Coordinated care: what does that really mean?

Barriers and facilitators of collaboration during the implementation of vocational rehabilitation interventions: a systematic review

BACKGROUND

Stakeholders from the mental health care sector and the social security sector are often involved in the implementation of vocational rehabilitation (VR) interventions, so-called coordinated or integrated program, as clients need support from both fields. Collaboration of the involved stakeholders from both sectors is therefore important. In this study, a review was performed to provide an overview of the barriers and facilitators for collaboration during the implementation of coordinated or integrated vocational rehabilitation interventions.

METHODS

A systematic review (PROSPERO ID CRD42023404823) was performed in the databases of Medline PubMed (n = 11.511), Web of Science (n = 4821), and PSYCINFO (n = 368). We used the AI-driven tool ASReview to support the screening process, conducted by two researchers independently. A thematic content analysis was performed to analyse the reported barriers and facilitators. Appraisal of the quality of included studies was conducted using Critical Appraisal Skills Programme (CASP).

RESULTS

We included 105 of the 11,873 identified articles for full text screening, of which 26 were included for final analysis. Six themes of barriers and facilitators were found: attitude and beliefs, engagement and trust, governance and structure, practical issues, professionals involved, and client-centeredness. We found a reporting quality between 8 and 20, based on CASP.

CONCLUSION

We found that a positive attitude towards and belief of those involved in collaboration during coordinated of integrated VR interventions can enhance collaboration. Moreover, a negative attitude or lack of trust, most often found among mental health professionals, hindered collaboration. Collaboration between stakeholders from different sectors could be increased by improving positive attitudes and mutual trust and increasing knowledge about each other's expertise. Also sharing success stories, co-location of professionals, and having a clear governance were found to be a factor in collaborations' success.

Patients report high information coordination between rostered primary care physicians and specialists: A cross-sectional study

Our study aimed to describe patient experience of information coordination between their primary care physician and specialists and to examine the associations between their experience and their personal and primary care characteristics. We conducted a cross-sectional study of Ontario residents rostered to a primary care physician and visited a specialist physician in the previous 12 months by linking population-based health administrative data to the Health Care Experience Survey collected between 2013 and 2020. We described respondents' sociodemographic and health care utilization characteristics and their experience of information coordination between their primary care physician and specialists. We measured the adjusted association between patient-reported measures of information coordination before and after respondents received care from a specialist physician and their type of primary care model. 1,460 out 20,422 (weighted 7.5%) of the respondents reported that their specialist physician did not have basic medical information about their visit from their primary care physician in the previous 12 months. 2,298 out of 16,442 (weighted 14.9%) of the respondents reported that their primary care physician seemed uninformed about the care they received from the specialist. Females, younger individuals, those with a college or undergraduate level of education, and users of walk-in clinics had a higher likelihood of reporting a lack of information coordination between the primary care and specialist physicians. Only respondents rostered to an enhanced fee-for-service model had a higher odds of reporting that the specialist physician did not have basic medical information about their visit compared to those rostered to a Family Health Team (OR 1.22, 95% Cl 1.12-1.40). We found no significant association between respondent's type of primary care model and that their primary care physician was uninformed about the care received from the specialist physician. In this population-based health study, respondents reported high information coordination between their primary care physician and specialists. Except for respondents rostered to an enhanced fee-for-service model of care, we did not find any difference in information coordination across other primary care models.

Understanding collaborative and coordinated care in a mental health and well-being context: Essential elements for effective service integration

Multiple system reforms in Australia, including the National Disability Insurance Scheme (NDIS), are changing mental health (MH) and disability-related service provision, whilst policy drivers continue to require service integration. This has necessitated service providers discovering new ways of working collaboratively to achieve an integrated model of care. This qualitative study examined what does and does not work to support collaborative and coordinated care (CCC), as essential components of service integration. The study sample (n = 59) included four cohorts: health and community service leaders (n = 16), staff (n = 23); MH service consumers with complex needs (n = 10), and MH carers (n = 10). Thematic analysis from interviews was applied to data from each cohort to identify overarching themes that described the lived experience of current CCC delivery. COREQ and EQUATOR guidelines were applied to reporting the findings. Themes emphasized CCC is enabled by the development and sustainability of positive working relationships, and depth of knowledge across health and community services. Unnavigable service systems, stigmatization, perceived power differentials, multiple and rapid service reforms and Fee-For-Service (FFS) models provide significant barriers to CCC. Recommendations include the need for accessible service navigation, consumer-friendly service environments, a stable workforce, standardization of knowledge across sectors, outcome measures and funding attached to CCC as part of a raft of potential changes.

Proposal for a shared definition of « primary healthcare » by health professionals: A national cross-sectional survey

INTRODUCTION

Forty years passed between the two most important definitions of primary health care from Alma Alta Conference in 1978 to WHO's definition in 2018. Since then, reforms of healthcare systems, changes in ambulatory sector and COVID 19, have created a need for reinterpretations and redefinition of primary healthcare. The primary objective of the study was to precise the definitions and the representations of primary healthcare by healthcare professionals.

METHODS

We conducted a descriptive cross-sectional study using a web-based anonymized questionnaire including opened-ended and closed-ended questions but also "real-life" case-vignettes to assess participant's perception of primary healthcare, from September to December 2020. Five case-vignette, describing situations involving a specific primary health care professional in a particular place for a determined task were selected, before the study, by test/retest method.

RESULTS

A total of 585 healthcare practitioners were included in the study, 29% were general practitioners and 32% were midwives. Amongst proposed healthcare professions, general practitioners (97.6%), nurses (85.3%), midwives (85.2%) and pharmacists (79.3%) were those most associated with primary healthcare. The functions most associated with primary healthcare, with over 90% of approval were "prevention, screening", "education to good health", "orientation in health system". Two case-vignettes strongly emerged as describing a situation of primary healthcare: Midwife/Hospital/Pregnancy (74%) and Pharmacist/Pharmacy/Flu shot (90%). The profession and the modality of practice of the responders lead to diverging answers regarding their primary healthcare representations.

