Integrated Package Of Care Research Articles

Barriers and enablers towards integrated care for sexual violence victims in humanitarian settings

Abstract Background Sexual violence (SV) is a complex public health issue that necessitates a coordinated multisectoral response. Ideally, this response should be provided through an integrated care package to strengthen timely access and comprehensive care for victims. However, in humanitarian settings with high levels of SV, care is often offered through fragmented silos, exacerbating the burden on the health workforce and victims. Methods Using the Valentijn framework, a qualitative, real-time Delphi study was conducted with 17 SV care experts representing 7 geographical subregions to gain informed opinions on key contextual and health system barriers and enablers for integrated care for SV victims in humanitarian settings. Results Challenges and enablers reported across the diversity of the participants’ contexts showed consistency. Contextual challenges included volatile contexts, collapsed health systems, and poor infrastructure. Professional challenges included a lack of expertise among healthcare providers (HCPs), high staff attrition, and compassion fatigue among HCPs. Health systems challenges included poor referral and coordination mechanisms, insufficient resources, misaligned donor-programme priorities and low prioritisation of SV comprehensive care. Key enablers reported were effective networking, community engagement, capacity building, co-locating services, participatory management, promoting staff’s sense of ownership, digitalised information systems, and joint patient files. Conclusions The sustainability of integrated care for SV victims can be strengthened by ensuring HCPs access regular psychological support and training and are incentivised to provide quality care. Regular coordination among actors, including donors, can support integrating care that responds to patients’ holistic needs. Further research is needed to assess HCPs’ and SV victims’ experiences of current service delivery and how to optimise integrated care in humanitarian settings. Key messages • Addressing care providers challenges in humanitarian settings, such as high attrition, lack of training, psychosocial support, and burnout, can ensure proper integration of sexual violence care. • Integration of sexual violence care demands systemic changes, including aligning donor-programme goals, building accountability mechanisms and the buy-in of political and community leaders.

Evaluation of the Implementation of Integrated Primary Care for Patients with Type 2 Diabetes and Hypertension in Belgium, Cambodia, and Slovenia.

Integrated care of chronic patients improves quality of their management, but there is scarce evidence of its implementation in different healthcare settings. With this article, we wanted to determine the level of integrated care implementation in the management of T2D (diabetes) and HT (hypertension) in three different settings: Belgium, Slovenia, and Cambodia. This was an observational study with integrated approach. It was conducted in primary health care organisations in three countries. In each primary health care organisation, we aimed to include primary care workers that worked with Type 2 Diabetes (T2D) and hypertension (HT) patients. Data was collected with the Integrated Care Package (ICP) grid (consisting of six elements: identification, treatment, health education, self-management, caregiver collaboration, and care organisation). ICP is almost completely implemented without major differences within Slovenia. There is a considerable variability across practice types in Belgium. Implementation is constrained by health system resources in Cambodia. Some elements, especially identification, are better implemented then others, across health systems. Countries can enhance integrated care for chronic diseases by implementing central policies, standardized protocols, and local adaptation, addressing resource constraints, promoting systematic screening and health education, and providing training for healthcare workers, tailored to community needs, to improve patient outcomes and healthcare delivery.

Towards Integrated Care for the Elderly: Exploring the Acceptability of Telemonitoring for Hypertension and Type 2 Diabetes Management.

Telemonitoring has been proposed as an effective method to support integrated care for older people with hypertension and type 2 diabetes. This paper examines acceptability of telemontioring, its role in supporting integrated care, and identifies scale-up barriers. A concurrent triangulation mixed-methods study, including in-depth interviews (n = 29) and quantitative acceptability tool (n = 55) was conducted among individuals who underwent a 12-month telemonitoring routine. The research was guided by the Theoretical Framework of Acceptability. Interviews were analysed using template content analysis (TCA). TCA identified seven domains of acceptability, with twenty-one subthemes influencing it positively or negatively. In the quantitative survey, acceptability was high across all seven domains with an overall score of 4.4 out of 5. Urban regions showed higher acceptability than rural regions (4.5 vs. 4.3), with rural participants perceiving initial training and participation effort as significantly more burdensome than their urban counterparts. Patients described several instances where telemonitoring supported self-management, education, treatment, and identification elements of the integrated care package. However, there were barriers that may limit its further scale-up. For further scale-up, it is important to screen patients for monitoring eligibility, adapt telemonitoring devices to elderly needs, combine telemonitoring with health education, involve family members, and establish follow-up programmes.

