Relevant models and elements of integrated care for multi-morbidity: Results of a scoping review

Scope of practice, competencies and impact of advanced practice nurses within APN-led models of care for young and middle-aged adult patients with multimorbidity and/or complex chronic conditions in hospital settings: a scoping review

INTRODUCTION

The number of young and middle-aged adult patients with multimorbid and/or complex chronic conditions is rising, presenting challenges for healthcare systems. Advanced practice nurses (APNs) are crucial in treating these patients due to their expertise and advanced nursing skills. The article outlines the scope of practice (SOP), competencies and impact of APNs in APN-led models of care for this patient group in hospital settings.

OBJECTIVES

Description of the SOP, competencies and impact of APNs within APN-led care models for young and middle-aged adult patients in hospital settings.

DESIGN

Scoping review based on the methodological framework by Arksey and O'Malley, incorporating the methodological enhancement of Levac and collegues, complying with the Preferred Reporting Items for Systematic Reviews and Meta-analysis extension for Scoping Reviews guidelines of Tricco and collegues. DATA SOURCES: Systematic research was conducted in the databases MEDLINE (PubMed), CINAHL (EBSCO), EMBASE (Ovid), CENTRAL and PsycINFO (Ovid) using all recognised keywords, item terms and search strings, and OpenGrey was scanned until December 2023. Studies published in English, German or translatable to English using translation tools were included.

ELIGIBILITY CRITERIA

Studies of APN-led models of care in hospitals were included if they involved adult participants aged 18-64 years with multimorbidity (two or more chronic conditions) and/or complex chronic conditions and provided information on SOP, competencies or impact.

DATA EXTRACTIONS AND SYNTHESIS

Data from full-text articles meeting the inclusion criteria were extracted independently by two reviewers, and a narrative summary was developed to present the results related to the objectives and questions of the study.

RESULTS

A total of 2119 records were retrieved, with five studies ultimately included. The results included predischarge, postdischarge and bridging transition SOP. The competencies of APNs varied in both form and intensity, due to the heterogeneity of the APN-led models. Direct clinical practice competencies were most frequently described, especially regarding nursing or medical tasks, and shaped and influenced competencies in leadership, collaboration, guidance and coaching, and evidence-based practice. Indirect care activities were often mentioned. These studies indicated that APNs in APN-led care models positively impact clinical and patient outcomes, although high-intensity integrated care did not lead to cost reductions.

CONCLUSION

The review aims to highlight the heterogeneity and current state of knowledge about the potential role of APNs in the integrated care of this increasing patient group in hospitals. The findings emphasise the significance of focusing on the unique needs of this patient population and may serve as a foundation for developing an APN-led model of care for this group in the clinical setting. However, further research is necessary to better elucidate the role of APNs within APN-led care models in relation to the care needs of this patient group.

TRIAL REGISTRATION NUMBER

OSF 4PM38.

Care Transitions After Critical Illness

Patients and their caregivers navigate multiple transitions of care across the health system as they recover from their critical illness. Current research supports the development of integrated models of care to improve patient outcomes after critical illness. Future research to ensure the development of integrated models across different regions and to understand the optimal mode of delivery of these is required.

Combinations of multiple long term conditions and risk of hospital admission or death during winter 2021-22 in England: population based cohort study

Objective

To describe which combinations of long term conditions were associated with a higher risk of hospital admission or death during winter 2021-22 (the third wave of the covid-19 pandemic) in adults in England.

Design

Population based cohort study.

Setting

Linked primary and secondary care data from the General Practice Extraction Service Data for Pandemic Planning and Research (GDPPR) database, Hospital Episode Statistics, and Office for National Statistics death registry, comprising pseudoanonymised routinely collected electronic medical records from the whole population of England registered at a general practice, 1 December 2021 to 31 March 2022.

Participants

48 253 125 individuals, registered in GDPPR in England, aged ≥18 years, and alive on 1 December 2021.

Main outcomes measures

All cause hospital admissions and deaths associated with combinations of multiple long term conditions compared with those with no long term conditions, during the winter season (1 December 2021 to 31 March 2022). Overdispersed Poisson regression models were used to estimate the incidence rate ratios after adjusting for age, sex, ethnic group, and index of multiple deprivation.

Results

Complete data were available for 48 253 125 adults, of whom 15 million (31.2%) had multiple long term conditions. Rates of hospital admissions and deaths among individuals with no long term conditions were 96.3 and 0.8 per 1000 person years, respectively. Compared with those with no long term conditions, the adjusted incidence rate ratio of hospital admissions were 11.0 (95% confidence interval (CI) 9.4 to 12.7) for those with a combination of cancer, chronic kidney disease, cardiovascular disease, and type 2 diabetes mellitus; 9.8 (8.3 to 11.4) for those with cancer, chronic kidney disease, cardiovascular disease, and osteoarthritis; and 9.6 (8.6 to 10.7) for those with cancer, chronic kidney disease, and cardiovascular disease. Compared with those with no long term conditions, the adjusted rate ratio of death was 21.4 (17.5 to 26.0) for those with chronic kidney disease, cardiovascular disease, and dementia; 23.2 (17.5 to 30.3) for those with cancer, chronic kidney disease, cardiovascular disease, and dementia; and 24.3 (19.1 to 30.4) for those with chronic kidney disease, cardiovascular disease, dementia, and osteoarthritis. Cardiovascular disease with dementia appeared in all of the top five combinations of multiple long term conditions for mortality, and this two disease combination was associated with a substantially higher rate of death than many three, four, and five disease combinations.

Conclusions

In this study, rates of hospital admission and death varied by combinations of multiple long term conditions and were substantially higher in those with than in those without any long term conditions. High risk combinations for prioritisation and preventive action by policy makers were highlighted to help manage the challenges imposed by winter pressures on the NHS.

Experiences and preliminary effects of the Comprehensive chrOnic caRe outpatiEnt (CORE) clinic for patients with multimorbidity in the hospital setting

RATIONALE

Healthcare systems remain disease oriented despite growing sustainability concerns caused by inadequate management of patients with multimorbidity. Comprehensive care programmes (CCPs) can play an important role in streamlining care delivery, but large differences in setup and results hinder firm conclusions on their effectiveness. Many elements for successful implementation of CCPs are identified, but strategies to overcome barriers and embed programmes within health systems remain unknown.

AIMS AND OBJECTIVES

To address this knowledge gap through a detailed study of implementing a CCP in a Dutch hospital setting, including patient experiences, facilitators, barriers and ways to overcome those barriers. Additionally, this study aims to explore effects on patient satisfaction and healthcare use.

METHODS

A qualitative study design with 39 semistructured interviews and focus groups between July 2020 and February 2023 with 16 patients and 17 involved professionals. Additionally, effects on quantitative outcomes for patient satisfaction (PACIC-20) and healthcare use were explored.

RESULTS

Professionals expressed a wide range of topics related to implementation and ways to overcome barriers at hospital and system level. Alterations in the design to accommodate varying care demands, focus on inclusions through referrals, and lack of long-term support and appropriate financing were key topics. Patients expressed varying experiences, stated a strong desire for comprehensive information, and emphasised the importance of trust in caregivers. Patient satisfaction showed no effects, while healthcare use showed slight decreases in trends, but patient numbers were limited.

CONCLUSION

The introduction of a CCP is feasible, and exploratory analysis on effectiveness shows lower hospital care use without decreasing patient satisfaction. However, this is accompanied by several challenges that show current fragmented systems still do not support implementation of integrated care initiatives. Overcoming those comes with substantial costs and may require a strong bottom-up implementation within a motivated team and actions on all levels of healthcare systems.

The effect of consultations performed by specialised nurses or advanced nurse practitioners on patient and organisational outcomes in patients with complex health conditions: An umbrella review

BACKGROUND

Policymakers and researchers often suggest that nurses may play a crucial role in addressing the evolving needs of patients with complex conditions, by taking on advanced roles and providing nursing consultations. Nursing consultations vary widely across settings and countries, and their activities range from complementing to substituting traditional physician-led consultations or usual care.

OBJECTIVE

This study was aimed at describing the effects of nursing consultations with patients with complex conditions in any setting on patient outcomes (quality of life, physical status, psychosocial health, health behaviour, medication adherence, mortality, anthropometric and physiological outcomes, and patient satisfaction) and organisational outcomes (health resource use and costs).

DESIGN

Umbrella review.

METHODS

We followed the Joanna Briggs Institute method for umbrella reviews. We searched PubMed, Embase, Cochrane Database of Systematic Reviews and CINAHL to identify relevant articles published in English, Dutch, French, Spanish or German between January 2013 and February 2023. We included systematic literature reviews, with or without meta-analyses, that included randomised controlled trials conducted in high-income countries. Reviews were eligible if they pertained to consultations led by specialised nurses or advanced nurse practitioners. Article selection, data extraction and quality appraisal were performed independently by at least two reviewers.

