Exploring improvement plans of fourteen European integrated care sites for older people with complex needs

Models of Integrated Acute Care for Older Adult Inpatients That Incorporate Integrative Health: An Integrative Review

Background

The use of integrated acute care for older adult inpatients is a growing field, especially the use of integrative health-care practices for managing complex, chronic, age-related health conditions. Scientific evidence suggests that these practices should be incorporated into older adult inpatients' daily care.

Aim

Conduct an integrative review of studies on integrated acute-care models for older adult inpatients that incorporate integrative health services.

Methods

We searched Medline Ovid ALL, Embase.com, CINAHL, APA PsycINFO Ovid, Web of Science Core Collection, ProQuest Dissertations & Theses A&I, Cochrane Library, and CAMBase bibliographic databases for studies, published between 1990 and 2023, on integrated acute-care models for older adult inpatients that incorporated integrative health services. The search associated the domains of acute care, geriatrics, internal medicine, rehabilitation, hospitalization, geriatric psychiatry, integrated/integrative care, care models, practices and coordination, interprofessionalism and multidisciplinarity, collaborative practices, and complementary therapies. The review was completed in June 2024.

Results

We retained 32 studies conducted in North America, Europe, Australia, and Asia, including 46,899 older adult inpatients, 39 physicians, 148 nurses, 695 allied health-care professionals, and 358 informal caregivers. Three integrated acute care models were identified: the Acute Care for Elders model, the Integrated General Hospital model, and the Transitional Care model. Three integrated acute psychogeriatric-care models were identified: the Admiral Nursing model, the Lewy body dementia Admiral nursing service model, and the Care for Acute Mentally Infirm Elders model. A single, hybrid, Integrated, People-Centred Health Services model for acute and community health care was identified. We found the Scaling Integrated Care in Context model for measuring integrated care development within health-care systems.

Conclusion

Few studies have investigated integrated acute-care models incorporating integrative health services for older adult inpatients. Existing acute-care models including integrative medicine should be explored further, and new, more inclusive models should be developed.

Socio-Healthcare for Older People in the Mediterranean Basin: An Integrative Review and Quality Appraisal

OBJECTIVES

The aging Mediterranean Basin population presents complex challenges for healthcare systems, which require innovative care approaches. The study aimed to critically assess 19 socio-healthcare practices in the Mediterranean Basin that target the elderly population by analyzing their theoretical foundations, integration of care services, ethical considerations, gender-specific approaches, and use of technology.

DESIGN

An integrative literature review was conducted using a structured methodology.

SAMPLE

Diverse sources across multiple languages were searched, with the inclusion criteria focusing on the alignment of socio-healthcare practices with the components of the nursing metaparadigm, the incorporation of transversal values, and relevance to the elderly population.

RESULTS

The socio-healthcare practices exhibited common themes, such as person-centered care, interdisciplinary collaboration, and incorporation of technology for coordinated care delivery. Ethical principles of autonomy, dignity, and respect were central, with some socio-healthcare practices addressing gender-specific care needs. Evidence-based findings emphasized holistic care, integration, ethics, and innovation in elderly socio-healthcare.

CONCLUSIONS

New eldercare frameworks should integrate these aspects, which offer a comprehensive approach to addressing the complex needs of elderly patients. Managers should design systems prioritizing patient well-being, whereas policymakers should develop equitable and high-quality care policies that collectively improve the well-being of the elderly population in the Mediterranean Basin.

How comprehensive is our comprehensive geriatric assessment in clinical practice? An Irish perspective

PURPOSE

Comprehensive geriatric assessment (CGA) is the cornerstone of high-quality care for older adults. There is no current gold standard to guide what should be included as the baseline measure for CGAs. We examined what metrics are being captured in CGA baseline assessments completed by community based integrated care teams in Ireland.

METHODS

CGA's care pathways in Ireland are usually initiated with a written document that establish patients baseline in various assessment areas. These documents were the focus of this study. We completed a cross-sectional study of the components captured in CGA baseline assessments completed in a community setting. We contacted operational leads in each of the community health organisations in Ireland and requested a copy of their current initial baseline screening document for CGA.

