Barriers and facilitators to integrating care: experiences from the English Integrated Care Pilots

Understanding for whom, under what conditions, and how an integrated approach to atrial fibrillation service delivery works: a realist review

AIMS

To understand for whom, under what conditions, and how an integrated approach to atrial fibrillation (AF) service delivery works (or does not work).

METHODS AND RESULTS

A realist review of integrated approaches to AF service delivery for adult populations aged ≥18 years. An expert panel developed an initial programme theory, searched and screened literature from four databases until October 2022, extracted and synthesized data using realist techniques to create context-mechanism-outcome configurations for integrated approaches to AF service, and developed an integrated approach refined programme theory. A total of 5433 documents were screened and 39 included. The refined programme theory included five context-mechanism-outcome configurations for how clinical and system-wide outcomes are affected by the way integrated approaches to AF service delivery are designed and delivered. This review identifies core mechanisms underpinning the already known fundamental components of integrated care. This includes having a central coordinator responsible for service organization to provide continuity of care across primary and secondary care ensuring services are patient centred. Additionally, a fifth pillar, lifestyle and risk factor reduction, should be recognized within an AF care pathway.

CONCLUSION

It is evident from our provisional theory that numerous factors need to interlink and interact over time to generate a successfully integrated model of care in AF. Stakeholders should embrace this complexity and acknowledge that the learnings from this review are integral to shaping future service delivery in the face of an aging population and increased prevalence of AF.

Factors influencing effective data sharing between health care and social care regarding the care of older people: a qualitative evidence synthesis

Background

Sharing data about patients between health and social care organisations and professionals, such as details of their medication, is essential to provide co-ordinated and person-centred care. While professionals can share data in a number of ways - for example, through shared electronic record systems or multidisciplinary team meetings - there are many factors that make sharing data across the health and social care boundary difficult. These include professional hierarchies, inaccessible electronic systems and concerns around confidentiality. Data-sharing is particularly important for the care of older people, as they are more likely to have multiple or long-term conditions; understanding is needed on how to enable effective data-sharing.

Objectives

To identify factors perceived as influencing effective data-sharing, including the successful adoption of interventions to improve data-sharing, between healthcare and social care organisations and professionals regarding the care of older people.

Methods

MEDLINE and seven further databases were searched (in March 2023) for qualitative and mixed-methods studies. Relevant websites were searched and citation-chasing completed on included studies. Studies were included if they focused on older people, as defined by the study, and data-sharing, defined as the transfer of information between healthcare and social care organisations, or care professionals, regarding a patient, and were conducted in the United Kingdom. Purposive sampling was used to obtain a final set of studies which were analysed using framework synthesis. Quality appraisal was conducted using the Wallace checklist. Stakeholder and public and patient involvement groups were consulted throughout the project.

Results

Twenty-four studies were included; most scored highly on the quality appraisal checklist. Four main themes were identified. Within Goals, we found five purposes of data-sharing: joint (health and social care) assessment, integrated case management, transitions from hospital to home, for residents of care homes, and for palliative care. In Relationships, building interprofessional relationships, and therefore trust and respect, between professionals supported data-sharing, while the presence of professional prejudices and mistrust hindered it. Interorganisational Processes and procedures, such as a shared vision of care and operationalisation of formal agreements, for example data governance, supported data-sharing. Within Technology and infrastructure, the use of technology as a tool supported data-sharing, as did professionals' awareness of the wider care system. There were also specific factors influencing data-sharing related to its purpose; for example, there was a lack of legal frameworks in the area of palliative care.

Limitations

Data-sharing was usually discussed in the context of wider initiatives, for example integrated care, which meant the information provided was often limited. The COVID-19 pandemic has had significant impacts on ways of working; none of our included studies were conducted during or since the pandemic.

Conclusions

Our findings indicate the importance of building interprofessional relationships and ensuring that professionals are able to share data in multiple ways.

Future work

Exploration of the impact of new technologies and ways of working adopted as a result of the COVID-19 pandemic on data-sharing is needed. Additionally, research should explore patient experience and the prevention of digital exclusion among health and social care professionals.

Study registration

The protocol was registered on PROSPERO CRD42023416621.

Funding

This award was funded by the National Institute for Health and Care Research (NIHR) Health and Social Care Delivery Research programme (NIHR award ref: NIHR135660), as part of a series of evidence syntheses under award NIHR130538, and is published in full in Health and Social Care Delivery Research; Vol. 12, No. 12. See the NIHR Funding and Awards website for further award information.

The performance of general practice in the English National Health Service (NHS): an analysis using Starfield's framework for primary care

General practice in the English National Health Service (NHS) is in crisis. In response, politicians are proposing fundamental reform to the way general practice is organized. But ideas for reform are contested, and there are conflicting interpretations of the problems to be addressed. We use Barbara Starfield's "4Cs" framework for high-performing primary care to provide an overall assessment of the current role and performance of general practice in England. We first assessed theoretical alignment between Starfield's framework and the role of general practice in England. We then assessed actual performance using publicly available national data and targeted literature searches. We found close theoretical alignment between Starfield's framework and the model of NHS general practice in England. But, in practice, its model of universal comprehensive care risks being undermined by worsening and inequitable access, while continuity of care is declining. Underlying causes of current challenges in general practice in England appear more closely linked to under-resourcing than the fundamental design of the system. General practice in England must evolve, but wholesale re-organization is likely to damage and distract. Instead, policymakers should focus on adequately resourcing general practice while supporting general practice teams to improve the quality and coordination of local services.

Integrated care system leadership: a rapid realist review

PURPOSE

Given the complex nature of integrated care systems (ICSs), the geographical spread and the large number of organisations involved in partnership delivery, the importance of leadership cannot be overstated. This paper aims to present novel findings from a rapid realist review of ICS leadership in England. The overall review question was: how does leadership in ICSs work, for whom and in what circumstances?

DESIGN/METHODOLOGY/APPROACH

Development of initial programme theories and associated context-mechanism-outcome configurations (CMOCs) were supported by the theory-gleaning activities of a review of ICS strategies and guidance documents, a scoping review of the literature and interviews with key informants. A refined programme theory was then developed by testing these CMOCs against empirical data published in academic literature. Following screening and testing, six CMOCs were extracted from 18 documents. The study design, conduct and reporting were informed by the Realist And Metanarrative Evidence Syntheses: Evolving Standards (RAMESES) training materials (Wong et al., 2013).

FINDINGS

The review informed four programme theories explaining that leadership in ICSs works when ICS leaders hold themselves and others to account for improving population health, a sense of purpose is fostered through a clear vision, partners across the system are engaged in problem ownership and relationships are built at all levels of the system.

RESEARCH LIMITATIONS/IMPLICATIONS

Despite being a rigorous and comprehensive investigation, stakeholder input was limited to one ICS, potentially restricting insights from varied geographical contexts. In addition, the recent establishment of ICSs meant limited literature availability, with few empirical studies conducted. Although this emphasises the importance and originality of the research, this scarcity posed challenges in extracting and applying certain programme theory elements, particularly context.

ORIGINALITY/VALUE

This review will be of relevance to academics and health-care leaders within ICSs in England, offering critical insights into ICS leadership, integrating diverse evidence to develop new evidence-based recommendations, filling a gap in the current literature and informing leadership practice and health-care systems.

The development of an integrated neighborhood approach for health promotion and prevention: a qualitative exploration of stakeholders' views

BACKGROUND

Although the promise of integrated neighborhood approaches, including the essential roles of communities and collaboration between the medical and social domains, has been widely acknowledged, the realization of such approaches in practice often remains difficult. To gain insight into the development of integrated neighborhood approaches, this case study describes the experiences of stakeholders involved in such an approach for health promotion and prevention in Rotterdam.

