The Complexity of Health Service Integration: A Review of Reviews

How interventions to maintain services during the COVID-19 pandemic strengthened systems for delivery of maternal and child health services: a case-study of Wakiso District, Uganda

BACKGROUND

Health systems are resilient if they absorb, adapt, and transform in response to shocks. Although absorptive and adaptive capacities have been demonstrated during the COVID-19 response, little has been documented about their transformability and strengthened service delivery systems. We aimed to describe improvements in maternal and child health service delivery as a result of investments during the COVID-19 response.

METHODS

This was a descriptive case study conducted in Wakiso District in central Uganda. It included 21 nurses and midwives as key informants and 32 mothers in three focus group discussions. Data were collected using an interview guide following the Systems Engineering Initiative for Patient Safety theoretical framework for service delivery.

RESULTS

Maternal and child health service delivery during the pandemic involved service provision without changes, service delivery with temporary changes and outcomes, and service delivery that resulted into sustained changes and outcomes. Temporary changes included patient schedule adjustments, community service delivery and negative outcomes such as increased workload and stigma against health workers. Sustained changes that strengthened service delivery included new infrastructure and supplies such as ambulances and equipment, new roles involving infection prevention and control, increased role of community health workers and outcomes such as improved workplace safety and teamwork.

CONCLUSIONS

In spite of the negative impact the COVID-19 pandemic had on health systems, it created the impetus to invest in system improvements. Investments such as new facility infrastructure and emergency medical services were leveraged to improve maternal and child health services delivery. The inter-departmental collaboration during the response to the COVID-19 pandemic resulted into an improved intra-hospital environment for other service delivery. However, there is a need to evaluate lessons beyond health facilities and whether these learnings are deliberately integrated into service delivery. Future responses should also address the psychological and physical impacts suffered by health workers to maintain service delivery.

Smartfeeding: A Dynamic Strategy to Increase Nutritional Efficiency in Critically Ill Patients-Positioning Document of the Metabolism and Nutrition Working Group and the Early Mobilization Working Group of the Catalan Society of Intensive and Critical Care Medicine (SOCMiC)

Adequate medical nutrition therapy for critically ill patients has an impact on their prognoses. However, it requires an individualized approach that takes into account the activity (phases of metabolic stress) and particularity of these patients. We propose a comprehensive strategy considering the patients' nutritional status and the set of modifiable circumstances in these patients, in order to optimize/support nutritional efficiency: (1) A detailed anamnesis and an adequate initial nutritional assessment must be performed in order to implement medical nutrition therapy that is in line with the needs and characteristics of each patient. Furthermore, risks associated with refeeding syndrome, nutritrauma or gastrointestinal dysfunction must be considered and prevented. (2) A safe transition between nutrition therapy routes and between health care units will greatly contribute to recovery. The main objective is to preserve lean mass in critically ill patients, considering metabolic factors, adequate protein intake and muscle stimulation. (3) Continuous monitoring is required for the successful implementation of any health strategy. We lack precise tools for calculating nutritional efficiency in critically ill patients, therefore thorough monitoring of the process is essential. (4) The medical nutrition approach in critically ill patients is multidisciplinary and requires the participation of the entire team involved. A comprehensive strategy such as this can make a significant difference in the functional recovery of critically ill patients, but leaders must be identified to promote training, evaluation, analysis and feedback as essential components of its implementation, and to coordinate this process with the recognition of hospital management.

Exploring key determinants of health among individuals with serious mental Illness: qualitative insights from a first episode psychosis cohort, 20 years postdiagnosis

BACKGROUND

Individuals with serious mental illness (SMI) are more likely to experience functional decline, low well-being, comorbidities, shorter lifespan, and diminished quality of life than the general population. This qualitative study explores determinants of health that individuals with SMI perceive as important to their health, well-being, and ability to live a meaningful life.

METHOD

We conducted interviews with 13 individuals with early detected first episode psychosis as part of a 20-year follow-up study of a larger cohort. Interview data were analyzed using qualitative content analysis.

RESULTS

Analysis identified two themes comprising eight categories representing determinants of health. The first theme reflected management of mental and physical health. Categories in this theme were: access to mental healthcare adapted to individual needs, strategies during deterioration, use of psychotropic medication, maintenance of physical health and lifestyle. The second theme reflected social health determinants in coping with mental illness and comprised three categories: family and friends, engaging in meaningful hobbies and activities, and the influence of employment on mental health.

CONCLUSIONS

Individuals with SMI outlined mental, physical, and social determinants of health that were important for their health, well-being, and ability to live a meaningful life. In future clinical practice, coordinated care addressing the complexity of health determinants will be important.