RESULTS

We included 50 systematic reviews based on 473 unique trials. For all patient outcomes, nursing consultations achieved effects at least equivalent to those of physician-led consultations or usual care (i.e., non-inferiority). For quality of life, health behaviour, medication adherence, mortality and patient satisfaction, more than half the meta-analyses found statistically significant effects in favour of nursing consultations (i.e., superiority). Cost results must be interpreted with caution, because very few and heterogeneous cost-related data were extracted, and the methodological quality of the cost analyses was questionable. Narrative syntheses confirmed the overall conclusions of the meta-analyses.

CONCLUSIONS

The effects of nursing consultations on patients with complex health conditions across healthcare settings appear to be at least similar to physician-led consultations or usual care. Nursing consultations appear to be more effective than physician-led consultations or usual care in terms of quality of life, health behaviour, mortality, patient satisfaction and medication adherence. Further analysis of the primary data is necessary to determine the patient populations and settings in which nursing consultations are most effective. Moderate study quality, diversity amongst and within systematic reviews, and quality of reporting hamper the strength of the findings.

Women's Health Hubs: a rapid mixed-methods evaluation

Background

Women's sexual and reproductive health needs are complex and vary across the life course. They are met by a range of providers, professionals and venues. Provision is not well integrated, with inequalities in access. In some areas of the United Kingdom Women's Health Hubs have been established to improve provision, experience and outcomes for women, and to address inequalities and reduce costs. These models were established prior to the national implementation of Women's Health Hubs announced in the English 2022 Women's Health Strategy.

Objective

To explore the 'current state of the art', mapping the United Kingdom landscape, and studying experiences of delivering and using Women's Health Hubs across England, defining key features and early markers of success to inform policy and practice.

Design

A mixed-methods evaluation, comprising three work packages: Mapping the Women's Health Hub landscape and context and developing a definition of Women's Health Hubs, informed by an online national survey of Women's Health Hub leaders, and interviews with regional stakeholders. In-depth evaluation in four hub sites, including interviews with staff and women, focus groups in local communities and documentary analysis. Interviews with national stakeholders and consolidation of findings from work packages 1 and 2. Fieldwork was undertaken from May 2022 to March 2023. The evaluation was initiated prior to the national scale-up of Women's Health Hubs announced in the 2022 Women's Health Strategy.

Results

Most areas of the United Kingdom did not have a Women's Health Hub. Seventeen active services were identified, established between 2001 and 2022. Women's Health Hubs were diverse, predominantly GP-led, with different perspectives of the role and definition of a hub. Women using hubs reported positive experiences, finding services caring and convenient. Implementation facilitators included committed, collaborative leaders working across boundaries, sufficient workforce capacity and a supportive policy context. Challenges included access to funding, commissioning, workforce issues, facilities and equipment, stakeholder engagement and wider system integration, priorities and pressures. Leaders were committed to addressing inequalities, but evidence of impact was still emerging.

Limitations

It was challenging to locate models; therefore, some may have been missed. Data availability limited assessment of impact, including inequalities. Some population groups were not represented in the data, and the evaluation was more provider-oriented. It was not possible to develop a typology of Women's Health Hubs as planned due to heterogeneity in models.

Conclusions

Existing Women's Health Hub models were providing integrated approaches to meet local needs. Many were at an early stage of development. Evidence of system-level impact and costs was still emerging. Women's Health Hubs may widen inequalities if models are more accessible to advantaged groups. The important role of committed leaders in existing 'bottom-up' models may limit scalability and sustainability. Findings suggest that national scale-up will take time and requires funding and that it is necessary to design models according to local needs and resources. In 2023, the Department of Health and Social Care announced funding to establish a Women's Health Hub in every Integrated Care System in England.

Future work

Future evaluation should consider system-level impact and costs, explore unintended consequences and test assumptions.

Funding

This award was funded by the National Institute of Health and Care Research (NIHR) Health and Social Care Delivery Research programme (NIHR award ref: NIHR135589) and is published in full in Health and Social Care Delivery Research; Vol. 12, No. 30. See the NIHR Funding and Awards website for further award information.

Collaborative Care for Injured Older Adults: The Trauma Medical Home Randomized Clinical Trial

Importance

Older adults with recent injuries can have impaired long-term biopsychosocial function and may benefit from interventions adapted to their needs.

Objective

To determine if a collaborative care intervention, Trauma Medical Home (TMH), improved the biopsychosocial function of older patients in the year after injury.

Design, Setting, and Participants

This was a single-blinded, randomized clinical trial conducted at 4 level I trauma centers in Indianapolis, Indiana, and Madison, Wisconsin. Between October 2017 and October 2021, patients aged 50 years and older with an Injury Severity Score (ISS) of 9 or greater and without traumatic brain or spinal cord injury were enrolled. Exclusions were significant brain injury or a spinal cord injury with a persistent neurologic deficit at the time of enrollment, extensive burns, pregnancy, incarceration, neurodegenerative disease, visual or auditory impairment that would preclude study participation, a life expectancy of less than 1 year, significant alcohol or drug use history, and acute stroke during admission. Of 10 276 patients screened, 430 were randomized and 299 completed 12-month follow-up. Data were analyzed from March to July 2023.

Intervention

Intervention patients received 6 months of TMH delivered by a nurse care coordinator guided by an interdisciplinary team (trauma surgeon, pulmonary critical care and geriatrician physicians, nurses, and psychologist) in partnership with primary care. The care coordinator used standard protocols to monitor and treat biopsychosocial symptoms.

Main Outcomes and Measures

Primary outcomes were Medical Outcome Study Short Form-36 (SF-36) score and Short Physical Performance Battery (SPPB) score at 12 months. Secondary outcomes were Patient Health Questionnaire-9 (PHQ-9) score, the Generalized Anxiety Disorder scale-7 (GAD-7) score, and health care utilization.

Results

A total of 429 participants (228 [53.1%] female; mean [SD] age, 69.3 [10.8] years; mean [SD] ISS, 12.3 [4.6]) completed baseline assessments and were randomized. Follow-up was 76% (n = 324) at 6 months and 70% (n = 299) at 12 months. There were no differences between the TMH and usual care groups at 12 months in SF-36 Physical Component Summary score (mean [SD], 40.42 [12.82] vs 39.18 [12.43]), SF-36 Mental Component Summary score (mean [SD], 53.92 [10.02] vs 53.21 [10.82]), or SPPB score (mean [SD], 8.00 [3.60] vs 8.28 [3.88]). Secondary outcomes were also no different. Planned subgroup analysis revealed patients with baseline symptoms of anxiety or depression (high GAD-7 and PHQ-9 scores) experienced improvement in the Mental Component Summary score when randomized to the TMH intervention.

Conclusions and Relevance

The TMH intervention did not significantly influence quality of life, depressive and anxiety symptoms, or physical function of older adults with injury at 12 months. Subgroup analysis showed positive impact in patients with a high burden of anxiety and depression symptoms at enrollment. Collaborative care interventions may improve long-term outcomes of select patients, but further research is needed.

Trial Registration

ClinicalTrials.gov Identifier: NCT03108820.

Lost in the System: Responsibilisation and Burden for Women With Multiple Long-Term Health Conditions During Pregnancy

INTRODUCTION

Over a fifth of pregnant women are living with multiple long-term health conditions, which is associated with increased risks of adverse outcomes for mothers and infants. While there are many examples of research exploring individuals' experiences and care pathways for pregnancy with a single health condition, evidence relating to multiple health conditions is limited. This study aimed to explore experiences and care of women with multiple long-term health conditions around the time of pregnancy.

METHODS

Semistructured interviews were conducted between March 2022 and May 2023 with women with multiple long-term health conditions who were at least 28 weeks pregnant or had had a baby in the last 2 years, and healthcare professionals with experience of caring for these women. Participants were recruited from across the United Kingdom. Data were analysed using thematic analysis.

RESULTS

Fifty-seven women and 51 healthcare professionals participated. Five themes were identified. Women with long-term health conditions and professionals recognised that it takes a team to avoid inconsistent care and communication, for example, medication management. Often, women were required to take a care navigation role to link up their healthcare providers. Women described mixed experiences regarding care for their multiple identities and the whole person. Postnatally, women and professionals recognised a downgrade in care, particularly for women's long-term health conditions. Some professionals detailed the importance of engaging with women's knowledge, and recognising their own professional boundaries of expertise. Many participants described difficulties in providing informational continuity and subsequent impacts on care. Specifically, the setup of care systems made it difficult for everyone to access necessary information, especially when care involved multiple sites.

CONCLUSION

Pregnant women with long-term health conditions can experience a substantial burden of responsibility to maintain communication with their care team, often feeling vulnerable, patronised, and let down by a lack of acknowledgement of their expertise. These results will be used to inform the content of coproduction workshops aimed at developing a list of care recommendations for affected women. It will also inform future interventional studies aimed at improving outcomes for these women and their babies.

PATIENT OR PUBLIC CONTRIBUTION

Our Patient and Public Involvement group were involved in the design of the study and the analysis and interpretation of the data, and a public study investigator was part of the author group.