Hypertension cascade across three healthcare systems and in relation to the level of implementation of the integrated care package of hypertension

Introduction: Primary health care (PHC) systems across the globe are struggling to produce an effective response to the rising burden of disease related to Type 2 Diabetes (T2D). However, effective T2D care at the PHC level – the ‘Integrated Care Package (ICP)’– exists and is cost-effective. Further, there is evidence that this integrated care package ((1) structure) leads to improved care processes (2), to health care responsive to people’s needs and eventually to better health outcomes (3). There is however a clear need for an assessment framework to enable countries to evaluate their progress towards integrated care for T2D.
 We aim to test an assessment framework incorporating these 3 elements: (1) a tool to assess the degree to which the T2D care provided corresponds to the ICP for T2D (structure); (2) cascades-of-care to visualize and detect the ‘leakages’ at each separate step of the care continuum (process and outcomes of T2D care); and (3) a contextualization of (1) and (2) in order to explain why the implementation of specific ICP elements has or has not led to the expected outcomes. This framework will be tested in 3 countries with different PHC approaches, namely Slovenia, Belgium and Cambodia.
 Methods: A mixed methods design is used. First, information about the level of ICP implementation is collected using the ICP Grid at the health care facility level. Secondly, patient level data is used to build de T2D cascades-of-care: we rely on representative survey data (5000 individuals) in Cambodia, on health insurance (+ laboratory) data in Belgium and routine data in Slovenia. Where feasible, we used ICP scores as explanatory variables explaining the drops in the cascade. Thirdly, expert consultations and stakeholder interviews were used to contextualize the findings.
 Results: The ICP grid scores showed considerable variations in the implementation of the ICP for patients with T2D between Belgium, Slovenia, and Cambodia – with Slovenia consistently reporting the highest scores. However, important in-country variations were observed for Belgium and Cambodia indicating that specific initiatives have resulted in higher levels of integrated care. In terms of T2D care process and outcomes, the country cascades-of-care display similar profiles with the biggest drops at the ‘diagnosis’ and ‘under control’-bars. The qualitative data on the health system clearly demonstrate that the context can hamper (1) the construction of the cascades (i.e. in Belgium and Cambodia due an absence of a routine monitoring system) and (2) the linking of the ICP grid data with the cascade-of-care data (i.e. in Cambodia where the private sector takes up a large proportion of T2D care).
 Conclusions: The developed framework offers a promising strategy to assess (1) the progress made in ICP implementation in PHC for T2D as well as (2) its impact on the T2D care process and outcomes. As such, the framework offers policy makers and stakeholders a tool to monitor T2D care and adapt specific elements where required. The study, however, also indicated severe challenges in collecting the required data which also limited the cross-country comparability of the produced outcomes.

Cross-country lessons from the SCUBY project on country-specific roadmaps for scaling up integrated care in Belgium, Slovenia, and Cambodia

Background: The aim of the SCUBY project was to provide evidence on the scaling up of an Integrated Care Package (ICP) for type II Diabetes (T2D) and hypertension (HT) across three distinct health systems (Cambodia, Slovenia, and Belgium) through the development and implementation of country-specific roadmaps for a national scale-up strategy. Harnessing mixed-methods research and stakeholder engagement informed the development of country-specific “living” roadmaps. Here, we aim to extract the different elements that make each country-specific roadmap, identify cross-country similarities and differences, and identify lessons learned. 
 Who is it for? The make-up of the different roadmaps, and the shared learnings in developing these roadmaps will be of interest to academic and non-academic stakeholders involved in the scale-up of complex health interventions, including integrated care. 
 Who did you involve and engage with? Stakeholder mapping and engagement included beneficiaries of integrated care, implementers, healthcare workers, academics, and policy makers. Extensive reflection took place between the consortium members driving the SCUBY roadmap work package, which included the various country-specific leads, to identify cross-country learnings. 
 What did you do? Qualitative content analysis was used to derive key roadmap elements from key SCUBY documents (n=20) including policy briefs, consortium meeting notes, interim reports, amongst others. Subsequently, the roadmap components were mapped against the ten core roadmap components as proposed by Weber et al. (2022).
 
