Integrated health and social care in the community: A critical integrative review of the experiences and well-being needs of service users and their families

'"Health" Is Just One Piece in the Puzzle of Wellbeing': Shifting From Preventing Health Deterioration to Improving Wellbeing in a Participatory Action Research Project With Care-Experienced Older People

INTRODUCTION

Prevention of health deterioration is a key policy objective in Sweden informed by active and healthy ageing initiatives. However, the perspectives of older people with mobility and health limitations on current prevention initiatives are seldom gained meaning these initiatives may fail to align to with the priorities of people whose health has ostensibly already deteriorated. We aimed to explore older care-experienced people's perspectives on the topic of health deterioration prevention and highlight aspects that they think are important to prioritise.

METHOD

Eight older people with experience in giving or receiving formal or informal care were involved as lay co-researchers in a participatory action research project that involved recruiting 11 further older informants to participate in peer interviews or complete a logbook. In a series of 13, 2-h workshops held over 1 year, we undertook data generation, training, reflection and analytic activities inspired by framework analysis.

FINDINGS

The lay co-researchers found the topic of health deterioration to be negatively and narrowly focussed opting instead to pursue a focus on articulating aspects, or puzzle pieces, that influence the improvement of wellbeing. Six influential puzzle pieces (stigma, digitalisation, services, losses, meaning and interactions) were regarded as important to prioritise which together illustrated that wellbeing is continually shaped in an interplay with dominant, but manipulable, social norms.

CONCLUSION

This study highlights how the language of active and healthy ageing, which pervades policy and practice, is imbued with ageist and ableist subtexts that can influence older people's wellbeing and lead to exclusionary experiences in society. We highlight wider societal trends, particularly digitalisation and effectivisation, whose negative impact on older people's wellbeing could be mitigated through inclusive co-design and resistance to normative influences.

PUBLIC CONTRIBUTION

This project was initiated in dialogue with stakeholder representatives from pensioner organisations in a larger scale participatory action research project. The care-experienced lay co-researchers collaborated in all phases of this project-gaining funding, formulating research questions, planning the study design, generating data in peer interviews, analysing and interpreting data, disseminating findings, prioritising future research and co-authoring articles.

New models of health and social care for people in later life: mapping of innovation in services in two regions of the United Kingdom using a mixed method approach

BACKGROUND

Innovation for reforming health and social care is high on the policy agenda in the United Kingdom in response to the growing needs of an ageing population. However, information about new innovations of care being implemented is sparse.

METHODS

We mapped innovations for people in later life in two regions, North East England and South East Scotland. Data collection included discussions with stakeholders (n = 51), semi-structured interviews (n = 14) and website searches that focused on technology, evaluation and health inequalities. We analysed qualitative data using framework and thematic analyses. Quantitative data were analysed descriptively.

RESULTS

One hundred eleven innovations were identified across the two regions. Interviewees reported a wide range of technologies that had been rapidly introduced during the COVID-19 pandemic and many remained in use. Digital exclusion of certain groups of older people was an ongoing concern. Innovations fell into two groups; system-level ones that aimed to alleviate systems pressures such as preventing hospital (re)admissions, and patient-level ones which sought to enhance health and wellbeing directly. Interviewees were aware of the importance of health inequalities but lacked data to monitor the impact of innovations on these, and evaluation was challenging due to lack of time, training, and support. Quantitative findings revealed that two thirds of innovations (n = 74, 67%) primarily focused on the system level, whilst a third (n = 37, 33%) primarily focused on the patient-level. Overall, over half (n = 65, 59%) of innovations involved technologies although relatively few (n = 12, 11%) utilised advanced technologies. Very few (n = 16, 14%) focused on reducing health inequalities, and only a minority of innovations (n = 43, 39%) had undergone evaluation (most of which were conducted by the service providers themselves).

CONCLUSIONS

We found a wide range of innovative care services being developed for people in later life, yet alignment with key policy priorities, such as addressing health inequalities, was limited. There was a strong focus on technology, with little consideration for the potential to widen the health inequality gap. The absence of robust evaluation was also a concern as most innovations were implemented without support to monitor effectiveness and/or without plans for sustainability and spread.