CONCLUSIONS

Primary healthcare is an ever-evolving part of the healthcare system, as is its definition. This study explored the perception of primary healthcare by French healthcare practitioners in two complementary ways: oriented way for the important functions and more practical way with the case-vignettes. Understanding their differences of representation, according to their profession and practice offered the authors a first step to a shared and operational version of the primary healthcare definition.

Nursing Care Coordination in Primary Healthcare for Patients with Complex Needs: A Comparative Case Study

Introduction

Despite nurses' substantial role in care coordination, few education programs exist to better support them in this role. Identification of a set of core care coordination activities across heterogeneous care coordination programs would facilitate the development of a standard of practice. We sought to examine care coordination activities across two care coordination programs in Family Medicine Groups in Quebec, and their relationship to the program design.

Methods

We performed a comparative case study of two care coordination programs in primary care targeting frequent users of healthcare services and people with Alzheimer's disease and related disorders. Data collection included documents and semi-structured interviews with key informants.

Results

Several activities were common to both programs, such as patient identification; assessment, development of an individualized service plan; and linking patients and caregivers with professionals and services. However, their components were different due to the impact of the integrated care program design, policy environment, and the target patient populations' complex needs.

Discussion

The homogeneity or heterogeneity of patients' complex needs shapes their care trajectory and the intensity of their care coordination needs. As the complexity of these needs grows, so does the necessity to build the care coordinators' capacity for integrated care.

"I'm Worth Saving": Making Sense of Medication Taking in a Care Coordination Organization

Patients and healthcare providers (HCPs) may communicatively make sense of medication taking in divergent ways. Often, HCPs prioritize medication adherence, the extent to which patients consume medications as prescribed. In contrast, patients may focus on how medications fit in with their everyday lives. Care coordination organizations (CCOs) provide cohesive, interdisciplinary, health services to chronically ill patients and may help bridge the gap between patient and HCP sensemaking. Our qualitative study asked: How do patients and HCPs involved in a CCO communicatively make sense of medication taking? Through thematic analysis, we found three themes related to patients' sensemaking. Patients (N = 9) made sense of medication taking (1) as necessary and important through embodied experiences, social discourses, and interpersonal interactions; (2) as easy when supported; and (3) through building bonds. We also found three themes related to HCPs' sensemaking: HCP participants (N = 5) made sense of medication taking (1) through dialogue with patients; (2) by interacting in patients' home spaces; and (3) through building relationships with patients. Our final theme explores how communicative sensemaking became more complicated for participants in the context of psychotropic medications. Using Mishler's Voice of the Lifeworld (VoL) and Weick's sensemaking, we advance a constitutive perspective on medication taking. We suggest that researchers and HCPs should focus on constructing shared meanings about medication taking through dialogue, rather than on increasing adherence. Our study provides evidence that, by promoting engagement with the VoL, CCOs may facilitate such dialogs.

Exploring views on medical care for people with intellectual disabilities: an international concept mapping study

Background

Medical care for people with intellectual and developmental disabilities (IDD) is organized differently across the globe and interpretation of the concept of medical care for people with IDD may vary across countries. Existing models of medical care are not tailored to the specific medical care needs of people with IDD. This study aims to provide an improved understanding of which aspects constitute medical care for people with IDD by exploring how international researchers and practitioners describe this care, using concept mapping.

Methods

Twenty-five experts (researchers and practitioners) on medical care for people with IDD from 17 countries submitted statements on medical care in their country in a brainstorming session, using an online concept mapping tool. Next, they sorted all collected statements and rated them on importance.

Results

Participants generated statements that reflect current medical and health care practice, their ideas on good practice, and aspirations for future medical and health care for people with IDD. Based on the sorting of all statements, a concept map was formed, covering 13 aspects that characterize medical and health care for people with IDD across nations. The 13 aspects varied minimally in importance ratings and were grouped into five overarching conceptual themes: (i) active patient role, (ii) provider role, (iii) context of care, (iv) consequences of care for people with IDD, and (v) quality of care.

Conclusions

The themes, clusters and statements identified through this explorative study provide additional content and context for the specific patient group of people with IDD to the dimensions of previous models of medical care.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12939-022-01700-w.

Experiences of care coordination among older adults in the United States: Evidence from the Health and Retirement Study

INTRODUCTION

The goal of this study was to examine variation in patient experiences and perceptions of care coordination across sociodemographic and health factors.

METHODS

Data come from the 2016 Health and Retirement Study (N = 1, 216). Three domains of coordination were assessed: 1) Perceptions (e.g., patient impressions of provider-provider communication), 2) Tangible supports (e.g., meeting with a care coordinator, being accompanied to appointments), and 3) Technical supports (e.g., use of a "patient portal"). Logistic regression was used to quantify the frequency of each domain and examine variation by racial minority status, socioeconomic status, and health status.

RESULTS

Approximately 42% of older adults perceived poor care coordination, including 14.8% who reported receiving seemingly conflicting advice from different providers. Only one-third had ever met with a formal care coordinator, and 40% were occasionally accompanied to appointments. Although racial minorities were less likely to have access to technical supports, they were more likely to use them. Better perceived coordination was associated with higher care satisfaction (Odds Ratio: 1.43, 95% CI: 1.27-1.61).

CONCLUSIONS

Important gaps in care coordination remain for older adults.

PRACTICE IMPLICATIONS

Providers should consider assessing patient perceptions of care coordination to address these gaps in an equitable manner.

