Integrated Health Service Delivery Research Articles

Operationalizing the Consolidated Framework for Implementation Research to build and support the lived experience workforce in direct health service provision.

The involvement of people with lived experience (LEX) workers in the development, design, and delivery of integrated health services seeks to improve service user engagement and health outcomes and reduce healthcare gaps. Yet, LEX workers report feeling undervalued and having limited influence on service delivery. There is a need for systematic improvements in how LEX workforces are engaged and supported to ensure the LEX workforce can fully contribute to integrated systems of care. This study aimed to operationalize the Consolidated Framework for Implementation Research (CFIR) using a rigorous scoping review methodology and co-creation process, so it could be used by health services seeking to build and strengthen their LEX workforce. A systematic literature search of four databases was undertaken to identify peer-reviewed studies published between 2016 and 2022 providing evidence of the inclusion of LEX workers in direct health service provision. A descriptive-analytical method was used to map current evidence of LEXworkers onto the CFIR. Then, co-creation sessions with LEX workers (n = 4) and their counterparts-nonpeer workers (n = 2)-further clarified the structural policies and strategies that allow people with LEX to actively participate in the provision and enhancement of integrated health service delivery. Essential components underpinning the successful integration of LEX roles included: the capacity to engage in a co-creation process with individuals with LEX before the implementation of the role or intervention; and enhanced representation of LEX across organizational structures. The adapted CFIR for LEX workers (CFIR-LEX) that was developed as a result of this work clarifies contextual components that support the successful integration of LEX roles into the development, design,and delivery of integrated health services. Further work must be done to operationalize the framework in a local context and to better understand the ongoing application of the framework in a health setting. People with LEX were involved in the operationalization of the CFIR, including contributing their expertise to the domain adaptations that were relevant to the LEX workforce.

Potential barriers to public awareness of integrated healthcare

The aim of this abstract is to focus on aspects of the regulatory framework that could potentially hinder the implementation of integrated healthcare when seen in the context of vertical integration. Integrated healthcare has been advocated in concept for a long time. International organisations, including the World Health Organisation, are promoting initiatives such as Integrated Delivery Networks, and the European Framework for Action on Integrated Health Services Delivery, which aim to support integrative approaches and reduce fragmentation of care. Within the European Union, the integrative approach is also supported by a number of initiatives and projects. At the same time, it should be borne in mind that healthcare is a multidisciplinary system in which the pharmaceutical industry also plays an important role. Moreover, the pharmaceutical sector is a highly competitive and regulated field, which is also subject to several constraints. Among them, the European Commission in its report "Competition enforcement in the pharmaceutical sector (2009-2017)" (Brussels, 28.1.2019) had reported on breaches of competition law found by national authorities related, inter alia, to vertical agreements. Vertical integration in the pharmaceutical business is seen in many countries as a competition-threatening factor when medical institutions and laboratories become owned by the pharmaceutical industry. Consequently, it can be assumed that there is a partial conceptual reluctance in society toward the introduction of "integrated healthcare". This aspect should be taken into account when working on the motivating and inhibiting factors for the introduction of integrated healthcare. This is an example of how influencing factors can be related not only to administrative issues and the involvement of doctors and patients in the implementation of integrated healthcare, but also to the public acceptance of a particular concept when there are different contextual interpretations. Thus, a clear and coherent explanation of the concept of integrated healthcare would be supportive of policymakers and the public and would facilitate the implementation of the integrated approach.

The Integrated Care Workforce - why is nobody interested?

