Different Contexts, Similar Challenges. SUSTAIN's Experiences with Improving Integrated Care in Europe

DementiaNet facilitates a sustainable transition toward integrated primary dementia care: A long-term evaluation

INTRODUCTION

Care integration is a promising strategy to achieve sustainable health-care systems. With DementiaNet, a 2-year program, we facilitated collaboration between primary health-care professionals. We studied changes in primary dementia care integration during and after DementiaNet participation.

METHODS

A longitudinal follow-up study was performed. Networks started between 2015 and 2020; follow-up ended in 2021. Quantitative and quantitative data were collected annually to assess quality of care, network collaboration, and number of crisis admissions. Growth modeling was used to identify changes over time.

RESULTS

Thirty-five primary care networks participated. Network collaboration and quality of care of newly formed networks increased significantly in the first 2 years (respectively, 0.35/year, P < .001; 0.29/year, P < .001) and thereafter stabilized.

CONCLUSION

Primary care networks improved their collaboration and quality of care during DementiaNet participation, which persisted after the program ended. This indicates that DementiaNet facilitated a sustainable transition toward integrated primary dementia care.

The Dutch Solid Start program: describing the implementation and experiences of the program's first thousand days

BACKGROUND

In 2018, the Dutch government initiated the Solid Start program to provide each child the best start in life. The program focuses on the crucial first thousand days of life, which span from preconception to a child's second birthday, and has a specific focus towards (future) parents and young children in vulnerable situations. A key program element is improving collaboration between the medical and social sector by creating Solid Start coalitions. This study aimed to describe the implementation of the Dutch Solid Start program, in order to learn for future practice and policy. Specifically, this paper describes to what extent Solid Start is implemented within municipalities and outlines stakeholders' experiences with the implementation of Solid Start and the associated cross-sectoral collaboration.

METHODS

Quantitative and qualitative data were collected from 2019 until 2021. Questionnaires were sent to all 352 Dutch municipalities and analyzed using descriptive statistics. Qualitative data were obtained through focus group discussions(n = 6) and semi-structured interviews(n = 19) with representatives of care and support organizations, knowledge institutes and professional associations, Solid Start project leaders, advisors, municipal officials, researchers, clients and experts-by-experience. Qualitative data were analyzed using the Rainbow Model of Integrated Care.

RESULTS

Findings indicated progress in the development of Solid Start coalitions(n = 40 in 2019, n = 140 in 2021), and an increase in cross-sectoral collaboration. According to the stakeholders, initiating Solid Start increased the sense of urgency concerning the importance of the first thousand days and stimulated professionals from various backgrounds to get to know each other, resulting in more collaborative agreements on cross-sectoral care provision. Important elements mentioned for effective collaboration within coalitions were an active coordinator as driving force, and a shared societal goal. However, stakeholders experienced that Solid Start is not yet fully incorporated into all professionals' everyday practice. Most common barriers for collaboration related to systemic integration at macro-level, including limited resources and collaboration-inhibiting regulations. Stakeholders emphasized the importance of ensuring Solid Start and mentioned various needs, including sustainable funding, supportive regulations, responsiveness to stakeholders' needs, ongoing knowledge development, and client involvement.

CONCLUSION

Solid Start, as a national program with strong local focus, has led to various incremental changes that supported cross-sectoral collaboration to improve care during the first thousand days, without major transformations of systemic structures. However, to ensure the program's sustainability, needs such as sustainable funding should be addressed.

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

BACKGROUND

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

METHODS

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

RESULTS

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

CONCLUSION

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

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.

Construct Validation of the Rainbow Model of Integrated Care Measurement Tool in Dutch Primary Care for Older Adults

Introduction

Care integration in primary elderly care is suboptimal. Validated instruments are needed to enable the implementation of integrated primary care. We aimed to assess construct validity of the Rainbow Model of Integrated Care measurement tool (RMIC-MT) for healthcare professionals working in an integrated primary elderly care setting in the Netherlands.

Methods

In a cross-sectional study, the RMIC-MT, a 36-item questionnaire covering all domains of the Rainbow Model of Integrated Care (RMIC), was sent out to local networks of primary elderly care professionals. Confirmatory factor analysis with maximum likelihood estimation was used for the validation of the factor structure of the RMIC-MT. Model fit was assessed by the chi-square test and fit indices.

