Conceptualizing and validating the human services integration measure

Does competition support integrated care to improve quality?

Introduction

This work investigates the compatibility of integrated care and competition in China and analyses the impact of integrated care on regional care quality (DeptQ) within a competitive framework.

Method

The study was built on multivariate correspondence analysis and a two-way fixed-effects model. The data were collected from Xiamen's Big Data Application Open Platform and represent nine specialised departments that regularly performed inter-institutional referrals between 2016 and 2019.

Results

First, care quality for referred patients (ReferQ) and the relative scale of referred patients (ReferScale) and competition have an antagonistic but not completely mutually exclusive relationship. Second, ReferQ and competition both have a significant effect on DeptQ, but only when competition is weak can ReferQ and competition act synergistically on DeptQ. When competition is fierce, competition will weaken the impact of ReferQ on DeptQ.

Conclusion

Changes in the intensity of integrated care and competition ultimately affect care quality.

Integration, effectiveness and costs of different models of primary health care provision for people who are homeless: an evaluation study

Background

There is a high prevalence of health problems among single people who are homeless. Specialist primary health care services for this population have been developed in several locations across England; however, there have been very few evaluations of these services.

Objectives

This study evaluated the work of different models of primary health care provision in England to determine their effectiveness in engaging people who are homeless in health care and in providing continuity of care for long-term conditions. It concerned single people (not families or couples with dependent children) staying in hostels, other temporary accommodation or on the streets. The influence on outcomes of contextual factors and mechanisms (service delivery factors), including integration with other services, were examined. Data from medical records were collated on participants' use of health care and social care services over 12 months, and costs were calculated.

Design and setting

The evaluation involved four existing Health Service Models: (1) health centres primarily for people who are homeless (Dedicated Centres), (2) Mobile Teams providing health care in hostels and day centres, (3) Specialist GPs providing some services exclusively for patients who are homeless and (4) Usual Care GPs providing no special services for people who are homeless (as a comparison). Two Case Study Sites were recruited for each of the specialist models, and four for the Usual Care GP model.

Participants

People who had been homeless during the previous 12 months were recruited as 'case study participants'; they were interviewed at baseline and at 4 and 8 months, and information was collected about their circumstances and their health and service use in the preceding 4 months. Overall, 363 participants were recruited; medical records were obtained for 349 participants. Interviews were conducted with 65 Case Study Site staff and sessional workers, and 81 service providers and stakeholders.

Results

The primary outcome was the extent of health screening for body mass index, mental health, alcohol use, tuberculosis, smoking and hepatitis A among participants, and evidence of an intervention if a problem was identified. There were no overall differences in screening between the models apart from Mobile Teams, which scored considerably lower. Dedicated Centres and Specialist GPs were more successful in providing continuity of care for participants with depression and alcohol and drug problems. Service use and costs were significantly higher for Dedicated Centre participants and lower for Usual Care GP participants. Participants and staff welcomed flexible and tailored approaches to care, and related services being available in the same building. Across all models, dental needs were unaddressed and staff reported poor availability of mental health services.

Limitations

There were difficulties recruiting mainstream general practices for the Usual Care GP model. Medical records could not be accessed for 14 participants of this model.

Conclusions

Participant characteristics, contextual factors and mechanisms were influential in determining outcomes. Overall, outcomes for Dedicated Centres and for one of the Specialist GP sites were relatively favourable. They had dedicated staff for patients who were homeless, 'drop-in' services, on-site mental health and substance misuse services, and worked closely with hospitals and homelessness sector services.

Funding

This project was funded by the National Institute for Health and Care Research (NIHR) Health and Social Care Delivery Research programme (HSDR 13/156/03) and will be published in full in Health and Social Care Delivery Research; Vol. 11, No. 16. See the NIHR Journals Library website for further project information.

A Good start in life: Effectiveness of integrated multicomponent multisector support on early child development—Study protocol

Introduction

Early childhood experiences have a lifelong impact on a child’s future. Social and environmental experiences and interactions have a profound relational effect on children’s physical and mental health which transfers agency to parents, caregivers and duty-bearers to care for the child’s welfare. In the Australian context early child development indices have been in decline in some communities. Hence, there is a sense of urgency to reverse these trends from an integrated perspective. A multisector, multi component program of interventions named A Good Start in Life is proposed and is being tested in the Australian Capital Territory across suburbs with high levels of early childhood development disadvantage. The aim of this study is to evaluate the outcomes and processes related to targeted interventions, designed to integrate child and family services within the local district and embed allied health programs into early childhood education, care services and playgroups.

Methods and analysis

The Good Start in Life study will use a quasi-experimental design (with a matched control geographical area) consisting of a combination of interventions that will build multisectoral collaboration across education, health and social services that connect and support families with children from birth to 5 years. The control area will be matched on demographic characteristics and early child development outcomes and trends over the pre-intervention period. Evaluation data will be collected at baseline, and then on an annual basis for a further three years. A mixed methods approach will be used to evaluate delivery processes: quantitative (checklists, questionnaires) and qualitative methods (observations, focus groups and key stakeholder interviews). Effectiveness of the programme will be evaluated by comparing early child development outcomes between the comparator areas from the Australian Early Development Census in 2024. The primary focus will be on reducing the number of children who are developmentally vulnerable on at least one early development index (EDI). Separate tests will be conducted for significant differences in the percentage of children at risk in each of the five individual EDI domains. These domains are physical health and wellbeing, social competence, emotional maturity, language and cognitive skills, and communication and general knowledge.

Trial registration

ACTRN12621001140842.

