Integrated Service Delivery Research Articles

The role of the community health delivery system in the health and well-being of justice-involved women: a narrative review

BackgroundOver seven million imprisoned and jailed women are released into the community each year and many are ill-equipped to meet the challenges of re-integration. Upon release into their community, women are faced with uncertain barriers and challenges using community services to improve their health and well-being and reuniting with families. Few studies have identified and described the barriers of the community health delivery system (CHDS)- a complex set of social, justice, and healthcare organizations that provide community services aimed to improve the health and well-being (i.e. safety, health, the success of integration, and life satisfaction) of justice-involved women. We conducted a narrative review of peer-reviewed and gray literature to identify and describe the CHDS and the CHDS service delivery.ResultsPeer-reviewed and gray literature (n = 82) describing the CHDS organizations’ missions, incentives, goals, and services were coded in three domains, justice, social, and healthcare, to examine their service delivery to justice-involved women and their efforts to improve the health and well-being of justice-involved women.ConclusionsWe found that the CHDS is fragmented, identified gaps in knowledge about the CHDS that serves justice-involved women, and offer recommendations to reduce fragmentation and integrate service delivery aimed to improve the health and well-being of justice-involved women.

Delivering community-led integrated HIV and sexual and reproductive health services for sex workers: A mixed methods evaluation of the DIFFER study in Mysore, South India.

IntroductionWomen in developing countries continue to face barriers to accessing sexual and reproductive health (SRH) services, with marginalized women facing increased challenges to accessing care. The Diagonal Interventions to Fast-Forward Enhanced Reproductive Health (DIFFER) project implemented a package of interventions for female sex workers and women from the general population which integrated horizontal health services for the general population with existing vertical targeted interventions aimed at sex workers with an aim to improve SRH and HIV services. We present an outcome evaluation of the DIFFER project in terms of uptake rates for SRH services among sex workers in Mysore, India.MethodsAshodaya Samithi, a sex worker-led organization, implemented the DIFFER strategy through their community-based clinic and a Well Women Clinic (WWC), established at a partner private hospital that provided SRH services for women living with HIV. Mixed methods were used to evaluate the intervention that included a baseline (2012–13) and end of project (2015–16) cross sectional surveys (CSS), focus group discussions (FGDs), key informant interviews, and analysis of service statistics from 2013–2016.ResultsThe CSS found that condom use, STI testing, and treatment were high before, and throughout the intervention; cervical cancer screening and treatment increased significantly, from 11.5% to 56% (aOR 9.85, p<0.001) and HIV testing in the last 3 months increased from 26.3% to 73.3% (aOR 7.25, p<0.001). The proportion of sex workers using any SRH service in the past year doubled from 25.7% to 51.4% (aOR 2.91, p<0.001). Service statistics showed similar trends. The FGDs and key informant interviews showed that women and stakeholders held high levels of satisfaction with the strategy, and affirmed potential for scale up.ConclusionThe DIFFER strategy demonstrated that SRH service uptake can occur in conjuction with HIV services offered to sex workers. This model of integrated service delivery has been accepted by policy makers and needs further analysis for scaling up.

Risk assessment practices among home visiting nurses and child protection caseworkers in Colorado, United States: A qualitative investigation.

Nurses and caseworkers engage in assessments with the families they serve. Nurse home visitors from Nurse-Family Partnership (NFP) improve maternal-child health outcomes with first-time low-income mothers through care, education and support. In the United States, Child Protective Services (CPS) are state-level governmental agencies that protect children, including responding to reports of child maltreatment. This paper aimed to characterise similarities and differences in risk assessment practices between NFP nurses and CPS caseworkers in Colorado, United States. Using a grounded theory approach, we conducted in-depth qualitative interviews with 112 NFP and CPS workers from seven Colorado NFP sites from 2013 to 2015. Study sites were purposefully selected based on size, structure, geography and degree of collaboration with CPS. We conducted interviews first with NFP sites and used snowball sampling to recruit CPS workers. Interviews were recorded, transcribed, validated and then coded in NVivo 10. Memo writing was conducted to organise and link concepts within the theme of risk assessment. NFP and CPS workers emphasised the importance of risk assessment in their respective practices. Although there were similarities in the types of risks assessed, we found variations in work processes, operational definitions and methods of risk assessment between the two organisations that impacted inter-organisational collaboration to serve high-risk mothers and their children. NFP and CPS workers may have different roles and responsibilities but their underlying goals are the same - to keep children and their families safe and healthy. By understanding these similarities and differences in practice, there lies potential to improve collaboration between home visiting programmes and child welfare to provide integrated service delivery of high-risk families and prevention of future child maltreatment.

