Integrated Care Pilots Research Articles

Integrating primary care and social services for older adults with multimorbidity: policy implications.

Over the next 20 years, the proportion of over-65s in the UK will rise by a quarter,1 around two-thirds of whom will live with multimorbidity (multiple long-term conditions).2 This change in demographic is likely to lead to a significant growth in care needs,3 further increasing demand on primary care and social services. In response, policymakers have been trying to accelerate the drive towards integrated care4 to deliver service efficiencies, cost savings and, concomitantly, improvements in outcomes for patients and service users. To this end, a variety of integrated care pilots have been trialled.4 There have been concerns that some of these testbeds have been rolled out nationally without a strong evidence base or comprehensive evaluation, for example, ’social prescribing’ initiatives.5 This has led to uncertainty around the efficacy of integrated care initiatives, and no consensus on how best to integrate primary care and social services for older adults with multimorbidity. To address this gap in the evidence base, we carried out a mixed methods programme of research. This included a scoping review of the literature,6 and a qualitative interview study to elicit key stakeholder views on drivers and barriers to integration of primary care and social services in England. Stakeholders included patients, care service users, carers, primary and secondary care clinicians, social prescribers, community nurses, social workers, voluntary sector workers, and multiple other relevant individuals.7 We used Valentijn’s Rainbow Model of Integrated …

Sláintecare implementation status in 2020: Limited progress with entitlement expansion

The Sláintecare report developed by political consensus sets out a ten year plan for achieving Universal Health Care (UHC) in Ireland. This paper evaluates the design and progress of the report to mid 2020, but with some reflection on the new COVID 19 era, particularly as it relates to the expansion of entitlements to achieve UHC. The authors explore how close Sláintecare is to the UHC ideal. They also review the phased strategy of implementation in Sláintecare that utilises a systems-thinking approach with interlinkages between entitlements, funding, capacity and implementation. Finally the authors review the Sláintecare milestones against the reality of implementation since the publication of the report in 2017, cognisant of government policy and practice. Some of the initial assumptions around the context of Sláintecare were not realised and there has been limited progress made toward expanding entitlements, and certainly short of the original plan. Nevertheless there have been positive developments in that there is evidence that Government’s Implementation Strategy and Action Plans are focussing on reforming a complex adaptive system rather than implementing a blueprint with such initiatives as integrated care pilots and citizen engagement. The authors find that this may help the system change but it risks losing some of the essential elements of entitlement expansion in favour of organisational change.

Lessons from integrated care pilots in England

PurposeThe purpose of this paper is to provide a summary of some of the lessons about implementing different types of integrated care.Design/methodology/approachThe author used evidence from the author’s own evaluations and the findings of other researchers to identify some important lessons for policy makers and practitioners.FindingsThe author identifies eight high-level lessons which may be of interest to policy makers and practitioners working in the field.Research limitations/implicationsThe lessons outlined in the paper provide only a starting point for those designing interventions or evaluation.Practical implicationsThe changes required to implement integrated care are complex and are embedded in a complex context. Change of this type is difficult and generally takes longer to deliver than expected. The evaluation of these models often requires longer than is often available and needs to focus on the impact on the whole system rather than narrow measures, e.g. hospital utilisation.Originality/valueThis is a viewpoint paper synthesising evidence from the English pilot programmes in integrated care.