RESULTS

We reviewed 16 individual CGA baseline documents for analysis in this study. Common assessment areas in all documents included frailty (with the Rockwood Clinical frailty scale used in 94%, n = 15), cognition (4AT-56% of CGAs, MMSE-25%, MOCA-25%, AMTS-19%, AD8-19%, Addenbrookes-13%, 6CIT-13%, mini cog-6%), mobility (100%, n = 16), falls (100%, n = 16), continence (100% n = 16), nutrition (100% n = 16). Mood (94%, n = 15), pain (44%, n = 7), bone health (63%, n = 10), sleep (62%, n = 10) and skin integrity (56%, n = 9). Formal functional assessment was completed in 94% (n = 15) of CGAs with the Barthel index being the tool most used 81% (n = 13). Half of the CGAs included a section describing carer strain (50%, n = 8). The majority of CGAs included a patient centred question which was some variation of 'what matters most to me' (75% n = 11). 87.5% of assessments included a care plan summary (n = 14).

CONCLUSIONS

This report highlights that the core tenets of CGA are being assessed across different community based initial CGA screening instruments. There was significant variability in the discussion of challenging topics such as carer strain and social well-being. Our results should prompt a discussion about whether a minimum dataset should be developed for inclusion in nationwide initial baseline CGA document, aiming to improve standardisation of assessments, which will impact areas highlighted for intervention and ultimately guide population health policy.

Ethical challenges and principles in integrated care

INTRODUCTION

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

SOURCES OF DATA

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

AREAS OF AGREEMENT

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

AREAS OF CONTROVERSY

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

GROWING POINTS

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

Barriers and Facilitators in the Implementation of Prevention Strategies for Chronic Disease Patients-Best Practice GuideLines and Policies' Systematic Review

Visits of chronically ill patients account for 80% of primary care consultations. Approximately 15-38% of patients have three or more chronic diseases, and 30% of hospitalisations result from the deteriorating clinical condition of these patients. The burden of chronic disease and multimorbidity is increasing in combination with the growing population of elderly people. However, many interventions found to be effective in health service studies fail to translate into meaningful patient care outcomes across multiple contexts. With the growing burden of chronic diseases, healthcare providers, health policymakers, and other healthcare system stakeholders are re-examining their strategies and opportunities for more effective prevention and clinical interventions. The study aimed to find the best practice guidelines and policies influencing effective intervention and making it possible to personalize prevention strategies. Apart from clinical treatment, it is essential to increase the effectiveness of non-clinical interventions that could empower chronic patients to increase their involvement in therapy. The review focuses on the best practice guidelines and policies in non-medical interventions and the barriers to and facilitators of their implementation into everyday practice. A systematic review of practice guidelines and policies was conducted to answer the research question. The authors screened databases and included 47 full-text recent studies in the qualitative synthesis.

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

Introduction:

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

Methods:

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

Results:

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

Discussion and conclusion:

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

Can the interconnection between public health and social work help address current and future population health challenges? A public health viewpoint

The debate over the function and role of public health in all societies (high, middle, and low-income) still continues today. Public health needs to interact with the social and translational sciences to achieve the best possible scientific evidence and practice aimed at development of effective policies for individual and population health practices. As a field, public health is most suited for development of transdisciplinary education, research and practice—improving population health would entail embedding with a variety of other disciplines including social work. Public health and social work in many ways share the same beginnings as well as their role in advocacy for social and health equity. For this reason, the transdisciplinary profession of public health social work is well placed to develop and build the inter-professional and cross-sectoral collaboration that is needed to address the many health challenges of the 21st century, based on theories, knowledge and interventions from both public health and social work. Furthermore, the profession can help in attempting to close the health inequalities gap, address social isolation, family violence and homelessness, advance long and productive lives, create social responses to the changing environment, reduce economic inequality, harness technology for social good, and work toward the achievement of justice and equality of opportunity.

Integrated care in Western Europe: a wise solution for the future?