Identifying Competencies of the ACT Program Nurse Using the DACUM Method

The nurse role on an Assertive Community Treatment (ACT) team requires a specialized set of skills in psychiatric community-based care. While the ACT model has existed for fifty years, no nationally recognized standard curriculum to train ACT nurses has been developed. The ACT Nursing Project described in this paper aimed to create a competency-based on-board training program using the Developing a Curriculum (DACUM) method. Eight ACT nurses from three states served as the expert panel to create a DACUM chart detailing the full set of nine duties and 127 tasks required of ACT nurses. To verify the DACUM results, 57 ACT nurses from four states completed a survey and confirmed that 80% of the tasks identified by the expert panel were also performed by the validation sample of ACT nurses. This paper describes how the DACUM duties and tasks provided the framework to develop onboard training curriculum for ACT program nurses. The next step is to pilot the onboard training curriculum to newly hired ACT nurses to ensure they are equipped to meet the complex needs of people living with serious mental illness, and to increase their competency, job satisfaction and decrease the high annual turnover rate among ACT nurses.

[The population perspective in assessing the performance of Germany's health care system: Results of a cross-sectional survey among members of a statutory health insurance]

INTRODUCTION

Since the World Health Report in 2000, Health System Performance Assessment (HSPA) has been established as a tool for the evaluation and evidence-informed governance of health systems. So far, the population perspective has not been integrated into HSPA in a systematic manner, although people's experiences and expectations are of great importance to improve health systems and especially to strengthen patient-centered care. Therefore, this study aims to conduct an HSPA of Germany's health system from the population's perspective covering all eight goals of WHO's Health Systems Framework, and to identify strengths and needs for improvement.

METHODS

In 2018, 32,000 people insured with the German sickness fund 'AOK Nordost' were invited by mail to participate in the survey. The questionnaire contained a total of 43 items covering the eight goals of WHO's Health Systems Framework (e.g., access, quality, safety) plus socioeconomics and other characteristics of the insured persons. The data on the health system goals were analyzed descriptively and by subgroups (age, sex, income, chronic conditions, health literacy).

RESULTS

The sample (n=1,481; response rate 4.6%) was 54.8% female and had a mean age of 59.1 years (±18.5). Altogether, the participants saw several needs for improvement within the German health system. For instance, 60.0% found quality differences between hospitals to be big, and between 3.9% and 8.5% reported mistakes related to their treatment or prescription medication in the previous two years. A big need for reform was especially seen regarding out-of-pocket payments (51.5%) and the coordination of ambulatory care physicians among each other (44.2%) and with hospitals (41.9%). In addition, big subgroup differences were seen, especially for income and health literacy. Of the participants in the lower income group, 37.2% reported a (very) strong financial burden due to out-of-pocket payments (vs. 20.7%). People with limited health literacy (52.1%) assessed the access to care generally as not being good, and they perceived greater quality differences and needs for reform, compared to their counterparts. For instance, 36.6% had experienced discrimination in the previous year (vs. 19.9%).

DISCUSSION

The survey results provide a comprehensive picture of Germany's health system from the population perspective. In some areas, previous findings were confirmed (e.g., a lack of coordination between providers). Other results expand existing knowledge (e.g., the role of health literacy in health care provision) or raise new questions (e.g., the difference between the subjectively assessed burden from out-of-pocket payments and the objective measures currently used). The great differences between subgroups are a call to action on the level of both politics and practice to better consider the individual's needs in order to make health better for everyone. Further research could provide deeper insights in this regard.

CONCLUSION

Strengthening the population perspective in HSPA allows for a better understanding and evaluation of health systems and, in particular, helps to identify areas for improvement in patient-centered care.

Prevalence of multimorbidity and polypharmacy among adults and older adults: a systematic review

Multimorbidity (multiple conditions) and polypharmacy (multiple medications) are increasingly common, yet there is a need to better understand the prevalence of co-occurrence. In this systematic review, we examined the prevalence of multimorbidity and polypharmacy among adults (≥18 years) and older adults (≥65 years) in clinical and community settings. Six electronic databases were searched, and 87 studies were retained after two levels of screening. Most studies focused on adults 65 years and older and were done in population-based community settings. Although the operational definitions of multimorbidity and polypharmacy varied across studies, consistent cut-points (two or more conditions and five or more medications) were used across most studies. In older adult samples, the prevalence of multimorbidity ranged from 4·8% to 93·1%, while the prevalence of polypharmacy ranged from 2·6% to 86·6%. High heterogeneity between studies indicates the need for more consistent reporting of specific lists of conditions and medications used in operational definitions.

Evaluation of the Implementation of Integrated Primary Care for Patients with Type 2 Diabetes and Hypertension in Belgium, Cambodia, and Slovenia

Introduction

Integrated care of chronic patients improves quality of their management, but there is scarce evidence of its implementation in different healthcare settings. With this article, we wanted to determine the level of integrated care implementation in the management of T2D (diabetes) and HT (hypertension) in three different settings: Belgium, Slovenia, and Cambodia.

Methods

This was an observational study with integrated approach. It was conducted in primary health care organisations in three countries. In each primary health care organisation, we aimed to include primary care workers that worked with Type 2 Diabetes (T2D) and hypertension (HT) patients. Data was collected with the Integrated Care Package (ICP) grid (consisting of six elements: identification, treatment, health education, self-management, caregiver collaboration, and care organisation).

Results

ICP is almost completely implemented without major differences within Slovenia. There is a considerable variability across practice types in Belgium. Implementation is constrained by health system resources in Cambodia. Some elements, especially identification, are better implemented then others, across health systems.

Conclusion

Countries can enhance integrated care for chronic diseases by implementing central policies, standardized protocols, and local adaptation, addressing resource constraints, promoting systematic screening and health education, and providing training for healthcare workers, tailored to community needs, to improve patient outcomes and healthcare delivery.

The Effect of Coordinating the Outpatient Treatment across Medical Specialities for Patients With Multimorbidity

Introduction

Patients with multimorbidity attend multiple outpatient clinics. We assessed the effects on hospital use of scheduling several outpatient appointments to same-day visits in a multidisciplinary outpatient pathway (MOP).

Methods

This study used a quasi-experimental design. Eligible patients had multimorbidity, were aged ≥18 years and attended ≥2 outpatient clinics in five different specialties. Patients were identified through forthcoming appointments from August 2018 to March 2020 and divided into intervention group (alignment of appointments) and comparison group (no alignment). We used patient questionnaires and paired analyses to study care integration and treatment burden. Using negative binomial regression, we estimated healthcare utilisation as incidence rates ratios (IRRs) at one year before and one year after baseline for both groups and compared IRR ratios (IRRRs).

Results

Intervention patients had a 19% reduction in hospital visits (IRRR: 0.81, 95% CI: 0.70-0.96) and a 17% reduction in blood samples (IRRR: 0.83, 0.73-0.96) compared to comparison patients. No effects were found for care integration, treatment burden, outpatient contacts, terminated outpatient trajectories, hospital admissions, days of admission or GP contacts.

Conclusion

The MOP seemed to reduce the number of hospital visits and blood samples. These results should be further investigated in studies exploring the coordination of outpatient care for multimorbidity.

Research question

Can an intervention of coordinating outpatient appointments to same-day visits combined with a multidisciplinary conference influence the utilisation of healthcare services and the patient-assessed integration of healthcare services and treatment burden among patients with multimorbidity?

Experiences of hospital care for people with multiple long-term conditions: a scoping review of qualitative research

BACKGROUND

Multiple long-term conditions-the co-existence of two or more chronic health conditions in an individual-present an increasing challenge to populations and healthcare systems worldwide. This challenge is keenly felt in hospital settings where care is oriented around specialist provision for single conditions. The aim of this scoping review was to identify and summarise published qualitative research on the experiences of hospital care for people living with multiple long-term conditions, their informal caregivers and healthcare professionals.

METHODS

We undertook a scoping review, following established guidelines, of primary qualitative research on experiences of hospital care for people living with multiple long-term conditions published in peer-reviewed journals between Jan 2010 and June 2022. We conducted systematic electronic searches of MEDLINE, CINAHL, PsycInfo, Proquest Social Science Premium, Web of Science, Scopus and Embase, supplemented by citation tracking. Studies were selected for inclusion by two reviewers using an independent screening process. Data extraction included study populations, study design, findings and author conclusions. We took a narrative approach to reporting the findings.

RESULTS

Of 8002 titles and abstracts screened, 54 papers reporting findings from 41 studies conducted in 14 countries were identified as eligible for inclusion. The perspectives of people living with multiple long-term conditions (21 studies), informal caregivers (n = 13) and healthcare professionals (n = 27) were represented, with 15 studies reporting experiences of more than one group. Findings included poor service integration and lack of person-centred care, limited confidence of healthcare professionals to treat conditions outside of their specialty, and time pressures leading to hurried care transitions. Few studies explored inequities in experiences of hospital care.

CONCLUSIONS

Qualitative research evidence on the experiences of hospital care for multiple long-term conditions illuminates a tension between the desire to provide and receive person-centred care and time pressures inherent within a target-driven system focussed on increasing specialisation, reduced inpatient provision and accelerated journeys through the care system. A move towards more integrated models of care may enable the needs of people living with multiple long-term conditions to be better met. Future research should address how social circumstances shape experiences of care.

