Integrated Service Delivery Research Articles

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.

People-centred integrated care in urban China.

In most countries, the demand for integrated care for people with chronic diseases is increasing as the population ages. This demand requires a fundamental shift of health-care systems towards more integrated service delivery models. To achieve this shift in China, the World Health Organization, the World Bank and the Chinese government proposed a tiered health-care delivery system in accordance with a people-centred integrated care model. The approach was pioneered in Luohu district of Shenzhen city from 2015 to 2017 as a template for practice. In September 2017, China’s health ministry introduced this approach to people-centred integrated care to the entire country. We describe the features of the Luohu model in relation to the core action areas and implementation strategies proposed and we summarize data from an evaluation of the first two years of the programme. We discuss the challenges faced during implementation and the lessons learnt from it for other health-care systems. We consider how to improve collaboration between institutions, how to change the population’s behaviour about using community health services as the first point of contact and how to manage resources effectively to avoid budget deficits. Finally, we outline next steps of the Luohu model and its potential application to strengthen health care in other urban health-care systems.

Quality of life after out of hospital interventional orthopaedic & regenerative medicine procedures in an integrated service delivery model

Background & Aim: Out of hospital interventional orthopaedic and regenerative medicine (IORM) procedures are a new addition to the subspecialty of interventional radiology. This study aimed to assess health outcomes following IORM procedures in an outpatient integrated service delivery model in clinical practice.Methods: Retrospective study of all patients who completed the pre- and post-procedure EuroQol 5D5L questionnaire over a 6 month period.Results: Forty-eight patients (age range=32-89, mean=60.5, median=63.5 years) were eligible. Mean and median pre-treatment EQ5D5L index values of 0.53 and 0.61(range: -0.248 to 0.879, SD: 0.28, 95% CI: [0.45, 0.61]) improved to 0.73 and 0.73 (range: 0.414-1.0; SD: 0.13, 95% CI [0.69, 0.76]) (p < 0.01, Cohen ‘d’ = 0.93) post-treatment. Improvements in ‘no problems’ in each health dimension were: pain (mathematical infinity), mobility (109%), usual activities (137.5%), self- care (56%), anxiety/depression (23.3%). Reductions in ‘any problems’ in each dimension of health were: pain (-14.5%), mobility (-32%), usual activities (-27.5%), self-care (-60.87%), anxiety/depression (-38.8%). Pre-treatment, a strong negative correlation between EQ5D5L index values versus mobility levels (r = -0.67, p < 0.01) and versus usual activities (r = -0.62, p < 0.01) was present. Post-treatment, a strong negative correlation between EQ5D5L index scores versus pain level (r = -0.68, p <0.01) and versus mobility (r = -0.75, p <0.01) was present.Conclusion: Significant improvements in all health dimensions with a large treatment effect was shown following outpatient IORM procedures in an integrated interventional radiology service delivery model. Improvements in mobility and pain were the most important determinants of health.

The Impact of Linked Administrative Data on Community Development of Integrated Mental Health Hubs: a Case Study

IntroductionIncreasingly, communities are designing and implementing contextualized approaches to integrated service delivery. Having communities in the lead is critical to successful design and implementation. However, how do researchers work with communities to ensure accurate contextual interpretations of linked administrative data?
 Objectives and ApproachPolicyWise for Children & Families has been working with communities to create a framework and assist in the implementation of integrated Community-based Mental Health Service Hubs for youth ages 11-24. The approach used to support these communities included multiple sources of data to highlight the need for youth specific mental health care, integrated service delivery and the opportunity for system transformation. This included, but wasn’t limited to, a qualitative environmental scan and individual-level linked administrative data from PolicyWise’s Child and Youth Data Lab.
 ResultsThe goal of presenting the qualitative and quantitative data summaries was to inform community-led design and implementation of the Mental Health Service Hubs. This presentation describes the constructive interplay of community context, qualitative literature and linked administrative data. Community context and the qualitative environmental scan assisted community members in interpreting the administrative data.
 Conclusion/ImplicationsThis applied project provides an example of how community members contextualize information from linked administrative data and environmental scan findings to influence program development. The implications of this is that data can reinforce or reshape what communities know about service use and impact how they proceed with planning.

