Why doesn't integrated care work? Using Strong Structuration Theory to explain the limitations of an English case

Transforming healthcare by prioritizing qualitative and quantitative clinical trial evidence: evaluating the Aging, Community and Health Research Unit's Community Partnership Program for Older Adults (ACHRU-CPP)

BACKGROUND

This study aimed to test the effectiveness and implementation of a complex integrated care intervention for older adults. We collected both quantitative and qualitative data, which is recommended in evaluating complex interventions to gain a comprehensive understanding of key success factors. Often, congruence is sought and considered desirable when integrating the findings from both data types. However, data are not always congruent, nor is it suboptimal when incongruence occurs, as we illustrate in this case study. We present the divergent findings from a large community-based implementation-effectiveness hybrid type II trial, and how the struggle to reconcile incongruent results yielded rich insights informing the next steps for translational research on the intervention being tested.

METHODS

Previous foundational research, including a pilot study and randomized controlled trial (RCT), showed promising results and supported proceeding with a multi-site pragmatic hybrid type II effectiveness-implementation RCT. This recent RCT was undertaken and quantitative and qualitative data were collected to inform the effectiveness and implementation evaluation. To synthesize the findings and guide integration of this large body of evidence, we developed a conceptual model which combined two existing frameworks: the Consolidated Framework for Implementation Research and Quintuple Aim. We used this model to identify the evidence and relate it to relevant implementation and intervention determinants/outcomes. We then synthesized the evidence to distall the main messages regarding the future of the intervention, which involved reconciling apparently discrepant findings from the quantitative and qualitative approaches.

RESULTS

The current RCT showed no statistically significant effect for participants for the primary (or secondary) outcomes yet the implementation evaluation consistently found perceived benefits of the intervention for patients, providers, and the healthcare system. Qualitative evidence was critical in understanding contextual factors potentially responsible for the absence of a treatment effect (e.g., COVID-19), strategies to overcome challenges experienced in participant engagement and intervention delivery, and recent policy/practice setting changes which showed strong alignment with the intervention and supported its future implementation.

CONCLUSIONS

With the goal of the hybrid type II effectiveness and implementation study in mind, stakeholders encouraged proceeding with a scalability assessment to consider the evidence from the current trial within the context of our prior research, the broader literature for similar interventions, and the ever-changing policy context.

TRIAL REGISTRATION

clinicaltrials.gov NCT03664583. Registration date: September 10, 2018.

The Chinese version of the patients' experiences scale for older inpatients in the medical group: Instrument development and cross-sectional validation study

Value-based healthcare is increasingly emphasizing attention to patients' self-reported experiences. However, due to the lack of effective tools, older patients in China lack feedback on the comprehensive care experience. Based on the psychometric assessment procedure, we developed a new geriatric inpatient experience scale (GIES). The study comprised two stages: (1) instrument development and (2) empirical testing. Through literature screening and Delphi methods, 26 preliminary items were identified. The content and facial validity tests then produced 23 items across eight factors: 'Doctor-patient communication', 'Engagement', 'Privacy', 'Right to know', 'Services timeliness', 'Continuity care', 'Visiting environment', and 'Overall satisfaction'. Using reliability analysis, exploratory and confirmatory factor analysis to evaluate psychometric characteristics, GIES showed good reliability and structural validity. As a multidimensional instrument for the experience of older patients, the application of GIES in clinical practice can assist healthcare providers in identifying areas for improvement to improve care experiences and outcomes for older patients.

Implementing integrated care infrastructure: A longitudinal study on the interplay of policies, interorganizational arrangements and interoperability in NHS England

BACKGROUND

New models of care that integrate health and social care provision around the patient require a supportive infrastructure, including interorganizational arrangements and information systems. While public policies have been designed to facilitate visions of integrated care, these often neglect the implementation of effective and efficient delivery mechanisms.