 What results did you get? The content of the three roadmaps differed according to priority needs and position of the change team in the country. The Cambodian team recognised the need of wider coverage of the proposed ICP, and the need to improve quality of the current implementation. The roadmap comprised quality improvement measures, referral pathways, and strengthening monitoring systems. The Belgium roadmap comprises three themes: primary care change management coaching, development of chronic care dashboards, and monitoring change in financing structures. The Slovenian roadmap included pilot studies to generate evidence for new e-health and peer-patient components to support expanding the ICP. Common cross-country elements were: (i) task-shifting to decentralise and involve patients, carers, and their environment, (ii) strengthening monitoring and evaluation, and (iii) creating an enabling environment for ICP implementation. The implementation of many included system-wide strategies extends beyond the project scope, which make it difficult to measure impact. 
 What is the learning for the international audience? Scale-up is a complex intervention that requires engagement with multiple stakeholders and adaptation of plans to the context and new development. The roadmaps are thus living documents that require continuous engagement and reflection amongst stakeholders to identify key elements and priorities. The linkage of research teams with key implementation stakeholders and policy makers leads to change-teams that allow moving from formative phase to implementation of roadmap strategies and full scale-up in due time.
 What are the next steps? Through the SCUBY project, members of the consortium have spanned boundaries and entered dialogues that can further assist the scale-up of integrated care across the various countries. The roadmaps and their development process have provided essential learnings that can help shape these dialogues moving forward.

Perceptions of the primary health care team about the implementation of integrated care of patients with type 2 diabetes and hypertension in Slovenia: qualitative study

BackgroundIntegrated care involves good coordination, networking, and communication within health care services and externally between providers and patients or informal caregivers. It affects the quality of services, is more cost-effective, and contributes to greater satisfaction among individuals and providers of integrated care. In our study, we examined the implementation and understanding of integrated care from the perspective of providers - the health care team - and gained insights into the current situation.MethodsEight focus groups were conducted with health care teams, involving a total of 48 health care professionals, including family physicians, registered nurses, practice nurses, community nurses, and registered nurses working in a health education center. Prior to conducting the focus groups, a thematic guide was developed based on the literature and contextual knowledge with the main themes of the integrated care package. The analysis was conducted using the NVivo program.ResultsWe identified 12 main themes with 49 subthemes. Health care professionals highlighted good accessibility and the method of diagnostic screening integrated with preventive examinations as positive aspects of the current system of integrated care in Slovenia. They mentioned the good cooperation within the team, with the involvement of registered nurses and community nurses being a particular advantage. Complaints were made about the high workload and the lack of workforce. They feel that patients do not take the disease seriously enough and that patients as teachers could be useful.ConclusionPrimary care teams described the importance of implementing integrated care for diabetes and hypertension patients at four levels: Patient, community, care providers, and state. Primary care teams also recognized the importance of including more professionals from different health care settings on their team.

Using Structural Equation Modelling in Routine Clinical Data on Diabetes and Depression: Observational Cohort Study.

Large data sets comprising routine clinical data are becoming increasingly available for use in health research. These data sets contain many clinical variables that might not lend themselves to use in research. Structural equation modelling (SEM) is a statistical technique that might allow for the creation of "research-friendly" clinical constructs from these routine clinical variables and therefore could be an appropriate analytic method to apply more widely to routine clinical data. SEM was applied to a large data set of routine clinical data developed in East London to model well-established clinical associations. Depression is common among patients with type 2 diabetes, and is associated with poor diabetic control, increased diabetic complications, increased health service utilization, and increased health care costs. Evidence from trial data suggests that integrating psychological treatment into diabetes care can improve health status and reduce costs. Attempting to model these known associations using SEM will test the utility of this technique in routine clinical data sets. Data were cleaned extensively prior to analysis. SEM was used to investigate associations between depression, diabetic control, diabetic care, mental health treatment, and Accident & Emergency (A&E) use in patients with type 2 diabetes. The creation of the latent variables and the direction of association between latent variables in the model was based upon established clinical knowledge. The results provided partial support for the application of SEM to routine clinical data. Overall, 19% (3106/16,353) of patients with type 2 diabetes had received a diagnosis of depression. In line with known clinical associations, depression was associated with worse diabetic control (β=.034, P<.001) and increased A&E use (β=.071, P<.001). However, contrary to expectation, worse diabetic control was associated with lower A&E use (β=-.055, P<.001) and receipt of mental health treatment did not impact upon diabetic control (P=.39). Receipt of diabetes care was associated with better diabetic control (β=-.072, P<.001), having depression (β=.018, P=.007), and receiving mental health treatment (β=.046, P<.001), which might suggest that comprehensive integrated care packages are being delivered in East London. Some established clinical associations were successfully modelled in a sample of patients with type 2 diabetes in a way that made clinical sense, providing partial evidence for the utility of SEM in routine clinical data. Several issues relating to data quality emerged. Data improvement would have likely enhanced the utility of SEM in this data set.

