Reframing the challenges to integrated care: a complex-adaptive systems perspective

Study protocol for a single-arm pilot trial investigating the feasibility of a multimodal digital technology for managing metabolic syndrome in patients with chronic obstructive pulmonary disease

Individuals diagnosed with Chronic Obstructive Pulmonary Disease (COPD) are exposed to an increased risk of metabolic syndrome (MetS), which negatively affects their health outcomes and quality of life. Lifestyle interventions have shown promise in managing MetS. This study outlines the protocol for a web-based multimodal self-care program, Digital Metabolic Rehabilitation, for managing MetS in patients with COPD. The Digital Metabolic Rehabilitation is a single-arm pilot trial that integrates the Canadian Health Advanced by Nutrition and Graded Exercise (CHANGE) Program and a web-based wellness platform. The web-based wellness platform employed in this study is My Viva Plan (MVP)®, which integrates a holistic, multicomponent approach to promote wellness. The intervention will primarily focus on lifestyle changes for patients with COPD. Over 6 months, participants will use the web-based wellness platform and engage in weekly online support group sessions. Fifty patients diagnosed with stage I-II COPD and MetS will participate. Blood tests, anthropometrics, body composition, physical function, muscle strength, physical activity, energy metabolism, quality of life and mental health will be assessed at baseline, 3, and 6 months. The Digital Metabolic Rehabilitation program aims to explore whether a multimodal integrative intervention delivered through a web-based wellness platform can be implemented by patients with COPD with MetS. By combining the expertise of the CHANGE Program with the digital delivery format, the intervention seeks to enhance self-monitoring and foster better self-management practices. The protocol outlines a novel and potentially impactful intervention for managing MetS in patients with COPD.

"Using the right tools and addressing the right issue": A qualitative exploration to support better care for intimate partner violence, brain injury, and mental health

BACKGROUND

Intimate partner violence (IPV) is a global public health crisis. Often repetitive and occurring over prolonged periods of time, IPV puts survivors at high risk of brain injury (BI). Mental health concerns are highly prevalent both among individuals who have experienced IPV and those who have experienced BI, yet the interrelatedness and complexity of these three challenges when experienced together is poorly understood. This qualitative study explored care provision for IPV survivors with BI (IPV-BI) and mental health concerns from the perspectives of both survivors and providers.

METHODS

This qualitative interpretive description study was part of a broader research project exploring employment, mental health, and COVID-19 implications for survivors of IPV-BI. Participants (N = 24), including survivors and service providers, participated in semi-structured group and individual interviews between October 2020 and February 2021. Interviews were recorded, transcribed, and thematically analyzed.

FINDINGS

Four themes were developed from interview findings: 1) identifying BI and mental health as contributing components to survivors' experiences is critical to getting appropriate care; 2) supporting survivors involves a "toolbox full of strategies" and a flexible approach; 3) connecting and collaborating across sectors is key; and 4) underfunding and systemic barriers hinder access to care. Finally, we share recommendations from participants to better support IPV survivors.

CONCLUSIONS

Identifying both BI and mental health concerns among IPV survivors is critical to providing appropriate supports. Survivors of IPV experiencing BI and mental health concerns benefit from a flexible and collaborative approach to care; health and social care systems should be set up to support these collaborative approaches.

Can collaboration among health and social care workers play a role in addressing geriatric care challenges? A qualitative case study in Central Vietnam

BACKGROUND

Vietnam's healthcare system offers limited services and facilities for older adults. This study explored the perceptions of health and social care workers regarding geriatric care issues, their impact on older adults and the potential of collaboration for enhancing older adults' health and well-being.

METHODS

This qualitative case study employed 27 focus group discussions and two in-depth interviews with 174 participants in Thua Thien Hue Province, Vietnam. An inductive thematic analysis was conducted.

RESULTS

According to the participants, the major challenges that hindered geriatric care consisted of caregiver and care recipient issues, which were identified to constrain care accessibility, resulting in decreased physical, mental and social health. Across different settings and professions, collaboration was considered a routine and natural aspect of daily work. It was perceived that establishing and strengthening collaboration could facilitate improvement in health and social welfare services through the prioritization of needs and enhancement of caregiver skills and training.

CONCLUSIONS

Collaboration was viewed as ad hoc but indispensable for addressing the identified geriatric care issues that could improve the general health and well-being of older adults. The findings indicate a need for better collaboration in Vietnam, achieved through defined guidelines, training and improved interprofessional education and practice.

Understanding critical factors associated with integration of community health workers into health and hospital systems

Community health worker (CHW) models have been shown to improve health behaviors and health outcomes and reduce cost, particularly among low-income underserved populations. Consequently, health systems are increasingly employing CHWs to provide health services in clinical environments. A growing body of the literature suggests that effective integration of CHWs within the healthcare system is important to achieve the desired outcomes, but the question of how to achieve effective integration is less clear. This study seeks to explore the integration of CHWs within a large state university health system to identify factors critical to the effective integration of CHWs into the clinical care environment. We conducted a qualitative descriptive multiple embedded case study of the University of Illinois at Chicago's Hospital and Health Science System (UI Health). The embedded subunits of analysis were teams within the UI Health System that currently employ CHWs to assist with the provision of clinical care or services to patients. Data were collected via semi-structured interviews and document review. In total, six sub-units were enrolled, and 17 interviews were conducted with CHWs (n = 9), and administrators or healthcare providers (n = 8). Fourteen factors related to effective CHW integration were identified and organized in four categories: individual, team, organization, and community. Findings suggest that in addition to commonly recognized elements of effective CHW models including training, supervision, and the presence of a champion, programs must consider the organizational context in which the program is positioned as well as the ways in which both CHWs and the organization engage with communities served. This research can serve as a roadmap for health systems that seek to integrate CHWs within healthcare services and can be used to promote best practice in CHW integration.

Healthcare workers' perceptions and experiences of primary healthcare integration: a scoping review of qualitative evidence

BACKGROUND

Primary healthcare (PHC) integration has been promoted globally as a tool for health sector reform and universal health coverage (UHC), especially in low-resource settings. However, for a range of reasons, implementation and impact remain variable. PHC integration, at its simplest, can be considered a way of delivering PHC services together that sometimes have been delivered as a series of separate or 'vertical' health programmes. Healthcare workers are known to shape the success of implementing reform interventions. Understanding healthcare worker perceptions and experiences of PHC integration can therefore provide insights into the role healthcare workers play in shaping implementation efforts and the impact of PHC integration. However, the heterogeneity of the evidence base complicates our understanding of their role in shaping the implementation, delivery, and impact of PHC integration, and the role of contextual factors influencing their responses.

OBJECTIVES

To map the qualitative literature on healthcare workers' perceptions and experiences of PHC integration to characterise the evidence base, with a view to better inform future syntheses on the topic.

SEARCH METHODS

We used standard, extensive Cochrane search methods. The latest search date was 28 July 2020. We did not search for grey literature due to the many published records identified.

SELECTION CRITERIA

We included studies with qualitative and mixed methods designs that reported on healthcare worker perceptions and experiences of PHC integration from any country. We excluded settings other than PHC and community-based health care, participants other than healthcare workers, and interventions broader than healthcare services. We used translation support from colleagues and Google Translate software to screen non-English records. Where translation was not feasible we categorised these records as studies awaiting classification.

DATA COLLECTION AND ANALYSIS

For data extraction, we used a customised data extraction form containing items developed using inductive and deductive approaches. We performed independent extraction in duplicate for a sample on 10% of studies allowed for sufficient agreement to be reached between review authors. We analysed extracted data quantitatively by counting the number of studies per indicator and converting these into proportions with additional qualitative descriptive information. Indicators included descriptions of study methods, country setting, intervention type, scope and strategies, implementing healthcare workers, and client target population.

MAIN RESULTS

The review included 184 studies for analysis based on 191 included papers. Most studies were published in the last 12 years, with a sharp increase in the last five years. Studies mostly employed methods with cross-sectional qualitative design (mainly interviews and focus group discussions), and few used longitudinal or ethnographic (or both) designs. Studies covered 37 countries, with close to an even split in the proportions of high-income countries (HICs) and low- and middle-income countries (LMICs). There were gaps in the geographical spread for both HICs and LMICs and some countries were more dominant, such as the USA for HICs, South Africa for middle-income countries, and Uganda for low-income countries. Methods were mainly cross-sectional observational studies with few longitudinal studies. A minority of studies used an analytical conceptual model to guide the design, implementation, and evaluation of the integration study. The main finding was the various levels of diversity found in the evidence base on PHC integration studies that examined healthcare workers' perceptions and experiences. The review identified six different configurations of health service streams that were being integrated and these were categorised as: mental and behavioural health; HIV, tuberculosis (TB) and sexual reproductive health; maternal, women, and child health; non-communicable diseases; and two broader categories, namely general PHC services, and allied and specialised services. Within the health streams, the review mapped the scope of the interventions as full or partial integration. The review mapped the use of three different integration strategies and categorised these as horizontal integration, service expansion, and service linkage strategies. The wide range of healthcare workers who participated in the implementation of integration interventions was mapped and these included policymakers, senior managers, middle and frontline managers, clinicians, allied healthcare professionals, lay healthcare workers, and health system support staff. We mapped the range of client target populations.

