Integrated Healthcare Model Research Articles

Restoring the Blessings of the Morning Star: Childbirth and Maternal-Infant Health for First Nations near Edmonton, Alberta

It is not only remote Aboriginal communities in Canada that have poorer maternal-infant health status than Canadian averages; residents of First Nation communities located close to large urban centres also experience this health status gap. Alexander, Alexis, Enoch, and Paul First Nations are located within an hour of healthcare services in greater Edmonton. The narratives of 75 predominantly Cree and Stoney women from these communities were gathered through seven talking circles and five semi-structured interviews. The participants described their experiences of loss and separation as pregnancy care and childbirth moved out of the community and into the hospital over the last two generations. This shift was not only a geographic relocation; it also disconnected the childbirth experience from elders, family and community, traditional teachings, and spiritual meaning. Conversely, the participants’ hospital experiences were characterized by a limited sense of cultural safety. Participants highlighted the urgent need to reintegrate culturally based community support and health perspectives into the childbirth experience. The implementation of such a culturally integrated healthcare model in all Aboriginal communities—remote, rural, suburban, and urban—may be the key finally to closing the gap between Aboriginal and non-Aboriginal maternal and infant health status in Canada.

Desarrollo de un indicador de la calidad de atención en Centros de Salud Familiar para la medición de la eficiencia técnica

Using indicators to evaluate the quality of primary healthcare provided by family healthcare centers plays an important role in improving the service and evaluating its performance. The objective of this work is to develop and validate an indicator for primary healthcare quality service in Chile which is also consistent with the Integrated Healthcare Model with Emphasis on the Family and the Community; it also provides a new variable to evaluate Technical Efficiency. It is developed based upon a detailed literature review, gathering of primary and secondary data, survey applications, focus groups and expert opinions. It is made of two elements: structure and process, divided into four weighted dimensions which outcome is one quality indicator. We present the results of the calculation for the designed indicator based on 259 Chilean Familiy Healthcare Centers, which is validated through four centers, obtaining values of 0.461, 0.876, 0.640, and 0.880, respectively. The CESFAM with the highest value has a better relative quality since there is no standard CESFAM to compare. It is concluded the indicator is valid, useful and consistent; the Pearson Correlation Coefficient analysis and Cronbach’s Alpha values confirm these results. Further studies require estimating the value of the indicator at national level.

Implementation of an Integrative Holistic Healthcare Model for People Living with Parkinson's Disease.

Research demonstrates that people with Parkinson's disease (PD) benefit greatly from multidisciplinary medical care. Delaware does not have a Movement Disorder Center or a movement disorder specialist. To address this issue, the University of Delaware Nurse Managed Health Center (NMHC) developed a novel PD Telehealth Clinic serving individuals with PD and their caregivers throughout Delaware. The PD clinic is based on a collaborative framework that uses synchronous videoconferencing telehealth technology to bring together out-of-state clinicians and scientists with expertise in PD to help deliver specialized care to PD patients and their caregivers. The team includes a movement disorder specialist, psychologists, nurse practitioners, researchers, physical and speech therapists, exercise physiologists, nutritionists, and graduate students. The PD Clinic delivery model seamlessly blends telehealth provider and onsite provider interactions, enabling the diagnosis, treatment, and ongoing management of PD. In the first 6 months of the Parkinson's clinic opening, the nurse practitioners along with the movement disorder specialist evaluated 36 PD patients. Several patients have received recommendations to change their medication regimen by the movement disorder specialist. About 20 patients were referred to physical therapy, 7 to speech therapy, 9 to mental health services, 1 to occupational therapy, and 12 to local support groups. The location of the NMHC-PD clinic has reduced travel time and distance by as much as 1.5 hr or 80 miles, each way, and wait time for a new patient appointment is less than 3 months. The NMHC - PD Telehealth Clinic provides access to specialized multidisciplinary and advanced care and was successfully implemented. This model can be replicated in other nurse managed health centers across the United States.

What is Shared Care Planning?