Results

The RMIC-MT was completed by 323 professionals, primarily general practitioners, community nurses, practice nurses, and case managers. Confirmatory factor analysis and corresponding fit indices showed moderate to good fit, thereby confirming a nine factor model with a total of 36 items.

Conclusions

The RMIC-MT is promising for the primary elderly care setting in the Netherlands. It can be used for evaluating integrated care initiatives in a primary care setting, thereby contributing to implementation of integrated primary elderly care.

Integration of Chronic Care in a Fragmented Healthcare System Comment on "Integration or Fragmentation of Health Care? Examining Policies and Politics in a Belgian Case Study"

The authors of "Integration or Fragmentation of Health Care? Examining Policies and Politics in a Belgian Case Study" present a fresh perspective on the inertia of integrated care (IC) implementation. They conclude that the decisive power in Belgium is fragmented and undermines efforts towards IC. As researchers in integrated heart failure (HF) care and active primary healthcare professionals, we comment on the three policy initiatives evaluated by Martens et al from a bottom-up perspective. A Learning Healthcare Network (LHCN) was established September 2019 to overcome fragmentation, the lack of evaluation and capacity loss each time a pilot project ends. This commentary wishes to illustrate that a LHCN can be a powerful meso-level mechanism to engage in alignment work and to overcome macro-level barriers that are often difficult to change and not supportive of IC.

Integrated care for older people based on information and communication technology: a scoping review protocol

INTRODUCTION

Integrated care is an effective means of coping with the increasingly complex healthcare needs of elderly and alleviating pressure on national pension services. WHO regards integrated care as a method of providing high-quality healthcare and advocates integrated care based on digital technology. Against the backdrop of the COVID-19 pandemic, information and communication technology (ICT) has become a facilitator for the successful implementation of integrated care by providing a platform for information sharing, team communication and resource integration. This scoping review aims to assess internationally published evidence concerning experiences and practice of ICT-based implementation of integrated care for older people.

METHODS AND ANALYSIS

The study will follow the research framework developed by Arksey and O'Malley for scoping reviews. We will conduct a systematic search of the literature published from January 2000 to March 2022 via electronic databases, grey literature databases, websites of key organisations and project funding sources, key journals and reference lists included in selected papers, employ the Joanna Briggs Institute Literature Quality Assessment Tool to assess the quality of the included literature and apply thematic analysis to sort and summarise the content of the included studies. This study will begin in March 2022 and will be completed in December 2022.

ETHICS AND DISSEMINATION

Ethical approval for this scoping review was granted by the Academic Committee of Zhengzhou University (ZZUIRB2021-155). This study will summarise the modes of operation and effects, barriers and facilitators of ICT-based implementation of integrated care for older people. We propose to recruit older people and integrated care service providers in rural primary healthcare centres and use a structured process of concept mapping to consult and discuss the results of our scoping review to construct an integrated care model and service pathway for older adults that is appropriate to the Chinese social context.

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

Introduction:

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

Methods:

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

Results:

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

Discussion and conclusion:

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

The Long-Term Care with Focus on an Integrative Care Model in the Slovak Republic: A Pilot Study

An integrative care model is a challenge and the future of social and healthcare systems globally in establishing interdisciplinary cooperation. The integrative care model responds to the needs of patients suffering from various diseases as well as their families. Planning and policy making should involve professionals in both the medical and social care disciplines; additionally, the management and administrators of social and healthcare services, at both the national and community levels, are crucial in integrating health services. This article aims to present and describe the selection methods of functional groupings of municipalities as appropriate locations for implementing care practices for elderly, in this case an integrative social and health services model. The study employed an exploratory mixed methods design. The proposed methodology of the selection of the functional groupings of municipalities has a mixed-methodological character, consisting of quantitative as well as qualitative methods. Our research focused on quantitative data processing using two approaches: the multicriteria evaluation method to create a composite index and the ArcGIS system to express the geographical distribution of the value of the composite index. The qualitative document study was applied to analyses of community-based plans for health and social services. The methodology also includes an evaluation of municipalities, which was not the subject of our paper. Furthermore, the article suggests the need to consider other factors in connection with the methodology of the selection of functional groupings and explains some of its limitations in the discussion.