METHODS

Interviews with 18 stakeholders (including health and social care professionals, health insurance employees, and policymakers) were conducted, and stakeholders' statements were analyzed thematically.

RESULTS

The results reveal a lack of alignment among the professional, organizational, and system levels. Elements needed for collaboration between health and social care professionals are not supported at the organizational and system levels. The lack of integration at the policy and organizational levels encourages competition and self-interest instead of stimulating collaboration.

CONCLUSIONS

Intersectoral collaboration and coordination must take place not only between professionals, but also at the organizational and policy levels. As long as integration at the organizational and system levels is lacking, professionals' ability to collaborate and provide coordinated support to neighborhood residents will be compromised.

Outsourcing the Management of Reusable Medical Devices in a Chain-Wide Care Setting: Mixed Methods Feasibility Study

BACKGROUND

Managing reusable medical devices incurs substantial health care costs and complexity, particularly in integrated care settings. This complexity hampers care quality, safety, and costs. Studying logistical innovations within integrated care can provide insights to medical devices use among staff effectively.

OBJECTIVE

This study aimed to establish the feasibility of a logistical intervention through outsourcing and a web portal. The goal was to provide insights into users' acceptability of the intervention, on whether the intervention was successfully implemented, and on the intervention's preliminary efficacy, thus benefiting practitioners and researchers.

METHODS

This paper presents a mixed methods feasibility study at a large chain-wide health care provider in the Netherlands. The intervention entailed outsourcing noncritical reusable medical devices and introducing a web portal for device management. A questionnaire gauged perceived ordering and delivery times, satisfaction with the ordering and delivery process, compliance with safety and hygiene certification, and effects on the care delivery process. Qualitative data in the form of observations, documentation, and interviews were used to identify implementing challenges. Using on-site stocktaking and data from information systems, we analyzed the utilization, costs, and rental time of medical devices before and after the intervention for wheelchairs and anti-pressure ulcer mattresses.

RESULTS

Looking at the acceptability of the intervention, a high user satisfaction with the ordering and delivery process was reported (rated on a 5-point Likert scale). With respect to preliminary efficacy, we noted a reduction in the utilization of wheelchairs (on average, 1106, SD 106 fewer utilization d/mo), and a halted increase in the utilization of anti-pressure ulcer mattresses. In addition, nurses who used the web portal reported shorter ordering times for wheelchairs (-2.7 min) and anti-pressure ulcer mattresses (-3.1 min), as well as shorter delivery times for wheelchairs (-0.5 d). Moreover, an increase in device certification was reported (average score of 1.9, SD 1.0), indicating higher levels of safety and hygiene standards. In theory, these improvements should translate into better outcomes in terms of costs and the quality of care. However, we were unable to establish a reduction in total care costs or a reduced rental time per device. Furthermore, respondents did not identify improvements in safety or the quality of care. Although implementation challenges related to the diverse supply base and complexities with different care financers were observed, the overall implementation of the intervention was considered successful.

CONCLUSIONS

This study confirms the feasibility of our intervention, in terms of acceptability, implementation success, and preliminary efficacy. The integrated management of medical devices should enable a reduction in costs, required devices, and material waste, as well as higher quality care. However, several challenges remain related to the implementation of such interventions.

Back to basics: A mediation analysis approach to addressing the fundamental questions of integrated care evaluations

Health systems around the world are aiming to improve the integration of health and social care services to deliver better care for patients. Existing evaluations have focused exclusively on the impact of care integration on health outcomes and found little effect. That suggests the need to take a step back and ask whether integrated care programmes actually lead to greater clinical integration of care and indeed whether greater integration is associated with improved health outcomes. We propose a mediation analysis approach to address these two fundamental questions when evaluating integrated care programmes. We illustrate our approach by re-examining the impact of an English integrated care program on clinical integration and assessing whether greater integration is causally associated with fewer admissions for ambulatory care sensitive conditions. We measure clinical integration using a concentration index of outpatient referrals at the general practice level. While we find that the scheme increased integration of primary and secondary care, clinical integration did not mediate a decrease in unplanned hospital admissions. Our analysis emphasizes the need to better understand the hypothesized causal impact of integration on health outcomes and demonstrates how mediation analysis can inform future evaluations and program design.

[Impact of CoCare, a Complex Model Intervention, on medical care in long-term care nursing homes in Germany: An overview of the outcome and process evaluation]

INTRODUCTION

More and more people are being cared for in nursing homes these days. Multimorbidity results in frequent but sometimes unnecessary patient transports and hospitalisations. The CoCare intervention was developed as a nursing home-based intervention to improve coordination of medical care and GP and specialist care in long-term care homes. The project aimed to reduce avoidable hospital admissions and ambulance transportation, minimise costs through the resulting better collaboration and improving the quality of life of nursing home residents. This article presents the results of the process and outcome evaluation of the intervention in an integrated way and assesses them against the background of the project objectives.

METHODS

Intervention and data collection started in January 2018 and ended in September 2020. A mixed-methods design was chosen for the evaluation. The (cost) effectiveness of the intervention was tested by a controlled observational study, comparing intervention (IG) and control group (CG). As part of the evaluation of the results, claims data from health insurance funds and a questionnaire-based survey among nursing staff, physicians and nursing home residents were analysed. As part of the process evaluation, subjectively perceived changes in care and implementation difficulties were recorded with the help of focus groups and telephone interviews conducted quarterly.

RESULTS

From the point of view of the health economic evaluation, with a decrease in total costs of € 468.56 (p<.001) per nursing home resident and quarter, an advantageous cost-benefit ratio can be assumed. Thus, the significant increase in outpatient care for nursing home residents goes along with a reduction of ambulance transportation by 0.19 (p=.049) and hospitalization rates by 0.08 (p=.001). In the nursing staff sample, a significant positive difference between IG (T1) and CG was observed with regard to communication and cooperation. In addition, pre-post comparison showed a significant improvement in the nursing staff's assessment of interprofessional cooperation in IG at T1 compared to T0. Both nursing staff and physicians perceived positive changes in care and positively assessed the benefit of the intervention. While practitioners experienced an intensification and improvement of communication and cooperation through the implementation of the CoCare measures, these changes were not perceived by residents.

DISCUSSION

The CoCare intervention lowered the barriers for nursing homes to contact general practitioners, specifically in unclear situations and can thus be seen as an effective tool to reduce potentially avoidable hospital admissions and costs. It is conceivable that results can be transferred to other regions in Germany and to similar care scenarios. It should be examined to what extent approaches of this new form of care can be transferred to standard care and whether adjustments to facilitate the implementation of coordinated care approaches across occupational groups in inpatient care facilities can be proposed within the framework of legislative procedures.

Primary care services in the English NHS: are they a thorn in the side of integrated care systems? A qualitative analysis

BACKGROUND

As integrated care systems are embedded across England there are regions where the integration process has been evaluated and continues to evolve. Evaluation of these integrated systems contributes to our understanding of the challenges and facilitators to this ongoing process. This can support integrated care systems nationwide as they continue to develop. We describe how two integrated care partnerships in different localities, at differing stages of integration with contrasting approaches experienced challenges specifically when integrating with primary care services. The aim of this analysis was to focus on primary care services and how their existing structures impacted on the development of integrated care systems.

METHODS

We carried out an exploratory approach to re-analysing our previously conducted 51 interviews as part of our prior evaluations of integrated health and care services which included primary care services. The interview data were thematically analysed, focussing on the role and engagement of primary care services with the integrated care systems in these two localities.

