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In this perspective paper we use publicly-available data to show that, despite much positive rhetoric in support of reforms in Scotland to integrate health and social care, these reforms, in their current state, have failed to meet their stated objectives. Rather than regress to the previous system, we propose continued evaluation of even more radical forms of such integration. This analysis, and set of future proposals, are timely given current considerations with respect to a National Care Service in Scotland and recent similar reforms in England and in other countries. [ABSTRACT FROM AUTHOR]

Introduction: Observational data are increasingly seen as a valuable source for integrated care research. Especially since the growing availability of routinely collected data and quasi-experimental methods. The aim of this paper is to describe the potentials and challenges when using observational data for integrated maternity care research, based on our experience from developing and working with the Data-InfrAstructure for ParEnts and childRen (DIAPER). Methods and Results: We provide a description of DIAPER, which is a linked datainfrastructure on the individual level based on maternity care claims data, quality and utilization of maternity care and data from municipal registries, covering the life course from preconception to adulthood. We then discuss potentials and practical applications of DIAPER such as to evaluate alternative payment models for integrated maternity care, to set the policy agenda regarding postpartum care, to provide insights into value of care and into provider variation, and to evaluate (policy) interventions designed to promote and support integrated maternity care. This is relevant for several stakeholders: policy makers, payers, providers and clients/patients. Based on experiences with DIAPER, we identify remaining challenges: missing data sources (especially self-reported outcomes), suboptimal quality of data, privacy concerns and potential biases introduced during data linkage, and describe how these challenges were tackled within the applications of DIAPER. Conclusions: With DIAPER we demonstrated that using observational data can be of added value for integrated care research, but also that challenges remain. It is essential to keep exploring and developing the possibilities of observational data and continue the discussions in the scientific community. Learning from each other's successes and failures will be critical. [ABSTRACT FROM AUTHOR]

Introduction: China is promoting integrated care. However, incomplete payment methods led to medical insurance overspending and intensified service fragmentation. Sanming implemented Integrated Medicare Payment Methods (IMPM) in October 2017, which integrates multi-level payment policies. Sanming’s IMPM works well and has been promoted by the Chinese government. Therefore, in this paper, we aim to systematically analyze Sanming’s IMPM, and conduct preliminary evaluations of Sanming’s IMPM. Policy Description: IMPM integrates two levels of policy that are implemented simultaneously: (1) The payment policy for healthcare providers refers to how to calculate the global budget (GB) of the medical insurance fund paid to the healthcare providers and the policy guidance for the healthcare providers on how to use GB. (2) The payment policy for medical personnel refers to the adjustment of the evaluation index of the annual salary system (ASS) according to the IMPM’s purpose and the payment policy that adjust pay levels based on performance. Discussion and lessons learned: After the IMPM reform, county hospitals (CHs) may reduce over-providing dispensable healthcare, and cooperation between hospitals may increase. The policy guidance (Determining GB according to population; Medical insurance balance can be used for doctors’ salary, cooperation between hospitals, and promotion of residents’ health; Adjusting ASS assessment indicators according to IMPM purposes) increases CHs’ motivation to promote balances of medical insurance fund by cooperating with primary healthcare and increasing health promotion actions. Conclusion: As a model promoted by the Chinese government, the specific policies of Sanming’s IMPM are better matched with policy goals, which may be more conducive to promoting medical and health service providers to pay more attention to cooperation among medical institutions and population health. [ABSTRACT FROM AUTHOR]

Introduction: Over the last decade in the United States (US), the burden of chronic disease, health care costs, and fragmented care delivery have increased at alarming rates. To address these challenges, policymakers have prioritized new payment and delivery models to incentivize better integrated health and social services. Policy practice: This paper outlines three major national and state policy initiatives to improve integrated health and social care over the last ten years in the US, with a focus on the Medicaid public insurance program for Americans with low incomes. Activities supported by these initiatives include screening patients for social risks in primary care clinics; building new cross-sector collaborations; financing social care with healthcare dollars; and sharing data across health, social and community services. Stakeholders from the private sector, including health systems and insurers, have partnered to advance and scale these initiatives. This paper describes the implementation and effectiveness of such efforts, and lessons learned from translating policy to practice. Discussion and Conclusion: National policies have catalyzed initiatives to test new integrated health and social care models, with the ultimate goal of improving population health and decreasing costs. Preliminary findings demonstrated the need for validated measures of social risk, engagement across levels of organizational leadership and frontline staff, and greater flexibility from national policymakers in order to align incentives across sectors. [ABSTRACT FROM AUTHOR]