Measuring partnership synergy and functioning: Multi-stakeholder collaboration in primary health care

In primary health care, multi-stakeholder partnerships between clinicians, policy makers, academic representatives and other stakeholders to improve service delivery are becoming more common. Literature on processes and approaches that enhance partnership effectiveness is growing. However, evidence on the performance of the measures of partnership functioning and the achievement of desired outcomes is still limited, due to the field's definitional ambiguity and the challenges inherent in measuring complex and evolving collaborative processes. Reliable measures are needed for external or self-assessment of partnership functioning, as intermediate steps in the achievement of desired outcomes. We adapted the Partnership Self-Assessment Tool (PSAT) and distributed it to multiple stakeholders within five partnerships in Canada and Australia. The instrument contained a number of partnership functioning sub-scales. New sub-scales were developed for the domains of communication and external environment. Partnership synergy was assessed using modified Partnership Synergy Processes and Partnership Synergy Outcomes sub-scales, and a combined Partnership Synergy scale. Ranking by partnership scores was compared with independent ranks based on a qualitative evaluation of the partnerships' development. 55 (90%) questionnaires were returned. Our results indicate that the instrument was capable of discriminating between different levels of dimensions of partnership functioning and partnership synergy even in a limited sample. The sub-scales were sufficiently reliable to have the capacity to discriminate between individuals, and between partnerships. There was negligible difference in the correlations between different partnership functioning dimensions and Partnership Synergy sub-scales. The Communication and External Environment sub-scales did not perform well metrically. The adapted partnership assessment tool is suitable for assessing the achievement of partnership synergy and specific indicators of partnership functioning. Further development of Communication and External Environment sub-scales is warranted. The instrument could be applied to assess internal partnership performance on key indicators across settings, in order to determine if the collaborative process is working well.

Toward Sustainable ICT-Supported Neighborhood Development—A Maturity Model

Scientists promote the fostering of caring communities as a means of sustainably coping with demographic changes. They consider community-based technologies to have a high potential for supporting the establishment of caring communities. However, implementing community-based technologies is a complex endeavor, making sustainable adoption difficult. We have developed a maturity model aimed at standardizing the monitoring and evaluation of neighborhood projects. Based on a maturity model for integrated care, we conducted a Delphi study, to develop a maturity model for information and communication technology (ICT)-supported neighborhood development. In eight case studies, the model was validated and subsequently adapted to the specific needs and requirements of neighborhood projects. These studies emphasized the importance of at least 12 decisive dimensions and showed that the maturity model could be applied at different stages of a project. The current form of the maturity model can be used to help orient, as well as monitor and evaluate, neighborhood development projects. Future work will be necessary to further develop accompanying materials and services and to foster the exchange of best practices and experience between projects.

Qualitative assessment of interorganisational partnership at a perinatal and family substance abuse centre: stakeholders' perceptions of quality and development of their collaboration

Partnerships are required in health and social care services to meet the increasingly complex needs of vulnerable populations. It is essential to assess these partnerships to ensure partners are supported as they strive to improve their practices. This qualitative study assessed the quality and development of the partnership of an integrated service centre for pregnant women and substance-abusing parents and their young children aged 5 and under. The data were gathered over a period of three years, by means of group and individual interviews. Twenty respondents (practitioners and managers) shared their perceptions of the interagency collaboration at the beginning, the midpoint and the end of the project funding period. Their responses were examined by means of thematic analysis. Conditions facilitating or hindering implementation of the partnership included (a) partners' participation and engagement; (b) nature of the project and its functioning (aspects of governance); (c) partners' joint work with families; and (d) social and political issues. The study highlights critical elements to consider for the development and success of a partnership project. Participants reported a number of barriers to effective collaboration; the main ones, the importance of thorough planning of project implementation, as well as the challenges relating to communication and shared leadership, are discussed.

Exploring the psychometric properties of the Rainbow Model of Integrated Care measurement tool for care providers in Australia

OBJECTIVE

To assess the reliability and validity of a shortened version of the Rainbow Model of Integrated Care (RMIC) measurement tool (MT). The original version of the measurement tool has been modified (shortened) for the Australian context.

DESIGN

Validation of the psychometric properties of the RMIC-MT.

SETTING

Healthcare providers providing services to a geographically defined rural area in New South Wales (NSW), Australia.

PARTICIPANTS

A sample of 56 healthcare providers providing mental and physical healthcare.

MAIN OUTCOME MEASURES

The psychometric properties of the tool were tested using principal component analysis for validity and Cronbach's alpha for reliability.

RESULTS

The tool was shown to have good validity and reliability. The 35 items used in the shortened version of the tool were reduced to 29 items grouped into four dimensions: community-governance orientation, normative integration, functional integration and clinical-professional coordination.

CONCLUSIONS

The shortened version of the RMIC-MT is a valid and reliable tool that evaluates integrated care from a healthcare provider's perspective in NSW, Australia. In order to assess the tool's appropriateness in an international context, future studies should focus on validating the tool in other healthcare settings.

Evaluating Program Integration and the Rise in Collaboration: Case study of A Palliative Care Network

Introduction: There is increasing global interest in using regional palliative care networks (PCNs) to integrate care and create systems that are more cost-effective and responsive. We examined a PCN that used a community development approach to build capacity for palliative care in each distinct community in a region of southern Ontario, Canada, with the goal of achieving a competent integrated system. Methods: Using a case study methodology, we examined a PCN at the structural level through a document review, a survey of 20 organizational administrators, and an interview with the network director. Results: The PCN identified 14 distinct communities at different stages of development within the region. Despite the lack of some key features that would facilitate efficient palliative care delivery across these communities, administrators largely viewed the network partnership as beneficial and collaborative. Conclusion: The PCN has attempted to recognize specific needs in each local area. Change is gradual but participatory. There remain structural issues that may negatively affect the functioning of the PCN.

