Sustaining the Collaborative Care Model (CoCM): Billing Newly Available CoCM CPT Codes in an Academic Primary Care System

Novel Current Procedural Terminology (CPT) codes specific to the collaborative care model (CoCM) offer advantages over traditional billing options, but their uptake may require considerable billing and clinical workflow adjustments. This column presents a case study addressing the challenges of using these codes within the University of Washington Neighborhood Clinics (UWNC), an academically affiliated primary care clinic system in western Washington State. The UWNC experience thus far demonstrates that CoCM CPT codes can successfully be used in a large academic primary care system to help move this evidence-based service model toward financial sustainability.

The Over 75 Service: Continuity of Integrated Care for Older People in a United Kingdom Primary Care Setting

Continuity of care is concerned with quality of care over a period of time. It describes a process by which service users and their families are co-operatively involved with health and social care professionals in managing their care needs. Continuity of care can be divided into informational, managerial and relational and has been associated with improved user- and service-related outcomes. To date, there have been few studies which examine how continuity of care is developed and maintained in integrated primary care systems. This paper explores continuity of care in an integrated Over 75 Service for people living at home with complex health and social care needs. Using a case study approach, qualitative data was collected from multiple sources including interviews with managers and professionals, users and carers, care plans, steering group minutes and field notes. Data was analysed thematically. A number of factors are identified which characterise continuity of care, namely: information sharing through direct communication between providers and the development of trusted relationships within the team; identified care co-ordinators who acted as a conduit for information and communication; the development of ongoing relationships with users and carers requiring dedicated time and accessible and flexible services delivered in the users’ own home.

Extending Contsys Standard with Social Care Concepts: A Methodology Proposed by the UNINFO Working Group in Italy

The increasing demand for territorial services requires the improvement of the coordination and cooperation among stakeholders in planning and delivery of integrated health and social services. In this scenario, to improve the communication among stakeholders there is a need of a formal conceptual model that facilitates the interoperability between organizations and professionals. This paper presents the methodology adopted by a UNINFO working group established in Italy to extend the ContSys standard with social care concepts to integrate health and social care contexts in a continuity of care perspective. An example of this extension is also provided considering the definition of patient's care plans.

Better Evaluations to Support the Needs of Older People in the UK

Transforming health and care for older people is complex and demanding. Evaluating such efforts requires a range of approaches and ideas, and a reflection on ways to improve how evaluations are commissioned, completed and used in a changing policy landscape. This article by researchers at RAND Europe summarises three workshops undertaken with evaluators, commissioners of evaluations and services, and those delivering services that are evaluated with the explicit aim of addressing these questions.

An integrated approach to meet the needs of high-vulnerable families: a qualitative study on integrated care from a professional perspective

BACKGROUND

To meet the needs of high-vulnerable families with severe and enduring problems across several life domains, professionals must improve their ability to provide integrated care timely and adequately. The aim of this study was to identify facilitators and barriers professionals encounter when providing integrated care.

METHODS

Experiences and perspectives of 24 professionals from integrated care teams in the Netherlands were gathered by conducting semi-structured interviews. A theory-driven framework method was applied to systematically code the transcripts both deductively and inductively.

RESULTS

There was a consensus among professionals regarding facilitators and barriers influencing their daily practice, leading to an in depth, thematic report of what facilitates and hinders integrated care. Themes covering the facilitators and barriers were related to early identification and broad assessment, multidisciplinary expertise, continuous pathways, care provision, autonomy of professionals, and evaluation of care processes.

CONCLUSIONS

Professionals emphasized the need for flexible support across several life domains to meet the needs of high-vulnerable families. Also, there should be a balance between the use of guidelines and a professional's autonomy to tailor support to families' needs. Other recommendations include the need to improve professionals' ability in timely stepping up to more intensive care and scaling down to less restrictive support, and to further our insight in risk factors and needs of these families.

Embedding collective leadership to foster collaborative inter-professional working in the care of older people (ECLECTIC): Study protocol

Background: The National Integrated Care Programme for Older People (NICPOP), formerly NCPOP aims to support older people to live well in their homes by developing primary and secondary care services for older people, especially those with complex needs. The programme develops integrated intermediate care which traverses both hospital and community settings through multidisciplinary and interagency teams. This team-based approach to the integration of health services is a novel innovation in Irish health service delivery and will require, over time, a shift in cultures of care to allow for the development of competencies for inter-professional collaboration across the care continuum.