RESULTS

Four key themes from the data are discussed: (i) Workforce engagement (engagement with integration), (ii) Organisational communication (information sharing), (iii) Financial issues, (iv) Managerial information systems (data sharing, IT systems and quality improvement data). We report on the challenges of ensuring the workforce feel engaged and informed. Communication is a factor in workforce relationships and trust which impacts on the success of integrated working. Financial issues highlight the conflict between budget decisions made by the integrated care systems when primary care services are set up as individual businesses. The incompatibility of information technology systems hinders integration of care systems with primary care.

CONCLUSIONS

Integrated care systems are national policy. Their alignment with primary care services, long considered to be the cornerstone of the NHS, is more crucial than ever. The two localities we evaluated as integration developed both described different challenges and facilitators between primary care and integrated care systems. Differences between the two localities allow us to explore where progress has been made and why.

The forgotten dimension of integrated care: barriers to implementing integrated clinical care in English NHS hospitals

Multimorbid patients who enter English NHS hospitals are frequently subject to care pathways designed to assess, diagnose and treat single medical conditions. Opportunities are thereby lost to offer patients more holistic, person-centred care. Hospital organisations elsewhere are known to use in-hospital, multi-specialty, integrated clinical care (ICC) to overcome this problem. This perspective piece aims to critically discuss barriers to implementing this form of ICC in the English NHS focusing on six key areas: information technologies, the primary-secondary care interface, internal hospital processes, finance, workload, professional roles and behaviours. Integrated care programmes currently underway are largely focused on macro (system) and meso (organisational) levels. A micro (clinical) level ICC, offering highly coordinated multispecialty expertise to multimorbid hospital patients could fill an important gap in the current care pathways.

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.

Implementing Four Transitional Care Interventions for Older Adults: A Retrospective Collective Case Study

BACKGROUND AND OBJECTIVES

Four interventions to improve care transitions between hospital and home or community settings for older adults were implemented in Leuven, Belgium over the past 4 years. These complex interventions consist of multiple components that challenge their implementation in practice. This study examines the influencing factors, strategies used to address challenges in implementing these interventions, and implementation outcomes from the perspectives of health care professionals involved.

RESEARCH DESIGN AND METHODS

This was a qualitative, collective case study that was part of the TRANS-SENIOR research network. Authors conducted semistructured interviews with health care professionals about their perceptions regarding the implementation. Thematic analysis was used, and the Consolidated Framework for Implementation Research guided the final data interpretation.

RESULTS

Thirteen participants were interviewed. Participants reported major implementation bottlenecks at the organizational level (resources, structure, and information continuity), while facilitators were at the individual level (personal attributes and champions). They identified engagement as the primary strategy used, and suggested other important strategies for the future sustainability of the interventions (building strategic partnerships and lobbying for policies to support transitional care). They perceived the overall implementation favorably, with high uptake as a key outcome.

DISCUSSION AND IMPLICATIONS

This study highlights the strong role of health care providers, being motivated and self-driven, to foster the implementation of interventions in transitional care in a bottom-up way. It is important to use implementation strategies targeting both the individual-level factors as well as the organizational barriers for transitional care interventions in the future.

Exploring readiness for implementing goal-oriented care in primary care using normalization process theory

AIM

To use normalization process theory (NPT) to build a strategy for the implementation of goal-oriented care (GOC) in primary care in Flanders, Belgium.

BACKGROUND

GOC is a possible approach to more coordinated and integrated care and tailors care to patients' personal life goals. The concept has gained interest among policy makers and researchers, but the main drivers for successful implementation are the primary healthcare professionals (PHCPs) who need to see added value of GOC in order to embed it into their daily practice. NPT, developed to understand the processes of implementing new ways of organizing care, offers a useful lens to understand adoption of GOC in primary care practice.

METHOD

PHCPs (n = 131) who participated in a 2-hour community meeting on GOC were asked to complete the Normalization MeAsure Development survey. This 23-item survey is based on NPT and describes participants' views about how an intervention would impact their work, their expectations about it, and whether it could become a routine part of their work.

FINDINGS

The NPT constructs coherence (sense-making work) and cognitive participation (relational work) showed positive tendency toward implementation of GOC. The participants had an initial understanding on GOC and there was much interest in supporting and start working with this approach. The other constructs collective action (operational work) and reflexive monitoring (appraisal work) will need further efforts to trigger implementation. A common ground is needed to integrate GOC as a common practice which can be achieved by intensive interprofessional collaboration.

Frailty nurse and GP-led models of care in care homes: the role of contextual factors impacting Enhanced health in care homes framework implementation

BACKGROUND

The Enhanced Health for Care homes (EHCH) framework is an innovative response to provide more proactive, preventative approaches to care for residents living in care homes. It involves co-producing a shared vision with primary care. As part of EHCH a UK clinical commissioning group supported GP's in two localities to implement their preferred delivery approach involving a new Frailty Nurse-led (FN-led) model in care homes alongside an existing General Practitioner-led (GP-led) model. This paper focuses on implementation of the new FN-led model.

METHODS

A qualitative study design was adopted. Forty-eight qualitative semi-structured interviews were undertaken across six care home sites in a Northern locality: three implementing the FN-led and three engaged in an existing GP-led model. Participants included residents, family members, care home managers, care staff, and health professionals working within the EHCH framework.

RESULTS

Two overarching themes were generated from data analysis: Unanticipated implementation issues and Unintended consequences. Unsuccessful attempts to recruit Frailty Nurses (FN) with enhanced clinical skills working at the desired level (UK NHS Band 7) led to an unanticipated evolution in the implementation process of the FN-led model towards 'training posts'. This prompted misaligned role expectations subsequently provoking unexpected temporary outcomes regarding role-based trust. The existing, well understood nature of the GP-led model may have further exacerbated these unintended consequences.

CONCLUSION

Within the broader remit of embedding EHCH frameworks, the implementation of new FN roles needed to evolve due to unforeseen recruitment issues. Wider contextual factors are not in the control of those developing new initiatives and cannot always be foreseen, highlighting how wider factors can force evolution of planned implementation processes with unintended consequences. However, the unintended consequences in this study highlight the need for careful consideration of information dissemination (content and timing) to key stakeholders, and the influence of existing ways of working.

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

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

Implementing a community specialist team to support the delivery of integrated diabetes care: experiences in Ireland during the COVID-19 pandemic

Background: While models of integrated care for people with chronic conditions have demonstrated promising results, there are still knowledge gaps about how these models are implemented in different contexts and which strategies may best support implementation. We aimed to evaluate the implementation of a multidisciplinary diabetes Community Specialist Team (CST) to support delivery of integrated type 2 diabetes care during COVID-19 in two health networks. Methods: A mixed methods approach was used. Quantitative data included administrative data on CST activity and caseload, and questionnaires with GPs, practice nurses (PN) and people with type 2 diabetes. Qualitative data were collected using semi-structured interviews and focus groups about the service from CST members, GPs, PNs and people with type 2 diabetes. We used the Consolidated Framework for Implementation Research framework to explain what influences implementation and to integrate different stakeholder perspectives. Results: Over a 6-month period (Dec 2020-May 2021), 516 patients were seen by podiatrists, 435 by dieticians, and 545 by CNS. Of patients who had their first CST appointment within the previous 6 months (n=29), 69% (n=20) waited less than 4 weeks to see the HCP. During initial implementation, CST members used virtual meetings to build ‘rapport’ with general practice staff, supporting ‘upskilling’ and referrals to the CST. Leadership from the local project team and change manager provided guidance on how to work as a team and ‘iron out’ issues. Where available, shared space enhanced networking between CST members and facilitated joint appointments. Lack of administrative support for the CST impacted on clinical time. Conclusions: This study illustrates how the CST benefited from shared space, enhanced networking, and leadership. When developing strategies to support implementation of integrated care, the need for administrative support, the practicalities of co-location to facilitate joint appointments, and relative advantages of different delivery models should be considered.