Introduction: The health and care workforce was under pressure long before the pandemic, not least because of the constant development of new technologies, policy reforms and dwindling ressources. In recent years, concepts like the Quadruple Aim or the WHO European Framework for Action for integrated health services delivery have helped to highlight the importance of workforce planning, education and training or role definitions for integrated care. If we want the principles of integrated care working to become engrained in the work ethic and culture of health and care, a lot more needs to happen on many levels in order to ensure that the full potential of the individual and the concept as a whole can be fulfilled. However, as the lack of response to a recent call for papers on the subject has shown, there still doesn’t seem to be much interest in the research, practice and planning to support an integrated care workforce.
 Aims and Scope of the workshop: We want to use this workshop therefore to discuss with the integrated care community, why so little is done to support the integrated care workforce. We understand the integrated care workforce to comprise of health and social care professionals, carers, volunteers, etc. but we are open to being challenged on this point. Interesting questions to explore include:
 •Why are there hardly any integrated care cases, which include continuous professional education and training programmes?
 •Why are professionals so seldomly included in research and practice design?
 •What role do patients, service users, volunteers, families, etc. play in the future workforce? Are they a part of it? How formal or informal should their role be? How can we use them more strategically in education and training at the least?
 •What support does the workforce need during the transition process from fragmented to integrated working?
 •How can professional associations become promoters of integrated care?
 •What are some of the good examples which illustrate the development of a resilient, compassionate and integrated workforce? How can digital solutions support them?
 Audience: The workshop is for professionals, policy makers, educators and teachers, managers and academics, as well as people with lived experience of health and social care (including family carers) who are committed to a healthy, integrated workforce as the basis of integrated care implementation.
 Programme:
 5 minutes introduction to the topic
 15 minutes brainstorming world café round 1
 5 minutes change over
 15 minutes world café round 2
 15 minutes plenary discussion on key messages and next steps
 5 minutes wrap-up and personal actions
 Objectives and outcomes: Th objective of this workshop is to identify the reasons, why the workforce is still not recognised as a crucial topic in theory and practice, except for headlines in the media. It will also define the most urgent research questions, and priorities for policy and practice, which should be discussed within the international network of integrated care to support a better prepared workforce for the future.

"Integration as organising principle to strengthen quality of chronic care: Scoping Review results (First part of work commissioned by the World Health Organization on specifications of quality of care for chronic conditions)"

Introduction & Who Is It For? There is a need to strengthen quality of chronic care to benefit people with chronic conditions (PwCC). Cascades of care for chronic conditions consistently show marked decline from “overall prevalence” to “good control”[1,2]. Qualitative studies demonstrate that user-related barriers redound on care quality, e.g. accessibility (geographically inaccessible, service non-availability), (non-)affordability, and affective concerns (not person-centered)[3,4]. Hence, many do not complete the “journey”: those screened do not return for confirmatory diagnosis, those diagnosed do not return for treatment; and those on treatment are not adherent. The WHO recognizes this and has proposed putting forth financing mechanisms to strengthen chronic care quality. However, there is currently no existing sound conceptualization of good quality chronic care.
 Involvement & Methodology: For a comprehensive overview of dimensions of chronic care quality, a multi-disciplinary team (PwCC, general practitioner, public health/health system/policy researcher, anthropologist, sociologist, health economist) conducted scoping review. We reviewed 48 scientific articles studying implementation of (new/established) models and/or dimensions of chronic care quality. We purposively retrieved 26 grey literature. 
 Results: We retained the Institute of Medicine’s quality aims/dimensions: effectiveness; efficiency; safety; equitability; accessibility, affordability, timeliness; and person-centredness[5]; and added continuity of care. We considered the health system determinants groups: leadership and governance; financing; resources; and service delivery[6]. 
 Learnings: Analysis indicates that acting on determinants would achieve chronic care quality dimensions. Applying integration principles[7] can organize actions. Akin to population-based integrated care models, we envision an integrated health service delivery model for PwCC, including those at risk. This model offers community-based and facility-based chronic care services responsive to population and individual needs, encompassing health promotion, and primary, secondary, tertiary prevention; addressing risks, social determinants; involving different sectors, disciplines; and with virtual integration[8] of care levels/organisations. This way, multi-sectoral strategies and chronic care services at different levels delivered by various healthcare providers are integrated to include population actions, incorporate mechanisms connecting PwCC with various resources, and assure seamless access to all care levels, including informal caregiver- and self-management. Thus, covering all steps of the “journey”. 
 At the same time, functional integration[9] would organize actions on: 
 -Leadership and governance (policies,engagement). PwCC engagement is crucial to co-formulate policies and co-design and co-implement interventions with greater likelihood for success. Multi-sectoral engagement is relevant for co-designing/co-implementing interventions on risks and determinants of chronic conditions.
 -Financing (generation/sharing, [re-]allocation), and 
 -Resources (generation/sharing/augmentation, re-distribution). 
 These integrative approaches can increase efficiency, effectiveness and person-centredness; ensure continuity; feasibly make services equitably accessible; and motivate people to complete the “journey” to prevent/control risks, augment adherence, and achieve good control.
 We previously demonstrated integration of integrated primary diabetes care with other ongoing health care activities in a lower-middle-income country, which improved diabetes care quality[10,11]. 
 Successful integration of “integrated chronic care services” to improve chronic care quality is therefore plausible. Chronic care quality dimensions can then be measured through specific indicators (structures, processes, outcomes) and corresponding financing mechanism(s) put in place. 
 Next Step: The chronic care quality indicators will be finalised through Delphi surveys with various stakeholders from the different WHO regions.