AUTHORS' CONCLUSIONS

This scoping review provides a systematic, descriptive overview of the heterogeneity in qualitative literature on healthcare workers' perceptions and experience of PHC integration, pointing to diversity with regard to country settings; study types; client populations; healthcare worker populations; and intervention focus, scope, and strategies. It would be important for researchers and decision-makers to understand how the diversity in PHC integration intervention design, implementation, and context may influence how healthcare workers shape PHC integration impact. The classification of studies on the various dimensions (e.g. integration focus, scope, strategy, and type of healthcare workers and client populations) can help researchers to navigate the way the literature varies and for specifying potential questions for future qualitative evidence syntheses.

Healthcare workers' perceptions and experiences of primary healthcare integration: a scoping review of qualitative evidence

BACKGROUND

Primary healthcare (PHC) integration has been promoted globally as a tool for health sector reform and universal health coverage (UHC), especially in low-resource settings. However, for a range of reasons, implementation and impact remain variable. PHC integration, at its simplest, can be considered a way of delivering PHC services together that sometimes have been delivered as a series of separate or 'vertical' health programmes. Healthcare workers are known to shape the success of implementing reform interventions. Understanding healthcare worker perceptions and experiences of PHC integration can therefore provide insights into the role healthcare workers play in shaping implementation efforts and the impact of PHC integration. However, the heterogeneity of the evidence base complicates our understanding of their role in shaping the implementation, delivery, and impact of PHC integration, and the role of contextual factors influencing their responses.

OBJECTIVES

To map the qualitative literature on healthcare workers' perceptions and experiences of PHC integration to characterise the evidence base, with a view to better inform future syntheses on the topic.

SEARCH METHODS

We used standard, extensive Cochrane search methods. The latest search date was 28 July 2020. We did not search for grey literature due to the many published records identified.

SELECTION CRITERIA

We included studies with qualitative and mixed methods designs that reported on healthcare worker perceptions and experiences of PHC integration from any country. We excluded settings other than PHC and community-based health care, participants other than healthcare workers, and interventions broader than healthcare services. We used translation support from colleagues and Google Translate software to screen non-English records. Where translation was not feasible we categorised these records as studies awaiting classification.

DATA COLLECTION AND ANALYSIS

For data extraction, we used a customised data extraction form containing items developed using inductive and deductive approaches. We performed independent extraction in duplicate for a sample on 10% of studies allowed for sufficient agreement to be reached between review authors. We analysed extracted data quantitatively by counting the number of studies per indicator and converting these into proportions with additional qualitative descriptive information. Indicators included descriptions of study methods, country setting, intervention type, scope and strategies, implementing healthcare workers, and client target population.

MAIN RESULTS

The review included 184 studies for analysis based on 191 included papers. Most studies were published in the last 12 years, with a sharp increase in the last five years. Studies mostly employed methods with cross-sectional qualitative design (mainly interviews and focus group discussions), and few used longitudinal or ethnographic (or both) designs. Studies covered 37 countries, with close to an even split in the proportions of high-income countries (HICs) and low- and middle-income countries (LMICs). There were gaps in the geographical spread for both HICs and LMICs and some countries were more dominant, such as the USA for HICs, South Africa for middle-income countries, and Uganda for low-income countries. Methods were mainly cross-sectional observational studies with few longitudinal studies. A minority of studies used an analytical conceptual model to guide the design, implementation, and evaluation of the integration study. The main finding was the various levels of diversity found in the evidence base on PHC integration studies that examined healthcare workers' perceptions and experiences. The review identified six different configurations of health service streams that were being integrated and these were categorised as: mental and behavioural health; HIV, tuberculosis (TB) and sexual reproductive health; maternal, women, and child health; non-communicable diseases; and two broader categories, namely general PHC services, and allied and specialised services. Within the health streams, the review mapped the scope of the interventions as full or partial integration. The review mapped the use of three different integration strategies and categorised these as horizontal integration, service expansion, and service linkage strategies. The wide range of healthcare workers who participated in the implementation of integration interventions was mapped and these included policymakers, senior managers, middle and frontline managers, clinicians, allied healthcare professionals, lay healthcare workers, and health system support staff. We mapped the range of client target populations.

AUTHORS' CONCLUSIONS

This scoping review provides a systematic, descriptive overview of the heterogeneity in qualitative literature on healthcare workers' perceptions and experience of PHC integration, pointing to diversity with regard to country settings; study types; client populations; healthcare worker populations; and intervention focus, scope, and strategies. It would be important for researchers and decision-makers to understand how the diversity in PHC integration intervention design, implementation, and context may influence how healthcare workers shape PHC integration impact. The classification of studies on the various dimensions (e.g. integration focus, scope, strategy, and type of healthcare workers and client populations) can help researchers to navigate the way the literature varies and for specifying potential questions for future qualitative evidence syntheses.

Identifying facilitators and barriers to integrated and equitable care for community-dwelling older adults with high emergency department use from historically marginalized groups

BACKGROUND

High rates of emergency department (ED) use by older adults persist despite attempts to improve accessibility of appropriate and comprehensive care. Understanding the drivers of ED visits from the perspective of older adults from historically marginalized groups could help reduce ED use by patients with needs that are preventable or could have been treated in a more appropriate setting. This interpretivist, feminist study aims to explore the unmet care needs of older adults (age 65 +) with high ED use and belonging to historically marginalized groups to better understand how social and structural inequities reinforced by neoliberalism; federal and provincial governance structures and policy frameworks; and regional processes and local institutional practices, shape the experiences of these older adults, particularly those at risk of poor health outcomes based on the social determinants of health (SDH).

METHODS/DESIGN

This mixed methods study will employ an integrated knowledge translation (iKT) approach, starting with a quantitative phase followed by a qualitative phase. Older adults self-identifying as belonging to a historically marginalized group, having visited an ED three or more times in the past 12 months, and living in a private dwelling, will be recruited using flyers posted at two emergency care sites and by an on-site research assistant. Data obtained through surveys, short answer questions, and chart review will be used to compile case profiles of patients from historically marginalized groups with potentially avoidable ED visits. Descriptive and inferential statistical analyses and inductive thematic analysis will be conducted. Findings will be interpreted using the Intersectionality-Based Policy Analysis Framework to identify the interconnections between unmet care needs, potentially avoidable ED admissions, structural inequalities, and the SDH. Semi-structured interviews will be conducted with a subset of older adults at risk of poor health outcomes based on SDH, family care partners, and health care professionals to validate preliminary findings and collect additional data on perceived facilitators and barriers to integrated and accessible care.

DISCUSSION

Exploring the linkages between potentially avoidable ED visits by older adults from marginalized groups and how their care experiences have been shaped by inequities in the systems, policies, and institutions that structure health and social care provision will enable researchers to offer recommendations for equity-focused policy and clinical practice reforms to improve patient outcomes and system integration.

Using Independent Contracting Arrangements in Integrated Care Programs for Older Adults: Implications for Clients and the Home Care Workforce in a Time of Neoliberal Restructuring

Integrated care programs reshape the processes of health and social care delivery in the home care sector to be more continuous, cooperative, equitable, and efficient. An independent contracting model is one approach being used to overcome issues related to home care fragmentation. To better understand the implications of this model of service delivery for clients and carers, interviews were conducted in 2013 with 22 key informants. Data were analyzed using thematic analysis and interpreted using a feminist political economy framework. This study finds that independent contracting arrangements improve care continuity for clients while simultaneously reinforcing precarious working conditions for home care workers. This research calls for reform to this model of service delivery to better support home care workers as they provide the care necessary for older adults to age in place.

Lessons learnt while integrating services for children: qualitative interviews with professional stakeholders

BACKGROUND

In the English NHS, integrated care is seen as an opportunity to deliver joined-up care for children and families. This paper examines the lessons learnt by professional stakeholders in the process of developing different examples of integrated models of care/frameworks for children's services.

METHODS

Initial desk research was undertaken to identify different examples of integrated care models and systems/frameworks for children's services. This identified forty-three examples in England. Of these, twelve examples were shortlisted after consultation with the senior managers within the Health and Care Partnership that had commissioned the research, and a more detailed online search for published documents was undertaken. Semi-structured qualitative interviews were then conducted with sixteen professional stakeholders in eight of these examples, ranging from one to four interviewees per example. Interviews focused on the lessons learnt from integrating and transforming services. Data were analysed using framework analysis.

RESULTS

The eight examples vary in their design but have several broad commonalities. A number of common themes and learning have emerged, of which two were identified within all eight examples: the first is about focusing on children and young people; the second is about focusing on partner engagement and collaboration and the importance of building trust and relationships between partners. A number of other important themes also emerged together with several challenges.