The ECLECTIC project will develop an implementation framework for achieving, maintaining and monitoring competencies for interprofessional collaboration among multi-disciplinary teams charged with delivering care for older people across the continuum from acute to community settings.

Design: The ECLECTIC research design has been developed in collaboration with the NICPOP. In phase one of the project, a co-design team will collaborate to define and shape competencies for interprofessional collaboration. Phase two will involve the delivery of a collective leadership intervention over a 10-month period with multidisciplinary professionals working with older people across two geographical regions (Mullingar/Midlands and Beaumont/Dublin North). Each group will comprise of members of two multidisciplinary teams charged with coordinating and delivering care to older people across the continuum of acute to community care. Observations of collaborative inter-professional working will take place before, during, and after intervention. In phase three of the study, analysis of the interview and observation data will be presented to the co-design team in order to develop an implementation framework for future teams.

Discussion: The co-design process will develop core competencies and performance indicators for collaborative interprofessional working. The resulting implementation framework will be implemented nationally as part of the NICPOP.

The Michigan Child Collaborative Care Program: Building a Telepsychiatry Consultation Service

This column describes the establishment of the Michigan Child Collaborative Care (MC3), a statewide telepsychiatry consultation program that provides support to primary care providers (PCPs) in meeting the mental health needs of youths and perinatal women. The MC3 program provides cost-effective, timely, remote consultation to primary care providers in an effort to address the lack of access and scarcity of resources in child, adolescent, and perinatal psychiatry. Data from 10,445 service requests are summarized. Common diagnoses included attention-deficit hyperactivity disorder, mood disorders, anxiety disorders, and autistic spectrum disorders, with many cases (58%) deemed moderate to severe. Co-occurring psychological trauma was suspected in 9% of service requests. Partnerships, stakeholder roles, PCP engagement, and workflow integration are highlighted as keys to the program's success.

Designing an Integrated Care Initiative for Vulnerable Families: Operationalisation of Realist Causal and Programme Theory, Sydney Australia

Introduction:

In July 2015 Sydney Local Health District (SLHD) implemented an integrated care initiative for vulnerable families in the Inner West region of Sydney, Australia. The initiative was designed as a cross-agency care coordination network that would ensure that vulnerable families: had their complex health and social needs met; kept themselves and their children safe; and were connected to society. We will describe the development of the design that drew on earlier realist causal and program theoretical work.

Methods:

Realist causal and program theory were used to inform the collaborative design of an initiative for vulnerable families. The collaborative design process included: identification of desirable and undesirable outcomes and contextual factors, stakeholder consultation, interagency planning, and development of a service proposal.

Results:

The design elements included: identification of vulnerable family cohorts; care coordination; evidence-informed intervention(s); general practice engagement and support; family health improvement; placed-based neighbourhood initiatives; interagency system change and collaborative planning; monitoring of individual and family outcomes; and evaluation.

Conclusions:

The design study described advances toward the implementation of a whole-of-government integrated health and social care initiative. The initiative was designed as a cross-agency care coordination network that would ensure that vulnerable families: had their complex health and social needs met; kept themselves and their children safe; and were connected to society. In so doing we aim to break intergenerational cycles of poverty, violence and crime, poor education and employment opportunities, psychopathology, and poor lifestyle and health behaviours, through strengthening family resilience, improving access to services, and addressing the social determinants of health and wellbeing.

Improving Behavioral Health Equity through Cultural Competence Training of Health Care Providers

Racial/ethnic disparities have long persisted in the United States despite concerted health system efforts to improve access and quality of care among African Americans and Latinos. Cultural competence in the health care setting has been recognized as an important feature of high-quality health care delivery for decades and will continue to be paramount as the society in which we live becomes increasingly culturally diverse. Unfortunately, there is limited empirical evidence of patient health benefits of a culturally competent health care workforce in integrated care, its feasibility of implementation, and sustainability strategies. This article reviews the status of cultural competence education in health care, the merits of continued commitment to training health care providers in integrated care settings, and policy and practice strategies to ensure emerging health care professionals and those already in the field are prepared to meet the health care needs of racially and ethnically diverse populations.

