A 10 Step Framework to Implement Integrated Care for Older Persons

Establishing the core elements of a frailty at the front door model of care using a modified real-time Delphi technique

BACKGROUND

Innovations in models of care for older adults living with frailty presenting to the emergency department (ED) have become a key priority for clinicians, researchers and policymakers due to the deleterious outcomes older adults experience due to prolonged exposure to such an environment. This study aimed to develop a set of expert consensus-based statements underpinning operational design, outcome measurement and evaluation of a Frailty at the Front Door (FFD) model of care for older adults within an Irish context.

METHODS

A modified real-time Delphi method was used. Facilitation of World Café focus groups with an expert panel of 86 members and seperate advisory groups with a Public and Patient Involvement panel of older adults and members of the Irish Association of Emergency Medicine generated a series of statements on the core elements of the FFD model of care. Statements were analysed thematically and incorporated into a real-time Delphi survey, which was emailed to members of the expert panel. Members were asked to rank 70 statements across nine domains using a 9-point Likert scale. Consensus criteria were defined a priori and guided by previous research using 9-point rating scales.

RESULTS

Fifty members responded to the survey representing an overall response rate of 58%. Following analyses of the survey responses, the research team reviewed statements for content overlap and refined a final list of statements across the following domains: aims and objectives of the FFD model of care; target population; screening and assessment; interventions; technology; integration of care; evaluation and metrics; and research.

CONCLUSION

Development of a consensus derived FFD model of care represents an important step in generating national standards, implementation of a service model as intended and enhances opportunities for scientific impact. Future research should focus on the development of a core outcome set for studies involving older adults in the ED.

Practical management of complexity in older people with HIV: approaching an international consensus

ABSTRACTGlobally the community of people with HIV is ageing, and some of these have increasingly complex care needs, with a known excess of non-HIV related comorbidities and related issues including consequent polypharmacy. At the 2022 International AIDS Conference in Montréal, Canada, the "Silver Zone" was created in the Global Village as a safe space for older people with HIV. As part of the Silver Zone activities, a session discussing global models of care for in this group was held. HIV treatment providers and advocates from diverse resource settings and with a diversity of expertise were invited to share their experience, reflections, and ideas, and this consensus statement was formed based on these discussions. Different approaches to care emerged, based on local needs and resources, and it became clear that issues of complexity and frailty need not be age limited. Despite clear regional differences, some common themes became apparent, and a consensus was established on basic principles that may be considered in diverse settings. These are discussed here, with agreement on necessary proximal steps to develop bespoke person-centred care models.

How to not revert to type: Complexity-informed learnings from the pandemic response for health system reform and universal access to integrated care

This article is part of the Research Topic 'Health Systems Recovery in the Context of COVID-19 and Protracted Conflict'.

Background

COVID-19 has highlighted existing health inequalities and health system deficiencies both in Ireland and internationally; however, understanding of the critical opportunities for health system change that have arisen during the pandemic is still emerging and largely descriptive. This research is situated in the Irish health reform context of Sláintecare, the reform programme which aims to deliver universal healthcare by strengthening public health, primary and community healthcare functions as well as tackling system and societal health inequities.

Aims and objectives

This study set out to advance understanding of how and to what extent COVID-19 has highlighted opportunities for change that enabled better access to universal, integrated care in Ireland, with a view to informing universal health system reform and implementation.

Methods

The study, which is qualitative, was underpinned by a co-production approach with Irish health system leadership. Semi-structured interviews were conducted with sixteen health system professionals (including managers and frontline workers) from a range of responses to explore their experiences and interpretations of social processes of change that enabled (or hindered) better access to universal integrated care during the pandemic. A complexity-informed approach was mobilized to theorize the processes that impacted on access to universal, integrated care in Ireland in the COVID-19 context.

Findings

A range of circumstances, strategies and mechanisms that created favorable system conditions in which new integrated care trajectories emerged during the crisis. Three key learnings from the pandemic response are presented: (1) nurturing whole-system thinking through a clear, common goal and shared information base; (2) harnessing, sharing and supporting innovation; and (3) prioritizing trust and relationship-building in a social, human-centered health system. Policy and practice implications for health reform are discussed.

Health and social care of home-dwelling frail older adults in Switzerland: a mixed methods study

Background

Home-dwelling frail older adults are often faced with multimorbidity and complex care needs, requiring health and social care systems that support frail older adults to age in place. The objective of this paper was to investigate the types of formal health and social care as well as informal care and social support used by home-dwelling frail older adults; whether they perceive their support as sufficient; and their experience with and preferences for care and support.

Methods

Using an explanatory sequential mixed methods design, we first conducted a secondary analysis of a subset of cross-sectional data from the ImplemeNtation of a community-baSed care Program for home dwelling senIoR citizEns (INSPIRE) population survey using descriptive analysis. Subsequently, we analyzed existing data from interviews in the parent study to help explain the survey results using applied thematic analysis. Results were organized according to adapted domains and concepts of the SELFIE framework and integrated via a joint display table.