CONCLUSIONS

A number of common factors were identified that are essential to success in integrating health and care systems. Common across all localities were being child-centric and focusing on child outcomes plus the importance of building trust, engagement and relationships with partners. The findings can help health and care system leaders transform services to ensure efficiency, improvement in services and integration.

Application of complexity theory in health and social care research: a scoping review

BACKGROUND

Complexity theory has been chosen by many authors as a suitable lens through which to examine health and social care. Despite its potential value, many empirical investigations apply the theory in a tokenistic manner without engaging with its underlying concepts and underpinnings.

OBJECTIVES

The aim of this scoping review is to synthesise the literature on empirical studies that have centred on the application of complexity theory to understand health and social care provision.

METHODS

This scoping review considered primary research using complexity theory-informed approaches, published in English between 2012 and 2021. Cochrane Database of Systematic Reviews, MEDLINE, CINAHL, EMBASE, Web of Science, PSYCHINFO, the NHS Economic Evaluation Database, and the Health Economic Evaluations Database were searched. In addition, a manual search of the reference lists of relevant articles was conducted. Data extraction was conducted using Covidence software and a data extraction form was created to produce a descriptive summary of the results, addressing the objectives and research question. The review used the revised Arksey and O'Malley framework and adhered to the Preferred Reporting Items for Systematic Reviews and Meta-analysis Extension for Scoping Reviews (PRISMA-ScR).

RESULTS

2021 studies were initially identified with a total of 61 articles included for extraction. Complexity theory in health and social care research is poorly defined and described and was most commonly applied as a theoretical and analytical framework. The full breadth of the health and social care continuum was not represented in the identified articles, with the majority being healthcare focused.

DISCUSSION

Complexity theory is being increasingly embraced in health and care research. The heterogeneity of the literature regarding the application of complexity theory made synthesis challenging. However, this scoping review has synthesised the most recent evidence and contributes to translational systems research by providing guidance for future studies.

CONCLUSION

The study of complex health and care systems necessitates methods of interpreting dynamic prcesses which requires qualitative and longitudinal studies with abductive reasoning. The authors provide guidance on conducting complexity-informed primary research that seeks to promote rigor and transparency in the area.

REGISTRATION

The scoping review protocol was registered at Open Science Framework, and the review protocol was published at BMJ Open (https://bit.ly/3Ex1Inu).

How to not revert to type: Complexity-informed learnings from the pandemic response for health system reform and universal access to integrated care

This article is part of the Research Topic 'Health Systems Recovery in the Context of COVID-19 and Protracted Conflict'.

Background

COVID-19 has highlighted existing health inequalities and health system deficiencies both in Ireland and internationally; however, understanding of the critical opportunities for health system change that have arisen during the pandemic is still emerging and largely descriptive. This research is situated in the Irish health reform context of Sláintecare, the reform programme which aims to deliver universal healthcare by strengthening public health, primary and community healthcare functions as well as tackling system and societal health inequities.

Aims and objectives

This study set out to advance understanding of how and to what extent COVID-19 has highlighted opportunities for change that enabled better access to universal, integrated care in Ireland, with a view to informing universal health system reform and implementation.

Methods

The study, which is qualitative, was underpinned by a co-production approach with Irish health system leadership. Semi-structured interviews were conducted with sixteen health system professionals (including managers and frontline workers) from a range of responses to explore their experiences and interpretations of social processes of change that enabled (or hindered) better access to universal integrated care during the pandemic. A complexity-informed approach was mobilized to theorize the processes that impacted on access to universal, integrated care in Ireland in the COVID-19 context.

Findings

A range of circumstances, strategies and mechanisms that created favorable system conditions in which new integrated care trajectories emerged during the crisis. Three key learnings from the pandemic response are presented: (1) nurturing whole-system thinking through a clear, common goal and shared information base; (2) harnessing, sharing and supporting innovation; and (3) prioritizing trust and relationship-building in a social, human-centered health system. Policy and practice implications for health reform are discussed.

Therapeutic Communication Experiences of Nurses Caring for Patients with Hematology

Nurses who take care of patients with hematology have more difficulty in therapeutic communication. The aim of this study is to explore the therapeutic communication experiences of nurses caring for patients with hematology and the meaning of the essential structure of therapeutic communication. Colaizzi's phenomenological method was applied to explore the essential structures and meanings of therapeutic communication in depth through a focus group interview. The interview was conducted at a tertiary care hospital with 20 nurses caring for patients with hematology. As a result of the analyses, 22 themes, 14 theme clusters, and 5 categories were derived. The categories derived from the analyses included "acquiring core competencies as nursing professionals", "improving patient-centered nursing performance", "forming a partnership treatment relationship", "obtaining clinical performance skills to solve problems", and "preparing efficient system improvement". Based on this study's results, it will be possible to provide high-quality nursing to patients by improving the therapeutic communication ability of nurses caring for patients with hematology. In addition, it will be the basis for the development of a nurses' therapeutic communication promotion program for nurses caring for such patients.

Barriers and facilitators for coherent rehabilitation among people with inflammatory arthritis - a qualitative interview study

BACKGROUND

People with chronic diseases have contact with several different professionals across hospital wards, municipality services and general practice and often experience lack of coherence. The purpose was to explore perceived barriers and facilitators to coherent rehabilitation pathways for health care users with inflammatory arthritis and how coherence can be improved.

METHODS

Semi-structured individual interviews were conducted before a planned inpatient rehabilitation stay, 2-3 weeks and 4-6 months after discharge. Thematic reflexive analysis guided the analysis of data. Concepts of person-centred care, complex adaptive systems and integrated care were applied in the interpretations.

RESULTS

In all, 11 participants with IA were included. There was one overarching theme, The importance of a person-centred approach, illuminating the significance of professionals who respect healthcare user' preferences. To use a person-centred approach, demands professionals who are interested in exploring the persons own values, preferences and experiences and incorporate these when planning care and rehabilitation.Connected to the overarching theme, three sub-themes were derived; 1) Experiences of empowerment and dis-empowerment, covering that most want to be in control and act themselves, but felt overwhelmed and lost energy and they tended to give up; 2) Experiences of communication and coordination, encompass how people feel forced to take on coordination and communication tasks themselves although they do not always feel qualified for this. Some asked for a coordination person and 3) Facing everyday life after discharge, covering how initiatives taken by professionals were not always experienced as helpful after discharge. Some gave up and some tried to find alternative paths themselves.

CONCLUSION

Professionals taking a person-centred approach facilitated coherent rehabilitation pathways. This encompassed care with respect for individual needs and professionals who empowered patients to self-management. Furthermore, to be aware that interprofessional communication and coordination need to take place both between professional within the same department, between departments and between professionals in different sectors. After discharge, some patients were challenged in their everyday life when trying to follow the advice from the professionals. Professionals, who do not use a person-centred approach, hinder coherence. Patients thus feel compelled to take on communication and coordination tasks.

Implementing Coordinated Care Networks: The Interplay of Individual and Distributed Leadership Practices

How does leadership emerge and function when multiple health care organizations come together to form a network? In this qualitative comparative case study, we draw on distributed leadership theory to examine the leadership practices that manifested during the implementation of three coordinated care networks. Thirty leaders and care providers participated in semistructured interviews. Interview data were inductively analyzed using thematic analysis. Although established in response to the same policy initiative, each case differed in its leadership approach and implementation strategy. We found that manifestation of distributed leadership was contingent on the presence of an individual leader who acted as a unifying force across their respective network. Our findings suggest that policies to encourage the development of interorganizational networks should include sufficient resources to support an individual leader who enables distributed leadership.

Deconstructing design thinking as a tool for the implementation of a population health initiative

Background

The translation of evidence-based practices and rapid uptake of innovations into global health practice is challenging. Design thinking is a consultative process involving multiple stakeholders and has been identified as a promising solution to create and apply implementation strategies in complex environments like health systems.

Methods

We conducted a process evaluation of a real-world example, namely an initiative to innovate hypertension screening, diagnosis and care in São Paulo, Brazil. The parameters of the evaluation were informed by a specification rubric and categorization system, recommended for the investigation of implementation strategies, and the double-diamond conceptual framework to describe and examine the strategic architecture and nature of the design thinking approach, with particular emphasis on identifying potential areas of “value-add” particular to the approach. The retrospective evaluation was performed by an independent partner who had not been involved in the setting up and implementation of the design thinking process.

Results

The evaluation unveiled a dense catalogue of strategically driven, mostly theoretically based, activities involving all identified health system stakeholders including patients. Narrative reconstruction illuminated the systematic and coherent nature of this approach, with different resulting actions progressively accounting for all relevant layers of the health system to engineer a broad selection of specific implementation solutions. The relevance of the identified features and the mechanics used to promote more successful implementation practices was manifested in several distinct ways: design thinking offered a clear direction on which innovations really mattered and when, as well as several new dimensions for consideration in the development of an innovation mindset amongst stakeholders. It thereby promoted relationship quality in terms of familiarity and trust, and commitment to evidence-based enquiry and action. Design thinking was also able to navigate the territory between the need for intervention “fidelity” versus “adaptation” and provide the operational know-how to face familiar implementation hurdles. Lastly, it brought a new kind of skill set to the public health stakeholders that incorporated diplomacy, multidisciplinary approaches and management sciences—skills that are considered necessary but not yet widely taught as part of public health training.