"They don't like us….": Barriers to antiretroviral and opioid substitution therapy among homeless HIV positive people who inject drugs in Delhi: A mixed method study.

BackgroundProvision of Anti-Retroviral Therapy (ART) and Opioid Substitution Therapy (OST) are important components of the targeted intervention (TI) programme for people who inject drugs (PWID). Homeless HIV positive PWIDs in Delhi is a key population experiencing gaps in uptake of these services, especially the ART uptake which is reportedly far from 90%, UNAIDS’ 90-90-90 target to end the AIDS epidemic.ObjectiveTo assess the gaps and barriers in accessing the ART and OST services uptake among HIV positive homeless PWID in Delhi and to explore experiences and perspectives of the PWIDs and service providers.MethodologyWe used a convergent parallel mixed methods design which included a cross-sectional quantitative survey and a qualitative study. Two hundred thirty five homeless HIV positive PWID were interviewed and in-depth interviews were conducted with five PWIDs and nine health providers.ResultsWhile only 12% of PWIDs were on ART, 80% were availing OST services. The top individual, health system related and structural barriers for ART service access were insufficient and incorrect knowledge (63%), long waiting time (86%) and lack of family support (44%) respectively. Inconvenient timings, stringent registration requirements and negative attitude of health providers were expressed as major barriers of accessing ART services during the interviews while these were not a concern in OST services. Homelessness, poverty, stigma were common barriers for both services. Integrated, ‘single window’ service and provision of additional support like nutrition and shelter were suggested as measures to improve access by both health providers and the PWIDs themselves.ConclusionThere is an urgent need for structural and health systems changes to improve access to ART and OST services. These include integrated service delivery, flexibility in timing of the centers, accelerated ART initiation, simplification of bureaucratic procedures, nutritional and social support to all homeless HIV positive PWIDs.

Collaborative Practices Among Australian School Psychologists, Guidance Officers and School Counsellors: Important Lessons for School Psychological Practice

In Australia, policies such as the Better Outcomes in Mental Health Care initiative have been the impetus for improved collaboration between medical practitioners and psychologists in general. However, policies that promote collaboration between school psychologists and community mental health, health, justice and/or human services professionals are yet to occur. This is despite known benefits arising from integrated service delivery to people with complex needs, including young people. School psychologists are an integral part of the service mix and are in an excellent position to promote collaborative practices and to assist students and families to navigate and access school-based and community-based support. This study, conducted in Queensland, Australia, investigated school psychologists’, guidance officers’ and school counsellors’ current and preferred levels of collaboration, their perceptions of the drivers and barriers to collaborative practices, and their views on how collaborative practices affect students. Results revealed that participants engaged more fully in within-school collaboration than collaboration with professionals and agencies outside of the school; they had a desire to collaborate more fully both internally and externally; and that concerns regarding confidentiality, time restrictions, and lack of access to appropriate services can sometimes make collaboration and information sharing difficult. Implications for school psychological practice are discussed.

Costs and cost-effectiveness of HIV/noncommunicable disease integration in Africa: from theory to practice.

: The current article reviews economic aspects of selected HIV/noncommunicable disease (NCD) service delivery integration programs to assess the efficiency of integration in limited capacity settings. We define economies of scope and scale and their relevance to HIV/NCD integration. We summarize the results of a systematic review of cost and cost-effectiveness studies of integrated care, which identified 12 datasets (nine studies) with a wide range of findings driven by differences in research questions, study methods, and health conditions measured. All studies were done in Africa and examined screening interventions only. No studies assessed the cost of integrated, long-term disease management. Few studies estimated the cost-effectiveness of integrated screening programs. The additional cost of integrating NCD screening with HIV care platforms represented a 6-30% increase in the total costs of the programs for noncancer NCDs, with cervical cancer screening costs dependent on screening strategy. We conducted 11 key informant interviews to uncover perceptions of the economics of HIV/NCD integration. None of the informants had hard information about the economic efficiency of integration. Most expected integrated care to be more cost-effective than current practice, though a minority thought that greater specialization could be more cost-effective. In the final section of this article, we summarize research needs and propose a 'minimum economic dataset' for future studies. We conclude that, although integrated HIV/NCD care has many benefits, the economic justification is unproven. Better information on the cost, cost-effectiveness, and fiscal sustainability of integrated programs is needed to justify this approach in limited-resource countries.