Designing and Implementing a New Seniors Services Coordinator Role for Low-Income Housing: A Qualitative Study

Older adults living in social housing are disproportionally impacted by poverty, social isolation, and chronic health conditions that negatively impact their housing stability. In response, service coordination models of care that provide proactive case management have seen widespread adoption across low-income seniors housing communities. We examined the design and implementation of a new "seniors services coordinator" (SSC) role that was introduced by a social housing provider in Toronto, Canada. We conducted qualitative focus groups with tenants (n = 16), housing and policy staff (n = 16), and government-funded care coordinators (n = 16) to understand how the new SSC position formed relationships with tenants, assessed tenant needs and coordinated services, and built partnerships with government-funded system navigators. Since staff were assigned to specific buildings and had smaller caseloads, stakeholders felt that the SSC would be well positioned to build relationships of trust with tenants. Histories of mistrust, boundaries and time management, role conflicts, and system-level barriers, however, made it difficult for SSCs to fully carry out their role. Our findings highlight several design and implementation considerations that may impact the success of tenant-facing support staff such as SSCs, which can serve as a roadmap for other housing providers looking to implement similar initiatives.

Integrating Nutrition Actions in Service Delivery: The Practices of Frontline Workers in Uganda

BACKGROUND

Integrating nutrition actions into service delivery in different policy sectors is an increasing concern. Nutrition literature recognizes the discrepancies existing between policies as adopted and actual service delivery. This study applies a street-level bureaucracy (SLB) perspective to understand frontline workers' practices that enact or impede nutrition integration in services and the conditions galvanizing them.

METHODS

This qualitative exploratory study assesses the contextual conditions and practices of 45 frontline workers employed by the agriculture, health and community development departments in two Ugandan districts.

RESULTS

Frontline workers incur different demands and resources arising at societal, organizational, and individual level. Hence, they adopt nine co-existing practices that ultimately shape nutrition service delivery. Nutrition integration is accomplished through: (1) ritualizing task performance; (2) bundling with established services; (3) scheduling services on a specific day; and (4) piggybacking on services in other domains. Disintegration results from (5) non-involvement and (6) shifting blame to other entities. Other practices display both integrative and disintegrative effects: (7) creaming off citizens; (8) down prioritization by fixating on a few nutrition actions; and (9) following the bureaucratic 'jobs worth'. Integrative practices are driven mostly by donors.

CONCLUSION

Understanding frontline workers' practices is crucial for identifying policy solutions to sustain nutrition improvements. Sustaining services beyond timebound projects necessitates institutionalizing demands and resources within government systems. Interventions to facilitate effective nutrition service delivery should strengthen the integrative capacities of actors across different government levels. This includes investing in integrative leadership, facilitating frontline workers across sectors to provide nutrition services, and adjusting the nutrition monitoring systems to capture cross-sector data and support policy learning.

Developing evaluation capacities in integrated care projects: Lessons from a scientific support mission implemented in Belgium

The capacity of self-assessment, to learn from experience, to make information-based decisions, and to adapt over time are essential drivers of success for any project aiming at healthcare system change. Yet, many of those projects are managed by healthcare providers' teams with little evaluation capacity. In this article, we describe the support mission delivered by an interdisciplinary scientific team to 12 integrated care pilot projects in Belgium, mobilizing a set of tools and methods: a dashboard gathering population health indicators, a significant event reporting method, an annual report, and the development of a sustainable "learning community." The article provides a reflexive return on the design and implementation of such interventions aimed at building organizational evaluation capacity. Some lessons were drawn from our experience, in comparison with the broader evaluation literature: The provided support should be adapted to the various needs and contexts of the beneficiary organizations, and it has to foster experience-based learning and requires all stakeholders to adopt a learning posture. A long-time, secure perspective should be provided for organizations, and the availability of data and other resources is an essential precondition for successful work.

Using Normalisation Process Theory (NPT) to develop an intervention to improve referral and uptake rates for self-management education for patients with type 2 diabetes in UK primary care

Background

Referral and uptake rates of structured self-management education (SSME) for Type 2 diabetes (T2DM) in the UK are variable and relatively low. Research has documented contributing factors at patient, practitioner and organisational levels. We report a project to develop an intervention to improve referral to and uptake of SSME, involving an integrative synthesis of existing datasets and stakeholder consultation and using Normalisation Process Theory (NPT) as a flexible framework to inform the development process.

Methods

A three-phase mixed-methods development process involved: (1) synthesis of existing evidence; (2) stakeholder consultation; and (3) intervention design. The first phase included a secondary analysis of data from existing studies of T2DM SSME programmes and a systematic review of the literature on application of NPT in primary care. Influences on referral and uptake of diabetes SSME were identified, along with insights into implementation processes, using NPT constructs to inform analysis. This gave rise to desirable attributes for an intervention to improve uptake of SSME. The second phase involved engaging with stakeholders to prioritise and then rank these attributes, and develop a list of associated resources needed for delivery. The third phase addressed intervention design. It involved translating the ranked attributes into essential components of a complex intervention, and then further refinement of components and associated resources.

Results

In phase 1, synthesised analysis of 64 transcripts and 23 articles generated a longlist of 46 attributes of an embedded SSME, mapped into four overarching domains: valued, integrated, permeable and effectively delivered. Stakeholder engagement in phase 2 progressed this to a priority ranked list of 11. In phase 3, four essential components attending to the prioritised attributes and forming the basis of the intervention were identified: 1) a clear marketing strategy for SSME; 2) a user friendly and effective referral pathway; 3) new/amended professional roles; and 4) a toolkit of resources.

Conclusions

NPT provides a flexible framework for synthesising evidence for the purpose of developing a complex intervention designed to increase and reduce variation in uptake to SSME programmes in primary care settings.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12913-022-08553-7.

So Happy Together: A Review of the Literature on the Determinants of Effectiveness of Purpose-Oriented Networks in Health Care

While purpose-oriented networks are widely recognized as organizational forms to address wicked problems in health care such as increasing demands and expenditure, the associated literature is fragmented. We therefore reviewed empirical studies to identify the determinants of the effectiveness of these networks. Our search yielded 3,657 unique articles, of which 19 met our eligibility criteria. After backward snowballing and expert consultation, 33 articles were included. Results reveal no less than 283 determinants of effective health care networks. The majority of these determinants are processual and involving professionals from the operational level is particularly salient. In addition, most studies relate determinants to process outcomes (e.g., improved collaboration or sustainability of the network) and only a few to members' perception of whether the network attains its goals. We urge future research to adopt configurational approaches to identify which sets of determinants are associated with networks' ability to attain their goal of addressing wicked problems.

Values Underpinning Integrated, People-Centred Health Services: Similarities and Differences among Actor Groups Across Europe

Introduction:

In addition to the functional aspects of healthcare integration, an understanding of its normative aspects is needed. This study explores the importance of values underpinning integrated, people-centred health services, and examines similarities and differences among the values prioritised by actors across Europe.

Methods:

Explorative cross-sectional design with quantitative analysis. A questionnaire of 18 values was conducted across Europe. A total of 1,013 respondents indicated the importance of each of the values on a nine-point scale and selected three most important values. Respondents were clustered in four actor groups, and countries in four European sub-regions.

Results:

The importance scores of values ranged from 7.62 to 8.55 on a nine-point scale. Statistically significant differences among actor groups were found for ten values. Statistically significant differences across European sub-regions were found for six values. Our analysis revealed two clusters of values: ‘people related’ and ‘governance and organisation’.

Discussion and conclusion:

The study found that all 18 values in the set are considered important by the respondents. Additionally, it revealed distinctions in emphasis among the values prioritised by actor groups and across sub-regions. The study uncovered two clusters of values that contribute to a conceptually based definition of integrated, people-centred health services.