Conclusions

Design thinking is a sound and viable tool to use as part of an implementation strategy for engaging with health system stakeholders and successfully translating evidence-based practices and new innovations into routine practice, thereby addressing an important knowledge—practice gap and, more broadly, contributing to the strategic repertoire available to implementation science.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12961-022-00892-5.

Integrating Self-Management Education and Support in Routine Care of People With Type 2 Diabetes Mellitus: A Conceptional Model Based on Critical Interpretive Synthesis and A Consensus-Building Participatory Consultation

The integration of self-management education and support into the routine diabetes care is essential in preventing complications. Currently, however, there is no consensus on how to conceptualise integration in relation to self-management education and support. Therefore, this synthesis presents a framework conceptualising integration and self-management.

Methods

Seven electronic databases (Medline, HMIC, PsycINFO, CINAHL, ERIC, Scopus and Web of Science) were searched. Twenty-one articles met the inclusion criteria. Data were synthesised using principles of critical interpretive synthesis to build the conceptual framework. The framework was presented to 49 diabetes specialist nurses working at different levels of care during a multilingual workshop.

Results

A conceptual framework is proposed in which integration is influenced by five interacting components: the programme ethos of the diabetes self-management education and support intervention (content and delivery), care system organisation (the framework in which such interventions are delivered), adapting to context (the aspects of the people receiving and delivering the interventions), interpersonal relationship (the interactions between the deliverer and receiver of the intervention), and shared learning (what deliverer and receiver gain from the interactions). The critical inputs from the workshop participants related to the different priorities given to the components according to their sociolinguistic and educational experiences, Overall, they agreed with the conceptualisation of the components and their content specific to diabetes self-management education and support.

Discussion

Integration was conceptualised in terms of the relational, ethical, learning, contextual adapting, and systemic organisational aspects of the intervention. It remains uncertain which prioritised interactions of components and to what extent these may moderate the integration of self-management education and support into routine care; in turn, the level of integration observed in each of the components may moderate the impact of these interventions, which may also apply to the impact of the professional training.

Conclusion

This synthesis provides a theoretical framework that conceptualises integration in the context of diabetes self-management education and support in routine care. More research is required to evaluate how the components identified in the framework can be addressed in clinical practice to assess whether improvements in self-management education and support can be effectively realised in this population.

Patient- and Community-Oriented Primary Care Approaches for Health in Rural, Remote and Resource-Dependent Places: Insights for Eco-Social Praxis

Accelerating ecological and societal changes require re-imagining the role of primary care and public health to address eco-social concerns in rural and remote places. In this narrative review, we searched literatures on: community-oriented primary care, patient-oriented research engagement, public health and primary care synergies, and primary care addressing social determinants of health. Our analysis was guided by questions oriented to utility for addressing concerns of social-ecological systems in rural, remote contexts characterized by a high degree of reliance on resource extraction and development (e.g., forestry, mining, oil and gas, fisheries, agriculture, ranching and/or renewables). We describe a range of useful frameworks, processes and tools that are oriented toward bolstering the resilience and engagement of both primary care and public health, though few explicitly incorporated considerations of eco-social approaches to health or broader eco-social context(s). In synthesizing the existing evidence base for integration between primary care and public health, the results signal that for community-oriented primary care and related frameworks to be useful in rural and remote community settings, practitioners are required to grapple with complexity, durable relationships, sustainable resources, holistic approaches to clinician training, Indigenous perspectives, and governance.

Building integrated, adaptive and responsive healthcare systems - lessons from paramedicine in Ontario, Canada

BACKGROUND

Being responsive and adaptive to local population needs is a key principle of integrated care, and traditional top-down approaches to health system governance are considered to be ineffective. There is need for more guidance on taking flexible, complexity-aware approaches to governance that foster integration and adaptability in the health system. Over the past two decades, paramedics in Ontario, Canada have been filling gaps in health and social services beyond their traditional mandate of emergency transport. Studying these grassroots, local programs can provide insight into how health systems can be more integrated, adaptive and responsive.

METHODS

Semi-structured interviews were conducted with people involved in new, integrated models of paramedic care in Ontario. Audio recordings of interviews were transcribed and coded inductively for participants' experiences, including drivers, enablers and barriers to implementation. Thematic analysis was done to ascertain key concepts from across the dataset.

RESULTS

Twenty-six participants from across Ontario's five administrative health regions participated in the study. Participants described a range of programs that included acute, urgent and preventative care driven by local relationship networks of paramedics, hospitals, primary care, social services and home care. Three themes were developed that represent participants' experiences implementing these programs in the Ontario context. The first theme, adapting and being nimble in tension with system structures, related to distributed versus central control of programs, a desire to be nimble and skepticism towards prohibitive legal and regulatory systems. The second theme, evolving and flexible professional role identity, highlighted the value and challenges of a functionally flexible workforce and interest in new roles amongst the paramedic profession. The third theme, unpredictable influences on program implementation, identified events such as the COVID-19 pandemic and changing government priorities as accelerating, redirecting or inhibiting local program development.

CONCLUSIONS

The findings of this study add to the discourse on governing health systems towards being more integrated, adaptive and responsive to population needs. Governance strategies include: supporting networks of local organizational relationships; considering the role of a functionally flexible health workforce; promoting a shared vision and framework for collaboration; and enabling distributed, local control and experimentation.

Public Opinion on European Health Policy, Lessons from the COVID-19 Pandemic

Often, global crises, such as the COVID-19 pandemic, bring to light crucial weaknesses in political, economic, social and health systems. First, there are governments who formulate and implement policies and, second, there are the citizens who support them, thus contributing a great deal to their success. Our paper investigates the European citizens' opinion on health policy, focusing on their preference for European health policy during the coronavirus pandemic. The paper uses bibliometric analysis, descriptive statistics, and logistic regression to discuss the public opinion on health policy, the factors of influence, the change in perspectives between 2020 and 2021, and the socio-demographic profile of those favorable for the development of a European health policy in response to the coronavirus pandemic. Our findings show that citizens from southern and central European countries are more likely to prioritize the development of a European health policy, as compared to Nordic countries. Between 2020 and 2021, pro-European health policy citizens profile changes and becomes clearer, from pensioners to young working age males with medium education. In general, people prioritizing a European health policy value health as the most important issue at a national level are generally satisfied with the European Union and do not trust their national government.

The evolution and inter-sectoral interaction mechanism of China's national medical alliance: An analysis based on complex systems theory

This work investigates the performance and inter-sectoral interaction mechanism of China's largest vertically integrated care network, the national medical alliance (NMA). The data collected derive from the China Health Statistics Bulletin and the China Health Statistical Yearbook for the period 2009-2018. The data include 64 observation indicators for five medical sectors in the NMA, namely, tertiary hospitals (THS), secondary hospitals (SHS), community health centres (CHCS), township hospitals (TsHS) and professional public health institutions (PPHIS). This research combines complex systems theory with a multilevel structural dynamic factor model, and yields two main results. First, although the trend for the NMA's global factor is increasing, the evolutionary paths for sectoral factors differ substantially. Among the sectoral factors, the sectoral factor of THS continued to decline, and neither the sectoral factor of CHCS nor the sectoral factor of TsHS has significantly improved. Then, the interaction mechanism between the various NMA sectors is investigated. While a close relationship has been formed between THS and CHCS and between SHS and CHCS, there remains no close two-way relationship between either THS and TsHS or THS and SHS. Thus, going forward, to reach the policy expectations, China's NMA implementation must consider the interaction between different constituent sectors.

Care Integration in Primary Dementia Care Networks: A Longitudinal Mixed-Methods Study

Introduction:

Currently, care integration for community-dwelling persons with dementia is poor and knowledge on how to effectively facilitate development of integrated dementia care is lacking. The DementiaNet program aims to overcome this with a focus on interprofessional collaboration. The objective of this study is to investigate how care integration in interprofessional primary dementia care networks matures and to identify factors associated with (un)successfully maturation.

Theory and methods:

A longitudinal mixed-methods study, including 17 primary care networks participating in the DementiaNet study, was performed. Semi-structured interviews based on the Rainbow Model of Integrated Care were conducted at start, at 12- and 24 months. Network maturity scores (range 1–4) were derived from the interviews and qualitative data was used to explain the observed patterns.

Results:

Networks consisted on average of 9 professionals (range 4–22) covering medical, care and social disciplines. Network maturity yearly increased with 0.29 (95%-CI: 0.20–0.38). Important factors for improvement included getting to know each other’s expertise, having a capable network leader(s), stable network composition and participation of a general practitioner.

