Impact of Integrated Care on Patient-Related Outcomes Among Older People - A Systematic Review

The impact of an integrative healthcare system on longevity in a nonagenarian population in Northern Mexico: an observational study

BACKGROUND

Despite the growth in the older population, there is a noticeable research gap regarding integrative health systems for older people and their impact on longevity in nonagenarians. This study aimed to evaluate the effect of an integrative health system consisting of medical services, recreational facilities, and housing on longevity in a population of nonagenarians in Northern Mexico.

METHODS

This was a cross-sectional, retrospective, descriptive-analytical study in which we measured and analyzed medical history such as number of hospitalizations, visits to geriatric consultation, hypertension, history of chronic pain, polypharmacy, dementia, rheumatic disease, diabetes mellitus, insomnia, depression, ischemic cardiomyopathy, among others. We also measured social engagement and number of caregivers. A logistic regression was performed to evaluate the predictors of mortality in this population.

RESULTS

We included one hundred and ninety-five nonagenarians with a mean (SD) age of 94 (4.2) years and of which 112 (55.7%) were female. The findings from logistic regression analysis indicated that a higher frequency of hospitalizations was associated with an elevated mortality risk (OR = 1.272, p = 0.049). Conversely, increased visits to geriatric consultation services as primary care were linked to a reduced mortality risk (OR = 0.953, p = 0.002). Additionally, social engagement displayed a protective effect (OR = 0.336, p = 0.05).

CONCLUSIONS

This study highlighted the role of systemic health approaches in extending life through insights into nonagenarian patients' involvement in primary care, as measured by consultation frequency, and participation in social activities, mitigating mortality risks. Meanwhile, it emphasized the potential consequences of higher hospitalization rates on increased mortality risk.

Differential Effect of Patient- and Provider-Level Factors on Patient Satisfaction Scores in Academic General Internal Medicine Clinics

OBJECTIVE

Determine whether patient-level or provider-level factors have greater influence on patient satisfaction scores in an academic general internal medicine clinic.

METHODS

Two years of data (2017-2019) from the Clinician and Group Consumer Assessment of Healthcare Providers and Systems (CGCAHPS) surveys from ambulatory internal medicine clinic visits in an academic health center located in the Midwest United States were used. Patient satisfaction was measured using the overall provider satisfaction score (0-10), dichotomized with 9-10 defined as satisfactory and 0-8 as unsatisfactory. Provider-level independent variables included age, sex, race/ethnicity, provider type, service type, clinical effort, academic rank, and years since graduation. Patient-level factors included age, sex, race/ethnicity, education, and Epic Risk Score. Generalized mixed-effects logistic regression models were used to investigate associations between top-box satisfaction score and patient- and provider-level factors, accounting for the nesting of patients within providers.

RESULTS

Thirty-three providers and 4597 patients were included in the analysis. Male providers (OR, 1.57; 95% CI, 1.00, 2.47), minority group 2 (OR, 3.54; 95% CI, 1.24, 10.07) and minority group 3 (OR, 6.04; 95% CI, 1.45, 25.12), faculty (OR, 3.83; 95% CI, 1.56, 9.36), and primary care providers (OR, 5.60; 95% CI, 1.62, 19.34) had increased odds of having a top-box rating compared with females, minority group 1, advanced practice providers, and perioperative providers respectively. Age was the only patient independent correlate of top-box rating with a 3% increased odds of top-box rating for every year increase in age (OR, 1.03; 95% CI 1.02, 1.03).

CONCLUSIONS

In this academic general internal medicine clinic, top-box satisfaction scores were more strongly associated with provider-level factors, including provider race/ethnicity, provider type, and service type, as opposed to patient-level factors. Further research is needed to confirm these findings and identify potential system-level interventions.

Patterns of inpatient acute care and emergency department utilization within one year post-initial amputation among individuals with dysvascular major lower extremity amputation in Ontario, Canada: A population-based retrospective cohort study

INTRODUCTION

Lower extremity amputation (LEA) is a life altering procedure, with significant negative impacts to patients, care partners, and the overall health system. There are gaps in knowledge with respect to patterns of healthcare utilization following LEA due to dysvascular etiology.

OBJECTIVE

To examine inpatient acute and emergency department (ED) healthcare utilization among an incident cohort of individuals with major dysvascular LEA 1 year post-initial amputation; and to identify factors associated with acute care readmissions and ED visits.

DESIGN

Retrospective cohort study using population-level administrative data.

SETTING

Ontario, Canada.

POPULATION

Adults individuals (18 years or older) with a major dysvascular LEA between April 1, 2004 and March 31, 2018.

INTERVENTIONS

Not applicable.

MAIN OUTCOME MEASURES

Acute care hospitalizations and ED visits within one year post-initial discharge.

RESULTS

A total of 10,905 individuals with major dysvascular LEA were identified (67.7% male). There were 14,363 acute hospitalizations and 19,660 ED visits within one year post-discharge from initial amputation acute stay. The highest common risk factors across all the models included age of 65 years or older (versus less than 65 years), high comorbidity (versus low), and low and moderate continuity of care (versus high). Sex differences were identified for risk factors for hospitalizations, with differences in the types of comorbidities increasing risk and geographical setting.

CONCLUSION

Persons with LEA were generally more at risk for acute hospitalizations and ED visits if higher comorbidity and lower continuity of care. Clinical care efforts might focus on improving transitions from the acute setting such as coordinated and integrated care for sub-populations with LEA who are more at risk.

Improving outcomes of type 2 diabetes mellitus patients in primary care with Chronic Care Model: A narrative review

Designed and implemented over two decades ago, the Chronic Care Model is a well-established chronic disease management framework that has steered several healthcare systems in successfully improving the clinical outcomes of patients with type 2 diabetes mellitus. Research evidence cements the role of the Chronic Care Model (with its six key elements of organization of healthcare delivery system, self-management support, decision support, delivery system design, clinical information systems, and community resources and policies) as an integrated framework to revamp the type 2 diabetes mellitus-related clinical practice and care that betters the patient care and clinical outcomes. The current review is an evidence-lit summary of importance of use of Chronic Care Model in primary care and their impact on clinical outcomes for patients afflicted with one of the most debilitating metabolic diseases, type 2 diabetes mellitus.

Effectiveness of integrated person-centered interventions for older people's care: Review of Swedish experiences and experts' perspective

Older adults have multiple medical and social care needs, requiring a shift toward an integrated person-centered model of care. Our objective was to describe and summarize Swedish experiences of integrated person-centered care by reviewing studies published between 2000 and 2023, and to identify the main challenges and scientific gaps through expert discussions. Seventy-three publications were identified by searching MEDLINE and contacting experts. Interventions were categorized using two World Health Organization frameworks: (1) Integrated Care for Older People (ICOPE), and (2) Integrated People-Centered Health Services (IPCHS). The included 73 publications were derived from 31 unique and heterogeneous interventions pertaining mainly to the micro- and meso-levels. Among publications measuring mortality, 15% were effective. Subjective health outcomes showed improvement in 24% of publications, morbidity outcomes in 42%, disability outcomes in 48%, and service utilization outcomes in 58%. Workshop discussions in Stockholm (Sweden), March 2023, were recorded, transcribed, and summarized. Experts emphasized: (1) lack of rigorous evaluation methods, (2) need for participatory designs, (3) scarcity of macro-level interventions, and (4) importance of transitioning from person- to people-centered integrated care. These challenges could explain the unexpected weak beneficial effects of the interventions on health outcomes, whereas service utilization outcomes were more positively impacted. Finally, we derived a list of recommendations, including the need to engage care organizations in interventions from their inception and to leverage researchers' scientific expertise. Although this review provides a comprehensive snapshot of interventions in the context of Sweden, the findings offer transferable perspectives on the real-world challenges encountered in this field.

The Portuguese NHS 2024 reform: transformation through vertical integration

Vertical integration models aim for the integration of services from different levels of care (e.g., primary, and secondary care) with the objective of increasing coordination and continuity of care as well as improving efficiency, quality, and access outcomes. This paper provides a view of the Portuguese National Health Service (NHS) healthcare providers' vertical integration, operationalized by the Portuguese NHS Executive Board during 2023 and 2024. This paper also aims to contribute to the discussion regarding the opportunities and constraints posed by public healthcare organizations vertical integration reforms. The Portuguese NHS operationalized the development and generalization of Local Health Units management model throughout the country. The same institutions are now responsible for both the primary care and the hospital care provided by public services in each geographic area, in an integrated manner. This 2024 reform also changed the NHS organic and organizational structures, opening paths to streamline the continuum of care. However, it will be important to ensure adequate monitoring and support, with the participation of healthcare services as well as community structures and other stakeholders, to promote an effective integration of care.

Implementation of value-based healthcare in ophthalmology: a scoping review

OBJECTIVE

This review aimed to identify and summarise how value-based healthcare (VBHC) is implemented in the field of ophthalmology.