At the coalface of collaborative mental health care: A qualitative study of governance and power in district-level service provision in South Africa

Globally, there is an urgency to address fragmented mental health systems, especially in low-to-middle income countries. State and non-state mental health service collaboration is a central strategy to strengthen care. The study was undertaken to analyse the power in governance processes of public mental health service provision. Semi-structured interviews were conducted with state and non-state actors in mental health care in a South African district. Transcriptions were thematically analysed using the Framework for Assessing Power in Collaborative Processes. Findings suggested that collaborative processes were significantly state-owned, in terms of funding models, administrative and legislative jurisdiction, and state hierarchical referral structure. No formal agreements were in place, elevating the importance of key network actors to bring less-endowed NGOs into the service network. Fragmentation between the Departments of Health and Social Development was telling in district forums. Resistance to power structures unfolded, some participants sidestepping traditional hierarchies to leverage funding and support. The paper highlights the complexities and different facets of power in integrated mental health care in a South African district, adding to growing literature on the social mechanisms that influence collaboration.

An Instrument to Measure Maturity of Integrated Care: A First Validation Study

INTRODUCTION

Lessons captured from interviews with 12 European regions are represented in a new instrument, the B3-Maturity Model (B3-MM). B3-MM aims to assess maturity along 12 dimensions reflecting the various aspects that need to be managed in order to deliver integrated care. The objective of the study was to test the content validity of B3-MM as part of SCIROCCO (Scaling Integrated Care into Context), a European Union funded project.

METHODS

A literature review was conducted to compare B3-MM's 12 dimensions and their measurement scales with existing measures and instruments that focus on assessing the development of integrated care. Subsequently, a three-round survey conducted through a Delphi study with international experts in the field of integrated care was performed to test the relevance of: 1) the dimensions, 2) the maturity indicators and 3) the assessment scale used in B3-MM.

RESULTS

The 11 articles included in the literature review confirmed all the dimensions described in the original version of B3-MM. The Delphi study rounds resulted in various phrasing amendments of indicators and assessment scale. Full agreement among the experts on the relevance of the 12 B3-MM dimensions, their indicators, and assessment scale was reached after the third Delphi round.

CONCLUSION AND DISCUSSION

The B3-MM dimensions, maturity indicators and assessment scale showed satisfactory content validity. While the B3-MM is a unique instrument based on existing knowledge and experiences of regions in integrated care, further testing is needed to explore other measurement properties of B3-MM.

Indicators and Measurement Tools for Health Systems Integration: A Knowledge Synthesis

Background:

Despite far reaching support for integrated care, conceptualizing and measuring integrated care remains challenging. This knowledge synthesis aimed to identify indicator domains and tools to measure progress towards integrated care.

Methods:

We used an established framework and a Delphi survey with integration experts to identify relevant measurement domains. For each domain, we searched and reviewed the literature for relevant tools.

Findings:

From 7,133 abstracts, we retrieved 114 unique tools. We found many quality tools to measure care coordination, patient engagement and team effectiveness/performance. In contrast, there were few tools in the domains of performance measurement and information systems, alignment of organizational goals and resource allocation. The search yielded 12 tools that measure overall integration or three or more indicator domains.

Discussion:

Our findings highlight a continued gap in tools to measure foundational components that support integrated care. In the absence of such targeted tools, “overall integration” tools may be useful for a broad assessment of the overall state of a system.

Conclusions:

Continued progress towards integrated care depends on our ability to evaluate the success of strategies across different levels and context. This study has identified 114 tools that measure integrated care across 16 domains, supporting efforts towards a unified measurement framework.

Improving performance of long-term care networks at their initial stage: an empirical study of factors affecting results

Until now very little research has been carried out on the performance of health and human services networks in evolution. In particular, previous studies mainly referred to "centrally governed services networks" in the US context. According to Provan and Kenis (2008), these networks are "lead organization-governed", and are different from the "participant-governed" model or the "network administrative organization (NAO)" solution. We focused our attention on the Apulia region care services networks (Italy). In the last few years, the governance of these networks has passed from the "participant-governed" model to the NAO approach. We examined how the integration mechanisms work in this type of networks, and if there were challenges to tackle in order to improve their overall performance. These networks were examined at their initial stage, exactly when their governance model moved to a more integrated solution. We collected survey data from 17 health and human services networks out of 45 (38%). The research is carried out by means of statistical methods (OLS). The analysis is cross sectional. The implementation of "rational/technocratic" factors is important but not sufficient to enhance collaboration. The integration at the "professional level" should be kept in mind. In particular, the role of network (case) managers is paramount. Copyright © 2016 John Wiley & Sons, Ltd.

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OBJECTIVES

Over the past twenty years, numerous community social pediatrics centres (CSPCs) have been established in Quebec. Because the needs of the children followed are so complex, collaboration with organizations in social services and public and community health networks is paramount. The purpose of this study is to document CSPCs’level of integration into these networks and the issues and challenges involved in such collaborations.

METHOD

Telephone surveys were conducted with 75 respondents from public and community networks and with representatives from CSPCs that have been open for at last one year. Two questionnaires were used to document the depth and quality of connections and an open question helped identify certain collaboration-related issues and challenges.

RESULTS

CSPCs perceive a higher level of collaboration with the social services and public health network than with the community network. Similarly, CSPCs want to collaborate more with the public network than with the community network. With respect to the quality of collaborations, the climate is more positive and the level of joint coordination is higher between CSPCs and the public network. Although they are similar, the issues related to collaboration can be seen differently in terms of challenges, depending on the stakeholders' network.

CONCLUSION

Results are discussed in light of challenges that characterize the collaborations between CSPCs and the networks, which include the recognition of their identity and the funding of the organizations.

