between the mutation and the phenotypic expression of disease] that we don’t understand. When you throw in environmental influences, it makes the complexity picture completely non-linear.”Gordon gave an example of how genetics contribute to understanding the differential phenotypic expression of schizophrenia based on his own work at Columbia University and the New York Psychiatric Institute prior to his becoming director of NIMH. He and colleagues focused on the 22q11 microdeletion, a tiny mutation in a portion of chromosome 22 known to be associated with schizophrenia and cognitive deficits. They found that mice bred with the 22q11 microdeletion took longer to learn a working memory task than those that did not have the mutation. Additional analyses suggested that the working memory impairments in the mice appear to be due to disrupted communication between the hippocampus and the prefrontal cortex, where spatial information is encoded in memory. Even further, Gordon and his long-time collaborator Joseph Gogos, M.D., Ph.D., were able to elucidate neurochemical abnormalities in the development of axons (the threadlike fibers from a neuron that transmit information to another neuron), which appear to account for disrupted communication between the hippocampus and prefrontal cortex. Gordon said this work illustrates how genetic mutations and the various behavioral phenotypes associated with schizophrenia can be linked to offer a more complete understanding of the neurobiology of the disorder. In this case, one phenotypic expression (impaired working memory) is associated with a genetic mutation (22q11) that is linked to cells and neural networks specifically associated with disrupted communication of information between two brain structures (the hippocampus and prefrontal cortex). Yet as elegant as it appears, Gordon said it almost certainly oversimplifies the true picture of what happens in schizophrenia. “The bigger problem is that it represents only a portion of what we know about schizophrenia genetics,” Gordon said, with hundreds of other possible gene mutations that may act alone or in concert with each other to determine phenotypic expression. What is necessary and what Gordon said he and other researchers hope to find is “critical convergence” of research findings—“where some significant amount of schizophrenia is explained by one common convergent pathophysiology.” For that, he said, it will be necessary to collect data on extremely large population cohorts to link genomics to phenotypes. That’s an enormous undertaking. Gordon said he has appointed the Workgroup on Genomics of the National Advisory Mental Health Council and charged it with answering the following questions: What are the best strategies for prioritizing genetic signals/genes for functional analyses?What are the best experimental and computational tools for investigating genetic risk factors?How can NIMH leverage diverse population-based cohorts to enable large-scale genomic discovery?How should dimensional phenotypes be used to further elucidate the genetic architecture of mental disorders?In the meantime, Gordon suggested the way forward toward better treatment of patients with schizophrenia is to leverage developing integrated care networks to make the treatments that exist—antipsychotic medication and evidence-based psychosocial therapies—available to patients in primary care. “But I deeply believe that in order to truly transform the efficacy of drug treatment for schizophrenia we need to understand the neurobiology of the disease,” he said. ■ ISSUES NewArchived