A Policy Guide on Integrated Care (PGIC): Lessons Learned from EU Project INTEGRATE and Beyond

Cooperation Improvement in an Integrated Healthcare Network: A Social Network Analysis

Background

Cooperation is a core feature of integrated healthcare systems and an important link in their value-creating mechanism. The premise is that providers who cooperate can promote more efficient use of health services while improving health outcomes. We studied the performance of an integrated healthcare system in improving regional cooperation.

Methods

Using claims data and social network analysis, we constructed the professional network from 2004 to 2017. Cooperation was studied by analyzing the evolution of network properties at network and physician practice (node) level. The impact of the integrated system was studied with a dynamic panel model that compared practices that participated in the integrated system versus nonparticipants.

Results

The regional network evolved favourably towards cooperation. Network density increased 1.4% on average per year, while mean distance decreased 0.78%. At the same time, practices participating in the integrated system became more cooperative compared to other practices in the region: Degree (1.64e-03, p = 0.07), eigenvector (3.27e-03, p = 0.06) and betweenness (4.56e-03, p < 0.001) centrality increased more for participating practices.

Discussion

Findings can be explained by the holistic approach to patients' care needs and coordination efforts of integrated healthcare. The paper provides a valuable design for performance assessment of professional cooperation.

Highlights

Using claims data and social network analysis, we identify a regional cooperation network and conduct a panel analysis to measure the impact of an integrated care initiative on enhancing professional cooperation.Physician practices participating in the integrated system became more cooperative and improved their influence in the regional network more than non-participating practices.Integrated healthcare systems effectively incentivize cooperation through a holistic approach to patient care needs and coordination efforts.

How do clients with multiple problems and (in)formal caretakers coproduce integrated care and support? A longitudinal study on integrated care trajectories of clients with multiple problems

INTRODUCTION

Integrated care can create several advantages, such as better quality of care and better outcomes. These advantages apply especially to clients with multiple problems (CWMPs) who have multiple, interconnected needs that span health and social issues and require different health care (e.g., mental health care or addiction care), social care (e.g., social benefits) and welfare services at the same time. Integrated care is most often studied as a phenomenon taking place at the system, organizational, professional and clinical levels. Therefore, in many studies, clients seem to be implicitly conceptualized as passive recipients of care. Less research has been conducted on how clients and (in)formal caretakers coproduce integrated care.

METHODS

We performed a longitudinal study to investigate how CWPMs and (in)formal caretakers coproduce integrated care. Data were collected among CWMPs and their (in)formal caretakers in Rotterdam, the Netherlands. CWMPs' care trajectories were followed for 1-1.5 years. CWMPs were interviewed three times at an interval of 6 months (T0, T1, T2). Informal caretakers were interviewed three times (T0, T1, T2), and formal caretakers of 16 clients were interviewed twice (T1, T2). Data in the municipal record systems about participating CWMPs were also included.

RESULTS

Our study shows that the CWMPs' multidimensional needs, which should function as the organizing principle of integrated care, are rarely completely assessed at the start (first 6 weeks) of CWMPs' care trajectories. Important drivers behind this shortcoming are the urgent problems CWMPs enter the support trajectory with, their lack of trust in 'the government' and the complexity of their situations. We subsequently found two distinct types of cases. The highest level of integrated care is achieved when formal caretakers initiate an iterative process in which the CWMP's multidimensional needs are constantly further mapped out and interventions are attuned to this new information.

CONCLUSIONS

Our study indicates that integrated care is the joint product of formal caretakers and CWMPs. Integrated care however does not come naturally when CWMPs are 'put at the center'. Professionals need to play a leading role in engaging CWMPs to coproduce integrated care.

PATIENT CONTRIBUTION

CWMPs and their (in)formal caretakers participated in this study via interviews and contributed with their experiences of the process.

Integration or Fragmentation of Health Care? Examining Policies and Politics in a Belgian Case Study

BACKGROUND

Globally, health systems have been struggling to cope with the increasing burden of chronic diseases and respond to associated patient needs. Integrated care (IC) for chronic diseases offers solutions, but implementing these new models requires multi-stakeholder action and integrated policies to address social, organisational, and financial barriers. Policy implementation for IC has been little studied, especially through a political lens. This paper examines how IC policies in Belgium were developed over the last decade and how stakeholders have played a role in these policies.