Conclusions:

The DementiaNet approach enables a transition towards more mature networks. Identified success factors provide better understanding of how network maturity can be achieved and gives guidance to future care integration strategies.

A sector-wide response to national policy on client-centred care and support: a document analysis of the development of a range of instruments to assess clients' experiences in the care and support for people with (intellectual) disabilities

Background

Client-centred care serves as the foundation for healthcare policy. Indeed, various instruments for assessing clients’ experiences of care and support are increasingly used to provide insights into the quality, and client-centred nature, of the care and support provided, which, in turn, aids the development of subsequent improvements. The unique characteristics of care and support for people with intellectual disabilities (ID), such as the need for both lifelong and life-wide care and support across all aspects of clients’ lives, led to an initiative within Dutch ID care to jointly develop a range of instruments to assess the experiences of clients receiving ID care and support. Individual clients’ experiences and suggestions for improvement, which are embedded in clients’ care plan cycles, constitute the foundation of this Range of Instruments. This paper provides a unique, bottom-up, exhaustive account of the process of developing the Range of instruments used to assess the experiences of clients in the field of Dutch ID care.

Methods

Relevant documents at three levels (i.e. 1) national documents, such as policy papers and governmental reports, 2) documents and reports from the Dutch Association of Healthcare Providers for People with Disabilities (VGN) along with minutes from the meetings of the expert Committee who assessed the instruments, and 3) correspondence between the Committee and developers as well as the forms used in the assessment process for each instrument) were qualitatively analysed by two researchers who had no affiliation with the development of the Range of instruments used to assess clients’ experiences in ID care and support. All of the documents were inductively coded using a thematic analytical approach. Informants who were either currently or previously involved in the development of these instruments were asked to provide clarification over the documents themselves and to explain the context in which they were produced.

Results

The development of the range of instruments can be classified into four phases, namely: 1) supporting the bottom-up development of initiatives to assess clients’ experiences, 2) focusing on learning and further development, 3) stimulating exchange between the developers and users of the instruments and the Committee responsible for assessing them, and 4) further development in response to the changing times and new landscape.

Conclusions

The range of instruments were found to be appropriate for a variety of clients in ID care and support, specifically in terms of assessing their individual experiences and gaining insight into their suggestions for improvement, and effective in terms of collaboratively improving the quality of ID care and support. In so doing, these instruments potentially provide an avenue through which clients’ experiences can be embedded in the process of ID care and support. Other specific features in the development of these instruments, namely their incremental adoption, ongoing evaluation and strong practice orientation, were also found to be suitable for other care contexts’ attempts to respond to the top-down policy objectives of client-centeredness and translating outcomes into direct care practice.

Early Implementation of a Patient-Centered Medical Home in Singapore: A Qualitative Study Using Theory on Diffusion of Innovations

Patient-Centered Medical Home (PCMH) has been found to improve care for complex needs patients in some countries but has not yet been widely adopted in Singapore. This study explored the ground-up implementation of a PCMH in Singapore by describing change strategies and unpacking initial experience and perception. In-depth interviews were conducted for twenty-two key informants from three groups: the implementers, their implementation partners, and other providers. “Diffusion of innovations” emerged as an overarching theory to contextualize PCMH in its early implementation. Three core “innovations” differentiated the PCMH from usual primary care: (i) team-based and integrated care; (ii) empanelment; and (iii) shared care with other general practitioners. Change strategies employed to implement these innovations included repurposing pre-existing resources, building a partnership to create supporting infrastructure and pathways in the delivery system, and doing targeted outreach to introduce the PCMH. Initial experience and perception were characterized by processes to “adopt” and “assimilate” the innovations, which were identified as challenging due to less predictable, self-organizing behaviors by multiple players. To work with the inherent complexity and novelty of the innovations, time, leadership, standardized methods, direct communication, and awareness-building efforts are needed. This study was retrospectively registered (Protocol ID: NCT04594967).

The Active Hospital pilot: A qualitative study exploring the implementation of a Trust-wide Sport and Exercise Medicine-led physical activity intervention

BACKGROUND

In 2017 Public Health England and Sport England commissioned a Consultant-led Sport and Exercise Medicine (SEM) pilot to test the feasibility and acceptability of embedding physical activity interventions in secondary care clinical pathways. The aim of this paper is to report qualitative findings exploring the experience of healthcare professionals (HCPs) and patients involved in the Active Hospital pilot.

METHODS

Qualitative data was collected by semi-structured interviews with Active Hospital pilot SEM Consultants, and staff and patients involved in three clinical pathways. Interviews with SEM Consultants explored the experience of developing and implementing the pilot. Interviews with staff and patients explored the experience of delivering and receiving Active Hospital interventions. Data were analysed thematically.

RESULTS

Interviews identified the importance of the Active Hospital pilot being Consultant-led for the following reasons; i) having trusting relationships with decision makers, ii) having sufficient influence to effect change, iii) identifying champions within the system, and iv) being adaptable to change and ensuring the programme fits within the wider strategic frameworks. HCPs emphasised the importance of the Active Hospital interventions fitting easily within existing work practices, the need for staff training and to tailor interventions for individual patient needs. The Active Hospital pilot was well received by patients, however a lack of dedicated resource and capacity to deliver the intervention was highlighted as a challenge by both patients and HCPs.

CONCLUSION

The SEM Consultants' ability to navigate the political climate of a large National Health Service (NHS) Trust with competing agendas and limited resource was valuable. The interventions were well received and a valued addition to usual clinical care. However, implementation and ongoing delivery of the pilot encountered challenges including lack of capacity within the system and delays with recruiting to the delivery teams in each pathway.

Process Evaluation of a Hub-and-Spoke Model to Deliver Coordinated Care for Children with Medical Complexity across Ontario: Facilitators, Barriers and Lessons Learned

Background:

Complex Care for Kids Ontario (CCKO) is a multi-year strategy aimed at expanding a hub-and-spoke model to deliver coordinated care for children with medical complexity (CMC) across Ontario.

Objective:

This paper aims to identify the facilitators, barriers and lessons learned from the implementation of the Ontario CCKO strategy.

Method:

Alongside an outcome evaluation of the CCKO strategy, we conducted a process evaluation to understand the implementation context, process and mechanisms. Semi-structured interviews were conducted with 38 healthcare leaders, clinicians and support staff from four regions involved in CCKO care delivery and/or governance.

Results:

Facilitators to CCKO implementation were sustained engagement of system-wide stakeholders, inter-organizational partnerships, knowledge sharing and family engagement. Barriers to CCKO implementation were resources and funding, fragmentation of care, aligning perspectives between providers and clinical staff recruitment and retention.

Conclusion:

A flexible approach is required to implement a complex, multi-centre policy strategy. Other jurisdictions considering such a model of care delivery would benefit from attention to contextual variations in implementation setting, building cross-sector engagement and buy-in, and offering continuous support for modifications to the intervention as and when required.

Nurses' assessments of horizontal collaboration in municipal health and care services for older adults: A cross-sectional study

Interprofessional and interorganizational collaboration is considered key to achieving high-quality care and positive patient outcomes, but there is limited research into how nurses working in nursing homes and home care services perceive collaboration with other municipal health and care service providers and how their assessments of collaboration vary with individual characteristics and context. The objective of this study was to map variation in nurses' assessments of horizontal collaboration with core care services for older adults, specifically nursing homes, home care services, general practitioners, the allocation office and physio- and occupational therapy services. The study draws on findings from a nationwide cross-sectional survey on posthospital care for older adults, conducted among nurses working in nursing homes and home care services in Norway (N = 3717). Nurses were asked to assess collaboration with these five services. Independent variables were workplace, age, years at current workplace, part-time work, postgraduate education, and municipality size. Statistical analyses were conducted using descriptive statistics and analysis of variance (ANOVA). A majority of nurses evaluated horizontal collaboration as good. Collaboration with the home care services was evaluated as best, while collaboration with general practitioners was evaluated as least good. The study showed that workplace and municipality size were important for nurses' assessments of collaboration. Generally, nurses in smaller municipalities evaluated collaboration as better than nurses in larger municipalities. That workplace and municipality size impact on nurses' evaluations of collaboration in municipal care services for older adults is important knowledge for leaders and policy-makers aiming to improve patient care and teamwork.

Exploring the Quality Paradigms in Integrated Care: The Need for Emergence and Reflection

INTRODUCTION AND AIM

There are four quality paradigms, of which the Empirical and Reference paradigm fit best in stable circumstances, and the Reflective and Emergence paradigms, which fit best in unstable circumstances. This study aims to explore the use of the four quality paradigms in integrated care, and to shed light on the different paradigmatic commitments and different perspectives on quality.

METHODS

Peer-reviewed articles from the International Journal of Integrated care published between January 2015 and December 2019 were included in this study. For each article was determined in which paradigm it belonged. Additionally, the role of the patient and domain of impact in research, policy or practice in relationship to the paradigms were investigated.