Stakeholder perspectives on an integrated package of care for lower limb disorders caused by podoconiosis, lymphatic filariasis or leprosy: A qualitative study.

Lower limb disorders including lymphoedema create a huge burden for affected persons in their physical and mental health, as well as socioeconomic and psychosocial consequences for them, their families and communities. As routine health services for the integrated management and prevention of lower limb disorders are still lacking, the 'Excellence in Disability Prevention Integrated across Neglected Tropical Diseases' (EnDPoINT) study was implemented to assess the development and delivery of an integrated package of holistic care-including physical health, mental health and psychosocial care-within routine health services for persons with lower limb disorders caused by podoconiosis, lymphatic filariasis and leprosy. This study was part of the first of three phases within EnDPoINT, involving the development of the integrated care package. Focus group discussions and key informant interviews were undertaken with 34 participants between January-February 2019 in Awi zone, Ethiopia, in order to assess the draft care package's feasibility, acceptability and appropriateness. Persons affected by lower limb disorders such as lymphoedema experience stigma, exclusion from families, communities and work as well as physical and financial hardship. Beliefs in disease causation inhibit affected persons from accessing care. Ignorance was a barrier for health care providers as well as affected persons. Training and education of affected persons, communities and caregivers is important in improving care access. It also requires time, space, materials and financial resources. Both top-down and grass roots input into service development are key, as well as collaboration across stakeholders including charities, community leaders and "expert patients". This study highlighted the need for the EnDPoINT integrated care package and provided suggestions for solutions according to its three aspects of integrated care (integration into routine care; integration of mental health and psychosocial care; and integration of care across the three diseases), thereby giving support for its feasibility, acceptability and appropriateness.

A qualitative study on the implementation of a holistic care package for control and management of lymphoedema: experience from a pilot intervention in northern Ethiopia

BackgroundNeglected Tropical Diseases (NTDs) such as podoconiosis, lymphatic filariasis (LF) and leprosy mainly affect communities in low resource settings. These diseases are associated with physical disability due to lymphoedema as well as poor mental health and psychosocial outcomes. Integration of care across these NTDs at primary health care level, which includes mental health and psychosocial care alongside physical health care, is increasingly recommended.MethodsA holistic integrated care package was developed and piloted as part of the EnDPoINT project in Gusha district, Awi zone, Ethiopia. The intervention was conducted at the health care organization, health facility and community levels. To assess the impact of the care package in terms of acceptability, scalability, sustainability and barriers to implementation, a qualitative study was conducted in January 2020. This included four focus group discussions (29 participants) and ten key informant interviews with decision makers, health professionals, patients, and community representatives.ResultsThe integrated lymphoedema care package was found to be efficient compared to vertical programs in saving time and resources. It also resulted in improved awareness of the causes, treatment and prevention of lymphoedema, in marked improvements in the lymphoedema, and in reduced stigma and discrimination. The care package was found to be acceptable to patients, health professionals and decision makers. The barriers to integrated care were unrealistic patient expectations, inadequate dissemination across health workers, and poor transportation access. Health professionals, decision makers and patients believed the integrated lymphoedema care package to be scalable and sustainable.ConclusionThe integrated holistic care package was found to be acceptable to patients, health professionals and decision makers. We recommend its scale-up to other endemic districts.

Implementation of Integrated Primary Care for Patients with Diabetes and Hypertension: A Case from Slovenia.

Introduction:Research on models of integrated health care for hypertension and diabetes is one of the priority issues in the world. There is a lack of knowledge about how integrated care is implemented in practice. Our study assessed its implementation in six areas: identification of patients, treatment, health education, self-management support, structured collaboration and organisation of care.Methods:This was a mixed methods study based on a triangulation method using quantitative and qualitative data. It took place in different types of primary health care organisations, in one urban and two rural regions of Slovenia. The main instrument for data collection was the Integrated Care Package (ICP) Grid, assessed through four methods: 1) a document analysis (of a current health policy and available protocols; 2) observation of the infrastructure of health centres, organisation of work, patient flow, interaction of patients with health professionals; 3) interview with key informants and 4) review of medical documentation of selected patients.Results:The implementation of the integrated care in Slovenia was assessed with the overall ICP score of 3.7 points (out of 5 possible points). The element Identification was almost fully implemented, while the element Self-management support was weakly implemented.Discussion:The implementation of the integrated care of patients with diabetes and/or hypertension in Slovenian primary health care organisations achieved high levels of implementation. However, some week points were identified.Conclusion:Integrated care of the chronic patients in Slovenia is already provided at high levels, but the area of self-management support could be improved.