Introduction: The concept of shared care, with synergy from integrated, collaborative and coordinated care as well as case management, has attracted interest internationally. A New Zealand (NZ) pilot (2011-2012) implemented a shared care planning model to enable patientcentred care as a key element of the NZ Ministry of Health’s strategy 1) to address some of the clinical and system issues involved in caring for people with complex long-term conditions and multi-morbidity and 2) to identify a sustainable and integrated health care model for the 21st century. The pilot approach featured Information technology (IT)-facilitated information sharing and communication among all involved in a person’s care, including patients, and IT-supported shared care planning activities [1, 2]. Methods: Inspired by this NZ pilot, we reviewed literature for relevant definition and evaluation of shared care, shared decision making and care planning to provide a perspective and clarification on what a shared care planning model is, where its value might lie and what evidence supports it. Results: Key terms for defining shared care planning include shared care [3], integrated care [4, 5], shared decision making [6] and care planning [7]. Our interpretation of these components is that the *shared care planning* concept includes sharing of skills, knowledge and planning by a wider healthcare team who together undertake responsibility for a patient’s care, balanced equally with the need to share decision making, goal setting and responsibility for day-to-day health decisions with the patient and family. This implies monitoring and exchanging of patient health 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:10-1-117071– http://www.ijic.org/ data, sharing knowledge between disciplines, creating a proactive goal-centered care plan and involving patients within a care team. Systematic reviews that evaluate shared care planning outcomes have reported somewhat inconsistent findings including mixed results on cost benefit [811]. However, some projects reported potential benefits such as better care continuity and care quality. Discussion: We found no agreed definition consensus for ‘shared care planning’ or the essential elements, roles or responsibilities needed for its delivery. We believe the ideal of shared care is equally about sharing the care and responsibility with patients and their family as it is about sharing care within the interdisciplinary team. Conclusions: Combining the shared care philosophy with proven care planning processes, shared care planning is a comprehensive approach to integrated, culturally appropriate and patient-centred care through facilitating both care coordination and supported self-management. Lessons learned: The literature and NZ experience suggest that shared care planning approaches need to address various complex challenges such as shortage of workforce skills to deliver care planning, lack of time/personnel and funding models to implement shared care, IT interface challenges and mechanisms to involve patients and families. Limitations: A key limitation of this review is its lack of systematic rigour. However, we do not believe a meaningful systematic review is currently possible with few high-quality studies and the inconsistency in definitions and terminology of shared care planning interventions. Suggestions for future research: NZ research is needed, e.g., to explore barriers/ facilitators of funding models for shared care and patient role in shared decision making.

Systematic review of integrated models of health care delivered at the primary-secondary interface: how effective is it and what determines effectiveness?

Integrated multidisciplinary care is difficult to achieve between specialist clinical services and primary care practitioners, but should improve outcomes for patients with chronic and/or complex chronic physical diseases. This systematic review identifies outcomes of different models that integrate specialist and primary care practitioners, and characteristics of models that delivered favourable clinical outcomes. For quality appraisal, the Cochrane Risk of Bias tool was used. Data are presented as a narrative synthesis due to marked heterogeneity in study outcomes. Ten studies were included. Publication bias cannot be ruled out. Despite few improvements in clinical outcomes, significant improvements were reported in process outcomes regarding disease control and service delivery. No study reported negative effects compared with usual care. Economic outcomes showed modest increases in costs of integrated primary-secondary care. Six elements were identified that were common to these models of integrated primary-secondary care: (1) interdisciplinary teamwork; (2) communication/information exchange; (3) shared care guidelines or pathways; (4) training and education; (5) access and acceptability for patients; and (6) a viable funding model. Compared with usual care, integrated primary-secondary care can improve elements of disease control and service delivery at a modestly increased cost, although the impact on clinical outcomes is limited. Future trials of integrated care should incorporate design elements likely to maximise effectiveness.

Novel type of nurse-physician collaboration and medical safety

Quality of care is key to medical safety which has a close bearing on patients’life and health,and on the branding and efficiency of the hospital.Medical safety is one of the key indicators of the overall performance appraisal of the hospital.This novel type of nurse-physician collaboration,abandoning the traditional model of health care,is a new integrated model of health care which improves the overall quality of care,enhances medical safety and patient satisfaction.This paper described in detail the implementation methods and steps of the collaboration,the progress of such a collaboration and its contribution to medical safety are also discussed. Key words: Novel nurse-physician collaboration; Medical safety; Patient satisfaction

Case Study: Heartbreak and Lessons Learned

Case Study: Heartbreak and Lessons Learned

Innovative integrated health care models in Germany

Purpose: To identify successful implementation strategies for regional integrated health care models in Germany. Context: In Germany, an imminent GP workforce shortage, especially in rural areas, threatens the sustainable provision of primary care services. Initiatives to reorganise care have been launched on the regional level, as well as local support programmes to attract young GPs. A recent health care reform stipulated the right for federal states to participate in regional planning of ambulatory health care. As part of the research project “Innovative Health Care Models”, we identified strategies and success factors of regional initiatives, with a particular focus on integrated care. State of the art: Successful models were initiated by local GP networks, regional district administrators, district councils, or local mayors. Success factors included good working relationships of local health care actors and sufficient start-up financing. Transfer of strategies to other regions seemed possible. Statements for debate: 1. Are strategies initiated by regional health authorities are better able to support integration than models initiated by GPs and GP networks (top-down vs. bottom-up)? 2. How can good cooperation and personal contacts between all participants be facilitated? 3. Which incentives (financial and otherwise) are needed to support local initiatives to integrate care?