METHODS

We used a case study design. After an exploratory document review, we selected three IC policies. We then interviewed 25 key stakeholders in the field of IC. The stakeholder analysis entailed a detailed mapping of the stakeholders' power, position, and interest related to the three selected policies. Interview participants included policy-makers, civil servants (from ministry of health and health insurance), representatives of health professionals' associations, academics, and patient organisations. Additionally, a processual analysis of IC policy processes (2007-2020) through literature review was used to frame the interviews by means of a chronic care policy timeline.

RESULTS

In Belgium, a variety of policy initiatives have been developed in recent years both at central and decentralised levels. The power analysis and policy position maps exposed tensions between federal and federated governments in terms of overlapping competence, as well as the implications of the power shift from federal to federated levels as a consequence of the 2014 state reform.

CONCLUSION

The 2014 partial decentralisation of healthcare has created fragmentation of decisive power which undermines efforts towards IC. This political trend towards fragmentation is at odds with the need for IC. Further research is needed on how public health policy competences and reform durability of IC policies will evolve.

Hospital at home for acute medical illness: The 21st century acute medical unit for a changing population

Recent trends across Europe show a year-on-year increase in the number of patients with acute medical illnesses presenting to hospitals, yet there are no plans for a substantial expansion in acute hospital infrastructure or staffing to address demand. Strategies to meet increasing demand need to consider the fact that there is limited capacity in acute hospitals and focus on new care models in both hospital and community settings. Increasing the efficiency of acute hospital provision by reducing the length of stay entails supporting acute ambulatory care, where patients receive daily acute care interventions but do not stay overnight in the hospitals. This approach may entail daily transfer between home and an acute setting for ongoing treatment, which is unsuitable for some patients living with frailty. Acute hospital at home (HaH) is a care model which, thanks to advances in point of care diagnostic capability, can provide a credible model of acute medical assessment and treatment without the need for hospital transfer. Investment and training to support scaling up of HaH are key strategic aims for integrated healthcare systems.

Implementing Asset-Based Integrated Care: A Tale of Two Localities

BACKGROUND

To date, few studies have examined the implementation of asset-based integrated care in the UK. This paper aims to address this gap in knowledge through examining the implementation of one model of asset-based integrated care, Local Area Coordination (LAC), within two localities in England.

METHODS

This paper draws upon data collected from two local authorities (site A and site B), which had both implemented LAC. Using a case study approach, qualitative data was collected from interviews with relevant stakeholders both internal and external to the local authorities. Data was analysed thematically.

RESULTS

The findings demonstrate the marked differences between the two sites' approaches to LAC, especially in relation to: the implementation process; impact; and their collaboration with other agencies and communities.

DISCUSSION

The evidence presented in this paper demonstrates that the implementation of LAC, as with most complex service innovations, is dependent on the interplay of organisational and people-based components. In particular, successful implementation depends on maintaining a common vision of what an intervention will achieve and how it will work in practice, continual engagement with the political and organisational leaders of influence, positively addressing the anxieties of existing services and professions, and working with community groups.

What are the priorities for the future development of integrated care? A scoping review

Purpose

“Integrated care” (IC) is an approach to health and social care delivery that aims to prevent problems arising from fragmented care systems. The collective content of the IC literature, whilst valuable, has become extensive and wide-ranging to such a degree that knowing what is most important in IC is a challenge. This study aims to address this issue.

Design/methodology/approach

A scoping review was conducted using Arksey and O'Malley's framework to determine IC priority areas.

Findings

Twenty-one papers relevant to the research question were identified. These included studies from many geographical regions, encompassing several study designs and a range of populations and sample sizes. The findings identified four priority areas that should be considered when designing and implementing IC models: (1) communication, (2) coordination, collaboration and cooperation (CCC), (3) responsibility and accountability and (4) a population approach. Multiple elements were identified within these priorities, all of which are important to ensuring successful and sustained integration of care. These included education, efficiency, patient centredness, safety, trust and time.

Originality/value

The study's findings bring clarity and definition to what has become an increasingly extensive and wide-ranging body of work on the topic of IC. Future research should evaluate the implementation of these priorities in care settings.