Social Prescribing: Implementation and delivery

Introduction : Social prescription is an innovative approach that aims to link patients in primary care with sources of support within the community and voluntary sector to help improve their health, wellbeing, and care experience. Social prescription provides healthcare professionals with a non-medical referral option, which can operate alongside medical treatments, to address non-clinical factors that precipitate and perpetuate ill health and often lead to frequent primary and secondary care visits. It is based on the bio-psycho-social model of health that considers physical, as well as psychological and social factors as determinants of health and wellbeing. Research on social prescription indicates that there is a potential for psychosocial benefits and health and wellbeing improvements for service users. While most attention has been paid to outcome evaluations, there is a lack of research on factors affecting the implementation process of social prescription interventions. This study aimed to explore factors facilitating and hindering the implementation and delivery of a social prescription intervention in the East of England Luton. The Luton social prescribing programme is based in primary care and involves navigators, who support and work with referred patients to identify their non-medical needs. Methods : A qualitative study was conducted including 22 semi-structured interviews with managers and policy-makers 9, GPs 3, navigators 4, and service providers in the third sector 6 involved in the Luton social prescribing programme. Thematic analysis was used to analyse the data. Results : Due to the differences in stakeholders’ experiences and views, barriers and facilitators were often two sides of the same coin e.g. good communication/ poor communication. Therefore, the identified issues are presented by theme, rather than separately for barriers and facilitators. Identified issues include the availability of resources, stakeholder involvement and engagement, information technology, organisational culture and readiness, existing infrastructures, leadership, staff turnover, support and supervision, planning, communication, and relationships between stakeholders. Discussion : This study contributes to the development of an evidence base on barriers and facilitators to the implementation and delivery of social prescribing programmes. Some of the identified barriers and facilitators seem to be similar to those of other integrated care pilots in the UK, whereas others are specific to social prescribing interventions. Thus, it is important to conduct more robust and transparent research on social prescribing, to address potential barriers to implementation. Conclusion : This study produced evidence on factors that hinder and facilitate the implementation of a social prescription programme in the East of England. Findings can contribute to the development of an evidence base for social prescription programmes in the UK, and inform practice, policy, and future research in the field.

Integrating children's services - between aspiration and reality

Integrating children's services - between aspiration and reality

PM206 Building the Evidence of New Models of CVD Care From the Integrated Care Pilots

PM206 Building the Evidence of New Models of CVD Care From the Integrated Care Pilots

Obstacles and Facilitators in Developing Integrated Team Based Home Care Services in Lithuania

Introduction. The development of innovative high quality care forms is a challenging issue in rapidly aging society of Lithuania. The new shape integrated homecare services for people with chronic conditions have been constructed and have been functioning over the year as the pilot projects in the 21 municipality around Lithuania. In almost all integrated care pilot municipalities except two regions (in Alytus and Sakiai, with primary health care units as integrated care providers) the initiative to develop team based integrated homecare services to persons with chronic conditions has been taken by departments of social services. The purpose of this study is to identify the key contextual elements and related strategic, organizational processes from pilot municipalities as facilitators and obstacles in developing mobile team based integrated homecare services as contrast to traditional institutionalised care. Theory/Methods. Pettigrew and Whipp's context, content and process model of strategic change was used as theoretical framework for the case studies