Multimorbidity and mental health: can psychiatry rise to the challenge?

Multimorbidity--the co-occurrence of two or more long-term conditions in an individual - is highly relevant to psychiatry. Changes to training and a more integrated model of psychiatric and physical healthcare are needed in the future if we are to improve the long-term health of our patients.

Systematische Literaturübersicht zur Implementierung der sektorübergreifenden Versorgung (Regionalbudget, integrierte Versorgung) in Deutschland

Cross-sectoral integrated health-care and the regional psychiatry budget are two models of cross-sectoral health care (comprising in-patient and out-patient care) in Germany. Both models of financing were created in order to overcome the so-called fragmentation in German health care. The regional psychiatry budget is a specific solution for psychiatric services whereas integrated health care models can be developed for all areas of health care. The purpose of this overview is to elucidate both the current state of implementation of these models and the results of evaluation research. Systematic literature review, additional manual search. 28 journal articles and 38 websites referring to 21 projects were identified. The projects are highly heterogenuous in terms of size, included populations and services, aims, and steering-function (concerning the different pathways of care). The projects yield innovative models of mental health care capable of competing with the co-existing traditional financing systems of in-patient and out-patient services. The future of mental health care organisation in Germany is currently open and under political discussion.

Integrated Behavioral Health

A major change is underway in health care practice. Increasing numbers of patients with psychological factors, soaring costs, and the effectiveness of behavioral health interventions is driving the shift to a more integrated model of health care. Behavioral health is becoming increasingly integrated into health care practice. The need for an integrated form of behavioral health is described as well as its theoretical basis, including the medical offset effect. Several emerging trends in psychotherapy practice are also noted as well as the implications of integrated behavioral health for mental health and family counseling practice.

Health outcomes and cost of care among older adults with schizophrenia: a 10-year study using medical records across the continuum of care.

The population of older patients with schizophrenia is increasing. This study describes health outcomes, utilization, and costs over 10 years in a sample of older patients with schizophrenia compared with older patients without schizophrenia. An observational cohort study of 31,588 older adults (mean age: 70.44 years) receiving care from an urban public health system, including a community mental health center, during 1999-2008. Of these, 1,635 (5.2%) were diagnosed with schizophrenia and 757 (2.4%) had this diagnosis confirmed in the community mental health center. Patients' electronic medical records were merged with Medicare claims, Medicaid claims, the Minimum Dataset, and the Outcome and Assessment Information Set. Information on medication use was not available. Rates of comorbid conditions, healthcare utilization, costs, and mortality. Patients with schizophrenia had significantly higher rates of congestive heart failure (45.05% versus 38.84%), chronic obstructive pulmonary disease (52.71% versus 41.41%), and hypothyroidism (36.72% versus 26.73%) than the patients without schizophrenia (p <0.001). They had significantly lower rates of cancer (30.78% versus 43.18%) and significantly higher rates of dementia (64.46% versus 32.13%). The patients with schizophrenia had significantly higher mortality risk (hazard ratio: 1.25, 95% confidence interval: 1.07-1.47) than the patients without schizophrenia. They also had significantly higher rates of healthcare utilization. The mean costs for Medicare and Medicaid were significantly higher for the patients with schizophrenia than for the patients without schizophrenia. The management of older adult patients with schizophrenia is creating a serious burden for our healthcare system, requiring the development of integrated models of healthcare.