The role of social work in the opioid epidemic: office-based opioid treatment programs

The opioid epidemic is a national emergency in the United States. To meet the needs of individuals diagnosed with Opioid Use Disorder (OUD) office-based opioid treatment programs (OBOT) are quickly expanding. However, social workers roles in OBOT programs are not clearly described. This paper will emphasize three roles social workers may fulfill in OBOT programs to combat the opioid crisis.

Project INTEGRATE: Developing a Framework to Guide Design, Implementation and Evaluation of People-centred Integrated Care Processes

Background:

People-centred integrated care is an acknowledged approach to improve the quality and effectiveness of health systems in delivering care around people’s needs and preferences. Nevertheless, more guidance on how to effectively design, implement and evaluate the care process of people-centred integrated care services is needed. Under Project INTEGRATE, a framework was developed to guide managers in the assessment, transformation and delivery of these health service innovations.

Methods:

The framework is a product of the synthesis of operations, service and project management literature, relevant health care literature, and the analysis of four good practice integrated care case studies analysed under Project INTEGRATE. A first iteration of the framework was developed and then applied to one of the integrated care case studies to test its validity and utility.

Results and Discussion:

The tool combines a number of important considerations and criteria that have not been previously included in integrated care assessment frameworks, allowing for a pragmatic and comprehensive analysis of the care process.

Conclusion:

This framework can be used as a stand-alone or combined tool to guide managers to plan and evaluate the care process design of people-centred integrated care services; future work should apply this tool to other settings.

The Learning Curve After Implementation of Collaborative Care in a State Mental Health Integration Program

OBJECTIVE

This study examined organizational variability of process-of-care and depression outcomes at eight community health centers (CHCs) in the years following implementation of collaborative care (CC) for depression.

METHODS

The authors used 8 years of observational data for 13,362 unique patients at eight CHCs that participated in Washington State's Mental Health Integration Program. Organization-level changes in depression and process-of-care outcomes over time were studied.

RESULTS

On average, depression outcomes improved for the first 2 years before improvement slowed, peaking at year 5. Significant organization-level variation was noted in outcomes. Improvements in depression outcomes tended to follow process-of-care measures.

CONCLUSIONS

Findings suggest that it may take 2 years after implementation of CC to fully observe depression outcome improvement at an organization level. Substantial variation between organizations in depression outcomes over time suggests that sustained attention to processes of care may be necessary to maintain initially achieved gains.

Fully-integrated medical home for people with severe and persistent mental illness: A description and outcome analysis of a Medicare Advantage Chronic Special Needs Program

People with severe persistent mental illness pose a significant challenge to managed care organizations and society in general. The financial costs are staggering as is the community impact including homelessness and incarceration. This population also has a high incident of chronic comorbid disorders that not only drives up healthcare costs but also significantly shortens longevity. Traditional case management approaches are not always able to provide the intense and direct interventions required to adequately address the psychiatric, medical and social needs of this unique population. This article describes a Medicare Advantage Chronic Special Needs Program that provides a Medical Home, Active Community Treatment, and Integrated Care. A comparison of utilization and patient outcome measures of this program with fee for service Medicare found significant reduction in utilization and costs, as well as increased adherence to the management of chronic medical conditions and preventative services.

The Patient Experience of Integrated Care Scale: A Validation Study among Patients with Chronic Conditions Seen in Primary Care

Introduction:

Valid and comprehensive instruments to measure integrated care are required to capture patient experience and improve quality of patient care. This study aimed to validate the Patient Experience of Integrated Care Scale (PEICS), among patients with chronic conditions seen in primary care.

Methods:

One hundred and fifty-nine (159) French-speaking adults with at least one chronic condition were recruited in two family medicine clinics in Quebec (Canada) and completed the 17-item PEICS (T1). Fifty (50) participants completed it a second time 2 weeks later (T2). The internal consistency of the scale was assessed using Cronbach’s alpha, the test-retest reliability with the intraclass correlation coefficient (ICC), and concurrent validity using three dimensions of the Continuity of Care from Multiple Clinicians (CC-MC), with Spearman’s rank correlation coefficients.

Results:

Cronbach’s alpha for the questionnaire was 0.88 (95% CI: 0.85 to 0.91). The intraclass correlation coefficient was 0.81 (95% CI: 0.64 to 0.90) and Spearman’s rank correlation coefficient with the three dimensions of the CC-MC varied from 0.44 to 0.54.

Conclusions and discussion:

The PEICS showed good psychometric properties. This scale could be used in a population with chronic conditions followed in primary care to measure patient experience of integrated care.