INTRODUCTION

IC is a term commonly adopted across the world underpinning a positive attitude against fragmentation of healthcare service provision. While the principles supporting IC are simple, their implementation is more controversial.

AREAS COVERED

The growing number of IC definitions is related to the increasing domains of applications, which reflect the increasing demand induced by aging multi-morbid patients. A comprehensive definition of IC should now include the coordination of health and social services useful to deliver continuous care across organizational boundaries. The recent debate on IC is largely influenced by the mismatch between the increasing burden of health and social needs for chronic conditions from the demand side, and the design of health-care systems still focused on acute care from the supply side.

EXPERT OPINION

The major reasons of persisting IC weakness in European countries stem from arguable choices of health policy taken in the recent past. The political creed in 'market competition' is probably the most emblematic. All initiatives encouraging health-care providers to compete with each other are likely to discourage IC. Since most European GPs are still self-employed professionals working in their own cabinets, the anachronistic professional status of GPs is another historically rooted reason of IC weakness.

Integrated Care for Multimorbidity Population in Asian Countries: A Scoping Review

Background

The complex needs of patients with multiple chronic diseases call for integrated care (IC). This scoping review examines several published Asian IC programmes and their relevant components and elements in managing multimorbidity patients.

Method

A scoping review was conducted by searching electronic databases encompassing Medline, Embase, Scopus, and Web of Science. Three key concepts - 1) integrated care, 2) multimorbidity, and 3) Asian countries - were used to define searching strategies. Studies were included if an IC programme in Asia for multimorbidity was described or evaluated. Data extraction for IC components and elements was carried out by adopting the SELFIE framework.

Results

This review yielded 1,112 articles, of which 156 remained after the title and abstract screening and 27 studies after the full-text screening - with 23 IC programmes identified from seven Asian countries. The top 5 mentioned IC components were service delivery (n = 23), workforce (n = 23), leadership and governance (n = 23), monitoring (n = 15), and environment (n = 14); whist financing (n = 9) was least mentioned. Compared to EU/US countries, technology and medical products (Asia: 40%, EU/US: 43%-100%) and multidisciplinary teams (Asia: 26%, EU/US: 50%-81%) were reported less in Asia. Most programmes involved more micro-level elements that coordinate services at the individual level (n = 20) than meso- and macro-level elements, and programmes generally incorporated horizontal and vertical integration (n = 14).

Conclusion

In the IC programmes for patients with multimorbidity in Asia, service delivery, leadership, and workforce were most frequently mentioned, while the financing component was least mentioned. There appears to be considerable scope for development.

Highlights

First scoping review to synthesise the key components and elements of integrated care programmes for multimorbidity in Asia.All programmes emphasized 'distinctive service delivery', 'leadership', and 'workforce' components.'Financing' component was least mentioned in identified integrated care programmes.

Integrated care: easy in theory, harder in practice?

Integrated care (IC) is a term now commonly adopted across the world, which implies a positive attitude towards addressing fragmentation of service provision inside health systems. While the principles of IC are simple, their implementation is more controversial. The ever growing number of IC definitions is related to the increasing domains of applications, which reflect the increasing demand induced by ageing multi-morbid patients. An exhaustive definition of IC should now enclose the coordination of health and social services useful to deliver seamless care across organizational boundaries. The current debate on IC is largely fueled by the modern mismatch between the growing burden of health needs for chronic conditions from the demand side and the design of health systems still largely centered on acute care from the supply side. The major reasons of persisting IC weakness in Western European nations stem from arguable choices of health policy taken in a quite recent past. The political creed in 'market competition' is likely to be the most emblematic. All initiatives encouraging healthcare providers to compete with each other are likely to discourage IC. Another historically rooted reason of IC weakness is the occupational status of European general practitioners (GPs). While single large-scale organizations have become a pressing priority for a modern primary care, most GPs are still selfemployed professionals working in their own cabinets. It is time to reconsider the anachronistic status of GPs so as to enhance IC in the future.

