Integrated Care Program Research Articles

Towards a focus on the person behind the patient: Is the TARGET integrated care program feasible and acceptable for general practice?

The International Journal of Integrated Care (IJIC) is an online, open-access, peer-reviewed scientific journal that publishes original articles in the field of integrated care on a continuous basis.IJIC has an Impact Factor of 2.913 (2021 JCR, received in June 2022)The IJIC 20th Anniversary Issue was published in 2021.

Untangling the interrelatedness within integrated care programmes for community-dwelling frail older people: a rapid realist review

The International Journal of Integrated Care (IJIC) is an online, open-access, peer-reviewed scientific journal that publishes original articles in the field of integrated care on a continuous basis.IJIC has an Impact Factor of 2.913 (2021 JCR, received in June 2022)The IJIC 20th Anniversary Issue was published in 2021.

National Implementation of the Integrated Care Programme for Chronic Disease in the time of COVID

The International Journal of Integrated Care (IJIC) is an online, open-access, peer-reviewed scientific journal that publishes original articles in the field of integrated care on a continuous basis.IJIC has an Impact Factor of 2.913 (2021 JCR, received in June 2022)The IJIC 20th Anniversary Issue was published in 2021.

The covid-19 pandemic and the usability of telehealth in a midlife women's health integrated care program

BackgroundTelehealth has emerged as an alternative to conventional, face-to-face visits, and the COVID pandemic has hastened its introduction. Telephone appointments make use of an easy-to-use and accessible technology. AimTo investigate the usability of telephone-based telehealth in a women's health outpatient clinic and whether this may be affected by the severity of the COVID pandemic. MethodA telephone survey was prepared to explore two usability domains: interaction quality (4 items) and satisfaction, preference and future use (6 items). Women were selected from two periods during the COVID pandemic when the infection rates were high and low. ResultsThe survey was completed by 106 women (60 when the prevalence of COVID was high, mean age 53.58 years, and 46 when it was low, mean age 48.59 years) out of the 153 women who had a telephone appointment. The severity of the COVID pandemic showed an effect on responses. Women were less enthusiastic about using the telephone during the period of low COVID prevalence, as shown by lower scores on 3 of the 4 items of the first domain [I had enough time; I would have understood better in person; I would have expressed myself better in person (p < 0.001 for comparison between groups on each of the 3 items)], and on 4 of the 6 items in the second domain [satisfied with quality of care (p < 0.001), or with the information received (p = 0.018); use of telephone in future (p < 0.001); preference to try other technologies in future (p < 0.001)]. Overall, women expressed a preference for in-person visits regardless of COVID prevalence rates. ConclusionTelephone calls were a feasible alternative to face-to-face visits in a women's health outpatient clinic, but the pandemic pressure modified usability parameters. Respondents preferred in-person visits at any pandemic stage.

Effectiveness of an integrated care program for intensive home care services after discharge of stroke patients

The International Journal of Integrated Care (IJIC) is an online, open-access, peer-reviewed scientific journal that publishes original articles in the field of integrated care on a continuous basis.IJIC has an Impact Factor of 2.913 (2021 JCR, received in June 2022)The IJIC 20th Anniversary Issue was published in 2021.

Exploring the Role of Interprofessional Education in Ontario Hospital to Home Integrated Care Programs

The International Journal of Integrated Care (IJIC) is an online, open-access, peer-reviewed scientific journal that publishes original articles in the field of integrated care on a continuous basis.IJIC has an Impact Factor of 2.913 (2021 JCR, received in June 2022)The IJIC 20th Anniversary Issue was published in 2021.

Mediators of quality of life change in people with severe psychotic disorders treated in integrated care: ACCESS II study.