Quantifying collaboration using Himmelman ' s strategies for working together

Purpose

– Coordinated school health programs (CSHPs), a type of health promoting school (HPS) program adopted by Canada and the USA, were developed to provide a comprehensive approach to school health in the USA. Community partnerships are central to CSHP and HPS efforts, yet the quality of collaboration efforts is rarely assessed. The purpose of this paper is to use Himmelman’s strategies for working together to assess the types of partnerships that are being formed by CSHPs and to explore the methodological usefulness of this framework. The Himmelman methodology describes four degrees of partnering interaction: networking, coordinating, cooperating, and collaborating, with each degree of interaction signifying a different level of partnership between organizations.

Design/methodology/approach

– Data were collected as part of the 2008-2009 and 2009-2010 CSHP annual Requests for Proposal from all 131 public school systems in Tennessee. Thematic analysis methods were used to assess partnerships in school systems. Descriptive analyses were completed to calculate individual collaboration scores for each of the eight CSHP components (comprehensive health education, physical education/activity, nutrition services, health services, mental health services, student, family, and community involvement, healthy school environment, and health promotion of staff) during the two data collection periods. The level of collaboration was assessed based on Himmelman’s methodology, with higher scores indicating a greater degree of collaboration. Scores were averaged to obtain a mean score and individual component scores were then averaged to obtain statewide collaboration index scores (CISs) for each CSHP component.

Findings

– The majority of CSHPs partnering activities can be described as coordination, level two in partnering interaction. The physical activity component had the highest CISs and scored in between coordinating and cooperating (2.42), while healthy school environment had the lowest score, scoring between networking and coordinating (1.93), CISs increased from Year 1 to Year 2 for all of the CSHP components. Applying the theoretical framework of Himmelman’s methodology provided a novel way to quantify levels of collaboration among school partners. This approach offered an opportunity to use qualitative and quantitative methods to explore levels of collaboration, determine current levels of collaboration, and assess changes in levels of collaboration over the study period.

Research limitations/implications

– This study provides a framework for using the Himmelman methodology to quantify partnerships in a HPS program in the USA. However, the case study nature of the enquiry means that changes may have been influenced by a range of contextual factors, and quantitative analyses are solely descriptive and therefore do not provide an opportunity for statistical comparisons.

Practical implications

– Quantifying collaboration efforts is useful for HPS programs. Community activities that link back to the classroom are important to the success of any HPS program. Himmelman’s methodology may be useful when applied to HPSs to assess the quality of existing partnerships and guide program implementation efforts.

Originality/value

– This research is the first of its kind and uses a theoretical framework to quantify partnership levels in school health programs. In the future, using this methodology could provide an opportunity to develop more effective partnerships in school health programs, health education, and public health.

Indicators and measurement tools for health system integration: a knowledge synthesis protocol

BACKGROUND

Health system integration is a key component of health system reform with the goal of improving outcomes for patients, providers, and the health system. Although health systems continue to strive for better integration, current delivery of health services continues to be fragmented. A key gap in the literature is the lack of information on what successful integration looks like and how to measure achievement towards an integrated system. This multi-site study protocol builds on a prior knowledge synthesis completed by two of the primary investigators which identified 10 key principles that collectively support health system integration. The aim is to answer two research questions: What are appropriate indicators for each of the 10 key integration principles developed in our previous knowledge synthesis and what measurement tools are used to measure these indicators? To enhance generalizability of the findings, a partnership between Canada and Brazil was created as health system integration is a priority in both countries and they share similar contexts.

METHODS/DESIGN

This knowledge synthesis will follow an iterative scoping review process with emerging information from knowledge-user engagement leading to the refinement of research questions and study selection. This paper describes the methods for each phase of the study. Research questions were developed with stakeholder input. Indicator identification and prioritization will utilize a modified Delphi method and patient/user focus groups. Based on priority indicators, a search of the literature will be completed and studies screened for inclusion. Quality appraisal of relevant studies will be completed prior to data extraction. Results will be used to develop recommendations and key messages to be presented through integrated and end-of-grant knowledge translation strategies with researchers and knowledge-users from the three jurisdictions.

DISCUSSION

This project will directly benefit policy and decision-makers by providing an easy accessible set of indicators and tools to measure health system integration across different contexts and cultures. Being able to evaluate the success of integration strategies and initiatives will lead to better health system design and improved health outcomes for patients.

Towards a taxonomy for integrated care: a mixed-methods study

INTRODUCTION

Building integrated services in a primary care setting is considered an essential important strategy for establishing a high-quality and affordable health care system. The theoretical foundations of such integrated service models are described by the Rainbow Model of Integrated Care, which distinguishes six integration dimensions (clinical, professional, organisational, system, functional and normative integration). The aim of the present study is to refine the Rainbow Model of Integrated Care by developing a taxonomy that specifies the underlying key features of the six dimensions.

METHODS

First, a literature review was conducted to identify features for achieving integrated service delivery. Second, a thematic analysis method was used to develop a taxonomy of key features organised into the dimensions of the Rainbow Model of Integrated Care. Finally, the appropriateness of the key features was tested in a Delphi study among Dutch experts.

RESULTS

The taxonomy consists of 59 key features distributed across the six integration dimensions of the Rainbow Model of Integrated Care. Key features associated with the clinical, professional, organisational and normative dimensions were considered appropriate by the experts. Key features linked to the functional and system dimensions were considered less appropriate.

DISCUSSION

This study contributes to the ongoing debate of defining the concept and typology of integrated care. This taxonomy provides a development agenda for establishing an accepted scientific framework of integrated care from an end-user, professional, managerial and policy perspective.

Charting the trajectory of domestic violence policy change in the Republic of Ireland since the mid-1990s - a path towards integration?