Signifikante Reduktion von Krankenhauseinweisungen aufgrund osteoporoseassoziierter Frakturen durch intensivierte multimodale Therapie - Ergebnisse der Integrierten Versorgung Osteoporose Nordrhein

Osteoporosis is known as being undertreated in Germany. The aim of the integrated health care model "osteoporosis" was the improvement of patient care by multimodal treatment within an integrated health care network. This paper shows the results of the accompanying evaluation. A retrospective cross-sectional analysis was performed using routine data from the AOK Rheinland/Hamburg for the years 2007-2010. Patients were included if they were 50-89 years old and had a diagnosis of osteoporosis (ICD-10 M80 or M81) and at least three prescriptions of osteoporosis-specific medication. Data were analysed separately for integrated health care and regular health care. 22 040 patients were detected, thereof 3173 patients in the integrated health care group (IV). The hospitalisation rate for hip fractures was significantly lower in the IV group: 5.93/1000 patient years versus 22.96/1000 patient years (- 74 %, p < 0.05). Also the hospitalisation rate of all other osteoporosis-related fractures was reduced by 73 %: 46.92/1000 patient years versus 172.88/1000 patient years (p < 0.05). Osteoporosis-related medication costs were doubled in the IV group, while total medication costs were lower in the IV group (1438 € vs. 1702 €). This observational, cross-sectional study shows that an intensified, multimodal treatment of osteoporosis within an integrated health care network of highly qualified physicians can reduce the hospitalisation rate due to osteoporosis-associated fractures and simultaneously reduce direct costs even in the short term.

Effectiveness of an integrative health-care model for climacteric-stage women

Objectives To evaluate an integrative health-care model (IHCM) with an empowerment approach for self-care in terms of improving health-related quality of life (HR-QoL) and lifestyle.Methods We conducted a field trial with one intervention (IHCM) and one comparison group receiving usual care (UC), with ex ante and ex post measurements. The IHCM was provided for 3 months to each woman in the first group, with follow-up of both groups at 3 and 6 months. The differences in differences estimator was used to assess the effect of intervention, adjusting for clinically important covariates in the framework of a generalized linear regression model.Results A total of 380 women (IHCM 190 and UC 190) participated in the study. The differences in differences estimator between IHCM and UC for aerobic physical activity was 81 and 87 min/week at 3 and 6 months, respectively; for consumption of dairy products, fruit and vegetables the estimator was 4.8, 6.6 and 9.4 servings per week respectively at 3 months, and 3.9, 6.3 and 9.7 servings at 6 months. The effect of IHCM on HR-QoL at 3 months was greater for the domains of vasomotor, somatic symptoms and sleep problems (11.7, 10.0 and 13.2 points, respectively); at 6 months the differences of major positive change were observed in the domains of memory/concentration, vasomotor symptoms and sleep problems (12.2, 10.4 and 10.8 points, respectively).Conclusion The results support the importance of patient-centered health care during the climacteric stage, within integrative care programs with an empowerment approach.

Postpartum emotional support: a qualitative study of women’s and men’s anticipated needs and preferred sources

Australian health policy emphasises prevention, early intervention and improved pathways to treatment for perinatal mental disorders. Primary care is vital to achieving these aims. The aim of this study was to understand the anticipated needs and preferred sources of mental health information and support of men and women expecting their first baby. Nulliparous English-speaking expectant parents attending childbirth education programs in public and private hospitals participated in single sex small group discussions in late pregnancy. Discussions were audio-recorded, transcribed and analysed thematically using the group as the unit of analysis. Eight groups (22 women; 16 men) encompassing diverse socioeconomic circumstances were conducted. Analyses showed idealised fantasies consistently tempered with realistic expectations about adjustment to life with a baby. However, there were diverse and gendered views about whether primary care providers should discuss mental health with parents of infants and willingness to complete written questionnaires or be referred for specialist mental health care. Men regard primary family care as mother not father inclusive. Expectant parents readily anticipate realistic postnatal adjustment and need for emotional support. Increased provision of services that meet men's needs and public understanding and acceptance of Australian integrated models of primary postnatal mental health care are needed.

Toward healthy aging through empowering self-care during the climacteric stage

Background While they progress through the climacteric stage, women often develop physical and psychological health needs, calling for innovative health-care services that can be translated into preventive programs and empowerment towards self-care.Objective To identify the changes in women's discourse regarding their concerns and needs about the climacteric stage and self-care after they had participated in an integrative women-centered health-care model with empowerment for self-care.Methods Women's narratives during counseling group sessions were analyzed using qualitative inductive thematic analysis.Results A total of 121 women between 45 and 59 years of age participated. At the beginning of the counseling group sessions, we identified the following themes: (1) Lack of information about changes during the climacteric stage and self-care; (2) Tradition: the climacteric stage as a taboo subject; (3) Life's changes and transitions: the complexity of the climacteric experience; (4) Stigma of menopause; (5) Relationship between the traditional gender role and the lack of self-care. At the end of the counseling group sessions, the themes were: (1) The climacteric as a natural stage; (2) Expectations for old age; (3) Empowerment and the change of awareness for self-care; (3) De-medicalization of the climacteric; (4) The richness of group work; (5) Empowerment as motivation to convey acquired knowledge.Conclusion Women in the climacteric stage require more information about their physical, psychological and social needs, as well as the potential impact on their health during old age. Empowerment during the climacteric can contribute to improving the perception about this stage as well as the importance of self-care.