Patients with severe psychotic disorders exhibit a severely reduced quality of life (QoL) at all stages of the disease. Integrated care often led to an improvement in QoL. However, the specific mediators of QoL change are not yet well understood. The ACCESS II study is a prospective, long-term study investigating the effectiveness of an integrated care program for people with severe psychotic disorders (IC-TACT) that includes Therapeutic Assertive Community Treatment within a care network of in- and outpatient services at the University Medical Center Hamburg-Eppendorf, Germany. We examined longitudinal associations between QoL and the hypothesized mediators of change (i.e., negative symptoms, depression, and anxiety), using cross-lagged panel models. The sample includes 418 severely ill patients treated in IC-TACT for at least 1 year. QoL increased, whereas symptom severity decreased significantly from baseline to 6-month follow-up (p-values ≤ 0.001), and remained stable until 12-month follow-up. QoL and symptom severity demonstrated significant auto-correlated effects and significant cross-lagged effects from QoL at baseline to negative symptoms (6 months, β = -0.20, p < 0.001) to QoL (12 months, β = -0.19, p < 0.01) resulting in a significant indirect, mediated effect. Additionally, negative symptoms after 6 months had a significant effect on the severity of depression after 12 months (β = 0.13, p < 0.05). Negative symptoms appear to represent an important mechanism of change in IC-TACT indicating that improvement of QoL could potentially be achieved through optimized intervention on negative symptoms. Moreover, this may lead to a reduction in the severity of depression after 12 months.

Integrated Care Programme for Older Persons and Community Palliative Care Team Joint Care Model for Patients with Advanced Dementia

The International Journal of Integrated Care (IJIC) is an online, open-access, peer-reviewed scientific journal that publishes original articles in the field of integrated care on a continuous basis.IJIC has an Impact Factor of 2.913 (2021 JCR, received in June 2022)The IJIC 20th Anniversary Issue was published in 2021.

166 INAPPROPRIATE PRESCRIBING IN COMMUNITY-DWELLING OLDER ADULTS: A CROSS SECTIONAL REVIEW USING THE STOPP/START CRITERIA

Abstract Background Older adults are a heterogenous cohort of patients, often with multiple comorbidities and prescribed numerous drugs. Polypharmacy, defined as use of five or more medications, and inappropriate prescribing are risk factors for adverse outcomes. STOPP (Screening Tool of Older Persons’ Prescriptions) and START (Screening Tool to Alert to Right Treatment) are criteria that facilitate medication review in older people to aid better prescribing and health outcomes. This review aims to identify inappropriate prescribing in the community-dwelling older adult attending Integrated Care Programme for Older Persons (ICPOP). Methods We performed a cross-sectional review of patients attending the ICPOP Hub between January 2022 and May 2022. Patients’ prescriptions were obtained from pharmacies and/or General Practitioners (GP) and cross checked against the medications brought to their appointment. Patients’ past medical history was obtained from the patient, GP and hospital letters. Their prescriptions were analysed using the STOPP/START criteria. Results This study included 68 patients. The mean age was 83.5 years. Polypharmacy was present in 94%, with an average of 9.5 drugs prescribed. Common medications identified via STOPP criteria were hypnotic z-drugs in patients with falls (13.2%); loop diuretics for pedal oedema without heart failure (11.8%) and benzodiazepines for &amp;gt;4 weeks in patients with falls (10.3%). Common medications identified to commence via START criteria were vitamin D supplement in those with falls (32.4%); bone anti-resorptive therapy in those with osteoporosis (13.2%); laxatives in patients taking opiates (11.8%) and acetylcholinesterase inhibitors in those with memory impairment (8.8%). 48 participants had medications commenced with 46 having medications stopped. Only 9 patients required no change to their medication prescription. Following STOPP/START, there was an overall reduction in prescribed medications by 0.12 (p=0.494). Conclusion Applying STOPP/START criteria lead to a reduction in inappropriate medications prescribed in our multi-morbid older people cohort while identifying appropriate treatments to improve health outcomes.

11 A QUALITY IMPROVEMENT INITIATIVE TO MAXIMISE UTILISATION OF EARLY SUPPORTED DISCHARGE SERVICE IN A LEVEL 3 HOSPITAL SETTING