Patient and health provider costs of integrated HIV, diabetes and hypertension ambulatory health services in low-income settings \u2014 an empirical socio-economic cohort study in Tanzania and Uganda

BackgroundIntegration of health services might be an efficient strategy for managing multiple chronic conditions in sub-Saharan Africa, considering the scope of treatments and synergies in service delivery. Proven to promote compliance, integration may lead to increased economies-of-scale. However, evidence on the socio-economic consequences of integration for providers and patients is lacking.We assessed the clinical resource use, staff time, relative service efficiency and overall societal costs associated with integrating HIV, diabetes and hypertension services in single one-stop clinics where persons with one or more of these conditions were managed.Methods2273 participants living with HIV infection, diabetes, or hypertension or combinations of these conditions were enrolled in 10 primary health facilities in Tanzania and Uganda and followed-up for up to 12 months. We collected data on resources used from all participants and on out-of-pocket costs in a sub-sample of 1531 participants, while a facility-level costing study was conducted at each facility. Health worker time per participant was assessed in a time-motion morbidity-stratified study among 228 participants. The mean health service cost per month and out-of-pocket costs per participant visit were calculated in 2020 US$ prices. Nested bootstrapping from these samples accounted for uncertainties. A data envelopment approach was used to benchmark the efficiency of the integrated services. Last, we estimated the budgetary consequences of integration, based on prevalence-based projections until 2025, for both country populations.ResultsTheir average retention after 1 year service follow-up was 1911/2273 (84.1%). Five hundred and eighty-two of 2273 (25.6%) participants had two or all three chronic conditions and 1691/2273 (74.4%) had a single condition. During the study, 84/2239 (3.8%) participants acquired a second or third condition. The mean service costs per month of managing two conditions in a single participant were $39.11 (95% CI 33.99, 44.33), $32.18 (95% CI 30.35, 34.07) and $22.65 (95% CI 21.86, 23.43) for the combinations of HIV and diabetes and of HIV and hypertension, diabetes and hypertension, respectively. These costs were 34.4% (95% CI 17.9%, 41.9%) lower as compared to managing any two conditions separately in two different participants. The cost of managing an individual with all three conditions was 48.8% (95% CI 42.1%, 55.3%) lower as compared to managing these conditions separately.Out-of-pocket healthcare expenditure per participant per visit was $7.33 (95% CI 3.70, 15.86). This constituted 23.4% (95% CI 9.9, 54.3) of the total monthly service expenditure per patient and 11.7% (95% CI 7.3, 22.1) of their individual total household income. The integrated clinics’ mean efficiency benchmark score was 0.86 (range 0.30–1.00) suggesting undercapacity that could serve more participants without compromising quality of care. The estimated budgetary consequences of managing multi-morbidity in these types of integrated clinics is likely to increase by 21.5% (range 19.2–23.4%) in the next 5 years, including substantial savings of 21.6% on the provision of integrated care for vulnerable patients with multi-morbidities.ConclusionIntegration of HIV services with diabetes and hypertension control reduces both health service and household costs, substantially. It is likely an efficient and equitable way to address the increasing burden of financially vulnerable households among Africa’s ageing populations.Additional economic evidence is needed from longer-term larger-scale implementation studies to compare extended integrated care packages directly simultaneously with evidence on sustained clinical outcomes.

Using a theory of change to develop an integrated intervention for depression, diabetes and hypertension in Zimbabwe: lessons from the Friendship Bench project

