Exploring the implementation and evaluation of a distributed leadership model within a Scottish, integrated health and care context

Background

Health and care systems are facing unprecedented challenges, exacerbated by wicked issues that have no single solution and are complex to solve. It has recently been suggested that how such systems are structured (ie, in hierarchies) may not be the most effective approach to tackling these issues. Increasing calls have been made for senior leaders within these systems to adopt structures that emphasise leadership as a distributed endeavour as an approach to foster greater collaboration and enhance innovation. Here, the implementation and evaluation of a distributed leadership model within a Scottish, integrated health and care context is described.

Methods

Aberdeen City Health & Social Care Partnership’s leadership team (N=17 as of time in 2021) have been operating in a flat, distributed leadership model since 2019. The model is characterised by a 4P approach (professional; performance; personal development and peer support). The evaluation approach was a national healthcare survey administered at three time points and a further evaluation questionnaire specifically assessing constructs associated with high-performing teams.

Results

Results indicated that staff satisfaction increased 3 years into the flat structure (mean score=7.7/10) compared with the traditional, hierarchal structure (mean score=5.18/10). Respondents were agreeable that the model had increased autonomy (67% agreeableness); collaboration (81% agreeableness) and creativity (67% agreeableness)

Conclusions

Overall, results suggest that a flat, distributed leadership model is preferable to a traditional, hierarchal leadership model within this context. Future work should aim to explore the impact that this model has on the effectiveness of planning and delivering integrated care services.

Interventions for reducing sedentary behaviour in community-dwelling older adults

BACKGROUND

Older adults are the most sedentary segment of society, often spending in excess of 8.5 hours a day sitting. Large amounts of time spent sedentary, defined as time spend sitting or in a reclining posture without spending energy, has been linked to an increased risk of chronic diseases, frailty, loss of function, disablement, social isolation, and premature death.

OBJECTIVES

To evaluate the effectiveness of interventions aimed at reducing sedentary behaviour amongst older adults living independently in the community compared to control conditions involving either no intervention or interventions that do not target sedentary behaviour.

SEARCH METHODS

We searched the Cochrane Central Register of Controlled Trials (CENTRAL), MEDLINE, Embase, CINAHL, PsycINFO, PEDro, EPPI-Centre databases (Trials Register of Promoting Health Interventions (TRoPHI) and the Obesity and Sedentary behaviour Database), WHO ICTRP, and ClinicalTrials.gov up to 18 January 2021. We also screened the reference lists of included articles and contacted authors to identify additional studies.

SELECTION CRITERIA

We included randomised controlled trials (RCTs) and cluster-RCTs. We included interventions purposefully designed to reduce sedentary time in older adults (aged 60 or over) living independently in the community. We included studies if some of the participants had multiple comorbidities, but excluded interventions that recruited clinical populations specifically (e.g. stroke survivors).

DATA COLLECTION AND ANALYSIS

Two review authors independently screened titles and abstracts and full-text articles to determine study eligibility. Two review authors independently extracted data and assessed risk of bias. We contacted authors for additional data where required. Any disagreements in study screening or data extraction were settled by a third review author.

MAIN RESULTS

We included seven studies in the review, six RCTs and one cluster-RCT, with a total of 397 participants. The majority of participants were female (n = 284), white, and highly educated. All trials were conducted in high-income countries. All studies evaluated individually based behaviour change interventions using a combination of behaviour change techniques such as goal setting, education, and behaviour monitoring or feedback. Four of the seven studies also measured secondary outcomes. The main sources of bias were related to selection bias (N = 2), performance bias (N = 6), blinding of outcome assessment (N = 2), and incomplete outcome data (N = 2) and selective reporting (N=1). The overall risk of bias was judged as unclear. Primary outcomes The evidence suggests that interventions to change sedentary behaviour in community-dwelling older adults may reduce sedentary time (mean difference (MD) -44.91 min/day, 95% confidence interval (CI) -93.13 to 3.32; 397 participants; 7 studies; I² = 73%; low-certainty evidence). We could not pool evidence on the effect of interventions on breaks in sedentary behaviour or time spent in specific domains such as TV time, as data from only one study were available for these outcomes. Secondary outcomes We are uncertain whether interventions to reduce sedentary behaviour have any impact on the physical or mental health outcomes of community-dwelling older adults. We were able to pool change data for the following outcomes. • Physical function (MD 0.14 Short Physical Performance Battery (SPPB) score, 95% CI -0.38 to 0.66; higher score is favourable; 98 participants; 2 studies; I² = 26%; low-certainty evidence). • Waist circumference (MD 1.14 cm, 95% CI -1.64 to 3.93; 100 participants; 2 studies; I² = 0%; low-certainty evidence). • Fitness (MD -5.16 m in the 6-minute walk test, 95% CI -36.49 to 26.17; higher score is favourable; 80 participants; 2 studies; I² = 29%; low-certainty evidence). • Blood pressure: systolic (MD -3.91 mmHg, 95% CI -10.95 to 3.13; 138 participants; 3 studies; I² = 73%; very low-certainty evidence) and diastolic (MD -0.06 mmHg, 95% CI -5.72 to 5.60; 138 participants; 3 studies; I² = 97%; very low-certainty evidence). • Glucose blood levels (MD 2.20 mg/dL, 95% CI -6.46 to 10.86; 100 participants; 2 studies; I² = 0%; low-certainty evidence). No data were available on cognitive function, cost-effectiveness or adverse effects.