RESULTS

In total, 255 articles were assessed based on the four quality paradigms. 55 (21.6%) of the articles were placed in the Empirical paradigm, 147 (57.6%) in the Reference paradigm and 45 (17.6%) in the Reflective paradigm. The Emergence paradigm occurred the least (n = 8, 3.1%).

DISCUSSION AND CONCLUSION

Of all reviewed studies, 80% were placed in the Empirical and Reference paradigm. This raises the question if the used research approaches are consistent with the complexity and contexts in the field of integrated care and support a personalised care approach. More awareness of all four paradigms and reflection on the used epistemologies is needed.

Irrational use of antibiotics in Iran from the perspective of complex adaptive systems: redefining the challenge

Background

Irrational use of antibiotics is proving to be a major concern to the health systems globally. This results in antibiotics resistance and increases health care costs. In Iran, despite many years of research, appreciable efforts, and policymaking to avoid irrational use of antibiotics, yet indicators show suboptimal use of antibiotics, pointing to an urgent need for adopting alternative approaches to further understand the problem and to offer new solutions. Applying the Complex Adaptive Systems (CAS) theory, to explore and research health systems and their challenges has become popular. Therefore, this study aimed to better understand the complexity of the irrational use of antibiotics in Iran and to propose potential solutions.

Method

This research utilized a CAS observatory tool to qualitatively collect and analyse data. Twenty interviews and two Focus Group discussions were conducted. The data was enriched with policy document reviews to fully understand the system. MAXQDA software was used to organize and analyze the data.

Result

We could identify several diverse and heterogeneous, yet highly interdependent agents operating at different levels in the antibiotics use system in Iran. The network structure and its adaptive emergent behavior, information flow, governing rules, feedback and values of the system, and the way they interact were identified. The findings described antibiotics use as emergent behavior that is formed by an interplay of many factors and agents over time. According to this study, insufficient and ineffective interaction and information flow regarding antibiotics between agents are among key causes of irrational antibiotics use in Iran. Results showed that effective rules to minimize irrational use of antibiotics are missing or can be easily disobeyed. The gaps and weaknesses of the system which need redesigning or modification were recognized as well.

Conclusion

The study suggests re-engineering the system by implementing several system-level changes including establishing strong, timely, and effective interactions between identified stakeholders, which facilitate information flow and provision of on-time feedback, and create win-win rules in a participatory manner with stakeholders and the distributed control system.

Surveying work-as-done in post-operative delirium risk factors collection and diagnosis monitoring

Post-operative delirium (POD) is a health hazard condition for the patients and it is associated with increased costs for the healthcare system. Following a system-theoretic approach, firstly a model, then a questionnaire, have been designed to probe the collective awareness about POD throughout the entire patient's perioperative pathway. The 58 reported answers pointed out that most of the information, specifically associated with POD, are routinely recorded but not used to stratify the patients' individual risk to develop POD. The results suggest the need for design a new socio-technical role within modern health care systems: the POD analyst. A Systems-Theoretic Accident Model and Processes (STAMP) model is proposed both to propel the awareness about POD and as a template for future POD risk factors collections.

Seniors' campus continuums: local solutions for broad spectrum seniors care

BACKGROUND

As demand and desire to "age-in-place" grows within an aging population, and new areas of need emerge, governments nationally and internationally are focusing effort and attention on innovative and integrative approaches to health and well-being. Seniors' Campus Continuums are models of care that seek to broaden access to an array of services and housing options to meet growing health and social needs of aging populations. The objective of this study is to increase understanding of this model and factors that influence their evolution, development, ongoing functioning and capacity to integrate care for older adults wishing to age in their own home and community.

METHODS

This research uses a comparative case study approach across six-bounded cases offering four geographically co-located components (mixed housing options, internal and external community supports, and a long-term care home) in various contexts across Ontario, Canada. Onsite in-person and phone interviews with senior campus staff (N = 30), and campus partners (N = 11), enhanced by direct observation at campuses explored historical and current efforts to offer health, housing and social care continuums for older adults.

RESULTS

Analysis highlighted eight key factors. Enabling factors include i. rich historical legacies of helping people in need; ii. organizational vision and readiness to capitalize on windows of opportunity; iii. leveraging organizational structure and capacity; iv. intentional physical and social design; v. broad services mix, amenities and innovative partnerships. Impeding factors include vi. policy hurdles and rigidities; vii. human resources shortages and inequities; and viii. funding limitations. A number of benefits afforded by campuses at different levels were also observed.

CONCLUSION

Findings from this research highlight opportunities to optimize campus potential on many levels. At an individual level, campuses increase local access to a coordinated range of health and social care services, supports and housing options. At an organizational level, campuses offer enhanced collaboration opportunities across providers and partners to improve consistency and coordination of care, and improved access to shared resources, expertise and infrastructure. At a system level, campuses can address a diversity of health, social, financial, and housing needs to help seniors avoid premature or inappropriate use of higher intensity care settings.

Improving Primary Care Medication Processes by Using Shared Electronic Medication Plans in Switzerland: Lessons Learned From a Participatory Action Research Study

Background

Several countries have launched health information technology (HIT) systems for shared electronic medication plans. These systems enable patients and health care professionals to use and manage a common list of current medications across sectors and settings. Shared electronic medication plans have great potential to improve medication management and patient safety, but their integration into complex medication-related processes has proven difficult, and there is little scientific evidence to guide their implementation.

Objective

The objective of this paper is to summarize lessons learned from primary care professionals involved in a pioneering pilot project in Switzerland for the systemwide implementation of shared electronic medication plans. We collected experiences, assessed the influences of the local context, and analyzed underlying mechanisms influencing the implementation.

Methods

In this formative action research study, we followed 5 clusters of health care professionals during 6 months. The clusters represented rural and urban primary care settings. A total of 18 health care professionals (primary care physicians, pharmacists, and nurses) used the pilot version of a shared electronic medication plan on a secure web platform, the precursor of Switzerland’s electronic patient record infrastructure. We undertook 3 group interviews with each of the 5 clusters, analyzed the content longitudinally and across clusters, and summarized it into lessons learned.

Results

Participants considered medication plan management, digitalized or not, a core element of good clinical practice. Requirements for the successful implementation of a shared electronic medication plan were the integration into and simplification of clinical routines. Participants underlined the importance of an enabling setting with designated reference professionals and regular high-quality interactions with patients. Such a setting should foster trusting relationships and nurture a culture of safety and data privacy. For participants, the HIT was a necessary but insufficient building block toward better interprofessional communication, especially in transitions. Despite oral and written information, the availability of shared electronic medication plans did not generate spontaneous demand from patients or foster more engagement in their medication management. The variable settings illustrated the diversity of medication management and the need for local adaptations.

Conclusions

The results of our study present a unique and comprehensive description of the sociotechnical challenges of implementing shared electronic medication plans in primary care. The shared ownership among multiple stakeholders is a core challenge for implementers. No single stakeholder can build and maintain a safe, usable HIT system with up-to-date medication information. Buy-in from all involved health care professionals is necessary for consistent medication reconciliation along the entire care pathway. Implementers must balance the need to change clinical processes to achieve improvements with the need to integrate the shared electronic medication plan into existing routines to facilitate adoption. The lack of patient involvement warrants further study.

Advancing integrated care evaluation in shifting contexts: blending implementation research with case study design in project SUSTAIN

BACKGROUND

Despite many studies evaluating the effectiveness of integrated care, evidence remains inconsistent. There is increasing commentary pointing out the mismatch between the ability to capture the somewhat 'illusive' impact of integrated care initiatives and programmes, and the most appropriate way to do this. Focusing on methodology, this paper describes and critically reviews the experiences of SUSTAIN, a Horizon 2020 funded project (2015-2019) with the purpose of advancing knowledge and understanding of cross-European integrated care evaluation. SUSTAIN sought to improve integrated care initiatives for older people in seven countries, and to maximise the potential for knowledge transfer and application across Europe. The methods approach drew from implementation research, employing the participative Evidence Integration Triangle (EIT) and incorporating a mixed method, multiple embedded case study design. A core set of qualitative and quantitative indicators, alongside context and process data, were created and tested within four key project domains (person-centredness, prevention-orientation, safety and efficiency). The paper critically discusses the overall approach, highlighting the value of the EIT and case study design, and signalling the challenges of data collection with frail older people and stakeholder involvement at the sites, as well as difficulties developing the core set of indicators.

CONCLUSIONS

Lessons learned and recommendations for advancing integrated care evaluation are put forward that focus on the status of integrated care as a complex intervention and a process. The use of implementation research methods and case study design are recommended as an additional evaluation approach for researchers to consider, alongside suggested ways of improving methods of data collection with frail populations and cost analysis.

Leadership in Integrated Care Networks: A Literature Review and Opportunities for Future Research

Introduction

In many countries, elderly patients with chronic conditions require a web of services delivered by several providers collaborating in inter-organisational networks. In view of their global importance, it is surprising how little we know how these networks are led. Like traditional organisations, networks require leadership to function effectively. This paper reviews central characteristics of leadership in integrated care networks and proposes opportunities for future research.

