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

The role of primary health care in improving health status, financial protection and health equity in the context of China's health system reform

BACKGROUND

Stronger primary health care (PHC) is critical to achieving the United Nations' Sustainable Development Goals. However, there is scarce evidence on the impact of PHC on health system performance in developing countries. Since 2009, China has implemented an ambitious health system reform, among which PHC has received unprecedented attention. This study investigates the role of PHC resource in improving health status, financial protection and health equity.

METHODS

We obtained province-level and individual-level data to conduct a longitudinal study across the period of China's health system reform. The dependent variables included health outcomes and financial protection. The independent variables were the number of PHC physicians and share of PHC physicians in all physicians. Mixed-effect models were used for adjusted associations.

RESULTS

From 2003 to 2017, the number of PHC physicians slightly increased by 31.75 per 100,000 persons and the share of PHC physicians in all physicians increased by 3.62 percentage points. At the province level, greater PHC physician density was positively associated with life expectancy, negatively associated with age-standardized excess mortality, infectious disease mortality, perinatal mortality low birth weight, as well as the share of health expenses in total consumption expenses. At the individual and household level, greater PHC physician density was positively associated with self-assessed health, and negatively associated with incidence of catastrophic health expenditures. Compared to other quintiles, the poorest quintile benefited more from PHC physician density.

CONCLUSIONS

In China, an increased PHC physician supply was associated with improved health system performance. While China's PHC system has been strengthened in the context of China's health system reforms, further effective incentives should be developed to attract more qualified PHC workers.

Turning Strategy into Action - Using the ECHO Model to Empower the Australian Workforce to Integrate Care

Introduction

Children's Health Queensland (CHQ) established a telementoring hub in Queensland, using the Project ECHO® model, to pilot and scale a range of virtual communities of practice (CoP) to empower the Australian workforce to integrate care.

Description

The establishment of the first Project ECHO hub in Queensland facilitated the implementation of a variety of child and youth health CoP that strategically aligned to the organisation's approach to integrate care through workforce development. Subsequently, other organisations nationally have also been trained to implement and replicate the ECHO model to effect more integrated care through CoPs in other priority areas.

Discussion

Findings from a database audit and desktop analysis of project documentation highlighted that using the ECHO model was effective in establishing co-designed and interprofessional CoP to support a cross-sector workforce to deliver more integrated care.

Conclusion

CHQ's use of Project ECHO highlights an intentional approach to establishing virtual CoP to build workforce capability to integrate care. The approach explored in this paper highlights the value of workforce collaboration amongst non-traditional partners to foster more integrated care.

Integrated People-Centred Care in Canada – Policies, Standards, and Implementation Tools to Improve Outcomes

Introduction:

Despite the national and international policy commitment to implement integrated health systems, there is an absence of national standards that support evidence-based design, implementation, and monitoring for improvement. Health Standards Organization (HSO)’s CAN/HSO 76000:2021 – Integrated People-Centred Health Systems (IPCHS) National Standard of Canada (NSC) has been developed to help close this gap. This manuscript outlines the policy context and the process taken to develop the IPCHS standard.

Description:

The IPCHS standard is built around 10 design principles with detailed, action-oriented criteria and guidance for policy makers and health system partners. The IPCHS standard was co-designed with a technical committee that included balanced representation of policy makers, health system decision-makers, Indigenous leaders, providers, patients, caregivers, and academics. Additional feedback was received from a diverse audience during two public review periods and targeted consultation via interviews. This qualitative feedback, combined with the evidence reviews completed by the technical committee, informed the final content of the IPCHS standard.

Discussion:

The IPCHS standard was developed through a co-design process and complements existing frameworks by providing 66 detailed, action-oriented criteria, with specific guidance. The co-design process and consultations resulted in increased awareness and capacity among policy makers and health system partners. Supplementary tools are also in development to facilitate implementation and monitoring of progress and outcomes. This manuscript was developed in collaboration with technical committee members and HSO staff who led the targeted consultation and adoption of the IPCHS standard in six integrated care networks.