Development and Evaluation of Two Integrated Care Models for Children Using a Partnered Formative Evaluation Approach

Objective

To describe the development and evaluation of two integrated care models using a partnered formative evaluation approach across a private foundation, clinic leaders, providers and staff, and a university-based research center.

Design

Retrospective cohort study using multiple data sources.

Setting

Two federal qualified health care centers serving low-income children and families in Chicago.

Participants

Private foundation, clinic and academic partners.

Interventions

Development of two integrated care models and partnered evaluation design.

Main Outcome Measures

Accomplishments and early lessons learned.

Results

Together, the foundation-clinic-academic partners worked to include best practices in two integrated care models for children while developing the evaluation design. A shared data collection approach, which empowered the clinic partners to collect data using a web-based tool for a prospective longitudinal cohort study, was also created.

Conclusion

Across three formative evaluation stages, the foundation, clinic, and academic partners continued to reach beyond their respective traditional roles of project oversight, clinical service, and research as adjustments were collectively made to accommodate barriers and unanticipated events. Together, an innovative shared data collection approach was developed that extends partnered research to include data collection being led by the clinic partners and supported by the technical resources of a university-based research center.

Achieving Integrated Care for Older People: What Kind of Ship? Comment on "Achieving Integrated Care for Older People: Shuffling the Deckchairs or Making the System Watertight for the Future?"

This paper considers an implication of the idea that proposals for integrated care for older people should start from a focus on the patient, consider co-production solutions to the problems of care fragmentation, and be at a system-wide, cross-organisational level. It follows that the analysis, design and therefore evaluation of integrated care projects should be based upon the journeys which older patients with multiple chronic conditions usually have to make from professional to professional and service to service. A systematic realistic review of recent research on integrated care projects identified a number of key mechanisms for care integration, including multidisciplinary care teams, care planning, suitable IT support and changes to organisational culture, besides other activities and contexts which assist care 'integration.' Those findings suggest that bringing the diverse services that older people with multiple chronic conditions need into a single organisation would remove many of the inter-organisational boundaries that impede care 'integration' and make it easier to address the interprofessional and inter-service boundaries.

Integrated Care for Depression in Older Primary Care Patients

For decades, depression in older adults was overlooked and not treated. Most treatment was by primary care providers and typically poorly managed. Recent interventions that integrate mental health services into primary care have increased the number of patients who are treated for depression and the quality of that treatment. The most effective models involve systematic depression screening and monitoring, multidisciplinary teams that include primary care providers and mental health specialists, a depression care manager to work directly with patients over time and the use of guideline-based depression treatment. The article reviews the challenges and opportunities for providing high-quality depression treatment in primary care; describes the 3 major integrated care interventions, PRISM-E, IMPACT, and PROSPECT; reviews the evidence of their effectiveness, and adaptations of the model for other conditions and settings; and explores strategies to increase their scalability into real world practice.

Reflections from Key Policy Decision-makers on Integrated Care and the Value of Decision-maker Involvement in Research

The iCOACH study involved key health care system decision-makers from Ontario, Quebec and New Zealand. This article is written by the key decision-makers involved in the iCOACH study and discusses their motivations to engage in the research project, the value of participation and key recommendations for best practices to engage decision-makers in research projects. Suggestions for knowledge translation are identified including practical tools for decision-makers and providers to use to assess readiness to implement integrated community-based primary health care. Case study briefs with key enablers and 'talking-points' and infographics are similarly recommended as approaches to transfer knowledge gained from this research study.

Achieving Integrated Care for Older People: Shuffling the Deckchairs or Making the System Watertight For the Future?

Integrated care has been recognised as a key initiative to resolve the issues surrounding care for older people living with multi-morbidity. Multiple strategies and policies have been implemented to increase coordination of care globally however, evidence of effectiveness remains mixed. The reasons for this are complex and multifactorial, yet many strategies deal with parts of the problem rather than taking a whole systems view with the older person clearly at the centre. This approach of fixing parts of the system may be akin to shuffling the deckchairson the Titanic, rather than dealing with the fundamental reasons why the ship is sinking. Attempts to make the ship more watertight need to be firmly centred on the older person, pay close attention to implementation and embrace approaches that promote collaborative working between all the stakeholders involved.