Information-Driven Integrated Healthcare: An Analysis of the Cooperation Strategy of County Medical Community Based on Multi-Subject Simulation

The fragmentation and uneven quality of primary medical resources in China call for a deepening of integrated healthcare reform. China is promoting its county medical community (CMC) reform on a large scale in county-level administrative regions to promote the integration of local primary healthcare systems through information technology, which is consistent with the current trend of the digital governance era. Considering that the construction of a county medical community involves collaborative relationships between multi-level subjects, the evolutionary game theory was adopted in this study to construct a game model between the lead hospital of a CMC and primary healthcare institutions, and then the incentives of government department support were introduced to analyze the behavioral evolution of these three subjects. Taking into account the uncertainty of the real-life environment and information transformation, white Gaussian noise was introduced as a random disturbance term, and a numerical simulation was performed. In the two-subject model we focus on four parameters: information and management authority ceded by the primary healthcare institutions, integration coefficient of CMC information construction, intensity factor of information integration in the CMC, and medical resources delivered by the lead hospital. In the three-subject model we focus on three parameters: information and portion of authority ceded by the primary healthcare institutions and government departments, policy effect coefficient of CMC construction, and intensity of government departments' support for CMC construction. The simulation results show that there is a positive incentive for the concession of management power and information from the primary healthcare institutions to the lead hospital, but further determination of empowerment boundaries is needed. The lead hospital can improve the balance of medical resources in the county through the downward transfer of medical resources, but long-term resource delivery may inhibit the enthusiasm of the lead hospital. An improvement in the information integration intensity of the CMC can promote the efficient flow of information and knowledge and enhance the organizational closeness of the county medical community. At the same time, the integration of CMC information construction reduces the cost of collaboration among medical community members and streamlines and consolidates business modules, which can promote more efficient use of medical resources. The government departments' policies and funds provide obvious incentives to the lead hospital and primary healthcare institutions, but there is a need to explore appropriate financial payment ratios to balance the government's financial pressure.

Strategies to integrate oral health into primary care: a systematic review

OBJECTIVES

Integration of oral health into primary care has been proposed as a primary healthcare approach for efficient and sustainable delivery of oral health services, and the effective management of oral diseases. This paper aimed to synthesise evidence on the effectiveness of strategies to integrate oral health into primary care.

DESIGN

Systematic review.

DATA SOURCES

MEDLINE, CINAHL, Embase, Scopus, ProQuest, Cochrane and Google Scholar were searched without date limits until the third week of June 2022. Reference lists of eligible studies were also searched. Experts in the field and existing professional networks were consulted.

ELIGIBILITY CRITERIA

Only studies that evaluated integration strategies were included in the review. Eligibility was restricted to English language studies published in academic peer-reviewed journals.

DATA EXTRACTION AND SYNTHESIS

Two reviewers independently extracted data and performed the risk of bias assessments. A narrative synthesis approach was used to report review findings. Heterogeneity among included studies precluded a meta-analysis.

RESULTS

The search identified 8731 unique articles, of which 49 were included in the review. Majority of the studies explored provision of oral healthcare by primary care professionals in primary care settings, where integration was primarily via training/education and/or policy changes. Most studies reported results favouring the integration strategy, such as improvements in referral pathways, documentation processes, operating efficiencies, number of available health staff, number of visits to non-dental primary care professionals for oral health issues, proportion of children receiving fluoride varnish applications/other preventive treatment, proportion of visits to an oral health professional and dental caries estimates.

CONCLUSION

The findings from this review demonstrate that the majority of identified strategies were associated with improved outcomes and can be used to inform decision-making on strategy selection. However, more research and evaluation are required to identify best practice models of service integration.

PROSPERO REGISTRATION NUMBER

CRD42020203111.

Supporting integration: the creation of a framework to support the design and delivery of clinical academic integration across a complex system

Transforming outcomes for patients by aligning and integrating care requires complex systems change and management across multiple organisational boundaries. This case study outlines one part of the integration journey across a partnership between three independent NHS foundation trusts with strong affiliations to two universities, the combined expertise of which places them at the forefront of being able to deliver the best heart and lung outcomes for patients. It specifically describes the process of designing, testing and implementing a bespoke tool called the Clinical Academic Integration Framework (CAIF) to support clinical and academic teams in owning, planning and delivering their paths to full integration, defined as 'one team, across multiple sites' in this context.

Interventions to Promote the Utilization of Physical Health Care for People with Severe Mental Illness: A Scoping Review

BACKGROUND

The main contributor to excess mortality in severe mental illness (SMI) is poor physical health. Causes include unfavorable health behaviors among people with SMI, stigmatization phenomena, as well as limited access to and utilization of physical health care. Patient centered interventions to promote the utilization of and access to existing physical health care facilities may be a pragmatic and cost-effective approach to improve health equity in this vulnerable and often neglected patient population.

OBJECTIVE/METHODS

In this study, we systematically reviewed the international literature on such studies (sources: literature databases, trial-registries, grey literature). Empirical studies (quantitative, qualitative, and mixed methods) of interventions to improve the utilization of and access to medical health care for people with a SMI, were included.

RESULTS

We identified 38 studies, described in 51 study publications, and summarized them in terms of type, theoretical rationale, outcome measures, and study author's interpretation of the intervention success.

CONCLUSIONS

Useful interventions to promote the utilization of physical health care for people with a SMI exist, but still appear to be rare, or at least not supplemented by evaluation studies. The present review provides a map of the evidence and may serve as a starting point for further quantitative effectiveness evaluations of this promising type of behavioral intervention.