Barriers and enablers of integrated care in the UK: a rapid evidence review of review articles and grey literature 2018-2022

Integrated care refers to person-centered and coordinated, health and social care, and community services. Integrated care systems are partnerships of organizations that deliver health and care services which were placed on a statutory footing in England, April 2022. Due to the need for fast, accessible, and relevant evidence, a rapid review was conducted according to World Health Organization methods to determine barriers and enablers of integrated care across the United Kingdom, 2018-2022. Nine databases were searched for review articles reporting evaluation of integrated care interventions involving medical (clinical and diagnostic) and nonmedical (public health services and community-based or social care/person-centred care) approaches, quality checked with the Critical Appraisal Skills Program qualitative checklist. OpenGrey and hand searches were used to identify grey literature, quality checked with the Authority, Accuracy, Coverage, Objectivity, Date, and Significance checklist. Thirty-four reviews and 21 grey literature reports fitted inclusion criteria of adult physical/mental health outcomes/multiple morbidities. Thematic analysis revealed six themes (collaborative approach; costs; evidence and evaluation; integration of care; professional roles; service user factors) with 20 subthemes including key barriers (cost effectiveness; effectiveness of integrated care; evaluation methods; focus of evidence; future research; impact of integration) and enablers (accessing care; collaboration and partnership; concept of integration; inter-professional relationships; person-centered ethos). Findings indicated a paucity of robust research to evaluate such interventions and lack of standardized methodology to assess cost effectiveness, although there is growing interest in co-production that has engendered information sharing and reduced duplication, and inter-professional collaborations that have bridged task-related gaps and overlaps. The importance of identifying elements of integrated care associated with successful outcomes and determining sustainability of interventions meeting joined-up care and preventive population health objectives was highlighted.

Integrated Care Models for Older Adults with Depression and Physical Comorbidity: A Scoping Review

Objective

Multimorbidity is a growing challenge in the care for older people with mental illness. To address both physical and mental illnesses, integrated care management is required. The purpose of this scoping review is to identify core components of integrated care models for older adults with depression and physical comorbidity, and map reported outcomes and implementation strategies.

Methods

PubMed, EMBASE, CINAHL and Cochrane Library were searched independently by two reviewers for studies concerning integrated care interventions for older adults with depression and physical comorbidity. We used the SELFIE framework to map core components of integrated care models. Clinical and organisational outcomes were mapped.

Results

Thirty-eight studies describing thirteen care models were included. In all care models, a multidisciplinary team was involved. The following core components were mainly described: continuity, person-centredness, tailored holistic assessment, pro-activeness, treatment interaction, individualized care planning, and coordination tailored to complexity of care needs. Twenty-seven different outcomes were evaluated, with more attention given to clinical than to organisational outcomes.

Conclusion

The core components that comprise integrated care models are diverse. Future studies should focus more on implementation aspects of the intervention and describe financial parts, e.g., the cost of the intervention for the healthcare user, more transparently.

Defining Vision and Mission of a Medical Psychiatry Unit (MPU) for Older Adults: A Focus Group Study

This study aims to determine the vision and mission of an academic hospital's medical psychiatry unit (MPU) that exclusively treats geriatric patients. All healthcare providers working at an academic hospital's geriatric MPU were invited to reflect on formulate the vision and mission of this ward. Twenty-two of them took part in the focus group interviews. The interviews focused on defining the MPU's functioning, its objectives, how it will reach these objectives, and where the MPU aspires to go. The interviews were transcribed verbatim and analyzed according to the QUAGOL guide. The themes from the analysis emerged from these group discussions. The participants defined the MPU's vision as to excel in integrated mental and physical geriatric inpatient healthcare, inspiring others to shed the stigma related to this vulnerable patient population. The mission that emerged from the focus group discussions is to provide patient-centered, integrated healthcare for older adults with combined mental and physical disorders. To achieve this, involving the patient's network, interdisciplinarity, shared decision-making, clear communication between all stakeholders, and reintegration of patients into their communities emerged as important themes. This study provides a vision and mission of a geriatric MPU in an academic psychiatric hospital. Since there is no consensus in the literature about the characteristics of MPUs despite the international call for integrated care for older persons with combined mental and physical disorders, these vision and mission statements can feed the discussion on how to install excellent healthcare for this vulnerable patient population.

Building on value-based health care: Towards a health system perspective

A variety of methodologies have been developed to help health systems increase the 'value' created from their available resources. The urgency of creating value is heightened by population ageing, growth in people with complex morbidities, technology advancements, and increased citizen expectations. This study develops a policy framework that seeks to reconcile the various approaches towards value-based policies in health systems. The distinctive contribution is that we focus on the value created by the health system as a whole, including health promotion, thus moving from value-based health care towards a value-based health system perspective. We define health system value to be the contribution of the health system to societal wellbeing. We adopt a framework of five dimensions of value, embracing health improvement, health care responsiveness, financial protection, efficiency and equity, which we map onto a society's aggregate wellbeing. Actors within the health system make different contributions to value, and we argue that their perspectives can be aligned with a unifying concept of health system value. We provide examples of policy levers and highlight key actors and how they can promote certain aspects of health system value. We discuss advantages of value-based approach based on the notion of wellbeing and some practical obstacles to its implementation.

Supporting professionals to implement integrated, person-centered care for people with chronic conditions: the TARGET pilot study

OBJECTIVE

The TARGET program for integrated, person-centered care for people with chronic conditions offers primary care (PC) professionals a set of tools and trainings to actively engage in population segmentation and person-centered needs assessments (PCNAs). A pilot study was conducted to gain insight into the program's feasibility and acceptability, and identify preconditions for successful implementation.

DESIGN AND SETTING

Seven Dutch PC practices participated in a half-year pilot study starting in August 2020. We performed a review of the population segmentation tool, observed four training sessions and 15 PCNAs, and interviewed 15 professionals and 12 patients.

RESULTS

Regarding feasibility and acceptability, we found that the tools and trainings provided professionals with skills to use the segmentation tool and take a more coaching role in the well-appreciated PCNAs. Concerning implementation preconditions, we found that team commitment and network connections need improvement, although work pleasure increased and professionals generally wanted the program to continue.

CONCLUSIONS

While the content of the TARGET program is supported by its users, the implementation process, for instance team commitment to the program, needs more attention in future upscaling efforts.

Evaluation of patients´ perspective on a multimorbidity patient-centered care model piloted in the chilean public health system

BACKGROUND

The progressive multimorbidity explosion has challenged Chile's health systems and worldwide. The Centro de Innovación en Salud ANCORA UC implemented a new Multimorbidity Patient-Centered Care Model in Chile.

OBJECTIVE

Evaluate the perspective of high-risk patients about the core elements of the model.

METHODOLOGY

We conducted a cross sectional telephone-based survey that considered the application of a 13 items questionnaire. Of them, nine were Likert scale questions with scores from 1 to 7, one dichotomic question, and three open-ended questions. 231 high-risk patients who received care through the model at primary care centers participated in the study. Quantitative data were encoded, consolidated, and analyzed with the SPSS software. We performed descriptive and analytic statistics techniques to assess different variables and their potential associations. Thematic analysis was conducted for qualitative data.

RESULTS

The overall score was 5.84 (range: 1 to 7), with a standard deviation of 1.25. Questions with the best scores were those related with personalized care and the primary care teams. The lowest scored was for the item regarding the continuity of care between primary nurses and inpatient care at the hospital. There was a difference in patient outcomes depending on their health center. Regarding sociodemographic characteristics, age did not significantly affect the results.

CONCLUSIONS

The study reveals the perceptions about a complex multimorbidity intervention from the patient's perspective. It complements the impact on health services utilization evaluation that supports decision-makers currently scaling up a similar strategy in our country and could be considered in other countries dealing with non-communicable diseases.

Improving Outcomes of Pediatric Lupus Care Delivery With Provider Goal-Setting Activities and Multidisciplinary Care Models

OBJECTIVE

The present study was undertaken to evaluate high-quality care delivery in the context of provider goal-setting activities and a multidisciplinary care model using an electronic health record (EHR)-enabled pediatric lupus registry. We then determined associations between care quality and prednisone use among youth with systemic lupus erythematosus (SLE).

METHODS

We implemented standardized EHR documentation tools to autopopulate a SLE registry. We compared pediatric Lupus Care Index (pLCI) performance (range 0.0-1.0; 1.0 representing perfect metric adherence) and timely follow-up 1) before versus during provider goal-setting activities and population management, and 2) in a multidisciplinary lupus nephritis versus rheumatology clinic. We estimated associations between pLCI and subsequent prednisone use adjusted for time, current medication, disease activity, clinical features, and social determinants of health.

RESULTS

We analyzed 830 visits by 110 patients (median 7 visits per patient [interquartile range 4-10]) over 3.5 years. The provider-directed activity was associated with improved pLCI performance (adjusted β 0.05 [95% confidence interval (95% CI) 0.01, 0.09]; mean 0.74 versus 0.69). Patients with nephritis in multidisciplinary clinic had higher pLCI scores (adjusted β 0.06 [95% CI 0.02, 0.10]) and likelihood of timely follow-up than those in rheumatology (adjusted relative risk [RR] 1.27 [95% CI 1.02, 1.57]). A pLCI score of ≥0.50 was associated with 0.72-fold lower adjusted risk of subsequent prednisone use (95% CI 0.53, 0.93). Minoritized race, public insurance, and living in areas with greater social vulnerability were not associated with reduced care quality or follow-up, but public insurance was associated with higher risk of prednisone use.