METHODS

A scoping review was conducted by searching empirical and non-empirical articles from from electronic databases (PubMed, Science Direct, ProQuest and Scopus) and other methods starting January 2006 (the year Porter and Teisberg introduced VBHC) up to 31 December 2023.

RESULTS

1.081 records were screened, and 12 articles (8 empirical studies and 4 non-empirical articles) were used for data extraction. Most articles were published in the UK. Most articles described the implementation of VBHC agenda by measuring outcomes and costs. All the included empirical studies reported implementation effect; otherwise, non-empirical articles were only described proposed implementation.

CONCLUSION

The implementation of VBHC in ophthalmology has shown a positive impact on enhancing patient value and reducing healthcare costs. Nevertheless, the study highlighted that no provider or healthcare system has fully embraced and implemented VBHC, comprehensively addressing the entire value agenda.

Implementation and impact of integrated health and social care services: an umbrella review

Governments in many European countries have been working towards integrating health and social care services to eliminate the fragmentation that leads to poor care coordination for patients. We conducted a systematic review to identify and synthesize knowledge about the integration of health and social care services in Europe. We identified 490 records, in 14 systematic reviews that reported on 1148 primary studies and assessed outcomes of integration of health care and social care. We categorized records according to three purposes: health outcomes, service quality and integration procedures outcomes. Health outcomes include improved clinical outcomes, enhanced quality of life, and positive effects on quality of care. Service quality improvements encompass better access to services, reduced waiting times, and increased patient satisfaction. Integration procedure outcomes involve cost reduction, enhanced collaboration, and improved staff perceptions; however, some findings rely on limited evidence. This umbrella review provides a quality-appraised overview of existing systematic reviews.

Value-Based Integrated Care: A Systematic Literature Review

BACKGROUND

Healthcare services worldwide are transforming themselves into value-based organizations. Integrated care is an important aspect of value-based healthcare (VBHC), but practical evidence-based recommendations for the successful implementation of integrated care within a VBHC context are lacking. This systematic review aims to identify how value-based integrated care (VBIC) is defined in literature, and to summarize the literature regarding the effects of VBIC, and the facilitators and barriers for its implementation.

METHODS

Embase, Medline ALL, Web of Science Core Collection, and Cochrane Central Register of Controlled Trails databases were searched from inception until January 2022. Empirical studies that implemented and evaluated an integrated care intervention within a VBHC context were included. Non-empirical studies were included if they described either a definition of VBIC or facilitators and barriers for its implementation. Theoretical articles and articles without an available full text were excluded. All included articles were analysed qualitatively. The Rainbow Model of Integrated Care (RMIC) was used to analyse the VBIC interventions. The quality of the articles was assessed using the Mixed Methods Appraisal Tool (MMAT).

RESULTS

After screening 1328 titles/abstract and 485 full-text articles, 24 articles were included. No articles were excluded based on quality. One article provided a definition of VBIC. Eleven studies reported-mostly positive- effects of VBIC, on clinical outcomes, patient-reported outcomes, and healthcare utilization. Nineteen studies reported facilitators and barriers for the implementation of VBIC; factors related to reimbursement and information technology (IT) infrastructure were reported most frequently.

CONCLUSION

The concept of VBIC is not well defined. The effect of VBIC seems promising, but the exact interpretation of effect evaluations is challenged by the precedence of multicomponent interventions, multiple testing and generalizability issues. For successful implementation of VBIC, it is imperative that healthcare organizations consider investing in adequate IT infrastructure and new reimbursement models. Systematic Review Registration: PROSPERO (CRD42021259025).

Effects of vertical integration on the healthcare system in China: a systematic review and meta-analysis

Vertical integration is one possible way to improve the performance of a healthcare system; however, its effects are inconsistent, and there is a lack of evidence from undeveloped nations. This study aims to systematically review the evidence regarding effects of vertical integration on healthcare systems in China. We searched PubMed, Embase, Cochrane Library, Web of Science, ProQuest Health & Medicine Collection, China Knowledge Resource Integrated Database and Wanfang databases from April 2009 (initiation of new healthcare reform) to May 2021 for randomized controlled trials (RCTs), controlled before and after (CBA) trials, cohort studies and interrupted time series (ITS) trials. Vertical integration in the included studies must involve both primary health institutions and secondary or tertiary hospitals. After screening 3109 records, we ultimately analysed 47 studies, including 27 CBA trials, 18 RCTs and 2 ITS trials. The narrative synthesis shows that all but three studies indicated that vertical integration improved efficiency (utilization and cost of health services), quality of public health services and medical services, health provider-centred outcomes (knowledge and skill) and patient-centred outcomes (patients' clinical outcomes, behaviour and satisfaction). Despite the heterogeneity of vertical integration interventions across different studies, the meta-analysis reveals that it lowered diastolic blood pressure (mean difference (MD) -8.41, 95% confidence interval (CI) -15.18 to -1.65) and systolic blood pressure (MD-5.83, 95% CI -9.25 to -2.40) among hypertension patients, and it lowered HbA1c levels (MD -1.95, 95% CI -2.69 to -1.21), fasting blood glucose levels (MD -1.02, 95% CI -1.53 to -0.50) and 2-hour postprandial blood glucose levels (MD -1.78, 95% CI -2.67 to -0.89). The treatment compliance behaviour was improved for hypertension participants (risk ratio (RR) 1.08, 95% CI 1.04-1.13) and for diabetes patients (RR 1.32, 95% CI 1.08-1.61). Vertical integration in China can improve efficiency, quality of care, health provider-centred outcomes and patient-centred outcomes, but high-quality original studies are highly needed.

Barriers and enablers of integrated care in the UK: a rapid evidence review of review articles and grey literature 2018-2022

Integrated care refers to person-centered and coordinated, health and social care, and community services. Integrated care systems are partnerships of organizations that deliver health and care services which were placed on a statutory footing in England, April 2022. Due to the need for fast, accessible, and relevant evidence, a rapid review was conducted according to World Health Organization methods to determine barriers and enablers of integrated care across the United Kingdom, 2018-2022. Nine databases were searched for review articles reporting evaluation of integrated care interventions involving medical (clinical and diagnostic) and nonmedical (public health services and community-based or social care/person-centred care) approaches, quality checked with the Critical Appraisal Skills Program qualitative checklist. OpenGrey and hand searches were used to identify grey literature, quality checked with the Authority, Accuracy, Coverage, Objectivity, Date, and Significance checklist. Thirty-four reviews and 21 grey literature reports fitted inclusion criteria of adult physical/mental health outcomes/multiple morbidities. Thematic analysis revealed six themes (collaborative approach; costs; evidence and evaluation; integration of care; professional roles; service user factors) with 20 subthemes including key barriers (cost effectiveness; effectiveness of integrated care; evaluation methods; focus of evidence; future research; impact of integration) and enablers (accessing care; collaboration and partnership; concept of integration; inter-professional relationships; person-centered ethos). Findings indicated a paucity of robust research to evaluate such interventions and lack of standardized methodology to assess cost effectiveness, although there is growing interest in co-production that has engendered information sharing and reduced duplication, and inter-professional collaborations that have bridged task-related gaps and overlaps. The importance of identifying elements of integrated care associated with successful outcomes and determining sustainability of interventions meeting joined-up care and preventive population health objectives was highlighted.

Outcomes of the Pilot Project for Community Care Among Older Adults in South Korea

The Korean government implemented the pilot project for community care for older adults in June 2019. This study investigated the outcomes of the pilot project among Korean older adults by linking survey data from the pilot project with data of Korean National Health Insurance Service. The final sample included 17,801 pilot project participants and 68,145 in a matched comparison group. Pilot program participants experienced an increase of 4.8 days for length of home stay and a reduction of $956 (US) per participant relative to the matched comparison group. Pilot program participants with long-term care insurance who used home care services experienced an increase of 8.9 days for length of home stay and a reduction in $1,177 (US) in total costs, along with a reduction in the admission to long-term care facilities, compared to the matched comparison group. Patients discharged from hospitals indicated an increase of 35.2 days for length of home stay and a reduction of $6,947 (US) in total costs, but a 3.53 times increase in hospital readmissions relative to the matched comparison group. The pilot project for community care resulted in increased length of home stay and reduced total costs among older adults in Korea.

Equity Promoting Integrated Care: Definition and Future Development

Over the last three decades, integrated care has emerged as an important health system strategy to improve population health while addressing the unique needs of structurally marginalised communities. However, less attention has been given to the role of integrated care in addressing issues related to inequities in health and health care. In this commentary we introduce the concept of Equity Promoting Integrated Care (EPIC) that situates integrated care in a social justice context to frame the actions necessary to center equity as a priority for integrated care. We suggest that efforts to advance the design and implementation of integrated care should focus on three avenues for future research and practice, namely, the collaborative mobilization of a global network of integrated care stakeholders to advocate for social justice and health equity, investing in equity-focused approaches to implementation science that highlight the importance of social concepts such as colonialism and intersectionality to advance the theory and practice of implementing EPIC models of care, and leveraging innovative approaches to measuring equity-related aspects of integrated care to inform continuous improvement of health systems.