Introduction: Over the last decade in the United States (US), the burden of chronic disease, health care costs, and fragmented care delivery have increased at alarming rates. To address these challenges, policymakers have prioritized new payment and delivery models to incentivize better integrated health and social services. Policy practice: This paper outlines three major national and state policy initiatives to improve integrated health and social care over the last ten years in the US, with a focus on the Medicaid public insurance program for Americans with low incomes. Activities supported by these initiatives include screening patients for social risks in primary care clinics; building new cross-sector collaborations; financing social care with healthcare dollars; and sharing data across health, social and community services. Stakeholders from the private sector, including health systems and insurers, have partnered to advance and scale these initiatives. This paper describes the implementation and effectiveness of such efforts, and lessons learned from translating policy to practice. Discussion and Conclusion: National policies have catalyzed initiatives to test new integrated health and social care models, with the ultimate goal of improving population health and decreasing costs. Preliminary findings demonstrated the need for validated measures of social risk, engagement across levels of organizational leadership and frontline staff, and greater flexibility from national policymakers in order to align incentives across sectors. [ABSTRACT FROM AUTHOR]

This policy paper aims to compare what policies are developed in Italy for the management of chronic patients in order to improve population health, quality of care and patient experience and reduce per-capita cost. The paper also aims to identify the key trends and evolutionary trajectories across the Country. Methodology: The analysis focuses on 10 Italian Regions and the time span of observation is 7 years (from 2014 to 2020). Data collection and analysis adopts mixed methods in order to have a more in-depth picture of the contextual factors, mechanisms and outcomes. It includes a desk research of the literature and documentary analysis; semi-structured interviews; a theory driven evaluation of 12 programmes identified at the regional level; and a Consensus Conference to discuss and validate the results with an Expert Panel Group. Conclusions: The paper firstly describes the main policies developed in Italy in the last seven years; secondly, it discusses six main trends and clusters them into three strategies: demand management strategies; strategies to improve the management of comorbid and frail patients; and strategies to improve the coordination between levels of care and the patient journey; thirdly, it discusses eight trends and evolutionary trajectories which are now emerging. [ABSTRACT FROM AUTHOR]

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. [ABSTRACT FROM AUTHOR]

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. [ABSTRACT FROM AUTHOR]

Introduction: Primary healthcare (PHC) in Sweden is under transformation following an extensive governmental reform, called "Good quality, local health care". The reform aims to re-establish PHC as 'front-line care' and to strengthen the quality of PHC, largely by integrating person-centred solutions. Digital solutions are foreseen to play a significant part in the transformation as well as stronger coordination between municipalities and regions. The suggested focus of the reform indicates areas where policy makers think changes are needed. It is important to scrutinize the "solutions" proposed, as problem representations justify or legitimise certain policies or policy solutions. Aim and method: This policy analysis aims to explore problem representations in the Swedish healthcare reform. Four main policies underpinning the reform were identified and documentations of those retrieved. To unpack the 'problems' represented in the reform, the "What is the problem represented to be" (WPR) approach developed by Bacchi was applied (1). Guided by Bacchi, the proposed solutions in the policy documents were analysed and evolved into three preliminary themes, which form the basis for the problem formulations. This paper is work under progress. Key findings: Three overarching problem formulations unfolded. First, by proposing that the development of a modern, accessible, and effective healthcare system that focus on PHC will depend upon a new definition and a common roadmap, the reform represents the 'problem' as a 'nebulous care mission and narrow health system scope'. The second 'problem' was developed based on solutions concerned with strengthening the collaboration between regional and municipal care actors. The reform locates the 'problem' primarily within the organisational realm of the health system while representing it as the 'silos of differentiated care systems and processes'. The third 'problem' builds on solutions intended to bring services closer to people and ensuring that the services are relevant to the needs, wishes and preferences of the patient(s). In this regard, the 'problem' is represented as care that is 'distant and detached from (individual) patients'. Conclusion: The problem representations developed by the policy analysis can be traced to earlier PHC reforms aiming to give the municipalities the responsibility of elderly care (2) and individual patients more power to influence their care (3). The reform is silent on equity between social groups which warrants further scrutiny. Implications to the ICIC 2022 Conference: The paper suits the first theme since personcenteredness is at the core of the reform. Being a policy proposal, it adheres especially well to the sixth pillar which directly addresses policymaking. Knowledge-sharing from Swedish healthcare may thus be useful for other countries in transition. 1. Bacchi C, Eveline J. What's the problem represented to be Mainstreaming Politics: Gendering Practices and Feminist Theory. 2010;111. 2. Edebalk PG. Den dramatiska Ädelreformen. Äldre i centrum: tidskrift för aktuell äldreforskning, 2021, 35, 111-113 3. Burström, B., Burström, K., Nilsson, G., Tomson, G., Whitehead, M., & Winblad, U. (2017). Equity aspects of the Primary Health Care Choice Reform in Sweden-a scoping review. International journal for equity in health, 2017, 16(1), 1-10. [ABSTRACT FROM AUTHOR]