CONCLUSION

Greater attention to quality metrics is associated with better outcomes in childhood SLE. Multidisciplinary care models with population management may additionally facilitate equitable care delivery.

Impact, scope of practice and competencies of Advanced Practice Nurses within APN-led models of care for young and middle-aged adult patients with multimorbidity and/or complex chronic conditions in hospital settings: a scoping review protocol

INTRODUCTION

The increase of young and middle-aged adult patients with multimorbid and/or complex chronic conditions has created new challenges for healthcare systems and services. Advanced Practice Nurses (APNs) play an essential role in treating these patients because of their expertise and advanced nursing skills. Little is known about competencies, scope of practice and impact of APNs within APN-led care models for young and middle-aged adult patients with multimorbidity and/or complex chronic conditions in hospital settings. The objective of this scoping review is to describe the impact, scope of practice and competencies of APNs within APN-led care models for young and middle-aged adult patients in hospital settings.

METHODS AND ANALYSIS

This scoping review will be conducted using the methodological framework proffered by Arksey and O'Malley, incorporating the methodological enhancement of Levac et al. It will comply with the Preferred Reporting Items for Systematic Reviews and Meta-analyses (PRISMA) for Scoping Reviews' guidelines of Tricco et al. Systematic research will be conducted in the databases MEDLINE (PubMed), CINAHL (EBSCO), EMBASE (Ovid), CENTRAL and PsycINFO (Ovid) using all recognised keywords, index terms and search strings. Grey literature will be scanned. Bibliography of all selected studies will be hand searched. Studies will be selected based on defined inclusion and exclusion criteria, screened by title and abstracts. Data from full-text articles meeting the inclusion criteria will be extracted independently by two authors. Disagreements in evaluation will be discussed and resolved by consensus. Results will be reported in the form of descriptive tables. Narrative summery is used to present the results of the review in the context of the study's objectives and questions.

ETHICS AND DISSEMINATION

This scoping review does not require ethics approval. The review will be handed in as part of a doctoral thesis and published in a peer-reviewed journal.

TRIAL REGISTRATION NUMBER OSF

4PM38.

Nurses' Challenges to Developing Interpersonal Relationships During Integrated Care for Complex Patients

BACKGROUND

Individuals with multimorbidity and complexity have multifaceted care needs requiring integrated and collaborative care from nurses, families, and health care teams. Nurses, as the frontline care professionals, should develop therapeutic relationships with patients and their families and professional relationships with health care team members to ensure the delivery of effective integrated care. Failure to develop effective interpersonal and professional relationships can negatively affect patient care.

OBJECTIVE

The purpose of this study was to explore nurses' challenges with developing interpersonal and professional relationships during integrated care for individuals with multimorbidity and complexity.

METHODS

A descriptive qualitative design was used. We interviewed a purposive sample of 19 nurses with experience of caring for individuals with multimorbidity and complexity across two hospitals in Pakistan. Semi-structured interviews were used for data collection, and data were analyzed using reflexive thematic analysis.

RESULTS

Two challenges were identified affecting the relationships between patients' families and nurses, and two challenges influencing the professional relationships within the team. Families withheld information, controlled care access of their relatives, posed unrealistic demands, and abused nurses, affecting nurse-family relationships. Power struggles to demonstrate authority in decision-making were common within health care teams, affecting nurses' professional capacity to provide effective care.

CONCLUSIONS

Health care team, patient, and family collaboration is instrumental in improved care for individuals with multimorbidity and complexity. Nurse leaders and health care organizations should take initiatives to address nurses' interpersonal confrontations to support them in the provision of quality care.

Sociocultural and patient-health care professional related factors influencing self-management of multiethnic patients with multimorbidities: A thematic synthesis

Self-management is critical for the general well-being and disease management of individuals with multimorbidities. A better understanding of sociocultural and patient-professional level factors affecting self-management can be valuable for designing individual and community-based strategies to promote optimal self-management. The purpose of this review was to explore sociocultural and patient-health care professional related factors affecting self-management among patients with multimorbidities. A metasynthesis was conducted. Literature was searched in PubMed, CINAHL, Scopus, Web of Science, and OVID databases. In total, 21 qualitative studies published from January 2010-March 2023 were critically appraised and reviewed. Thematic synthesis was used for analysis and eight descriptive and three analytical themes were generated. The analytical themes illustrated that personal and structural vulnerabilities, social and family struggles, and fragmented interpersonal relationships with health care professionals affect health care access, navigation, and self-management of individuals with multimorbidities. Engagement in self-management for individuals with multiple chronic conditions is hampered by under-resourced community and health care environments, structural vulnerabilities, familial and interpersonal conflicts, and disjointed relationships. There is a dire need to ensure optimal community resources to support individuals to address and navigate complexities associated with accessing care and effectively managing their illnesses.

Exploration of understanding of integrated care from a public health perspective: A scoping review

Background

Many health care systems attempt to develop an integrated care approach that is a whole population health-oriented system. However, knowledge of strategies to support this effort are scarce and fragmented. The aim of the current paper is to investigate existing concepts of integrated care and their elements from a public health perspective and to propose an elaborated approach that could be applied to explore the public health orientation of integrated care.

Design and methods

We applied a scoping review approach. A literature search was conducted in Embase, Medline, CINAHL, Scopus and Web of Science for the period 2000-2020 yielding 16 studies for inclusion.

Results

Across the papers, 14 frameworks were identified. Nine of these referred to the Chronic Care Model (CCM). Service delivery, person-centeredness, IT systems design and utilization and decision support were identified as the core elements of most of the included frameworks. The descriptions of these elements were mainly clinical-oriented focusing particularly on clinical care processes and treatment of diseases instead of wider determinants of population health.

Conclusions

A synthesized model is proposed that emphasizes the importance of mapping the unique needs and characteristics of the population it aims to serve, leans on the social determinants approach with a commitment to individual and community empowerment, health literacy and suggests reorienting services to meet the expressed needs of the population.

Assessing the Readiness to Provide Integrated Management of Cardiovascular Diseases and Type 2 Diabetes in Kenya: Results from a National Survey

Introduction

Integrated chronic disease management is the desired core function of a responsive healthcare system. However, many challenges surround its implementation in Sub-Saharan Africa. The current study assessed the readiness of healthcare facilities to provide integrated management of cardiovascular diseases (CVDs) and type 2 diabetes in Kenya.

Methods

We used data from a nationally representative cross-sectional survey of 258 public and private health facilities conducted in Kenya between 2019 and 2020. Data were collected using a standardised facility assessment questionnaire and observation checklists modified from the World Health Organization Package of Essential Non-communicable Diseases. The primary outcome was the readiness to provide integrated care for CVDs and diabetes-defined as the mean availability of tracer items comprising trained staff and clinical guidelines, diagnostic equipment, essential medicines, diagnosis, treatment and follow-up. A cut-off threshold of ≥70% was used to classify facilities as 'ready'. Gardner-Altman plots and modified Poisson regression were used to examine the facility characteristics associated with care integration readiness.

Results

Of the surveyed facilities, only a quarter (24.1%) were ready to provide integrated care for CVDs and type 2 diabetes. Care integration readiness was lower in public versus private facilities [aPR = 0.6; 95% CI 0.4 to 0.9], and primary healthcare facilities were less likely to be ready compared to hospitals [aPR = 0.2; 95% CI 0.1 to 0.4]. Facilities located in Central Kenya [aPR = 0.3; 95% CI 0.1 to 0.9], and the Rift Valley region [aPR = 0.4; 95% CI 0.1 to 0.9], were less likely to be ready compared to the capital Nairobi.

Conclusions

There are gaps in the readiness of healthcare facilities particularly primary healthcare facilities in Kenya to provide integrated care services for CVDs and diabetes. Our findings inform the review of current supply-side interventions for integrated management of CVDs and type 2 diabetes, especially in lower-level public health facilities in Kenya.

Towards A Framework for Implementing Remote Patient Monitoring From an Integrated Care Perspective: A Scoping Review

BACKGROUND

Remote patient monitoring (RPM) has been increasingly adopted over the last decade, with the COVID-19 pandemic fostering its rapid development. As RPM implementation is recognised as complex and highly demanding in terms of resources and processes, there are multiple challenges in providing RPM in an integrated logic.

METHODS

To examine the structural elements that are relevant for implementing RPM integrated care, a scoping review was conducted in PubMed, Scopus, and Web of Science, leveraging a search strategy that combines terms relative to (1) conceptual models and reallife initiatives; (2) RPM; and (3) care integration.

RESULTS

28 articles were included, covering nine conceptual models and 19 real-life initiatives. Eighteen structural elements of RPM integrated care implementation were identified among conceptual models, defining a structure for assessing real-life initiatives. 78.9% of those initiatives referred to at least ten structural elements, with patient education and self-monitoring promotion, multidisciplinary core workforce, ICTs (information and communications technologies) and telemonitoring devices, and health indicators measurement being present in all studies, and therefore being core elements to the design of RPM initiatives.