The role of leadership in times of systems disruption: a qualitative study of health and social care integration

OBJECTIVES

To understand whether and how effective integration of health and social care might occur in the context of major system disruption (the COVID-19 pandemic), with a focus on how the initiative may overcome past barriers to integration.

DESIGN

Rapid, descriptive case study approach with deviant case sampling to gather and analyse key informant interviews and relevant archival documents.

SETTING

The innovation ('COVID-19 Protect') took place in Norfolk and Waveney, UK, and aimed to foster integration across highly diverse organisations, capitalising on existing digital technology to proactively identify and support individuals most at risk of severe illness from COVID-19.

PARTICIPANTS

Twenty-six key informants directly involved with project conceptualisation and early implementation. Participants included clinicians, executives, digital/information technology leads, and others. Final sample size was determined by theoretical saturation.

RESULTS

Four primary recurrent themes characterised the experiences of diverse team members in the project: (1) ways of working that supported rapid collaboration, (2) leveraging diversity and clinician input for systems change, (3) allowing for both central control and local adaptation and (4) balancing risk taking and accountability.

CONCLUSIONS

This rapid case study underscores the role of leadership in large systems change efforts, particularly in times of major disruption. Project leadership overcame barriers to integration highlighted by prior studies, including engaging with aversion to clinical/safety risk, fostering distributed leadership and developing shared organisational practices for data sharing and service delivery. These insights offer considerations for future efforts to support strategic integration of health and social care.

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

OBJECTIVES

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

METHODS

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

RESULTS

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

CONCLUSIONS

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

A framework to support the progressive implementation of integrated team-based care for the management of COPD: a collective case study

Background

In Canada, there is widespread agreement about the need for integrated models of team-based care. However, there is less agreement on how to support the scale-up and spread of successful models, and there is limited empirical evidence to support this process in chronic disease management. We studied the supporting and mitigating factors required to successfully implement and scale-up an integrated model of team-based care in primary care.

Methods

We conducted a collective case study using multiple methods of data collection including interviews, document analysis, living documents, and a focus group. Our study explored a team-based model of care for chronic obstructive pulmonary disease (COPD) known as Best Care COPD (BCC) that has been implemented in primary care settings across Southwestern Ontario. BCC is a quality improvement initiative that was developed to enhance the quality of care for patients with COPD. Participants included healthcare providers involved in the delivery of the BCC program.

Results

We identified several mechanisms influencing the scale-up and spread of BCC and categorized them as Foundational (e.g., evidence-based program, readiness to implement, peer-led implementation team), Transformative (adaptive process, empowerment and collaboration, embedded evaluation), and Enabling Mechanisms (provider training, administrative support, role clarity, patient outcomes). Based on these results, we developed a framework to inform the progressive implementation of integrated, team-based care for chronic disease management. Our framework builds off our empirical work and is framed by local contextual factors.

Conclusions

This study explores the implementation and spread of integrated team-based care in a primary care setting. Despite the study’s focus on COPD, we believe the findings can be applied in other chronic disease contexts. We provide a framework to support the progressive implementation of integrated team-based care for chronic disease management.

"We could be good partners if we work together": the perspectives of health and social service providers on the barriers to forming collaborative partnerships with social housing providers for older adults

BACKGROUND

Many older adults are aging-at-home in social housing. However, the lack of integration between housing and health services makes it difficult for older tenants to access needed supports. We examined barriers and facilitators health and social service providers face providing on-site services to older tenants.

METHODS

We conducted semi-structured qualitative interviews and focus groups with health and social service professionals (n = 58) in Toronto, Canada who provide community programs in support of older tenants who live in non-profit, rent-geared-to-income social housing. Interviews examined the barriers they faced in providing on-site services to older tenants.

FINDINGS

Service providers strongly believed that collaboration with on-site housing staff led to better health and housing outcomes for older tenants. Despite the recognized benefits of partnering with housing staff, service providers felt that their ability to work effectively in the building was dependent on the staff (particularly the superintendent) assigned to that building. They also identified other barriers that made it difficult to work collaboratively with the housing provider, including staffing challenges such as high staff turnover and confusion about staff roles, a lack of understanding among housing staff about the link between housing and health, challenges sharing confidential information across sectors, and complex and inefficient partnership processes.

CONCLUSION

Older adult tenants are increasingly vulnerable and in need of supports but the housing provider has a long history of ineffective partnerships with service providers driven by complex and inefficient staffing models, and an organizational culture that questions the role of and need for partnerships. Findings highlight the need for more effective integration of housing and health services. Simplified processes for establishing partnerships with service agencies and more opportunities for communication and collaboration with housing staff would ensure that services are reaching the most vulnerable tenants.

Healthcare stakeholders' perspective on barriers to integrated care in Switzerland: Results from the open-ended question of a nationwide survey

OBJECTIVE

We aimed to identify the main barriers to integrated care (IC) as reported by healthcare stakeholders from various linguistic regions and health system specificities, according to their reality of practice.

METHODS

Information was gathered through an open-ended question from a national survey conducted in Switzerland in 2019. Responses were analysed qualitatively with the IRaMuTeQ software.

RESULTS

Answers from 410 respondents were obtained. Respondents reported barriers at two levels: the system and professional level. Threat to financial benefits, concerns for patient data sharing and tensions between quality of care and benefits for patients versus costs were mentioned at the professional level, in their activity and in patient care. At the system level, limitations at the political level due to federalism and the lack of support and training for professionals were important barriers, in addition to the lack of recognition and compensation for professionals and the fragmented functioning of the health care system.

CONCLUSION

Our study underlines the importance of implementing innovative funding strategies and reimbursement schemes, as well as political willingness to move towards IC. The alignment between federal policies and cantonal specificities also appears as necessary to achieve involvement of professionals, promote integration of services and coordination of professionals for continuous and efficient care.

Transformational Change in maternity services in England: a longitudinal qualitative study of a national transformation programme 'Early Adopter'

BACKGROUND

Large system transformation in health systems is designed to improve quality, outcomes and efficiency. Using empirical data from a longitudinal study of national policy-driven transformation of maternity services in England, we explore the utility of theory-based rules regarding 'what works' in large system transformation.

METHODS

A longitudinal, qualitative case study was undertaken in a large diverse urban setting involving multiple hospital trusts, local authorities and other key stakeholders. Data was gathered using interviews, focus groups, non-participant observation, and a review of key documents in three phases between 2017 and 2019. The transcripts of the individual and focus group interviews were analysed thematically, using a combined inductive and deductive approach drawing on simple rules for large system transformation derived from evidence synthesis and the findings are reported in this paper.

RESULTS

Alignment of transformation work with Best et al's rules for 'what works' in large system transformation varied. Interactions between the rules were identified, indicating that the drivers of large system transformation are interdependent. Key challenges included the pace and scale of change that national policy required, complexity of the existing context, a lack of statutory status for the new 'system' limiting system leaders' power and authority, and concurrent implementation of a new overarching system alongside multifaceted service change.

CONCLUSIONS

Objectives and timescales of transformation policy and plans should be realistic, flexible, responsive to feedback, and account for context. Drivers of large system transformation appear to be interdependent and synergistic. Transformation is likely to be more challenging in recently established systems where the basis of authority is not yet clearly established.

What does Success Look Like for Leaders of Integrated Health and Social Care Systems? a Realist Review

Introduction

Health and social care services in England are moving towards greater integration, yet little is known about how leadership of integrated care teams and systems can be supported and improved. This realist review explores what works about the leadership of integrated care teams and systems, for whom, in what circumstances and why.

Methods

A realist synthesis approach was undertaken in 2020 to explore English language literature on the leadership of integrated care teams and systems, complemented by ongoing stakeholder consultation.

