Integrated Care Network Research Articles

Service Coordination for Frail Elderly Individuals: An Analysis of Case Management Practices in Québec

The objective of this article is to understand coordination as it unfolds in case management practices in the context of integrated care networks devoted to frail elderly individuals. More specifically, my goal is to describe practical coordination processes. I conducted a qualitative exploratory study using an embedded case study design. My research covers three Health and Social Services Centres in Québec. I observed that case management is more frequently justified by a situation in which home care is precarious than by the intensity and multidimensionality present in a situation. In such instances, case management intervenes through a standby mode.

Integrated care network for mental health: experience of psychiotric reform process in the scenario of Brazilian Northeast

RESUMO O presente artigo é um relato de experiência do processo de reforma psiquiátrica em um cenário do Nordeste brasileiro, em Sobral (CE), mediante o fechamento do hospital psiquiátrico Casa de Repouso Guararapes, em julho de 2000, e a implantação de uma Rede de Atenção Integral à Saúde Mental, que se caracteriza por uma atenção de qualidade, humanizada, tendo como horizonte de trabalho a integralidade do cuidado. Ela enfrenta desafios importantes como habilitação social dos usuários assistidos; ampliação das ações de saúde mental na atenção primária; e educação permanente dos trabalhadores da saúde.

Merseyside and Cheshire palliative care network audit and guidelines for managing breathlessness

BackgroundMerseyside and Cheshire Palliative Care Network (MCPCN) Audit Group was established in 1995. It is a multi-professional group composed of individuals working in palliative care across eight integrated care networks...

Supervised exercise therapy for intermittent claudication: current status and future perspectives

Intermittent claudication (IC) has a high prevalence in the older population and is closely associated with cardiovascular and cerebrovascular disease. High mortality rates are reported due to ongoing atherosclerotic disease. Because of these serious health risks, treatment of IC should address reduction of cardiovascular events (and related morbidity/mortality) and improvement of the poor health-related quality of life (QoL) and functional capacity. In several randomized clinical trials and systematic reviews, supervised exercise therapy (SET) is compared with non-supervised exercise, usual care, placebo, walking advice or vascular interventions. The current evidence supports SET as the primary treatment for IC. SET improves maximum walking distance and health-related QoL with a marginal risk of co-morbidity or mortality. This is also illustrated in contemporary international guidelines. Community-based SET appears to be at least as efficacious as programs provided in a clinical setting. In the Netherlands, a national integrated care network (ClaudicatioNet) providing specialized care for patients with IC is currently being implemented. Besides providing a standardized form of SET, the specialized physical therapists stimulate medication compliance and perform lifestyle coaching. Future research should focus on the influence of co-morbidities on prognosis and effect of SET outcome and the potential beneficial effects of SET combined with a vascular intervention.

The ClaudicatioNet concept: design of a national integrated care network providing active and healthy aging for patients with intermittent claudication.

Introduction:Intermittent claudication (IC) is a manifestation of peripheral arterial occlusive disease (PAOD). Besides cardiovascular risk management, supervised exercise therapy (SET) should be offered to all patients with IC. Outdated guidelines, an insufficient number of specialized physiotherapists (PTs), lack of awareness of the importance of SET by referring physicians, and misguided financial incentives all seriously impede the availability of a structured SET program in The Netherlands.Description of care practice:By initiating regional care networks, ClaudicatioNet aims to improve the quality of care for patients with IC. Based on the chronic care model as a conceptual framework, these networks should enhance the access, continuity, and (cost) efficiency of the health care system. With the aid of a national database, health care professionals will be able to benchmark patient results while ClaudicatioNet will be able to monitor quality of care by way of functional and patient reported outcome measures.Discussion:The success of ClaudicatioNet is dependent on several factors. Vascular surgeons, general practitioners and coordinating central caregivers will need to team up and work in close collaboration with specialized PTs. A substantial task in the upcoming years will be to monitor the quality, volume, and distribution of ClaudicatioNet PTs. Finally, misguided financial incentives within the Dutch health care system need to be tackled.Conclusion:With ClaudicatioNet, integrated care pathways are likely to improve in the upcoming years. This should result in the achievement of optimal quality of care for all patients with IC.

