Beyond integrated care: challenges on the way towards population health management

Towards an integrative approach of healthcare: implementing positive health in three cases in the Netherlands

BACKGROUND

The healthcare system is under tremendous pressure. One possible solution towards relieving some of this pressure is to use Positive Health, which takes 'health' as a starting point, rather than 'illness'. Positive Health provides opportunities for stimulating integrated care.

METHODS

Three cases in the Netherlands are studied in this paper. Their way of working with Positive Health is investigated through semi-structured and narrative interviews, using realist-evaluation and thematic analyses.

RESULTS

Seven 'working elements' are identified that enhance the chances of successfully implementing Positive Health in practice (part 1). The interviews show that healthcare professionals have noticed that people adopt a healthier lifestyle and gain a greater degree of control over their own health. This boosts job satisfaction for healthcare professionals too. The organisations and professionals involved are enthusiastic about working with Positive Health, but still experience barriers (part 2).

CONCLUSIONS

The results of this study imply that implementing Positive Health in practice can facilitate collaboration between organisations and professionals from different disciplines, such as healthcare, welfare, and municipal health services. Operating from the perspective of a shared goal, professionals from different disciplines will find it easier to jointly organise activities to foster citizens' health. Additionally, more attention is paid to non-medical problems affecting people's well-being, such as loneliness or financial problems.

Supporting professionals to implement integrated, person-centered care for people with chronic conditions: the TARGET pilot study

OBJECTIVE

The TARGET program for integrated, person-centered care for people with chronic conditions offers primary care (PC) professionals a set of tools and trainings to actively engage in population segmentation and person-centered needs assessments (PCNAs). A pilot study was conducted to gain insight into the program's feasibility and acceptability, and identify preconditions for successful implementation.

DESIGN AND SETTING

Seven Dutch PC practices participated in a half-year pilot study starting in August 2020. We performed a review of the population segmentation tool, observed four training sessions and 15 PCNAs, and interviewed 15 professionals and 12 patients.

RESULTS

Regarding feasibility and acceptability, we found that the tools and trainings provided professionals with skills to use the segmentation tool and take a more coaching role in the well-appreciated PCNAs. Concerning implementation preconditions, we found that team commitment and network connections need improvement, although work pleasure increased and professionals generally wanted the program to continue.

CONCLUSIONS

While the content of the TARGET program is supported by its users, the implementation process, for instance team commitment to the program, needs more attention in future upscaling efforts.

More than meets the eye: a critical discourse analysis of a Swedish health system reform

BACKGROUND

In line with international trends acknowledging the importance of Primary Health Care (PHC) for improving population health and reducing health inequalities, the Swedish health system is undergoing a restructuring towards the coordinated development of a modern, equitable, accessible, and effective system, with PHC principles and functions at its core. Since discursive analyses of documents underpinning PHC reforms are scarce in Sweden and beyond, the aim of this study was to explore how the reorientation towards good quality and local health care has been represented in official government reports.

METHODS

Based on a policy-as-discourse analysis, four Swedish Government Official Reports underpinning the good quality and local health care reform were interrogated following four questions of Bacchi's "What's the Problem Represented to be?" (WPR) approach. By applying the first WPR question, concrete proposals guiding the reorientation were identified, analyzed and thematized into candidate problem representations. These problem representations were then analyzed in relation to previous empirical and conceptual research considering WPR questions two and three, which resulted in the development of three problem representations. Potential silences that the problem representations might produce were then identified by applying WPR question four.

RESULTS

The three problem representations connected the Swedish health system "problem" to a narrow mission, a siloed structure, and a front-line service disconnected, especially from the needs and preferences of individual patients. By representing the problem along these lines, the analysis also illustrated how the policy reorientation towards good quality and local health care risk silencing important PHC aspects such as health promotion, equitable access, and human resources.

CONCLUSION

The results from this study indicate that as discursively framed within concrete proposals, government official reports in Sweden represent the health system problem in particular ways and with these problem representations overlooking several aspects that are central to a health system characterized by PHC principles and functions. In the continued reorientation towards good quality and local health care, these silences might need to be acknowledged.