Community hospitals of the future-challenges and opportunities

Background

Medical training through specialization and even subspecialization has contributed significantly to clinical excellence in treating single acute conditions. However, the needs of complex patients go beyond single diseases, and there is a need to identify a group of generalists who are able to deliver cost-effective, holistic care to patients with multiple comorbidities and multi-faceted needs. Community hospitals (CHs) are a critical part of Singapore's shift toward a community-centric care model as the population ages. Community Hospitals of the Future ("CHoF") represent a series of emerging conversations around approaches to reimagine and redesign care delivery in a CH setting in response to changing care needs.

Methods

An environmental scan in the CH landscape using semi-structured interviews was conducted with 26 senior management, management, and working-level staff from seven community hospitals in Singapore. This environmental scan aims to understand the current barriers and future opportunities for CHs; to guide how CHs would have to shift in terms of (i) care delivery and resourcing, (ii) information flow, and (iii) financing; and to conceptualize CHoF to meet the changing care needs in Singapore.

Findings

The analysis of all transcripts revealed four broad sections of themes: (i) current care delivery in CHs, (ii) current challenges of CHs, (iii) future opportunities, and (iv) challenges in reimagining CHs. An emerging theme regarding the current key performance indicators used also surfaced. Resource limitations and financing structure of CH surfaced as limitations to expanding its capability. However, room for expansion of CH roles tapping on the current expertise were acknowledged and shared.

Conclusion

With the current issues of (i) rapidly aging population, (ii) specialist-centric healthcare system, and (iii) fragmentation of care ecosystem, there is a need to further understand how CHoF can be modeled to better tackle them. Therefore, several important questions have been devised to land us in a microscopic view on how to develop CHoF in the right constructs. Demographic changes, patient segmentation, service and regulatory parameters, patient's perspective, care delivery, and financial levers (or lack of) are some of the categories that the interview questions looked into. Therefore, the data gathered would be used to guide and refine the concept of CHoF.

Exploration of understanding of integrated care from a public health perspective: A scoping review

Background

Many health care systems attempt to develop an integrated care approach that is a whole population health-oriented system. However, knowledge of strategies to support this effort are scarce and fragmented. The aim of the current paper is to investigate existing concepts of integrated care and their elements from a public health perspective and to propose an elaborated approach that could be applied to explore the public health orientation of integrated care.

Design and methods

We applied a scoping review approach. A literature search was conducted in Embase, Medline, CINAHL, Scopus and Web of Science for the period 2000-2020 yielding 16 studies for inclusion.

Results

Across the papers, 14 frameworks were identified. Nine of these referred to the Chronic Care Model (CCM). Service delivery, person-centeredness, IT systems design and utilization and decision support were identified as the core elements of most of the included frameworks. The descriptions of these elements were mainly clinical-oriented focusing particularly on clinical care processes and treatment of diseases instead of wider determinants of population health.

Conclusions

A synthesized model is proposed that emphasizes the importance of mapping the unique needs and characteristics of the population it aims to serve, leans on the social determinants approach with a commitment to individual and community empowerment, health literacy and suggests reorienting services to meet the expressed needs of the population.

Perceptions of the primary health care team about the implementation of integrated care of patients with type 2 diabetes and hypertension in Slovenia: qualitative study

BACKGROUND

Integrated care involves good coordination, networking, and communication within health care services and externally between providers and patients or informal caregivers. It affects the quality of services, is more cost-effective, and contributes to greater satisfaction among individuals and providers of integrated care. In our study, we examined the implementation and understanding of integrated care from the perspective of providers - the health care team - and gained insights into the current situation.

METHODS

Eight focus groups were conducted with health care teams, involving a total of 48 health care professionals, including family physicians, registered nurses, practice nurses, community nurses, and registered nurses working in a health education center. Prior to conducting the focus groups, a thematic guide was developed based on the literature and contextual knowledge with the main themes of the integrated care package. The analysis was conducted using the NVivo program.

RESULTS

We identified 12 main themes with 49 subthemes. Health care professionals highlighted good accessibility and the method of diagnostic screening integrated with preventive examinations as positive aspects of the current system of integrated care in Slovenia. They mentioned the good cooperation within the team, with the involvement of registered nurses and community nurses being a particular advantage. Complaints were made about the high workload and the lack of workforce. They feel that patients do not take the disease seriously enough and that patients as teachers could be useful.

CONCLUSION

Primary care teams described the importance of implementing integrated care for diabetes and hypertension patients at four levels: Patient, community, care providers, and state. Primary care teams also recognized the importance of including more professionals from different health care settings on their team.

The Impact of the Swedish Care Coordination Act on Hospital Readmission and Length-of-Stay among Multi-Morbid Elderly Patients: A Controlled Interrupted Time Series Analysis

Coordinating follow-up care after discharge from hospital is critical to ensuring good outcomes for patients, but is difficult when multiple care providers are involved. In 2018, Sweden adopted the Care Coordination Act, which modified economic incentives to reduce discharge delays and mandated a discharge planning process for patients requiring post-discharge social- or primary care services. This study evaluates the impact of this reform on hospital length-of-stay and unplanned readmissions among multi-morbid elderly patients. Interrupted time series analysis of all in-patient care episodes involving multi-morbid elderly patients in Sweden from 2015 - 2019 (n = 2 386 039) was performed. Secondary analyses using case-mix adjustment and controlled interrupted time series analysis were employed to assess for bias. Average length of stay decreased during the post-reform period, corresponding to 248 521 saved care days. Unplanned readmissions meanwhile increased, corresponding to 7 572 excess unplanned readmissions. While reductions in length-of-stay were concentrated among patients targeted by the reform, increases in readmission rates were similar in patients not targeted by the reform, indicating potential confounding. The reform thus appears to have achieved its goal of decreasing in-patient length of stay, but a robust effect on readmissions, outpatient visits, or mortality was not found. This may be due to lackluster implementation or an ineffective mandated intervention.

Nurses' experience of managing adults living with multimorbidity: A qualitative study

BACKGROUND

The number of adults living with two or more chronic conditions is increasing worldwide. Adults living with multimorbidity have complex physical, psychosocial and self-management care needs.

AIM

This study aimed to describe Australian nurses' experience of care provision for adults living with multimorbidity, their perceived education needs and future opportunities for nurses in the management of multimorbidity.

DESIGN

Qualitative exploratory.

METHODS

Nurses providing care to adults living with multimorbidity in any setting were invited to take part in a semi-structured interview in August 2020. Twenty-four registered nurses took part in a semi-structured telephone interview.

RESULTS

Three main themes were developed: (1) The care of adults living with multimorbidity requires skilled collaborative and holistic care; (2) nurses' practice in multimorbidity care is evolving; and (3) nurses value education and training in multimorbidity care.

CONCLUSION

Nurses recognize the challenge and the need for change in the system to support them to respond to the increasing demands they face.

IMPACT

The complexity and prevalence of multimorbidity creates challenges for a healthcare system configured to treat individual disease. Nurses are key in providing care for this population, but little is known about nurses' experiences and perceptions of their role. Nurses believe a person-centred approach is important to address the complex needs of adults living with multimorbidity. Nurses described their role as evolving in response to the growing demand for quality care and believed inter-professional approaches achieve the best outcomes for adults living with multimorbidity. The research has relevance for all healthcare providers seeking to provide effective care for adults living with multimorbidity. Understanding how best to equip and support the workforce to meet the issues and demands of managing the care of adults living with multimorbidity has the potential to improve patient outcomes.

PATIENT OR PUBLIC CONTRIBUTION

There was no patient or public contribution. The study only concerned the providers of the service.

Challenges to Systems of Long-Term Care: Mapping of the Central Concepts from an Umbrella Review

The ageing of the population poses urgent challenges to the health and social protection sectors, including the need for greater adequacy and integration of health care services provided to older people. It is considered necessary and urgent to understand the state-of-the-art of community-based models of care for older people in institutional care and at home. This study aims to map the concepts that politicians and providers need to address through an umbrella review as a review method. Articles describing the structuring aspects of care models appropriate to the needs in long-term care and systematic reviews or meta-analyses targeting people aged 65 years or more were considered. A total of 350 studies met the inclusion criteria and were included in the review. The results identified the need to contribute to effective and more efficient integration and articulation of all the stakeholders, based essentially on professional care at the patient's homes, focused on their needs using the available technologies, empowering patients and families. Eight categories emerged that addressed factors and variables involved in care models for the long-term care needs of institutionalised and home-based older people as a guarantee of accessibility to healthcare and to enhance the well-being and quality of life of patients and family caregivers.

Struggling with the governance of interprofessional elderly care in mandated collaboratives: a qualitative study

BACKGROUND

Governing interprofessional elderly care requires the commitment of many different organisations connected in mandated collaboratives. Research over a decade ago showed that the governance relied on clan-based mechanisms, while lacking formal rules and incentives for collaborations. Awareness and reflection were seen as first steps towards progression. We aim to identify critical governance features of contemporary mandated collaboratives by discussing cases introduced by the healthcare professionals and managers themselves.

