Measuring horizontal integration among health care providers in the community: an examination of a collaborative process within a palliative care network

Improving Clinician Communication through Action Research

There are many challenges to interdisciplinary communication in home care. Management often takes a top-down approach, instructing home care clinicians on methods to improve communication. In this pretest-posttest intervention study, a bottom-up approach was taken using a focus group to allow home care clinicians to identify, develop, and implement strategies to share critical clinical and social information. The participants in the intervention group were compared with a control group who did not participate in the focus group. We found that empowering home care clinicians to develop strategies to improve interdisciplinary communication was beneficial in improving interdisciplinary collaboration. Actively involving home care clinicians in identifying issues and developing solutions may lead to improved collaboration.

Lagging coverage for mental health services among children and adolescents through home and community-based Medicaid waivers

PROBLEM

Many states cover mental health home and community-based services (HCBS) for youth through 1915(c) Medicaid HCBS waivers that allow states to waive certain Medicaid eligibility criteria and define high-risk populations based on age, medical condition(s), and disability status. We sought to evaluate how States are covering children and adolescents with mental health needs through 1915(c) waivers compared to other youth waiver populations.

METHODS

Data elements were extracted from Medicaid 1915(c) approved waivers applications for all included waivers targeting any pediatric age range through October 31, 2018. Normalization criteria were developed and an aggregate overall coverage score and level of funding per person per waiver were calculated for each waiver.

FINDINGS

One hundred and forty-two waivers across 45 states were included in this analysis. Even though there was uniformity in the Medicaid applications, there was great heterogeneity in how waiver eligibility, transition plans, services covered, and wait lists were defined across group classifications. Those with mental health needs (termed serious emotional disturbance) represented 5% of waivers with the least annual funding per person per waiver.

CONCLUSIONS

We recommend greater links between public policy, infrastructure, health care providers, and a family-centered approach to extend coverage and scope of services for children and adolescents with mental health needs.

Inter-organisational collaboration in palliative care trajectories for nursing home residents: A nation-wide mixed methods study among key persons

Introduction

Multiple care organisations, such as home care services, nursing homes and hospitals, are responsible for providing an appropriate response to the palliative care needs of older people admitted into long-term care facilities. Integrated palliative care aims to provide seamless and continuous care. A possible organisational strategy to help realise integrated palliative care for this population is to create a network in which these organisations collaborate. The aim is to analyse the collaboration processes of the various organisations involved in providing palliative care to nursing home residents.

Method

A sequential mixed-methods study, including a survey sent to 502 participants to evaluate the collaboration between home and residential care, and between hospital and residential care, and additionally three focus group interviews involving a purposive selection among the survey participants. Participants are key persons from the nursing homes, hospitals and home care organisations that are part of the 15 Flemish palliative care networks dispersed throughout the region of Flanders, Belgium.

Results

Survey data were gathered from 308 key persons (response rate: 61%), and 16 people participated in three focus group interviews. Interpersonal dimensions of collaboration are rated higher than structural dimensions. This effect is statistically significant. Qualitative analyses identified guidelines, education, and information-transfer as structural challenges. Additionally, for further development, members should become acquainted and the network should prioritise the establishment of a communication infrastructure, shared leadership support and formalisation.

Discussion

The insights of key persons suggest the need for further structuration and can serve as a guideline for interventions directed at improving inter-organisational collaboration in palliative care trajectories for nursing home residents.

Health Care Coordination Theoretical Frameworks: a Systematic Scoping Review to Increase Their Understanding and Use in Practice

BACKGROUND

Care coordination is crucial to avoid potential risks of care fragmentation in people with complex care needs. While there are many empirical and conceptual approaches to measuring and improving care coordination, use of theory is limited by its complexity and the wide variability of available frameworks. We systematically identified and categorized existing care coordination theoretical frameworks in new ways to make the theory-to-practice link more accessible.