METHOD

This study examines a decade of attempts to move from fragmented health and care delivery to integrated care at scale in NHS England by developing and implementing a support infrastructure. We undertook a longitudinal qualitative investigation -encompassing interviews and documentary analysis- of the implementation of interorganizational and digital interoperability infrastructures intended to support integrated care policies.

FINDINGS

Our findings underscore the long-term symbiotic relationship between institutional interorganizational frameworks and the construction of interoperability infrastructures, emphasizing how they mutually reinforce each other to support their ongoing evolution. Iterative, flexible, and experimental approaches to implementation provide opportunities to adapt to local realities while learning in the making.

CONCLUSION

This study underlines the importance of adaptable, locally-informed implementation strategies in supporting the vision of integrated care, and the need to understand such development as a long-term, ongoing process of construction and learning.

Scaling up integrated care: Can community hospitals be an answer? A multiple-case study from the Emilia-Romagna region in Italy

Integrated care is considered to be essential in improving care for people with chronic conditions who need continuous care. In 2022, the Italian Government asked all regions to build or renovate a massive number of community care facilities, employing European Next Generation funds, to be spent by 2026. Under the theoretical lens of the Structural Contingency Theory, the paper aims at aims at describing the contextual and organizational factors underlying the interconnection between integrated care and community hospitals. The study employs a multiple-case study design, relying both on quantitative and qualitative data, conducted in a 6 months-period. It investigated seven community hospitals belonging to a single Local Health Authority in Emilia-Romagna region in Italy. The choice of the empirical context was driven by Emilia-Romagna's long- and well-established tradition of community-based care. Overall, our analysis shows that community hospitals offers opportunities of integrated care, including better integration between care sectors, between primary care and specialist staff, between healthcare structures and their local community. The study confirms the value of the Structural Contingency Theory and its key message: implementation is not a mechanical step of the policy cycle and requires important adjustments to the planning phase according to environment and organizational factors.

Strategies and practices for organizational learning in integrated care

PURPOSE

The purpose of this study is to identify important strategies and practices supporting inter-organizational learning (IOL) in integrated care. The two research questions ask how organizational network architectures can help involved organizations overcome the barriers of IOL in integrated care (RQ1) and what design recommendations can strengthen the processes of IOL in integrated care (RQ2).

DESIGN/METHODOLOGY/APPROACH

This study applies a qualitative design to analyze an improvement initiative in a regional, integrated care service for elderly patients with multiple illnesses in Norway. An inductive thematic analysis for the triangulating of qualitative data from different sources was applied. Patterns within the data were organized into themes, categories and subcategories. No software was applied.

FINDINGS

The identified characteristics of the organizational network architectures supporting IOL in integrated care in the case under study were: equality of the involved parties, shared goals, recognition of expertise and the abilities to coordinate, design IOL processes and make joint decisions (RQ1). The categories of practices supporting the process of IOL were: insight into complex realities, contradictions, iteration, motivation and prototypes (RQ2).

ORIGINALITY/VALUE

This study offers much-needed insight into a successful approach for IOL in integrated care. The results offer strategies to be considered when building organizational networks for the improvement of integrated care and relevant practices useful when designing IOL processes in such care services. We believe such knowledge has important implications for policymakers, frontline personnel, education, research and leaders.

Integrated System Responses for Families Impacted by Violence: A Scoping Review

Introduction

Violence within families is a complex problem which significantly impacts health and wellbeing. Despite the ubiquitous call for integrated family violence service delivery, integrated approaches vary significantly and challenges to implementation remain. This scoping review explored how integrated approaches to family violence service delivery are conceptualised within international and Aotearoa New Zealand literature.

Methods

Following a documented scoping review process identified from literature, dynamic interplay between system agents within integrated family violence service delivery were mapped with the assistance of a complexity theory lens. We analysed characteristics of included studies, agents involved, how they interacted and the methods and mechanisms of integration among them.