Being bound and tied by the ropes of frugality: a case study on public management values and service integration

Purpose

New Public Management (NPM) has increased fragmentation in municipal health and social care organizations. In response, post-NPM reforms aim to enhance integration through service integration. Integration of municipal services is important for people with complex health and social challenges, such as concurrent substance abuse and mental health problems. This article explores the conditions for service integration in municipal health and social services by studying how public management values influence organizational and financial structures and professional practices.

Design/methodology/approach

This is a case study with three Norwegian municipalities as case organizations. The study draws on observations of interprofessional and interagency meetings and in-depth interviews with professionals and managers. The empirical field is municipal services for people with concurrent substance abuse and mental health challenges. The data were analyzed both inductively and deductively.

Findings

The study reveals that opportunities to assess, allocate and deliver integrated services were limited due to organizational and financial structures as the most important aim was to meet the financial goals. The authors also find that economic and frugal values in NPM doctrines impede service integration. Municipalities with integrative values in organizational and financial structures and in professional approaches have greater opportunities to succeed in integrating services.

Originality/value

Applying a public management value perspective, this study finds that the values on which organizational and financial structures and professional practices are based are decisive in enabling and constraining service integration.

Development of an evidence-based reference framework for care coordination with a focus on the micro level of integrated care: A mixed method design study combining scoping review of reviews and nominal group technique

BACKGROUND

Because of the limits in conceptualisation of care coordination linked to a large array of care coordination models and definitions available, a care coordination framework is needed with a particular focus on the micro level.

OBJECTIVE

To develop an evidence-based reference framework for person-centred care coordination interventions based on international validated definitions.

METHODS

This two-step mixed-methods study included first, a scoping review of reviews focus on the impact of care coordination interventions and then, a nominal group technique. The scoping review aimed at identifying the components of the four dimensions of the framework (contexts, activities, actors and tools, and effects). The nominal group technique was to select the relevant components of the dimension 'activities' of the reference framework.

RESULTS

The scoping review selected 52 articles from the 1407 retrieved at first. The nominal group selected the 66 most relevant activities from the 159 retrieved in the literature (28 activities of care organisation, 24 activities of care, and 14 activities of facilitation).

CONCLUSION

This operational framework focused on care coordination at the micro level, is a useful and innovative tool, applicable in any clinical condition, and in any health care system for describing, implementing and evaluating care coordination programmes.

Coordination of paediatric oncology care: an explorative Swedish case study

Purpose

The aim of this paper is to empirically describe and analyze factors deemed to be relevant for the successful provision of coordinated paediatric oncology care by physicians and nurses involved.

Design/methodology/approach

A qualitative case study primarily consisting of interviews.

Findings

The paper's findings indicate that certain factors (i.e. distinct mission, clear treatment protocols and support from external stakeholders) relevant for the provision of coordinated paediatric oncology care have not received sufficient attention in previous research. In addition, emphasis is placed on the necessity of facilitating constructive working relationships and a bottom-up perspective when pursuing improved care coordination.

Originality/value

The factors described and analyzed may act as insights for how paediatric oncology might be improved in terms of care coordination and thus facilitate care integration. In addition, the paper's findings identify factors relevant for further empirical studies in order to delineate their generalizability.

Nursing Care Coordination for Patients with Complex Needs in Primary Healthcare: A Scoping Review

INTRODUCTION

Millions of people worldwide have complex health and social care needs. Care coordination for these patients is a core dimension of integrated care and a key responsibility for primary healthcare. Registered nurses play a substantial role in care coordination. This review draws on previous theoretical work and provides a synthesis of care coordination interventions as operationalized by nurses for complex patient populations in primary healthcare.

METHODOLOGY

We followed Arksey and O'Malley's methodological framework for scoping reviews. We carried out a systematic search across CINAHL, MEDLINE, Scopus and ProQuest. Only empirical studies were included. We performed a thematic analysis using deductive (the American Nurses Association Framework) and inductive approaches. Findings were discussed with a group of experts.

RESULTS

Thirty-four articles were included in the synthesis. Overall, nursing care coordination activities were synthesized into three categories: those targeting the patient, family and caregivers; those targeting health and social care teams; and those bringing together patients and professionals. Interpersonal communication and information transfer emerged as cross-cutting activities that support every other activity. Our results also brought to light the nurses' contribution to care coordination efforts for patients with complex needs as well as critical components that should be present in every care coordination intervention for this clientele. These include an increased intensity and frequency of activities, relational continuity of care, and home visits.

CONCLUSION

With the growing complexity of patient's needs, efforts must be directed towards enabling the primary healthcare level to effectively play its substantial role in care coordination. This includes finding primary care employment models that would facilitate multidisciplinary teamwork and the delivery of integrated care, and guarantee the delivery of intensive yet efficient coordinated care.

Perception of nurse managers’ care coordination practices among nurses at the unit level

Introduction

Nursing practice demands coordination of activities within and across units to enable quality delivery of healthcare services. Nurse managers are best positioned to ensure effective care coordination at the operational level in the hospitals. The purpose of this study was to examine the care coordination practices of nurse managers at the unit level.

Methods

A quantitative exploratory descriptive approach using a cross-sectional survey design was used to collect data from 522 nurses in 19 hospitals in the Greater Accra region of Ghana. Descriptive and regression analyses were performed to describe the sample and to predict the behaviour of nurse managers. The systems model was used as a conceptual framework for the survey. Data collection was from October 2015 to March 2016.

Results

The response rate for collection of data was 95.7%. Nurse managers exhibited an acceptable level of care coordination practices. Nurse managers’ characteristics together predicted the care coordination practices at the unit (R2=0.111, p < 0.001). The unit, unit workload, experience as a nurse manager, and work duration with nurses were the significant predictors in the regression model.

Discussion

Care coordination is needed at the unit level to prevent conflict, overlapping, and constant interdepartmental friction which enables nurses to take a broad overview of coordinated care instead of myopic observation and reflection in the unit. Nurse managers are best positioned to coordinate care due to their vast professional knowledge and experience. Effective communication, good interpersonal relationship, and good listening skills are essential coordination practices critical to the efficiency of the unit.