of team based integrated homecare pilots. According this framework the data collection focused on three entities: what external and internal contexts instigated municipalities and service providers to take the challenge to develop the new shape integrated team based homecare services and how service providers perceive, construct and implement integrated team based homecare; and finally, what outcomes have been shaped with new form integrated care. Data were analysed from transcripts of 20 focus groups with administrators, social and health care providers and 12 in depth interviews with care receivers (informal caregivers and patients) in ten purposively sampled municipalities: pilots executed by municipality social provision departments in partnership with private and state agencies, directly by social services departments and by primary health care unit. The findings were compared with factors and dimensions of Normalisation Process Theory (May et al. 2007). Results and discussion. The study revealed the obstacles and facilitators related to individual and different organizational levels in constructing team based integrated homecare. The study 15th International Conference on Integrated Care, Edinburgh, UK, March 25-27, 2015 1 International Journal of Integrated Care – Volume 15, 27 May – URN:NBN:NL:UI:10-1-117127– http://www.ijic.org/ revealed individual level topics such as trust and collaboration building between integrated team care providers and informal caregivers, challenges in building new routines and habits for patient in homecare process, resistance and adaptation to presence of constant changing strangers’ at home. The study exposed the organizational issues related to interaction between team members and administration, tensions issues in status difference between social and health care providers, tasks distributions between team members, perception diversity of team and care, lack of teamwork experience and sense of shared responsibility, issues of staff commitment due to termed pilots. The inter-institutional and intra-institutional hindering tensions between social and health care providers unclosed the competition over the homecare field; new institution as threat to monocracy of health care; lack of skills and early transition from hierarchical to dialog based horizontal structures; inequality of resource distribution between integrated team members uncompensated travel costs for social care providers vs. car with fuel coverage for health care providers. The mentality of monolog culture with highly hierarchic structures in health care system hinders recognition of nursing as separate profession with certain competencies: avoidance by nurses to take decisions on nursing issues without consultation with physician even in areas of their professional competence supremacy as care of bedsores. The important facilitators were the support of municipality in service development and participatory involvement of the unit from the beginning of project planning. The professionally organized integrated homecare services facilitated transition to collaborative relationship between health care and social care providers. The requirement to follow literally description of project activities even the performance of planned activities contradicted the reality in practice hinders development of new service. As study limitation is the administrators gatekeepers’ role in accessing research participants: patients, informal caregivers, health and social care providers. In some municipalities the presence of head of the unit in the focus group suppressed openness of the staff. The study had insufficient data on patients’ experience of care as the integrated care pilots addressed severely ill patients with limited communication abilities. Conclusions. The study revealed micro, mezzo and macro levels obstacles and facilitators in constructing team based integrated homecare. The distinction of developed models of team based integrated homecare services participatory interaction between stakeholders of the care with the traits of patient centred approach and collaborative practices between existing social and health care structures. The move from the tradition of hierarchical model of service development ( i.e. from “above” perspective constructing orders of ministers with limited perception of reality and municipalities as executive committees with resistance performing commandments and shaping service delivery imitation) grounded the participatory practice in service development.