Vagueness and Ambiguity in Communication of Case Management: A Content Analysis in the Australian National Disability Insurance Scheme

Case management (CM) is an integrated care strategy, characterised by a set of actions to support person-centred planning, coordination of health and social services. Decades of CM, organisational psychology and occupational research highlight how vagueness and ambiguity in role communication can create role conflict and job stress, negatively impacts staff turnover, intra-organisational collaboration, job performance, and that poor communication of CM impedes policy, quality analysis service development and practice. We conducted a detailed top-down hierarchical, quality analysis of communication about CM roles and responsibilities in a Scheme for people with disability in Australia. The study used content analysis methods and the main actions as defined in a validated CM taxonomy (Appendix 1). We systematically searched and analysed 53 Scheme policy and practice documents of CM from 2013-2019. The results showed poor role communication with vagueness, ambiguity, gaps in the description of CM roles and responsibilities. Poor role communication has contributed to negative experiences and outcomes of CM actions of planning and coordination, as reported by CM users in many Scheme-related parliamentary inquiries, research, formal complaints, and decision appeals. The results reinforce the importance of an ontological approach in communication of CM roles and actions and provides learnings for integrated care roles across countries and contexts.

Implementing Mobile Health-Enabled Integrated Care for Complex Chronic Patients: Intervention Effectiveness and Cost-Effectiveness Study

Background

Integrated care can generate health and social care efficiencies through the defragmentation of care and adoption of patient-centered preventive models. eHealth can be a key enabling technology for integrated care.

Objective

The aim of this study was to assess the effectiveness and cost-effectiveness of the implementation of a mobile health (mHealth)-enabled integrated care model for complex chronic patients.

Methods

As part of the CONNECARE Horizon 2020 project, a prospective, pragmatic, two-arm, parallel implementation trial was held in a rural region of Catalonia, Spain. During 3 months, elderly patients with chronic obstructive pulmonary disease or heart failure and their carers experienced the combined benefits of the CONNECARE organizational integrated care model and the eHealth platform supporting it, consisting of a patient self-management app, a set of integrated sensors, and a web-based platform connecting professionals from different settings, or usual care. We assessed changes in health status with the 12-Item Short-Form Survey (SF-12), unplanned visits and admissions during a 6-month follow up, and the incremental cost-effectiveness ratio (ICER).

Results

A total of 48 patients were included in the integrated care arm and 28 patients receiving usual care were included in the control arm (mean age 82 years, SD 7 years; mean Charlson index 7, SD 2). Integrated care patients showed a significant increase in the SF-12 physical domain with a mean change of +3.7 (SD 8.4) (P=.004) and total SF-12 score with a mean change of +5.8 (SD 12.8) (P=.003); however, the differences in differences between groups were not statistically significant. Integrated care patients had 57% less unplanned visits (P=.004) and 50% less hospital admissions related to their main chronic diseases (P=.32). The integrated care program generated savings in different cost scenarios and the ICER demonstrated the cost-effectiveness of the program.

Conclusions

The implementation of a patient-centered mHealth-enabled integrated care model empowering the patient, and connecting primary, hospital, and social care professionals reduced unplanned contacts with the health system and health costs, and was cost-effective. These findings support the notion of system-wide cross-organizational care pathways supported by mHealth as a successful way to implement integrated care.

Implementing Mobile Health-Enabled Integrated Care for Complex Chronic Patients: Patients and Professionals' Acceptability Study

BACKGROUND

Integrated care (IC) can promote health and social care efficiency through prioritization of preventive patient-centered models and defragmentation of care and collaboration across health tiers, and mobile health (mHealth) can be the cornerstone allowing for the adoption of IC.

OBJECTIVE

This study aims to assess the acceptability, usability, and satisfaction of an mHealth-enabled IC model for complex chronic patients in both patients and health professionals.

METHODS

As part of the CONNECARE Horizon 2020 project, a prospective, pragmatic, 2-arm, parallel, hybrid effectiveness-implementation trial was conducted from July 2018 to August 2019 in a rural region of Catalonia, Spain. Home-dwelling patients 55 years and older with chronic conditions and a history of hospitalizations for chronic obstructive pulmonary disease or heart failure (use case [UC] 1), or a scheduled major elective hip or knee arthroplasty (UC2) were recruited. During the 3 months, patients experienced an mHealth-enabled IC model, including a self-management app for patients, a set of integrated sensors, and a web-based platform connecting professionals from different settings or usual care. The Person-Centered Coordinated Care Experience Questionnaire (P3CEQ) and the Nijmegen Continuity Questionnaire (NCQ) assessed person-centeredness and continuity of care. Acceptability was assessed for IC arm patients and staff with the Net Promoter Score (NPS) and the System Usability Scale (SUS).