Identifying Behavioral Health Needs of Individuals Screened at the Booking Counter of Montgomery County Jail

Background: Many of the individuals who are released from incarceration are re-arrested and re-incarcerated within three years of release. Challenges that predispose individuals to re-arrest and re-incarceration include lack of education, employment opportunities, decent affordable housing, and treatment for substance use disorders (SUD) and/or mental illness. This report summarizes the behavioral health needs of newly arrested individuals in Montgomery County, Ohio.Methods: For this project, 4,809 adult individuals arrested for non-violent crimes received behavioral health screening and case management at booking in the Montgomery County Jail. Criminogenic assessment using the Risk-Needs-Responsivity (RNR) tool was conducted with 484 arrestees. Descriptive statistics and chi square statistics were calculated for gender, race, referrals made, education level, employment status, housing status, alcohol and other drug use, and mental health status.Results: As a group, the arrestees were undereducated, underemployed, and homeless. Based on RNR assessment, 67% had an SUD,and 60% required mental health treatment. Significant gender and racial differences were found among the arrestees, with womensignificantly more likely to have SUD and mental health issues.Conclusions: Individuals arrested and booked into the Montgomery County Jail experience a complex interaction among mental health, poly-substance use, medical, employment, and housing needs that must be addressed in a comprehensive and coordinated funding manner. This interactive complexity of issues demand a response from an integrated service delivery system that would best benefit the person served and the community.

At what cost is performance-based financing implemented? Novel evidence from Malawi.

Our study estimated the full economic cost of implementing performance-based financing [PBF, the Support for Service Delivery Integration Performance-Based Incentives (SSDI-PBI) programme], as a means of first introducing strategic purchasing in a low-income setting, Malawi. Our analysis distinguished design from implementation costs and traces costs across personnel and non-personnel cost categories over the 2012-15 period. The full cost of the SSDI-PBI programme amounted to USD 3402187, equivalent to USD 6.46 per targeted beneficiary. The design phase accounted for about one-third (USD 1161332) of the total costs, while the incentives (USD 1140436) represented about one-third of the total cost of the intervention and about half the cost of the implementation phase. With a cost of USD 1605178, personnel costs represented the dominant cost category. Our study indicated that the introduction of PBF entailed consumption of a substantial amount of resources, hence representing an important opportunity cost for the health system.

Implementation fidelity of a strategy to integrate service delivery: learnings from a transitional care program for individuals with complex needs in Singapore

BackgroundTo cope with rising demand for healthcare services in Singapore, Regional Health Systems (RHS) comprising of health and social care providers across care settings were set up to integrate service delivery. Tasked with providing care for the western region, in 2012, the National University Health System (NUHS) – RHS developed a transitional care program for elderly patients with complex healthcare needs who consumed high levels of hospital resources. Through needs assessment, development of personalized care plans and care coordination, the program aimed to: (i) improve quality of care, (ii) reduce hospital utilization, and (iii) reduce healthcare-related costs. In this study, recognizing the need for process evaluation in conjunction with outcome evaluation, we aim to evaluate the implementation fidelity of the NUHS-RHS transitional care program to explain the outcomes of the program and to inform further development of (similar) programs.MethodsGuided by the modified version of the Conceptual Framework for Implementation Fidelity (CFIF), adherence and moderating factors influencing implementation were assessed using non-participatory observations, reviews of medical records and program databases.ResultsMost (10 out of 14) components of the program were found to be implemented with low or moderate level of fidelity. The frequency or duration of the program components were observed to vary based on the needs of users, availability of care coordinators (CC) and their confidence. Variation in fidelity was influenced predominantly by: (1) complexity of the program, (2) extent of facilitation through guiding protocols, (3) facilitation of program implementation through CCs’ level of training and confidence, (4) evolving healthcare participant responsiveness, and (5) the context of suboptimal capability among community providers.ConclusionThis is the first study to assess the context-specific implementation process of a transitional care program in the context of Southeast Asia. It provides important insights to facilitate further development and scaling up of transitional care programs within the NUHS-RHS and beyond. Our findings highlight the need for greater focus on engaging both healthcare providers and users, training CCs to equip them with the relevant skills required for their jobs, and building the capability of the community providers to implement such programs.