Abstract Background Early Supported Discharge (ESD) originated in stroke care however also applies to general medical patients. This ESD service was funded by the local Integrated Care Programme for Older Persons (ICPOP) and saw over 100 patients in its first year. A review of current ESD criteria and limitations was undertaken Methods Data was collected, by chart review, over a 2-week period on medical wards. A general townland was used as the patient's address. All patients aged over 70 were included. ESD criteria include all of: living within 30km of the hospital, not living alone, assistance of 1 with mobility or Activities of Daily Living, medically discharged. Results 91 patients aged over 70 years included 54 patients were medically discharged 27% of medically suitable patients lived outside the ESD radius 2 of 12 patients that met all ESD criteria but had been referred Conclusion From our data 54 patients met some ESD criteria but awaited assessment by the multidisciplinary team (MDT). Only 2 of 12 patients who met all criteria were referred to ESD. Education campaigns are ongoing within the hospital to increase awareness of the service. This includes a daily discharge huddle to identify potential candidates. Distance from the hospital was identified as a limiting factor. A business case is under development to support increasing this radius to allow an increased number of patients to avail of the service. ESD has been utilised successfully in urban settings. The continued success of this new service in a rural setting requires ongoing education to increase awareness of the service and development of existing criteria. Limited access to therapists in hospital reduces the effectiveness of ESD.

77 EXPERIENCES OF OLDER PEOPLE AND CARERS REFERRED TO AMBULATORY OUTREACH TEAM WITHIN INTEGRATED CARE PROGRAMME FOR OLDER PERSONS (ICPOP) SERVICE

Abstract Background Ambulatory outreach services are part of new pathways to reduce reliance on secondary care as outlined in the Integrated Care Programme for Older Persons. Multidisciplinary outreach teams provide urgent medical and rehabilitation services in the person’s home to stabilise a health crisis. Methods The study aimed to explore the experiences of older people accessing a ambulatory outreach service and identify development opportunities. Interpretive description, an inductive analytic approach, was used to seek an understanding of clinical phenomena that illuminate their characteristics, patterns and structure. Data collection used qualitative telephone interviews. A purposeful sample of older people and carers were recruited following discharge from the outreach service over a three-month period. Results Sixteen participants (patients n=9 and carers n=7) were interviewed, 77% were female with a mean age of 83 years. Three major themes and seven sub-themes were identified: Theme 1: Gratitude for specialised care: a) Moment of crisis “It was absolutely brilliant”; b) Care in my home: physical and psychological benefits Theme 2: Living with and managing complexity: c) Resilience and resignation: living in the moment “Well she’s doing good at the moment, God forbids if there is more injuries”, d) Work of patients: maintain motivation &amp; control; task and service boundaries e) Work of Families “We’re doing it so far”. Theme 3:Scope for pro-active planning &amp; Integration: f) What happens next? an unpredictable future; h) Integration with GP &amp; community, g) Unspoken plan- sub-conscious advanced care planning “Nobody makes the decision on their own they call someone else” Conclusion The Outreach Team was highly valued by participants and was seen as vital in regaining functional capability and confidence to cope. Future developments need to examine task and service boundaries that undermine resilience, post outreach follow-up, integration with primary care, and opportunities for advanced care conversations.

151 A CROSS-SECTIONAL EXPLORATION OF INTERPROFESSIONAL COLLABORATION WITHIN INTEGRATED CARE TEAMS OPERATING UNDER THE NATIONAL INTEGRATED CARE PROGRAMME FOR OLDER PERSONS

Abstract Background There is an evidence and practice gap in understanding the knowledge, skills, and behaviours required of Health Care Professionals (HCPs) for effective interprofessional collaboration in the context of integrated care for older people. Furthermore, little is known about the outcome factors that may be associated with effective interprofessional collaboration among HCPs working in integrated care teams for older people. Methods A cross-sectional representative survey of HCPs employed in the 30 integrated care teams (ICTs) operating under the National Integrated Care Programme for Older Persons was undertaken. The survey measured indicators of competence identified in a previously co-designed framework for core competencies for interprofessional collaboration within ICTs for older people. Results The study explores an association between competencies in interprofessional collaboration among HCPs employed in ICTs for older persons and factors associated with higher job satisfaction including psychological safety, trust, and work engagement. Findings elaborate on instances of service innovation which resulted from interprofessional collaboration within the team. Conclusion The study findings provide a baseline understanding of competencies for interprofessional collaboration within the ICTs operating in the NICPOP. This will support an implementation evaluation of the co-designed framework that will generate realist evidence regarding how ICTs for older people foster, enhance and sustain their proficiency in interprofessional collaboration. This realist evaluation will identify new models of interprofessional team working and explore the outcomes that are associated with interprofessional collaboration from the perspective of older people, their family carers, and HCPs who are working as part of an interprofessional team.