Health consumer and health provider preferences for an integrative healthcare service delivery model: A national cross-sectional study.

Although global interest in integrative healthcare (IHC) has escalated over the past few decades, stakeholder perspectives and preferences in relation to IHC remain poorly understood. Our study aimed to address this knowledge gap by exploring Australian health consumer (HC) and healthcare provider (HCP) understanding, attitudes and preferences for an IHC service delivery model, and to translate these views into an operational framework for IHC. The research used a cross-sectional study design. Eligible persons were informed of the study using a multi-modal recruitment approach. Adult HCs and HCPs from any medical, nursing, allied and traditional and complementary medicine discipline, who had internet access and resided in Australia, were eligible to complete the 55-item online questionnaire. Four hundred and nine participants completed the survey. HCs and HCPs shared a common understanding of, and positive attitude towards, IHC. When asked about the IHC service delivery model, participants advocated the provision of diverse healthcare and support services across multiple centres, to individuals mainly presenting with chronic/terminal conditions. The preference was for these services to be charged as fee-for-service, paid using a split payment system, and managed by a customised team of clinicians following triage by a non-medical staff member. These findings were subsequently translated into an operational framework for IHC. This is first known study to translate HC and HCP attitudes and preferences into an operational framework for IHC. A logical next step of this work will be to ascertain the feasibility of this model in primary care.

Measuring Variation Across Dimensions of Integrated Care: The Maryland Medicaid Health Home Model.

Despite the proliferation of initiatives to integrate services for people with serious mental illness (SMI), measures of distinct dimensions of integration, such as spatial arrangement and care team expertise, are lacking. Such measures are needed to support organizations' assessment of progress toward integrated service delivery. We developed measures characterizing integration of behavioral, somatic, and social services to operationalize the integrated care dimensions conceived by the Agency for Healthcare Research and Quality. In a survey fielded to 46 Maryland Medicaid health homes (response rate: 96%) serving adults with SMI during 2015-2016, we found that these measures provided a useful description of variation across dimensions of integration.

Integrated Care Approaches Used for Transitions from Hospital to Community Care: A Scoping Review.

ABSTRACTIntegrated care is a promising approach for improving care transitions for older adults, but this concept is inconsistently defined and applied. This scoping review describes the size and nature of literature on integrated care initiatives for transitions from hospital to community care for older adults (aged 65 and older) and how this literature conceptualizes integrated care. A systematic search of literature from the past 10 years yielded 899 documents that were screened for inclusion by two reviewers. Of the 48 included documents, there were 26 journal articles and 22 grey literature documents. Analysis included descriptive statistics and a content analysis approach to summarize features of the integrated care initiatives. Results suggest that clinical and service delivery integration is being targeted rather than integration of funding, administration, and/or organization. To promote international comparison of integrated care initiatives aiming to improve care transitions, detailed descriptions of organizational context are also needed.

Health Peer Support Workers - Agents of change bringing a lived experience workforce to support the health of people with serious mental illness

Theme 5 1. Living Well Living Longer is a program funded to improve physical health outcomes for people living with severe mental illness. Health Peer Support Workers(HPSW) are employed in community mental health teams to strengthen consumer engagement in their own health and wellbeing 2. HPSWs have increased rates of engagement in care, increase rates of physical health screening, and contributed to improved social, emotional and physical wellbeing of care co-ordinated mental health consumers 3. HPSWs facilitate patient centred care that is consumer led, recovery focussed, strengths based and develops connections between the consumer, the mental health service, primary care providers and the non government sector. They provide a focus on integrated physical health care that champions the consumer as the expert in their own experience, and they partner with the consumer in the recovery journey, to address health disparities using a range of non clinical strategies 4. People living with severe and enduring mental illness, who are care co-ordinated by the Sydney Local Health District mental health service. Key stakeholders are HPSWs, mental health consumers, their carers/families, care co-ordinators and primary care providers. 5. The positions were funded for 3 years through a NSW Health Innovator grant, and became permanently funded in June 2017 6. Embedding the positions into a mental health team had significant impact on the way the team worked with consumers, and subsequent improved health outcomes The program is the first of its kind in NSW to use HPSW to target physical health as part of a strengths based recovery framework for improving physical health outcomes amongst the cohort. HPSW support increased consumerhealth literacy and healthy lifestyle goal setting, and improved screening and treatment for physical health co-morbidities. 7. The workforce will be further developed as the positions are an enhancement to the existing model of care for Sydney Local Health District mental health services. 8. The model can be adapted to unique needs of other mental health settings and services 9. Evaluation showed an increase in consumers who accessed a GP, received screening and treatment, and identified the HPSW engagement as a positive, non-clinical experience. The positions act as care navigators across complex health systems, reducing consumer distress. They use positive story-telling and individualised support. They improve meaningful communication and consumer connection to the treating team. 10. HPSWs assist care co-ordinators and consumers to increase rates of physical health screening, improving short term and long term physical health outcomes for consumers. By sharing their own recovery journey, HPSW provide consumers with hope that recovery can be positive, done in partnership, focussing care on the whole person, not just the mental illness. The HPSW have also assisted consumers to access healthy lifestyle activities and clinincal services 11. HPSWs are not clinical service providers. There is a discreet and unique aspect to their role and their interactions with consumers and care co-ordinators The community mental health teams saw value in the unique approach the HPSWs brought to integrated service delivery through their participation as team members