Co-Creating Descriptors and a Definition for Person-Centred Coordinated Health Care: An Action Research Study

The aim of this study was to co-create a definition and generic descriptors for person-centred coordinated care for Ireland generated from service users’ narratives. An overarching action research approach was used to engage and empower people to tangibly impact health policy and practice. Through focus groups and a qualitative survey, primary data were collected from a national sample of health services users, caregivers and health care service users’ representative groups. Thematic analysis was used to analyse the data. Three major themes were co-produced as essential care elements. These were: ‘My experience of healthcare’, ‘Care that I am confident in’ and ‘My journey through healthcare’. Through an IPPOSI partner project steering group and their membership groups’ contribution, these themes were further refined into a definition of person-centred coordinated care and nineteen related generic descriptors. Key findings demonstrate that within complex, fragmented healthcare systems, the subjective expectations of service users should be integrated into care delivery, with a scaffolding of services to meet service users’ needs between care settings and disciplines and over time.

Rethinking Integrated Care: A Systematic Hermeneutic Review of the Literature on Integrated Care Strategies and Concepts

Policy Points Integrated care is best understood as an emergent set of practices intrinsically shaped by contextual factors, and not as a single intervention to achieve predetermined outcomes. Policies to integrate care that facilitate person-centered, relationship-based care can potentially contribute to (but not determine) improved patient experiences. There can be an association between improved patient experiences and system benefits, but these outcomes of integrated care are of different orders and do not necessarily align. Policymakers should critically evaluate integrated care programs to identify and manage conflicts and tensions between a program's aims and the context in which it is being introduced.

CONTEXT

Integrated care is a broad concept, used to describe a connected set of clinical, organizational, and policy changes aimed at improving service efficiency, patient experience, and outcomes. Despite examples of successful integrated care systems, evidence for consistent and reproducible benefits remains elusive. We sought to inform policy and practice by conducting a systematic hermeneutic review of literature covering integrated care strategies and concepts.

METHODS

We used an emergent search strategy to identify 71 sources that considered what integrated care means and/or tested models of integrated care. Our analysis entailed (1) comparison of strategies and concepts of integrated care, (2) tracing common story lines across multiple sources, (3) developing a taxonomy of literature, and (4) generating a novel interpretation of the heterogeneous strategies and concepts of integrated care.

FINDINGS

We identified four perspectives on integrated care: patients' perspectives, organizational strategies and policies, conceptual models, and theoretical and critical analysis. We subdivided the strategies into four framings of how integrated care manifests and is understood to effect change. Common across empirical and conceptual work was a concern with unity in the face of fragmentation as well as the development and application of similar methods to achieve this unity. However, integrated care programs did not necessarily lead to the changes intended in experiences and outcomes. We attribute this gap between expectations and results, in part, to significant misalignment between the aspiration for unity underpinning conceptual models on the one hand and the multiplicity of practical application of strategies to integrate care on the other.

CONCLUSIONS

Those looking for universal answers to narrow questions about whether integrated care "works" are likely to remain disappointed. Models of integrated care need to be valued for their heuristic rather than predictive powers, and integration understood as emerging from particular as well as common contexts.

The Evidence Base for an Ideal Care Pathway for Frail Multimorbid Elderly: Combined Scoping and Systematic Intervention Review

Background

There is a call for bold and innovative action to transform the current care systems to meet the needs of an increasing population of frail multimorbid elderly. International health organizations propose complex transformations toward digitally supported (1) Person-centered, (2) Integrated, and (3) Proactive care (Digi-PIP care). However, uncertainty regarding both the design and effects of such care transformations remain. Previous reviews have found favorable but unstable impacts of each key element, but the maturity and synergies of the combination of elements are unexplored.

Objective

This study aimed to describe how the literature on whole system complex transformations directed at frail multimorbid elderly reflects (1) operationalization of intervention, (2) maturity, (3) evaluation methodology, and (4) effect on outcomes.

Methods

We performed a systematic health service and electronic health literature review of care transformations targeting frail multimorbid elderly. Papers including (1) Person-centered, integrated, and proactive (PIP) care; (2) at least 1 digital support element; and (3) an effect evaluation of patient health and/ or cost outcomes were eligible. We used a previously published ideal for the quality of care to structure descriptions of each intervention. In a secondary deductive-inductive analysis, we collated the descriptions to create an outline of the generic elements of a Digi-PIP care model. The authors then reviewed each intervention regarding the presence of critical elements, study design quality, and intervention effects.

Results

Out of 927 potentially eligible papers, 10 papers fulfilled the inclusion criteria. All interventions idealized Person-centered care, but only one intervention made what mattered to the person visible in the care plan. Care coordinators responsible for a whole-person care plan, shared electronically in some instances, was the primary integrated care strategy. Digitally supported risk stratification and management were the main proactive strategies. No intervention included workflow optimization, monitoring of care delivery, or patient-reported outcomes. All interventions had gaps in the chain of care that threatened desired outcomes. After evaluation of study quality, 4 studies remained. They included outcome analyses on patient satisfaction, quality of life, function, disease process quality, health care utilization, mortality, and staff burnout. Only 2 of 24 analyses showed significant effects.

Conclusions

Despite a strong common-sense belief that the Digi-PIP ingredients are key to sustainable care in the face of the silver tsunami, research has failed to produce evidence for this. We found that interventions reflect a reductionist paradigm, which forces care workers into standardized narrowly focused interventions for complex problems. There is a paucity of studies that meet complex needs with digitally supported flexible and adaptive teamwork. We predict that consistent results from care transformations for frail multimorbid elderly hinges on an individual care pathway, which reflects a synergetic PIP approach enabled by digital support.