Care Integration in Primary Dementia Care Networks: A Longitudinal Mixed-Methods Study

Introduction:

Currently, care integration for community-dwelling persons with dementia is poor and knowledge on how to effectively facilitate development of integrated dementia care is lacking. The DementiaNet program aims to overcome this with a focus on interprofessional collaboration. The objective of this study is to investigate how care integration in interprofessional primary dementia care networks matures and to identify factors associated with (un)successfully maturation.

Theory and methods:

A longitudinal mixed-methods study, including 17 primary care networks participating in the DementiaNet study, was performed. Semi-structured interviews based on the Rainbow Model of Integrated Care were conducted at start, at 12- and 24 months. Network maturity scores (range 1–4) were derived from the interviews and qualitative data was used to explain the observed patterns.

Results:

Networks consisted on average of 9 professionals (range 4–22) covering medical, care and social disciplines. Network maturity yearly increased with 0.29 (95%-CI: 0.20–0.38). Important factors for improvement included getting to know each other’s expertise, having a capable network leader(s), stable network composition and participation of a general practitioner.

Conclusions:

The DementiaNet approach enables a transition towards more mature networks. Identified success factors provide better understanding of how network maturity can be achieved and gives guidance to future care integration strategies.

What Makes Integration of Chronic Care so Difficult? A Macro-Level Analysis of Barriers and Facilitators in Belgium

Introduction

Although many countries have been implementing integrated care, the scale-up remains difficult. Macro-level system barriers play an important role. By selecting three key policies, which have implemented integrated care in Belgium over the last 10 years, we aim to go beyond the identification of their specific barriers and facilitators to obtain an overarching generic view.

Methods

27 participants were purposefully selected, to include all important stakeholders involved on the macro-level in chronic care in Belgium. Semi-structured interviews were guided by a timeline of policies and an inductive thematic analysis was performed.

Results

Barriers and facilitators were identified on both health care and policy level. The major factors restraining the scale-up of integrated care are the fee-for-service reimbursement system, limited data sharing and the fragmentation of responsibilities between different levels of government. Remarkably, these factors strongly interact.

Discussion

This paper highlights the importance of homogenization of responsibilities of governments regarding integrated care and the interdependency of policy and health care system factors. A whole system change is needed instead of the current Belgian model of prolonged search for common ground between conflicting opinions. Political commitment and citizen participation will be crucial.

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

Introduction

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

Methods

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

Results

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

Conclusion

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

Integrated Care in the Community: The Case of the Programa Maior Cuidado (Older Adult Care Programme) in Belo Horizonte-Minas Gerais, BRA

Internationally, there is a large body of scientific evidence concerning the benefits of integrating health and social care to ensure that frail older people living in the community receive the assistance they need to maintain independence. In the Brazilian city of Belo Horizonte, located in the state of Minas Gerais, an integrated care intervention has been developed: the Programa Maior Cuidado – Older Adult Care Programme (PMC). This programme represents a pioneering example in Brazil of the provision of carers for highly vulnerable older people, through integrated action between public health and social service agencies. This paper draws on the first phase of a mixed method evaluation of PMC, including data from documentary sources, focus groups, empirical observation and expert workshops, to examine the processes that led to the establishment of programme. The origins of the PMC are discussed and its operational processes, with a particular emphasis on integrated activities and the roles of different actors. The paper situates PMC within comparable international experiences of integrated provision for older people and considers how it has been affected by unique context and challenging of a middle-income country.

Achieving person-centredness through technologies supporting integrated care for older people living at home: an integrative review

Purpose

The purpose of this paper is to identify the range, type and outcomes of technological innovations aimed at supporting older people to maintain their independence within the context of integrated care at home. We also discuss key emergent themes relevant to the use of person-centred technology for older people in integrated care and propose recommendations for policy and practice.

Design/methodology/approach

An integrative review methodology was used to identify and describe recent scientific publications in four stages: problem identification, literature search, data evaluation and data analysis.

Findings

Twelve studies were included in the review. Three studies described remote consultations, particularly telemedicine; five studies described tools to support self-management; three studies described the use of healthcare management tools, and one study described both remote consultation and self-care management. Emergent themes were: acceptability, accessibility and use of digital technologies; co-ordination and integration of services; the implementation of digital technologies; and safety and governance. Several recommendations are proposed relevant to integrated care teams, technology developers and researchers.

Originality/value

This review uniquely considers the extent to which novel digital technologies used in integrated care for older people are person-centred.