RESULTS

The analyses included 77 IC patients, 58 controls who completed the follow-up, and 30 health care professionals. The mean age was 78 (SD 9) years in both study arms. Perception of patient-centeredness was similarly high in both arms (usual care: mean P3CEQ score 16.1, SD 3.3; IC: mean P3CEQ score 16.3, SD 2.4). IC patients reported better continuity of care than controls (usual care: mean NCQ score 3.7, SD 0.9; IC: mean NCQ score 4.0, SD 1; P=.04). The scores for patient acceptability (UC1: NPS +67%; UC2: NPS +45%) and usability (UC1: mean SUS score 79, SD 14; UC2: mean SUS score 68, SD 24) were outstanding. Professionals' acceptability was low (UC1: NPS -25%; UC2: NPS -35%), whereas usability was average (UC1: mean SUS score 63, SD 20; UC2: mean SUS score 62, SD 19). The actual use of technology was high; 77% (58/75) of patients reported physical activity for at least 60 days, and the ratio of times reported over times prescribed for other sensors ranged from 37% for oxygen saturation to 67% for weight.

CONCLUSIONS

The mHealth-enabled IC model showed outstanding results from the patients' perspective in 2 different UCs but lacked maturity and integration with legacy systems to be fully accepted by professionals. This paper provides useful lessons learned through the development and assessment process and may be of use to organizations willing to develop or implement mHealth-enabled IC for older adults.

Towards an Integrated Care Organisation from a CEO Perspective

Many experimental projects towards Person-Centred Care (PCC) are successful in the early stages, but founder when the attempt is made to scale them up to encompass the whole organisation. This case study therefore focusses on one manager's attempts to extend the successes of a preliminary project 'Etxean Ondo' that aimed to provide adequate support for the elderly living at home or in nursing homes, as well as for their families and care professionals. Through in-depth interviews with stakeholders, this qualitative study, based on Grounded Theory, sets out to analyse which behaviours, attitudes and values on the part of management appeared to favour full-integration of PCC in this wider context. Analysis of the data gathered allowed the researcher to generate an experimental case model which suggests how the extrinsic, intrinsic and transcendent motivation of stakeholders can be aligned with the goals of upper management to promote full-integration of PCC in such a way as to generate trust, increase participant engagement and create a win-win situation for all. Whilst this is clearly an experimental project, it is hoped that the model provided may prove helpful to other researchers and managers interested in pioneering this type of comprehensive organisational strategic change towards integration.

Integrated Care for Older Adults: A Struggle for Sustained Implementation in Northern Netherlands

Introduction:

Integrated care has been suggested as a promising solution to the disparities in access and sustained high quality long-term care emerging in Europe’s ageing population. We aim to gain a better understanding of context-specific barriers to and facilitators of implementation of integrated care by doing a retrospective assessment of seven years of Embrace. This Dutch integrated person-centred health service for older adults was based on two evidence-based models (the Chronic Care Model and the Kaiser Permanente Triangle). Despite successful deployment the programme ended in 2018. In this case study we assess the impact of the programme based on past evaluations, reflect on why it ended, lessons learned and ideas to take forward.

Discussion:

The majority of health outcomes were positive and the perceived quality of care improved, albeit no clear-cut savings were observed, and the costs were not balanced across stakeholders. The Embrace payment model did not support the integration of health services, despite reforms in long-term care in 2015.

Key lessons:

Enabling policy and funding are crucial to the sustained implementation of integrated person-centred health services. The payment model should incentivize the integration of care before the necessary changes can be made at organizational and clinical levels towards providing proactive and preventive health services.

From the service user association's perspective

Purpose

The aim of this study was to identify key components of integrated mental health and social care services that contribute to value for service users in Sweden.

Design/methodology/approach

An explorative research study design was used, based on data from four group interviews conducted in June and August 2017 with service user representatives.

Findings

The analysis resulted in eight subcategories reflecting components that were reported to contribute to value for service users. These subcategories were grouped into three main categories: (1) professionals who see and support the whole person, (2) organizational commitment to holistic care and (3) support for equal opportunities and active participation in society.

Research limitations/implications

The findings are primarily transferable to integrated mental health and social care services, as they emphasize key components that contribute to value for service users in these specific settings.

Practical implications

The complexity of integrated mental health and social care services requires coordination across the individual and organizational levels as well as ongoing dialogue and partnerships between service users, service user associations and health and social care organizations. In this integration, it is important that service users and service user associations not only are invited but also keen to participate in the design of care and support efforts.