The impact of inter-organizational alignment (IOA) on implementation outcomes: evaluating unique and shared organizational influences in education sector mental health

BackgroundIntegrated healthcare delivered by work groups in nontraditional service settings is increasingly common, yet contemporary implementation frameworks typically assume a single organization—or organizational unit—within which system-level processes influence service quality and implementation success. Recent implementation frameworks predict that inter-organizational alignment (i.e., similarity in values, characteristics, activities related to implementation across organizations) may facilitate the implementation of evidence-based practices (EBP), but few studies have evaluated this premise. This study’s aims examine the impact of overlapping organizational contexts by evaluating the implementation contexts of externally employed mental health clinicians working in schools—the most common integrated service delivery setting for children and adolescents. Aim 1 is to estimate the effects of unique intra-organizational implementation contexts and combined inter-organizational alignment on implementation outcomes. Aim 2 is to examine the underlying mechanisms through which inter-organizational alignment facilitates or hinders EBP implementation.Methods/designThis study will conduct sequential, exploratory mixed-methods research to evaluate the intra- and inter-organizational implementation contexts of schools and the external community-based organizations that most often employ school-based mental health clinicians, as they relate to mental health EBP implementation. Aim 1 will involve quantitative surveys with school-based, externally-employed mental health clinicians, their supervisors, and proximal school-employed staff (total n = 120 participants) to estimate the effects of each organization’s general and implementation-specific organizational factors (e.g., climate, leadership) on implementation outcomes (fidelity, acceptability, appropriateness) and assess the moderating role of the degree of clinician embeddedness in the school setting. Aim 2 will explore the mechanisms through which inter-organizational alignment influences implementation outcomes by presenting the results of Aim 1 surveys to school-based clinicians (n = 30) and conducting semi-structured qualitative interviews. Qualitative data will be evaluated using an integrative inductive and deductive approach.DiscussionThe study aims are expected to identify intra- and inter-organizational constructs that are most instrumental to EBP implementation success in school-based integrated care settings and illuminate mechanisms that may account for the influence of inter-organizational alignment. In addition to improving school-based mental health, these findings will spur future implementation science that considers the relationships across organizations and optimize the capacity of implementation science to guide practice in increasingly complex systems of care.

Experiences of child protection workers in collaborating with adult mental health providers: An exploratory study from Ontario, Canada

Collaboration between child welfare and adult mental health service providers is important to address parental risk factors that may affect child wellbeing. The aim of this paper is to describe findings from a survey which identified barriers and facilitators to collaboration between these two sectors. A semi-structured instrument, adapted from Frederico et al. (2014), was used for data collection. A total of 339 service providers in Ontario, Canada, completed the survey. The collaborative strategies used most frequently were co-working with staff from other services and case conferences; yet, these strategies were only used by just over one half of all respondents. Several barriers and facilitators to collaboration were identified by respondents.To improve collaboration between child welfare and adult mental health services, respondents recommended better clarity of roles and goals, increased information sharing, capacity building across sectors and new models of integrated service delivery.

