Integrated care: easy in theory, harder in practice?

Loneliness among older adults in Europe: time to integrate health and social care

Loneliness is a major concern for public health in contemporary societies. Older adults are particularly vulnerable to loneliness because of their reduced social connections following life changes, such as retirement. Loneliness is often investigated and discussed together with social isolation. While social isolation implies an actual lack of social connections, loneliness implies a perceived deficit of social relations regardless of the real amount of social contacts. However, since living alone may lead to loneliness, individuals can experience both loneliness and social isolation together. Loneliness is not an inevitable consequence of aging and can be tackled with various interventions that can be classified into individual- and group-based formats and can be conducted either in-person or online. In terms of contents, interventions for lonely older adults vary widely, from psychological therapies to contacts with nature and pet company. Although many lonely patients are seen in primary care settings, they are often hospitalized through emergency departments. Social prescriptions, which are more and more perceived as an important add-on to clinical treatments, are non-medical interventions designed to help patients to improve their health by linking traditional clinical practice with social activities and support services within the community. Health- and social-integrated care in the community has become a major priority among older adults to ensure their continuity and quality of care. A European model for welfare systems should be framed by a full integration of care across health and social services. Investing in integrated community care should improve the broad efficiency of the European welfare systems.

Lessons Learned From the Implementation of an Integrated Health and Social Care Child and Family Hub - a Case Study

Introduction

Childhood adversity is associated with poor physical and mental health outcomes across the lifespan. Integration of health and social care may provide a solution to childhood adversity through practices of better detection and response. There is growing interest in the creation of child and family hubs that integrate health and social care but little literature that describes the development process.

Description

We aimed to evaluate and describe the implementation of a co-designed health and social care child and family hub in Victoria, Australia. Rapid ethnographic methodology was used to iterate the hub components. Practitioners and researchers co-created solutions to barriers identified during implementation.

Discussion

There were five key learnings: (i) Practice change takes time and intensive coaching, (ii) Lived experience is a powerful motivator for practice change, (iii) Integration of services requires more than co-location to break down silos, (iv) Reflective practice is a key driver of practice change, and (v) Using real time data enabled rapid implementation change and directly informed the development of solutions.

Conclusions

Maintaining and developing practice change during implementation requires time and access to a broad range of data to enable iteration and the development of solutions.

Ethical challenges and principles in integrated care

INTRODUCTION

Integrated care is an established approach to delivery in parts of the healthcare infrastructure, and an ideal which, it is claimed, should be realized system-wide. Its ethical weight derives from its defence of a view about how healthcare ought to operate. Although the goal of integration is laudable, it is ethically and practically complex, involving trade-offs.

SOURCES OF DATA

Considerable evidence attests to widespread enthusiasm for integration, given the need to prevent harm and extend the reach of scarce resources. Equally, evidence increasingly highlights the obstacles to successfully translating this ideal into practice.

AREAS OF AGREEMENT

The principle that healthcare should be seamless, ensuring that patients do not come to harm through gaps in care enjoys broad agreement. There is a similar consensus that placing the patient's perspective at the centre of decision-making is vital, since this enables identification of these gaps.

AREAS OF CONTROVERSY

Integrating care by making it seamless entails blurring boundaries of care domains. This risks undermining the locus of responsibility for care decisions via confusion about who has ownership of specialist knowledge where domains overlap. There is a lack of consensus about how successful integration should be measured.

GROWING POINTS

More research into the relative cost-effectiveness of upstream public health investment in preventing chronic ill-health caused by modifiable lifestyle factors vs integrating care for people already ill; further research into ethical implications of integration in practice, which can be obscured by the simplicity of the fundamental normative principle guiding integration in theory.