CONCLUSION

RPM goes far beyond technology, with underlying processes and involved actors playing a central role in care provision. The structural elements identified can guide RPM implementation and promote maturity in adoption. Future research may focus on assessing design completeness, evaluating impacts, and analysing related financial arrangements.

A Realist Evaluation of Case Management Models for People with Complex Health Conditions Using Novel Methods and Tools-What Works, for Whom, and under What Circumstances?

Case management developed from a generalist model to a person-centred model aligned with the evidence-informed evolution of best practice people-centred integrated care. Case management is a multidimensional and collaborative integrated care strategy where the case manager performs a set of interventions/actions to support the person with a complex health condition to progress in their recovery pathway and participate in life roles. It is currently unknown what case management model works in real life for whom and under what circumstances. The purpose of this study was to answer these questions. The study methods used realistic evaluation framework, examined the patterns and associations between case manager actions (mechanisms), the person's characteristics and environment (context), and recovery (outcomes) over 10 years post severe injury. There was mixed methods secondary analysis of data extracted via in-depth retrospective file reviews (n = 107). We used international frameworks and a novel approach with multi-layered analysis including machine learning and expert guidance for pattern identification. The study results confirm that when provided, a person-centred case management model contributes to and enhances the person's recovery and progress towards participation in life roles and maintaining well-being after severe injury.Furthermore, the intensity of case management for people with traumatic brain injury, and the person-centred actions of advising, emotional and motivational support, and proactive coordination contribute to the person achieving their goals. The results provide learnings for case management services on the case management models, for quality appraisal, service planning, and informs further research on case management.

How Can a Bundled Payment Model Incentivize the Transition from Single-Disease Management to Person-Centred and Integrated Care for Chronic Diseases in the Netherlands?

To stimulate the integration of chronic care across disciplines, the Netherlands has implemented single-disease management programmes (SDMPs) in primary care since 2010; for example, for COPD, type 2 diabetes mellitus, and cardiovascular diseases. These disease-specific chronic care programmes are funded by bundled payments. For chronically ill patients with multimorbidity or with problems in other domains of health, this approach was shown to be less fit for purpose. As a result, we are currently witnessing several initiatives to broaden the scope of these programmes, aiming to provide truly person-centred integrated care (PC-IC). This raises the question if it is possible to design a payment model that would support this transition. We present an alternative payment model that combines a person-centred bundled payment with a shared savings model and pay-for-performance elements. Based on theoretical reasoning and results of previous evaluation studies, we expect the proposed payment model to stimulate integration of person-centred care between primary healthcare providers, secondary healthcare providers, and the social care domain. We also expect it to incentivise cost-conscious provider-behaviour, while safeguarding the quality of care, provided that adequate risk-mitigating actions, such as case-mix adjustment and cost-capping, are taken.

Implementation considerations for non-communicable disease-related integration in primary health care: a rapid review of qualitative evidence

BACKGROUND

Integrated delivery of primary health care (PHC) services is a health reform recommended for achieving ambitious targets of the Sustainable Development Goals and Universal Health Coverage, responding to growing challenges of managing non-communicable and multimorbidity. However, more evidence is needed on effective implementation of PHC integration in different country settings.

OBJECTIVE

This rapid review synthesized qualitative evidence on implementation factors affecting integration of non-communicable disease (NCD) into PHC, from the perspective of implementers. The review contributes evidence to inform the World Health Organizations' guidance on integration of NCD control and prevention to strengthen health systems.

METHOD

The review was guided by standard methods for conducting rapid systematic reviews. Data analysis was guided by the SURE and WHO health system building blocks frameworks. We used Confidence in the Evidence of Reviews of Qualitative Research (GRADE-CERQual) to assess the confidence of the main findings.

RESULTS

The review identified 81 records eligible for inclusion, from 595 records screened. We sampled 20 studies for analysis (including 3 from expert recommendations). Studies covered a wide range of countries (27 countries from 6 continents), the majority from low-and middle-income countries (LMICs), with a diverse set of NCD-related PHC integration combinations and implementation strategies. The main findings were categorised into three overarching themes and several sub-themes. These are, A: Policy alignment and governance, B: Health systems readiness, intervention compatibility and leadership, and C: Human resource management, development, and support. The three overarching findings were assessed as each having a moderate level of confidence.

CONCLUSION

The review findings present insights on how health workers responses may be shaped by the complex interaction of individual, social, and organizational factors that may be specific to the context of the intervention, the importance of cross-cutting influences such as policy alignment, supportive leadership and health systems constraints, knowledge that can inform the development of future implementation strategies and implementation research.

Collective Competence as an Enabler for Service Integration in Health and Social Care Services

PURPOSE

Fragmentation in health and social care services can result in poor access to services, lack of continuity and inadequate provision for needs. A focus on integration of services are thus suggested to prevent negative consequences of fragmentation for service recipients. There are, however, few studies that explore the competence needed for integration of services in municipal health and social care organizations. This study explores which types of competence stakeholders require and how collective competence can promote service integration.

METHODS

This is a single-case study, and the data consist of focus group interviews and individual interviews with service recipients, family caregivers, professionals and managers. The data were analysed both inductively and deductively.

RESULTS

The analysis resulted in four main themes: 1) Knowledge about individual life situations and organization and system, 2) investigation competence, 3) person-centred collaboration competence and 4) facilitating competence. The themes form the basis for a collective competence framework that can promote service integration.

CONCLUSION

As service integration involves a high degree of interlinked activities between professionals and organizational units, a collective approach to the concept of competence is presumably applicable. When service integration competence is approached as a collective attribute of a network within and between organizational units, the organization can facilitate this competence by encouraging an active exchange of knowledge between professionals. We also argue that service integration competence increases connectivity and interdependency between professionals and organizational units, and includes service recipients and family caregivers as legitimate extra-professional parts of the collaborative network.

Predictors and outcomes in primary depression care (POKAL) - a research training group develops an innovative approach to collaborative care

BACKGROUND

The interdisciplinary research training group (POKAL) aims to improve care for patients with depression and multimorbidity in primary care. POKAL includes nine projects within the framework of the Chronic Care Model (CCM). In addition, POKAL will train young (mental) health professionals in research competences within primary care settings. POKAL will address specific challenges in diagnosis (reliability of diagnosis, ignoring suicidal risks), in treatment (insufficient patient involvement, highly fragmented care and inappropriate long-time anti-depressive medication) and in implementation of innovations (insufficient guideline adherence, use of irrelevant patient outcomes, ignoring relevant context factors) in primary depression care.

METHODS

In 2021 POKAL started with a first group of 16 trainees in general practice (GPs), pharmacy, psychology, public health, informatics, etc. The program is scheduled for at least 6 years, so a second group of trainees starting in 2024 will also have three years of research-time. Experienced principal investigators (PIs) supervise all trainees in their specific projects. All projects refer to the CCM and focus on the diagnostic, therapeutic, and implementation challenges.

RESULTS

The first cohort of the POKAL research training group will develop and test new depression-specific diagnostics (hermeneutical strategies, predicting models, screening for suicidal ideation), treatment (primary-care based psycho-education, modulating factors in depression monitoring, strategies of de-prescribing) and implementation in primary care (guideline implementation, use of patient-assessed data, identification of relevant context factors). Based on those results the second cohort of trainees and their PIs will run two major trials to proof innovations in primary care-based a) diagnostics and b) treatment for depression.

CONCLUSION

The research and training programme POKAL aims to provide appropriate approaches for depression diagnosis and treatment in primary care.

[Patients, Partners, Professionals, Payers and Policy Makers Preferences for Integrated Care for Multimorbidity in Germany: A Discrete Choice Experiment]

AIM OF THE WORK

The aim of this study was to measure and compare the relative importance that patients with multimorbidity, partners and other informal caregivers, professionals, payers and policy makers attribute to different outcome measures of integrated care (IC) programmes in Germany.

METHODS

A DCE was conducted, asking respondents to choose between two IC programmes for persons with multimorbidity. Each IC programme was presented by means of attributes or outcomes reflecting the Triple Aim. They were divided into the outcomes health/ wellbeing, experience with care and costs with in total eight attributes and three levels of performance.

RESULTS

The results of n=676 questionnaires showed that the attributes "enjoyment of life" and "continuity of care" received the highest ratings across all stakeholder groups. The lowest relative scores remained for the attribute "total costs" for all stakeholders. The preferences of professionals and informal caregivers differed most distinctly from the patients' preferences. The differences mostly concerned "physical functioning", which was rated highest by patients, and "person centeredness" and "continuity of care", which received the highest ratings from professionals.

CONCLUSIONS

The preference heterogeneities identified in relation to the outcomes of IC programmes between different stakeholders highlight the importance of informing professionals and policy makers about the different perspectives in order to optimise the design of IC programmes. The results also support the relevance of joint decision-making and coordination processes between professionals, informal caregivers and patients.