Perceptions of Facilitators and Barriers to Implementation of Falls Prevention Programs in Primary Health Care Settings in China

IMPORTANCE

Falls have become a major public health issue in China with population aging. Although falls prevention for older community-dwelling people has been included in the National Essential Public Health Service Package since 2009, there is limited understanding of the implementation of this program.

OBJECTIVE

To identify the associated factors and provide recommendations to inform the better implementation of falls prevention in the Chinese primary health care system.

DESIGN, SETTING, AND PARTICIPANTS

This qualitative study was conducted in 3 purposively selected cities in China from March 1 to June 7, 2021. Health administrators from the local health commission or bureau, staff members from local Centers for Disease Control and Prevention and primary health care facilities and community-dwelling older people were recruited, using a combination of purposive sampling and snowball sampling.

MAIN OUTCOMES AND MEASURES

In-depth interviews were conducted with health administrators and focus groups with other participants. Data analysis followed the guidance of the Consolidated Framework for Implementation Research. Study outcomes included facilitators and barriers of implementing falls prevention for older people in the Chinese primary health care settings. A framework with recommendations was developed to inform the future intervention implementation.

RESULTS

Among a total of 130 participants interviewed, 77 (59.2%) were female and the mean (SD) age was 47.4 (16.7) years. Clear recognition of the challenges and benefits of falls prevention, adaptive regionally tailored guidance plans, and continuous governmental policy and financial support were the major facilitators, whereas the major barriers consisted of insufficient confidence in delivering interventions and poor understanding of the falls burden, low recognition of the importance of falls prevention, limited multisectoral collaboration, and weak financial incentives. A 7-strategy embedded framework-including data-driven surveillance, audit and feedback, implementation strategy, workforce strengthening, community empowerment, internal services integration, and external enabling environment-was developed to foster successful implementation.

CONCLUSIONS AND RELEVANCE

This qualitative study identified major facilitators and barriers to the implementation of falls prevention for older people at the primary care level, which have the potential to contribute to better implementation of falls prevention for older people in the Chinese primary health care system.

Application of Medical-Nursing-Assistance Integration Model Based on Theoretical Basis of Behavioral Psychology in Management of Children’s ICU

The children's intensive care unit is a closed management area with limited visiting time and no accompanying persons. It fails to systematically reflect and summarize the opinions and needs of the families of the children. The more critically ill the family members are, the higher the requirements for medical care. Good relationship between doctors, nurses, assistant, and patients can promote the rehabilitation of children's diseases and achieve the advanced medical model level of “seamless management and no loopholes.” In order to aid the complete intensive care process, it is vital to understand children's psychological and physical development based on children's behavioral psychology when the medical-nursing-assistance (MNA) integration model is used in the children's intensive care unit. Therefore, this paper has completed the following tasks: (1) the development status of the domestic and foreign MNA integration model in the quality management of children's intensive care units is introduced, and the MNA integration model based on the theoretical basis of behavioral psychology is proposed for the following article in children's intensive care. The effect evaluation system of room management provides a theoretical basis. (2) The principle of BP neural network is introduced, and the effect evaluation model of the integrated mode of MNA based on BPNN in the management of children's intensive care unit is constructed. (3) The relevant data collected are used to form an available data set for the model accuracy test. The experimental results show that, after the research in this paper, the BPNN model proposed in this paper is introduced into the MNA integration model to evaluate the effect of the management of children's intensive care units which is practical and effective.

Improving public health sector service delivery in the Free State, South Africa: development of a provincial intervention model

Background

Public health sector service delivery challenges leading to poor population health outcomes have been observed in the Free State province of South Africa for the past decade. A multi-method situation appraisal of the different functional domains revealed serious health system deficiencies and operational defects, notably fragmentation of healthcare programmes and frontline services, as well as challenges related to governance, accountability and human resources for health. It was therefore necessary to develop a system-wide intervention to comprehensively address defects in the operation of the public health system and its major components.

Methods

This study describes the development of the ‘Health Systems Governance & Accountability’ (HSGA) intervention model by the Free State Department of Health (FSDoH) in collaboration with the community and other stakeholders following a participatory action approach. Documented information collected during routine management processes were reviewed for this paper. Starting in March 2013, the development of the HSGA intervention model and the concomitant application of Kaplan and Norton’s (1992) Balanced Scorecard performance measurement tool was informed by the World Health Organization’s (2007) conceptual framework for health system strengthening and reform comprised of six health system ‘building blocks.’ The multiple and overlapping processes and actions to develop the intervention are described according to the four steps in Kaplan et al.’s (2013) systems approach to health systems strengthening: (i) problem identification, (ii) description, (iii) alteration and (iv) implementation.

Results

The finalisation of the HSGA intervention model before end-2013 was a prelude to the development of the FSDoH’s Strategic Transformation Plan 2015–2030. The HSGA intervention model was used as a tool to implement and integrate the Plan’s programmes moving forward with a consistent focus on the six building blocks for health systems strengthening and the all-important linkages between them.