How to successfully implement population health management: a scoping review

BACKGROUND

Despite international examples, it is unclear for multisector initiatives which want to sustainably improve the health of a population how to implement Population Health Management (PHM) and where to start. Hence, the main purpose of this research is to explore current literature about the implementation of PHM and organising existing knowledge to better understand what needs to happen on which level to achieve which outcome.

METHODS

A scoping review was performed within scientific literature. The data was structured using Context-Mechanism-Outcome, the Rainbow model of integrated care and six elements of PHM as theoretical concepts.

RESULTS

The literature search generated 531 articles, of which 11 were included. Structuring the data according to these three concepts provided a framework that shows the skewed distribution of items that influence the implementation of PHM. It highlights that there is a clear focus on normative integration on the organisational level in 'accountable regional organisation'. There is less focus on the normative integration of 'cross domain business model', 'integrated data infrastructure', and 'population health data analytics', and overall the perspective of citizen and professionals, indicating possible gaps of consideration.

CONCLUSIONS

A first step is taken towards a practical guide to implement PHM by illustrating the depth of the complexity and showing the partial interrelatedness of the items. Comparing the results with existing literature, the analysis showed certain gaps that are not addressed in practice, but should be according to other frameworks. If initiators follow the current path in literature, they may be missing out on some important components to achieve proper implementation of PHM.

Factors that support readiness to implement integrated evidence-based practice to increase cancer screening

BACKGROUND

In 2015, the Centers for Disease Control and Prevention (CDC) funded the Colorectal Cancer Control Program (CRCCP), which partners with health care systems and primary care clinics to increase colorectal cancer (CRC) screening uptake. We interviewed CRCCP stakeholders to explore the factors that support readiness for integrated implementation of evidence-based interventions (EBIs) and supporting activities to promote CRC screening with other screening and chronic disease management activities in primary care clinics.

METHODS

Using the Consolidated Framework for Implementation Research (CFIR), we conducted a literature review and identified constructs to guide data collection and analysis. We purposively selected four CRCCP awardees that demonstrated ongoing engagement with clinic partner sites, willingness to collaborate with CDC and other stakeholders, and availability of high-quality data. We gathered background information on the selected program sites and conducted primary data collection interviews with program site staff and partners. We used NVivo QSR 11.0 to systematically pilot-code interview data, achieving a kappa coefficient of 0.8 or higher, then implemented a step-wise process to identify site-specific and cross-cutting emergent themes. We also included screening outcome data in our analysis to examine the impact of integrated cancer screening efforts on screening uptake.

RESULTS

We identified four overarching factors that contribute to clinic readiness to implement integrated EBIs and supporting activities: the funding environment, clinic governance structure, information sharing within clinics, and clinic leadership support. Sites reported supporting clinic partners' readiness for integrated implementation by providing coordinated funding application processes and braided funding streams and by funding partner organizations to provide technical assistance to support efficient incorporation of EBIs and supporting activities into existing clinic workflows. These actions, in turn, support clinic readiness to integrate the implementation of EBIs and supporting activities that promote CRC screening along with other screening and chronic disease management activities.

DISCUSSION

The selected CRCCP program sites supported clinics' readiness to integrate CRC EBIs and supporting activities with other screening and chronic disease management activities increasing uptake of CRC screening and improving coordination of patient care.

CONCLUSIONS

We identified the factors that support clinic readiness to implement integrated EBIs and supporting activities including flexible funding mechanisms, effective data sharing systems, coordination across clinical staff, and supportive leadership. The findings provide insights into how public health programs and their clinic partners can collectively support integrated implementation to promote efficient, coordinated patient-centered care.

A methodological framework for evaluating transitions in acute care services in the Netherlands to achieve Triple Aim

Objective

The accessibility of acute care services is currently under pressure, and one way to improve services is better integration. Adequate methodology will be required to provide for a clear and accessible evaluation of the various intervention initiatives. The aim of this paper is to develop and propose a Population Health Management(PHM) methodology framework for evaluation of transitions in acute care services.