Results

Seventy-two published reports were included. The most common interactions occurred between statutory agencies such as police and child protection. While health care service providers were included within 55 studies, their engagement was often peripheral. Qualitative analysis elucidated three broad pathways to service delivery impact underpinned by systems-centred, person-centred, or Indigenous-centred worldviews.

Discussion and Conclusion

Integrated approaches to family violence service delivery are highly variable. Despite a strong assumption that integration leads to improved safety, health, and wellbeing for care-seekers, most studies did not include evidence of such impact. Consideration of how worldviews characterise service provision provides insight into why integration has proven challenging over time.

Older adults experience of transition to the community from the emergency department: a qualitative evidence synthesis

AIM

Older adults comprise a growing proportion of Emergency Department (ED) attendees and are vulnerable to adverse outcomes following an ED visit including ED reattendance within 30 days. Interventions to reduce older adults' risk of adverse outcomes following an ED attendance are proliferating and often focus on improving the transition from the ED to the community. To optimise the effectiveness of interventions it is important to determine how older adults experience the transition from the ED to the community. This study aims to systematically review and synthesise qualitative studies reporting older adults' experiences of transition to the community from the ED.

METHODS

Six databases (Academic Search Complete, CINAHL, MEDLINE, PsycARTICLES, PsycINFO, and Social Science Full Text) were searched in March 2022 and 2023. A seven-step approach to meta-ethnography, as described by Noblit and Hare, was used to synthesise findings across included studies. The methodological quality of the included studies was appraised using the 10-item Critical Appraisal Skills Programme (CASP) checklist for qualitative research. A study protocol was registered on PROSPERO (Registration: CRD42022287990).

FINDINGS

Ten studies were included, and synthesis led to the development of five themes. Unresolved symptoms reported by older adults on discharge impact their ability to manage at home (theme 1). Limited community services and unresolved symptoms drive early ED reattendance for some older adults (theme 2). Although older adults value practical support and assistance transporting home from the ED this is infrequently provided (theme 3). Accessible health information and interactions are important for understanding and self-managing health conditions on discharge from the ED (theme 4). Fragmented Care between ED and community is common, stressful and impacts on older adult's ability to manage health conditions (theme 5). A line of argument synthesis integrated these themes into one overarching concept; after an ED visit older adults often struggle to manage changed, complex, health and care needs at home, in the absence of comprehensive support and guidance.

DISCUSSION/ CONCLUSION

Key areas for consideration in future service and intervention development are identified in this study; ED healthcare providers should adapt their communication to the needs of older adults, provide accessible information and explicitly address expectations about symptom resolution during discharge planning. Concurrently, community health services need to be responsive to older adults' changed health and care needs after an ED visit to achieve care integration. Those developing transitional care interventions should consider older adults needs for integration of care, symptom management, clear communication and information from providers and desire to return to daily life.

How Person-Centred Is Cardiac Rehabilitation in England? Using Bourdieu to Explore Socio-Cultural Influences and Personalisation

The National Health Service (NHS) cardiac rehabilitation patient care pathway has remained largely unchanged for many years despite, on average, half of all eligible patients declining to engage. To investigate reasons for non-engagement, we explored the experiences of ten cardiac patients who participated in cardiac rehabilitation, dropped out, or declined, as well as experiences of seven people deemed significant others by participants. Our ethnographic study involved participant observations, repeat in-depth semi-structured interviews, and reflexive journaling. Reflexive thematic analysis was conducted, focusing on participants' lived experiences. Utilising Bourdieusian concepts of habitus, capital, and field, this article highlights how personal biography, material conditions, and dispositional inclinations combine to make cardiac health care decision-making individual and complex. Despite this, health professionals were not always attuned to specific circumstances arising from differences in patients' experiences and lifeworlds. By considering service improvement recommendations that acknowledge socio-cultural influences, cardiac rehabilitation can work towards providing patients and their significant others with more appropriate, personalised, and person-centred support.