Making sense of self-care practices at the intersection of severe mental illness and physical health-An Australian study

The poor physical health of people who experience severe mental illness (SMI) is an important public health issue that has been acknowledged, yet not properly addressed. People who live with SMI perform a myriad of complex tasks in order to take care of their physical health, while receiving unpredictable levels of support and assistance from health professionals. In this qualitative study, we aimed to uncover the kinds of work people with SMI do in order to look after their physical health. In a metropolitan area in Queensland, Australia, 32 people with lived experience of SMI participated in semi-structured, face-to-face interviews. Data were digitally recorded, transcribed verbatim and open coded. They were then themed using a constant comparative process. We found that people with SMI were engaged in a "rhythm of life with illness" that consisted of relatively short, acute and chaotic cycles of mental and physical illness, accompanied by much longer mental and physical illness recovery cycles. Participants engaged in three specific types of health-related work to manage these cycles: discovery work (and the associated role of the health professional); sense-making work to meaningfully interpret health and illness; and embedding work to become engaged self-managers of illness and producers of health. We discuss how varying levels of support from health professionals impact consumers' self-management of their physical and mental health; how health professionals influence consumers' experience of treatment burden; and implications for practice.

Patient-provider disconnect: A qualitative exploration of understanding and perceptions to care integration

BACKGROUND

Integrated care has been well-recognized as a solution to improve quality of care for patients with complex needs. As Singapore increasingly develops and promotes integrated models of care, it is unclear if providers, patients, and caregivers share similar understanding of changes in the healthcare system.

OBJECTIVES

This study aims at exploring three dimensions of care integration: a) understanding of integration; b) challenges and c) changes perceived as essential among three distinct stakeholder groups: providers, patients and caregivers.

METHODS

This qualitative study was conducted among 41 care providers (clinicians and administrators) and care consumers (patients and caregivers) in Singapore utilizing 29 semi-structured interviews and 2 focus group discussions. Study participants were selected by purposive, snowball sampling from various clinical settings. Data were transcribed, familiarized, coded and analyzed using a conceptual framework.

RESULTS

Understanding of care integration was generally lacking among patient and caregivers. Most of them focused on healthcare costs and accessibility of services. Providers characterized care integration in clinical process terms and had a more systems view of the concept. Most participants viewed resource constraints as a key challenge in integrating care. Additionally, providers expressed the need for patients and their families to play a greater role in managing their health. Individuals and the community are key components of an integrated care system in the future. Reliance on the healthcare system alone is not sustainable.

CONCLUSIONS

Patients, caregivers and providers have varying degrees of understanding towards care integration. The success of engaging stakeholders on the ground to be active participants in the healthcare system integration process requires policymakers and healthcare leaders to increase patient engagement efforts and to better appreciate the challenges faced by the healthcare workers in the rapidly changing national and global healthcare landscape.

Practice change in chronic conditions care: an appraisal of theories

Background

Management of chronic conditions can be complex and burdensome for patients and complex and costly for health systems. Outcomes could be improved and costs reduced if proven clinical interventions were better implemented, but the complexity of chronic care services appears to make clinical change particularly challenging. Explicit use of theories may improve the success of clinical change in this area of care provision. Whilst theories to support implementation of practice change are apparent in the broad healthcare arena, the most applicable theories for the complexities of practice change in chronic care have not yet been identified.

Methods

We developed criteria to review the usefulness of change implementation theories for informing chronic care management and applied them to an existing list of theories used more widely in healthcare.

Results

Criteria related to the following characteristics of chronic care: breadth of the field; multi-disciplinarity; micro, meso and macro program levels; need for field-specific research on implementation requirements; and need for measurement. Six theories met the criteria to the greatest extent: the Consolidate Framework for Implementation Research; Normalization Process Theory and its extension General Theory of Implementation; two versions of the Promoting Action on Research Implementation in Health Services framework and Sticky Knowledge. None fully met all criteria. Involvement of several care provision organizations and groups, involvement of patients and carers, and policy level change are not well covered by most theories. However, adaptation may be possible to include multiple groups including patients and carers, and separate theories may be needed on policy change. Ways of qualitatively assessing theory constructs are available but quantitative measures are currently partial and under development for all theories.

Conclusions

Theoretical bases are available to structure clinical change research in chronic condition care. Theories will however need to be adapted and supplemented to account for the particular features of care in this field, particularly in relation to involvement of multiple organizations and groups, including patients, and in relation to policy influence. Quantitative measurement of theory constructs may present difficulties.

The Role of Care Coordinator for Children with Complex Care Needs: A Systematic Review

Introduction:

This systematic review seeks to identify the intended components of the role of care coordinator for children with complex care needs and the factors that determine its composition in practice.

Theory and methods:

The initial search identified 1,157 articles, of which 37 met the inclusion criteria. They were quality assessed using the SIGN hierarchy of evidence structure.

Results:

Core components of the role include: coordination of care needs, planning and assessment, specialist support, emotional support, administration and logistics and continuing professional development. Influencing factors on the role include the external environment (political and socio-economic), the internal environment (organisational structure and funding protocols), the skills, qualifications and experience of the coordinator, the family circumstances and the nature of the interaction between the care coordinator and the family.

Discussion:

The lack of consistent terminology creates challenges and there is a need for greater consensus on this issue. Organisations and healthcare professionals need to recognise the extent to which contextual factors influence the role of a care coordinator in practice and plan accordingly. Despite evidence that suggests that the role is pivotal in ensuring that care needs are sustained, there remains great variability in the understanding of the role of a care coordinator for this population.

Conclusions:

As the provision of care increasingly moves closer to home there is a need for greater understanding of the nature and composition of the interaction between care coordinators and families to determine the extent to which appropriate services are being provided. Further work in this area should take into consideration any potential variance in service provision, for example any potential inequity arising due to geographic location. It is also imperative, where appropriate, to seek the views of children with complex care needs and their siblings about their experiences.