AUTHORS' CONCLUSIONS

It is not clear whether interventions to reduce sedentary behaviour are effective at reducing sedentary time in community-dwelling older adults. We are uncertain if these interventions have any impact on the physical or mental health of community-dwelling older adults. There were few studies, and the certainty of the evidence is very low to low, mainly due to inconsistency in findings and imprecision. Future studies should consider interventions aimed at modifying the environment, policy, and social and cultural norms. Future studies should also use device-based measures of sedentary time, recruit larger samples, and gather information about quality of life, cost-effectiveness, and adverse event data.

Staff views of a hospital at home model implemented in a Scottish care setting

Purpose

Demographic and financial challenges mean prioritising a shift in healthcare provision from acute to community settings. One well-evidenced model encapsulating this is 'hospital at home', however limited research has examined staffs' views on its implementation, which may inform service development and increase job satisfaction. The aim within was to explore the staff perspective of implementing a 'hospital at home' model in a Scottish care setting which can inform service provision and ultimately increase job satisfaction.

Methods

The 'Acute Care @ Home' (AC@H) service had a multi-disciplinary team. Referrals were predominantly received from a geriatric hospital ward. Inclusion criteria were older adults with geriatric syndromes and who required care input for a duration between one to seven days. In-depth staff interviews (N = 13) were conducted and analysed thematically to understand barriers and facilitators to implementation. These were supplemented with questionnaires assessing constructs of interest including training, communication and overall satisfaction.

Results

Several themes urged from our study: inter-team and intra-team collaboration, service development and operation, and scaling considerations. High job satisfaction was reported (mean score 73%), particularly due to a perceived non-hierarchical team structure and inclusive management style. Staff attributed positive outcomes through better identifying patients' needs at home compared to in hospital. Continuity of care facilitated rapport building. Recruitment challenges restricted the acuity and volume of patients the team were able to care for.

Conclusions

This qualitative methodology could be useful for future implementation of intermediate care resources for the future health and care system building. Patient assessments at home, as opposed to in hospital, in conjunction with care continuity by staff, may mitigate against hospital risks and better facilitate reablement. Where recruitment challenges are present, agile models of care delivery should be considered.

Evaluation of an unscheduled care model delivered by advanced nurse practitioners in a primary-care setting

BACKGROUND

Considering new models of delivery may help reduce increasing pressures on primary care. One potentially viable solution is utilising Advanced Practitioners to deliver unscheduled afternoon visits otherwise undertaken by a General Practitioner (GP).

AIMS

Evaluate the feasibility of utilising an Advanced Nurse Practitioner (ANP) to deliver unscheduled home visits on behalf of GPs in a primary care setting.

METHODS

Following a telephone request from patients, ANPs conducted unscheduled home visits on behalf of GPs over a six-month period. Service-level data collected included patient-facing time and outcome of visits. Practice staff and ANPs participated in mind-mapping sessions to explore perceptions of the service.

RESULTS

There were 239 accepted referrals (total visiting time 106.55 hours). The most common outcomes for visits were 'medication and worsening statement given' (107 cases) and 'self-care advice' (47 cases). GPs were very satisfied with the service (average score 90%), reporting reductions in stress and capacity improvements. Given the low referral rejection rate, ANPs discussed the potential to increase the number of practices able to access this model, in addition to the possibility of utilising other practitioners (such as paramedics or physiotherapists) to deliver the same service.

CONCLUSIONS

It appears delivering unscheduled care provision using an ANP is feasible and acceptable to GPs.