METHODS

Semi-structured interviews (n = 24) with two regional mandated collaboratives took place from November 2019 to November 2020 in the Netherlands to learn more about critical governance features. The interviews were thematically analysed by the project team (authors) to synthesise the results and were subsequently validated during a focus group.

RESULTS

Critical governance features of interorganisational activities in mandated collaboratives include the gradual formulation of shared vision and clear client-centred goals, building trust and acquaintanceship for the advancement of an open collaborative culture, establishing a non-extreme formalised governance structure through leadership, mutual trust and innovation support and facilitating information exchange and formalisation tools for optimal elderly care.

CONCLUSION

Trust and leadership form the backbone of interorganisational functioning. Interorganisational functioning should be seen in light of their national embedment and resources that are (being made) available, which makes them susceptible to constant change as they struggle with balancing between critical features in a fluid and intermingled governance context. The identified critical features of (contemporary) mandated collaboratives may aid in assessing and improving interprofessional functioning within integrated elderly care. International debate on governance expectations of mandated collaboratives may further contribute to sharpening the roles of both managers and healthcare professionals.

Supporting care engagement in primary care; the development of a maturity matrix

BACKGROUND

Care engagement or active patient involvement in healthcare contributes to the quality of primary care, but organisational preconditions in routine practice need to be aligned. A Maturity Matrix for Care Engagement to assess and discuss these preconditions in the general practice team was developed and tested on feasibility and acceptability in general practice.

METHODS AND FINDINGS

A systematic user-centred approach was applied, starting with a scoping literature search to describe the domains on the horizontal axis of the maturity matrix. The domains and growing steps (vertical axis) were refined by patients (n = 16) and general practice staff (n = 11) in three focus group discussions and reviewed by six experts (local facilitators and scientists). Seven domains could be distinguished: Personalised Care, Shared Decision Making, Self-Management, Patient as Partner, Supportive Means, Patient Environment, and Teamwork among Healthcare Professionals. The growing steps described three to six activities per domain (n = 32 in total) that contribute to care engagement. Local facilitators implemented the tool in two general practice teams according to a user guide, starting with a two-hour kick-off meeting on care engagement. In the next step, practitioners, nurses and assistants in each practice indicated their score on the domains individually. The scores were discussed in the facilitated practice meeting which was aimed at SMART improvement plans. Feasibility and acceptability were assessed in interviews showing that the tool was well received by the pilot practices, although the practice assistants had difficulties scoring some of the activities as they did not always relate to their daily work. An assessment after three months showed changes in practice organisation towards increased care engagement.

CONCLUSIONS

The maturity matrix on care engagement is a tool to identify the organisational practice maturity for care engagement. Suggested adaptations must be implemented before large-scale testing.

Protocol for a mixed methods feasibility and implementation study of a community-based integrated care model for home-dwelling older adults: The INSPIRE project

BACKGROUND

Evaluations of integrated care models for home-dwelling frail older adults have shown inconclusive results on health and service outcomes. However, limited research has focused on the implementation of integrated care models. Applying implementation science methods may facilitate uptake of integrated care models, thus generating positive outcomes e.g., reduced hospital admissions. This paper describes the protocol to assess the feasibility of an integrated care model (featuring a four-step comprehensive geriatric assessment: screening, a multi-dimensional assessment, a coordinated individualized care plan and follow-up) designed for a new community-based center for home-dwelling older adults in Switzerland. The study includes the following objectives: 1) to assess implementation by a) monitoring respondents to the outreach strategies and describing the Center's visitors; b) assessing implementation outcomes related to the care model (i.e., adoption, acceptability, feasibility, fidelity) and implementation processes related to collaboration; and 2) assessing implementation costs.

METHODS

For objective 1a, we will use a descriptive design to assess respondents to the outreach strategies and describe the Center's visitors. We will use a parallel convergent mixed methods design for objective 1b. Implementation outcomes data will be collected from meetings with the Center's staff, interviews with older adults and their informal caregivers, and reviewing older adults' health records at the Center. Implementation processes related to collaboration will be assessed through a questionnaire to external collaborators (e.g., GPs) towards the end of the study. For objective 2, implementation costs will be calculated using time-driven activity-based costing methods. Data collection is anticipated to occur over approximately six months.

DISCUSSION

This study of a contextually adapted integrated care model will inform adaptations to the outreach strategies, care model and implementation strategies in one community center, prior to evaluating the care model effectiveness and potentially scaling out the intervention.

TRIAL REGISTRATION

Feasibility study registration ID with clinicaltrials.gov: NCT05302310; registration ID with BMC: ISRCTN12324618.

Patient-reported outcomes among patients undergoing total hip replacement in an integrated care system and in a standard care system in Region Stockholm, Sweden

BACKGROUND

Coordination, cooperation and efficient use of resources is vital for the health- and social care sector if it is to meet the needs of an aging population. Integrated care is a patient-centred approach to provision of care aiming to improve quality of care and overcome fragmented care through co-productive partnerships and may positively affect quality of care and health outcomes, especially among those in need of highly coordinated care services.

AIM

To compare patient-reported outcomes (PROs) among patients undergoing total hip replacement (THR) in the integrated care system in Norrtälje Municipality and in the standard care system in other municipalities in Region Stockholm, Sweden.

METHODS

Swedish Hip Arthroplasty Register PRO data during 2008-2015 were compared 1 year after THR among patients (≥50 years) in integrated care (n = 407) and standard care (n = 3501) systems using linear (EQ VAS score), logistic (EQ-5D-3L dimensions) and negative binomial (hip pain VAS score) regressions. Analyses were adjusted for the preoperative factors age, sex, BMI, ASA class and type of incision.

RESULTS

1-year postoperatively, patients in the integrated care system did not report their health significantly different from patients receiving standard care. Exceptions: Female patients in integrated care reported less problems with self-care (OR:0.52; 0.29-0.96) and patients above 70 years reported more problems with mobility (OR: 1.37; 1.01-1.87).

CONCLUSION

No significant differences were found between the two care systems for postoperative PROs. A longer follow-up time and analyses by socioeconomic groups would be valuable.

Effectiveness of community-based multidisciplinary integrated care for older people: a protocol for a systematic review

INTRODUCTION

The increasing number of older adults with multiple complex care needs has placed increased pressure on healthcare systems internationally to reorientate healthcare delivery. For many older adults, their first point of contact with the health service is with their general practitioner (GP) and GP participation with integrated care models is the foundation of a population-based approach. A knowledge gap remains in relation to the effectiveness of GP participation in community-based integrated health and social care approaches for older adults. This systematic review aims to examine the effectiveness of multidisciplinary-integrated care for community-dwelling older adults with GP participation.

METHODS AND ANALYSIS

This systematic review will include randomised controlled trials (RCTs), quasi and cluster RCTs focusing on integrated care interventions for community-dwelling older adults by multidisciplinary teams including health and social care professionals and GPs. The databases PUBMED, EMBASE, CINAHL, Central Register of Controlled Trials in the Cochrane Library and MEDLINE will be searched. The primary outcome measure will be functional status. Secondary outcomes will include: primary healthcare utilisation, secondary healthcare utilisation, participant satisfaction with care, health-related quality of life, nursing home admission and mortality. The methodological quality of the studies will be assessed using the Cochrane Risk of Bias Tool V.2. The elements of care integration will be mapped in the individual studies using the Rainbow Model of Integrated Care taxonomy. A meta-analysis will be completed, depending on the uniformity of the data. Grading of Recommendations, Assessment, Development and Evaluation will be used to assess the certainty of evidence.

ETHICS AND DISSEMINATION

Formal ethical approval is not required as all data included are anonymous secondary data. Scientific outputs will be presented at relevant conferences and in collaboration with our public and patient involvement stakeholder panel of older adults at the Ageing Research Centre at the University of Limerick.

PROSPERO REGISTRATION NUMBER

CRD42022309744.

Changes in Barriers That Cause Unmet Healthcare Needs in the Life Cycle of Adulthood and Their Policy Implications: A Need-Selection Model Analysis of the Korea Health Panel Survey Data

Using 68,930 observations selected from 16,535 adults in the Korea Health Panel Survey (2014-2018), this study explored healthcare barriers that prevent people from meeting their healthcare needs most severely during adulthood, and the characteristics that are highly associated with the barrier. This study derived two outcome variables: a dichotomous outcome variable on whether an individual has experienced healthcare needs, and a quadchotomous outcome variable on how an individual's healthcare needs ended. An analysis was conducted using a multivariable panel multinomial probit model with sample selection. The results showed that the main cause of unmet healthcare needs was not financial difficulties but non-financial barriers, which were time constraints up to a certain age and the lack of caring and support after that age. People with functional limitations were at a high risk of experiencing unmet healthcare needs due to a lack of caring and support. To reduce unmet healthcare needs in South Korea, the government should focus on lowering non-financial barriers to healthcare, including time constraints and lack of caring and support. It seems urgent to strengthen the foundation of "primary care", which is exceptionally scarce now, and to expand it to "community-based integrated care" and "people-centered care".