Youth Policy Innovation in the Netherlands: The Realization of Centers for Youth and Families by Municipalities

ABSTRACTIn many countries “one-stop shops” have been considered an innovative mode of integrated service delivery in case of cross-cutting problems in fields such as sustainability, social exclusion, and youth policy. In this article, we explore how the Dutch national government implemented the innovative “one-stop shop” concept in municipal youth policies (Center for Youth and Family; CYF). In particular, we examine the conditions affecting the timing of the realization of these centers in Dutch municipalities between 2008 and 2012. We found considerable differences among municipalities in the timing of the realization of CYFs. In explaining these differences, we assumed motivations to be more important than obstacles and resources, because municipalities received financial compensation, and because CYFs can be considered a social policy innovation. Our findings indicate that the degree of political alignment between the municipal council and national government is an important motivation, and that increasing numbers of adopting municipalities in the same policy network and organizational capacity were important resources. Thus, opposite to what theory suggested, we found that resources were more important than motivations for the realization of CYFs. These findings challenge the decentralization thesis.

Numbers, systems, people: how interactions influence integration. Insights from case studies of HIV and reproductive health services delivery in Kenya.

Drawing on rich data from the Integra evaluation of integrated HIV and reproductive-health services, we explored the interaction of systems hardware and software factors to explain why some facilities were able to implement and sustain integrated service delivery while others were not. This article draws on detailed mixed-methods data for four case-study facilities offering reproductive-health and HIV services between 2009 and 2013 in Kenya: (i) time-series client flow, tracking service uptake for 8841 clients; (ii) structured questionnaires with 24 providers; (iii) in-depth interviews with 17 providers; (iv) workload and facility data using a periodic activity review and cost-instruments; and (v) contextual data on external activities related to integration in study sites. Overall, our findings suggested that although structural factors like stock-outs, distribution of staffing and workload, rotation of staff can affect how integrated care is provided, all these factors can be influenced by staff themselves: both frontline and management. Facilities where staff displayed agency of decision making, worked as a team to share workload and had management that supported this, showed better integration delivery and staff were able to overcome some structural deficiencies to enable integrated care. Poor-performing facilities had good structural integration, but staff were unable to utilize this because they were poorly organized, unsupported or teams were dysfunctional. Conscientious objection and moralistic attitudes were also barriers.Integra has demonstrated that structural integration is not sufficient for integrated service delivery. Rather, our case studies show that in some cases excellent leadership and peer-teamwork enabled facilities to perform well despite resource shortages. The ability to provide support for staff to work flexibly to deliver integrated services and build resilient health systems to meet changing needs is particularly relevant as health systems face challenges of changing burdens of disease, climate change, epidemic outbreaks and more.

How linked are national HIV and SRHR strategies? A review of SRHR and HIV strategies in 60 countries

The connection between HIV and sexual and reproductive health and rights (SRHR) is widely recognised along with the benefits of linking them at the legal/policy, health systems, and service delivery levels. However, despite increased rhetoric about the need for this three-tiered approach, integrated service delivery has not been fully addressed at the legal/policy level through national strategies. Thus a review of HIV and SRHR strategies was conducted for 60 countries, determining the extent to which they reflected the intersections between HIV and SRHR. Each HIV strategy was scored on whether five key SRHR components were incorporated and had an associated measurable target. SRHR strategies were similarly assessed for incorporation of five HIV components and associated targets. HIV strategies had a higher level of inclusion of SRHR components with a global average of 6.6/10 compared to 3.7/10 for SRHR strategies. The highest scoring component was the elimination of mother-to-child transmission of HIV (EMTCT) and the lowest was SRHR of people living with HIV. Countries with higher scores in one strategy tended to have higher scores in the other but there was no difference over time. Whilst there has been increased global commitment since 2004 to link SRHR and HIV, insufficient headway has been made in linking related national strategies. Although EMTCT is included with targets in the majority of HIV and SRHR strategies, the broader SRHR needs of women living with HIV are not. Also, condoms are not being considered an effective triple protection tool. HIV and SRHR strategies provide direction and targets which ultimately may influence funding and vice versa. Therefore, it is essential that these strategies are right-based and incorporate the key connections between SRHR and HIV with measurable targets to realise the full benefits of a joint response.