Commissioning [Integrated] Care in England: An Analysis of the Current Decision Context.

Background:The emergence of Integrated Care Systems (ICSs) across England poses an additional challenge and responsibility for local commissioners to accelerate the implementation of integrated care programmes and improve the overall efficiency across the system. To do this, ICS healthcare commissioners could learn from the experience of the former local commissioning structures and identify areas of improvement in the commissioning process. This study describes the investment decision process in integrated care amid the transition toward ICSs, highlights challenges, and provides recommendations to inform ICSs in their healthcare commissioning role.Methods:Twenty-six semi-structured interviews were conducted with local commissioners and other relevant stakeholders in South East England in 2021. Interviews were supplemented with literature.Results:England’s local healthcare commissioning has made the transition towards a new organisational architecture, with some integrated care programmes running, and a dual top-down and bottom-up prioritisation process in place. The commissioning and consequent development of integrated care programmes have been hindered by various barriers, including difficulties in accessing and using information, operational challenges, and resource constraints. Investment decisions have mainly been driven by national directives and budget considerations, with a mixture of subjective and objective approaches. A systematic and data-driven framework could replace this ad-hoc prioritisation of integrated care and contribute to a more rational and transparent commissioning process.Conclusion:The emerging ICSs seem to open an opportunity for local commissioners to strengthen the commissioning process of integrated care with evidence-based priority-setting approaches similar to the well-established health technology assessment framework at the national level.

Using Independent Contracting Arrangements in Integrated Care Programs for Older Adults: Implications for Clients and the Home Care Workforce in a Time of Neoliberal Restructuring.

Integrated care programs reshape the processes of health and social care delivery in the home care sector to be more continuous, cooperative, equitable, and efficient. An independent contracting model is one approach being used to overcome issues related to home care fragmentation. To better understand the implications of this model of service delivery for clients and carers, interviews were conducted in 2013 with 22 key informants. Data were analyzed using thematic analysis and interpreted using a feminist political economy framework. This study finds that independent contracting arrangements improve care continuity for clients while simultaneously reinforcing precarious working conditions for home care workers. This research calls for reform to this model of service delivery to better support home care workers as they provide the care necessary for older adults to age in place.

The forgotten dimension of integrated care: barriers to implementing integrated clinical care in English NHS hospitals.

Multimorbid patients who enter English NHS hospitals are frequently subject to care pathways designed to assess, diagnose and treat single medical conditions. Opportunities are thereby lost to offer patients more holistic, person-centred care. Hospital organisations elsewhere are known to use in-hospital, multi-specialty, integrated clinical care (ICC) to overcome this problem. This perspective piece aims to critically discuss barriers to implementing this form of ICC in the English NHS focusing on six key areas: information technologies, the primary-secondary care interface, internal hospital processes, finance, workload, professional roles and behaviours. Integrated care programmes currently underway are largely focused on macro (system) and meso (organisational) levels. A micro (clinical) level ICC, offering highly coordinated multispecialty expertise to multimorbid hospital patients could fill an important gap in the current care pathways.

16.4 The Allcove Youth Mental Health Imperative: Developing Early Intervention Mental Health Programs by and With Young People

Youth in the United States are in the midst of a devastating public mental health crisis. The headspace model from Australia was the first stand-alone, integrated care program for young people to access early mental health, physical health, and school/education support. The headspace model, and other international models that followed, were proven effective to improve young people’s mental, social, and emotional well-being. This presentation will explain the US development of allcove, an innovative integrated health system for young people aged 12 to 25 years, based on headspace, currently established in several locations in California.

The ‘Service Transformation Outline’ toolkit to assist in the design, comparison and replication of integrated care programmes