Monitoring Health Systems through a Primary Health Care Lens: Toward People-Centred Integrated Health Service Delivery

Monitoring Health Systems through a Primary Health Care Lens: Toward People-Centred Integrated Health Service Delivery

Organization of healthcare systems to confront COVID-19: a scoping reviewOrganización de los sistemas de salud para hacer frente a la COVID-19: revisión del alcance

To identify evidence in the literature on the response of managers regarding the organization of global healthcare systems to face the COVID-19 pandemic. For this scoping review, searches were performed in 11 databases accessible through the Virtual Health Library. Eleven studies, published in 2019 and 2020, were selected based on the following guiding question: "How did managers act to organize healthcare systems to face the coronavirus pandemic?". The results were organized in terms of the categories outlined in the Pan-American Health Organization's Framework for the response of Integrated Health Service Delivery Networks to COVID-19: governance; model of care; organizational and management; financial allocations. Managers in countries that invested and articulated actions in the categories of the Reference Framework, with coordination of care at the primary healthcare level, achieved better outcomes in coping with the COVID-19 pandemic. Situating the coordination of healthcare systems at the primary care level, preparing managers and ensuring the continued allocation of financial resources to healthcare are important factors to secure a satisfactory response to crises such as the covid-19 pandemic.

"Using the same hand": The complex local perceptions of integrated one health based interventions in East Africa.

BackgroundNeglected Tropical Diseases (NTDs) such as soil transmitted helminths (STH) and human rabies represent a significant burden to health in East Africa. Control and elimination remains extremely challenging, particularly in remote communities. Novel approaches, such as One Health based integrated interventions, are gaining prominence, yet there is more to be learned about the ways in which social determinants affect such programmes.MethodologyIn 2015 a mixed method qualitative study was conducted in northern Tanzania to determine community perceptions towards integrated delivery of two distinct healthcare interventions: treatment of children for STH and dog vaccination for rabies. In order to assess the effectiveness of the integrated approach, villages were randomly allocated to one of three intervention arms: i) Arm A received integrated mass drug administration (MDA) for STH and mass dog rabies vaccination (MDRV); ii) Arm B received MDA only; iii) Arm C received MDRV only.Principle findingsIntegrated interventions were looked upon favourably by communities with respondents in all arms stating that they were more likely to either get their dogs vaccinated if child deworming was delivered at the same time and vice versa. Participants appreciated integrated interventions, due to time and cost savings and increased access to essential health care. Analysis of qualitative data allowed deeper exploration of responses, revealing why people appreciated these benefits as well as constraints and barriers to participation in integrated programmes.Conclusions/significanceAn interdisciplinary One Health approach that incorporates qualitative social science can provide key insights into complex local perceptions for integrated health service delivery for STH and human rabies. This includes providing insights into how interventions can be improved while acknowledging and addressing critical issues around awareness, participation and underlying health disparities in remote pastoralist communities.

Can eHealth Support Managing an Integrated Health Service Delivery? A Case Study of an Integrated Care Program in Poland

There is a growing evidence that eHealth offers support for healthcare management, but the value of existing solutions for integrated healthcare delivery is still underestimated. The aim of this work is to explore the potential benefits for ICT-based tools for managing an integrated care program. The case study approach has been applied to map ICT-based services to assist the management of the selected coordinated care program and decision support systems (DSS) in health. The cross-case analysis followed a variables-oriented strategy of eHealth impact on seven eCCM components, assessed from the perspective of three segments of health stakeholders. The research results provide a fresh look at the range of eHealth solutions and their impact on managing integrated healthcare programs in Poland. Nevertheless, more research is needed to demonstrate the benefits of ICT-based solutions from perspectives of all health system's stakeholders.

Accountability in Integrated Health Service Delivery in The Netherlands: An Integrated Personalised Approach.