Rapid evidence review to understand effective frailty care pathways and their components in primary and community care

Purpose

Different pathways of frailty care to prevent or delay progression of frailty and enable people to live well with frailty are emerging in primary and community care in the UK. The purpose of the study is to understand effective frailty care pathways and their components to inform future service development and pathway evaluation in primary- and community-care services.

Design/methodology/approach

A rapid evidence review was conducted: 11 research publications met the inclusion criteria and were analysed using narrative thematic synthesis.

Findings

There is strong evidence that resistance-based exercise, self-management support, community geriatric services and hospital at home (HAH) improve patient health and function. In general, evaluation and comparison of frailty care pathways, components and pathway operations is challenging due to weaknesses, inconsistencies and differences in evaluation, but it is essential to include consideration of process, determinant and implementation of pathways in evaluations.

Originality/value

To achieve meaningful evaluations and facilitate comparisons of frailty pathways, a standardised evaluation toolkit that incorporates evaluation of how pathways are operated is required for evaluating the impact of frailty pathways of care.

Measuring Older Peoples' Experiences of Person-Centred Coordinated Care: Experience and Methodological Reflections from Applying a Patient Reported Experience Measure in SUSTAIN

Introduction

While several evaluation studies on (cost-)effectiveness of integrated care have been conducted in recent years, more insight is deemed necessary into integrated care from the perspective of service users. In the context of a European project on integrated care for older people living at home (SUSTAIN), this paper shares the experience and methodological reflections from applying a Patient Reported Experience Measure (PREM) on person-centred coordinated care -the P3CEQ- among this population.

Methods

A combination of quantitative and qualitative data and analysis methods was used to assess the usability and the quality of applying a PREM among older people presenting complex care needs, using the P3CEQ delivery in SUSTAIN as a case study. 228 service users completed the P3CEQ and nine SUSTAIN researchers participated in a consultation about their experience administering the questionnaire. P3CEQ scores were analysed quantitatively using principal component analysis and multilevel linear regression. P3CEQ open responses and researcher notes collected when administering the questionnaire were thematically analysed.

Results

Service user inclusion was high and most P3CEQ items had low non-response rates. Quantitative analysis and researcher experience indicate the relevance of face-to-face administration for obtaining such an amount of data in this population group. The presence of a carer increased inclusion of more vulnerable respondents, such as the cognitively impaired, but posed a challenge in data interpretation. Although several P3CEQ items were generally understood as intended by questionnaire developers, the analysis of open responses highlights how questions can lead to diverging and sometimes narrow interpretations by respondents. Cognitive impairment and a higher educational attainment were associated with lower levels of perceived person-centredness of care.

Conclusion

This study shows essential preconditions to meaningfully collect and analyse PREM data on older peoples' experiences with integrated care: face-to-face administration away from care providers, collection of reasons for non-response and open comments providing nuances to answers, and multilevel modelling taking into account diversity in the target population. Several areas of improvement for future PREM use in this population have been identified: use of administration and coding guides, inclusion of clear and easy to understand definitions and examples illustrating what questions do and do not mean, measures of the expectations of person-centred coordinated care, and procedures ensuring sound ethical research. These methodological learnings can enhance future evaluation of integrated care from a service user perspective.

Exploring the determinants of synergetic development of social organizations participating in home-based elderly care service: An SEM method

The current aging service industry has problems in meeting the ever-increasing demand for the home-based elderly care service (HECS). Social organizations participating in HECS seems to be a promising way to address these problems but also raises new challenges, like uncoordinated cooperation among stakeholders, which could lead to low management efficiency and low service quality. However, Synergetic development can be promising to enhance the participation of social organizations and to improve social welfare. This study introduces a conceptual model to explore relationships between five determinants and synergetic development of social organizations participating in HECS. A structural equation model (SEM) based on questionnaire survey is used as a test methodology. The results indicated that stakeholder engagement plays a critical role in synergetic development in HECS, resource allocation can only be improved by institutional climate, and supervision capacity cannot facilitate information sharing. This study provides effective strategies and directions for the improvement of home-based elderly care services.