Results

Evidence was identified for seven potentially important components of leadership in integrated care teams and systems: 'inspiring intent to work together'; 'creating the conditions'; 'balancing multiple perspectives'; 'working with power'; 'taking a wider view'; 'a commitment to learning and development' and 'clarifying complexity'.

Discussion

Research into the leadership of integrated care teams and systems is limited, with ideas often reverting to existing framings of leadership, where teams and organisations are less complex. Research also often focuses on the importance of who the leader is rather than what they do.

Conclusion

This review has generated new perspectives on the leadership of integrated care teams and systems that can be built upon, developed, and tested further.

Integrated Care in England - what can we Learn from a Decade of National Pilot Programmes?

Introduction

For more than a decade the English NHS has pursued integrated care through three national pilot programmes. The independent evaluators of these programmes here identify several common themes that inform the development of integrated care.

Description

The three pilot programmes shared the aim of better coordination between hospital and community-based health services and between health and social care. Each programme recruited local pilot sites that designed specific interventions to support inter-professional and inter-organisational collaboration.The pilots were highly heterogenous and results varied both within and between the three programmes. While staff were generally positive about their achievements, pilots had mixed success especially in reducing unplanned hospital admissions. Common facilitators to achieving pilots' objectives included effective senior leadership and shared values, simple interventions and additional funding. Barriers included short timescales, poor professional engagement, information and data sharing problems, and conflicts with changing national policy.

Discussion

There was little stable or shared understanding of what 'integrated care' meant resulting in different practices and priorities. An increasing focus on reducing unplanned hospital use among national sponsors created a mismatch in expectations between local and national actors.

Conclusion

Pilots in all three national programmes made some headway against their objectives but were limited in their impact on unplanned hospital admissions.

What Makes Integration of Chronic Care so Difficult? A Macro-Level Analysis of Barriers and Facilitators in Belgium

Introduction

Although many countries have been implementing integrated care, the scale-up remains difficult. Macro-level system barriers play an important role. By selecting three key policies, which have implemented integrated care in Belgium over the last 10 years, we aim to go beyond the identification of their specific barriers and facilitators to obtain an overarching generic view.

Methods

27 participants were purposefully selected, to include all important stakeholders involved on the macro-level in chronic care in Belgium. Semi-structured interviews were guided by a timeline of policies and an inductive thematic analysis was performed.

Results

Barriers and facilitators were identified on both health care and policy level. The major factors restraining the scale-up of integrated care are the fee-for-service reimbursement system, limited data sharing and the fragmentation of responsibilities between different levels of government. Remarkably, these factors strongly interact.

Discussion

This paper highlights the importance of homogenization of responsibilities of governments regarding integrated care and the interdependency of policy and health care system factors. A whole system change is needed instead of the current Belgian model of prolonged search for common ground between conflicting opinions. Political commitment and citizen participation will be crucial.

Barriers and facilitators for implementation of a complex health services intervention in long-term care homes: a qualitative study using focus groups

Background

With rising numbers of elderly people living in nursing homes in Germany, the need for on-site primary care is increasing. A lack of primary care in nursing homes can lead to unnecessary hospitalization, higher mortality, and morbidity in the elderly. The project CoCare (“coordinated medical care”) has therefore implemented a complex health intervention in nursing homes, using inter alia, regular medical rounds, a shared patient medical record and medication checks, with the aim of improving the coordination of medical care. This study reports upon the results of a qualitative study assessing the perceived barriers and facilitators of the implementation of CoCare by stakeholders.

Methods

Focus group interviews were held between October 2018 and November 2019 with nurses, general practitioners and GP’s assistants working or consulting in a participating nursing home. A semi-structured modular guideline was used to ask participants for their opinion on different aspects of CoCare and which barriers and facilitators they perceived. Focus groups were analyzed using qualitative content analysis.

Results

In total, N = 11 focus group interviews with N = 74 participants were conducted. We found six themes describing barriers and facilitators in respect of the implementation of CoCare: understaffing, bureaucracy, complexity, structural barriers, financial compensation, communication and collaboration. Furthermore, participants described the incorporation of the intervention into standard care.

Conclusion

Barriers perceived by stakeholders are well known in the literature (e.g. understaffing and complexity). However, CoCare provides a good structure to overcome barriers and some barriers will dissolve after implementation into routine care (e.g. bureaucracy). In contrast, especially communication and collaboration were perceived as facilitators in CoCare, with the project being received as a team building intervention itself.

Trial registration

WHO UTN: U1111–1196-6611; DRKS-ID: DRKS00012703 (Date of Registration in DRKS: 2017 Aug 23).

Supplementary Information

The online version contains supplementary material available at 10.1186/s12877-021-02579-y.

Implementation and Early Impacts of an Integrated Care Pilot Program in China: Case Study of County-level Integrated Health Organizations in Zhejiang Province

BACKGROUND

One of the most noticeable integrated care-related policies in China is the growth and proliferation of County-level Integrated Health Organizations (CIHOs), which take over a set of primary healthcare institutions to form an integrated delivery network in order to achieve an ordered hierarchical delivery system by strengthening primary care.

OBJECTIVES

This paper presents emerging findings from an ongoing evaluation of the early impacts of the demonstrator site, Deqing CIHO, in Zhejiang Province, in order to examine the extent to which the implementation has achieved its core objectives: (1) establishing the hierarchical referral system, (2) capacity building of primary healthcare providers, and (3) reducing the costs.

DESIGN

This case study was conducted to determine institutional and managerial processes.

SETTINGS

Data were collected and analyzed at the CIHO and county level. A structured questionnaire was used for data collection.

PRIMARY AND SECONDARY OUTCOME MEASURES

Indicators were selected from the existing database of the county health system and arranged into three segments to assess (1) service utilization among each level of care; (2) capacity-building progress for primary care centers, (3) cost-related indicators for both levels of care.

RESULTS

Service utilization data show that one year after CIHO implementation, the proportion of patients who chose to get inpatient care outside of the county decreased from 27.3% to 24.5%. Hospital admissions were retrieved from outside the county, while service volume slightly shifted from hospitals to primary care sites. Capacity-building indicators for township health centers show that 6 out of 12 items showed better performance compared to the national average growth rate, and a moderated growth rate appeared in terms of per capita cost.

CONCLUSION

Progress evaluation results from Deqing CIHO indicated some positive effects on three main outcomes, which reveal the potential of CIHOs in not only strengthening primary care but also controlling cost as a result of early implementation. Further emphases of evaluation are required to determine the impacts on the quality and experience of care that are estimated using claim-based data at the individual level.

Evaluation of the Impact and Implementation of Social Prescribing in Primary Healthcare Units in Lisbon: A Mixed-Methods Study Protocol

BACKGROUND

Social Prescribing (SP) is an intervention to link users of the primary healthcare services to non-clinical organizations based on the community to tackle social determinants of health. Despite the potential benefits of SP, the effectiveness of this complex intervention remains uncertain. This paper presents the study protocol of the evaluation of the first SP project in Portugal.

METHODS

A mixed-methods study will be conducted to evaluate the SP project. For the quantitative component, a longitudinal, prospective study with a pre-post design will be performed. Data on patients referred to SP will be collected in four different points in time throughout the intervention, using questionnaires on patients' health status and sociodemographic characteristics, and scales on patients' well-being, quality of life and activation. The secondary data will be collected using patients' medical records and SP's forms about the referral and social responses elaborated within the intervention. Semi-structured interviews with patients and focus groups with stakeholders will be conducted to assess experiences of participation and improvement suggestions on SP.

CONCLUSION

Comprehensive and complementary evidence will provide insights and learning for the implementation of future SP interventions. This can contribute to inform policy and practice, and to increase investment in social prescribing interventions.