Differences in Covid-19 mortality among persons 70 years and older in an integrated care setting in region Stockholm: a multi-level analysis between March 2020-February 2021

BACKGROUND

In Norrtälje municipality, within Region Stockholm, there is a joint integrated care organisation providing health and social care, which may have facilitated a more coordinated response to the covid-19 pandemic compared to the otherwise decentralised Swedish system. This study compares the risk of covid-19 mortality among persons 70 years and older, in the municipalities of Stockholm, Södertälje, and Norrtälje, while considering area and individual risk factors.

METHODS

A population-based study using linked register data to examine covid-19 mortality among those 70 + years (N = 127,575) within the municipalities of interest between the periods March-August 2020 and September 2020-February 2021. The effect of individual and area level variables on covid-19 mortality among inhabitants in 68 catchment areas were examined using multi-level logistic models.

RESULTS

Individual factors associated with covid-19 mortality were sex, older age, primary education, country of birth and poorer health as indicated by the Charlson Co-morbidity Index. The area-level variables associated were high deprivation (OR: 1.56, CI: 1.18-2.08), population density (OR: 1.14, CI: 1.08-1.21), and usual care. Together, this explained 85.7% of the variation between catchment areas in period 1 and most variation was due to individual risk factors in period 2. Little of the residual variation was attributed to differences between catchment areas.

CONCLUSION

Integrated care in Norrtälje may have facilitated a more coordinated response during period 1, compared to municipalities with usual care. In the future, integrated care should be considered as an approach to better protect and meet the care needs of older people during emergency situations.

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.

Transforming Integrated Care Through Co-production: A Systematic Review Using Meta-ethnography

Introduction

There is a requirement for health and care systems and services to work on an equitable basis with people who use and provide integrated care. In response, co-production has become essential in the design and transformation of services. Globally, an array of approaches have been implemented to achieve this. This unique review explores multi-context and multi-method examples of co-production in integrated care using an exceptional combination of methods.

Aim

To review and synthesise evidence that examines how co-production with service users, unpaid carers and members of staff can affect the design and transformation of integrated care services.

Methods

Systematic review using meta-ethnography with input from a patient and public involvement (PPI) co-production advisory group. Meta-ethnography can generate theories by interpreting patterns between studies set in different contexts. Nine academic and four grey literature databases were searched for publications between 2012-2022. Data were extracted, analysed, translated and interpreted using the seven phases of meta-ethnography and PPI.

Findings

A total of 2,097 studies were identified. 10 met the inclusion criteria. Studies demonstrated a variety of integrated care provisions for diverse populations. Co-production was most successful through person-centred design, innovative planning, and collaboration. Key impacts on service transformation were structural changes, accessibility, and acceptability of service delivery. The methods applied organically drew out new interpretations, namely a novel cyclic framework for application within integrated care.

Conclusion

Effective co-production requires a process with a well-defined focus. Implementing co-delivery, with peer support, facilitates service user involvement to be embedded at a higher level on the 'ladder of co-production'. An additional step on the ladder is proposed; a cyclic co-delivery framework. This innovative and operational development has potential to enable better-sustained person-centred integrated care services.

Builder, Expert, Disruptor, Leader: The Many Roles of People with Lived Experience

People with lived experience of health and social care, including family carers, should be at the heart of integrated care policy and practice. One of the challenges to achieving such co-production is insufficient clarity and limited understanding of the different roles that people with lived experience are asked or choose to undertake. Following research and workshops, four roles have been identified - community builder, improvement expert, disruptor/advocate, and citizen leader. Recognising the distinct contribution and demands of these roles will enable appropriate support and development for people with lived experience and the professionals and managers with whom they collaborate.

Activism and immigrant women's mental health and wellbeing: Building Canadian service provider capacity in the settlement and mental health sectors

In this qualitative community-based research, we explore service providers' use of activism-based resources and the supports they need to use activism as a tool to promote the mental health and wellbeing of racialized immigrant women. 19 service providers working in settlement and mental health services in the Greater Toronto Area, Canada, participated in one of three focus groups. We analyzed the data using a postcolonial feminist lens. Service providers' understandings of activism, strategies for promoting client mental health and wellbeing, and organizational barriers shaping their practice emerged as relevant. We offer recommendations for building activism-based resources, programs and services that include collaborations with racialized immigrant women communities and action at the organizational level to support service provider practice.