Introduction

This paper assesses the policy developments pertaining to the implementation of an integrated approach to domestic violence over the past 15 years. The contextual setting is outlined in terms of the international policy response to the problem of domestic violence based on an ecological perspective.

Description of policy and case

Periods of core strategic policy and related structural developments are considered illustrating the Irish experience of domestic violence policy-making and service provision. The value of adopting an integrated approach to domestic violence based on the rationale of improving strategic policy formulation, coordinating service provision and facilitating joined-up governance is set out. The core facilitators and challenges associated with such an approach are described.

Analysis and conclusion

The policy framework and restructured landscape of domestic violence in Ireland has undergone significant change over the past decade and a half. The paper uses a three-dimensional matrix of domestic violence policy development and service integration as a means of addressing horizontal, vertical and resource aspects of collaboration and integration. While the changes have been characterised by significant phases of fluctuation in terms of coordinated action and the situation currently appears promising, however it is too early to judge the outcomes of the most recent reforms.

Instruments to assess integrated care: a systematic review

INTRODUCTION

Although several measurement instruments have been developed to measure the level of integrated health care delivery, no standardised, validated instrument exists covering all aspects of integrated care. The purpose of this review is to identify the instruments concerning how to measure the level of integration across health-care sectors and to assess and evaluate the organisational elements within the instruments identified.

METHODS

An extensive, systematic literature review in PubMed, CINAHL, PsycINFO, Cochrane Library, Web of Science for the years 1980-2011. Selected abstracts were independently reviewed by two investigators.

RESULTS

We identified 23 measurement instruments and, within these, eight organisational elements were found. No measurement instrument covered all organisational elements, but almost all studies include well-defined structural and process aspects and six include cultural aspects; 14 explicitly stated using a theoretical framework.

CONCLUSION AND DISCUSSION

This review did not identify any measurement instrument covering all aspects of integrated care. Further, a lack of uniform use of the eight organisational elements across the studies was prevalent. It is uncertain whether development of a single 'all-inclusive' model for assessing integrated care is desirable. We emphasise the continuing need for validated instruments embedded in theoretical contexts.

Comparing patient and provider perceptions of home- and community-based services: social network analysis as a service integration metric

Integrated home- and community-based services (HCBS) for frail seniors require a unique style of teamwork and collaboration. In four case studies, patient perceptions of teamwork and collaboration among their HCBS care providers are compared with those of the providers themselves using network analysis. The degree of coherence between these perceived networks are examined using network analytics, and network visualizations are discussed. The value of network analysis in research on HCBS is considered.

Exploration of the integration of care for persons with a traumatic brain injury using social network analysis methodology

Introduction

Integration is a popular strategy to increase the quality of care within systems of care. However, there is no common language, approach or tool allowing for a valid description, comparison and evaluation of integrated care. Social network analysis could be a viable methodology to provide an objective picture of integrated networks.

Goal of the article

To illustrate social network analysis use in the context of systems of care for traumatic brain injury.

Method

We surveyed members of a network using a validated questionnaire to determine the links between them. We determined the density, centrality, multiplexity, and quality of the links reported.

Results

The network was described as moderately dense (0.6), the most prevalent link was knowledge, and four organisation members of a consortium were central to the network. Social network analysis allowed us to create a graphic representation of the network.

Conclusion

Social network analysis is a useful methodology to objectively characterise integrated networks.

Examining intersectoral integration for malaria control programmes in an urban and a rural district in Ghana: a multinomial multilevel analysis

BACKGROUND

Intersectoral integration is acknowledged to be essential for improving provision of health care and outcomes, yet it remains one of the main primary health care strategic challenges. Although this is well articulated in the literature, the factors that explain differentials in levels of intersectoral integration have not been systematically studied, particularly in low and middle-income countries. In this study, we examine the levels and determinants of intersectoral integration amongst institutions engaged in malaria control programmes in an urban (Kumasi Metropolitan) district and a rural (Ahafo Ano South) district in Ghana.

METHODS

Interviews were conducted with representatives of 32 institutions engaged in promoting malaria prevention and control. The averaging technique proposed by Brown et al. and a two-level multinomial multilevel ordinal logistic regression were used to examine the levels of integration and the factors that explain the differentials.

RESULTS

The results show high disparity in levels of integration amongst institutions in the two districts. Integration was higher in the rural district compared to the urban district. The multivariate analysis revealed that the district effect explained 25% of the variations in integration. The type of institution, level of focus on malaria and source of funding are important predictors of intersectoral integration.

CONCLUSION

Although not causal, integrated malaria control programmes could be important for improving malaria-related health outcomes in less developed regions as evident from the rapid decline in malaria fatality rates observed in the Ahafo Ano South district. Harmonisation of programmes should be encouraged amongst institutions and the public and private sectors should be motivated to work in partnership.

Shared mental models of integrated care: aligning multiple stakeholder perspectives

PURPOSE

Health service organizations and professionals are under increasing pressure to work together to deliver integrated patient care. A common understanding of integration strategies may facilitate the delivery of integrated care across inter-organizational and inter-professional boundaries. This paper aims to build a framework for exploring and potentially aligning multiple stakeholder perspectives of systems integration.

DESIGN/METHODOLOGY/APPROACH

The authors draw from the literature on shared mental models, strategic management and change, framing, stakeholder management, and systems theory to develop a new construct, Mental Models of Integrated Care (MMIC), which consists of three types of mental models, i.e. integration-task, system-role, and integration-belief.

FINDINGS

The MMIC construct encompasses many of the known barriers and enablers to integrating care while also providing a comprehensive, theory-based framework of psychological factors that may influence inter-organizational and inter-professional relations. While the existing literature on integration focuses on optimizing structures and processes, the MMIC construct emphasizes the convergence and divergence of stakeholders' knowledge and beliefs, and how these underlying cognitions influence interactions (or lack thereof) across the continuum of care.