'Value-based methodology for person-centred, integrated care supported by Information and Communication Technologies' (ValueCare) for older people in Europe: study protocol for a pre-post controlled trial

Background

Older people receive care from multiple providers which often results in a lack of coordination. The Information and Communication Technology (ICT) enabled value-based methodology for integrated care (ValueCare) project aims to develop and implement efficient outcome-based, integrated health and social care for older people with multimorbidity, and/or frailty, and/or mild to moderate cognitive impairment in seven sites (Athens, Greece; Coimbra, Portugal; Cork/Kerry, Ireland; Rijeka, Croatia; Rotterdam, the Netherlands; Treviso, Italy; and Valencia, Spain). We will evaluate the implementation and the outcomes of the ValueCare approach. This paper presents the study protocol of the ValueCare project; a protocol for a pre-post controlled study in seven large-scale sites in Europe over the period between 2021 and 2023.

Methods

A pre-post controlled study design including three time points (baseline, post-intervention after 12 months, and follow-up after 18 months) and two groups (intervention and control group) will be utilised. In each site, (net) 240 older people (120 in the intervention group and 120 in the control group), 50–70 informal caregivers (e.g. relatives, friends), and 30–40 health and social care practitioners will be invited to participate and provide informed consent. Self-reported outcomes will be measured in multiple domains; for older people: health, wellbeing, quality of life, lifestyle behaviour, and health and social care use; for informal caregivers and health and social care practitioners: wellbeing, perceived burden and (job) satisfaction. In addition, implementation outcomes will be measured in terms of acceptability, appropriateness, feasibility, fidelity, and costs. To evaluate differences in outcomes between the intervention and control group (multilevel) logistic and linear regression analyses will be used. Qualitative analysis will be performed on the focus group data.

Discussion

This study will provide new insights into the feasibility and effectiveness of a value-based methodology for integrated care supported by ICT for older people, their informal caregivers, and health and social care practitioners in seven different European settings.

Trial registration

ISRCTN registry number is 25089186. Date of trial registration is 16/11/2021.

Value-based person-centred integrated care for frail elderly living at home: a quasi-experimental evaluation using multicriteria decision analysis

OBJECTIVE

To evaluate the value of the person-centred, integrated care programme Care Chain Frail Elderly (CCFE) compared with usual care, using multicriteria decision analysis (MCDA).

DESIGN

In a 12-month quasi-experimental study, triple-aim outcomes were measured at 0, 6 and 12 months by trained interviewers during home-visits.

SETTING

Primary care, community-based elderly care.

PARTICIPANTS

384 community-dwelling frail elderly were enrolled. The 12-month completion rate was 70% in both groups. Propensity score matching was used to balance age, gender, marital status, living situation, education, smoking status and 3 month costs prior to baseline between the two groups.

INTERVENTION

The CCFE is an integrated care programme with unique features like the presence of the elderly and informal caregiver at the multidisciplinary team meetings, and a bundled payment.

PRIMARY AND SECONDARY OUTCOMES MEASURES

The MCDA results in weighted overall value scores that combines the performance on physical functioning, psychological well-being, social relationships and participation, enjoyment of life, resilience, person-centredness, continuity of care and costs, with importance weights of patients, informal caregivers, professionals, payers and policy-makers.

RESULTS

At 6 months, the overall value scores of CCFE were higher in all stakeholder groups, driven by enjoyment of life (standardised performance scores 0.729 vs 0.685) and person-centredness (0.749 vs 0.663). At 12 months, the overall value scores in both groups were similar from a patient's perspective, slightly higher for CCFE from an informal caregiver's and professional's perspective, and lower for CCFE from a payer's and policy-maker's perspective. The latter was driven by a worse performance on physical functioning (0.682 vs 0.731) and higher costs (€22 816 vs €20 680).

CONCLUSIONS

The MCDA indicated that the CCFE is the preferred way of delivering care to frail elderly at 6 months. However, at 12 months, MCDA results showed little difference from the perspective of patients, informal caregivers and professionals, while payers and policy-makers seemed to prefer usual care.

Trends over two decades in life expectancy with complex health problems among older Swedes: implications for the provision of integrated health care and social care

BACKGROUND

Due to population aging, it is essential to examine to what extent rises in life expectancy (LE) consist of healthy or unhealthy years. Most health expectancy studies have been based on single health measures and have shown divergent trends. We used a multi-domain indicator, complex health problems (CHP), indicative of the need for integrated medical and social care, to investigate how LE with and without CHP developed in Sweden between 1992 and 2011. We also addressed whether individuals with CHP more commonly lived in the community in 2011 compared to earlier years.

METHODS

CHP were defined as having severe problems in at least two of three health domains related to the need for medical and/or social care: symptoms/diseases, cognition/communication, and mobility. The Swedish Panel Study of Living Conditions of the Oldest Old (SWEOLD), a nationally representative survey of the Swedish population aged ≥ 77 years with waves in 1992, 2002 and 2011 (n≈2000), was used to estimate the prevalence of CHP. Age- and gender-specific death rates were obtained from the Human Mortality Database. The Sullivan method was deployed to calculate the remaining life expectancy with and without CHP. The estimates were decomposed to calculate the contribution of changes from morbidity and mortality to the overall trends in LE without CHP.

RESULTS

Between 1992 and 2011, both total LE (+ 1.69 years [95% CI 1.56;1.83] and LE without CHP (+ 0.84 years [-0,87;2.55]) at age 77 increased for men, whereas LE at age 77 increased for women (+ 1.33 [1.21;1.47]) but not LE without CHP (-0.06 years [-1.39;1.26]). When decomposing the trend, we found that the increase in LE with CHP was mainly driven by an increase in the prevalence of CHP. Among individuals with CHP the proportion residing in care homes was lower in 2011 (37%) compared to 2002 (58%) and 1992 (53%).

CONCLUSIONS

The findings, that an increasing number of older people are expected to live more years with CHP, and increasingly live in the community, point towards a challenge for individuals and families, as well as for society in financing and organizing coordinated and coherent medical and social services.

A Nurse-Led Integrated Chronic Care E-Enhanced Atrial Fibrillation (NICE-AF) Clinic in the Community: A Preliminary Evaluation

The current physician-centric model of care is not sustainable for the rising tide of atrial fibrillation. The integrated model of care has been recommended for managing atrial fibrillation. This study aims to provide a preliminary evaluation of the effectiveness of a Nurse-led Integrated Chronic care E-enhanced Atrial Fibrillation (NICE-AF) clinic in the community. The NICE-AF clinic was led by an advanced practice nurse (APN) who collaborated with a family physician. The clinic embodied integrated care and shifted from hospital-based, physician-centric care. Regular patient education, supplemented by a specially curated webpage, fast-tracked appointments for hospital-based specialised investigations, and teleconsultation with a hospital-based cardiologist were the highlights of the clinic. Forty-three participants were included in the six-month preliminary evaluation. No significant differences were observed in cardiovascular hospitalisations (p-value = 0.102) and stroke incidence (p-value = 1.00) after attending the NICE-AF clinic. However, significant improvements were noted for AF-specific QoL (p = 0.001), AF knowledge (p < 0.001), medication adherence (p = 0.008), patient satisfaction (p = 0.020), and depression (p = 0004). The preliminary evaluation of the NICE-AF clinic demonstrated the clinical utility of this new model of integrated care in providing safe and effective community-based AF care. Although a full evaluation is pending, the preliminary results highlighted its promising potential to be expanded into a permanent, larger-scale service.

Identifying and understanding the factors that influence the functioning of integrated healthcare systems in the NHS: a systematic literature review

OBJECTIVES

The National Health Service has been moving towards integrated care for the best part of two decades to address the growing financial and service pressures created by an ageing population. Integrated healthcare systems (IHSs) join up health and social care services and have been established to manage the care of individuals with complex chronic conditions but with varied success. It is therefore imperative to conduct a Systematic Literature Review (SLR) to identify and understand the factors that influence their successful functioning, and ascertain the factor with the greatest influence, in order to ensure positive outcomes when establishing future IHSs.

METHODS

Articles published between 1 January 1997 and 8 March 2020 were analysed from the following six databases: Healthcare Management Information Consortium, Nuffield Trust, Cumulative Index to Nursing and Allied Health Literature, PubMed, National Institute for Health and Care Excellence Evidence and Health Systems Evidence. Those deemed relevant after title and abstract screening were procured for subsequent review of the full-text article.

RESULTS

Thirty-three finalised articles were analysed in this SLR to provide a comprehensive overview of the factors that influence the functioning of IHSs. Factors were stratified into six key categories: organisational culture, workforce management, interorganisational collaboration, leadership ability of staff, economic factors and political factors. Leadership was deemed to be the most influential factor due to its intrinsic and instrumental role in influencing the other key factors.

CONCLUSIONS

The findings of this SLR may serve as a guide to developing tailor-made recommendations and policies that address the identified key factors and thereby improve the functioning of present and future IHSs. Furthermore, due to both its overarching influence and the inadequacy of literature in this field, there is a strong case for further research exploring leadership development specifically for IHSs.