Conclusion

The model was developed to address fragmentation and improve public health service delivery by the provincial health department. In January 2016, the intervention model became an official departmental policy, meaning that it was approved for implementation, compliance, monitoring and reporting, and became the guiding framework for health systems strengthening and transform in the Free State.

A systematic review on integrated care for traumatic brain injury, mental health, and substance use

Traumatic brain injuries (TBI) and mental health or substance use disorders (MHSU) are global public health concerns due to their prevalence and impact on individuals and societies. However, care for individuals with TBI and MHSU remains fragmented with a lack of appropriate services and supports across the continuum of healthcare. This systematic review provided an evidence-based foundation to inform opportunities to mobilize and adapt existing resources to integrate care for individuals with TBI and MHSU by comprehensively summarizing existing integrated activities and reported barriers and facilitators to care integration. MEDLINE, EMBASE, PsycINFO, CINAHL, Cochrane Central Register of Controlled Trials, Sociological Abstracts, and Dissertations & Theses Global were independently reviewed by two reviewers based on pre-determined eligibility criteria. Data on the integration activity, level and type of integration, reported barriers and facilitators, and the strategies aligning with the World Health Organization’s (WHO) Framework on Integrated Person-Centred Care were extracted to form the basis for a narrative synthesis. Fifty-nine peer-reviewed articles were included, describing treatments (N = 49), programs (N = 4), or screening activities (N = 7). Studies discussing clinical integration at the micro- (N = 38) and meso- (N = 10) levels, service integration at the micro- (N = 6) and meso- (N = 5) levels, and functional integration at the meso-level (N = 1) were identified. A minority of articles reported on facilitators (e.g., cognitive accommodations in treatment plans; N = 7), barriers (e.g., lack of education on cognitive challenges associated with TBI; N = 2), or both (N = 6), related to integrating care. This review demonstrated that integrated TBI and MHSU care already exists across a range of levels and types. Given the finite and competing demands for healthcare resources, cognitive accommodations across treatment plans to facilitate integrated TBI and MHSU care should be considered. Multidisciplinary teams should also be explored to provide opportunities for education among health professionals so they can be familiar with TBI and MHSU.

Trial registration: Prospero Registration: CRD42018108343.

Improving interagency service integration of the Australian Nurse Family Partnership Program for First Nations women and babies: a qualitative study

Background

The Australian Nurse Family Partnership Program (ANFPP) is an evidence-based, home visiting program that offers health education, guidance, social and emotional support to first-time mothers having Aboriginal and/or Torres Strait Islander (First Nations) babies. The community-controlled sector identified the need for specialised support for first time mothers due to the inequalities in birthing and early childhood outcomes between First Nations’ and other babies in Australia. The program is based on the United States’ Nurse Family Partnership program which has improved long-term health outcomes and life trajectories for mothers and children. International implementation of the Nurse Family Partnership program has identified interagency service integration as key to program recruitment, retention, and efficacy. How the ANFPP integrates with other services in an Australian urban setting and how to improve this is not yet known. Our research explores the barriers and enablers to interagency service integration for the Australian Nurse Family Partnership Program ANFPP in an urban setting.

Methods

A qualitative study using individual and group interviews. Purposive and snowball sampling was used to recruit clients, staff (internal and external to the program), Elders and family members. Interviews were conducted using a culturally appropriate ‘yarning’ method with clients, families and Elders and semi-structured interview guide for staff. Interviews were audio-recorded and transcribed prior to reflexive thematic analysis.

Results

Seventy-six participants were interviewed: 26 clients, 47 staff and 3 Elders/family members. Three themes were identified as barriers and three as enablers. Barriers: 1) confusion around program scope, 2) duplication of care, and 3) tensions over ‘ownership’ of clients. Enablers (existing and potential): 1) knowledge and promotion of the program; 2) cultural safety; and 3) case coordination, co-location and partnership forums.

Conclusion

Effective service integration is essential to maximise access and acceptability of the ANFPP; we provide practical recommendations to improve service integration in this context.

A systematic review of disability, rehabilitation and lifestyle services in rural and remote Australia through the lens of the people-centred health care

PURPOSE

The aim of this systematic review was to identify models of community disability, rehabilitation and lifestyle service delivery in non-metropolitan areas of Australia, and to describe these models through an Integrated People-Centred Health Services (IPCHS) lens.

MATERIALS AND METHODS

We identified peer-reviewed studies published between 2000 and June 2021 that met the following criteria: described or evaluated a community service delivery model, intervention or program in regional, rural or remote Australia; provided for people with a disability or a potentially disabling health condition. A scoring rubric was developed covering the five IPCHS strategies.

RESULTS

Nineteen studies were included in the review. We identified a range of service delivery models providing support to people with a range of disabilities or conditions. We report evidence of the use of the IPCHS strategies in ways relevant to the local context.