Health service preferences among veterans in supported housing in relation to needs expressed and services used

Background Understanding consumer service preferences is important for recovery-oriented care. Aims To test the influence of perceived service needs on importance attached to treatment for alcohol, drug, mental health, and physical health problems and identify the influence of service needs and preferences on service use. Methods Formerly homeless dually diagnosed Veterans in supported housing were surveyed in three waves for 1 year, with measures of treatment interests, health problems, social support, clinician-assessed risk of housing loss, and sociodemographics. Multiple regression analysis was used to identify independent influences on preferences in each wave. Different health services at the VA were distinguished in administrative records and baseline predictors for services used throughout the project were identified with multiple regression analysis. Results Self-assessed problem severity was associated with the importance of treatment for alcohol, drug, mental health, and physical health problems. Social support also had some association with treatment interest for alcohol abuse, as did baseline clinician risk rating at the project’s end. Preferences, but not perceived problem severity, predicted the use of the corresponding health services. Conclusions The health beliefs model of service interests was supported, but more integrated service delivery models may be needed to strengthen the association of health needs with service use.

Complications of diabetes in China: health system and economic implications

BackgroundThe prevalence of diabetes and diabetic complications increased alarmingly which also brought heavy burden to patients and health system.MethodsWe used mix approaches to summarize evidence from published articles and policy documents on the extent and trends of diabetic complications, potential causes, and awareness and services utilization of diabetes in China.ResultsThe annual direct medical expense per patient varied among different types of complications and increased dramatically with the number of diabetic complication and patients were exposed to great financial risk. The number of health policies and strategies on diabetes and its complications at the national level is limited. Primary and secondary preventions such as health education and early diagnosis are necessary.ConclusionsWith an increasingly burden of non-communicable diseases such as diabetes and its complications, efforts should be invested in education, early screening mechanism and patient management programs to improve the primary and secondary prevention of diabetes and its complications. An integrated services delivery system centered on primary level is recommended to promote education, early case-detection and screening, patient management, referral and care-coordination between primary, secondary and tertiary health care providers.

Integrated Service Delivery and Health-Related Quality of Life of Individuals in Permanent Supportive Housing Who Were Formerly Chronically Homeless.

To investigate the impact of an integrated care model on the health-related quality of life (HRQOL) of formerly chronically homeless individuals in permanent supportive housing. From 2014 to 2017, eligible individuals in Houston, Texas (n = 323), were placed in 1 of 2 permanent supportive housing service delivery models. Both models included coordinated care teams. In the intervention group, teams had a single plan of care with the partnering clinic. The 9-item Patient Health Questionnaire and 36-item Short Form Survey were administered at baseline and every 6 months for 30 months. We assessed intervention group emergency department use at 2 years. We evaluated change by using hierarchical linear growth models. There was a significant and clinically meaningful increase in HRQOL in the intervention group, with the intervention group reporting improvement over the comparison group. Intervention group emergency department use decreased by 70% (no comparison group). Those in the intervention group with a single, coordinated plan of care reported significant and clinically meaningful increases in their HRQOL. Public Health Implications. Coordinated care models have potential to reduce societal costs and increase HRQOL, providing a financial and humanitarian justification for the continued investment in collaborative care in permanent supportive housing.

Using rapid reviews to strengthen health policy and systems and progress towards universal health coverage

### Summary box As many countries are developing policies addressing universal health coverage (UHC) and the Sustainable Development Goals, there is increasing demand for relevant and contextualised evidence to inform...

The Influences on Practice in Social Care: An Australian Study

ABSTRACTMuch of the discourse regarding social care practice focuses on the differences between the various professions, practice fields, geographical, and organizational contexts involved in the provision of social care. This study surveyed Australian social care practitioners’ (N = 438) perceptions of influence on their practice and what similarities and differences existed in these perceptions. Eighteen influential factors were identified with minimal differences across the participants’ profession, practice field, organizational sector, or geographical context. These findings suggest that a common ground of experience exists that can be used as a basis for critical discussions and interdisciplinary practice and, thereby, provide a foundation for more consistent and integrated service delivery and outcomes.