Acceptability of delivering an adapted Buurtzorg model in the Scottish care context

OBJECTIVES

Given increasing epidemiological and financial pressures on services, there is a need to test new models of integrated health and social care. Crucial to this testing is determining acceptability, particularly to those delivering services. The Dutch 'Buurtzorg' model, characterised by self-managing nursing teams, has shown promise, but its principles are yet to be adapted and tested in Scotland. The study aim was to understand the experiences of working in a self-managing, integrated, health and social care team.

STUDY DESIGN

This is a case study within a primary care setting.

METHODS

The Integrated Neighbourhood Care Aberdeen (INCA) project comprised two self-managing teams of support workers and nurses working at different sites in Aberdeen. Acceptability was explored through semistructured interviews with staff. Data were recorded and analysed thematically.

RESULTS

Staff reported high-quality patient care, which they attributed to autonomy over the frequency and duration of visits. Tensions between team members and between teams and management were apparent partly due to the predominantly social care caseload, confounding guidance on how to implement self-management and communication challenges. The team colocated within a General Practice reported positive relationships with other professionals.

CONCLUSIONS

Self-management requires a clear framework in which to function. Allowing staff autonomy to vary care provision according to need may improve patient outcomes.

Co-Creating Recommendations to Redesign and Promote Strength and Balance Service Provision

Background: Awareness of physical activity guidelines are low, particularly the "forgotten guidelines" of strength and balance. Increasing awareness of guidelines, but also of appropriate local services that can be utilised, is an important step towards active ageing. Co-creation can inform tailored service provision to potentially increase uptake and adherence. The aim was to co-create recommendations to redesign and promote local leisure services, emphasising strength and balance activity provision. Method: Twenty-four ageing and older adults engaged in 10 co-creation workshops. Workshops consisted of interactive tasks, and fieldwork tasks were undertaken externally. Data were collected using field notes, worksheet tasks and facilitator reflections and were analysed using qualitative content analysis. Results: Retention and adherence rates were 92% and 85%. Co-creators cited group cohesion, scientific input from experts and perceived knowledge development as enjoyable elements of the process. Four key themes emerged from analysis: (1) localised strategies for awareness raising, (2) recruitment of volunteer champions to increase uptake and maintenance, (3) accessibility of activities, including what they are and when they are, and (4) evaluation of impact. Conclusion: This has been the first study, to our knowledge, to utilise co-creation for informed leisure service provision improvement. Future work should aim to implement these recommendations to ascertain what impact these themes might make.

Implementation of a neighbourhood care model in a Scottish integrated context-views from patients

There is a need to test new models of integrated health and social care, particularly due to increasing financial and epidemiological pressures on services. One critical component of testing new models is the acceptability to patients. Here, the aim was to understand the acceptability of a new model of care to patients by understanding their experience of being supported by a self-managing, community-based, integrated, health and social care team. The INCA service consisted of three support workers and three nurses in two teams. These teams were self-managing and had autonomy over service operations and care delivery. Eight interviews and satisfaction questionnaires were conducted with patients. Interviews were transcribed and analysed thematically. Patients found the service highly acceptable (mean overall satisfaction of 98%), self-reporting a variety of benefits to their wellbeing. Central to this acceptability was the autonomy of staff to adjust care frequency and duration to patients' needs, in addition to describing an active engagement and partnership within their support plans. Future work should aim to ascertain the experiences of staff working in this model and whether receiving support in this way improves clinical outcomes.

Framework, principles and recommendations for utilising participatory methodologies in the co-creation and evaluation of public health interventions

PLAIN ENGLISH SUMMARY

Background: Society has to cope with a large burden of health issues. There is need to find solutions to prevent diseases and help individuals live healthier lifestyles. Individual needs and circumstances vary greatly and one size fit all solutions do not tend to work well. More tailored solutions centred on individuals' needs and circumstances can be developed in collaboration with these individuals. This process, known as co-creation, has shown promise but it requires guiding principles to improve its effectiveness. The aim of this study was to identify a key set of principles and recommendations for co-creating public health interventions.Methods: These principles were collaboratively developed through analysing a set of case studies targeting different health behaviours (such as reducing sitting and improving strength and balance) in different groups of people (such as adolescent schoolgirls and older adults living in the community).Results: The key principles of co-creation are presented in four stages: Planning (what is the purpose of the co-creation; and who should be involved?); Conducting (what activities can be used during co-creation; and how to ensure buy-in and commitment?); Evaluating (how do we know the process and the outcome are valid and effective?) and Reporting (how to report the findings?). Three models are proposed to show how co-created solutions can be scaled up to a population level.Conclusions: These recommendations aim to help the co-creation of public health interventions by providing a framework and governance to guide the process.