Efforts are underway in many European countries to channel efforts into creating improved integrated health and social care services. But most countries lack a strategic plan that is sustainable over time, and that reflects a comprehensive systems perspective. The Policy Guide on Integrated Care (PGIC) as presented in this paper resulted from experiences with the EU Project INTEGRATE and our own work with healthcare reform for patients with chronic conditions at the national and international level. This project is one of the largest EU funded projects on Integrated Care, conducted over a four-year period (2012-2016) and included partners from nine European countries. Project Integrate aimed to gain insights into the leadership, management and delivery of integrated care to support European care systems to respond to the challenges of ageing populations and the rise of people living with long-term conditions. The objective of this paper is to describe the PGIC as both a tool and a reasoning flow that aims at supporting policy makers at the national and international level with the development and implementation of integrated care. Any Policy Guide on Integrated should build upon three building blocks, being a mission, vision and a strategy that aim at capturing the large amount of factors that directly or indirectly influence the successful development of integrated care. [ABSTRACT FROM AUTHOR]

The description of case management in research and clinical practice is highly variable which impedes quality analysis, policy and planning. Case management makes a unique contribution towards the integration of health care, social services and other sector services and supports for people with complex health conditions. There are multiple components and variations of case management depending on the context and client population. This paper aims to scope and map case management in the literature to identify how case management is described in the literature for key complex health conditions (e.g., brain injury, diabetes, mental health, spinal cord injury). Following literature searches in multiple databases, grey literature and exclusion by health condition, community-based and adequate description, there were 661 potential papers for data extraction. Data from 79 papers (1988-2013) were analysed to the point of saturation (no new information) and mapped to the model, components and activities. The results included 22 definitions, five models, with 69 activities or tasks of case managers mapped to 17 key components (interventions). The results confirm the significant terminological variance in case management which produces role confusion, ambiguity and hinders comparability across different health conditions and contexts. There is an urgent need for an internationally agreed taxonomy for the coordination, navigation and management of care. [ABSTRACT FROM AUTHOR]

Introduction: Collaboration was legislated in the delivery of integrated care in the early 2000s in the UK. This research explored how the reality of practice met the rhetoric of collaboration. Theory: The paper is situated against a theoretical framework of structure, agency, identity and empowerment. Collectively and contextually these concepts inform the proposed model of 'collaborative agency' to sustain integrated care. The paper brings sociological theory on structure and agency to the dilemma of collaboration. Methods: Participative action research was carried out in collaborative teams that aspired to achieve integrated care for children, young people and families between 2009 and 2013. It was a part time, PhD study in collaborative practice. Results: The research established that people needed to be able to be jointly aware of their context, to make joint decisions, and jointly act in order to deliver integrated services, and proposes a model of collaborative agency derived from practitioner's experiences and integrated action research and literature on agency. The model reflects the effects of a range of structures in shaping professional identity, empowerment, and agency in a dynamic. The author proposes that the collaborative agency model will support integrated care, although this is, as yet, an untested hypothesis. [ABSTRACT FROM AUTHOR]

Community-based primary health care describes a model of service provision that is oriented to the population health needs and wants of service users and communities, and has particular relevance to supporting the growing proportion of the population with multiple chronic conditions. Internationally, aspirations for community-based primary health care have stimulated local initiatives and influenced the design of policy solutions. However, the ways in which these ideas and influences find their way into policy and practice is strongly mediated by policy settings and institutional legacies of particular jurisdictions. This paper seeks to compare the key institutional and policy features of Ontario, Québec and New Zealand that shape the 'space available' for models of community-based primary health care to take root and develop. Our analysis suggests that two key conditions are the integration of relevant health and social sector organisations, and the range of policy levers that are available and used by governments. New Zealand has the most favourable conditions, and Ontario the least favourable. All jurisdictions, however, share a crucial barrier, namely the 'barbed-wire fence' that separates funding of medical and 'non-medical' primary care services, and the clear interests primary care doctors have in maintaining this fence. Moves in the direction of system-wide community-based primary health care require a gradual dismantling of this fence. [ABSTRACT FROM AUTHOR]