Active Ageing - Implementing integrated care for falls prevention and bone health at scale

Introduction and aim: The purpose of AFFINITY (activating falls and fractures prevention in Ireland together), a national population health improvement project, is to implement a national strategy on the prevention of harmful falls and fractures in older persons. Harmful falls and fractures in older persons are on the whole predictable and preventable and are a significant human, social and economic cost burden. AFFINITY is also a commitment within a pan European programme on active and healthy ageing that aims to increase the average healthy lifespan of citizens by 2 years by 2020. Practice Changes,Timeline and Stakeholders: AFFINITY has adopted a whole system approach (2014-2020), with multi-stakeholders, multi-professional and multi-sectoral collaborative working. Key implementation approaches: empowering citizen self-management, supporting older persons to actively age, robust project governance, integrated service delivery model, work practice changes and system change management supports. AFFINITY is a joint project of the national service provider and the publicly funded health & social care system indemnifier. Highlights and Lessons Learned: AFFINITY is being embedded within new service provider structures and processes, including the national service provider integrated care framework for older persons using enablers such as digital technologies, funding and human resources. Four early adapter sites for falls prevention and bone health are developing bespoke, evidence informed integrated care pathways (ICP) since 2014 to address the needs of their older populations: key indicators include timely access to quality multidisciplinary team interventions with measurable outcomes at an individual and population health level. Learnings from these early adapters is being used to identify and scale up additional sites within all service areas nationally to improve access, quality and outcomes of falls and fracture prevention services in 2017. Outcomes and targeted population: Full implementation of this project will mean that persons 65 years and older: will be proactively co-producing their own health & wellbeing, will have access to quality ICP according to need, will have less harmful falls & fracture sequelae will enjoy safer age friendly environments and improved quality of life years. Transferability and Sustainability: AFFINITY, enabled by the European programme, will be an exemplar of a coordinated, sustainable and effective model of care for older persons, that is both proactive and reactive. Cooperation between AFFINITY and its European partners will enhance and enrich the underlying information and process models, supporting the embedding of evidence informed practices and upscaling to spread and sustain the gains. Change management success factors and approaches to barriers will be available for similar large scale implementation projects to learn from. The political, funding, legislative and organisational reforms and challenges happening at national level will resonate with other countries in their desire for better quality care, more efficient health and social care delivery systems and new economic opportunities and investments, especially within the digital and silver economy.

Providers perspectives on mandated local health networks for older adults in the province of Quebec, Canada

Background : In 2004, the government of Quebec made major reforms in the organisation of its health system by implementing Local Health Networks (LHNs) focused on the needs of various sub-populations. Informed by two prominent pilot projects (1, 2), the Ministry of Health and Social Services aimed at improving the continuity, coherence, quality and efficiency of health and social services by mandating the implementation of LHNs for older people with complex needs in its territory following a co-ordination model of integration (3). Understanding how mandated innovations are adopted and routinized in different contexts may give insights on which components of the innovation work where and why they work. Hence this project questions how and why does the implementation of LHNs for older adults vary between three LHNs in Quebec according to the perspectives of providers? Theory/Methods : A multiple case study, consisting of a highly urban, an urban and a rural setting. Semi-structured interviews of providers (n=29) and key documents were collected. Analysis done with the NVIVO software was based on themes inspired by The Rainbow Model of Integrated Care(4) which distinguishes 59 constructs in six interlinked integration dimensions: clinical, professional, organisational, system, functional and normative integration. Results : Variable implementation of components of LHNs in all three cases. Providers reported great variability in the implementation of clinical integration components such as the elaboration of individualised care plans for patients, care coordination through case management, and the engagement of patients/caregivers in the organisation and delivery of care. Providers experienced professional integration through the usage of multidisciplinary client evaluation tools, which facilitated inter-professional collaborations. Merging organisations of the LHNs and creating various inter-organisational strategies such as liaison nurses, aimed at promoting organisational integration, ensured continuity of services. Usage of various health information systems by providers eased functional integration, communication and collaborations between partners. Pertaining to system integration, the three cases shared the same political, economic and social climate. Discussion : Variability in the implementation of LHNs in the cases studied may be attributed to several factors. Characteristics of the local context, such as lack of appropriate personnel resulted in the rural LHN not instituting case managers or liaison nurses, a problem not faced in the other two cases. Characteristics of the innovation, such as the cumbersomeness of the multidisciplinary client evaluation tool resulted in some providers not using it in their LHNs. Providers often worked with multiple unaligned health information systems which varied within and between cases due to inappropriate managerial decisions. Mostly, providers ensured optimal care delivery to their clients by adjusting to these variations. Conclusion : The breadth and depth of different components of LHNs varied across the cases. Providers need flexibility and adaptability while carrying out their duties. Lessons learned : Different factors may influence the implementation variability of LHNs, which in turn influences the way providers perform their duties. Limitations : Only one perspective was studied, and these findings may be generalised only to similar LHNs. Suggestions for future research : Effects analysis of the implementation of the LHNs for older people.