Building a Comprehensive System of Services to Support Adults Living with Long-Term Mechanical Ventilation

Background. Increasing numbers of individuals require long-term mechanical ventilation (LTMV) in the community. In the South West Local Health Integration Network (LHIN) in Ontario, multiple organizations have come together to design, build, and operate a system to serve adults living with LTMV. Objective. The goal was to develop an integrated approach to meet the health and supportive care needs of adults living with LTMV. Methods. The project was undertaken in three phases: System Design, Implementation Planning, and Implementation. Results. There are both qualitative and quantitative evidences that a multiorganizational system of care is now operational and functioning in a way that previously did not exist. An Oversight Committee and an Operations Management Committee currently support the system of services. A Memorandum of Understanding has been signed by the participating organizations. There is case-based evidence that hospital admissions are being avoided, transitions in care are being thoughtfully planned and executed collaboratively among service providers, and new roles and responsibilities are being accepted within the overall system of care. Conclusion. Addressing the complex and variable needs of adults living with LTMV requires a systems response involving the full continuum of care.

The ideal healthcare: priorities of people with chronic conditions and their carers

BACKGROUND

It is well established that health consumer opinions should be considered in the design, delivery, and evaluation of health services. However, the opinions of people with chronic conditions and their carers and what they actually consider as ideal healthcare is limited. The aim of this study is to investigate the healthcare priorities of consumers with chronic conditions and their carers, if there are differences between these two groups, and if priorities differ depending on geographical location.

METHODS

The nominal group technique was used as a method to identify what is currently important to, or valued by, participants. This method was also particularly suited to learning about healthcare problems and generating important solutions, thereby helping to bridge the gap between research and policy. Recruitment was carried out via purposive sampling, with the assistance of community pharmacies, general practices, various health agencies, government and non-government organisations. A total of 11 nominal groups were conducted; five groups consisted predominantly of consumers (n = 33 participants), two groups consisted predominantly of carers (n = 12 participants) and four were mixed groups, i.e. consumers, carers, and both (n = 26 participants).

RESULTS

The findings suggested that to create a model of ideal healthcare for people with chronic conditions and their carers, appropriate and timely healthcare access was of paramount importance. Continuity and coordinated care, patient-centred care and affordability were equally the second most important healthcare priorities for all groups. When compared with other groups, access was discussed more frequently among participants residing in the rural area of Mount Isa. Compared to consumers, carers also discussed priorities that were more reminiscent with their caring roles, such as increased access and continuity and coordinated care.

CONCLUSIONS

Access to healthcare is the most important priority for people with chronic conditions and their carers. In the event of inappropriate access for certain groups, all other efforts to increase the quality of healthcare delivery, e.g. patient-centred care, may be pointless. However, health professionals alone may be limited in their ability to address the concerns related to healthcare access; structural changes by health policy makers may be needed.

Specialist rehabilitation for people with Parkinson’s disease in the community: a randomised controlled trial

Background

Multidisciplinary rehabilitation is recommended for Parkinson’s disease, but evidence suggests that benefit is not sustained.

Objectives

(1) Implement a specialist domiciliary rehabilitation service for people with Parkinson’s and carers. (2) Provide continuing support from trained care assistants to half receiving the rehabilitation. (3) Evaluate the clinical effectiveness of the service, and the value added by the care assistants, compared with usual care. (4) Assess the costs of the interventions. (5) Investigate the acceptability of the service. (6) Deliver guidance for commissioners.

Design

Pragmatic three-parallel group randomised controlled trial.

Setting

Community, county of Surrey, England, 2010–11.

Participants

People with Parkinson’s, at all stages of the disease, and live-in carers.

Interventions

Groups A and B received specialist rehabilitation from a multidisciplinary team (MDT) – comprising Parkinson’s nurse specialists, physiotherapists, occupational therapists, and speech and language therapists – delivered at home, tailored to individual needs, over 6 weeks (about 9 hours’ individual therapy per patient). In addition to the MDT, participants in group B received ongoing support for a further 4 months from a care assistant trained in Parkinson’s (PCA), embedded in the MDT (1 hour per week per patient). Participants in control group (C) received care as usual (no co-ordinated MDT or ongoing support).

Main outcome measures

Follow-up assessments were conducted in participants’ homes at 6, 24 and 36 weeks after baseline. Primary outcomes: Self-Assessment Parkinson’s Disease Disability Scale (patients); the Modified Caregiver Strain Index (carers). Secondary outcomes included: for patients, disease-specific and generic health-related quality of life, psychological well-being, self-efficacy, mobility, falls and speech; for carers, strain, stress, health-related quality of life, psychological well-being and functioning.

Results

A total of 306 people with Parkinson’s (and 182 live-in carers) were randomised [group A,n = 102 (n = 61); group B,n = 101 (n = 60); group C,n = 103 (n = 61)], of whom 269 (155) were analysed at baseline, pilot cohort excluded. Attrition occurred at all stages. A per-protocol analysis [people with Parkinson’s,n = 227 (live-in carers,n = 125)] [group A,n = 75 (n = 45); group B,n = 69 (n = 37); group C,n = 83 (n = 43)] showed that, at the end of the MDT intervention, people with Parkinson’s in groups A and B, compared with group C, had reduced anxiety (p = 0.02); their carers had improved psychological well-being (p = 0.02). People with Parkinson’s in groups A and B also had marginally reduced disability (primary outcome,p = 0.09), and improved non-motor symptoms (p = 0.06) and health-related quality of life (p = 0.07), compared with C. There were significant differences in change scores between week 6 (end of MDT) and week 24 (end of PCA for group B) in favour of group B, owing to worsening in group A (no PCA support) in posture (p = 0.001); non-motor symptoms (p = 0.05); health-related quality of life (p = 0.07); and self-efficacy (p = 0.09). Carers in group B (vs. group A) reported a tendency for reduced strain (p = 0.06). At 36 weeks post recruitment, 3 months after the end of PCA support for group B, there were few differences between the groups. Participants reported learning about Parkinson’s, and valued individual attention. The MDT cost £833; PCA support was £600 extra, per patient (2011 Great British pounds).