Results

Of the parent population survey respondents, 2314 older adults indicating frailty were included in the quantitative arm of this study. Interview data was included from 7 older adults who indicated frailty. Support from health and social, formal and informal caregivers is diverse and anticipated to increase (e.g., for ‘care and assistance at home’ and ‘meal services’). Informal caregivers fulfilled various roles and while some older adults strongly relied on them for support, others feared burdening them. Most participants (93.5%) perceived their overall support to meet their needs; however, findings suggest areas (e.g., assessment of overall needs) which merit attention to optimize future care.

Conclusions

Given the anticipated demand for future care and support, we recommend efforts to prevent fragmentation between health and social as well as formal and informal care.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12877-022-03552-z.

Integrated Care for Multimorbidity Population in Asian Countries: A Scoping Review

Background:

The complex needs of patients with multiple chronic diseases call for integrated care (IC). This scoping review examines several published Asian IC programmes and their relevant components and elements in managing multimorbidity patients.

Method:

A scoping review was conducted by searching electronic databases encompassing Medline, Embase, Scopus, and Web of Science. Three key concepts – 1) integrated care, 2) multimorbidity, and 3) Asian countries – were used to define searching strategies. Studies were included if an IC programme in Asia for multimorbidity was described or evaluated. Data extraction for IC components and elements was carried out by adopting the SELFIE framework.

Results:

This review yielded 1,112 articles, of which 156 remained after the title and abstract screening and 27 studies after the full-text screening – with 23 IC programmes identified from seven Asian countries. The top 5 mentioned IC components were service delivery (n = 23), workforce (n = 23), leadership and governance (n = 23), monitoring (n = 15), and environment (n = 14); whist financing (n = 9) was least mentioned. Compared to EU/US countries, technology and medical products (Asia: 40%, EU/US: 43%-100%) and multidisciplinary teams (Asia: 26%, EU/US: 50%–81%) were reported less in Asia. Most programmes involved more micro-level elements that coordinate services at the individual level (n = 20) than meso- and macro-level elements, and programmes generally incorporated horizontal and vertical integration (n = 14).

Conclusion:

In the IC programmes for patients with multimorbidity in Asia, service delivery, leadership, and workforce were most frequently mentioned, while the financing component was least mentioned. There appears to be considerable scope for development.

Highlights

"We could be good partners if we work together": the perspectives of health and social service providers on the barriers to forming collaborative partnerships with social housing providers for older adults

BACKGROUND

Many older adults are aging-at-home in social housing. However, the lack of integration between housing and health services makes it difficult for older tenants to access needed supports. We examined barriers and facilitators health and social service providers face providing on-site services to older tenants.

METHODS

We conducted semi-structured qualitative interviews and focus groups with health and social service professionals (n = 58) in Toronto, Canada who provide community programs in support of older tenants who live in non-profit, rent-geared-to-income social housing. Interviews examined the barriers they faced in providing on-site services to older tenants.

FINDINGS

Service providers strongly believed that collaboration with on-site housing staff led to better health and housing outcomes for older tenants. Despite the recognized benefits of partnering with housing staff, service providers felt that their ability to work effectively in the building was dependent on the staff (particularly the superintendent) assigned to that building. They also identified other barriers that made it difficult to work collaboratively with the housing provider, including staffing challenges such as high staff turnover and confusion about staff roles, a lack of understanding among housing staff about the link between housing and health, challenges sharing confidential information across sectors, and complex and inefficient partnership processes.

CONCLUSION

Older adult tenants are increasingly vulnerable and in need of supports but the housing provider has a long history of ineffective partnerships with service providers driven by complex and inefficient staffing models, and an organizational culture that questions the role of and need for partnerships. Findings highlight the need for more effective integration of housing and health services. Simplified processes for establishing partnerships with service agencies and more opportunities for communication and collaboration with housing staff would ensure that services are reaching the most vulnerable tenants.

Assessing the scalability of an integrated falls prevention service for community-dwelling older people: a mixed methods study

Background

There is growing acknowledgement of the need for a phased approach to scaling up health interventions, beginning with an assessment of ‘scalability’, that is, the capacity of an individual intervention to be scaled up. This study aims to assess the scalability of a multi-component integrated falls prevention service for community-dwelling older people and to examine the applicability of the Intervention Scalability Assessment Tool (ISAT). The ISAT consists of 10 domains for consideration when determining the scalability of an intervention, and each domain comprises a series of questions aimed at examining readiness for scale-up.

Methods

Multiple methods were used sequentially as recommended by the ISAT: a review of policy documents, results from a service evaluation and falls-related literature; one-to-one interviews (n = 11) with key stakeholders involved in management and oversight of the service; and a follow-up online questionnaire (n = 10) with stakeholders to rate scalability and provide further feedback on reasons for their scores.