The ClaudicationNet concept: design of a national integrated care network of supervised exercise therapy for patients with intermittent claudication

Context: Intermittent claudication is a manifestation of peripheral arterial disease. The primary and most effective intervention is exercise therapy. When exercise therapy is supervised by a physical therapist, superior results on walking distance and quality of life have been found (Level I). Caregivers like physical therapists, vascular surgeons and general practitioners should collaborate in regional integrated care networks. Case description: ClaudicationNet aims to implement nationwide coverage of regional networks for supervised exercise therapy. Participating physical therapists comply with a progressive set of quality markers. Over a period of five years a fully transparent and high quality care, evaluated by quality indicators, should be achieved. This new standard of integrated care will also hold lifestyle interventions. Results of maximal walking ability, quality of life, comorbidities, lifestyle parameters and cardiovascular risk factors will be gathered in a national database as well as reported back to referring physicians.

Divergent modes of integration: the Canadian way.

The paper highlights key trajectories and outcomes of the recent policy developments toward integrated health care delivery systems in Quebec and Ontario in the primary care sector and in the development of regional networks of health and social services. It particularly explores how policy legacies, interests and cultures may be mitigated to develop and sustain different models of integrated health care that are pertinent to the local contexts. In Quebec, three decades of iterative developments in health and social services evolved in 2005 into integrated centres for health and social services at the local levels (CSSSs). Four integrated university-based health care networks provide ultra-specialised services. Family Medicine Groups and network clinics are designed to enhance access and continuity of care. Ontario's Family Health Teams (2004) constitute an innovative public funding for private delivery model that is set up to enhance the capacity of primary care and to facilitate patient-based care. Ontario's Local Health Integration Networks (LHINs) with autonomous boards of provider organisations are intended to coordinate and integrate care. Integration strategies in Quebec and Ontario yield clinical autonomy and power to physicians while simultaneously making them key partners in change. Contextual factors combined with increased and varied forms of physician remunerations and incentives mitigated some of the challenges from policy legacies, interests and cultures. Virtual partnerships and accountability agreements between providers promise positive but gradual movement toward integrated health service systems.

Clinicians' perceptions of organizational readiness for change in the context of clinical information system projects: insights from two cross-sectional surveys

BackgroundThe adoption and diffusion of clinical information systems has become one of the critical benchmarks for achieving several healthcare organizational reform priorities, including home care, primary care, and integrated care networks. However, these systems are often strongly resisted by the same community that is expected to benefit from their use. Prior research has found that early perceptions and beliefs play a central role in shaping future attitudes and behaviors such as negative rumors, lack of involvement, and resistance to change. In this line of research, this paper builds on the change management and information systems literature and identifies variables associated with clinicians' early perceptions of organizational readiness for change in the specific context of clinical information system projects.MethodsTwo cross-sectional surveys were conducted to test our research model. First, a questionnaire was pretested and then distributed to the future users of a mobile computing technology in 11 home care organizations. The second study took place in a large teaching hospital that had approved a budget for the acquisition of an electronic medical records system. Data analysis was performed using partial least squares.ResultsScale items used in this study showed adequate psychometric properties. In Study 1, four of the hypothesized links in the research model were supported, with change appropriateness, organizational flexibility, vision clarity, and change efficacy explaining 75% of the variance in organizational readiness. In Study 2, four hypotheses were also supported, two of which differed from those supported in Study 1: the presence of an effective project champion and collective self-efficacy. In addition to these variables, vision clarity and change appropriateness also helped explain 75% of the variance in the dependent variable. Explanations for the similarities and differences observed in the two surveys are provided.ConclusionsOrganizational readiness is arguably a key factor involved in clinicians' initial support for clinical information system initiatives. As healthcare organizations continue to invest in information technologies to improve quality and continuity of care and reduce costs, understanding the factors that influence organizational readiness for change represents an important avenue for future research.

Integrated Care Network as a Key Concept for the Health System of Highly Aged Society

Integrated Care Network as a Key Concept for the Health System of Highly Aged Society

Analysis of the continuity of services from the viewpoint of clinical files in the perspective of quality improvement

Purpose: According to the most recent conceptual model, the continuity of services is increasingly recognized as a robust quality indicator. However, while many authors estimate that clinical files are, in principle, good observatories of continuity; very few have studied continuity from the files’ viewpoint. Theory: Global continuity comprises three dimensions, i.e., informational continuity, management continuity and relational continuity. These three forms of continuity can be observed in clinical files by identifying continuity moments and events. Methods: In the context of a larger embedded case study, we analyzed 21 clinical cases, equally distributed in three different integrated care networks, of users followed by case managers. Their content was decorticated using a validated clinical information extractor and then transposed to a temporal line allowing a sequential identification of continuity moments and events. Results and conclusions: The clinical files allow a better understanding of the specific deployment patterns of the three types of continu ity which appear to be dependant of the different contexts’ tools and norms of completion of the files.