Conclusions

Further research is needed into ways of sustaining benefits from rehabilitation including the use of care assistants.

Study registration

Current Controlled Trials: ISRCTN44577970.

Funding

This project was funded by the National Institute for Health Research Health Services and Delivery Research programme and the South East Coast Dementias and Neurodegenerative Disease Research Network (DeNDRoN), and the NHS South East Coast. The report will be published in full inHealth Services and Delivery Research; Vol. 2, No. 51. See the NIHR Journals Library website for further project information.

Reconciling recovery, personalisation and Housing First: integrating practice and outcome in the field of multiple exclusion homelessness

'Recovery' is a key concept in the organisation and delivery of interdisciplinary support for people experiencing multiple exclusion homelessness (MEH, that is, situations where homelessness overlaps with a range of other complex problems such as mental health issues and drug and alcohol dependencies). At the level of individual support planning, practitioners are expected to 'work together' to motivate service users to make positive changes to their lives and to secure outcomes (results) such as employment and permanent accommodation. Drawing on the accounts of 34 (n = 34) people with first-hand experience of MEH in England, we outline some of the limitations of 'recovery-orientated practices', namely the exclusion of people with unresolved needs and the implications this may have for continuity of provision. To address this issue, we argue that there is a need for a more personalised and inclusive practice model, which can accommodate 'recovery' (change outcomes) alongside those for maintenance and prevention. In proposing one such model, we show how this might also take forward the principles of 'Housing First' (a US blueprint for tackling entrenched homelessness), which has already begun to challenge the orthodox view that permanent accommodation should be provided only when recovery has been achieved.

Best-practice care for people with advanced chronic obstructive pulmonary disease: the potential role of a chronic obstructive pulmonary disease care co-ordinator

OBJECTIVE

To explore service availability and accessibility for people with advanced chronic obstructive pulmonary disease (COPD) and their carers and strategies for improvement, including the potential role of a COPD care co-ordinator in ensuring best-practice care in the Australian context.

METHODS

This qualitative study used focus groups and interviews with health professionals, carers and consumers to explore gaps and restrictions in services, barriers to access and the functioning of services. Data were analysed deductively.

RESULTS

Key themes arising from the data included difficulties around access to care, lack of continuity of care, poor care co-ordination, the need for active disease management as well as supportive care, and poor communication. A COPD care co-ordinator was suggested as an effective strategy for ensuring best-practice care.

CONCLUSIONS

People with advanced COPD often have difficulty navigating the acute, primary and community care systems to deal with the multiple services that they may require. Lack of communication between health professionals and services is frequently a significant issue. A COPD care co-ordinator, encompassing advanced nursing skills, could ensure that care is centred on the needs of the person and their carer and that they receive continuing, appropriate and accessible care as they approach the end of their life.

How does care coordination provided by registered nurses "fit" within the organisational processes and professional relationships in the general practice context?

AIM

The aim of this study was to develop understanding about how a registered nurse-provided care coordination model can "fit" within organisational processes and professional relationships in general practice.

BACKGROUND

In this project, registered nurses were involved in implementation of registered nurse-provided care coordination, which aimed to improve quality of care and support patients with chronic conditions to maintain their care and manage their lifestyle.

METHOD

Focus group interviews were conducted with nurses using a semi-structured interview protocol. Interpretive analysis of interview data was conducted using Normalization Process Theory to structure data analysis and interpretation.

RESULTS

Three core themes emerged: (1) pre-requisites for care coordination, (2) the intervention in context, and (3) achieving outcomes. Pre-requisites were adequate funding mechanisms, engaging organisational power-brokers, leadership roles, and utilising and valuing registered nurses' broad skill base. To ensure registered nurse-provided care coordination processes were sustainable and embedded, mentoring and support as well as allocated time were required. Finally, when registered nurse-provided care coordination was supported, positive client outcomes were achievable, and transformation of professional practice and development of advanced nursing roles was possible.

CONCLUSION

Registered nurse-provided care coordination could "fit" within the context of general practice if it was adequately resourced. However, the heterogeneity of general practice can create an impasse that could be addressed through close attention to shared and agreed understandings. Successful development and implementation of registered nurse roles in care coordination requires attention to educational preparation, support of the individual nurse, and attention to organisational structures, financial implications and team member relationships.

'You say treatment, I say hard work': treatment burden among people with chronic illness and their carers in Australia

The aim of this study was to explore treatment burden among people with a variety of chronic conditions and comorbidities and their unpaid carers. The burden of living with ongoing chronic illness has been well established. However, the burden associated with proactively treating and managing chronic illness, commonly referred to as 'treatment burden', is less understood. This study helps to bridge this gap in our understanding by providing an in-depth analysis of qualitative data collected from a large sample of adults from diverse backgrounds and with various chronic conditions. Using semi-structured in-depth interviews, data were collected with a large sample of 97 participants that included a high representation of people from culturally and linguistically diverse backgrounds and indigenous populations across four regions of Australia. Interviews were conducted during May-October 2012, either face to face (n = 49) or over the telephone (n = 48) depending on the participant's preference and location. Data were analysed using an iterative thematic approach and the constant comparison method. The findings revealed four interrelated components of treatment burden: financial burden, time and travel burden, medication burden and healthcare access burden. However, financial burden was the most problematic component with the cost of treatment being significant for most people. Financial burden had a detrimental impact on a person's use of medication and also exacerbated other types of burden such as access to healthcare services and the time and travel associated with treatment. The four components of treatment burden operated in a cyclical manner and although treatment burden was objective in some ways (number of medications, and time to access treatment), it was also a subjective experience. Overall, this study underscores the urgent need for healthcare professionals to identify patients overwhelmed by their treatment and develop 'individualised' treatment options to alleviate treatment burden.