Originality/value

Service User Associations (SUAs) can act as a bridge between county and municipal services through their participation in the development of local activities; at the regional and national levels, SUAs can help achieve more equitable integrated services. It is important that SUAs are not only invited but encouraged to actively participate in the design of such care and support efforts.

The Odyssey of Integration: Is Management its Achilles' Heel?

Introduction

The importance of management to the implementation of integrated care is recognised in evidence and practice. Despite this recognition, there is a lack of clarity about what 'good' management of integrated care looks like, if the competences are different to management for 'traditional' care, and how such competences can be acquired.

Theory and methods

This exploratory study is based on qualitative interviews with participants with extensive experience of implementing integrated care in senior professional, research, administrative and/or policy roles. It conceptualises management as working at 'strategic' and 'operational' levels.

Results

Management of integrated care was seen to require an ability to create networks across professions and organisations, to be comfortable with distributing responsibilities, and to thoroughly understand the wider system. Competences to support these new ways of working included an understanding of how to implement people-centredness, to have courage to challenge the status quo, and to demonstrate humility to learn from others. Structured development opportunities for managers were lacking, but seen as vital for the sustainability of change.

Discussion and conclusion

Management for integrated care remains an underdeveloped concept and practice. A first formulation of the competences necessary was achieved, but more work is urgently required to understand how to better prepare and support managers to achieve necessary changes in practice and culture.

Sharing a vision. Do participants in integrated care programmes have the same goals and objectives?

Integrating health and social care services remains one of the most difficult undertakings in the field of care delivery. One of the key requirements for success in integration programmes is a shared vision amongst care providers. Shared visions may contain views as to what the new services should look like, how it should operate and what it should be able to achieve. The paper reports findings of an evaluation of a service integration programme in the North of England. It confirms that a programme consensus on issues such as aims and objectives and programme logics is seen by participants as a key to success. Yet, the study also found that there is a specific window of opportunity in integration programmes when participating organisations start on relatively high levels of commitment and enthusiasm which tend to tail off relatively quickly. The paper closes with a discussion about the implications of the findings for programme designers and service planners.

The dialogic construction of patient involvement in patient-centred neurorehabilitation

This paper explores how the practice of patient involvement in neurorehabilitation is constructed in tension-riddled professional narratives. I adopt dialogic communication theory to focus on how involvement is constructed across different roles and voices. My analysis is based on an action research project that uses a dialogical communication perspective and participatory methods to explore patient-centred care through the eyes of healthcare professionals. I argue that patient involvement is constructed as a demanding process that requires memory, presence, communicative abilities and temporal understanding of personal needs. These requirements are not explicit in the situated institutionalized practices. As well, I show how the available involvement strategies are laced with taken for granted characteristics, which fall short in the situation that arises when patients do not have the ability to participate or play the role of an active patient. The findings in this paper contribute to the growing literature on patient-centred healthcare by empirically investigating how the discursive configuration of patient, health professional and institutional practices intertwine in producing certain inherent expectations, habits and taken for granted perspectives in care delivery. I also suggest that the findings can usefully be incorporated into patient-centred care design and organizational strategies in order to take into account both the patient, relatives and healthcare professionals as vital for creating a patient-centred practice, organization and professional environment.

The Nature of Patient- and Family-Centred Care for Young Adults Living with Chronic Disease and their Family Members: A Systematic Review

BACKGROUND AND AIM

The published literature addressing the nature of patient- and family-centred care (PFCC) among young adults (16-25 years old) living with chronic disease and their family members is diverse. The aim of this systematic review was to collect and interpretatively synthesise this literature to generate a conceptual understanding of PFCC in this age group.

METHOD

From an initial pool of 10,615 papers, 51 were systematically identified as relevant to the research question and appraised using the Critical Appraisal Skills Programme tools. A total of 24 papers passed the quality appraisal and proceeded to a qualitative meta-synthesis.

RESULTS

The qualitative meta-synthesis revealed three major elements of PFCC relevant to young adults living with chronic disease and their family members: (1) patients and practitioners felt able to engage with each other on an emotional and social level; (2) patients and families felt empowered to be part of the care process; and (3) patients and families experienced care as effective at addressing their individual needs.

CONCLUSION

There is agreement among young adult patients and families about what constitutes PFCC in a chronic disease setting, independent of the aetiology of the pathological process. Patients and families also have strong feelings about how practitioners can achieve PFCC in practice. These findings have implications for the delivery of health services to young adults living with chronic disease and their family members.