Building an understanding of goal-oriented care through the experiences of people living with chronic conditions

OBJECTIVE

To understand the concept of goal-oriented care (GOC) through the experiences of people with chronic conditions.

METHOD

Interviews with people living with chronic conditions (n = 50) were analyzed in two ways. A deductive approach based on GOC attributes generated in a concept analysis on GOC: goal-elicitation, goal-setting, goal-evaluation, patients' context, and patients' needs and preferences. An inductive approach based on a thematic analysis using descriptive phenomenology.

RESULTS

The phase of goal-elicitation was recognized by the participants, whereas goal-setting and goal-evaluation were experienced to a lesser extent. Regarding the underpinning attributes, mixed feelings were reported concerning the integration of the patient's context and the presence of their needs and preferences throughout the care process. The inductive analysis revealed specific attention to informing patients about their condition and treatment options and discussing goals in interprofessional collaboration.

CONCLUSION

Goal-elicitation was already present and seems to be a good foundation for GOC. More attention should be given to goal-setting and goal-evaluation.

PRACTICE IMPLICATIONS

Developing guidance by means of a workflow, tools, or questions might support people with chronic conditions and providers to underpin the entire care process with patients' personal goals.

A co-production approach to exploring an integrated service model in UK local authorities

Purpose

Integrated service models aim to simplify access, enable effective delivery, remove duplication and provide a holistic and person-centred approach. This project explored the development of integrated well-being services in two local authorities in North-East England. The purpose of this paper is to address this issue.

Design/methodology/approach

Underpinned by public health and co-production approaches, the project utilised a mixed-methods approach. Data were collected via online surveys (n = 95), virtual interviews with members of the local population (n = 8) and practitioners and commissioners (n = 8) to explore needs for a new service. Thematic analysis was used to identify key themes and issues.

Findings

Several benefits of an integrated service were highlighted by both staff and service users, with a central anticipated benefit being the provision of holistic care. Improvement in information sharing was also seen to increase the efficiency of services and communication barriers between services. Beneficial aspects and barriers related to the COVID-19 pandemic on current service provision were reported that have informed our future recommendations.

Originality/value

The authors’ findings provide a much deeper insight into function, care, social inclusion and ongoing support needs, from both the perspectives of staff and service users. Service users and staff saw value in an integrated model for themselves, as well as the wider community. The authors’ findings indicate that the integrated service model is a promising one for the development of services within local authorities.

An Exploratory Multi-Case Study of the Health and Wellbeing Needs, Relationships and Experiences of Health and Social Care Service Users and the People who Support them at Home

Introduction

International policies and legislation set a precedence of person-centred sustainable integrated Health and Social Care (HSC) that meets the health and wellbeing needs of service users through improved experiences. However, current research focuses on service models, with fewer studies investigating experiences and needs.

Methods

This qualitative multi-case [n = 7] study was co-designed with key stakeholders and aimed to explore experiences and needs of people who access and provide HSC at home. Data were collected in a regional area of Scotland (UK) via single [n = 10] or dyad [n = 4] semi-structured interviews with service users [n = 6], informal carers [n = 5] and HSC staff [n = 7] and synthesised using Interpretive Thematic Analysis.

Findings

Interpersonal connections and supportive relationships were instrumental in helping all participant groups feel able to cope with their changing HSC needs and roles. They promoted reassurance, information sharing and reduced anxiety; when they were lacking, it negatively impacted upon experiences of HSC.

Discussion

Promoting inter-personal connections that encourage supportive relationships between people who access and provide HSC and their communities, could promote person-centred Relationship-based care and improve HSC experiences.

Conclusions

This study identifies indicators for improved HSC, advocating co-produced community-driven services to meet the self-defined needs of those who access and provide care.

A typology of integrated care policies in the care home sector: A policy document analysis

Background

Health and social care systems in many countries have begun to trial and adopt "integrated" approaches. Yet, the significant role care homes play within the health and social care system is often understated. A key first step to identifying the care home integration interventions that are most (cost-)effective is the ability to precisely identify and record what has been implemented, where, and when-a "policy map."