Integrating primary care and social services for older adults with multimorbidity: a qualitative study

Background

Growing demand from an increasingly ageing population with multimorbidity has resulted in complex health and social care needs requiring more integrated services. Integrating primary care with social services could utilise resources more efficiently, and improve experiences for patients, their families, and carers. There is limited evidence on progress including key barriers to and drivers of integration to inform large-scale national change.

Aim

To elicit stakeholder views on drivers and barriers of integrated primary care and social services, and highlight opportunities for successful implementation.

Design and setting

A qualitative interview study.

Method

Semi-structured interviews with maximum variation sampling to capture stakeholder views across services and professions.

Results

Thirty-seven interviews were conducted across England with people including GPs, nurses, social care staff, commissioners, local government officials, voluntary and private sector workers, patients, and carers. Drivers of integration included groups of like-minded individuals supported by good leadership, expanded interface roles to bridge gaps between systems, and co-location of services. Barriers included structural and interdisciplinary tension between professions, organisational self-interest, and challenges in record sharing.

Conclusion

Drivers and barriers to integration identified in other contexts are also present in primary care and social services. Benefits of integration are unlikely to be realised if these are not addressed in the design and execution of new initiatives. Efforts should go beyond local- and professional-level change to include wider systems- and policy-level initiatives. This will support a more systems-wide approach to integrated care reform, which is necessary to meet the complex and growing needs of an ageing multimorbid population.

Making a difference: workforce skills and capacity for integrated care

Purpose

The aim of this action research was to explore, from a workforce and a patient/carer perspective, the skills and the capacity required to deliver integrated care and to inform future workforce development and planning in a new integrated care system in England.

Design/methodology/approach

Semi-structured interviews and focus groups with primary, community, acute care, social care and voluntary care, frontline and managerial staff and with patients and carers receiving these services were undertaken. Data were explored using framework analysis.

Findings

Analysis revealed three overarching themes: achieving teamwork and integration, managing demands on capacity and capability and delivering holistic and user-centred care. An organisational development (OD) process was developed as part of the action research process to facilitate the large-scale workforce changes taking place.

Research limitations/implications

This study did not consider workforce development and planning challenges for nursing and care staff in residential, nursing care homes or domiciliary services. This part of the workforce is integral to the care pathways for many patients, and in line with the current emerging national focus on this sector, these groups require further examination. Further, data explore service users' and carers' perspectives on workforce skills. It proved challenging to recruit patient and carer respondents for the research due to the nature of their illnesses.

Practical implications

Many of the required skills already existed within the workforce. The OD process facilitated collaborative learning to enhance skills; however, workforce planning across a whole system has challenges in relation to data gathering and management. Ensuring a focus on workforce development and planning is an important part of integrated care development.

Social implications

This study has implications for social and voluntary sector organisations in respect of inter-agency working practices, as well as the identification of workforce development needs and potential for informing subsequent cross-sector workforce planning arrangements and communication.

Originality/value

This paper helps to identify the issues and benefits of implementing person-centred, integrated teamworking and the implications for workforce planning and OD approaches.

Patient experiences of integrated care within the United Kingdom: A systematic review

Introduction

Integrated care and patient experience are central to the coordination and delivery of high quality health and social care in the UK, but their joint application is poorly understood. This systematic review aimed to gain an understanding of patient experience within current integrated care services in the UK, and specifically, whether they reflect person-centred coordinated care (PCCC).

Methods

Following PRISMA, electronic databases (ProQuest, EBSCO and Cochrane Library) were searched from 2012 to 2019 for primary, peer-reviewed literature. Papers were included where patients’ or carers’ experiences of integrated care were reported. Papers were excluded where they focused on acute integrated care interventions, measured experience via satisfaction scores only, or findings lacked sufficient depth to answer the research question. Quality was assessed using Mixed Methods Appraisal Tool, and findings synthesised using a framework approach, incorporating the Rainbow Model of Integrated Care and Measuring Integrated Care Patient Framework.

Results

Sixteen studies were included. Person-centred and shared responsibility experiences were most often discussed. Experiences were not always described as positive and some patients experienced a lack of PCCC. Clinical, professional/organisational and functional integration processes were associated with experiencing domains of PCCC.

Discussion

People with complex needs experience a lack of coordination across teams and wider community resources, and limited associations were made between integration processes and patient experience. Further research which gives context to individual experience, provides greater detail of integration processes and utilises validated patient experience measures of PCCC is required to understand the association between integration processes and domains of PCCC.

Implementation of sustainable complex interventions in health care services: the triple C model

BACKGROUND

The changing and evolving healthcare environment means organisations are under increasing pressure to deliver value-based, high quality care to patients through enabling access, reducing costs and improving outcomes. These factors result in an increased pressure to deliver efficient and beneficial interventions to improve patient care and support sustainability beyond the scope of the implementation of such interventions. Additionally, the literature highlights the importance of coordination, cooperation and working together across areas is critical to achieving implementation success. This paper discusses the development of a triple C model for implementation that supports sustainability of complex interventions in health care services.

METHODS

In order to develop the proposed implementation model, we adapted the formal tradition of theory building that is described in sociology. Firstly, we conducted a review of the literature on complex interventions and the available implementation models used to embed these interventions to identify the key aspects relating to successful implementation. Secondly, we devised a framework that encompassed these findings into a simple and workable model that can be easily embedded into everyday practice. This proposed model uses clear, systemic explanation, adds to the current knowledge in this area and is fit for purpose, providing healthcare workers with a simple easy-to-follow framework to embed practice change.

RESULTS

A three-stage implementation model was devised based on the findings of the literature and named the Triple C model (Consultation, Collaboration and Consolidation). The three stages are interconnected and overlap to support sustainability is considered at all levels of the project ensuring its greater success. This model considers the sustainability within any implementation project. Sustainability of interventions are a key consideration for continuous and successful change in any health care organisation. A set of criteria were developed for each of the three stages to support adaptability and sustainment of interventions are maintained throughout the life of the intervention.

CONCLUSION

Ensuring sustainability of interventions requires continuing effort and embedding the need for sustainability throughout all stages of an implementation project. The Triple C model offers a new approach for healthcare clinicians to support sustainability of organizational change.

Understanding Young People and Their Care Providers' Perceptions and Experiences of Integrated Care Within a Tertiary Paediatric Hospital Setting, Using Interpretive Phenomenological Analysis

Introduction:

Benefits of integrated care include improved health outcomes and more satisfaction with experiences of care for consumers. For children and young people with chronic and complex health conditions, their care may be fragmented due to the multitude of healthcare providers involved. This paper describes the experiences of integrated care in a paediatric tertiary hospital.

Theory and methods:

Using an Interpretive Phenomenological Analysis approach, semi-structured interviews were conducted with children and young people, their parents and healthcare providers to explore stakeholders’ integrated care experiences.

Results:

Nineteen interviews were completed (6 children and young people, 7 parents and 6 healthcare providers) and transcribed verbatim. Two recurrent themes were applicable across the three cohorts: ‘agency and empowerment’ and ‘impact of organisational systems, supports and structures’.

Discussion and conclusion:

Stakeholders’ experiences of integrated care highlighted the need to examine the discrepancies between healthcare strategies, policies and service delivery within a complex, and often inflexible organisational structure. Power imbalance and family agency (including directly with children and young people) needs to be addressed to support the implementation of integrated care.

Implementing post-discharge care following acute kidney injury in England: a single-centre qualitative evaluation

OBJECTIVES

We sought to understand the factors influencing the implementation of a primary care intervention to improve post-discharge care following acute kidney injury (AKI).

DESIGN

Qualitative study using semi-structured interviews and thematic analysis.

SETTING

General practices in one Clinical Commissioning Group area in England.