Integrated care experiences and outcomes in Germany, the Netherlands, and England.

Care for people with chronic conditions is an issue of increasing importance in industrialized countries. This article examines three recent efforts at care coordination that have been evaluated but not yet included in systematic reviews. The first is Germany's Gesundes Kinzigtal, a population-based approach that organizes care across all health service sectors and indications in a targeted region. The second is a program in the Netherlands that bundles payments for patients with certain chronic conditions. The third is England's integrated care pilots, which take a variety of approaches to care integration for a range of target populations. Results have been mixed. Some intermediate clinical outcomes, process indicators, and indicators of provider satisfaction improved; patient experience improved in some cases and was unchanged or worse in others. Across the English pilots, emergency hospital admissions increased compared to controls in a difference-in-difference analysis, but planned admissions declined. Using the same methods to study all three programs, we observed savings in Germany and England. However, the disease-oriented Dutch approach resulted in significantly increased costs. The Kinzigtal model, including its shared-savings incentive, may well deserve more attention both in Europe and in the United States because it combines addressing a large population and different conditions with clear but simple financial incentives for providers, the management company, and the insurer.

A year older and a year more confident

The year will see Simon Stevens take over from Sir David Nicholson in April. He will arrive loaded with unrealistic expectations about how far and how fast he can provide a stronger sense of direction and strategy, and how far he can make instant changes. He will need all the support that anyone and everyone can give him. And for his first year in the job, he will have Hunt to deal with—the odds being strong that the health secretary will still be in his post come the general election. The position of Andy Burnham as his Labour opposite number is not so certain. One suspects that Ed Miliband will have one more chunky re-shuffle of his team ahead of the 2015 general election. Depending on how central Miliband decides to make the health service, and on which bits of ground he wants to stand, Burnham may or may not be there. It will be a year in which the new organisations that litter the landscape will be one year older and, doubtless, one year more confident. And it is a year that may well start to see some interesting variation in the way services are organised. That can only be a good thing. Newcastle foundation trust has already taken over or entered into partnership with a small number of GP practices. Birmingham is discussing the same. The Competition Commission permitting, some interesting experiments in vertical integration look to be on the way. Bids for the George Eliot hospital may see the independent sector take another stake in running NHS hospitals in the wake of Circle’s contract for Hinchingbrooke. The integrated care pilots will get up and running, and they will be evaluated, providing, it is hoped (though probably not be the end of the year), clearer evidence on how far they can improve services and whether they achieve better value for money or actually release cash. Bet that they may well do the former but are unlikely to do the latter. It will, of course, also be the year that runs up towards the May 2015 election, with any election more of less guaranteed to put the NHS centre-stage at some point, even if NHS matters have never yet been known to decide the result. Wars and terrorist attacks aside, the economy, stupid, will remain the central story. In NHS terms, that means the money. Will the hard landing financially that is almost certainly on the way happen in 2014? Or will the problem somehow be managed into 2015, just after the election? We will see. BJHCM Nick Timmins, senior fellow at the Institute for Government and the King’s Fund, asks what 2014 holds following Lansley’s reforms and the run-up to the next election A year older and a year more confident

Development of a questionnaire to assess interprofessional collaboration between two different care levels

This paper reports the development and validation of a questionnaire to assess collaboration between clinical professionals from two different care levels (primary and specialised care), according to the clinicians' own perceptions. This questionnaire has been elaborated to be used as part of the monitoring and evaluation process of the integrated care pilots in the public Basque Health Service. THE PROCESS WAS CARRIED OUT IN FOUR PHASES: development of the first version of the questionnaire, validation of the content, pre-testing, and evaluation of its construct validity and homogeneity in a sample of doctors and nurses. This last phase involved confirmatory factor analysis, as well as the calculation of Cronbach's α and various correlation coefficients. The process demonstrated that the theoretical content of the questionnaire was appropriate, and also that its items were clear, relevant and intelligible. The fit indices for the confirmatory factor analysis were: χ(2) of 45.51 (p=0.089), RMSEA of 0.043, RMR of 0.046, GFI of 0.92 and CFI of 0.99. The statistics indicate a good fit between the data and a conceptual two-factor structure, in which both personal relationships between professionals and characteristics of the organisational environment are understood to underlie interprofessional collaboration. The end-product is a new instrument with good validity to assess the degree of interprofessional collaboration between clinicians working at two different levels of care.

Integrating Care in Norfolk (ICN)—A case study on a two-year programme to improve integrated working between primary care, community health services and social care in six localities

The ICN programme was designed to test ways of integrating health and social care services in six localities with a population of nearly 300,000 residents with the objective of improving patient and staff satisfaction, and reducing demands on secondary care. The ICN programme is one of 16 national integrated care pilots in England. Data were sourced from questionnaires, focus groups, interviews, and recorded service activity. A core group of practitioners in each locality focused on redesigning services according to their local circumstances in order to improve care for adults and older people with complex care needs. Local arrangements included developing multidisciplinary teams based in GP practices, with coordinators operating in a local hub. 845 patients received ICN interventions. The study showed high levels of satisfaction from patients and staff, with surveyed staff being unanimous that this way of working should continue. A study of 12 of the 32 GP practices that engaged early in the programme showed a 31% reduction in unplanned admissions to hospital between the first and second year of the pilot. Issues included the time required for building trust and communication, the importance of building a platform for integrating care locally and extending to a whole-system approach.

Barriers and facilitators to integrating care: experiences from the English Integrated Care Pilots.