Results

Our methodological framework is developed from several concepts found in literature, including Triple Aim, integrated care and PHM, and includes continuous monitoring of results at both project and population levels. It is based on a broad view of health rather than focusing on a specific illness and facilitates the evaluation of various intervention initiatives in acute care services in the Netherlands and distinctly explains every step of the evaluation process and can be applied to a heterogeneous group of patients.

Supplementary Information

The online version contains supplementary material available at 10.1186/s13104-022-06187-w.

The Long-Term Care with Focus on an Integrative Care Model in the Slovak Republic: A Pilot Study

An integrative care model is a challenge and the future of social and healthcare systems globally in establishing interdisciplinary cooperation. The integrative care model responds to the needs of patients suffering from various diseases as well as their families. Planning and policy making should involve professionals in both the medical and social care disciplines; additionally, the management and administrators of social and healthcare services, at both the national and community levels, are crucial in integrating health services. This article aims to present and describe the selection methods of functional groupings of municipalities as appropriate locations for implementing care practices for elderly, in this case an integrative social and health services model. The study employed an exploratory mixed methods design. The proposed methodology of the selection of the functional groupings of municipalities has a mixed-methodological character, consisting of quantitative as well as qualitative methods. Our research focused on quantitative data processing using two approaches: the multicriteria evaluation method to create a composite index and the ArcGIS system to express the geographical distribution of the value of the composite index. The qualitative document study was applied to analyses of community-based plans for health and social services. The methodology also includes an evaluation of municipalities, which was not the subject of our paper. Furthermore, the article suggests the need to consider other factors in connection with the methodology of the selection of functional groupings and explains some of its limitations in the discussion.

What Makes Integration of Chronic Care so Difficult? A Macro-Level Analysis of Barriers and Facilitators in Belgium

Introduction

Although many countries have been implementing integrated care, the scale-up remains difficult. Macro-level system barriers play an important role. By selecting three key policies, which have implemented integrated care in Belgium over the last 10 years, we aim to go beyond the identification of their specific barriers and facilitators to obtain an overarching generic view.

Methods

27 participants were purposefully selected, to include all important stakeholders involved on the macro-level in chronic care in Belgium. Semi-structured interviews were guided by a timeline of policies and an inductive thematic analysis was performed.

Results

Barriers and facilitators were identified on both health care and policy level. The major factors restraining the scale-up of integrated care are the fee-for-service reimbursement system, limited data sharing and the fragmentation of responsibilities between different levels of government. Remarkably, these factors strongly interact.

Discussion

This paper highlights the importance of homogenization of responsibilities of governments regarding integrated care and the interdependency of policy and health care system factors. A whole system change is needed instead of the current Belgian model of prolonged search for common ground between conflicting opinions. Political commitment and citizen participation will be crucial.

Measuring Population Health from a Broader Perspective: Assessing the My Quality of Life Questionnaire

Introduction

Population health perspectives increasingly focus on people's perception of resilience, ability to adapt and self-manage. The goal of this study is to determine whether the MijnKwaliteitVanLeven.nl ("MyQualityOfLife.nl") survey is a valid and reliable instrument for assessing the broader health perspectives at population level.

Methods

19,809 entries of the MyQualityOfLife.nl survey were used. To assess face validity, Huber's six dimensions of positive health were used as a framework for expert feedback. A confirmative factor analyses was done using the expert's item clustering, followed by data-driven explorative factor analyses and reliability tests.

Results

Experts distributed 74 of the 118 items over all six dimensions of positive health. The confirmatory factor analysis model based on expert classification was not confirmed. The subsequent exploratory factor analysis excluded most items based on factor loading and suggested two factors; 'quality of life' and 'daily functioning', both showing excellent reliability.