PurposeThe author is introducing a toolkit that can assist stakeholders to design, compare and replicate integrated care programmes, by making explicit their view on the transformations of care and cure services, according to a structured template. The purpose of this paper is to address this issue.Design/methodology/approachThe toolkit is made of two elements: a classification and a template. The author adopted a step-wise approach of semantic modelling to work out three layers of a classification in the domain of integration needs related to care and cure services. The third layer consists of 23 non-overlapping classes that fully cover that semantic domain. The classes are used to build a template to elicit the stakeholder's standpoint about the transformations involved in the deployment of a programme. The result is the «Outline» of the programme.FindingsSo far, in eight years the author applied the toolkit to 100+ programmes either to design, simulate or evaluate them, either to compare them to similar ones in the same or in different jurisdictions, and we refined the description of the classes according to that experience.Research limitations/implicationsThe objective of the toolkit is not to provide solutions, but to stimulate reflections on the transformations involved in a programme and their practical consequences in a precise context. In fact, the Outlines cannot be generalized: they are conceived to reflect the perspective of the stakeholders and thus are intrinsically subjective; in addition, they must be contingent, as they must depend on the local context in the particular timeframe. In case of similar initiatives in other localities, the Outlines must be filled in again by the local stakeholders; however, a subsequent comparison could help to explore similarities and motivated differences.Practical implicationsIdeally the stakeholders should use the Outline of the actual transformations in a programme as a reference to mediate between the principles and the methodologies provided by the «Models» and «Conceptual Frameworks» in the literature (e.g. Chronic Care Model, Rainbow Model, Development Model of Integrated Care Patient-Centered Medical Home and Maturity Models) and the deeper studies using the specific tools developed in their disciplines (e.g. on information modelling, process modelling, cost–benefit analysis and health technology assessment). The toolkit could have its role also in a multi-annual roadmap made of a sequence of programmes to cope with the urgent challenges on ageing, social changes and technological evolution, in synergy with regulations, budget, context maturity, critical success factors and local priorities.Originality/valueThe author argues that the approach of the structured Outline is unique, as the scoring mechanism to assess the relevance of the transformation within each class on the overall change brought by the whole programme into the health systems.

Using More Equitable Integrated Care Programs to Reduce Fragmentation in Home Care.

Integrated care programs have been developed to deliver care across providers, settings, and support systems to meet the needs of community-dwelling older adults. This research asks how these programs are being used to combat issues of fragmentation in a home care sector fundamentally reshaped by neoliberalism. Data was collected through 118 key informant interviews in five Canadian integrated care programs and interpreted using a thematic analysis informed by Feminist Political Economy. This dissertation argues that integrated care programs are most useful as a policy solution to fragmented home care when they adopt policy techniques that promote equitable processes and outcomes.

Data and care integration for post-acute intensive care program of stroke patients: effectiveness assessment using a disease-matched comparator cohort

PurposeTo assess the effectiveness of an integrated care program for post-acute care of stroke patients, the return home program (RHP program), deployed in Barcelona (North-East Spain) between 2016 and 2017 in a context of health and social care information systems integration.Design/methodology/approachThe RHP program was built around an electronic record that integrated health and social care information (with an agreement for coordinated access by all stakeholders) and an operational re-design of the care pathways, which started upon hospital admission instead of discharge. The health outcomes and resource use of the RHP program participants were compared with a population-based matched control group built from central healthcare records of routine care data.FindingsThe study included 92 stroke patients attended within the RHP program and the patients' matched controls. Patients in the intervention group received domiciliary care service, home rehabilitation, and telecare significantly earlier than the matched controls. Within the first two years after the stroke episode, recipients of the RHP program were less frequently institutionalized in a long-term care facility (5 vs 15%). The use of primary care services, non-emergency transport, and telecare services were more frequent in the RHP group.Originality/valueThe authors' analysis shows that an integrated care program can effectively promote and accelerate delivery of key domiciliary care services, reducing institutionalization of stroke patients in the mid-term. The integration of health and social care information allows not only a better coordination among professionals (thus avoiding redundant assessments) but also to monitor health and resource use outcomes of care delivery.

Psychodynamic Psychiatry in Singapore.

The authors provide an overview of the history of psychiatric services and training in Singapore, and the more recent introduction of psychodynamic psychotherapy training for psychiatric residents. They describe the current state of psychodynamic psychiatry services in the public healthcare system, including efforts at fostering psychodynamic thinking in nonpsychiatric community partners via community mental health integrated care programs and activities such as Balint Groups. They discuss current challenges in psychodynamic practice, such as the impact of language and culture on the Singaporean individual's receptiveness to psychodynamic psychotherapy, as well as systemic challenges in funding and expanding psychodynamic services. They highlight future directions, including challenges and opportunities for the local psychodynamic community in Singapore.