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

Integrated health service delivery during COVID-19: a scoping review of published evidence from low-income and lower-middle-income countries

BackgroundIntegrated health service delivery (IHSD) is a promising approach to improve health system resilience. However, there is a lack of evidence specific to the low/lower-middle-income country (L-LMIC) health systems on...

Galvanizing Action on Primary Health Care: Analyzing Bottlenecks and Strategies to Strengthen Community Health Systems in West and Central Africa.

The renewed commitment to primary health care (PHC) presents an opportunity to strengthen health systems in West and Central Africa (WCA). Though evidence-based cost-effective interventions that are predicted to prevent up to one-third of maternal, newborn, and child health complications and deaths with universal coverage have been identified, more than 50% of people living in rural areas or from poor families still do not have access to these interventions in resource-constrained settings. We conducted a multicountry systematic analysis of bottlenecks and proposed solutions to strengthen community health systems through a series of collaborative workshops in 22 countries in WCA. Countries were categorized by their under-5 mortality rate (U5MR) to assess specificities related to reported challenges. We also reviewed existing data on selected health system tracer interventions to analyze country profiles. The bottlenecks identified as severe or very severe were related to health financing (19 countries, 86%), essential medical technology and products (16 countries, 73%), integrated health service delivery (14 countries, 64%), and community ownership and partnerships (self-reported by 14 countries, 64%). Only the integrated service delivery was self-reported as a severe challenge by countries with high U5MR. The issue of human resources for community health was one of the least reported challenges. In WCA, strengthening community health systems as part of PHC revitalization efforts should focus on increasing health financing and innovative investments, strengthening the logistics management system, and fostering community ownership and partnerships. Countries with high U5MR should also reinforce integrated service delivery approaches through innovation. Government actions galvanized by global and regional ongoing initiatives should be sustained to ensure that no one is left behind.

Towards a values framework for integrated health services: an international Delphi study

BackgroundIn order to organize person-centered health services for a growing number of people with multiple complex health and social care needs, a shift from fragmented to integrated health services delivery has to take place. For the organization of governance in integrated health services, it is important to better understand the underlying factors that drive collaboration, decision-making and behavior between individuals and organizations. Therefore, this article focuses on these underlying normative aspects of integrated health services. This study investigates the values that underpin integrated health services delivery as a concept, by examining the extent to which an initial literature based set of underlying values underpins integrated care and the relevance of these values on the different levels of integration.MethodsAn international Delphi study with 33 experts from 13 different countries was carried out to examine the initial set of underlying values of integrated health services. In addition, the relevance of the values was assessed on the different levels of integration: personal level, professional level, management level and system level.ResultsThe study resulted in a refined set of 18 values of integrated health services developed in three Delphi study rounds. In addition, the results provided insight into the relevance of these values on the personal level (e.g. ‘trustful’), professional level (e.g. ‘collaborative’), management level (e.g. ‘efficient’) and system level (e.g. ‘comprehensive’) of integration. Some of the values score consistent across the different levels of integration while other values score inconsistent across these levels.ConclusionsThe Delphi study resulted in an international normative basis for integrated health services delivery as a concept. The values can be used as ingredients for a values framework and provide a better understanding of the normative aspects of integrated health services delivery. Future research could focus on associated behaviors in practice, the relationship between normative integration and governance, and differences between the value priorities of stakeholder groups.

Accountability in integrated health service delivery in the netherlands, an evidence based integrated care approach

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

Assessment of the Integration between Primary Health Care and Public Health in Almaty