Effects of CDDO-EA in sepsis-induced acute lung injury: mouse model of endotoxaemia

OBJECTIVE

Aim: The aim of this research is to clarify the potential effect of CDDO-EA against experimentally sepsis induced lung injury in mice.

PATIENTS AND METHODS

Materials and Methods: Mice have divided into four groups: Sham group CLP group, Vehicle-treatment group, CDDO-EA-treated group: mice in this group received CDDO-EA 2mg/kg intraperitoneally, 1hr before CLP, then the animals were sacrificed 24hr after CLP. After exsAngpuinations, tissue samples of lung were collected, followed by markers measurement including, TNF-α, IL-1β, VEGF, MPO, caspase11, Angp-1and Angp-2 by ELISA, gene expression of TIE2 and VE-cadherin by qRT-PCR, in addition to histopathological study.

RESULTS

Results: A significant elevation (p<0.05) in TNF-α, IL-1β, MPO, ANGP-2, VEGF, CASPASE 11 in CLP and vehicle groups when compared with sham group. CDDO-EA group showed significantly lower levels p<0.05, level of ANGP-1 was significantly lower p<0.05 in the CLP and vehicle groups as compared with the sham group. Quantitative real-time PCR demonstrated a significant decrement in mRNA expression of TIE2&ve-cadherin genes p<0.05 in sepsis & vehicle.

CONCLUSION

Conclusions: CDDO-EA has lung protective effects due to its anti-inflammatory and antiAngpiogenic activity, additionally, CDDO-EA showes a lung protective effect as they affect tissue mRNA expression of TIE2 and cadherin gene. Furthermore, CDDO-EA attenuate the histopathological changes that occur during polymicrobial sepsis thereby lung protection effect.

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

BACKGROUND

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

METHODS

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

RESULTS

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

CONCLUSIONS

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

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

BACKGROUND

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

METHODS

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

RESULTS

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

CONCLUSIONS

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

Perceptions of the primary health care team about the implementation of integrated care of patients with type 2 diabetes and hypertension in Slovenia: qualitative study

BACKGROUND

Integrated care involves good coordination, networking, and communication within health care services and externally between providers and patients or informal caregivers. It affects the quality of services, is more cost-effective, and contributes to greater satisfaction among individuals and providers of integrated care. In our study, we examined the implementation and understanding of integrated care from the perspective of providers - the health care team - and gained insights into the current situation.

METHODS

Eight focus groups were conducted with health care teams, involving a total of 48 health care professionals, including family physicians, registered nurses, practice nurses, community nurses, and registered nurses working in a health education center. Prior to conducting the focus groups, a thematic guide was developed based on the literature and contextual knowledge with the main themes of the integrated care package. The analysis was conducted using the NVivo program.

RESULTS

We identified 12 main themes with 49 subthemes. Health care professionals highlighted good accessibility and the method of diagnostic screening integrated with preventive examinations as positive aspects of the current system of integrated care in Slovenia. They mentioned the good cooperation within the team, with the involvement of registered nurses and community nurses being a particular advantage. Complaints were made about the high workload and the lack of workforce. They feel that patients do not take the disease seriously enough and that patients as teachers could be useful.

CONCLUSION

Primary care teams described the importance of implementing integrated care for diabetes and hypertension patients at four levels: Patient, community, care providers, and state. Primary care teams also recognized the importance of including more professionals from different health care settings on their team.