Integrative health care model for climacteric stage women: design of the intervention

BackgroundClimacteric stage women experience significant biological, psychological and social changes. With demographic changes being observed in the growing number of climacteric stage women in Mexico, it is important to improve their knowledge about the climacteric stage and its potential associated problems, encourage their participation in screening programs, and promote the acquisition of healthy lifestyles.At Mexican health care institutions the predominant health care model for climacteric stage women has a biomedical perspective. Medical doctors provide mostly curative services and have limited support from other health professionals. This study aims to design an integrative health care model (IHCM: bio-psycho-social, multidisciplinary and women-centered) applicable in primary care services aimed at climacteric stage women.Methods/DesignWe present the design, inclusion criteria and detailed description of an IHCM. The IHCM consists of collaborative and coordinated provision of services by a health team, which is involves a family doctor, nurse, psychologist, and the woman herself. The health team promotes the empowerment of women through individual and group counseling on the climacteric stage and health related self-care. The intervention lasts three months followed by a three-month follow-up period to evaluate the effectiveness of the model. The effectiveness of the model will be evaluated through the following aspects: health-related quality of life (HR-QoL), empowerment, self-efficacy and knowledge regarding the climacteric stage and health-related self-care activities, use of screening services, and improvement in lifestyles (regular leisure time physical activity and healthy diet).DiscussionParticipation in preventive activities should be encouraged among women in Mexico. Designing and evaluating the effectiveness of an integrative health care model for women at the climacteric stage, based on the empowerment approach and focus on health-related self-care to improve their HR-QoL is pertinent for current health conditions of this age group.Trial registrationThe study is registered at the ClinicalTrials.gov (NCT01272115).

Public's View of Mental Health Services for the Elderly: Responses to Dear Abby

Public's View of Mental Health Services for the Elderly: Responses to Dear Abby

The description and evaluation of the implementation of an integrated healthcare model.

Two studies were conducted to examine the practical implementation of an integrated health care model in five primary care clinics in the Upstate New York Veterans Affairs (VA) system. The aims of the studies were: (a) to describe the basic clinical elements of the integrated health care service offered by behavioral health providers (BHPs) in the primary care setting, and (b) to evaluate the perceptions of providers and patients regarding integrated health care practices in their primary care clinics. In Study 1, we reviewed 180 electronic medical records of patients who met with a BHP in primary care. In Study 2, we used semistructured interviews and self-report questionnaires to collect information from 46 primary care providers, 12 BHPs, and 140 patients regarding their perceptions of integrated health care in their primary care clinics. Both studies illustrate a useful method for evaluating the practical implementation of integrated health care models.

Programa de prevenção de internação para idosos na saúde suplementar: um relato de caso

RESUMO INTRODUÇÃO: Este trabalho visa a apresentar um programa de prevenção de internação hospitalar para idosos na saúde suplementar e descrever as características da população sob intervenção do mesmo. MÉTODO: o programa realiza a captação de indivíduos de risco, com idade maior ou igual a 65 anos, aplicando um questionário de risco para internação hospitalar. Indivíduos de risco são contatados por telefone e convidados a participar do programa. Idosos que recusam o programa permanecem em cuidado usual, e os que o aceitam são visitados por enfermeira, em ambiente domiciliar para uma avaliação multidimensional. De acordo com essa avaliação, idosos são distribuídos em grupos funcionais que vão determinar seu acompanhamento por equipe multidisciplinar. RESULTADOS: 627 indivíduos aceitam o programa e 392 recusam. O sexo feminino é prevalente em ambos os grupos, assim como a idade média é semelhante. A maioria é casada, 19% das mulheres vivem sós, em oposição a 9% dos homens. Percentual de analfabetos é menor do que outros estudos; 67% dos usuários do programa apresentam têm três ou mais doenças crônicas; 49,6% apresentam limitação funcional em ao menos uma atividade de vida diária, enquanto 20% apresentam dependência total. CONCLUSÃO: É marcante a dependência funcional nos idosos do programa, o que fala a favor da presença de seleção adversa na adesão ao programa. A diferença para escolaridade sugere uma representação da classe socioeconômica na saúde suplementar. Sugere-se que modelos assistenciais de atenção integral à saúde do idoso sejam desenvolvidos na saúde suplementar.