An evaluation of speech and language therapy services for people with long COVID in the UK: a call for integrated care

Purpose

Long COVID is a complex and highly heterogeneous condition with a variable symptom profile, and calls have been made for an integrated care approach to be taken for its management. To date, no studies have explored speech and language therapy services or needs associated with long COVID. This service evaluation aimed to gauge the level of demand on speech and language therapy services for individuals with long COVID in the UK; their clinical needs, the organisational arrangements of services and the barriers and facilitators of delivering quality care.

Design/methodology/approach

A service evaluation was undertaken via distribution of an online survey to speech and language therapists (SLTs) receiving referrals for individuals with long COVID. Analysis was completed using descriptive statistics, with thematic analysis to evaluate qualitative data.

Findings

One hundred and eleven SLTs responded. Eighty-six percent were seeing individuals with long COVID in their “everyday” service, in uni- or multi-disciplinary teams, without any “dedicated” resource. Dysphagia and dysphonia were the most reported symptoms. Most respondents (66.7%) indicated the individuals they were seeing were of working age, and that an individuals' speech and language therapy needs were impacting their wellbeing. Perceived barriers to quality care included fragmented and non-integrated care pathways. Multi-disciplinary and integrated working was a key enabler.

Originality/value

This study provides novel insights into the current speech and language therapy needs of and care pathways for individuals with long COVID in the UK SLTs have unique expertise and are integral to supporting individuals with long COVID and should be a part of integrated care teams.

German physicians' expectations of healthcare management companies: An exploratory study

Background and aims

Even 20 years after the introduction of managed care (MC) in Germany, many physicians are skeptical of the concept, hindering its acceptance.

Methods

Based on multivariate statistical methods this exploratory study examines how so-called management companies, that is, administrative service providers within MC contracts, can increase physicians' acceptance of MC by offering, for example, day-to-day coordination and administrative tasks.

Results

As a main empirical result, we find support for this hypothesis, that is, that certain physicians evaluate their MC participation according to its prospective administrative support. Based on this, up to four clusters of physicians can be statistically identified in terms of their preferences regarding MC.

Conclusion

As a policy recommendation, we derive from our results that a future focus on the administrative support components of MC is essential to attract certain physician groups to participate in MC.

Commissioning [Integrated] Care in England: An Analysis of the Current Decision Context

Background:

Methods:

Results:

Conclusion:

Prospective cohort study for assessment of integrated care with a triple aim approach: hospital at home as use case

Background

Applicability of comprehensive assessment of integrated care services in real world settings is an unmet need. To this end, a Triple Aim evaluation of Hospital at Home (HaH), as use case, was done. As ancillary aim, we explored use of the approach for monitoring the impact of adoption of integrated care at health system level in Catalonia (Spain).

Methods

Prospective cohort study over one year period, 2017–2018, comparing hospital avoidance (HaH-HA) with conventional hospitalization (UC) using propensity score matching. Participants were after the first episode directly admitted to HaH-HA or the corresponding control group. Triple Aim assessment using multiple criteria decision analysis (MCDA) was done. Moreover, applicability of a Triple Aim approach at health system level was explored using registry data.

Results

HaH-HA depicted lower: i) Emergency Room Department (ER) visits (p < .001), ii) Unplanned re-admissions (p = .012); and iii) costs (p < .001) than UC. The weighted aggregation of the standardized values of each of the eight outcomes, weighted by the opinions of the stakeholder groups considered in the MCDA: i) enjoyment of life; ii) resilience; iii) physical functioning; iv) continuity of care; v) psychological wellbeing; (vi) social relationships & participation; (vii) person-centeredness; and (viii) costs, indicated better performance of HaH-HA than UC (p < .05). Actionable factors for Triple Aim assessment of the health system with a population-health approach were identified.

Conclusions

We confirmed health value generation of HaH-HA. The study identified actionable factors to enhance applicability of Triple Aim assessment at health system level for monitoring the impact of adoption of integrated care.

Registration

ClinicalTrials.gov (26/04/2017; NCT03130283).

Supplementary Information

The online version contains supplementary material available at 10.1186/s12913-022-08496-z.

Family-oriented interventions in long-term care residential facilities for older people: A scoping review of the characteristics and outcomes

INTRODUCTION

Family-oriented interventions in long-term care (LTC) residential facilities are heterogenous in design, characteristics, and outcomes.

OBJECTIVES

To synthesize characteristics (e.g., type, provider, and duration) and outcomes of family-oriented interventions in LTC residential facilities.

METHODS

We followed the JBI methodology and searched seven databases for quantitative, qualitative, and mixed method studies that reported family-oriented interventions in LTC residential settings for older people; defined in this review as ≥60 years. Interventions that included residents, resident families, health professionals, or any combinations of these three were included if the study reported post-intervention assessment of at least one family-related outcome.

RESULTS

Thirteen studies met the inclusion criteria. Interventions were found to be multifaceted, and education was the most common element. Nurses were the most common intervenors, and most interventions had more than one target (residents, resident families, or staff). Most outcomes were related to family involvement, satisfaction with care, quality of life, communication, symptom management, and shared decision making, and none of the studies reported a negative impact.

CONCLUSIONS

Family-oriented interventions were associated with high care quality and better resident-staff-family partnership. Staff education and staff-family conversation are relatively cheap interventions to help family involvement, facilitate shared decision-making, and improve family satisfaction.

Nurse-led care management models for patients with multimorbidity in hospital settings: A scoping review

AIM

The aim of this scoping review is to map the nurse-led care management models for patients with multimorbidity in hospital settings.

BACKGROUND

Patients with multimorbidity in hospital, due their complexity, benefit a nurse-led care management model. This care management model allows for better identification of patients' needs and a person-centred approach.

EVALUATION

This review followed the JBI methodology for scoping reviews. The search included the international databases Web of Science, CINAHL, MEDLINE, Nursing & Allied Health Collection and grey literature. A total of 21 articles were included in the final content analysis.

KEY ISSUES

Three categories of nurse-led care management models emerged from the data, namely, nurse-led programs, case management and nurse facilitator models. The interventions focused on training, discharge support, follow-up, health promotion and patient-centred care.

CONCLUSION

The centrality of the patient is a common characteristic of nurse-led care models, namely, the acquisition of disease self-management skills, preparation for hospital discharge and continuity of care in the community.

IMPLICATIONS FOR NURSING MANAGEMENT

Nurse-led care management models can empower patients to manage their chronic conditions more effectively. Adapting these care management models in hospital settings will be a challenge for nurse managers.

SCOPING REVIEW PROTOCOL

The full protocol used can be accessed at doi:10.11124/jbies-20-00222.

Design, development, and evaluation of a registry system for hyperbaric oxygen therapy: A methodological study

BACKGROUND AND AIMS

Hyperbaric oxygen therapy (HBOT), utilizes 100% oxygen at pressures greater than sea-level atmospheric pressure, for the treatment of conditions in which the tissues starve for oxygen. The Undersea and Hyperbaric Medical Society (UHMS) has granted HBOT approval for the treatment of various conditions. On the other hand, applying informatics registry systems can improve care delivery, ameliorate outcomes, and reduce the costs and medical errors for the patients receiving HBOT treatment. Therefore, we aimed to design, develop, and evaluate a registry system for patients undergoing HBOT.

METHODS

In the first phase, the conceptual and logical models were designed after conducting symposiums with experts and having other experts review the models. In the second phase, the system was developed on the web using ASP.NET  and C# programming languages frameworks. The last phase involved Nielsen's heuristic evaluation method for the system's usability. Five experts evaluated the system, including three health information management specialists and two medical informatics specialists.

RESULTS

The hyperbaric patient information registry system (HPIRS) interacts with three types of users-a specialist physician, a nurse, and a system administrator. A scenario for each predefined activity was designed, and all the information was stored in the SQL servers. The five experts independently found 152 issues, of which 84 were duplicates. The 68 distinct issues of the system were then resolved.

CONCLUSIONS

The design and development of such registry systems can make data available and stored carefully to improve clinical care and medical research and decrease costs and errors. These registries can provide the healthcare systems with E-health applications, improved data management, more secure data transfer, and support for statistical reporting. The implemented heuristic evaluation method can also provide a low-cost and readily available system to fix the issues of the designed systems.

Assessment of health system performance in Germany: Survey-based insights into the perspective of people with private health insurance

INTRODUCTION

The World Health Organization (WHO) defined intermediate and overall goals to assess the performance of health systems. As the population perspective becomes more important for improving health systems, the aim of this study was to gain insights into the perspective of people with private health insurance (PHI) in Germany along the predefined WHO goals.

METHODS

A cross-sectional survey was conducted in 2018 among people with PHI in Germany. The questionnaire included items on all intermediate (access, coverage, quality, and safety) and overall WHO goals (improved health, responsiveness, social and financial risk protection, and improved efficiency). Descriptive analyses were conducted for the total sample and subgroups (gender, age, income, and health status).

RESULTS

In total, 3601 respondents (age 58.5 ± 14.6; 64.7% male) assessed the German health system. For example, 3.3%-7.5% of the respondents with subjective needs reported forgone care in the past 12 months due to waiting time, distance, or financial reasons and 14.4% suspected medical errors in their care. During the last physician visit 94.2% experienced respectful treatment but only 60.6% perceived coordination of care as good. Unnecessary health services were perceived by 24.2%. For many items significant subgroup differences were found, particularly for age groups (18-64 vs. 65+).