Primary Health Care System Readiness for Diabetes Mellitus and Tuberculosis Service Integration in South Africa

Background: In recognition of the convergence of high levels of Tuberculosis (TB) and increasing Diabetes Mellitus (DM) in South Africa, the country has prioritized integrated clinical service management for acute diseases and chronic conditions at the primary health care level. The shift toward collaborative activities requires changes in all areas of the health system. Objective: To assess the readiness of the primary health care system to provide integrated tuberculosis and diabetes services, this case study assessed leadership/governance, the health workforce, health information systems, access to medicines, and service delivery. Methods: The mixed-method study included interviews with health facility managers, facility checklist of TB and DM supplies and commodities, review of health records, a patient survey, and focus group discussions with health managers in three districts in KwaZulu Natal Province, Eastern Cape Province, and Free State Province. Results: Performance in bi-directional screening and co-management of TB and DM was weak: TB patients sometimes received DM screening, and the results were sometimes reported. Whether DM patients were routinely being screened for TB was unclear due to the lack of systematic reporting on DM patients. Two potential factors undermining service delivery were the overburdened health workforce and the poor health information system, particularly for DM data recording and reporting. The availability of supplies and commodities for integrated service delivery was good. Conclusion: South Africa has exhibited a strong policy-level commitment to the integrated management of chronic and acute diseases at all levels. The challenge is on operationalizing the guidelines at the primary health care level. Investments need to focus particularly on strengthening the capacity of the health workforce at the primary health care level and establishing an integrated strategy for data collection and analysis.

ФЕНОМЕН «РОЗУМНОСТІ» МІСЬКОГО РОЗВИТКУ ДУБАЇ: ІНШИЙ СВІТ ЧИ ПРИКЛАД ДЛЯ НАСЛІДУВАННЯ?

The aim of this study is to analyze the content of “smart” city concept in its close relationship with different models of urban development, with an emphasis on the practice of their implementation in Dubai, and the conclusions that are relevant to the dissemination of best practice experience in municipal management of this metropolis. Methods. The study is based on a combination of general scientific and geographical methods (descriptive, content analysis, comparative geographic method etc.) with a view to implementing a theoretical discourse on sustainable urban development that introduces smart technologies. A "case-study" approach with the characteristics of the Dubai phenomenon on the background of comparison with other countries has been used. Results. It is substantiated that balanced urban development aimed to improving the quality of life of the population and efficient use of resources through the use of new technologies and the establishment of integrated service delivery systems should be considered as a “smart” urban development. It is determined that Dubai to some extent can be an example for implementation in other cities in the world, including Ukraine, because the “smartness” in its development now means balancing between different planning models and mechanisms of urban development and their simultaneous integration. The scientific novelty of the article is to identify significant trends in the development of the city of Dubai in the context of several modern models and to define the accompanying problems and benefits that could be taken into account in other countries. Practical significance. The materials of the publication and its conclusions can be used in the organization of next research of the best world practices of the urban organization, for educational purposes in the teaching of courses in geourbanistics.

Challenging times: building a health, housing and social care local workforce strategy

Purpose The purpose of this paper is to stimulate a wider debate around the coordination of workforce planning in non-statutory services (in this case, specialist housing for older people or those with long-term health and social care needs, such as learning disabilities). The authors argue that current NHS reforms do not go far enough in that they fail to include specialist housing and its workforce in integration, and by doing so, will be unable to optimise the potential efficiencies and streamlining of service delivery to this group. Design/methodology/approach The paper used exploratory study using existing research and data, enhanced by documentary analysis from industry bodies, regulators and policy think tanks. Findings That to achieve the greatest operational and fiscal impact upon the health care services, priority must be given to improving the efficiency and coordination of services to older people and those requiring nursing homes or registered care across the public and third sectors through the integration of service delivery and workforce planning. Research limitations/implications Whilst generalisable and achievable, the model proposed within the paper cannot be fully tested theoretically and requires further testing the in real health and social care market to evidence its practicality, improved quality of care and financial benefits. Originality/value The paper highlights some potential limitations to the current NHS reforms: by integrating non-statutory services, planned efficiency savings may be optimised and service delivery improved.