Application of a Mixed Methods Multi-Criteria Decision Analysis Framework in Integrated Health Care

Background:

Evaluating integrated care programs is complex. Integration benefits may not become apparent within short evaluation timeframes, and many programs provide a wide variety of health and non-health benefits. To address these challenges, we illustrate a mixed methods approach for evaluating multiple integrated care programs using multi-criteria decision analysis.

Methods:

We adapted a decision support tool used by local decision makers to compare data extracted from 17 different integrated care evaluations. Criteria included impact on health services capacity, patient outcomes, integration of care, workforce development and implementation risk, weighted based on stakeholder preferences. Program benefits were compared to their implementation costs, and assessed using cost-effectiveness methods. Sensitivity analysis examined the impact of different criteria weights.

Results and discussion:

This method captured a diverse range of benefits provided by integrated care programs and provided an accessible heuristic to compare many projects simultaneously. However, this approach may not be sensitive to the appropriateness of each criterion to the health system, the magnitude of difference in individual criteria, equity considerations or socio-political factors. Internal and external validation, especially for subjective criteria such as implementation risk, are needed.

Conclusions:

This work offers a feasible, flexible and pragmatic approach for evaluating integrated care programs.

Characteristics Associated With Financial or Non-financial Barriers to Healthcare in a Universal Health Insurance System: A Longitudinal Analysis of Korea Health Panel Survey Data

While many studies have explored the financial barriers to healthcare, there is little evidence regarding the non-financial barriers to healthcare. This study identified characteristics associated with financial and non-financial barriers to healthcare and quantified the effects of these characteristics in South Korea, using a nationally representative longitudinal survey dataset. Overall, 68,930 observations of 16,535 individuals aged 19 years and above were sampled from Korea Health Panel survey data (2014-2018). From self-reported information about respondents' experiences of unmet healthcare needs, a trichotomous dependent variable-no barrier, non-financial barrier, and financial barrier-was derived. Sociodemographics, physical and health conditions were included as explanatory variables. The average adjusted probability (AAP) of experiencing each barrier was predicted using multivariable and panel multinomial logistic regression analyses. According to the results, the percentage of people experiencing non-financial barriers was much higher than that of people experiencing financial barriers in 2018 (9.6 vs. 2.5%). Women showed higher AAPs of experiencing both non-financial (9.9 vs. 8.3%) and financial barriers (3.6 vs. 2.5%) than men. Men living in the Seoul metropolitan area showed higher AAPs of experiencing non-financial (8.7 vs. 8.0%) and financial barriers (3.4 vs. 2.1%) than those living outside it. Household income showed no significant associations in the AAP of experiencing a non-financial barrier. People with a functional limitation exhibited a higher AAP of experiencing a non-financial barrier, for both men (17.8 vs. 7.8%) and women (17.4 vs. 9.0%), than those without it. In conclusion, people in South Korea, like those in most European countries, fail to meet their healthcare needs more often due to non-financial barriers than financial barriers. In addition, the characteristics associated with non-financial barriers to healthcare differed from those associated with financial barriers. This finding suggests that although financial barriers may be minimised through various policies, a considerable degree of unmet healthcare needs and disparity among individuals is very likely to persist due to non-financial barriers. Therefore, current universal health insurance systems need targeted policy instruments to minimise non-financial barriers to healthcare to ensure effective universal health coverage.

Individual and contextual predictors of emergency department visits among community-living older adults: a register-based prospective cohort study

OBJECTIVES

To examine the extent to which contextual factors explain emergency department (ED) visits and ED revisits, additional to that explained by individual factors.

DESIGN

A register-based prospective cohort study.

SETTING

Swedish region of Dalarna.

PARTICIPANTS

Participants were 16 543 community-living adults aged 80 or older who were residents of the Dalarna region of Sweden, excluding older adults who moved out of Dalarna or into residential care during the study period.

OUTCOME MEASURES

Dependent variables were initial ED visit, and at least one ED revisit within 30 days of an initial ED visit.

RESULTS

Approximately 36% of the participants visited the ED during the study period with 18.9% returning to the ED within 30 days. For both initial ED visits and ED revisits, the addition of contextual factors to models containing individual factors significantly improved model fit (p<0.001; p<0.022) and the amount of variance explained in the outcome. In the final models, initial ED visit was significantly associated with older age, number of chronic diseases, receipt of home help, number of primary care visits, proportion of 80+ in the population and shorter distance to the ED; while an ED revisit was significantly associated with greater use of social care, number of hospital admissions and disposition (discharged; admitted to hospital) at initial ED visit.

CONCLUSION

Contextual factors explain variance in initial ED visit, additional to that explained by individual factors alone, which indicates inequitable access to ED care. These findings suggest considering local variations in contextual factors in order to improve health-related outcomes among older adults.

Aligning healthcare, public health and social services: A scoping review of the role of purpose, governance, finance and data

Organisations spanning social services, public health and healthcare have increasingly experimented with collaboration as a tool for improving population health and reducing health disparities. While there has been progress, the results have fallen short of expectations. Reflecting on these shortcomings, the Robert Wood Johnson Foundation (RWJF) recently proposed a new framework for cross-sector alignment intended to move the field towards improved outcomes. A central idea in this framework is that collaboratives will be more effective and sustainable if they develop collaborative systems in four core areas: shared purpose, governance, finance and shared data. The goal of this paper is to provide a foundation for research on the four core areas of the cross-sector alignment framework. Accordingly, this study is based on two guiding questions: (1) how are collaboratives currently implementing systems in the four core areas identified in the framework, and (2) what strategies does the literature offer for creating sustainable systems in these four areas? Given the emergent nature of research on health-oriented cross-sector collaboration and the broad research questions, we conducted a systematic scoping review including 179 relevant research papers and reports published internationally from the years 2010-2020. We identified the main contributions and coded each based on its relevance to the cross-sector alignment framework. We found that most papers focused on programme evaluations rather than theory testing, and while many strategies were offered, they tended to reflect a focus on short-term collaboration. The results also demonstrate that starting points and resource levels vary widely across individuals and organisations involved in collaborations. Accordingly, identifying and comparing distinct pathways by which different parties might pursue cross-sector alignment is an imperative for future work. More broadly, the literature is ripe with observations that could be assessed systematically to produce a firm foundation for research and practice.

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.

Nurses' perceptions and beliefs related to the care of adults living with multimorbidity: A systematic qualitative review

AIMS AND OBJECTIVES

To identify and synthesise the available qualitative evidence on nurses' perceptions and beliefs related to the care of adults living with multimorbidity.

BACKGROUND

The rising prevalence of adults living with multimorbidity has increased demand for health care and challenges nursing care. No review has been conducted to date of the studies of nurses' perceptions and beliefs related to the provision of care to guide policy makers, practitioners and further research to identify and deliver quality care for persons living with multimorbidity.

DESIGN

Systematic review of qualitative studies conducted in line with the PRISMA checklist.

METHODOLOGY

Eight electronic publication databases and sources of grey literature were searched to identify original qualitative studies of the experience of nurses caring for adults with multiple chronic conditions with no restrictions on the date of publication or study context. Study quality was assessed using the Joanna Briggs Institute Critical Appraisal Checklist for Qualitative Research. Data were extracted using the Joanna Briggs Institute standardised data extraction tool for qualitative research. Data synthesis was undertaken through meta-aggregation.

RESULTS

Eleven qualitative studies were included in the review. All studies met eight or more of the 10 assessment criteria of the JBI Critical Appraisal Checklist for Qualitative Research. Four synthesised findings were generated from the aggregated findings: (i) the challenge of providing nursing care; (ii) the need to deliver holistic and person-centred nursing care; (iii) the importance of developing a therapeutic nurse-patient relationship, and (iv) delivering nursing care as part of an interprofessional care team.

CONCLUSIONS

The complexity of multimorbidity and the predominant single-disease model of chronic care present challenges for the delivery of nursing care to adults living with multimorbidity.

RELEVANCE TO CLINICAL PRACTICE

The nursing care of persons with multimorbidity needs to incorporate holistic assessment and person-centred care principles as part of a collaborative and interprofessional team approach.

PROSPERO REGISTRATION

CRD42020186773.

The development and validation of population clusters for integrating health and social care: A protocol for a mixed-methods study in Multiple Long-Term Conditions (Cluster-AIM) (Preprint)

Background

Multiple long-term health conditions (multimorbidity) (MLTC-M) are increasingly prevalent and associated with high rates of morbidity, mortality, and health care expenditure. Strategies to address this have primarily focused on the biological aspects of disease, but MLTC-M also result from and are associated with additional psychosocial, economic, and environmental barriers. A shift toward more personalized, holistic, and integrated care could be effective. This could be made more efficient by identifying groups of populations based on their health and social needs. In turn, these will contribute to evidence-based solutions supporting delivery of interventions tailored to address the needs pertinent to each cluster. Evidence is needed on how to generate clusters based on health and social needs and quantify the impact of clusters on long-term health and costs.