PRACTICAL IMPLICATIONS

MMIC may help to: explain what differentiates effective from ineffective integration initiatives; determine system readiness to integrate; diagnose integration problems; and develop interventions for enhancing integrative processes and ultimately the delivery of integrated care.

ORIGINALITY/VALUE

Global interest and ongoing challenges in integrating care underline the need for research on the mental models that characterize the behaviors of actors within health systems; the proposed framework offers a starting point for applying a cognitive perspective to health systems integration.

Multidisciplinary group performance-measuring integration intensity in the context of the North West London Integrated Care Pilot

INTRODUCTION

Multidisciplinary Group meetings (MDGs) are seen as key facilitators of integration, moving from individual to multi-disciplinary decision-making, and from a focus on individual patients to a focus on patient groups. We have developed a method for coding MDG transcripts to identify whether they are or are not vehicles for delivering the anticipated efficiency improvements across various providers and apply it to a test case in the North West London Integrated Care Pilot.

METHODS

We defined 'integrating' as the process within the MDG meeting that enables or promotes an improved collaboration, improved understanding, and improved awareness of self and others within the local healthcare economy such that efficiency improvements could be identified and action taken. Utterances within the MDGs are coded according to three distinct domains grounded in concepts from communication, group decision-making, and integrated care literatures-the Valence, the Focus, and the Level. Standardized weighted integrative intensity scores are calculated across ten time deciles in the Case Discussion providing a graphical representation of its integrative intensity.

RESULTS

Intra- and Inter-rater reliability of the coding scheme was very good as measured by the Prevalence and Bias-adjusted Kappa Score. Standardized Weighted Integrative Intensity graph mirrored closely the verbatim transcript and is a convenient representation of complex communication dynamics. Trend in integrative intensity can be calculated and the characteristics of the MDG can be pragmatically described.

CONCLUSION

This is a novel and potentially useful method for researchers, managers and practitioners to better understand MDG dynamics and to identify whether participants are integrating. The degree to which participants use MDG meetings to develop an integrated way of working is likely to require management, leadership and shared values.

Understanding integrated care: a comprehensive conceptual framework based on the integrative functions of primary care

INTRODUCTION

Primary care has a central role in integrating care within a health system. However, conceptual ambiguity regarding integrated care hampers a systematic understanding. This paper proposes a conceptual framework that combines the concepts of primary care and integrated care, in order to understand the complexity of integrated care.

METHODS

The search method involved a combination of electronic database searches, hand searches of reference lists (snowball method) and contacting researchers in the field. The process of synthesizing the literature was iterative, to relate the concepts of primary care and integrated care. First, we identified the general principles of primary care and integrated care. Second, we connected the dimensions of integrated care and the principles of primary care. Finally, to improve content validity we held several meetings with researchers in the field to develop and refine our conceptual framework.

RESULTS

The conceptual framework combines the functions of primary care with the dimensions of integrated care. Person-focused and population-based care serve as guiding principles for achieving integration across the care continuum. Integration plays complementary roles on the micro (clinical integration), meso (professional and organisational integration) and macro (system integration) level. Functional and normative integration ensure connectivity between the levels.

DISCUSSION

The presented conceptual framework is a first step to achieve a better understanding of the inter-relationships among the dimensions of integrated care from a primary care perspective.

Measuring the degree of integration for an integrated service network

BACKGROUND

Integration involves the coordination of services provided by autonomous agencies and improves the organization and delivery of multiple services for target patients. Current measures generally do not distinguish between agencies' perception and expectation. We propose a method for quantifying the agencies' service integration. Using the data from the Children's Treatment Network (CTN), we aimed to measure the degree of integration for the CTN agencies in York and Simcoe.

THEORY AND METHODS

We quantified the integration by the agreement between perceived and expected levels of involvement and calculated four scores from different perspectives for each agency. We used the average score to measure the global network integration and examined the sensitivity of the global score.

RESULTS

Most agencies' integration scores were <65%. As measured by the agreement between every other agency's perception and expectation, the overall integration of CTN in Simcoe and York was 44% (95% CI: 39%-49%) and 52% (95% CI: 48%-56%), respectively. The sensitivity analysis showed that the global scores were robust.

CONCLUSION

Our method extends existing measures of integration and possesses a good extent of validity. We can also apply the method in monitoring improvement and linking integration with other outcomes.

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

INTRODUCTION

Despite over two decades of international experience and research on health systems integration, integrated care has not developed widely. We hypothesized that part of the problem may lie in how we conceptualize the integration process and the complex systems within which integrated care is enacted. This study aims to contribute to discourse regarding the relevance and utility of a complex-adaptive systems (CAS) perspective on integrated care.

METHODS

In the Canadian province of Ontario, government mandated the development of fourteen Local Health Integration Networks in 2006. Against the backdrop of these efforts to integrate care, we collected focus group data from a diverse sample of healthcare professionals in the Greater Toronto Area using convenience and snowball sampling. A semi-structured interview guide was used to elicit participant views and experiences of health systems integration. We use a CAS framework to describe and analyze the data, and to assess the theoretical fit of a CAS perspective with the dominant themes in participant responses.

RESULTS

Our findings indicate that integration is challenged by system complexity, weak ties and poor alignment among professionals and organizations, a lack of funding incentives to support collaborative work, and a bureaucratic environment based on a command and control approach to management. Using a CAS framework, we identified several characteristics of CAS in our data, including diverse, interdependent and semi-autonomous actors; embedded co-evolutionary systems; emergent behaviours and non-linearity; and self-organizing capacity.