METHODS

To identify relevant frameworks, we searched MEDLINE®, Cochrane, CINAHL, PsycINFO, and SocINDEX from 2010 to May 2018, and various other nonbibliographic sources. We summarized framework characteristics and organized them using categories from the Sustainable intEgrated chronic care modeLs for multi-morbidity: delivery, FInancing, and performancE (SELFIE) framework. Based on expert input, we then categorized available frameworks on consideration of whether they addressed contextual factors, what locus they addressed, and their design elements. We used predefined criteria for study selection and data abstraction.

RESULTS

Among 4389 citations, we identified 37 widely diverse frameworks, including 16 recent frameworks unidentified by previous reviews. Few led to development of measures (39%) or initiatives (6%). We identified 5 that are most relevant to primary care. The 2018 framework by Weaver et al., describing relationships between a wide range of primary care-specific domains, may be the most useful to those investigating the effectiveness of primary care coordination approaches. We also identified 3 frameworks focused on locus and design features of implementation that could prove especially useful to those responsible for implementing care coordination.

DISCUSSION

This review identified the most comprehensive frameworks and their main emphases for several general practice-relevant applications. Greater application of these frameworks in the design and evaluation of coordination approaches may increase their consistent implementation and measurement. Future research should emphasize implementation-focused frameworks that better identify factors and mechanisms through which an initiative achieves impact.

What is palliative care? Perceptions of healthcare professionals

Background

Despite increased attention and knowledge in palliative care, there is still confusion concerning how to interpret the concept of palliative care and implement it in practice. This can result in difficulties for healthcare professionals in identifying patients whom would benefit from palliative care, which, in turn, could lead to a delay in meeting patients’ needs.

Aim

To explore healthcare professionals’ perceptions of palliative care.

Method

Data were collected through twelve interprofessional focus group interviews in community care and hospital wards in south Sweden (n = 74). All interviews were analysed with latent content analysis.

Results

Three domains were revealed: first, a blurred conceptual understanding as participants described palliative care using synonyms, diagnoses, phases, natural care and holism; second, a challenge to communicate transitions concerned the importance of how and when the transition to palliative care was communicated and documented; finally, a need for interprofessional collaboration was described as well as the consequences for severely ill persons, relatives and healthcare professionals when it was not established.

Conclusion

The perceptions about how to interpret palliative care differed as well as when palliative care should be offered and decided, which might have practical consequences. How long a person has left to live is of great significance for decision‐making, caregiving and preparation in palliative care. The challenge is to use interprofessional communication to promote understanding and collaborate across varied care levels. Integrating palliative care across diverse care levels could be one way to reduce the ambiguity of palliative care.

An Instrument to Measure Maturity of Integrated Care: A First Validation Study

INTRODUCTION

Lessons captured from interviews with 12 European regions are represented in a new instrument, the B3-Maturity Model (B3-MM). B3-MM aims to assess maturity along 12 dimensions reflecting the various aspects that need to be managed in order to deliver integrated care. The objective of the study was to test the content validity of B3-MM as part of SCIROCCO (Scaling Integrated Care into Context), a European Union funded project.

METHODS

A literature review was conducted to compare B3-MM's 12 dimensions and their measurement scales with existing measures and instruments that focus on assessing the development of integrated care. Subsequently, a three-round survey conducted through a Delphi study with international experts in the field of integrated care was performed to test the relevance of: 1) the dimensions, 2) the maturity indicators and 3) the assessment scale used in B3-MM.

RESULTS

The 11 articles included in the literature review confirmed all the dimensions described in the original version of B3-MM. The Delphi study rounds resulted in various phrasing amendments of indicators and assessment scale. Full agreement among the experts on the relevance of the 12 B3-MM dimensions, their indicators, and assessment scale was reached after the third Delphi round.

CONCLUSION AND DISCUSSION

The B3-MM dimensions, maturity indicators and assessment scale showed satisfactory content validity. While the B3-MM is a unique instrument based on existing knowledge and experiences of regions in integrated care, further testing is needed to explore other measurement properties of B3-MM.