Executive Summary—2010 Consensus Conference

Executive Summary—2010 Consensus Conference

Designing an Integrated Health Care System — What are the Key Features?

This paper results from experience gained while developing and delivering the South Devon Integrated Care Network (ICN) and from more recent experience as an Integrated Care Pilot (ICP) organisation. It demonstrates that by taking an integrated approach a hospital can develop and prosper, and that it is possible to reduce the use of beds and manage care in the community within the levels of funding currently available. The paper focuses on integration at organisation level and proposes a model of key system drivers and controls necessary to manage an integrated health and social care system. The next level of integration is at individual customer level, and the paper discusses the enablers for this.

Inverted risk selection—a structural property of a new population-based integrated care system in Germany

Background and purpose: In the Kinzigtal region in Southwest Germany, a population-based integrative care system has been set up in 2005–2006, organising care across all health service sectors and indications. The system is run by a regional health management company (Gesundes Kinzigtal GmbH) in cooperation with the physicians’ network in the region and with two statutory health insurers (among them is the biggest health insurer in Southwest Germany: AOK Baden-Wurttemberg). Membership is optional for insured persons in the Kinzigtal area. In contrast to many other Managed Care organisations, Gesundes Kinzigtal and its partners have intentionally attempted to prevent a policy of risk selection and to organize a better (integrated) care first of all for the so-called ‘bad risks’ such as older persons and the chronically ill. To determine whether that attempt has been successful, we analyse the administrative data of the concerned health insurers during the building phase of the Kinzigtal system (2006–2008). Theory: A common critique of Managed Care initiatives holds that while economic and financial goals have come to dominate, a strat egy of risk selection—i.e. preferred recruitment of the young and/or healthy—has often been forwarded. To overcome this experience, Gesundes Kinzigtal and its partners have set up a specific system of contractual and financial incentives to realize a kind of inverted risk selection, implying the preferred recruitment of the so-called ‘bad risks’. In the contribution we outline the contractual and economic incentives which are to produce an inverted risk selection and a more efficient care in greater detail. Methods: To check whether Gesundes Kinzigtal has managed to realize an inverted risk selection, age, social status and morbidity costs of the insured members of the integrated care network are compared with the data of those assureds in the Kinzigtal region who have not (yet) become members. The contribution will focus on the health insurers’ administrative data that were collected during the whole building phase of the system (2006–2008). Results and conclusions: The available data show that the Kinzigtal integrated care system has indeed managed to realize an inverted risk selection during its building phase (2006–2008), i.e. its members are considerably older and cause remarkably higher morbidity costs than the non-members in that area. Discussion: The contractual and financial incentives of the Kinzigtal system have obviously been adequate means to realize an inverted risk selection. At the same time, the financial results of the first two years (2006–2007) of the system have turned out surprisingly positive (see other abstract)—thus Gesundes Kinzigtal demonstrates the huge potential of population-based integrated care approaches.

Models of mental health care in psychiatry across sectoral borders

Since 2004, article 140 of the fifth German Social Code Book (SGB V) provides the opportunity for developing and implementing models of Integrated Care (IC). The main aim of integrated care projects is to improve the quality and efficiency of health care in Germany by ameliorating the cooperation between the different sectors hospitals, ambulatory and rehabilitative care. As an example of implementing an integrated care network in the psychiatric sector, the first local network for integrated care in psychiatry in Aachen is described. It was founded in 2006 by the department of Psychiatry and Psychotherapy of the University Hospital Aachen, the DGPPN (German Association of Psychiatry and Psychotherapy) and the BVDN (Professional Association of German Neuropsychiatrists). The present interface problem between the separated sectors of medical care in Germany is being solved by evidence-based therapy, coordinated treatment between the different sectors, a standardised documentation and advanced training for all clinical participants. Early diagnosis and treatment of depression are improved by integrating clinical diagnostics, acute therapy, maintenance therapy, prophylaxis of relapse and after-care within one network. By the end of 2008, 1,081 patients have been treated within the integrated care network in Aachen by 56 ambulant general practitioners and psychiatrists and by 3 local psychiatric hospitals. Currently the network is going to be enlarged by integrating the diagnosis of schizophrenia. Following this, other mental illnesses should be integrated. The aim is to create a nationwide integrated care network across all diagnostic borders of mental illnesses.