Features of Intellectual Disability Information System: A Comparative Study

The aim of this paper is to review the literature related to intellectual disability information systems in the United States, England and Southern Ireland. Electronic databases were used to collate data using key terms such as intellectual disability, service providers, integrated service delivery, organizational structures and features of intellectual disability information system; exchanged data among service providers. This review of the literature presents features of intellectual disability information systems in studied developed countries. It highlights importance of applying integrated and collaborative approaches in providing services as well as exchanged information among the service providers. The study helps to identify what is needed to improve intellectual disability information systems in orderto promote appropriate and more effective service management.

Integrated models of care for diabetes and hypertension in low- and middle-income countries (LMICs)\xa0: Protocol for a systematic review

BackgroundIn low- and middle-income countries (LMICs), the burden of non-communicable diseases (NCDs) is growing against an existing burden of other diseases such as HIV/AIDS. Integrated models of care can help address the rising burden of multi-morbidity. Although integration of care can occur at various levels and has been defined in numerous ways, our aim is to assess the effects of integration of service delivery at primary healthcare level in LMICs.MethodsWe will consider randomised controlled trials (RCTs), cluster RCTs, non-randomised trials, controlled before-after studies and interrupted time series that examine integrated models of care among people with multi-morbidities, of which diabetes or hypertension is one, living in LMICs. We will compare fully integrated models of care to stand-alone care, partially integrated models of care to stand-alone care and fully integrated models to partially integrated models of care. Primary outcomes include all-cause mortality, disease-specific morbidity, HbA1c, systolic blood pressure and cholesterol levels. Secondary outcomes include access to care, retention in care, adherence, continuity of care, quality of care and cost of care. We will conduct a comprehensive search in the following databases: MEDLINE, EMBASE, the Cochrane Central Register of Control Trials, LILACS, Africa-Wide Information, CINAHL and Web of Science. In addition, we will search trial registries, relevant conference abstracts and check references lists of included studies. Selection of studies, data extraction and assessment of risk of bias will be performed independently by two review authors. We will resolve discrepancies through discussion with a third author. We will contact study authors in case of missing data. If included studies are sufficiently homogenous, we will pool results in a meta-analysis. Clinical heterogeneity related to the population, intervention, outcomes and context will be documented in table format and explored through subgroup analysis. We will assess χ2and I2 tests for statistical heterogeneity. We will use GRADE to make judgements about the certainty of evidence and present findings in a summary of findings table.DiscussionIn light of limited evidence on the provision of comprehensive care for diabetes and hypertension, and its comorbidity in LMCIs, we believe that the findings of this systematic review will provide a synthesis of evidence on effective models of integrated care for diabetes and hypertension and their comorbidities at primary healthcare level. This will enable policy-makers to device policies and programs that are evidence informed.Systematic review registrationPROSPERO CRD42018099314.

Developing a model for integrating sexual and reproductive health services with HIV prevention and care in KwaZulu-Natal, South Africa

BackgroundThere are few rigorous studies evaluating the benefits of vertical versus integrated delivery of healthcare services, and limited published studies describing conceptual models of integration at service-delivery level in public healthcare facilities. This article seeks to fill this gap, by describing the development of a district-based model for integrating sexual and reproductive health (SRH) and HIV services in KwaZulu-Natal, South Africa.MethodsBaseline data were collected from seven urban public healthcare facilities through client and provider interviews, and a facility inventory was completed to assess current service integration practices. Feedback sessions were held with health providers from participating facilities to share data collected and explore appropriate integration scenarios. A conceptual model of potential service integration was then designed, and subsequently implemented and evaluated in the research sites.ResultsKey principles of the model included a focus on health system strengthening and strong community input and involvement. The model was designed primarily to support the integration of family planning into HIV services, and included measures to improve client and commodity monitoring; capacity building through training and mentorship; and a ‘health navigation’ strategy to strengthen referrals within and between public healthcare facilities. Endline evaluation data were collected in the same facilities following implementation of the model.ConclusionsThis manuscript demonstrates the utility of the conceptual model. It shows that service integration can be accomplished in a phased manner with support of community and healthcare providers. In addition, local context must be taken into account and the components of the model should be flexible to suit the needs of the health system.