Indicators and Measurement Tools for Health Systems Integration: A Knowledge Synthesis

Background:

Despite far reaching support for integrated care, conceptualizing and measuring integrated care remains challenging. This knowledge synthesis aimed to identify indicator domains and tools to measure progress towards integrated care.

Methods:

We used an established framework and a Delphi survey with integration experts to identify relevant measurement domains. For each domain, we searched and reviewed the literature for relevant tools.

Findings:

From 7,133 abstracts, we retrieved 114 unique tools. We found many quality tools to measure care coordination, patient engagement and team effectiveness/performance. In contrast, there were few tools in the domains of performance measurement and information systems, alignment of organizational goals and resource allocation. The search yielded 12 tools that measure overall integration or three or more indicator domains.

Discussion:

Our findings highlight a continued gap in tools to measure foundational components that support integrated care. In the absence of such targeted tools, “overall integration” tools may be useful for a broad assessment of the overall state of a system.

Conclusions:

Continued progress towards integrated care depends on our ability to evaluate the success of strategies across different levels and context. This study has identified 114 tools that measure integrated care across 16 domains, supporting efforts towards a unified measurement framework.

Measuring healthcare integration: Operationalization of a framework for a systems evaluation of palliative care structures, processes, and outcomes

BACKGROUND

Healthcare integration is a priority in many countries, yet there remains little direction on how to systematically evaluate this construct to inform further development. The examination of community-based palliative care networks provides an ideal opportunity for the advancement of integration measures, in consideration of how fundamental provider cohesion is to effective care at end of life.

AIM

This article presents a variable-oriented analysis from a theory-based case study of a palliative care network to help bridge the knowledge gap in integration measurement.

DESIGN

Data from a mixed-methods case study were mapped to a conceptual framework for evaluating integrated palliative care and a visual array depicting the extent of key factors in the represented palliative care network was formulated.

SETTING/PARTICIPANTS

The study included data from 21 palliative care network administrators, 86 healthcare professionals, and 111 family caregivers, all from an established palliative care network in Ontario, Canada.

RESULTS

The framework used to guide this research proved useful in assessing qualities of integration and functioning in the palliative care network. The resulting visual array of elements illustrates that while this network performed relatively well at the multiple levels considered, room for improvement exists, particularly in terms of interventions that could facilitate the sharing of information.

CONCLUSION

This study, along with the other evaluative examples mentioned, represents important initial attempts at empirically and comprehensively examining network-integrated palliative care and healthcare integration in general.

Evaluating Stakeholder-Identified Barriers in Accessing Palliative Care at an NCI-Designated Cancer Center with a Rural Catchment Area

BACKGROUND

The new Commission on Cancer (CoC) accreditation standards encompass palliative care (PC) and a patient-centered approach, including specific quality measurements and outcomes. However, cancer centers differ in their interpretation of the CoC standards for PC in level of integration in the care trajectory and services provided.

OBJECTIVE

The aim of this study was to identify existing barriers in accessing PC services for cancer patients at a National Cancer Institute (NCI)-designated academic cancer center with a rural catchment area, using the CoC guidelines as a point of reference.

METHODS

This study utilized a cross-sectional qualitative design and conventional content analysis. Subjects were faculty/staff from the cancer center or from community affiliates located outside the main campus. Measurement was by semistructured qualitative interviews. Forty-two interviews were included in the final sample: clinicians, administrative support staff, and service support personnel.

RESULTS

Four themes were developed from the analysis focusing on barriers to PC integration: (1) fragmentation of services, (2) unclear pathways and triggers for referral, (3) demand exceeds available practitioners, and (4) insufficient or inadequate education for patients and oncology providers.

CONCLUSIONS

This study highlights aspects of integration of PC that can be enhanced from a process, education, and systems perspective with a particular focus on the care coordination of a rural cancer population.