PARTICIPANTS

A total of 18 healthcare staff took part in interviews. Participants were practice pharmacists, general practitioners, practice managers and administrators involved in implementing the intervention.

RESULTS

We identified three main factors influencing implementation: differentiation of the new intervention from other practice work; development of skill mix and communication across organisations. Overall, post-AKI processes of care were deemed straightforward to embed into existing practice. However, it was also important to separate the intervention from other work in general practice. Dedicating staff time to proactively identify AKI on discharge summaries and to coordinate the provision of care enabled implementation of the intervention. The post-AKI intervention provided an opportunity for practice pharmacists to expand their primary care role. Working in a new setting also brought challenges; time to develop trusting relationships including an understanding of boundaries of clinical expertise influenced pharmacists' roles. Unclear and inconsistent information on discharge summaries contributed to concerns about additional work in primary care.

CONCLUSIONS

The research highlights challenges around post-discharge management in the primary care context. Coordination and communication were key factors for improving follow-up care following AKI. Further consideration is required to understand patient experiences of the interface between secondary and primary care. The issues pertaining to discharge care following AKI are relevant to practitioners and commissioners as they work to improve transitions of care for vulnerable patient populations.

Development of transferability guidance for integrated care models with special focus on Central and Eastern European countries

AIM

To develop pragmatic recommendations for Central and Eastern European (CEE) policymakers about transferability assessment of integrated care models established in higher income European Union (EU) countries.

METHODS

Draft recommendations were developed based on Horizon 2020-funded SELFIE project deliverables related to 17 promising integrated care models for multimorbid patients throughout Europe, as well as on an online survey among CEE stakeholders on the relevance of implementation barriers. Draft recommendations were discussed at the SELFIE transferability workshop and finalized together with 22 experts from 12 CEE countries.

RESULTS

Thirteen transferability recommendations are provided in three areas. Feasibility of local implementation covers the identification and prioritization of implementation barriers and proposals for potential solutions. Performance measurement of potentially transferable models focuses on the selection of models with proven benefits and assurance of performance monitoring. Transferability of financing methods for integrated care explores the relevance of financing methodologies and planning of adequate initial and long-term financing.

CONCLUSIONS

Implementation of international integrated care models cannot be recommended without evidence on its local feasibility or scientifically sound and locally relevant performance assessment in the country of origin. However, if the original financing method is not transferable to the target region, development of a locally relevant alternative financing method can be considered.

Measuring the benefits of the integration of health and social care: qualitative interviews with professional stakeholders and patient representatives

BACKGROUND

Integrated care has the potential to ease the increasing pressures faced by health and social care systems, however, challenges around measuring the benefits for providers, patients, and service users remain. This paper explores stakeholders' views on the benefits of integrated care and approaches to measuring the integration of health and social care.

METHODS

Twenty-five semi-structured qualitative interviews were conducted with professional stakeholders (n = 19) and patient representatives (n = 6). Interviews focused on the benefits of integrated care and how it should be evaluated. Data was analysed using framework analysis.

RESULTS

Three overarching themes emerged from the data: (1) integrated care and its benefits, with stakeholders defining it primarily from the patient's perspective; (2) potential measures for assessing the benefits of integration in terms of system effects, patient experiences, and patient outcomes; and (3) broader considerations around the assessment of integrated care, including the use of qualitative methods.

CONCLUSIONS

There was consensus among stakeholders that patient experiences and outcomes are the best measures of integration, and that the main measures currently used to assess integration do not directly assess patient benefits. Validated health status measures are readily available, however, a substantial shift in practices is required before their use becomes commonplace.

More that unites us than divides us? A qualitative study of integration of community health and social care services

Background

The integration of community health and social care services has been widely promoted nationally as a vital step to improve patient centred care, reduce costs, reduce admissions to hospital and facilitate timely and effective discharge from hospital. The complexities of integration raise questions about the practical challenges of integrating health and care given embedded professional and organisational boundaries in both sectors. We describe how an English city created a single, integrated care partnership, to integrate community health and social care services. This led to the development of 12 integrated neighbourhood teams, combining and co-locating professionals across three separate localities. The aim of this research is to identify the context and the factors enabling and hindering integration from a qualitative process evaluation.

Methods

Twenty-four semi-structured interviews were conducted with equal numbers of health and social care staff at strategic and operational level. The data was subjected to thematic analysis.

Results

We describe three key themes: 1) shared vision and leadership; 2) organisational factors; 3) professional workforce factors. We found a clarity of vision and purpose of integration throughout the partnership, but there were challenges related to the introduction of devolved leadership. There were widespread concerns that the specified outcome measures did not capture the complexities of integration. Organisational challenges included a lack of detail around clinical and service delivery planning, tensions around variable human resource practices and barriers to data sharing. A lack of understanding and trust meant professional workforce integration remained a key challenge, although integration was also seen as a potential solution to engender relationship building.

Conclusions

Given the long-term national policy focus on integration this ambitious approach to integrate community health and social care has highlighted implications for leadership, organisational design and inter-professional working. Given the ethos of valuing the local assets of individuals and networks within the new partnership we found the integrated neighbourhood teams could all learn from each other. Many of the challenges of integration could benefit from embracing the inherent capabilities across the integrated neighbourhood teams and localities of this city.

Perceptive Dialogue for Linking Stakeholders and Units During Care Transitions - A Qualitative Study of People with Stroke, Significant Others and Healthcare Professionals in Sweden

INTRODUCTION

Care transitions are a complex set of actions that risk poor quality outcomes for patients and their significant others. This study explored the transition process between hospital and continued rehabilitation in the home. The process is explored from the perspectives of people with stroke, significant others and healthcare professionals in Stockholm, Sweden.

METHOD

Focus group interviews (n = 10), semi-structured individual interviews (n = 23) and interviews in dyad (n = 4) were conducted with healthcare professionals, people with stroke and significant others, altogether 71 participants. Data was collected and analyzed using Grounded Theory.

RESULTS

One core category "Perceptive dialogue for a coordinated transition", and two categories "Synthesis of parallel processes for common understanding" and "The forced transformation from passive attendant to uninformed agent" emerged from the analysis. The transition consisted of several parallel processes which made it difficult for the stakeholders to get a common understanding of the transition as a whole. Enabling a perceptive dialogue was as a prerequisite for the creation of a common understanding of the care transition.

CONCLUSION

This study elucidates that a perceptive dialogue with patients/significant others as well as within and across organizations is part of a coordinated and person-centred transition. There is an extensive need for increased involvement of patients and significant others regarding dialogue about health conditions, procedures at the hospital and preparation for self-management after discharge.

Financial Barriers Decrease Benefits of Interprofessional Collaboration within Integrated Care Programs: Results of a Nationwide Survey

Introduction

Interprofessional collaboration (IPC) is a key ingredient of integrated care. Nevertheless, IPC benefits remain unclear and its implementation within integrated care initiatives is not straightforward. In this study, we first explored whether IPC was associated with organisational and patient care improvements in Swiss integrated care initiatives; we then investigated the effect of various barriers faced by these initiatives, on these associations.

Methods

Self-reported data from 153 integrated care initiatives included in the Swiss Integrated Care Survey was used. We conducted moderated mediation analyses in which patient care improvements were the outcome, the degree of IPC implementation was the predictor, organisational improvements were the mediator, and professional, patient and financial barriers to integrated care, the moderators.

Results

IPC implementation within integrated care was associated with organisational improvements, which in turn were associated with patient care improvements; this path no longer existed when financial barriers to integrated care were considered.

Conclusion

Organisational improvements should be considered a priority when implementing IPC within integrated care initiatives since patient care improvements due to IPC can be expected mainly when organisational aspects are improved. More importantly, the role of financial barriers should be acknowledged, and actions taken to reduce their impact on integrated care.