Results

Three of the ISAT domains were rated highly by the participants. Analysis of the qualitative feedback and documents indicated that the issue of falls prevention among older people was of sufficient priority to warrant scale-up of the service and that the service aligned with national health policy priorities. Some participants also noted that benefits of the service could potentially outweigh costs through reduced hospital admissions and serious injuries such as hip fracture. The remaining domains received a moderate score from participants, however, indicating considerable barriers to scale-up. In the qualitative feedback, barriers identified included the perceived need for more healthcare staff to deliver components of the service, for additional infrastructure such as adequate room space, and for an integrated electronic patient management system linking primary and secondary care and to prevent duplication of services.

Conclusions

Plans to scale up the service are currently under review given the practical barriers that need to be addressed. The ISAT provides a systematic and structured framework for examining the scalability of this multi-component falls prevention intervention, although the iterative nature of the process and detailed and technical nature of its questions require considerable time and knowledge of the service to complete.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12877-021-02717-6.

Implementing Integrated Care in Practice - Learning from MDTs Driving the Integrated Care Programme for Older Persons in Ireland

The importance of multidisciplinary teams (MDTs) as critical implementation drivers emerged from this case study conducted with three pioneer sites implementing integrated care for older persons in Ireland as part of the Integrated Care Programme for Older Persons (ICPOP). We describe the practices of MDTs learning to deliver integrated care in service delivery settings, including the framework, resourcing, strategies, challenges and barriers they encounter. The study was conducted by a team of researchers in collaboration with ICPOP at both national programme and pioneer site levels. Qualitative methods of participant observation, workshopping, and documentary analysis were used to build a rich description, and using organisational and systems lenses identification of critical factors as both themes and resources for learning. The case study suggests the MDT is an essential driver of integrated care delivery. For example, ICPOP MDTs working across pioneer sites develop new service models and care opportunities, troubleshoot and challenge the systemic status quo, and disrupt professional silos. However, they also deliver on programme goals. Nonetheless, progress is constrained by organisational factors including fragmented funding structures, high turnover of senior level decision-makers, a lack of multiannual funding and complex professional arrangements. This study finds ICPOP offers practical and timely insight to inform health system reform. It embraces the complexity of delivery at national, local and community levels. The MDT emerges as an essential mechanism to manage such complexity and deliver on wider reform goals such as patient-centredness and timely access.

Health system foundations for Sláintecare implementation in 2020 and beyond - co-producing a Sláintecare Living Implementation Framework with Evaluation: Learning from the Irish health system's response to COVID-19. A mixed-methods study protocol

All over the world, health systems are responding to the major shock of the COVID-19 pandemic. The virus is causing urgent and fast-paced change in the delivery of health and social care as well as highlighting pre-existing deficiencies and inequalities in the health system and broader society. In Ireland, COVID-19 is occurring during the second full year of Sláintecare’s implementation – Ireland’s 10-year plan for health reform to deliver universal access to timely, integrated care.

This research will coproduce a Living Implementation Framework with Evaluation (LIFE) linking evidence, policy and practice that feeds into real-world Sláintecare implementation. In partnership with senior leadership in the Sláintecare Programme Implementation Office, the Department of Health and the HSE, the researchers will scope, document, measure and analyse the Sláintecare relevant COVID-19 responses using qualitative and quantitative methods.

The LIFE will initially take the form of a live spreadsheet which contains the COVID-19 responses most relevant to Sláintecare. For each response, 3-4 indicators will be collected which enables monitoring overtime. The spreadsheet will be accompanied by a series of rapid reviews, narrative descriptions of multiple case studies, research papers, stakeholder engagement and formative feedback. These collectively make up the ‘LIFE’, informing dialogue with the project partners, which is happening in real time (living), influencing health policy and system decision-making and implementation as the project progresses. The LIFE will inform health system reform in Ireland in the months and years after the emergence of COVID-19 as well as contributing to international health systems and policy research.

Nursing Home Design and COVID-19: Balancing Infection Control, Quality of Life, and Resilience

Many nursing home design models can have a negative impact on older people and these flaws have been compounded by Coronavirus Disease 2019 and related infection control failures. This article proposes that there is now an urgent need to examine these architectural design models and provide alternative and holistic models that balance infection control and quality of life at multiple spatial scales in existing and proposed settings. Moreover, this article argues that there is a convergence on many fronts between these issues and that certain design models and approaches that improve quality of life, will also benefit infection control, support greater resilience, and in turn improve overall pandemic preparedness.

Conceptual framework: factors enabling collaborative healthcare and social services integration

Purpose

A conceptual framework for collaboratively based integrated health and social care (IHSC) integration is proposed to aid in understanding how to accomplish IHSC.

Design/methodology/approach

This model is based on extant literature of successfully IHSC initiatives.

Findings

The model aims to identify enabling integration factors that support collaborative integration efforts between healthcare and social services organizations. These factors include shared goals and vision, culture, leadership, team-based care, information sharing and communications, performance measurement and accountability agreements, and dedicated resources and financing. It also identifies factors that act as external influencers that can support or hinder integration efforts among collaborating organizations. These factors are geographic setting, funding models, governance structures, and public policies. These factors are intended to ensure that a realist lens is applied when trying to understand and explain IHSC.

Originality/value

This model is intended to provide a framework to support research, policy and implementation efforts.