Designing initiatives for vulnerable families: from theory to design in Sydney, Australia

Introduction: Inequities in the health and wellbeing of Australian children and families who live in disadvantaged communities are growing despite a range of government initiatives designed to alleviate the impact of disadvantage and social exclusion (1). Increased understanding of the complex and inter-related issues that contribute to poor outcomes for vulnerable disadvantaged families have prompted concern from researchers and service providers about the often fragmented and inefficient service response. This has prompted an increased national policy commitment to community-led, multi-disciplinary, cross-sector integrated service delivery (1). The aim of the study was to use previously described realist causal and program theory to inform collaborative design of initiatives for vulnerable familiesTheory/Methods: Previously developed realist causal and program theory were used to inform the collaborative design of initiatives for vulnerable families (2). The collaborative design included: identification of outcomes and contextual factors, consultation forums, interagency planning, and development of a service proposal.Results: The Design proposed initiatives and service activities that:Are sustainable with an exit strategy or have the scope to be absorbed into the current service budgetBuild partnerships with the Medicare Local (primary health networks), Local Government, Government and non-Government agenciesProvide for capacity building within SLHD services, families and communities, and partner agenciesEstablish organisational structures and processes that provide options for future growth and organisational change.The Design Elements included: Perinatal coordination, Sustained home visiting, Integrated service model development, two place-based hubs, Health Promotion and strengthened research and analysis capability.Discussion: We have used critical realist meta-theory to assist in the translation of previously reported empirical explanatory theory building to theory driven interventions. Local quantitative and qualitative studies were used together with consultation forums and collaborative design approaches. In applying the realist programme theory to the local situation the analysis took into account: the role of the local agencies; evidence of program effectiveness; determinants and outcomes for local children and their families; the current deployment of service resources; and insights from front-line staff and interagency partners.Conclusions: We demonstrate here the design of interventions for vulnerable families in Sydney utilising translational research from previous realist causal and program theory building to operational service design.Lessons learned: In undertaking this study we identified the importance of our earlier hierarchal program analysis for identifying the elements for the full design. The application of theory added rigour to the design of integrated care initiatives.Limitations: The analysis and design elements remained health sector focused despite the collective approach to planning.Suggestions for future research: Further local qualitative studies should be undertaken to examine the barriers and enablers to achieving a balanced interagency design.

Integration of tuberculosis and HIV services: Exploring the perspectives of co-infected patients in Ghana

ABSTRACTScaling up of integrated tuberculosis (TB)–human immunodeficiency virus (HIV) services remains sub-optimal in many resource-limited countries, including Ghana, where the two conditions take a heavy toll on the financial resources of health systems as well as infected persons. Previous studies have documented several implementation challenges towards TB–HIV service integration, but views of patients on integrated service delivery have not received commensurate research attention. This paper explored the experiences of 40 TB–HIV co-infected patients at different stages of treatment in Ghana. Using Normalisation Process Theory as a framework, data were coded using inter-rater coding technique and analysed inductively and deductively with the help of QSR NVivo 10. For several participants, either of the diseases was diagnosed ‘accidentally’, leading to inconsistencies in co-therapy administration, constraints regarding separate clinic appointment dates for TB and HIV and prolonged TB treatment due to treatment failure. Put differently, there were widespread negative experiences among TB–HIV co-infected patients with regard to treatment and care, especially among patients who were accessing care in separate facilities or separate units in the same facility. Co-infected patients unanimously support full-service integration. However, they felt powerless to request for reforms on a mode of service delivery.