In 2008, the English Department of Health appointed 16 'Integrated Care Pilots' which used a range of approaches to provide better integrated care. We report qualitative analyses from a three-year multi-method evaluation to identify barriers and facilitators to successful integration of care. Data were analysed from transcripts of 213 in-depth staff interviews, and from semi-structured questionnaires (the 'Living Document') completed by staff in pilot sites at six points over a two-year period. Emerging findings were therefore built from 'bottom up' and grounded in the data. However, we were then interested in how these findings compared and contrasted with more generic analyses. Therefore after our analyses were complete we then systematically compared and contrasted the findings with the analysis of barriers and facilitators to quality improvement identified in a systematic review by Kaplan et al. (2010) and the analysis of more micro-level shapers of behaviour found in Normalisation Process Theory (May et al. 2007). Neither of these approaches claims to be full blown theories but both claim to provide mid-range theoretical arguments which may be used to structure existing data and which can be undercut or reinforced by new data. Many barriers and facilitators to integrating care are those of any large-scale organisational change. These include issues relating to leadership, organisational culture, information technology, physician involvement, and availability of resources. However, activities which appear particularly important for delivering integrated care include personal relationships between leaders in different organisations, the scale of planned activities, governance and finance arrangements, support for staff in new roles, and organisational and staff stability. We illustrate our analyses with a 'routemap' which identifies questions that providers may wish to consider when planning interventions to improve the integration of care.

Case management for at-risk elderly patients in the English integrated care pilots: observational study of staff and patient experience and secondary care utilisation.

In 2009, the English Department of Health appointed 16 integrated care pilots which aimed to provide better integrated care. We report the quantitative results from a multi-method evaluation of six of the demonstration projects which used risk profiling tools to identify older people at risk of emergency hospital admission, combined with intensive case management for people identified as at risk. The interventions focused mainly on delivery system redesign and improved clinical information systems, two key elements of Wagner's Chronic Care Model. Questionnaires to staff and patients. Difference-in-differences analysis of secondary care utilisation using data on 3646 patients and 17,311 matched controls, and changes in overall secondary care utilisation. Most staff thought that care for their patients had improved. More patients reported having a care plan but they found it significantly harder to see a doctor or nurse of their choice and felt less involved in decisions about their care. Case management interventions were associated with a 9% increase in emergency admissions. We found some evidence of imbalance between cases and controls which could have biased this estimate, but simulations of the possible effect of unobserved confounders showed that it was very unlikely that the sites achieved their goal of reducing emergency admissions. However, we found significant reductions of 21% and 22% in elective admissions and outpatient attendance in the six months following an intervention, and overall inpatient and outpatient costs were significantly reduced by 9% during this period. Area level analyses of whole practice populations suggested that overall outpatient attendances were significantly reduced by 5% two years after the start of the case management schemes. Case management may result in improvements in some aspects of care and has the potential to reduce secondary care costs. However, to improve patient experience, case management approaches need to be introduced in a way which respects patients' wishes, for example the ability to see a familiar doctor or nurse.

Integrated care cannot be designed in Whitehall.

In recent years England has introduced a number of initiatives to promote more integrated care. Two contrasting examples are the GP-led health centres and the Integrated Care Pilots announced in the interim and final reports, respectively, of the NHS Next Stage Review in 2007-2008. The GP-led health centres were proposed as a very centralised, prescriptive approach where the aim was that all the NHS should adopt the same model of facilitating integration through co-location. Integrated Care Pilots, on the other hand, looked to the NHS to suggest their own solutions to improve integration, resulting in a variety of solutions tailored to the needs of localities. Although the results of the evaluation of the Integrated Care Pilots have been equivocal, this bottom-up approach must be the right way to foster integrated care. Long-term commitment to integrate care is needed, as well as more exploration of integration between primary care and hospitals.

Evaluation of UK Integrated Care Pilots: research protocol.