Inter-Disciplinary Work in the Context of Integrated Care - a Theoretical and Methodological Framework

Inter-disciplinary team working is an essential mechanism for the delivery of integrated care. This paper summarises a narrative review of the research on the 'work' that teams do to develop inter-disciplinary practices, addressing the question 'How do interdisciplinary teams 'become' in the context of models of integrated care?'. The narrative review identities a gap in our understanding of the active boundary work that different disciplines working together to deliver care integration engage in when creating new interdisciplinary knowledge, creating an inter-disciplinary team identity and negotiating new social and power relations. This gap is particularly significant in relation to the role played by patients and care-givers. This paper presents a way of examining inter-disciplinary working as a process of creating knowledge, identity and power relations both in terms of a theoretical lens, circuits of power, and a methodology, institutional ethnography. An explicit focus on understanding power relations within inclusive inter-disciplinary teams in care integration will contribute to our understanding of the gap between theory and implementation of care integration by focusing on the 'work' that teams do to create new knowledge.

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

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

Strong structuration analysis of patterns of adherence to hypertension medication

Achieving blood pressure control is among the highest priorities for reducing the burden of cardiovascular diseases globally. Control is poor in the Philippines, especially in socioeconomically marginalised communities. This paper explores long-term adherence to anti-hypertensive medication in these communities, identifying 4 distinct medication adherence patterns. We draw on Strong Structuration Theory to explore motivations of action for those who are consistently adherent, consistently non-adherent, and those who became more or less adherent over time. We employ longitudinal qualitative methods comprising repeat interviews and digital diaries collected over 12 months by 34 participants. Twelve participants were consistently adherent, 9 consistently non-adherent, 9 increasingly adherent, and 4 increasingly non-adherent. For the consistently adherent, positive views about prescribed medication and family support encouraged adherence. Conversely, negative views of medication and lack of family support were notable amongst the consistently non-adherent, along with resistance to accepting a 'sick' label. A shift toward positive views of medication was detected amongst those whose adherence improved, along with worsening health and increased family support. A decrease in financial resources drove some participants to become less adherent, especially if they already held negative views toward medication. This study sheds light on the variety of medication adherence patterns among poor people with hypertension in the Philippines, as well as the complex web of elements influencing their treatment choices. The results point to the potential for measures that address concerns about medicines and increase family support.

Integrating Self-Management Education and Support in Routine Care of People With Type 2 Diabetes Mellitus: A Conceptional Model Based on Critical Interpretive Synthesis and A Consensus-Building Participatory Consultation

The integration of self-management education and support into the routine diabetes care is essential in preventing complications. Currently, however, there is no consensus on how to conceptualise integration in relation to self-management education and support. Therefore, this synthesis presents a framework conceptualising integration and self-management.

Methods

Seven electronic databases (Medline, HMIC, PsycINFO, CINAHL, ERIC, Scopus and Web of Science) were searched. Twenty-one articles met the inclusion criteria. Data were synthesised using principles of critical interpretive synthesis to build the conceptual framework. The framework was presented to 49 diabetes specialist nurses working at different levels of care during a multilingual workshop.

Results

A conceptual framework is proposed in which integration is influenced by five interacting components: the programme ethos of the diabetes self-management education and support intervention (content and delivery), care system organisation (the framework in which such interventions are delivered), adapting to context (the aspects of the people receiving and delivering the interventions), interpersonal relationship (the interactions between the deliverer and receiver of the intervention), and shared learning (what deliverer and receiver gain from the interactions). The critical inputs from the workshop participants related to the different priorities given to the components according to their sociolinguistic and educational experiences, Overall, they agreed with the conceptualisation of the components and their content specific to diabetes self-management education and support.

Discussion

Integration was conceptualised in terms of the relational, ethical, learning, contextual adapting, and systemic organisational aspects of the intervention. It remains uncertain which prioritised interactions of components and to what extent these may moderate the integration of self-management education and support into routine care; in turn, the level of integration observed in each of the components may moderate the impact of these interventions, which may also apply to the impact of the professional training.

Conclusion

This synthesis provides a theoretical framework that conceptualises integration in the context of diabetes self-management education and support in routine care. More research is required to evaluate how the components identified in the framework can be addressed in clinical practice to assess whether improvements in self-management education and support can be effectively realised in this population.

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.