Conclusion:

Implementing integration strategies requires that we create and sustain a culture of continuous improvement and learning. Key lessons from the development process focused on the importance of co-design, embedding people-centred practices throughout the standard, formal yet iterative methodology inclusive of broad consultation, clear accountability for both policy makers and system partners, tools that support action and can be adapted to local context and level of integrated system maturity.

Measuring the Success of a Project ECHO Implementation: Results from an International e-Delphi Study

There is an increasing global need for organisations to utilise high-quality telementoring models to support workforce development and mentorship. Project ECHO is a validated telementoring model that has been adopted by over 700 organisations globally across multiple sectors. To date there is no consolidated list of success indicators by which organisational teams can assess or benchmark their implementation of Project ECHO across sectors. An e-Delphi methodology was adopted to facilitate a comprehensive means of identifying indicators that could be used to assess the implementations of Project ECHO globally. This paper presents a consolidated framework of indicators that support teams to assess their implementation of Project ECHO. These indicators have been derived by an international panel of experts across the healthcare, education, and university sectors. The final framework identified 54 distinct indicators across four domains: (1) spoke participant engagement, (2) ECHO Hub/teleECHO Network design and operation, (3) ECHO Hub team engagement and (4) Local Impact. This paper highlights that Project ECHO implementation indicators can vary between being dynamic, static, and iterative, depending on the phase of implementation. These findings are significant because they are generalisable to any organisation/sector implementing Project ECHO or similar telementoring models.

Supplementary Information

The online version contains supplementary material available at 10.1007/s43477-022-00050-7.

Navigate Your Health: A Case Study of Organisational Learnings from an Integrated Care Pilot for Children and Young People in Care

Introduction:

Three peak organisations in Queensland, Australia partnered with consumers and other health and social sector partners to co-design and pilot the first known integrated, health navigation model to improve outcomes for children and young people in care in Australia.

Description:

An Organisational Learning theoretical lens has been used to present a narrative case study of findings structured as key learnings from the Navigate Your Health pilot to inform quality improvement, scalability and program sustainability. A developmental evaluation was completed whereby semi-structured interviews, focus groups, surveys, chart reviews, database excerpts and economic modelling was completed alongside project documentation analyses to create an evaluation framework.

Discussion:

Findings highlighted the agency partners’ drive to foster a more integrated and person-centred approach to care. The pilot’s aim of improving health outcomes for a vulnerable population were achieved through a co-designed process which provided additional insights regarding partnerships, improvement, scalability and sustainability.

Conclusion:

Inter-agency responses to system fragmentation provide significant organisational learning opportunities. System integration is achievable through strengthened partnerships that can be sustained beyond a pilot phase to improve health outcomes for vulnerable/priority populations.

Executive Decision-Making: Piloting Project ECHO® to Integrate Care in Queensland

Introduction:

A Queensland project team secured grant funding to pilot Project ECHO®, a telementoring model, to drive vertical and horizontal integration across paediatric, education and primary care services. This study sought to understand what influenced healthcare executives’ decision-making processes to organisationally commit to and financially invest in the pilot proposal within an organisational context.

Theory and Methods:

A phenomenological approach methodology was adopted to investigate healthcare executives’ conscious decision-making processes. Semi-structured interviews with key stakeholders were conducted alongside project documentation analyses to create a thematic framework.

Results:

The qualitative thematic analysis identified five key themes that influenced the decision-making processes of healthcare executives to invest in Project ECHO® as an integrated care pilot. The themes were: (i) personal experiences, (ii) benefits, (iii) risks, (iv) partnerships, and (v) timing. Executives’ reflections explored how their decision-making processes considered the intrapreneurial project team as an indicator of future sustainability.

Discussion:

Findings highlighted healthcare intrapreneurs’ drive to foster more integrated and people-centred approaches to care. Intrapreneurial aims of financial sustainability, ongoing improvement and scalability of the proposal positively influenced investment confidence.