CONCLUSION

Conducting a health system performance assessment from the population perspective gained new and unique insights into the perception of people with PHI in Germany. Areas to improve the health system were seen in, for example, coordination of care, financial risk protection, and quality of care, and inequalities between subgroups were identified.

Evolutionary game model of health care and social care collaborative services for the elderly population in China

INTRODUCTION

The synergy of health care and elderly social care organizations has become the focus of the research on integrated health care and social care. This study aims to propose a collaborative strategy among health care and elderly social care service providers.

METHODS

An evolutionary game model is applied for performance analysis and optimization of the cooperation between health care and elderly social care organizations. The behavioural strategies and the impact of key parameters on promoting the cooperation of the players are presented in detail.

RESULTS

Simulation experiments and sensitivity analysis results indicate that (1) the behavioural evolution of health care organizations and elderly social care organizations forms three types of integrated health care and social care services, namely, the bilateral cooperation type, health care organization-led type and elderly social care organization-led type. (2) Increasing the additional benefits for cooperation and reducing the additional costs for cooperation can promote the willingness to synergize to provide integrated health care and elderly social care services. At the early stage of evolution, increasing the costs that elderly social care organizations pay to purchase health care services or pay for negotiation in the bilateral cooperation type can provide incentives for health care organizations to cooperate while reducing the cooperation preferences of elderly social care organizations. However, the long-term impact of the costs on the behavioural strategies for cooperation of the two players cannot be determined.

CONCLUSION

The behavioural decisions on cooperation between health care and elderly social care organizations influence each other; commitment to integration and effective collaboration can be achieved by increasing the additional benefits and reducing the marginal costs. The findings suggest that the political-economic context and government policies have a greater influence on promoting cooperation, thus yielding positive or negative results for integrated care practice.

The development of a platform to ensure an integrated care plan for older adults with complex care needs living at home

Purpose

The purpose of this paper is to describe the design and development of the digital platform for the development and monitoring of care plans for older adults with complex care needs who are users of a home care service.

Design/methodology/approach

Case study. The authors conducted an iterative process of design adapted to the environment and user-centred, agile development and research methodologies and a framework of complex interventions. They followed a four-step process: (1) conceptualization: analysis and design; (2) usability and high-fidelity prototyping; (3) software development; and (4) field testing in usual care. Older adults, informal caregivers, professional caregivers, and healthcare and social workers identified specific requirements and participated continuously through interviews, focus groups and consensus.

Findings

In the conceptualization phase, the theory, context and requirements were identified, and the content and prototypes were developed. In the usability phase, the design was validated. The approach employed resulted in a digital technology that supports a person-centred care model in a home care company. In the conceptualization phase, the theory, context and requirements were identified, and the content and prototypes were developed. In the usability phase, the design was validated. The approach employed resulted in a digital technology that supports a person-centred care model in a home care company.

Originality/value

The methodology employed has allowed the development of a platform based on theory, user needs and context. This could increase the possibilities of use and implementation of the technology and inspire other developers.

Heterogeneity in preferences for outcomes of integrated care for persons with multiple chronic diseases: a latent class analysis of a discrete choice experiment

Purpose

For an integrated care programme to be successful, preferences of the stakeholders involved should be aligned. The aim of this study is to investigate to which extent outcomes beyond health are valued and to study the heterogeneity of preferences of those involved in integrated care.

Methods

A discrete choice experiment (DCE) was conducted to elicit preferences for eight Triple Aim outcomes, i.e., physical functioning, psychological well-being, social relationships & participation, enjoyment of life, resilience, person-centeredness, continuity of care and total health and social care costs. Stakeholders were recruited among Dutch persons with multi-morbidity, informal caregivers, professionals, payers, and policymakers. A Bayesian mixed-logit model was used to analyse the data. Subsequently, a latent class analysis was performed to identify stakeholders with similar preferences.

Results

739 stakeholders completed the DCE. Enjoyment of life was perceived as the most important outcome (relative importance: 0.221) across stakeholders, while total health and social care costs were perceived as least important (0.063). The latent class analysis identified four classes. The first class (19.9%) put most weight on experience with care outcomes. The second class (39%) favoured enjoyment of life. The third class (18%) focused relatively more on physical health. The fourth class (24%) had the least consistent preferences.

Conclusion

This study has highlighted the heterogeneity in views of stakeholders in integrated care on what is important in health(care) for persons with multi-morbidity. To accurately value integrated care a variety of outcomes beyond health–e.g., enjoyment of life and experience with care–should be taken into account.

Supplementary Information

The online version contains supplementary material available at 10.1007/s11136-022-03147-6.

Home care for patients with dirty homes: a qualitative study of the problems experienced by nurses and possible solutions

BACKGROUND

Home-care nurses are often the first care professionals to enter a dirty home. The perceived problems and support needs of home-care nurses in these situations are largely unknown.

OBJECTIVE

To examine the problems home-care nurses encounter in caring for patients living in dirty homes, and possible solutions for these problems.

DESIGN

Qualitative descriptive research.

SETTING

Communities across the Netherlands.

PARTICIPANTS

Twenty-three participants to investigate the problems or needs experienced, and 20 participants to investigate solutions. Participants included patients, home-care nurses and other professionals working in the community.

METHODS

Semi-structured interviews were conducted with 23 participants and analysed according to the principles of deductive thematic analysis. Subsequently, in interviews with 4 (representatives of) patients and four focus-group sessions with 16 professionals, the problems found were validated and solutions to the problems discussed.

RESULTS

Ten subthemes emerged that were clustered into three main themes: 'dilemmas arise in choosing the right nursing care'; 'cooperation and an integrated approach are often necessary, but lacking'; 'home-care nurses have insufficient competencies'. Seven possible solutions were found: (1) strengthening collaboration between organizations in the community; (2) involving others sooner; (3) case management; (4) person-centred care; (5) taking more time; (6) providing home-care nurses with tools and support services; and (7) strengthening the competencies of nurses.

CONCLUSIONS

Care for patients with a dirty home is complex. An integrated person-centred care approach is often necessary and home-care nurses need extra support to provide such care. Interventions should not only focus on patients, but address the nurses, the organization, and the collaboration between organizations in the community.

Construction of a conceptual model of comprehensive care for Indonesian children with human immunodeficiency virus

PURPOSE

To construct a conceptual model of comprehensive care for Indonesian children with Human Immunodeficiency Virus.

DESIGN AND METHODS

A qualitative constructivist grounded theory design. Purposive sampling was used to interview 12 children with Human Immunodeficiency Virus and 8 family members with the age of the children ranged from 9 to 18 years, and 23 health professionals, including general practitioners, paediatric specialists, nurses, midwife, and nutritionist from public health centres and provincial hospitals in East Java, Indonesia. Data was analysed using constant comparative coding methods, theoretical sensitivity, memo writing, and diagramming to facilitate the development of the substantive theory.

RESULTS

Exploring the perspectives of the participants has revealed the need to enhance the delivery of comprehensive care across the continuum, because HIV care and services for children was sub-optimal. Understanding children's needs and preferences forms the foundation of the development of a framework for the comprehensive care of children with HIV consisting of child-centred care and social support, delivered by integration and coordination of care through a healthcare service.

CONCLUSIONS

The conceptual model provides new knowledge and has the capacity to bring together optimal care across the continuum addressing the challenges of fragmentation of care for children and their families.

PRACTICE IMPLICATIONS

The model informs that children with HIV not only need pharmacotherapy, but also other care interventions depending on their individual needs, preferences, and age. Implementing the model may help to resolve such problems, to improve collaborative practice and enhance children's participation, thereby promoting children's health outcomes.

Shifting paradigms: Developmental milestones for integrated care

Frameworks for understanding integrated care risk underemphasizing the complexities of the development of integrated care in a local context. The objectives of this article are to (1) present a novel strategy for conceptualizing integrated care as developing through a series of milestones at the organizational level, and (2) present a typology of milestones empirically generated through the analysis of four cases of integrated community-based primary health care (ICBPHC) in Canada and New Zealand. Our paper reports on an analysis of 4 specific organizational case studies within a large dataset generated for an international multiple case study project of exemplar models of ICBPHC. Drawing on earlier analyses of 359 qualitative interviews with patients, caregivers, health care providers, managers, and policymakers, in this article we present a detailed analysis of 28 interviews with managers and leaders of local models of integrated care. We generated a detailed timeline of the development of integrated care as expressed by each participant, and synthesized themes across timelines within each case to identify specific milestone events. We then synthesized across cases to generate the broader milestone categories to which each event belongs. We generated 5 milestone categories containing 12 more specific milestone events. The milestone categories include (1) strategic relational, (2) strategic process change, (3) internal structural, (4) inter-organizational structural, and (5) external milestones. We propose a comprehensive framework of developmental milestones for integrated care. Milestones represent a compelling strategy for conceptualizing the development of integrated care. Practically, policymakers and health care leaders can support the implementation of integrated care by examining the history and context of a given model of care and identifying strategies to achieve milestones that will accelerate integrated care. Further research should document additional milestone events and advance the development of dynamic frameworks for integrated care.