BackgroundNon-communicable diseases (NCDs) are projected to become the leading cause of disability and mortality in sub-Saharan Africa by 2030; a vast treatment gap exists. There is a dearth of knowledge on developing evidence-based interventions that address comorbid NCDs using a task-shifting approach. The Friendship Bench, a brief psychological intervention for common mental disorders delivered by trained community grandmothers, is a promising intervention for comorbid NCDs. Although task-shifting appears to be a rational approach, evidence suggests that it may bring about tension between existing professionals from whom tasks are shifted. A Theory of Change approach is an effective way of managing the unintended tension by bringing together different stakeholders involved to build consensus on how to task shift appropriately to the parties involved. We aimed to use a theory of change approach to formulating a road map on how to successfully integrate diabetes and hypertension care into the existing Friendship Bench in order to come up with an integrated care package for depression, hypertension and diabetes aimed at strengthening NCD care in primary health care systems in Zimbabwe.MethodA theory of change workshop with 18 stakeholders from diverse backgrounds was carried out in February 2020. Participants included grandmothers working on the Friendship Bench project (n = 4), policymakers from the ministry of health (n = 2), people with lived experience for the three NCDs (n = 4), health care workers (n = 2), and traditional healers (n = 2).Findings from earlier work (situational analysis, desk review, FGDs and clinic-based surveys) on the three NCDs were shared before starting the ToC. A facilitator with previous experience running ToCs led the workshop and facilitated the co-production of the ToC map. Through an iterative process, consensus between the 18 stakeholders was reached, and a causal pathway leading to developing a framework for an intervention was formulated.ResultsThe ToC singled out the need to use expert clients (people with lived experience) to promote a patient-centred care approach that would leverage the existing Friendship Bench approach. In the face of COVID-19, the stakeholders further endorsed the use of existing digital platforms, notably WhatsApp, as an alternative way to reach out to clients and provide support. Leveraging existing community support groups as an entry point for people in need of NCD care was highlighted as a win-win by all stakeholders. A final framework for an NCD care package supported by Friendship Bench was presented to policymakers and accepted to be piloted in five geographical areas.ConclusionsThe ToC can be used to build consensus on how best to use using an existing intervention for common mental disorders to integrate care for diabetes and hypertension. There is a need to evaluate this new intervention through an adequately powered study.

Effectiveness of an Integrated Care Package for Refugee Mothers and Children: Protocol for a Cluster Randomized Controlled Trial.

BackgroundThousands of Rohingya refugee mothers at the world’s largest refugee camp located in Bangladesh are at risk of poor mental health. Accordingly, their children are also vulnerable to delayed cognitive and physical development.ObjectiveThe aim of this study is to evaluate the effectiveness of an integrated care package in reducing the prevalence of developmental delays among children aged 1 year and improving their mothers’ mental health status.MethodsThis is a parallel, two-arm, single-blind, cluster randomized controlled trial (cRCT). A total of 704 mother-child dyads residing at the Kutupalong refugee camp in Cox’s Bazar, Bangladesh, will be recruited from 22 clusters with 32 mother-child dyads per cluster. In the intervention arm, an integrated early childhood development and maternal mental health package will be delivered every quarter to mothers of newborns by trained community health workers until the child is 1 year old. Our primary outcome is a reduction in the prevalence of two or more childhood developmental delays of infants aged 1 year compared to the usual treatment. The secondary outcomes include reduced stunting among children and the prevalence of maternal depression. We will also assess the cost-effectiveness of the integrated intervention, and will further explore the intervention’s acceptability and feasibility.ResultsAt the time of submission, the study was at the stage of endpoint assessment. The data analysis started in December 2020, and the results are expected to be published after the first quarter of 2021.ConclusionsThis study will address the burden of childhood developmental delays and poor maternal mental health in a low-resource setting. If proven effective, the delivery of the intervention through community health workers will ensure the proposed intervention’s sustainability.Trial RegistrationISRCTN Registry ISRCTN10892553; https://www.isrctn.com/ISRCTN10892553International Registered Report Identifier (IRRID)DERR1-10.2196/25047

Development of an integrated, holistic care package for people with lymphoedema for use at the level of the Primary Health Care Unit in Ethiopia.

BackgroundNeglected Tropical Diseases (NTDs) are a group of several communicable and non-communicable diseases prevalent in tropical and subtropical areas. The co-endemicity of these diseases, the similarity of their clinical signs, and the need to maximize limited financial and human resources suggest the importance of adoptingan integratedapproach to their prevention and treatment.AimsThis study describes the development of a comprehensive package of physical, mental health and psychosocial care for people with lower-limb lymphoedema caused bypodoconiosis, lymphatic filariasis (LF)or leprosy as part of the EnDPoINT program in Ethiopia.MethodThe care package was developed using a mixed-methods approach, consisting of a literature review, situational analysis, Theory of Change (ToC) workshops, qualitative research, and additional workshops to fine-tune the draft care package. The care package was developed between March 2018 and January 2020 in Addis Ababa and the implementation research site, Awi zone in the North-West of Ethiopia.ResultsThe holistic care package includes components implemented at three levels of the health care system:health organization, facility, and community. Sections of the care package are directed at strengthening capacity building, program management, community engagement, awareness-raising, stigma-reduction, morbidity management, disability prevention, follow-up visits, referral linkage, community-based rehabilitation, and monitoring and evaluation.ConclusionsThe study developed a holistic integrated care package for lower limb disorder and co-morbid mental health problems caused by podoconiosis, LF or leprosy. The approach has the potential to significantly reduce lower limb disorder-associated morbidity, disability, and psychosocial problems. It also standardizes a scalable approach appropriate for the Ethiopian setting and, most likely, other countries where these NTDs are present.