Conclusion:

Intrapreneurial champions must provide a compelling narrative to convince executive decision-makers that benefits will outweigh risks, that integration is achievable through strengthened partnerships as well as future sustainability beyond the pilot phase.

Distributive Leadership Within an Emerging Network of Integrated Youth Health Centres: A Case Study of Foundry

Background

Distributive leadership has been proposed as an effective means towards achieving integrated health services. This study draws from the case of Foundry, a network of integrated youth health centres in British Columbia, Canada, and explores the function and impact of distributive leadership in the context of a large-scale effort towards integrated service delivery for youth experiencing mental health and substance use challenges.

Methods

Qualitative data was obtained from a developmental evaluation of Foundry using a longitudinal, ethnographic approach. Over 150 participants involved in the development of six Foundry centres were interviewed individually or in focus groups. Purposive and theoretical sampling strategies were used to maximize the diversity of perspectives represented in the data set.

Results and Discussion

Distributive leadership was observed to be a facilitator for achieving service and system-level integration. Distributive leadership was effective in promoting streamlined service provision, and coordinating efforts towards optimized access to care. A new culture of leadership emerged through collaboration and relationship-building based on a common value system to prioritize youth needs.

Conclusion

As Foundry, and other integrated youth services, continues to expand, distributive leadership shows promise in assuring diverse and coordinated input for integrating services.

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.

Relationships Among Structures, Team Processes, and Outcomes for Service Users in Quebec Mental Health Service Networks

Background:

Few studies have identified and compared profiles of mental health service networks (MHSN) in terms of structures, processes, and outcomes, based on cluster analyses and perceptions of team managers, MH professionals and service users. This study assessed these associations in Quebec metropolitan, urban and semi-urban MHSN.

Methods:

A framework adapted from the Donabedian model guided data management, and cluster analyses were used to identify categories. Study participants included team managers (n = 45), MH professionals (n = 311) and service users (n = 327).

Results:

For all three MHSN, a common outcome category emerged: service users with complex MH problems and negative outcomes. The Metropolitan network reported two categories for structures (specialized MH teams, primary care MH teams) and processes (senior medical professional, psychosocial professionals), and outcomes (middle-age men with positive outcomes, older women with few MH problems). The Urban and Semi-urban networks revealed one category for structures (all teams) and service user (young service users with drug disorders), but two for processes (psychosocial professionals: urban, all professionals: semi-urban).

Conclusion:

The Metropolitan MHSN showed greater heterogeneity regarding structures and team processes than the other two MHSN. Service user outcomes were largely associated with clinical characteristics, regardless of network configurations for structures and team processes.

A Realist Synthesis of Literature Informing Programme Theories for Well Child Care in Primary Health Systems of Developed Economies

INTRODUCTION

Well-child Care is the provision of preventative health care services for children and their families. The approach, however, to the universal provision of those services is contentious.

METHODS

We undertook a realist synthesis to enhance understanding of the theoretical mechanisms driving Well-child Care by searching for published and grey literature from multiple databases.

FINDINGS

Well-child Care is re-conceptualised as an integrated program delivered in the continuum of pregnancy, infancy and childhood. Depending on the context, Well-child Care can be a policy, a strategy, or an actual clinical practice that promotes child and family health. The main mechanisms include: role, training and continuity of health providers; administrators' views of the return of investment on achieved outcomes; access to services by families; and the adaptation of programs to meet the dynamic needs of stakeholders. Evidence indicates that for most outcomes, Well-child Care is best delivered in partnerships between community health, social care, and early childhood education sectors.

CONCLUSIONS

We conclude that Well-child Care policy and program leaders should shift their focus to the integration of: human and physical resources; policy instruments; and shared agreement on outcomes measures across health, social and education sectors. In addition, countries should work towards strengthening universal early education programs and parents' health literacy regarding child development, health and safety.