ABSTRACT

Background: Due to the chronic disease burden on society, there is a need for preventive public health interventions to stimulate society towards a healthier lifestyle. To deal with the complex variability between individual lifestyles and settings, collaborating with end-users to develop interventions tailored to their unique circumstances has been suggested as a potential way to improve effectiveness and adherence. Co-creation of public health interventions using participatory methodologies has shown promise but lacks a framework to make this process systematic. The aim of this paper was to identify and set key principles and recommendations for systematically applying participatory methodologies to co-create and evaluate public health interventions. Methods: These principles and recommendations were derived using an iterative reflection process, combining key learning from published literature in addition to critical reflection on three case studies conducted by research groups in three European institutions, all of whom have expertise in co-creating public health interventions using different participatory methodologies. Results: Key principles and recommendations for using participatory methodologies in public health intervention co-creation are presented for the stages of: Planning (framing the aim of the study and identifying the appropriate sampling strategy); Conducting (defining the procedure, in addition to manifesting ownership); Evaluating (the process and the effectiveness) and Reporting (providing guidelines to report the findings). Three scaling models are proposed to demonstrate how to scale locally developed interventions to a population level. Conclusions: These recommendations aim to facilitate public health intervention co-creation and evaluation utilising participatory methodologies by ensuring the process is systematic and reproducible.

Modifying Older Adults' Daily Sedentary Behaviour Using an Asset-based Solution: Views from Older Adults

OBJECTIVE

There is a growing public health focus on the promotion of successful and active ageing. Interventions to reduce sedentary behaviour (SB) in older adults are feasible and are improved by tailoring to individuals' context and circumstances. SB is ubiquitous; therefore part of the tailoring process is to ensure individuals' daily sedentary routine can be modified. The aim of this study was to understand the views of older adults and identify important considerations when creating a solution to modify daily sedentary patterns.

METHOD

This was a qualitative research study. Fifteen older adult volunteers (mean age = 78 years) participated in 1 of 4 focus groups to identify solutions to modify daily sedentary routine. Two researchers conducted the focus groups whilst a third took detailed fieldnotes on a flipchart to member check the findings. Data were recorded and analysed thematically.

RESULTS

Participants wanted a solution with a range of options which could be tailored to individual needs and circumstances. The strategy suggested was to use the activities of daily routine and reasons why individuals already naturally interrupting their SB, collectively framed as assets. These assets were categorised into 5 sub-themes: physical assets (eg. standing up to reduce stiffness); psychological assets (eg. standing up to reduce feelings of guilt); interpersonal assets (eg. standing up to answer the phone); knowledge assets (eg. standing up due to knowing the benefits of breaking SB) and activities of daily living assets (eg. standing up to get a drink).

CONCLUSION

This study provides important considerations from older adults' perspectives to modify their daily sedentary patterns. The assets identified by participants could be used to co-create a tailored intervention with older adults to reduce SB, which may increase effectiveness and adherence.

Exploring the context of sedentary behaviour in older adults (what, where, why, when and with whom)

BACKGROUND

Older adults are the most sedentary segment of the population. Little information is available about the context of sedentary behaviour to inform guidelines and intervention. There is a dearth of information about when, where to intervene and which specific behaviours intervention should target. The aim of this exploratory study was to obtain objective information about what older adults do when sedentary, where and when they are sedentary and in what social context.

METHODS

The study was a cross-sectional data collection. Older adults (Mean age = 73.25, SD ± 5.48, median = 72, IQR = 11) volunteers wore activPAL monitors and a Vicon Revue timelapse camera between 1 and 7 days. Periods of sedentary behaviour were identified using the activPAL and the context extracted from the pictures taken during these periods. Analysis of context was conducted using the Sedentary Behaviour International Taxonomy classification system.

RESULTS

In total, 52 days from 36 participants were available for analysis. Participants spent 70.1 % of sedentary time at home, 56.9 % of sedentary time on their own and 46.8 % occurred in the afternoon. Seated social activities were infrequent (6.9 % of sedentary bouts) but prolonged (18 % of sedentary time). Participants appeared to frequently have vacant sitting time (41 % of non-screen sedentary time) and screen sitting was prevalent (36 % of total sedentary time).

CONCLUSIONS

This study provides valuable information to inform future interventions to reduce sedentary behaviour. Interventions should consider targeting the home environment and focus on the afternoon sitting time, though this needs confirmation in a larger study. Tackling social isolation may also be a target to reduce sedentary time.