This article presents the results of the study on assessing the degree of integration between primary health care (PHC) and public health (PH) in Almaty. The purpose of the study is to assess the degree of integration between PHC and PH in Almaty in accordance with the European framework for action on integrated health services delivery (EFFA IHSD). The relevance of the studylies in a comprehensive analysis from the position of integration between PHC and PH in Almaty. Research team: Kazakhstan School of Public Health, with the methodological support of the European Regional Office of the World Health Organization (WHO EURO), conducted a study. The EFFA IHSD of WHO has formed the basis for its development. Methodology: We conducted an analytical review and interviews with key informants. The analytical review included an analysis of the indicators characterizing the healthcare system. In the study we used the following research methods: bibliographic, analytical and interviewing. For the interviews with key informants we used the Interview protocol for key informant interviews, developed by WHO EURO in a step-by-step guide for developing profiles on health services delivery transformations. Results: We evaluated the morbidity of the population of Almaty with priority (infectious and non-infectious) socially significant diseases: diseases of the circulatory system, diabetes mellitus, tuberculosis, oncology, injuries. Evaluating the morbidity and mortality, it should be stated that the introduction of an integrated approach with the development and improvement of PHC and PH yielded improved health outcomes in Almaty. According to the existing model of integration between PHC and PH in the Republic of Kazakhstan, we have identified and conducted several interviews with key informants on initiatives. Conclusion: This study shows trends and an overall picture in the integration between PHC and PH. The results of our study showed that PHC and PH have as a series of specific and a number of overlapping functions.

Occupational Therapy Perspective on Integrated Care

Introduction Background and problem statement: The current health system is medical and diagnosis based. Doctors ask “What is the matter” The Health system and the Social system are not compatible and often not complimentary, which makes integration of care complex. How occupational therapists can contribute towards a more integrated health service delivery is not always known.1 Description of policy context and objective: Health and Social systems have different concerns and structures. Health systems focus on acute care and medical treatment, whilst the social system is more focused on life-long support. Legislation and financing of both systems are different which makes it difficult for professionals to deliver integrated services.2 The objective is to understand the additional value of occupational therapists in Integrated Primary Care.1 Targeted population: The challenges facing healthcare services include ageing populations and increasing numbers of patients with long-term conditions and multi-morbidities. These populations will benefit for a paradigm-shift from problem-oriented to goal-oriented care.3,4 Highlights innovation, impact and outcomes: To realise patient centred and integrated care Occupational Therapists can offer their expert services along the following process: Focus on what the client wants using a client centred assessment tool5,6,7 Focus on activity and participation level of functioning8 Make a good analysis of the persons’ needs, wishes and the environment7 Involve family, carers and other stakeholders9 Share knowledge and skills between professionals and other persons2,5,6,10 Comments on transferability: This activity and participation perspective of functioning is reflected in the International Classification of Functioning, Disability and Health ICF-model of the World Health Organization WHO.11 When this ICF-model is used more strategically in daily practice of health care systems, it is hypothesized that it will help to better inform and organise integrated services based on what people find important. With concepts of activity and participation the area of social systems of health care delivery entered, which is occupational therapy's perspective and its actual and possible contribution towards integrated care.1,4,12 Conclusions comprising key findings, discussion and lessons learned: When you ask patients “What Matters to you? What would you like?”, they seldom answer: • I would like more medication or operation please, or • I would like to move my arm ten degrees higher please They answer with goals based on their desired functional status and social participation.1,2,13 Examples are: • Being able to get dressed • Visiting friends, go shopping • Being outside and gardening • Getting back to work Occupational therapists can contribute to more integrated services.14,15,16 “Occupational therapy is a profession concerned with improving well-being for persons of all ages through enabling occupations to promote health and participation in society. Occupational therapists do this by supporting persons’ engagement in occupations and activities that they want, need and choose to do in everyday life. Occupational therapists explore new ways of doing things by adapting activities and physical and social environments. Occupational therapists work in partnership with those involved in the persons’ life, i.e. family and carers, teachers and employers, to achieve persons’ and communities’ desired outcomes and promote an inclusive society.”17

Healthy Living: when engaging people makes a difference. Evidences from an experiment with teenagers in Tuscany