DISCUSSION

Several strengths emerged, with many services tailored to individual need, and significant community engagement. Innovative rural service delivery approaches were also identified. Key areas requiring action included improved coordination or integration within and across professions and sectors. There was limited evidence of co-production of solutions or participatory governance. While people-centred approaches show promise to improve community-based services, large-scale fundamental change is required.IMPLICATIONS FOR REHABILITATIONCommunity-based disability and rehabilitation services in rural and remote Australia performed well at delivering tailored care and engaging in community consultation.These services must urgently implement strategies to enhance community ownership of solutions and participatory governance.Services must place a greater focus on explicit strategies to integrate and coordinate across services and professions, and to create an enabling environment, to deliver people-centred care.The World Health Organisation Integrated People-Centred Health Services framework provides an important roadmap to improving service delivery in rural and remote Australian communities.

The impacts of collaboration between local health care and non-health care organizations and factors shaping how they work: a systematic review of reviews

BACKGROUND

Policymakers in many countries promote collaboration between health care organizations and other sectors as a route to improving population health. Local collaborations have been developed for decades. Yet little is known about the impact of cross-sector collaboration on health and health equity.

METHODS

We carried out a systematic review of reviews to synthesize evidence on the health impacts of collaboration between local health care and non-health care organizations, and to understand the factors affecting how these partnerships functioned. We searched four databases and included 36 studies (reviews) in our review. We extracted data from these studies and used Nvivo 12 to help categorize the data. We assessed risk of bias in the studies using standardized tools. We used a narrative approach to synthesizing and reporting the data.

RESULTS

The 36 studies we reviewed included evidence on varying forms of collaboration in diverse contexts. Some studies included data on collaborations with broad population health goals, such as preventing disease and reducing health inequalities. Others focused on collaborations with a narrower focus, such as better integration between health care and social services. Overall, there is little convincing evidence to suggest that collaboration between local health care and non-health care organizations improves health outcomes. Evidence of impact on health services is mixed. And evidence of impact on resource use and spending are limited and mixed. Despite this, many studies report on factors associated with better or worse collaboration. We grouped these into five domains: motivation and purpose, relationships and cultures, resources and capabilities, governance and leadership, and external factors. But data linking factors in these domains to collaboration outcomes is sparse.

CONCLUSIONS

In theory, collaboration between local health care and non-health care organizations might contribute to better population health. But we know little about which kinds of collaborations work, for whom, and in what contexts. The benefits of collaboration may be hard to deliver, hard to measure, and overestimated by policymakers. Ultimately, local collaborations should be understood within their macro-level political and economic context, and as one component within a wider system of factors and interventions interacting to shape population health.

Healthcare delivery for HIV-positive people with tuberculosis in Europe

BACKGROUND

In a 2013 survey, we reported distinct discrepancies in delivery of tuberculosis (TB) and HIV services in eastern Europe (EE) vs. western Europe (WE).

OBJECTIVES

To verify the differences in TB and HIV services in EE vs. WE.

METHODS

Twenty-three sites completed a survey in 2018 (EE, 14; WE, nine; 88% response rate). Results were compared across as well as within the two regions. When possible, results were compared with the 2013 survey.

RESULTS

Delivery of healthcare was significantly less integrated in EE: provision of TB and HIV services at one site (36% in EE vs. 89% in WE; P = 0.034), and continued TB follow-up in one location (42% vs. 100%; P = 0.007). Although access to TB diagnostics, standard TB and HIV drugs was generally good, fewer sites in EE reported unlimited access to rifabutin/multi-drug-resistant TB (MDR-TB) drugs, HIV integrase inhibitors and opioid substitution therapy (OST). Compared with 2013, routine usage of GeneXpert was more common in EE in 2018 (54% vs. 92%; P = 0.073), as was access to moxifloxacin (46% vs. 91%; P = 0.033), linezolid (31% vs. 64%; P = 0.217), and bedaquiline (0% vs. 25%; P = 0.217). Integration of TB and HIV services (46% vs. 39%; P = 1.000) and provision of OST to patients with opioid dependency (54% vs. 46%; P = 0.695) remained unchanged.

CONCLUSION

Delivery of TB and HIV healthcare, including integration of TB and HIV care and access to MDR-TB drugs, still differs between WE and EE, as well as between individual EE sites.

Diagnostic and therapeutic algorithm for colorectal peritoneal metastases. A consensus of the peritoneal surface malignancies onco-team of the Italian society of surgical oncology

AIM

the surgical workup for colorectal cancer peritoneal metastases (CRCPM) is complex and should be managed in specialized centers. Diagnostic and therapeutic algorithms (DTA) have been proposed to balance optimal patients management and correct use of resources. Aim of this study was to establish a consensus on DTA for CRCPM patients in Italy.

METHOD

a panel of 18 delegated members of centers afferent to Peritoneal Surface Malignancies Onco-team of the Italian Society of Surgical Oncology was established. A list of statements regarding the DTA of patients with CRCPM was prepared according to different activities and decision-making nodes with a defined entry and exit point. Consensus was obtained through RAND UCLA methodology.

RESULTS

two different DTA were defined and approved according to the modality of presentation of CRCPM (synchronous and metachronous). A consensus was also obtained on 17 of the 19 statements related to DTA.