Scale-up integrated care for diabetes and hypertension in Cambodia, Slovenia and Belgium (SCUBY): a study design for a quasi-experimental multiple case study

ABSTRACT Health systems worldwide struggle to manage the growing burden of type 2 diabetes and hypertension. Many patients receive suboptimal care, especially those most vulnerable. An evidence-based Integrated Care Package (ICP) with primary care-based diagnosis, treatment, education and self-management support and collaboration, leads to better health outcomes, but there is little knowledge of how to scale-up. The Scale-up integrated care for diabetes and hypertension project (SCUBY) aims to address this problem by roadmaps for scaling-up ICP in different types of health systems: a developing health system in a lower middle-income country (Cambodia); a centrally steered health system in a high-income country (Slovenia); and a publicly funded highly privatised health-care health system in a high-income country (Belgium). In a quasi-experimental multi-case design, country-specific scale-up strategies are developed, implemented and evaluated. A three-dimensional framework assesses scale-up along three axes: (1) increase in population coverage; (2) expansion of the ICP package; and (3) integration into the health system. The study includes a formative, intervention and evaluation phase. The intervention entails the development and implementation of an improved scale-up strategy through a roadmap with a minimum dataset to monitor proximal and distal outcomes. The SCUBY project is expected to result in three different roadmaps, tailored to the specific health system and country context, to progress scale-up of the ICP along three dimensions. These roadmaps can be adapted to other health systems with similar typology. Implementation is expected to increase the number of well-controlled patients with type 2 diabetes and hypertension in Cambodia, to reduce inequities in care and increase patient empowerment in Belgium and Slovenia.

Why are we hiding? A qualitative exploration of New Zealand acupuncturists views on interprofessional care

BackgroundIn recent years more health service users are utilising complementary and alternative medicine (CAM), including acupuncture, for the management of their health. Currently general practitioners (GPs), in most cases, act as the primary provider and access point for further services and also play an important role in integrated care management. However, the interaction and collaboration between GPs and acupuncturists in relation to shared care has not been investigated.This research explored interprofessional communication between GPs and acupuncturists in New Zealand. This article reports specifically the acupuncturists’ viewpoints. MethodsThis study formed part of a larger mixed methods trial investigating barriers and facilitators to communication and collaboration between acupuncturists and general practitioners in New Zealand. Semi structured interviews of 13 purposively sampled acupuncture participants were conducted and analysed using thematic analysis. ResultsThe data analysis identified both facilitators and barriers to integrative care. Facilitators included a willingness to engage, and the desire to support patient choice. Barriers included the limited opportunities for sharing of information and the lack of current established pathways for communication or direct referrals. The role evidence played in integrative practice provided complex and contrasting narratives. ConclusionsThis research contributes to the body of knowledge concerning communication and collaboration between GPs and acupuncturists, and suggests that by facilitating communication and collaboration, acupuncture can provide a significant component of integrated care packages. This research provides context within a New Zealand health care setting, and also provides insight through the disaggregation of specific provider groups for analysis, rather than a grouping together of CAM as a whole.

Feasibility of delivering integrated COPD-asthma care at primary and secondary level public healthcare facilities in Pakistan: a process evaluation.

BackgroundIn Pakistan,the estimated prevalence of chronic obstructive pulmonary disease (COPD) and asthma are 2.1% and 4.3% respectively, and existing care is grossly lacking both in coverage and quality. An integrated approach is recommended for delivering COPD and asthma care at public health facilities.AimTo understand how an integrated care package was experienced by care providers and patients, and to inform modifications prior to scaling up.Design & settingThe mixed-methods study was conducted as part of cluster randomised trials on integrated COPD and asthma care at 30 public health facilities.MethodThe care practices were assessed by analysing the clinical records of n = 451 asthma and n = 313 COPD patients. Semi-structured interviews with service providers and patients were used to understand their care experiences. A framework approach was applied to analyse and interpret qualitative data.ResultsUtilisation of public health facilities for chronic lung conditions was low, mainly because of the non-availability of inhalers. When diagnosed, around two-thirds (69%) of male and more than half (55%) of female patients had severe airway obstruction. The practice of prescribing inhalers differed between intervention and control arms. Patient non-adherence to follow-up visits remained a major treatment challenge (though attrition was lower and slower in the intervention arm). Around half of the male responders who smoked at baseline reported having quit smoking.ConclusionThe integrated care of chronic lung conditions at public health facilities is feasible and leads to improved diagnosis and treatment in a low-income country setting. The authors recommend scaling of the intervention with continued implementation research, especially on improving patient adherence to treatment.