Theory and methods

Analysing 73 studies published in leading academic journals, this paper consolidates research on leadership media, practices, activities and outcomes, covering the network, policy and organisation levels of analysis.

Results

Findings indicate that the field has focused on leadership media and outcomes at the network level. They also suggest that leadership in integrated care networks faces multiple tensions. Future research could usefully provide a fuller picture by examining leadership practices, activities and outcomes at the policy and organisation level, integrating advances in the wider leadership literature.

Discussion and conclusion

These findings contribute to the debate on leadership in integrated care networks. They also inform practice, drawing attention to persistent tensions as a core leadership challenge and offering latest scholarly evidence practitioners can use to reflect on and advance their own leadership practice.

The function of the Norwegian municipal acute units fails to fulfill the intention of health authorities

Objective: The aim of the study was to explore healthcare providers' perceptions of how Norwegian municipal acute units (MAUs) possibly can reduce hospital admittance and improve service integration.Method and material: Qualitative data were drawn from individual interviews with 40 healthcare providers, including general practitioners and staff in Norwegian MAUs, purchasing offices and home-based nursing services. Interview transcripts were analysed using systematic text condensation.Setting: Two MAUs operated by 12 municipalities in eastern Norway.Results: The healthcare providers disagreed on what MAUs are and should be. Frequent discussions between providers about which patients are appropriate for MAUs, as well as time- and resource-consuming procedures for patients' admittance and discharge, have hampered the efficient operation of MAUs. Although, MAUs are operated by municipalities, the providers expressed that the units represent a new level of organisation with new boundaries for collaboration. Having many physicians in part-time positions and lacking physicians during night shifts were also characterised as problematic.Conclusion: Several healthcare providers expressed uncertainty about the appropriateness of maintaining MAUs in Norway's healthcare system, given their questionable capacity to meet Norwegians' healthcare needs. It may appear that the MAUs are designed first to identify appropriate patients instead of identifying and mapping the population's needs and, thereafter, designing optimal healthcare services.KEY POINTSAs of 2016, Municipal Acute Units (MAUs) are statutory healthcare services in Norway. Exploring patients' and healthcare providers' views on MAUs can improve the services.Healthcare providers disagreed on which patients were suitable for the unitsThe units were perceived as a new (healthcare) level, entailing a new collaboration arena, with more bureaucracy and time expenditureThe patients were satisfied with their treatment and care in the MAUs and the units' proximity to their home.

Municipal Acute Units as Part of the Clinical Pathway for Older Patients

Introduction

Since 2016, Norwegian municipalities have been obliged to provide municipal acute 24-hour services representing a service before or instead of hospital treatment. This study explores two municipal acute units (MAUs) as part of the clinical pathway for older patients.

Methods

Patients and healthcare providers from MAUs, purchaser offices, home-based nursing, and physicians were interviewed. Interview transcripts were analysed using systematic text condensation.

Results

The collaboration between the MAU staff and the GPs, the purchaser offices and the home-based services is described as challenging, mostly due to disagreement regarding patients' admission and discharge. The providers' different understanding seems to derive especially from where they are working in a way that suits their own work functions.An exigent collaboration between providers in the MAUs and their collaborative partners hampers the clinical pathway for older patients in the municipal healthcare service.

Conclusion and discussion

When a new healthcare service such as an MAU becomes a part of the clinical pathway in a municipality, it is important to invest a considerable effort in measures designed to strengthen relational and structural collaboration to make the clinical pathway smooth.

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

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

Actions to influence the care network of home-dwelling elderly people: A qualitative study

Positive impact of care networks of home-dwelling elderly people may be based on several network mechanisms: navigation to resources, negotiation between participants and contagion of behaviours. Little is known about actions of participants-elderly people, informal caregivers or formal care providers-to activate such mechanisms and generate support. Aim of this study was to identify actions in relation to these network mechanisms. A cross-sectional qualitative study of 48 interviews with home-dwelling elderly people, informal caregivers and formal care providers in the eastern parts of the Netherlands was conducted between March and September 2016. A framework analysis on network mechanisms categorised actions. Actions were reviewed by network party and compared between networks to explore relations between actions and networks. Results showed that participants navigated through existing relations to seek support. Actions on negotiation were aimed at ameliorating existing relations. Few examples and no actions on contagion of behaviours were found. Actions seemed driven by incidents and existing relations. Elderly people rarely initiated actions, informal caregivers felt hampered by their position in the network. Consistent patterns of relations between actions and network characteristics did not emerge. We concluded that the full potential of network-based support of elderly people is probably underused. Particularly promising seem: navigating the neighbourhood for new informal care, using opposite opinions as a catalyst for change and bringing quality of life and dilemma's into dialogue in the network.

Integrating early palliative care into routine practice for patients with cancer: A mixed methods evaluation of the INTEGRATE Project

OBJECTIVE

With increasing evidence from controlled trials on benefits of early palliative care, there is a need for studies examining implementation in real-world settings. The INTEGRATE Project was a 3-year real-world project that promoted early identification and support of patients with cancer who may benefit from palliative care. This study assesses feasibility, stakeholder experiences, and early impact of the INTEGRATE Project METHODS: The INTEGRATE Project was implemented in four cancer centers in Ontario, Canada, and consisted of interdisciplinary provider education and an integrated care model. Providers used the Surprise Question to identify patients for inclusion. A mixed methods evaluation of INTEGRATE was conducted using descriptive data, interviews with providers and managers, and provider surveys.

RESULTS

A total of 760 patients with cancer (lung, glioblastoma, head and neck, gastrointestinal) were included. Results suggest improvement in provider confidence to deliver palliative care and to initiate the Advanced Care Planning (ACP) conversation. The majority of patients (85%) had an ACP or goals of care (GOC) conversation initiated within a mean time to conversation of 5-46 days (SD 20-93) across centers. A primary care report was transmitted to family doctors 48-100% of the time within a mean time to transmission of 7-54 days (SD 9-27) across centers. Enablers and barriers influencing success of the model were also identified.

CONCLUSIONS

A standardized model for the early introduction of palliative care for patients with cancer can be integrated into the routine practice of oncology providers, with appropriate education, integration into existing clinical workflows, and administrative support.

Facilitating mechanisms for integrating care to promote health equity across the life course: reflections from social work trainees

Integrated care is a promising practice to promote health equity and improve population health across the life course, but the mechanisms needed to integrate services remain nebulous. This study aimed to identify the components required to achieve a fully integrated health care system as articulated by social work trainees. The authors conducted five focus groups (N = 20). Transcripts were analyzed using structural and pattern coding. Three primary themes emerged: Organizational Structure and Support, Personal and Interpersonal Dynamics, and Practitioner Knowledge. Results from this study can inform the process of integration and has implications for social work education.

Implementation of Integrated Care in Singapore: A Complex Adaptive System Perspective

Background:

Integrated care that focuses on organising healthcare services around people and their communities rather than their diseases is promoted as the strategy to overcome the challenges associated with growing complexity in healthcare needs, demand for healthcare services and inadequate supply of services due to fragmentation in the provision of services. While conceptually appears to be simple, integrated care is made up of multicomponent delivery strategies targeting various levels of the healthcare system while engaging various stakeholders in their execution.

Methods:

We applied the complex adaptive system (CAS) perspective to two different initiatives that exemplify approaches towards integrating care in Singapore: the Regional Health System (RHS) model, implemented across healthcare institutions at the national level, and CARITAS Integrated Dementia Care implemented in the northern region of Singapore. We adopted an inductive approach in our analysis in which we studied the RHS and CARITAS Integrated Dementia Care according to the components of the CAS. We applied the typical characteristics of CAS: (i) diverse, interdependent and semi-autonomous actors (ii) self-organizing capacity and simple rules (iii) relationship with the bigger system, emergent behaviour and non-linearity in our analysis of key drivers behind the implementation of both the RHS and CARITAS integrated dementia care.

Results:

By considering the RHS and CARITAS as whole networks each comprising of interacting and adaptive components instead of separate entities within a bigger system, the CAS provided a new mind-set in surfacing issues associated to the implementation of these integrated care networks. In addition to important actors, systems, it informed understanding of relationships and dependencies between different parts of the network – revealing the lack of homogeneity, conformity and difficulties in designing any optimal system in advance given the many moving parts.

Conclusions:

Drawing on the two examples of integrated care networks, this paper highlights the significance of effective collaboration built on a common focus, responsiveness to emergent behaviours, simple rules, the ability to self-organize and adapt in response to unexpected situations in further development of integrated care in the Singapore context and beyond.

Advancing a Systemic Perspective on Multidisciplinary Teams: A Comparative Case Study of Work Organisation in Four Multiple Sclerosis Hospitals

Introduction:

Many care organisations claim to employ multidisciplinary teams, but the term is used to describe quite different forms of collaboration. A systemic view of the work organisation of care delivery is presented and applied in this article that allows to identify and understand often overlooked yet important differences regarding team composition, working relationships and therapeutic relationships.