Conclusion

The MyQualityOfLife.nl survey can assess the broader concept of health in a population as well as 'quality of life' and 'daily functioning'. However, the survey can currently not evaluate several of the positive health dimensions separately. Further research is needed to determine whether this is due to the instrument or the positive health dimensions.

Preserving Care Delivery in Hard-to-Serve Regions: A Case Study of a Population Health System in the Swiss Lower Engadin

Introduction

Many countries report difficulties in preserving access to care in rural areas. This paper examines how hard-to-serve regions sustain care provision by transforming service delivery into population health systems.

Theory and methods

The paper builds on theory on care delivery in hard-to-serve regions. It presents a qualitative case study from the Lower Engadin, a rural high mountain valley in the Swiss Alps. Data sources include semi-structured interviews, participant observations, and documents. Data are analysed using recent conceptual research on population health systems.

Results

The case study illustrates how politicians and providers in the Lower Engadin resolved a care crisis and preserved access to care by forming a population health system. The system is organised around the Healthcare Centre Lower Engadin. Citizen-centred interventions target an aging population and include health promotion and prevention programs as well as case management based on an ambulatory-before-inpatient care strategy.

Conclusion

Hard-to-serve regions like the Lower Engadin preserve access to care by reorganising service delivery towards population health systems. The paper contributes to research on population health systems and care provision in rural areas.

Translating the Elements of Health Governance for Integrated Care from Theory to Practice: A Case Study Approach

INTRODUCTION

Against a paucity of evidence, a model describing elements of health governance best suited to achieving integrated care internationally was developed. The aim of this study was to explore how health meso-level organisations used, or planned to use, the governance elements.

METHODS

A case study design was used to offer two contrasting contexts of health governance. Semi-structured interviews were conducted with participants who held senior governance roles. Data were thematically analysed to identify if the elements of health governance were being used, or intended to be in the future.

RESULTS

While all participants agreed that the ten elements were essential to developing future integrated care, most were not used. Three major themes were identified: (1) organisational versus system focus, (2) leadership and culture, and, (3) community (dis)engagement.

DISCUSSION

Several barriers and enablers to the use of the elements were identified and would require addressing in order to make evidence-based changes.

CONCLUSION

Despite a clear international policy direction in support of integrated care this study identified a number of significant barriers to its implementation. The study reconfirmed that a focus on all ten elements of health governance is essential to achieve integrated care.

Are low-value care measures up to the task? A systematic review of the literature

BACKGROUND

Reducing low-value care is a core component of healthcare reforms in many Western countries. A comprehensive and sound set of low-value care measures is needed in order to monitor low-value care use in general and in provider-payer contracts. Our objective was to review the scientific literature on low-value care measurement, aiming to assess the scope and quality of current measures.

METHODS

A systematic review was performed for the period 2010-2015. We assessed the scope of low-value care recommendations and measures by categorizing them according to the Classification of Health Care Functions. Additionally, we assessed the quality of the measures by 1) analysing their development process and the level of evidence underlying the measures, and 2) analysing the evidence regarding the validity of a selected subset of the measures.

RESULTS

Our search yielded 292 potentially relevant articles. After screening, we selected 23 articles eligible for review. We obtained 115 low-value care measures, of which 87 were concentrated in the cure sector, 25 in prevention and 3 in long-term care. No measures were found in rehabilitative care and health promotion. We found 62 measures from articles that translated low-value care recommendations into measures, while 53 measures were previously developed by institutions as the National Quality Forum. Three measures were assigned the highest level of evidence, as they were underpinned by both guidelines and literature evidence. Our search yielded no information on coding/criterion validity and construct validity for the included measures. Despite this, most measures were already used in practice.

CONCLUSION

This systematic review provides insight into the current state of low-value care measures. It shows that more attention is needed for the evidential underpinning and quality of these measures. Clear information about the level of evidence and validity helps to identify measures that truly represent low-value care and are sufficiently qualified to fulfil their aims through quality monitoring and in innovative payer-provider contracts. This will contribute to creating and maintaining the support of providers, payers, policy makers and citizens, who are all aiming to improve value in health care.