The evolving Semashko model of primary health care: the case of the Russian Federation.

This paper addresses the major developments in primary care in the Russian Federation under the evolving Semashko model. The overview of the original model and its current version indicates some positive characteristics, including the financial accessibility of care, focus on prevention, patient lists, and gatekeeping by primary-care providers. However, in practice these characteristics do not work according to expectations. The current primary-care system is inefficient and has low quality of care by international standards. The major reasons for the gap between the positive characteristics of the model and the actual developments are discussed, including the excessive specialization of primary care, weak health-workforce policy, the delay in the shift to a general practitioner model, and the dominance of the multispecialty polyclinic, which does not prove advantageous over alternative models. Government attempts to strengthen primary care cover a wide range of activities, but they are not enough to improve the system and cannot do this without more a systematic and consistent approach. The major lesson learnt is that the lack of generalists and coordination cannot be compensated for by the growing number of specialists in the staff of primary-care facilities. Big multispecialty settings (polyclinics in the Russian context) have the potential for more integrated service delivery, but to make it happen, action is needed. Simple decisions, like merging polyclinics, do not help much.

Back to the future with PACK

On 25 October 2018, the world’s governments convene again at Astana on the 40 anniversary of the Declaration of Alma-Ata. The draft Declaration for this Second International Conference on Primary...

The Financial Alignment Initiative for Low-Income Older People and Younger Adults with Disabilities: A Major Initiative to Integrate Medical Care and Long-Term Care

Introduction: Almost 12 million frail and disabled Americans depend on both Medicare and Medicaid programs for their care. Medicare is a near universal entitlement program for older people and some adults with disabilities, covering medical care, but not long-term care. In contrast, Medicaid is a means-tested welfare program largely designed by the states; Medicaid is the main source of funding for long-term care in the US. Individuals eligible for both Medicare and Medicaid must navigate two sets of rules and coverage requirements, resulting in fragmented care and poor health outcomes. This separation also leads to misaligned incentives for payers and providers, resulting in cost‐shifting, unnecessary spending, and an inefficient system of care. In July 2011, the Centers for Medicare & Medicaid Services CMS, the agency that administers both programs, launched the Medicare-Medicaid Financial Alignment Initiative FAI in which states were invited to test capitated and managed fee-for-service integrated service delivery and financing models across these programs. In 2017, fourteen state demonstrations across 13 states are being implemented. Methods: RTI International, the external independent evaluator for the FAI, designed and is currently conducting the multi-method evaluation of the state demonstrations. The evaluation research design has both qualitative and quantitative components and includes stakeholder interviews and focus groups, as well as claims data analysis. These analyses are performed to determine if each state demonstration was cost saving and to measure changes in utilization across settings, as well as to assess whether these demonstrations improved beneficiary experience, quality and access to care. Key Results: This presentation will briefly describe the state demonstrations and will focus on enrollment, care coordination, and the acute care reduction outcomes for the states where preliminary results are already available. Currently, twelve demonstrations use a capitated design and two demonstrations use a managed fee-for service MFFS design. As of June 2017, 438,780 dually eligible Medicare-Medicaid beneficiaries were enrolled in these demonstrations. In capitated model demonstrations, managed care organizations are implementing new care coordination approaches designed to integrate care across medical, LTSS, and behavioral health systems. In Washington MFFS demonstration, the care coordinating function resides within Medicaid health homes which receive monthly payments to provide extra services to enrollees. There is some evidence in the earliest demonstration states Washington, Ohio and Illinois that the FAI is helping to reduce acute and post-acute utilization. Discussion: The state demonstrations under the FAI represent largest effort in the US to integrate care, improve quality and reduce costs for dual eligibles to date. Multiple factors influenced the rate of enrollment of eligible beneficiaries in the demonstrations; in most demonstrations, passive enrollment was very important to building enrollments. Conclusions and Lessons learned: The FAI presents an important opportunity for state and federal government to integrate and streamline two financing and service delivery systems. Limitations: Significant data lags and limitations in data availability. Suggestions for future research: The evaluation is ongoing; state evaluations are released when complete data are available with final evaluation results being made public upon completion of each state demonstration and requisite data being complete.