The systematic approach to improving care for Frail Older Patients (SAFE) study: A protocol for co-designing a frail older person's pathway

Background: Frailty is the age-accelerated decline across multiple organ systems which leads to vulnerability to poor resolution of homeostasis after a stressor event. This loss of reserve means that a minor illness can result in a disproportionate loss of functional ability. Improving acute care for frail older patients is now a national priority and an important aspect of the National Programme for Older People in Ireland. Evidence suggests that an interdisciplinary approach incorporating rapid comprehensive geriatric assessment and early intervention by an interdisciplinary team can reduces susceptibility to hospitalisation related functional decline. The aim of the Systematic Approach to Improving Care for Frail Older Patients (SAFE) is to develop and explore the process of implementing a model of excellence in the delivery of patient-centred integrated care within the context of frail older people’s acute admissions.

Methods: The SAFE study will employ a mixed methodology approach, including a rapid realist review of the current literature alongside a review of baseline data for older people attending the emergency department. Semi-structured interviews will be undertaken to document the current pathway. The intervention processes and outcomes will be jointly co-designed by a patient and public involvement (PPI) group together with the interdisciplinary healthcare professionals from hospital, community and rehabilitation settings. Successive rounds of Plan-Do-Study-Act cycles will then be undertaken to test and refine the pathway for full implementation.

Discussion: This research project will result in a plan for implementing an integrated, patient-centred pathway for acute care of the frail older people which has been tested in the Irish setting. During the process of development, each element of the new pathway will be tested in turn to ensure that patient centred outcomes are being realised. This will ensure the resulting model of care is ready for implementation in the context of the Irish health service.

Realist evaluation of a complex integrated care programme: protocol for a mixed methods study

INTRODUCTION

The lack of understanding of how complex integrated care programmes achieve their outcomes due to the lack of acceptable methods leads to difficulties in the development, implementation, adaptation and scaling up of similar interventions. In this study, we evaluate an integrated care network, the National University Health System (NUHS) Regional Health System (RHS), consisting of acute hospitals, step down care, primary care providers, social services and community partners using a theory-driven realist evaluation approach. This study aims to examine how and for whom the NUHS-RHS works to improve healthcare utilisations, outcomes, care experiences and reduce healthcare costs. By using a realist approach that balances the needs of context-specific evaluation with international comparability, this study carries the potential to address current research gaps.

METHODS AND ANALYSIS

This evaluation will be conducted in three research phases: (1) development of initial programme theory (IPT) underlying the NUHS-RHS; (2) testing of programme theory using empirical data; and (3) refinement of IPT. IPT was elicited and developed through reviews of programme documents, informal discussions and in-depth interviews with relevant stakeholders. Then, a convergent parallel mixed method study will be conducted to assess context (C), mechanisms (M) and outcomes (O) to test the IPT. Findings will then be analysed according to the realist evaluation formula of CMO in which findings on the context, mechanisms will be used to explain the outcomes. Finally, based on findings gathered, IPT will be refined to highlight how to improve the NUHS-RHS by detailing what works (outcome), as well as how (mechanisms) and under what conditions (context).

ETHICS AND DISSEMINATION

The National Healthcare Group, Singapore, Domain Specific Review Board reviewed and approved this study protocol. Study results will be published in international peer-reviewed journals and presented at conferences and internally to NUHS-RHS and Ministry of Health, Singapore.

The Impact Of Medicare ACOs On Improving Integration And Coordination Of Physical And Behavioral Health Care

The accountable care organization (ACO) model holds the promise of reducing costs and improving the quality of care by realigning payment incentives to focus on health outcomes instead of service volume. One key to managing the total cost of care is improving care coordination for and treatment of people with behavioral health disorders. We examined qualitative data from ninety organizations participating in Medicare ACO demonstration programs from 2012 through 2015 to determine whether and how they focused on behavioral health care. These ACOs had mixed degrees of engagement in improving behavioral health care for their populations. The biggest challenges included a lack of behavioral health care providers, data availability, and sustainable financing models. Nonetheless, we found substantial interest in integrating behavioral health care into primary care across a majority of the ACOs.

How Key Stakeholders Perceive a Smart Mobile Integrated Care System for the Elderly

Integrated care has been an important model for caring the elderly. In China, it is still at its very early stage. We proposed a new model to develop a smart mobile system, taking the CARE instrument as the base and composed of apps for stakeholders. We did an usability study using the TAMM tool and, from a convenience sample of 11 elderly and 18 nurses, the results indicated the system was well appreciated.