Objective

We intend to develop and validate population clusters that consider determinants of health and social care needs for people with MLTC-M using data-driven machine learning (ML) methods compared to expert-driven approaches within primary care national databases, followed by evaluation of cluster trajectories and their association with health outcomes and costs.

Methods

The mixed methods program of work with parallel work streams include the following: (1) qualitative semistructured interview studies exploring patient, caregiver, and professional views on clinical and socioeconomic factors influencing experiences of living with or seeking care in MLTC-M; (2) modified Delphi with relevant stakeholders to generate variables on health and social (wider) determinants and to examine the feasibility of including these variables within existing primary care databases; and (3) cohort study with expert-driven segmentation, alongside data-driven algorithms. Outputs will be compared, clusters characterized, and trajectories over time examined to quantify associations with mortality, additional long-term conditions, worsening frailty, disease severity, and 10-year health and social care costs.

Results

The study will commence in October 2021 and is expected to be completed by October 2023.

Conclusions

By studying MLTC-M clusters, we will assess how more personalized care can be developed, how accurate costs can be provided, and how to better understand the personal and medical profiles and environment of individuals within each cluster. Integrated care that considers “whole persons” and their environment is essential in addressing the complex, diverse, and individual needs of people living with MLTC-M.

International Registered Report Identifier (IRRID)

PRR1-10.2196/34405

The Cost Consequences of the Gold Coast Integrated Care Programme

Introduction

The Australian Gold Coast Integrated Care programme trialled a model of care targeting those with chronic and complex conditions at highest risk of hospitalisation with the goal of producing the best patient outcomes at no additional cost to the healthcare system. This paper reports the economic findings of the trial.

Methods

A pragmatic non-randomised controlled study assessed differences between patients enrolled in the programme (intervention group) and patients who received usual care (control group), in health service utilisation, including Medicare Benefits Schedule and Pharmaceutical Benefits Scheme claims, patient-reported outcome measures, including health-related quality of life, mortality risk, and cost.

Results

A total of 1,549 intervention participants were enrolled and matched on the basis of patient level data to 3,042 controls. We found no difference in quality of life between groups, but a greater decrease in capability, social support and satisfaction with care scores and higher hospital service use for the intervention group, leading to a greater cost to the healthcare system of AUD$6,400 per person per year. In addition, the per person per year cost of being in the GCIC programme was AUD$8,700 equating to total healthcare expenditures of AUD$15,100 more for the intervention group than the control group.

Conclusion

The GCIC programme did not show value for money, incurring additional costs to the health system and demonstrating no significant improvements in health-related quality of life. Because patient recruitment was gradual throughout the trial, we had only one year of complete data for analysis which may be too short a period to determine the true cost-consequences of the program.

Health and Social Care Reform in Scotland - What Next?

INTRODUCTION

This paper analyses the important enablers, barriers and impacts of country-wide implementation of integrated health and social care in Scotland. It offers insights for other systems seeking to advance similar policy and practice.

DESCRIPTION

Landmark legislation was based on a shared vision and narrative about improving outcomes for people and communities. Implementation has involved coordination of multiple policies and interventions for different life stages, care groups, care settings and local context within a dynamic and complex system.

DISCUSSION

Relational and citizen led approaches are critical for success, but it takes time to build trusting relationships, influence organisational and professional cultures and cede power. Assessing national impacts is challenging and progress at a national level can seem slower than local experience suggests, due in part to the relative immaturity of national datasets for community interventions. Five years on there are many examples of innovation and positive outcomes despite increasing demographic, workforce, and financial challenges. However, inequalities continue to increase.

CONCLUSION

Realising the true value from integration will require a stronger focus on place-based prevention and early intervention to achieve a fairer Scotland where everybody thrives. Solidarity, equity, and human rights must guide the next phase of Scotland's story.

Measuring Older Peoples' Experiences of Person-Centred Coordinated Care: Experience and Methodological Reflections from Applying a Patient Reported Experience Measure in SUSTAIN

Introduction

While several evaluation studies on (cost-)effectiveness of integrated care have been conducted in recent years, more insight is deemed necessary into integrated care from the perspective of service users. In the context of a European project on integrated care for older people living at home (SUSTAIN), this paper shares the experience and methodological reflections from applying a Patient Reported Experience Measure (PREM) on person-centred coordinated care -the P3CEQ- among this population.

Methods

A combination of quantitative and qualitative data and analysis methods was used to assess the usability and the quality of applying a PREM among older people presenting complex care needs, using the P3CEQ delivery in SUSTAIN as a case study. 228 service users completed the P3CEQ and nine SUSTAIN researchers participated in a consultation about their experience administering the questionnaire. P3CEQ scores were analysed quantitatively using principal component analysis and multilevel linear regression. P3CEQ open responses and researcher notes collected when administering the questionnaire were thematically analysed.

Results

Service user inclusion was high and most P3CEQ items had low non-response rates. Quantitative analysis and researcher experience indicate the relevance of face-to-face administration for obtaining such an amount of data in this population group. The presence of a carer increased inclusion of more vulnerable respondents, such as the cognitively impaired, but posed a challenge in data interpretation. Although several P3CEQ items were generally understood as intended by questionnaire developers, the analysis of open responses highlights how questions can lead to diverging and sometimes narrow interpretations by respondents. Cognitive impairment and a higher educational attainment were associated with lower levels of perceived person-centredness of care.

Conclusion

This study shows essential preconditions to meaningfully collect and analyse PREM data on older peoples' experiences with integrated care: face-to-face administration away from care providers, collection of reasons for non-response and open comments providing nuances to answers, and multilevel modelling taking into account diversity in the target population. Several areas of improvement for future PREM use in this population have been identified: use of administration and coding guides, inclusion of clear and easy to understand definitions and examples illustrating what questions do and do not mean, measures of the expectations of person-centred coordinated care, and procedures ensuring sound ethical research. These methodological learnings can enhance future evaluation of integrated care from a service user perspective.

Increasing specialist intensity at weekends to improve outcomes for patients undergoing emergency hospital admission: the HiSLAC two-phase mixed-methods study

Background

NHS England’s 7-day services policy comprised 10 standards to improve access to quality health care across all days of the week. Six standards targeted hospital specialists on the assumption that their absence caused the higher mortality associated with weekend hospital admission: the ‘weekend effect’. The High-intensity Specialist-Led Acute Care (HiSLAC) collaboration investigated this using the implementation of 7-day services as a ‘natural experiment’.

Objectives

The objectives were to determine whether or not increasing specialist intensity at weekends improves outcomes for patients undergoing emergency hospital admission, and to explore mechanisms and cost-effectiveness.

Design

This was a two-phase mixed-methods observational study. Year 1 focused on developing the methodology. Years 2–5 included longitudinal research using quantitative and qualitative methods, and health economics.

Methods

A Bayesian systematic literature review from 2000 to 2017 quantified the weekend effect. Specialist intensity measured over 5 years used self-reported annual point prevalence surveys of all specialists in English acute hospital trusts, expressed as the weekend-to-weekday ratio of specialist hours per 10 emergency admissions. Hospital Episode Statistics from 2007 to 2018 provided trends in weekend-to-weekday mortality ratios. Mechanisms for the weekend effect were explored qualitatively through focus groups and on-site observations by qualitative researchers, and a two-epoch case record review across 20 trusts. Case-mix differences were examined in a single trust. Health economics modelling estimated costs and outcomes associated with increased specialist provision.

Results

Of 141 acute trusts, 115 submitted data to the survey, and 20 contributed 4000 case records for review and participated in qualitative research (involving interviews, and observations using elements of an ethnographic approach). Emergency department attendances and admissions have increased every year, outstripping the increase in specialist numbers; numbers of beds and lengths of stay have decreased. The reduction in mortality has plateaued; the proportion of patients dying after discharge from hospital has increased. Specialist hours increased between 2012/13 and 2017/18. Weekend specialist intensity is half that of weekdays, but there is no relationship with admission mortality. Patients admitted on weekends are sicker (they have more comorbid disease and more of them require palliative care); adjustment for severity of acute illness annuls the weekend effect. In-hospital care processes are slightly more efficient at weekends; care quality (errors, adverse events, global quality) is as good at weekends as on weekdays and has improved with time. Qualitative researcher assessments of hospital weekend quality concurred with case record reviewers at trust level. General practitioner referrals at weekends are one-third of those during weekdays and have declined further with time.

Limitations

Observational research, variable survey response rates and subjective assessments of care quality were compensated for by using a difference-in-difference analysis over time.

Conclusions

Hospital care is improving. The weekend effect is associated with factors in the community that precede hospital admission. Post-discharge mortality is increasing. Policy-makers should focus their efforts on improving acute and emergency care on a ‘whole-system’ 7-day approach that integrates social, community and secondary health care.

Future work

Future work should evaluate the role of doctors in hospital and community emergency care and investigate pathways to emergency admission and quality of care following hospital discharge.