Introduction: According to a recent definition of integrated health service that collocates people into a continuum of services throughout their entire life-course (1),the prevention of chronic diseases is especially important at an early life-stage. However, the prevalence of obesity among adolescents reveals that often, by appointing adults as advice delivers, public campaigns stumble in promoting health among young people. In contrast, the identification of populations’ and individuals’ needs and the work in partnership with them are crucial (2, 3). In this paper, we present the results of assigning a group of students, involved in a large-scale participatory survey(‘beFood’), with the responsibility of informing their peers about healthy lifestyles. Methods: A peer educational model, teenagers-driven, was used. Fifty 16/17-year-old Tuscan students were involved in this two-phases project. In the initial phase, during the mandatory training course, students were: informed about healthy lifestyle with a collaborative approach; trained about possible ways to communicate healthy conducts; and directly involved in research co-production, which included the validation of a questionnaire thought to investigate youth lifestyles, and in the development of a webAPP by means of which they personally conducted the survey. In the second phase, they had the responsibility of informing their peers on healthy behaviours, delivering the questionnaire. Results: The initiative proved to be fruitful in two respects: a large number of responses (n=5029) was gathered in a peer-to-peer approach and, more importantly, the process of education, activation and engagement of the adolescents produced fertile terrain for their empowerment and evolution into trained 'testimonials and instructors'. The students improved their behaviours (54% eating; 48% physical activity). In playing the role of ‘influencers’ (40% high or very high influence), a large part of them took the initiative to advice people about healthier lifestyles (26% about nutrition; 22% about physical activity). Conclusions: The fifty students acted as powerful testimonials and ‘change agents’. This experience demonstrated that, if adequately supported and engaged, message recipients can modify their lifestyle-related behaviours and become effective producers and providers of health-related information to their peers. Lessons learned: An effective strategy of health promotion and prevention should be based on a direct involvement, activation and empowerment of individuals, as active partners in the design, planning and delivery of health-related initiatives. Healthcare professionals and providers should support (younger) people in actively undertaking learning processes that may lead to the responsibility for their health, to the adoption of healthy behaviours and to the sponsorship of these latter. The delivery of health promotion services should be integrated and centred on people, by introducing inter-sectoral actions and partnerships with individuals.

Determinants of ambulatory care sensitive conditions hospitalizations – the patients’ perspective

Introduction: Ambulatory care sensitive conditions ACSC are health conditions for which hospitalization or emergency care can potentially be avoided through effective prevention, diagnosis and treatment in the ambulatory care setting. In Portugal, ACSC represent 12% of hospitalizations and an estimated financial impact of up to 450 million€. ACSC hospitalizations ACSH have been used as an indirect indicator of access and quality of ambulatory care and have also been suggested to measure integrated health services delivery. Despite previous research on ACSH determinants few studies investigate the patients’ perspective. The aim of this study is to compare the perspectives of patients', healthcare professionals' and evidence on determinants for ACSH. Methods: Firstly a literature review was conducted to map the domains of ACSH determinants, from multiple perspectives patients, caregivers, and health professionals. Then thirteen semi-structured interviews were conducted to include information on the patients’ perspective. Six representatives of patients associations and seven experts on primary health care and internal medicine were interviewed and asked what patients identify as determinants for ACSH. Results: The literature review identified 8 domains of ACSH determinants. The most frequent domains were “Healthcare access”, “Disease self-management” and “Individual characteristics”. While in “Healthcare access” and “Disease self-management” domains the most frequent determinants highlighted “Poor coordination across levels of care” and “Therapeutic adherence” in the “Individual characteristics” domain no determinant predominated. The interviewed representatives of patients associations identified more frequently “Inadequacy of available healthcare services” for the “Healthcare access” domain, “Non-stablished therapeutic plan” for “Disease self-management” domain, and “Dietary habits” for “Lifestyle” domain. Still, professionals interviewed stated equally “Poor coordination across levels of care” and “Difficulty to consult a practitioner” for “Healthcare access”, “Incapability to self-manage disease” for “Disease self-management” domain, as well as problems with “Formal care” for “Social support” domain. Discussion: The patients’ perspective about ACSH determinants is important to understand elements that quantitative methods and healthcare professionals’ perspective cannot explain. “Healthcare access” was the most referred domain on all perspectives being “Poor coordination across levels of care” the most referred determinant, eliciting the needs for integrated healthcare delivery. Other determinants were valued differently. Patients’ representatives elicited determinants related to patients’ daily behavior influencing status of disease. As stated by other studies, healthcare professionals highlighted specific needs of complementary care that are necessary for some patients groups. The limited number of interviews is a recognized limitation. Conclusion: The determinants for ACSH identified in the literature review and interviews differed, despite “Healthcare access” items predominating among these two methods. Based on a literature review and interviews, it appears that listening to the patients’ perspective about determinants for ACSH might allow to prioritize intervention with the focus on minimizing ACSH. Future research: In the future, the most important domains of determinants of ACSH will be assessed through a patient survey to be developed. Specific sets of questions for some ACSC may be justified. Funding acknowledgment WHO European Center for Primary Health Care