Advancing integrated care evaluation in shifting contexts: blending implementation research with case study design in project SUSTAIN

BACKGROUND

Despite many studies evaluating the effectiveness of integrated care, evidence remains inconsistent. There is increasing commentary pointing out the mismatch between the ability to capture the somewhat 'illusive' impact of integrated care initiatives and programmes, and the most appropriate way to do this. Focusing on methodology, this paper describes and critically reviews the experiences of SUSTAIN, a Horizon 2020 funded project (2015-2019) with the purpose of advancing knowledge and understanding of cross-European integrated care evaluation. SUSTAIN sought to improve integrated care initiatives for older people in seven countries, and to maximise the potential for knowledge transfer and application across Europe. The methods approach drew from implementation research, employing the participative Evidence Integration Triangle (EIT) and incorporating a mixed method, multiple embedded case study design. A core set of qualitative and quantitative indicators, alongside context and process data, were created and tested within four key project domains (person-centredness, prevention-orientation, safety and efficiency). The paper critically discusses the overall approach, highlighting the value of the EIT and case study design, and signalling the challenges of data collection with frail older people and stakeholder involvement at the sites, as well as difficulties developing the core set of indicators.

CONCLUSIONS

Lessons learned and recommendations for advancing integrated care evaluation are put forward that focus on the status of integrated care as a complex intervention and a process. The use of implementation research methods and case study design are recommended as an additional evaluation approach for researchers to consider, alongside suggested ways of improving methods of data collection with frail populations and cost analysis.

Improving Person-Centredness in Integrated Care for Older People: Experiences from Thirteen Integrated Care Sites in Europe

Introduction

Although person-centredness is a key principle of integrated care, successfully embedding and improving person-centred care for older people remains a challenge. In the context of a cross-European project on integrated care for older people living at home, the objective of this paper is to provide insight at an overarching level, into activities aimed at improving person-centredness within the participating integrated care sites. The paper describes experiences with these activities from the service providers' and service users' perspectives.

Methods

A multiple embedded case study design was conducted that included thirteen integrated care sites for older people living at home.

Results

Service providers were positive about the activities that aimed to promote person-centred care and thought that most activities (e.g. comprehensive needs assessment) positively influenced person-centredness. Experiences of service users were mixed. For some activities (e.g. enablement services), discrepancies were identified between the views of service providers and those of service users.

Discussion and conclusion

Evaluating activities aimed at promoting person-centredness from both the service providers' and service users' perspectives showed that not all efforts were successful or had the intended consequences for older people. Involvement of older people in designing improvement activities could ensure that care and support reflect their needs and preferences, and build positive experiences of care and support.

Addressing safety risks in integrated care programs for older people living at home: a scoping review

BACKGROUND

Many older people live at home, often with complex and chronic health and social care needs. Integrated care programs are increasingly being implemented as a way to better address these needs. To support older people living at home, it is also essential to maintain their safety. Integrated care programs have the potential to address a wide range of risks and problems that could undermine older people's ability to live independently at home. The aim of this scoping review is to provide insight into how integrated care programs address safety risks faced by older people living at home - an area that is rather underexplored.

METHODS

Safety was conceptualised as preventing or reducing the risk of problems, associated with individual functioning and behaviour, social and physical environments, and health and social care management, which could undermine older people's ability to live independently at home. For this scoping review a systematic literature search was performed to identify papers describing integrated care programs where at least one intervention component addressed safety risks. Data were extracted on the programs' characteristics, safety risks addressed, and the activities and interventions used to address them.

RESULTS

None of the 11 programs included in this review explicitly mentioned safety in their goals. Nevertheless, following the principles of our conceptual framework, the programs appeared to address risks in multiple domains. Most attention was paid to risks related to older people's functioning, behaviour, and the health and social care they receive. Risks related to people's physical and social environments received less attention.

CONCLUSION

Even though prevention of safety risks is not an explicit goal of integrated care programs, the programs address a wide range of risks on multiple domains. The need to address social and environmental risks is becoming increasingly important given the growing number of people receiving care and support at home. Prioritising a multidimensional approach to safety in integrated care programs could enhance the ability of health and social care systems to support older people to live safely at home.