Funding

This project was funded by the National Institute for Health Research (NIHR) Health Services and Delivery Research programme and will be published in full in Health Services and Delivery Research; Vol. 9, No. 13. See the NIHR Journals Library website for further project information.

What works? Interventions to reduce readmission after hip fracture: A rapid review of systematic reviews

BACKGROUND

Hip fracture is a common serious injury in older people and reducing readmission after hip fracture is a priority in many healthcare systems. Interventions which significantly reduce readmission after hip fracture have been identified and the aim of this review is to collate and summarise the efficacy of these interventions in one place.

METHODS

In a rapid review of systematic reviews one reviewer (ELS) searched the Ovid SP version of Medline and the Cochrane Database of Systematic Reviews. Titles and abstracts of 915 articles were reviewed. Nineteen systematic reviews were included. (ELS) used a data extraction sheet to capture data on interventions and their effect on readmission. A second reviewer (RK) verified data extraction in a random sample of four systematic reviews. Results were not meta-analysed. Odds and risk ratios are presented where available.

RESULTS

Three interventions significantly reduce readmission in elderly populations after hip fracture: personalised discharge planning, self-care and regional anaesthesia. Three interventions are not conclusively supported by evidence: Oral Nutritional Supplementation, integration of care, and case management. Two interventions do not affect readmission after hip fracture: Enhanced Recovery pathways and comprehensive geriatric assessment.

CONCLUSIONS

Three interventions are most effective at reducing readmissions in older people: discharge planning, self-care, and regional anaesthesia. Further work is needed to optimise interventions and ensure the most at-risk populations benefit from them, and complete development work on interventions (e.g. interventions to reduce loneliness) and intervention components (e.g. adapting self-care interventions for dementia patients) which have not been fully tested yet.

Impact of Integrated Care on the Rate of Hospitalization for Ambulatory Care Sensitive Conditions among Older Adults in Stockholm County: An Interrupted Time Series Analysis

Introduction:

Reducing avoidable hospital admissions is often viewed as a possible positive consequence of introducing integrated care (IC). The aim of this study was to investigate the impact of implementing IC in Norrtälje on the rate of admissions for ambulatory care sensitive conditions (ACSC).

Method:

Using interrupted time series analyses we investigated the effect of implementing IC in Norrtälje municipality in the northern part of Stockholm county, Sweden. The time period included 48 time points, from year 2000 to year 2011 with measurements before and after introducing IC in Norrtälje in 2006. In order to control for other extraneous events that could affect the outcome measure, but not related to the introduction of IC, we included a control population from Stockholm municipality.

Results:

After introducing IC in Norrtälje the rate of admissions for ACSC decreased. This decrease was greater in Norrtälje than in the matched control population, however the difference between the two areas was not statistically significant (p = 0.08).

Conclusion:

Introducing IC in Norrtälje may have had positive impact on admissions for ACSC for older people living in Norrtälje; however, the interpretation of the impact of IC on admissions for ACSC is complicated by intervening policy changes in health and social care during the study period.

The impacts of collaboration between local health care and non-health care organizations and factors shaping how they work: a systematic review of reviews

BACKGROUND

Policymakers in many countries promote collaboration between health care organizations and other sectors as a route to improving population health. Local collaborations have been developed for decades. Yet little is known about the impact of cross-sector collaboration on health and health equity.

METHODS

We carried out a systematic review of reviews to synthesize evidence on the health impacts of collaboration between local health care and non-health care organizations, and to understand the factors affecting how these partnerships functioned. We searched four databases and included 36 studies (reviews) in our review. We extracted data from these studies and used Nvivo 12 to help categorize the data. We assessed risk of bias in the studies using standardized tools. We used a narrative approach to synthesizing and reporting the data.

RESULTS

The 36 studies we reviewed included evidence on varying forms of collaboration in diverse contexts. Some studies included data on collaborations with broad population health goals, such as preventing disease and reducing health inequalities. Others focused on collaborations with a narrower focus, such as better integration between health care and social services. Overall, there is little convincing evidence to suggest that collaboration between local health care and non-health care organizations improves health outcomes. Evidence of impact on health services is mixed. And evidence of impact on resource use and spending are limited and mixed. Despite this, many studies report on factors associated with better or worse collaboration. We grouped these into five domains: motivation and purpose, relationships and cultures, resources and capabilities, governance and leadership, and external factors. But data linking factors in these domains to collaboration outcomes is sparse.

CONCLUSIONS

In theory, collaboration between local health care and non-health care organizations might contribute to better population health. But we know little about which kinds of collaborations work, for whom, and in what contexts. The benefits of collaboration may be hard to deliver, hard to measure, and overestimated by policymakers. Ultimately, local collaborations should be understood within their macro-level political and economic context, and as one component within a wider system of factors and interventions interacting to shape population health.

Effectiveness of a health and social care integration programme for home-dwelling frail older persons in Argentina

Introduction

The evidence of effectiveness of integrated care initiatives for home-dwelling frail older persons is still inconclusive. There is a need for more studies, especially in developing countries. Our objective was to assess the effectiveness of a health and social care integration programme versus the best standard of care to date in this population.

Methods

Quasi-experimental study performed in patients' homes in Buenos Aires, Argentina. The intervention arm had a health and social care counsellor that systematically reviewed the social and biological situation following a structured process, evaluating: functionality, nutrition, mobility, pain, cognition, medication reconciliation and adherence, need for care, quality of care, and environmental safety. The control group received the best standard of care to date, with access to the same health or social care services, but without the counsellor and related processes. The main outcome was the adjusted hazard ratio for hospitalizations after one year using a Cox-proportional hazards model.

Results

We recruited 121 persons in each group. The crude hazard ratio for hospital admissions, comparing the intervention to the control group was 0.622 (95% CI: 0.427–0.904; p = 0.013). The adjusted hazard ratio (aHR) was 0.503 (95% CI: 0.340–0.746; p = 0.001). The aHR for death was 0.993 (95% CI: 0.492–2.002; p = 0.984). The absolute difference in the quality of life was 16.59 points (95% CI: 12.03–21.14; p < 0.001).

Discussion

The integration programme had lower hospital admissions and better quality of life than the usual care. There was no significant difference in death rates.

Evaluating Large-Scale Integrated Care Projects: The Development of a Protocol for a Mixed Methods Realist Evaluation Study in Belgium

BACKGROUND

The twelve Integrated Care Program pilot projects (ICPs) created by the government plan 'Integrated Care for Better Health' aim to achieve four outcome types (the Quadruple Aim) for people with chronic diseases in Belgium: improved population health, improved patient and provider experiences and improved cost efficiency. The aim of this article is to present the development of a mixed methods realist evaluation of this large-scale, whole system change programme.

METHODS

A scientific team was commissioned to co-design and implement an evaluation protocol in close collaboration with the government, the ICPs and several other involved stakeholders.

RESULTS

A protocol for a mixed methods realist evaluation was developed to gain insights into the mechanisms that foster successful results in ICPs. The qualitative evaluation proposed will be based on the document analysis of yearly ICP progress reports, selected case studies and focus group interviews with stakeholders. Processes and outcomes of all the projects will be monitored using indicators based on administrative data on population health and the quality and costs of care. A yearly survey will be organized to collect data on patient-reported outcomes and experiences and on provider-reported measures of inter-professional collaboration and proper wellbeing. Using both quantitative and qualitative data, we will develop theories about the mechanisms and the associated contextual factors that lead to integrated care and the Quadruple Aim outcomes.

DISCUSSION

The objective of this study is to deliver policy recommendations on strategies and best practices to improve care integration in Belgium and to implement a sustainable monitoring system that serves both policy makers and the stakeholders within the ICPs. Some challenges due to the large scale of the project and the multiple stakeholders involved may impede the successful implementation of this proposal.

Challenges in measuring integrated care models: International knowledge and the case of Québec

Introduction

The implementation of integrated care models requires significant efforts, especially due to institutional and organisational inertial forces that characterize health and social care systems of developed countries. It is therefore crucial to deploy strategies that promote continuous adjustment to these barriers so as to improve the benefits of integrating care. Measuring the implementation and effects of integrated care models are key component of these strategies. However, measuring integrated care also faces major challenges. This study aims to identify and characterise integrated care measurement challenges.

Methods

A review of reviews on the measurement of integrated care identified 12 papers. A thematic analysis was conducted to identify and categorize measurement challenges. Document analysis was done on the measurement of an integrated care model for older adults in Québec.

Results

Eight categories of measurement challenges were identified. These challenges include difficulties in measuring structures, processes, and effects of models; conceptual ambiguity and heterogeneity of organisational forms; involving multiple actors in the measurement strategy; and including multiple data sources, amongst others. These challenges revealed and explained potential gaps in the measurement of integrated care for older adults in Québec. For instance, the Québec measurement strategy did not include effects indicators.

Conclusion

Although the measurement of integrated care is a complex endeavour, there is a need for adequate measurement strategies that allow to appreciate important elements of integrate care. The findings of this study could be used as a reflexive tool in advancing research and practice of measuring integrated care.