The effectiveness of inter-professional working for older people living in the community: a systematic review

Health and social care policy in the UK advocates inter-professional working (IPW) to support older people with complex and multiple needs. Whilst there is a growing understanding of what supports IPW, there is a lack of evidence linking IPW to explicit outcomes for older people living in the community. This review aimed to identify the models of IPW that provide the strongest evidence base for practice with community dwelling older people. We searched electronic databases from 1 January 1990-31 March 2008. In December 2010 we updated the findings from relevant systematic reviews identified since 2008. We selected papers describing interventions that involved IPW for community dwelling older people and randomised controlled trials (RCT) reporting user-relevant outcomes. Included studies were classified by IPW models (Case Management, Collaboration and Integrated Team) and assessed for risk of bias. We conducted a narrative synthesis of the evidence according to the type of care (interventions delivering acute, chronic, palliative and preventive care) identified within each model of IPW. We retrieved 3211 records and included 37 RCTs which were mapped onto the IPW models: Overall, there is weak evidence of effectiveness and cost-effectiveness for IPW, although well-integrated and shared care models improved processes of care and have the potential to reduce hospital or nursing/care home use. Study quality varied considerably and high quality evaluations as well as observational studies are needed to identify the key components of effective IPW in relation to user-defined outcomes. Differences in local contexts raise questions about the applicability of the findings and their implications for practice. We need more information on the outcomes of the process of IPW and evaluations of the effectiveness of different configurations of health and social care professionals for the care of community dwelling older people.

Self-Management Support in Chronic Illness Care: A Concept Analysis

Purpose: This article reports on the concept analysis of self-management support (SMS) to provide clarity for systematic implementation in practice. Background: SMS is a concept in its early phase of development. It is increasingly evident in literature on chronic illness care. However, the definition has been simplified or vague leading to variable SMS programs and inconsistent outcomes. Elucidation of SMS is necessary in chronic illness care to facilitate clear understanding and implementation. Method: Rodgers’ evolutionary concept analysis method was used to examine SMS. Data sources included systematic multidisciplinary searches of multiple search engines. Results: SMS refers to comprehensive sustaining approaches toward improving chronic illness outcomes consisting of patient-centered attributes (involving patients as partners; providing diverse, innovative educational modalities specific to patients’ needs; individualizing patient care), provider attributes (possessing adequate knowledge, skills, attitudes in providing care), and organizational attributes (putting an organized system of care in place, having multidisciplinary team approach, using tangible and social support). Implications: A well-clarified SMS concept is important in theory development. The attributes offer necessary components in SMS programs for systematic implementation, evaluation, and research. There is great potential that SMS can help improve outcomes of chronic illness care.

Models of inter professional working for older people living at home: a survey and review of the local strategies of English health and social care statutory organisations

BACKGROUND

Most services provided by health and social care organisations for older people living at home rely on interprofessional working (IPW). Although there is research investigating what supports and inhibits how professionals work together, less is known about how different service models deliver care to older people and how effectiveness is measured. The aim of this study was to describe how IPW for older people living at home is delivered, enacted and evaluated in England.

METHOD

An online survey of health and social care managers across England directly involved in providing services to older people, and a review of local strategies for older people services produced by primary care organisations and local government adult services organisations in England.

RESULTS

The online survey achieved a 31% response rate and search strategies identified 50 local strategies that addressed IPW for older people living at home across health and social care organisations. IPW definitions varied, but there was an internal consistency of language informed by budgeting and organisation specific definitions of IPW. Community Services for Older People, Intermediate Care and Re-enablement (rehabilitation) Teams were the services most frequently identified as involving IPW. Other IPW services identified were problem or disease specific and reflected issues highlighted in local strategies. There was limited agreement about what interventions or strategies supported the process of IPW. Older people and their carers were not reported to be involved in the evaluation of the services they received and it was unclear how organisations and managers judged the effectiveness of IPW, particularly for services that had an open-ended commitment to the care of older people.

CONCLUSION

Health and social care organisations and their managers recognise the value and importance of IPW. There is a theoretical literature on what supports IPW and what it can achieve. The need for precision may not be so necessary for the terms used to describe IPW. However, there is a need for shared identification of both user/patient outcomes that arise from IPW and greater understanding of what kind of model of IPW achieves what kind of outcomes for older people living at home.

Integrated care in Norway: the state of affairs years after regulation by law

INTRODUCTION

A mandatory multidisciplinary plan for individual care, the 'Individual care Plan', was introduced by law in Norway in 2001. The regulation was established to meet the need for improved efficiency and quality of health and social services, and to increase patient involvement. The plan was intended for patients with long-term and complex needs for coordinated care. The aim of this study was to elaborate on knowledge of such planning processes in Norwegian municipalities.

METHOD

A piloted questionnaire was sent to 92 randomly selected municipalities in 2005-2006, addressing local organization and participation in the work with individual care plans. Local political governance, size of the population, funds available for health care, and problems related to living conditions were indicators for analysing the extent to which the individual care plan was used five years after the regulation was introduced.

RESULTS

Our results showed that 0.5% as opposed to an expected 3% of the population had an individual care plan. This was independent of the political, social and financial situation in the municipalities or the way the planning process had been carried out. The planning process was mostly taken care of by local health and social care professionals, rather than by hospital staff and general practitioners.

DISCUSSION AND CONCLUSION

The low number of care plans and the oblique responsibility among professionals for planning showed that the objectives of the national initiative had not been achieved. More research is needed to determine the reasons for this lack of success and to contribute to solutions for improved multidisciplinary cooperation.