CONCLUSION

a shared model of DTA is now available for healthcare providers to monitor appropriateness in diagnosis and treatment of patients with isolated peritoneal metastases from CRC.

EPA guidance on the quality of mental health services: A systematic meta-review and update of recommendations focusing on care coordination

BACKGROUND

The quality of mental health services is crucial for the effectiveness and efficiency of mental healthcare systems, symptom reduction, and quality of life improvements in persons with mental illness. In recent years, particularly care coordination (i.e., the integration of care across different providers and treatment settings) has received increased attention and has been put into practice. Thus, we focused on care coordination in this update of a previous European Psychiatric Association (EPA) guidance on the quality of mental health services.

METHODS

We conducted a systematic meta-review of systematic reviews, meta-analyses, and evidence-based clinical guidelines focusing on care coordination for persons with mental illness in three literature databases.

RESULTS

We identified 23 relevant documents covering the following topics: case management, integrated care, home treatment, crisis intervention services, transition from inpatient to outpatient care and vice versa, integrating general and mental healthcare, technology in care coordination and self-management, quality indicators, and economic evaluation. Based on the available evidence, we developed 15 recommendations for care coordination in European mental healthcare.

CONCLUSIONS

Although evidence is limited, some concepts of care coordination seem to improve the effectiveness and efficiency of mental health services and outcomes on patient level. Further evidence is needed to better understand the advantages and disadvantages of different care coordination models.

Impact of the CareWell integrated care model for older patients with multimorbidity: a quasi-experimental controlled study in the Basque Country

Background

Older patients with multimorbidity have complex health and social care needs, associated with elevated use of health care resources. The aim of this study is to evaluate the impact of CareWell integrated care model for older patients with multimorbidity in the Basque Country.

Methods

The CareWell program for older patients with multimorbidity, based on the coordination between health providers, home-based care and patient empowerment, supported by information and communication technology tools. The program was deployed in four healthcare areas in the Basque Country. The control group was formed by two organizations in which the program had not been deployed and regular care procedures were applied.

Participants, older patients (aged ≥65) with two or more chronic conditions (at least one being chronic obstructive pulmonary disease, chronic heart failure, or diabetes mellitus), categorized as complex according to a risk stratification algorithm, were followed up to 12 months. The impact of the program on the use of health resources, clinical effectiveness, and satisfaction was evaluated using a mixed-method approach.

Semi-structured interviews were performed to assess satisfaction with the newly deployed model and mixed regression models to measure the effect of the intervention throughout the follow-up period.

Results

Two hundred patients were recruited (101 intervention and 99 control), mostly males (63%) with a mean age of 79 years and age-adjusted Charlson Comorbidity Index of 9.7 on average. Relevant differences between the groups were observed for all dimensions. In the intervention group, the number of hospitalizations and visits to emergency centers was reduced, and the number of primary care contacts increased. Clinical changes were also observed, such as a decrease in the body mass index and blood glucose levels. The satisfaction level was high for all stakeholders.

Conclusion

The implementation of CareWell integrated care model changed the profile of health resource utilization, strengthening the key role of primary care and reducing the number of emergency visits and hospitalizations. The satisfaction with this model of care was high.

Trial registration

ClinicalTrials.gov, NCT03042039. Registered 3 February 2017 - Retrospectively registered.

Integrated care pathways for Black persons with traumatic brain injury: a protocol for a critical transdisciplinary scoping review

BACKGROUND

Current understandings of the etiology of traumatic brain injury (TBI) and the trajectory of care significantly lack consideration for the inclusion of Black populations. The global prevalence of TBI is increasing, particularly in North America and Europe where approximately 65 million people are affected every year. Although community integration is an ultimate goal of rehabilitation post injury, persons with TBI, particularly Black populations continually face challenges with regards to unmet needs along the continuum of care including meaningful participation and vocation, resulting in occupational deprivation. While integrated care is seen as an appealing approach to service delivery, little is known about what this means for Black people with TBI. This protocol produces the first critical transdisciplinary (CTD) scoping review mapping the extent, range, and nature of integrated care pathways for Black people experiencing TBI.

METHODS

CTD provides an analytical tool with a health equity lens that will be applied as both a methodology and theory for undertaking this review. Under the methodological guidance of Arksey and O'Malley, CTD will be used to map the literature and better understand the elements of integrated care pathways for Black people experiencing TBI. To identify the published literature, several databases will be searched including MEDLINE, EMBASE, Cochrane Central Register of Controlled Trials, CINAHL, PsycINFO, and Sociological Abstracts.

DISCUSSION

The application of CTD compels health-care providers, administrators, clinician-scientists, rehabilitation specialists, and scholars in the field of TBI and integrated care to re-examine hidden assumptions about racism, racialization, and Blackness that are often embedded in current visions of health for all. The health equity lens of CTD asks about who is accounted for in the research and clinical literature and who is absented. It is anticipated that applying the health equity lens of CTD will provide a critical examination of the literature and illuminate significant implications for integrated care for Black persons experiencing TBI.

SYSTEMATIC REVIEW REGISTRATION

Not applicable.