In response to concerns that the needs of the aging population for well-integrated care were increasing, the English National Health Service (NHS) appointed 16 Integrated Care Pilots following a national competition. The pilots have a range of aims including development of new organisational structures to support integration, changes in staff roles, reducing unscheduled emergency hospital admissions, reduced length of hospital stay, increasing patient satisfaction, and reducing cost. This paper describes the evaluation of the initiative which has been commissioned. A mixed methods approach has been adopted including interviews with staff and patients, non-participant observation of meetings, structured written feedback from sites, questionnaires to patients and staff, and analysis of routinely collected hospital utilisation data for patients/service users. The qualitative analysis aims to identify the approaches taken to integration by the sites, the benefits which result, the context in which benefits have resulted, and the mechanisms by which they occur. The quantitative analysis adopts a 'difference in differences' approach comparing health care utilisation before and after the intervention with risk-matched controls. The qualitative data analysis adopts a 'theory of change' approach in which we triangulate data from the quantitative analysis with qualitative data in order to describe causal effects (what happens when an independent variable changes) and causal mechanisms (what connects causes to their effects). An economic analysis will identify what incremental resources are required to make integration succeed and how they can be combined efficiently to produce better outcomes for patients. This evaluation will produce a portfolio of evidence aimed at strengthening the evidence base for integrated care, and in particular identifying the context in which interventions are likely to be effective. These data will support a series of evaluation judgements aimed at reducing uncertainties about the role of integrated care in improving the efficient and effective delivery of healthcare.

Integrated care pilot programme—UK Department of Health

Introduction: The NHS Next Stage Review set the direction for a more locally-driven NHS, with quality as its organising principle. It also highlighted the need for improved integration between health and care services, to improve access to and quality of care within local communities. This was followed, in High Quality Care for All, by a commitment to test and evaluate a range of models of integrated care that should help improve patient, carer and service user outcomes. About the ICP: The programme of integrated care pilots (ICP) has been established to address that need. It is an exciting and innovative way of exploring the benefits that greater integration could deliver for local health and well-being. ICP is designed to examine different ways in which health and social care could be provided to help drive improvements in local health and well-being. It allows communities to take a fresh look at how to deliver such care, based solely around the needs of the local population. The aim is to look beyond traditional boundaries (e.g. between primary and secondary care) to explore whether new, integrated models can improve health and care services. Each pilot will be exploring a new approach to a key health issue within the local community, and seeking to deliver improvements in quality, service user satisfaction and local health and well-being. Although the pilots have designed new models for delivering care, they must also ensure that key features of the current health systems are safeguarded, e.g. choice, competition, and the role of the Primary Care Trust (PCT) as the commissioner of local health services. The pilots will run for two years and will be evaluated over three years against a set of national and local measures. The criteria involved include impact on health outcomes, improved quality of care, service user satisfaction, and effective relationships and systems. ICP sits alongside other programmes, such as practice-based commissioning (PBC), to inspire innovation in service development and to encourage stronger partnership between clinicians and those working in local government and social care. It is an exciting opportunity to help deliver better health, better care and better value for local populations and for taxpayers. The pilot sites: Table 1 summarises information of each of the selected pilot organisations. Table 1. Selected pilot organisations Pilot name Details of pilot Bournemouth and poole teaching pCt this pilot will be exploring a new model for delivering care for older people with dementia, involving collaboration between Gps, public sector organisations and third-sector services. It aims to provide a single point of access to an integrated community team. Cambridge assura LLp this pilot will look at how different organisations across the health, social care and third sectors can better communicate and co-ordinate end-of-life care to enable people to be cared for and die in the place they choose. the pilot will also be improving public and patient engagement to ensure services are fully sensitive to user needs. Church view medical practice this pilot will improve quality of care and experience of services for the area’s population of older people. the local acute trust and Gp practice will work together as an integrated organisation, and will work in partnership with the pCt provider arm, social services and the patient practice group. the pilot will aim to provide an improved, personalised experience through active management of long-term conditions. NHS Cumbria this pilot will be exploring a new approach to helping patients with chronic diseases to manage their own care. It will be focusing on increasing the collaboration between Gp and patient. It will aim to move care into a community setting and reduce hospital admissions. Durham Dales Integrated Care Organisation this pilot will involve seven partner organisations working together to meet the needs of a rural population, provide continuity of care and reduce health inequalities. It will explore a number of different care pathways aiming to improve planning information, move care into a community setting, increase patient/carer satisfaction and reduce hospital admissions.