DISCUSSION AND CONCLUSION

One possible explanation for the lack of systems change towards integration is that we have failed to treat the healthcare system as complex-adaptive. The data suggest that future integration initiatives must be anchored in a CAS perspective, and focus on building the system's capacity to self-organize. We conclude that integrating care requires policies and management practices that promote system awareness, relationship-building and information-sharing, and that recognize change as an evolving learning process rather than a series of programmatic steps.

System integration and its influence on the quality of life of children with complex needs

Purpose. To explore the interactions between child and parents psychosocial factors and team integration variables that may explain improvements in physical dimensions of the PEDS QL quality of life of children with complex needs after 2 years. Methods. In this 2-year study, parents were identified by the Children's Treatment Network. Families were eligible if the child was aged 0–19 years, had physical limitations, resided in either Simcoe County or the Region of York, Ontario, and there were multiple other family needs. Regression analysis used to explore associations and interactions; n = 110. Results. A child's physical quality of life was affected by interacting factors including child's behavior, parenting, and integrated care. Statistically significant interactions between team integration, processes of care, and child/parent variables highlight the complexity of the rehabilitation approach in real-life situations. Conclusions. Rehabilitation providers working with children with complex needs and their families should also address child and parent problematic behaviors. When this was the case in high integrated teams, the child's physical quality of life improved after two years.

Health systems integration: state of the evidence

INTRODUCTION

Integrated health systems are considered a solution to the challenge of maintaining the accessibility and integrity of healthcare in numerous jurisdictions worldwide. However, decision makers in a Canadian health region indicated they were challenged to find evidence-based information to assist with the planning and implementation of integrated healthcare systems.

METHODS

A systematic literature review of peer-reviewed literature from health sciences and business databases, and targeted grey literature sources.

RESULTS

Despite the large number of articles discussing integration, significant gaps in the research literature exist. There was a lack of high quality, empirical studies providing evidence on how health systems can improve service delivery and population health. No universal definition or concept of integration was found and multiple integration models from both the healthcare and business literature were proposed in the literature. The review also revealed a lack of standardized, validated tools that have been systematically used to evaluate integration outcomes. This makes measuring and comparing the impact of integration on system, provider and patient level challenging.

DISCUSSION AND CONCLUSION

Healthcare is likely too complex for a one-size-fits-all integration solution. It is important for decision makers and planners to choose a set of complementary models, structures and processes to create an integrated health system that fits the needs of the population across the continuum of care. However, in order to have evidence available, decision makers and planners should include evaluation for accountability purposes and to ensure a better understanding of the effectiveness and impact of health systems integration.

Evaluating intersectoral collaboration: a model for assessment by service users

INTRODUCTION

DELTA was launched as a project in 1997 to improve intersectoral collaboration in the rehabilitation field. In 2005 DELTA was transformed into a local association for financial co-ordination between the institutions involved. Based on a study of the DELTA service users, the purpose of this article is to develop and to validate a model that can be used to assess the integration of welfare services from the perspective of the service users.

THEORY

The foundation of integration is a well functioning structure of integration. Without such structural conditions, it is difficult to develop a process of integration that combines the resources and competences of the collaborating organisations to create services advantageous for the service users. In this way, both the structure and the process will contribute to the outcome of integration.

METHOD

The study was carried out as a retrospective cross-sectional survey during two weeks, including all the current service users of DELTA. The questionnaire contained 32 questions, which were derived from the theoretical framework and research on service users, capturing perceptions of integration structure, process and outcome. Ordinal scales and open questions where used for the assessment.

RESULTS

The survey had a response rate of 82% and no serious biases of the results were detected. The study shows that the users of the rehabilitation services perceived the services as well integrated, relevant and adapted to their needs. The assessment model was tested for reliability and validity and a few modifications were suggested. Some key measurement themes were derived from the study.

CONCLUSION

The model developed in this study is an important step towards an assessment of service integration from the perspective of the service users. It needs to be further refined, however, before it can be used in other evaluations of collaboration in the provision of integrated welfare services.

Measurement of integrated healthcare delivery: a systematic review of methods and future research directions

BACKGROUND

Integrated healthcare delivery is a policy goal of healthcare systems. There is no consensus on how to measure the concept, which makes it difficult to monitor progress.

PURPOSE

To identify the different types of methods used to measure integrated healthcare delivery with emphasis on structural, cultural and process aspects.

METHODS

Medline/Pubmed, EMBASE, Web of Science, Cochrane Library, WHOLIS, and conventional internet search engines were systematically searched for methods to measure integrated healthcare delivery (published - April 2008).

RESULTS

Twenty-four published scientific papers and documents met the inclusion criteria. In the 24 references we identified 24 different measurement methods; however, 5 methods shared theoretical framework. The methods can be categorized according to type of data source: a) questionnaire survey data, b) automated register data, or c) mixed data sources. The variety of concepts measured reflects the significant conceptual diversity within the field, and most methods lack information regarding validity and reliability.

CONCLUSION

Several methods have been developed to measure integrated healthcare delivery; 24 methods are available and some are highly developed. The objective governs the method best used. Criteria for sound measures are suggested and further developments should be based on an explicit conceptual framework and focus on simplifying and validating existing methods.

Interprofessional partnerships in chronic illness care: a conceptual model for measuring partnership effectiveness

INTRODUCTION

Interprofessional health and social service partnerships (IHSSP) are internationally acknowledged as integral for comprehensive chronic illness care. However, the evidence-base for partnership effectiveness is lacking. This paper aims to clarify partnership measurement issues, conceptualize IHSSP at the front-line staff level, and identify tools valid for group process measurement.