From the service user association's perspective

Purpose

The aim of this study was to identify key components of integrated mental health and social care services that contribute to value for service users in Sweden.

Design/methodology/approach

An explorative research study design was used, based on data from four group interviews conducted in June and August 2017 with service user representatives.

Findings

The analysis resulted in eight subcategories reflecting components that were reported to contribute to value for service users. These subcategories were grouped into three main categories: (1) professionals who see and support the whole person, (2) organizational commitment to holistic care and (3) support for equal opportunities and active participation in society.

Research limitations/implications

The findings are primarily transferable to integrated mental health and social care services, as they emphasize key components that contribute to value for service users in these specific settings.

Practical implications

The complexity of integrated mental health and social care services requires coordination across the individual and organizational levels as well as ongoing dialogue and partnerships between service users, service user associations and health and social care organizations. In this integration, it is important that service users and service user associations not only are invited but also keen to participate in the design of care and support efforts.

Originality/value

Service User Associations (SUAs) can act as a bridge between county and municipal services through their participation in the development of local activities; at the regional and national levels, SUAs can help achieve more equitable integrated services. It is important that SUAs are not only invited but encouraged to actively participate in the design of such care and support efforts.

A mixed methods evaluation of an integrated adult mental health service model

Background

The Floresco integrated service model was designed to address the fragmentation of community mental health treatment and support services. Floresco was established in Queensland, Australia, by a consortium of non-government organisations that sought to partner with general practitioners (GPs), private mental health providers and public mental health services to operate a ‘one-stop’ mental health service hub.

Methods

We conducted an independent mixed-methods evaluation of client outcomes following engagement with Floresco (outcome evaluation) and factors influencing service integration (process evaluation). The main data sources were: (1) routinely-collected Recovery Assessment Scale — Domains and Stages (RAS–DS) scores at intake and review (n = 108); (2) RAS–DS scores, mental health inpatient admissions and emergency department (ED) presentations among clients prospectively assessed at intake and six-month follow-up (n = 37); (3) semi-structured interviews with staff from Floresco, consortium partners, private practitioners and the local public mental health service (n = 20); and (4) program documentation.

Results

Interviews identified staff commitment, co-location of services, flexibility in problem-solving, and anecdotal evidence of positive client outcomes as important enablers of service integration. Barriers to integration included different organisational practices, difficulties in information-sharing and in attracting and retaining GPs and private practitioners, and systemic constraints on integration with public mental health services. Of 1129 client records, 108 (9.6%) included two RAS–DS measurements, averaging 5 months apart. RAS–DS ‘total recovery’ scores improved significantly (M = 63.3%, SD = 15.6 vs. M = 69.2%, SD = 16.1; p < 0.001), as did scores on three of the four RAS–DS domains (‘Looking forward’, p < 0.001; ‘Mastering my illness’, p < 0.001; and ‘Connecting and belonging’, p = 0.001). Corresponding improvements, except in ‘Connecting and belonging’, were seen in the 37 follow-up study participants. Decreases in inpatient admissions (20.9% vs. 7.0%), median length of inpatient stay (8 vs. 3 days), ED presentations (34.8% vs. 6.3%) and median duration of ED visits (187 vs. 147 min) were not statistically significant.

Conclusions

Despite the lack of a control group and small follow-up sample size, Floresco’s integrated service model showed potential to improve client outcomes and reduce burden on the public mental health system. Horizontal integration of non-government and private services was achieved, and meaningful progress made towards integration with public mental health services.

Electronic supplementary material

The online version of this article (10.1186/s12913-019-4501-7) contains supplementary material, which is available to authorized users.

Designing easy access to care for first-episode psychosis in complex organizations

AIMS

Developing early intervention services (EIS) in healthcare organizations (HCOs) is difficult because it is necessary to integrate service approaches across units. To accommodate the needs of patients and relatives, Oslo University Hospital (OUH) chose to use service design (SD) to redesign their first-episode services with an emphasis on easy access to care. This paper discusses the results and how SD can help to overcome known barriers to change in complex organizations.

METHOD

SD is a method that relies on principles of participation, innovation and visualization to develop coherent services. The method emphasizes the exploration of a problem area from the perspective of multiple stakeholders to create a shared understanding of the complexity. Idea generation, visualization and early modelling of possible solutions are employed to test alternatives involving stakeholders.

RESULTS

A low threshold EIS was developed. A helpline with a specialist managing the phone was established. High-quality assessment regarding possible psychosis development was thus made available to patients, relatives and professionals, eliminating the need for paper referral. This approach was supported by a communication strategy that includes web-based information. A dedicated cross-specialist team was established to increase collaboration in complex cases. Finally, outreach services were improved.

CONCLUSION

SD is a suitable method to incorporate the views of different stakeholders (patients, relatives and professionals) to develop EIS services in complex organizations and can help overcome known barriers to change in HCOs.