Integrated health care networks in Latin America: toward a conceptual framework for analysis

Las inequidades e ineficiencias de los sistemas de salud de America Latina motivaron algunas reformas, concentradas en las ultimas dos decadas, particularmente en el financiamiento y el suministro de la atencion sanitaria. Este trabajo se enfoca en la introduccion de redes integradas de atencion sanitaria (RIAS) en varios paises de America Latina y los ubica en el contexto internacional. La descripcion y el analisis de las RIAS, ya fueran regionales o de afiliacion, resaltan el debate actual sobre sus posibles beneficios y riesgos. El impacto de las RIAS -en terminos del mejoramiento del acceso a la atencion sanitaria o de la promocion de la eficiencia y la equidad en los sistemas de salud- se ha evaluado en muy pocas oportunidades. Para contribuir al tema, se propone un marco conceptual abarcador para el analisis del desempeno de las RIAS, que trata el proceso interno y los factores externos considerados criticos para alcanzar sus objetivos intermedios y finales.

The Evidence Base for Integrated Care

It has become commonplace to highlight that, despite the vigorous promotion of integrated working, both in health care and between health and social care, the evidence base, particularly in terms of outcomes for the presumed beneficiaries, is fragmentary. A number of oft-quoted reviews have explored the detail (Cameron et al, 2000; El Ansari et al, 2001; Dowling et al, 2004; Ramsay & Fulop, 2008). Perhaps surprisingly, however, there has been no readily accessible and regular update of the evidence base. This is now being rectified by an initiative at research in practice for adults, with support from the Integrated Care Network. The idea of establishing an evidence base, updated regularly, grew out of an ESRC research seminar series titled Partnership Working Between Health and Social Care: Building Capacity for Change held between 2005 and 2007. The systematic review by Cameron and colleagues (2000) identified four models for joint working: placement schemes, multi-agency teams and projects, case or care management, and strategic-level working. The team identified 32 studies from 38 papers which grouped drivers and barriers for joint working into three themes: organisational issues, cultural and professional issues, and contextual issues. The review concluded that there was a:

Montérégie Comprehensive Cancer Care Centre: Integrating nurse navigators in Montérégie’s oncology teams: One aspect of implementing the Cancer Control Program—Part 1

The oncology patient navigator role was developed to ensure both continuity and consultation in the delivery of care to cancer patients and their families. In Québec, this role is filled by a nurse. This first article in a series of two, aims to explain why nurses were selected as patient navigators and to describe how this new role has been integrated in the Montérégie Region. The Québec Cancer Control Program, the definition established for the oncology nurse navigator role and the implementation of an integrated care network based on the Montérégie experience will be discussed.

Centre intégré de cancérologie de la Montérégie : L’intégration des infirmières pivots dans les équipes d’oncologie en Montérégie : un aspect de l’implémentation du Programme de lutte contre le cancer, Partie 1

The oncology patient navigator role was developed to ensure both continuity and consultation in the delivery of care to cancer patients and their families. In Québec, this role is filled by a nurse. This first article in a series of two, aims to explain why nurses were selected as patient navigators and to describe how this new role has been integrated in the Montérégie Region. The Québec Cancer Control Program, the definition established for the oncology nurse navigator role and the implementation of an integrated care network based on the Montérégie experience will be discussed.

Integrated care networks for the vulnerable elderly: North American prototypes, performance and lessons

Purpose: To describe in general terms the managed care network (MCN) rationale and approach to the organisation and delivery of services to the long term care (LTC) elderly, report on the prototypes and performance associated with three major North American models (PACE in U.S. and SIPA and PRISMA in Canada), and present the major lessons learned from these three programmes.

Adult Care Joint Ventures: The Art of the Possible

In this first of two articles, the authors assess the implications of policy developments in partnership and contestability, commissioning and procurement, and local jurisdiction for adult services joint ventures. They argue for creative responses to service delivery in which policy implementation is seen as an opportunity for local health and social care agencies to honour the history of, and future aspirations for, local partnerships. A second article will detail the very different responses to the policy agenda of four case study sites, exploring the local contours and aspirations underlying their decisions, with the intention of provoking discussion about the art of the possible in the broader community of interest.The papers draw on the authors' work funded by the Integrated Care Network (ICN) and Care Services Improvement (CSIP), which comprised a series of workshops to inform the further development of the plans of four local health and social care communities ‐ Portsmouth, Wolverhampton, Barnsley and Milton Keynes ‐ for commissioning and provision of adult care services, providing a community of interest in which aspirations, challenges and emerging solutions were exchanged and explored. Here we summarise transferable learning for the broader community of interest, drawn from the more detailed reports available from the ICN (Freeman & Peck, 2006, 2007).