Integration of mental health services into an innovative health care delivery model for children with chronic conditions

Coordinated Healthcare for Complex Kids (CHECK) is an innovative health care delivery demonstration project for children with chronic conditions and is supported by the Centers for Medicare and Medicaid Services Health Care Innovation Award Round Two. CHECK integrated behavioral health care into the model of comprehensive healthcare delivery. CHECK has provided a total of 31,470 services to 5923 children and their families. CHECK has provided 12,243 mental health screenings, 18,411 preventive interventions, 7511 consultative services, 2443 direct interventions, and 3105 referral services. A significant relationship was found between type of mental health service and disease and age. Children received different types of mental health services based on their type of chronic medical condition and age. CHECK is a promising model that has the potential to inform the development of future integrated health and behavioral health care service delivery models for children and youth with chronic medical conditions.

Cost saving with a GP-led integrated health service delivery model for complex chronic disease: an optimal Beacon practice

Health policy internationally is promoting the benefit of delivering complex chronic disease care in the community rather than the hospital setting. The Beacon model is designed as a primary-secondary integrated model of outpatient substitution whereby patients with complex diabetes receive care through a community-based practice where GPs with a special interest (GPwSI) and advanced training in diabetes work alongside an endocrinologist and diabetes nurse educator (DNE). We draw on over a decade of research to sketch a profile of an optimal Beacon clinic in terms of capacity and cost. We measured costs at five study sites: two hospitals and three Beacons and computed the Beacon clinic duration and patient load that minimises the costs of treatment. While the costs varied across sites, an optimal Beacon was found to be a lower cost alternative to usual hospital outpatient care. It costs $4,998 to deliver one optimal clinic of four hours duration with two GPwSI and one endocrinologist treating 14 patients with the DNE employed 3-days/week. This estimate is based on an urban setting in which local patient treatment needs are sufficient to support weekly/fortnightly clinics. The model holds promise as a way to cost-effectively manage complex chronic conditions, while freeing resources in hospital settings to attend to acute and inpatient services. It is delivered via a shared Commonwealth and state funding model, currently an uncommon arrangement for chronic disease management. However, proposed pooled funding arrangements at the local level designed to support better integrated care could provide leverage for the model.

Integration of health service delivery networks in Honduras: a comparative assessment of theory and practice in five networks in the countryIntegração das redes de serviços de saúde em Honduras: avaliação comparativa entre o planejamento teórico e a aplicação prática em cinco redes do país

RESUMENObjetivoEn la Región de las Américas se han realizado pocas evaluaciones de redes integradas de servicios de salud (RISS). Honduras ha avanzado en la implementación de herramientas y estrategias basadas en los atributos esenciales de las RISS. Este estudio tiene como objetivo valorar y comparar el desarrollo de RISS en su planteamiento teórico-documental y en su aplicación práctica, por tipo de gestión, en cinco redes de Honduras.MétodosEl estudio se realizó en dos etapas: 1) valoración teórico-documental, mediante la revisión y síntesis de seis documentos oficiales de RISS publicados entre 2012 y 2017, y 2) valoración práctica con los equipos de coordinación de cinco redes, dos descentralizadas y tres mixtas, usando la Herramienta de Valoración de RISS de la Organización Panamericana de la Salud.ResultadosLa valoración teórica global alcanzó 55 puntos de desarrollo comparada con la valoración práctica de las cinco redes, que alcanzó 42,8. Según el análisis por ámbitos, el Modelo asistencial obtuvo mejores resultados en ambas valoraciones, mayor en la valoración teórica (62,5). Gobernanza y estrategia fue el ámbito que recibió la valoración más baja (41,7). Entre la valoración teórica y la práctica las diferencias en el análisis de ámbitos y de atributos fueron estadísticamente significativas (p = 0,007 y p < 0,001, respectivamente). Las redes con gestión descentralizada alcanzaron mejores valoraciones que las mixtas (p = 0,017).ConclusionesExiste una brecha entre la valoración teórica y la práctica que sugiere que la aplicación de las herramientas y las estrategias definidas en los documentos son incompletas. El componente provisional sigue siendo el que genera mayor interés e importancia. En las redes mixtas se observó mayor dificultad de integración, probablemente debido a la doble gobernanza. Es necesario seguir evaluando las RISS.