Theory and Methods:

We used modern socio-technical systems theory to study care delivery for a particular patient population as a system of interrelated activities. The concept of work organisation refers to the way in which the composite task of care delivery is divided into distinct tasks and how these are grouped in either monodisciplinary or multidisciplinary organisational units. The systemic perspective was applied in a comparative case study of four Multiple Sclerosis hospitals.

Results:

Among the hospitals, one was characterised by a functional work organisation, with similar tasks grouped in monodisciplinary teams. Cross-disciplinary working and therapeutic relationships were established on an ad hoc basis. The three other hospitals adopted a more process-oriented work organisation (which groups all tasks related to a specific care process within a single, multidisciplinary team). The more process-oriented the work organisation, the more working relationships and therapeutic relationships appeared to be fixed and continuous.

Conclusion and discussion:

The systemic view adopted in this study yields a better understanding of multidisciplinary teams through the concept of work organisation. The actual composition of multidisciplinary teams, and the related working and therapeutic relationships will vary depending on the type of underlying work organisation. Further validation of this conclusion will be needed in other settings.

The international knowledge base for new care models relevant to primary care-led integrated models: a realist synthesis

Background

The Multispecialty Community Provider (MCP) model was introduced to the NHS as a primary care-led, community-based integrated care model to provide better quality, experience and value for local populations.

Objectives

The three main objectives were to (1) articulate the underlying programme theories for the MCP model of care; (2) identify sources of theoretical, empirical and practice evidence to test the programme theories; and (3) explain how mechanisms used in different contexts contribute to outcomes and process variables.

Design

There were three main phases: (1) identification of programme theories from logic models of MCP vanguards, prioritising key theories for investigation; (2) appraisal, extraction and analysis of evidence against a best-fit framework; and (3) realist reviews of prioritised theory components and maps of remaining theory components.

Main outcome measures

The quadruple aim outcomes addressed population health, cost-effectiveness, patient experience and staff experience.

Data sources

Searches of electronic databases with forward- and backward-citation tracking, identifying research-based evidence and practice-derived evidence.

Review methods

A realist synthesis was used to identify, test and refine the following programme theory components: (1) community-based, co-ordinated care is more accessible; (2) place-based contracting and payment systems incentivise shared accountability; and (3) fostering relational behaviours builds resilience within communities.

Results

Delivery of a MCP model requires professional and service user engagement, which is dependent on building trust and empowerment. These are generated if values and incentives for new ways of working are aligned and there are opportunities for training and development. Together, these can facilitate accountability at the individual, community and system levels. The evidence base relating to these theory components was, for the most part, limited by initiatives that are relatively new or not formally evaluated. Support for the programme theory components varies, with moderate support for enhanced primary care and community involvement in care, and relatively weak support for new contracting models.

Strengths and limitations

The project benefited from a close relationship with national and local MCP leads, reflecting the value of the proximity of the research team to decision-makers. Our use of logic models to identify theories of change could present a relatively static position for what is a dynamic programme of change.

Conclusions

Multispecialty Community Providers can be described as complex adaptive systems (CASs) and, as such, connectivity, feedback loops, system learning and adaptation of CASs play a critical role in their design. Implementation can be further reinforced by paying attention to contextual factors that influence behaviour change, in order to support more integrated working.

Future work

A set of evidence-derived ‘key ingredients’ has been compiled to inform the design and delivery of future iterations of population health-based models of care. Suggested priorities for future research include the impact of enhanced primary care on the workforce, the effects of longer-term contracts on sustainability and capacity, the conditions needed for successful continuous improvement and learning, the role of carers in patient empowerment and how community participation might contribute to community resilience.

Study registration

This study is registered as PROSPERO CRD42016039552.

Funding

The National Institute for Health Research Health Services and Delivery Research programme.

Population health management guiding principles to stimulate collaboration and improve pharmaceutical care

Purpose A range of strategies to improve pharmaceutical care has been implemented by population health management (PHM) initiatives. However, which strategies generate the desired outcomes is largely unknown. The purpose of this paper is to identify guiding principles underlying collaborative strategies to improve pharmaceutical care and the contextual factors and mechanisms through which these principles operate. Design/methodology/approach The evaluation was informed by a realist methodology examining the links between PHM strategies, their outcomes and the contexts and mechanisms by which these strategies operate. Guiding principles were identified by grouping context-specific strategies with specific outcomes. Findings In total, ten guiding principles were identified: create agreement and commitment based on a long-term vision; foster cooperation and representation at the board level; use layered governance structures; create awareness at all levels; enable interpersonal links at all levels; create learning environments; organize shared responsibility; adjust financial strategies to market contexts; organize mutual gains; and align regional agreements with national policies and regulations. Contextual factors such as shared savings influenced the effectiveness of the guiding principles. Mechanisms by which these guiding principles operate were, for instance, fostering trust and creating a shared sense of the problem. Practical implications The guiding principles highlight how collaboration can be stimulated to improve pharmaceutical care while taking into account local constraints and possibilities. The interdependency of these principles necessitates effectuating them together in order to realize the best possible improvements and outcomes. Originality/value This is the first study using a realist approach to understand the guiding principles underlying collaboration to improve pharmaceutical care.

Elements of integrated care approaches for older people: a review of reviews

OBJECTIVE

The World Health Organization (WHO) recently proposed an Integrated Care for Older People approach to guide health systems and services in better supporting functional ability of older people. A knowledge gap remains in the key elements of integrated care approaches used in health and social care delivery systems for older populations. The objective of this review was to identify and describe the key elements of integrated care models for elderly people reported in the literature.

DESIGN

Review of reviews using a systematic search method.

METHODS

A systematic search was performed in MEDLINE and the Cochrane database in June 2017. Reviews of interventions aimed at care integration at the clinical (micro), organisational/service (meso) or health system (macro) levels for people aged ≥60 years were included. Non-Cochrane reviews published before 2015 were excluded. Reviews were assessed for quality using the Assessment of Multiple Systematic Reviews (AMSTAR) 1 tool.

RESULTS

Fifteen reviews (11 systematic reviews, of which six were Cochrane reviews) were included, representing 219 primary studies. Three reviews (20%) included only randomised controlled trials (RCT), while 10 reviews (65%) included both RCTs and non-RCTs. The region where the largest number of primary studies originated was North America (n=89, 47.6%), followed by Europe (n=60, 32.1%) and Oceania (n=31, 16.6%). Eleven (73%) reviews focused on clinical 'micro' and organisational 'meso' care integration strategies. The most commonly reported elements of integrated care models were multidisciplinary teams, comprehensive assessment and case management. Nurses, physiotherapists, general practitioners and social workers were the most commonly reported service providers. Methodological quality was variable (AMSTAR scores: 1-11). Seven (47%) reviews were scored as high quality (AMSTAR score ≥8).

CONCLUSION

Evidence of elements of integrated care for older people focuses particularly on micro clinical care integration processes, while there is a relative lack of information regarding the meso organisational and macro system-level care integration strategies.

Embracing uncertainty, managing complexity: applying complexity thinking principles to transformation efforts in healthcare systems

Background

Complexity thinking is increasingly being embraced in healthcare, which is often described as a complex adaptive system (CAS). Applying CAS to healthcare as an explanatory model for understanding the nature of the system, and to stimulate changes and transformations within the system, is valuable.

Main text

A seminar series on systems and complexity thinking hosted at the University of Toronto in 2016 offered a number of insights on applications of CAS perspectives to healthcare that we explore here. We synthesized topics from this series into a set of six insights on how complexity thinking fosters a deeper understanding of accepted ideas in healthcare, applications of CAS to actors within the system, and paradoxes in applications of complexity thinking that may require further debate: 1) a complexity lens helps us better understand the nebulous term “context”; 2) concepts of CAS may be applied differently when actors are cognizant of the system in which they operate; 3) actor responses to uncertainty within a CAS is a mechanism for emergent and intentional adaptation; 4) acknowledging complexity supports patient-centred intersectional approaches to patient care; 5) complexity perspectives can support ways that leaders manage change (and transformation) in healthcare; and 6) complexity demands different ways of implementing ideas and assessing the system. To enhance our exploration of key insights, we augmented the knowledge gleaned from the series with key articles on complexity in the literature.

Conclusions

Ultimately, complexity thinking acknowledges the “messiness” that we seek to control in healthcare and encourages us to embrace it. This means seeing challenges as opportunities for adaptation, stimulating innovative solutions to ensure positive adaptation, leveraging the social system to enable ideas to emerge and spread across the system, and even more important, acknowledging that these adaptive actions are part of system behaviour just as much as periods of stability are. By embracing uncertainty and adapting innovatively, complexity thinking enables system actors to engage meaningfully and comfortably in healthcare system transformation.

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

INTRODUCTION

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

METHODS

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

RESULTS

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

DISCUSSION

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

CONCLUSION

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