THEORY AND METHODS

A systematic literature review utilizing three interrelated searches was conducted. Thematic analysis techniques were supported by NVivo 7 software. Complexity theory was used to guide the analysis, ground the new conceptualization and validate the selected measures. Other properties of the measures were critiqued using established criteria.

RESULTS

There is a need for a convergent view of what constitutes a partnership and its measurement. The salient attributes of IHSSP and their interorganizational context were described and grounded within complexity theory. Two measures were selected and validated for measurement of proximal group outcomes.

CONCLUSION

This paper depicts a novel complexity theory-based conceptual model for IHSSP of front-line staff who provide chronic illness care. The conceptualization provides the underpinnings for a comprehensive evaluative framework for partnerships. Two partnership process measurement tools, the PSAT and TCI are valid for IHSSP process measurement with consideration of their strengths and limitations.

Conceptualization and measurement of integrated human service networks for evaluation

Introduction

Integration has been advanced as a strategy for the delivery of a number of human services that have traditionally been delivered by autonomous agencies with independent processes and funding sources. However, measurement of the dimensions of integration has been hampered by numerous factors, including a lack of definitional and conceptual clarity of integration, and the use of measurement tools with atheoretical foundations and limited psychometric testing.

Theory/methods

Based on a review of integration measurement approaches, a comprehensive approach to the measure of multiple dimensions of integrated human service networks was conceptualized. The combination of concepts was derived from existing theoretical, policy, and measurement approaches in order to establish the content validity and comprehensiveness of the proposed measure.

Results

The dimensions of human service integration measures are:

(1) Observed (current) and expected structural inputs, or the mix of agencies that comprise the network (e.g. extent, scope, depth, congruence within an agency, and reciprocity between agencies).

(2) Functioning of the network both in terms of the quality of the network or partnership functioning and ingredients of the integration of the networks' working arrangements and range of human services provided.

(3) Network outputs in terms of network capacity (e.g. what is accomplished, for how many and how quickly given the local demand) measured from dual perspectives of the agency and the family.

Conclusion

This newly developed measure unites multiple perspectives in a comprehensive approach to the measurement of integration of human service networks. Content validity has been established. Future work should focus on further refinement of this instrument through psychometric evaluation (e.g. construct validity) in diverse networks and relating these measures of network integration to client and system outcomes.

Improving the performance of the health service delivery system? Lessons from the Towards Unity for Health projects

CONTEXT

The World Health Organization developed the Towards Unity for Health (TUFH) strategy in 2000 for the improvement of health system performance. Twelve projects worldwide were supported to put this strategy into practice. A standard evaluation and monitoring framework was developed on the basis of which project coordinators prepared technical progress reports.

OBJECTIVES

To review the utility and effectiveness of the evaluation criteria recommended by TUFH and their application in four of the original twelve projects.

METHODS

We reviewed status reports provided by European project coordinators and developed a standardized reporting template to extract information using original TUFH evaluation criteria.

RESULTS

The original TUFH evaluation framework is very comprehensive and has only partly been followed by the field projects. The evaluation strategies employed by the projects were insufficient to demonstrate the connections between the intervention and the desired process improvements, and few of the evaluation measures address outcomes.

DISCUSSION

The evaluation strategies employed by the projects are limited in allowing us to associate the intervention with the desired process improvements. Few measures address outcomes. The evaluation of complex community interventions poses many challenges, however, tools are available to assess impact on structures and process, and selected outcome indicators may be identified to monitor progress in future projects.

CONCLUSION

Based on the review of evaluation status of the TUFH projects and resources available we recommend moving away from uniform evaluation and towards monitoring minimal, context-specific performance indicators criteria.

Proposal of a service delivery integration index of home care for older persons: application in several European cities

PURPOSE

To propose an integration index of home care delivery to older persons, to study its validity and to apply it to home care services of European cities.

THEORY

Home care delivery integration was based on two dimensions referring to process-centred integration and organisational structure approach.

METHOD

Items considered as part of both dimensions according to an expert consensus (face validity) were extracted from a standardised questionnaire used in "Aged in Home care" (AdHoc) study to capture basic characteristics of home care services. Their summation leads to a services' delivery integration index. This index was applied to AdHoc services. A factor analysis was computed in order to empirically test the validity of the theoretical constructs. The plot of the settings was performed.

RESULTS

Application of the index ranks home care services in four groups according to their score. Factor analysis identifies a first factor which opposes working arrangement within service to organisational structure bringing together provisions for social care. A second factor corresponds to basic nursing care and therapies. Internal consistency for those three domains ranges from 0.78 to 0.93. When plotting the different settings different models of service delivery appear.

CONCLUSION

The proposed index shows that behind a total score several models of care delivery are hidden. Comparison of service delivery integration should take into account this heterogeneity.

Evaluating integrated health care: a model for measurement

Purpose

In the development of integrated care, there is an increasing need for knowledge about the actual degree of integration between different providers of health services. The purpose of this article is to describe the conceptualisation and validation of a practical model for measurement, which can be used by managers to implement and sustain integrated care.

Theory

The model is based on a continuum of integration, extending from full segregation through intermediate forms of linkage, coordination and cooperation to full integration.

Methods

The continuum was operationalised into a ratio scale of functional clinical integration. This scale was used in an explorative study of a local health authority in Sweden. Data on integration were collected in self-assessment forms together with estimated ranks of optimum integration between the different units of the health authority. The data were processed with statistical methods and the results were discussed with the managers concerned.

Results

Judging from this explorative study, it seems that the model of measurement collects reliable and valid data of functional clinical integration in local health care. The model was also regarded as a useful instrument for managers of integrated care.

Discussion

One of the main advantages with the model is that it includes optimum ranks of integration beside actual ranks. The optimum integration rank between two units is depending on the needs of both differentiation and integration.