Community care for severely frail older people: Developing explanations of how, why and for whom it works.

A Community Wellness Team was implemented in North East England in 2014, in line with national policy directives to support frail older people in the community. The service provides a comprehensive and integrated care package, which aims to reduce avoidable admissions, inappropriate service use and enable patients to stay at home. A realist design combining a review of the literature and primary data collection from service providers and patients was used to develop programme theories explaining the links between the Team interventions and expected outcomes. Five programme theories were developed, detailing: trust development and relationship building; risk minimisation in the home environment; advice on self-management; referral to preventative services; and coordination of services. The programme theories explain the role and impact of the Community Wellness Team. These programme theories are interrelated and impact one another; a hypothesised progression of programme theories indicating how the Community Wellness Team "works" is discussed. Of particular importance was the comprehensive initial assessment, which leads to the alteration of the social and physical environment within which older people live. Severely frail older people present cases that are complex socially, medically, financially and environmentally. In order to meet these needs, the Team coordinators are adopting a complex and flexible person-centred approach. This study paves the way for further research into the care networks surrounding severely frail older people living in the community, and how they can most effectively be implemented.

Effectiveness of an integrated diabetes care package at primary healthcare facilities: a cluster randomised trial in Pakistan.

BackgroundThere were an estimated 7 million people living with diabetes in Pakistan in 2014, and this is predicted to reach 11.4 million by 2030.AimTo assess if an integrated care package can achieve better control of diabetes.Design & settingThe pragmatic cluster randomised controlled trial (cRCT) was conducted from December 2014–June 2016 at 14 primary healthcare facilities in Sargodha district. Opportunistic screening, diagnostic testing, and patient recording processes were introduced in both the control 'testing, treating, and recording' (TTR) arm, and the intervention 'additional case management' (ACM) arm, which also included a clinical care guide and pictorial flipbook for lifestyle education, associated clinician training, and mobile phone follow-up.MethodClinics were randomised on a 1:1 basis (sealed envelope lottery method) and 250 patients recruited in the ACM arm and 245 in the TTR-only arm (age ≥25 years and HbA1c >7%). The primary outcome was mean change in HbA1c (%) from baseline to 9-month follow-up. Patients and staff were not blinded.ResultsThe primary outcome was available for n = 238/250 (95.2%) participants in the ACM arm and n = 219/245 (89.4%) participants in the TTR-only arm (all clusters). Cluster level mean outcome was -2.26 pp (95% confidence intervals [CI] = -2.99 to -1.53) for the ACM arm, and -1.44 pp (95% CI = -2.34 to -0.54) for the TTR-only arm. Cluster level mean ACM–TTR difference (covariate-unadjusted) was -0.82 pp (95% CI = -1.86 to 0.21; P = 0.11).ConclusionThe ACM intervention in public healthcare facilities did not show a statistically significant effect on HbA1c reduction compared to the control (TTR-only) arm. Future evaluation should assess changes after a longer follow-up period, and minimal care enhancement in the comparator (control) arm.

Remote monitoring of implantable cardiac devices: health technology assessment

Clinical follow-up of patients with cardiac implantable electronic devices is challenging because of the increasing technical complexity of devices and clinical complexity of patients. Remote monitoring (RM) offers the opportunity to optimize clinic workflow and to improve device monitoring and patient management by reducing in-hospital visits, physician and nurse time required for patient follow-up, and hospital and social costs. Continuous RM may lead to early detection of device malfunctions and clinical events, such as arrhythmias and heart failure. Early reaction may improve patient outcome. RM is easy to use and patients show a high level of acceptance and satisfaction. Implementing RM in daily practice may require changes in clinical workflow. Primary nursing-based models have demonstrated the best results. In spite of a favorable cost-benefit ratio, RM reimbursement still represents an issue in several European countries, including Italy, which limits widespread RM utilization. The fee-for-service payment approach, the global budget for device patient follow-up and/or integrated care packages for heart failure management represent the keys to introduce reimbursement and to improve patient care, while reducing healthcare costs.