Methods

To address gaps relating to the identification and recording of (cost-)effective integrated care home interventions, we developed a new typology tool. We conducted a policy mapping exercise in a devolved region of England-Greater Manchester (GM). Specifically, we carried out systematic policy documentary searches and extracted a range of qualitative data relating to integrated health and social care initiatives in the GM region for care homes. The data were then classified according to existing national ambitions for England as well as a generic health systems framework to illustrate gaps in existing recording tools and to iteratively develop a novel approach.

Results

A combined total of 124 policy documents were identified and screened, in which 131 specific care home integration initiatives were identified. Current initiatives emphasized monitoring quality in care homes, workforce training, and service delivery changes (such as multi-disciplinary teams). There was comparatively little emphasis on financing or other incentive changes to stimulate provider behavior for the care home setting. We present a novel typology for capturing and comparing care home integration policy initiatives, largely conceptualizing which part of the system or specific transition point the care home integration is targeting, or whether there is a broader cross-cutting system intervention being enacted, such as digital or financial interventions.

Conclusions

Our typology builds on the gaps in current frameworks, including previous lack of specificity to care homes and lack of adaptability to new and evolving initiatives internationally. It could provide a useful tool for policymakers to identify gaps in the implementation of initiatives within their own areas, while also allowing researchers to evaluate what works most effectively and efficiently in future research based on a comprehensive policy map.

Conceptualising relevant social context indicators for people receiving home care: A multi-method approach in Flanders, Belgium

Despite an increasing awareness of the impact of the social context of a person on personalised care planning, there is currently no generally accepted classification of social context. As a result, home care professionals have a partial understanding of what social context is and how it affects and can even benefit their work. In this study, we define the main themes and concepts of the social context in the home care setting. The goal in this study is twofold. Initially, we want to offer a multidimensional and practical model of social context, founded on the perspectives of care users and professional caregivers in home care. This model of social context, in turn, will be the foundation for the development of a Social Supplement for the interRAI assessment instruments. We conducted nine focus groups in Flanders between September and November 2017. Fifty-four people participated. The focus groups followed a semi-structured format based on themes identified from the literature and three in-depth interviews with experts. Questions focused on defining the main themes of 'social context' and their subcategories. At the end of each discussion, participants were asked to consider which concept could be suitable and essential for a Social Supplement to the current interRAI instruments. Focus groups were recorded, transcribed and analysed using NVivo. We used investigator and theoretical triangulation to ensure the quality of our analysis, and identified five overarching themes of social context; (a) care and support, (b) physical environment, (c) life and care goals, (d) psychosocial well-being and (e) civic engagement. These main themes were mentioned throughout the nine focus group discussions, even though a diverse group of stakeholders participated. This model provides the basis for the development of a Social Supplement for the interRAI assessment instruments in Flanders, Belgium.

ICT-based person-centered community care platform (IPC3P) to enhance shared decision-making for integrated health and social care services

BACKGROUND

Community care is a care model with the aim of shifting care services from being hospital based toward community-based care. Advances in platforms based on information and communications technology (ICT) with a person-centered approach provide the potential to improve the delivery of health and social care services toward community-based settings.

OBJECTIVES

The aims of this study were to describe the ICT-Based Person-Centered Community Care Platform (IPC3P) and to determine its impact on health- and social-care-related shared decision-making and quality of life among community residents.

METHODS

An online platform was developed with the aim of enhancing community care. The platform had four components: (1) comprehensive health and social needs assessment system, (2) personalized community care planning, (3) needs-based health and social care services delivery, and (4) health community engagement. Community residents were invited to use and evaluate the impact of the IPC3P on their quality of life and shared decision-making regarding health and social care services. They provided feedback about the platform by completing two surveys: at baseline (before using the platform) and 6 months after using the platform.

RESULTS

Data of 164 community residents were analyzed in this study. Between baseline and after using the platform, the quality of life reported by the participants increased significantly in all domains, with clear improvements also noted for shared decision-making about health and social care services. The IPC3P received positive feedback from the participants for its usability, familiarity, and ease of use. Some participants also reported their desire for the addition of more functions that support health communities.

CONCLUSION

The IPC3P has the potential to enhance the involvement of community residents in their own care. The findings of this study can be used to support the wider implementation of the IPC3P to promote person-centered community care.