Public Health and Interprofessional Education as Critical Components in the Evolution of Osteopathic Medical Education

Public health and interprofessional education (IPE) are included among the osteopathic core competencies and Entrustable Professional Activities that should be reflected in osteopathic medical curricula. Cognizant of the importance of these 2 areas, Touro University College of Osteopathic Medicine-CA (TUCOM) has developed initiatives to advance them on campus as well as within its academic curriculum. The authors acknowledge the importance of incorporating public health content into osteopathic medicine as well as expanding IPE in the health professions as part of a larger project to impart a unique identity and relevance to osteopathic medical education at TUCOM. The authors describe TUCOM's public health and IPE initiatives and outcomes in the context of current and future relevance for osteopathic medicine. Future directions to assess the quality and impact of these programs that may be of value for other colleges of osteopathic medicine are also discussed.

Systematic review protocol for facilitators and barriers to integrating health services for traumatic brain injury and mental health or addictions

INTRODUCTION

In the most populous province of Canada, one in five adults and one in six students report a lifetime history of traumatic brain injury (TBI). These individuals were also more likely to report elevated psychological distress and use illicit substances compared with those without TBI. The need for integrated health services has been recognised globally, yet efforts to develop more comprehensive and effective care for TBI and mental health and/or addictions (MHA) continue to be challenged by the siloing of the two systems. This protocol is for a systematic review that describes the current types of integrated care for TBI and MHA and identifies the barriers and facilitators to integrating healthcare for these populations.

METHODS AND ANALYSIS

This review will systematically search MEDLINE, EMBASE, PsycINFO, CINAHL, Cochrane Central Register of Controlled Trials, Sociological Abstracts, and Dissertations & Theses Global. References of eligible articles will also be searched for additional relevant studies. The search strategy will include the use of text words and subject headings relevant to the concepts 'TBI,' 'substance abuse, gambling, or mental health,' 'integrated healthcare,' 'barriers and facilitators,' and 'healthcare access.' Two reviewers will independently screen all articles based on predetermined inclusion and exclusion criteria and perform quality assessment on eligible studies. A narrative synthesis will be conducted using the data abstracted by the two reviewers.

ETHICS AND DISSEMINATION

Findings from the systematic review will be published in peer-reviewed journals, presented at scientific meetings, and summarised for key stakeholders in the field of TBI and/or MHA. This protocol will form a systematic review that holds the potential to impact policy and planning in the development of integrated person-centred care for TBI and MHA and addresses a recognised gap in TBI care.

TRIAL REGISTRATION NUMBER

CRD42018108343.

Continuous Quality Improvement and Comprehensive Primary Health Care: A Systems Framework to Improve Service Quality and Health Outcomes

Continuous quality improvement (CQI) processes for improving clinical care and health outcomes have been implemented by primary health-care services, with resultant health-care impacts. But only 10–20% of gain in health outcomes is contributed by health-care services; a much larger share is determined by social and cultural factors. This perspective paper argues that health care and health outcomes can be enhanced through applying CQI as a systems approach to comprehensive primary health care. Referring to the Aboriginal and Torres Strait Islander Australian context as an example, the authors provide a systems framework that includes strategies and conditions to facilitate evidence-based and local decision making by primary health-care services. The framework describes the integration of CQI vertically to improve linkages with governments and community members and horizontally with other sectors to influence the social and cultural determinants of health. Further, government and primary health-care service investment is required to support and extend integration and evaluation of CQI efforts vertically and horizontally.

Translating the Elements of Health Governance for Integrated Care from Theory to Practice: A Case Study Approach

INTRODUCTION

Against a paucity of evidence, a model describing elements of health governance best suited to achieving integrated care internationally was developed. The aim of this study was to explore how health meso-level organisations used, or planned to use, the governance elements.

METHODS

A case study design was used to offer two contrasting contexts of health governance. Semi-structured interviews were conducted with participants who held senior governance roles. Data were thematically analysed to identify if the elements of health governance were being used, or intended to be in the future.

RESULTS

While all participants agreed that the ten elements were essential to developing future integrated care, most were not used. Three major themes were identified: (1) organisational versus system focus, (2) leadership and culture, and, (3) community (dis)engagement.

DISCUSSION

Several barriers and enablers to the use of the elements were identified and would require addressing in order to make evidence-based changes.

CONCLUSION

Despite a clear international policy direction in support of integrated care this study identified a number of significant barriers to its implementation. The study reconfirmed that a focus on all ten elements of health governance is essential to achieve integrated care.

[Methodological aspects of integrated care pathways]

An Integrated Healthcare Pathway (PAI) is a tool which has as its aim to increase the effectiveness of clinical performance through greater coordination and to ensure continuity of care. PAI places the patient as the central focus of the organisation of health services. It is defined as the set of activities carried out by the health care providers in order to increase the level of health and satisfaction of the population receiving services. The development of a PAI requires the analysis of the flow of activities, the inter-relationships between professionals and care teams, and patient expectations. The methodology for the development of a PAI is presented and discussed in this article, as well as the success factors for its definition and its effective implementation. It also explains, as an example, the recent PAI for Hypoglycaemia in patients with Type 2 Diabetes Mellitus developed by a multidisciplinary team and supported by several scientific societies.