This paper is a response to our recognition that approaches to equity and consumer involvement in research differed in emphasis between our researchers and jurisdictions. Whilst we shared common aspirations we varied in our priorities between equity groups and methods to represent consumer interests. New Zealand has a historical focus on equity for indigenous Maori and shares with Canada concern about enduring inequalities that affect people's lives. [ABSTRACT FROM AUTHOR]

The aim of this paper is to set the foundation for subsequent empirical studies of the "Implementing models of primary care for older adults with complex needs" project, by introducing and presenting a brief descriptive comparison of the nine case studies in Quebec, Ontario and New Zealand. Each case is described based on key dimensions of Rainbow model of Valentijn and al (2013) with a focus on "meso level" integration. Meso level integration is represented by organizational and professional elements of the Rainbow Model, which are of particular interest in our nine case studies. Each of the three cases in Ontario and three in New Zealand are different and described separately. In Quebec, a local health services network model is presented across the three cases studied with variations in the way it is implemented. The three cases selected in the three jurisdictions under study were not chosen to be representative of wider practice within each country, but rather represent interesting and unique models of communitybased primary healthcare integration. Similarities and variations in the integrated care models, context and dimension of integration offer insights regarding core component of integration of services, offering a foundational understanding of the cases on which future analysis will be based. [ABSTRACT FROM AUTHOR]

Introduction: Japan has the largest percentage of elderly people in the world. In 2012 the government implemented a community-based integrated care system which provides seamless community healthcare resources for elderly people with chronic diseases and disabilities. Methods: This paper describes the challenges of establishing a community-based integrated care system in 1974 in Mitsugi, a rural town of Japan. This system has influenced the government and become the model for the nationwide system. Results: In the 1970s, Mitsugi's aging population was growing faster than Japan's, but elder care was fragmented among a variety of service sections. A community-based integrated care system evolved because of the small but aging population size and the initiative of some local leaders of medical care and politics. After the system took effect, the proportion of bedridden people and medical care costs for the elderly dropped in Mitsugi while it continued to rise everywhere else in Japan. Mitsugi's community-based integrated care system is now shaping national policy. Conclusion: Mitsugi is in the vanguard of Japan's community-based integrated care system. The case showed the community-based integrated care system can diffuse from rural to urban areas. [ABSTRACT FROM AUTHOR]

This paper examines the provision of integrated advanced dementia care within seven European countries and critically reviews the potential contribution of the Prudent Healthcare perspective as a starting point for reform. Progressive efforts to innovate, promote quality and integrate care are tempered with the reality of resource constraints. Some policy makers in Europe and North America have turned their attention to the principles of Prudent Healthcare as a potential mechanism to maximise benefits for patients within available resources. As dementia progresses, living well requires increasing levels of support and care, people living with advanced dementia have complex health and social care needs, are highly dependent on others but are not yet at the terminal end stage of the condition. People with advanced dementia can benefit from a dementia specific palliative approach to care (Palliare), that helps them to live the best life possible for the months and often years they live with advanced dementia. It is also highly desirable to align policy innovations with integrated palliative care practice models and the education of the dementia workforce to accelerate informed improvements in advanced dementia care. There may be some coherence, at least superficially between Prudent Healthcare and integrated palliative care models such as Palliare. It is argued that for successful implementation, both require practitioners to be equipped with knowledge and skills and be empowered to deliver high quality care often within impoverished care environments. Adoption of the prudent perspective will however require development of a repertoire of approaches to hear the voice or proxy voice of people living with advanced dementia and to commit to the development and implementation of new evidence for advanced dementia practice. Evidence informing this policy debate draws upon contemporary literature and policy and the findings from research activities undertaken by the Palliare project supported through the Erasmus+ K2 Strategic Partnerships funding programme. [ABSTRACT FROM AUTHOR]

The issue of integrated care and inter-sectoral collaboration is on the health policy agenda in many countries. Yet, there is limited knowledge about the effects of the different policy instruments used to achieve this. This paper studies co-location as a driver for cross-sectoral collaboration with general practitioners (GPs) acting as coordinators in a municipal health centre. The purpose of the health centre, which is staffed by health professionals from municipal, regional and private sectors, is to provide primary health services to the citizens of the municipality. Co-locating these professionals is supposed to benefit e.g., elder citizens and patients with chronic diseases who frequently require services from health professionals across administrative sectors. Methodologically, the analysis is based on qualitative data in the form of semi-structured interviews with the health professionals employed at the health centre and with administrative managers from municipal and regional government levels. The study finds that co-location does not function as a driver for cross-sectoral collaboration in a health centre when GPs act as coordinators. Cross-sectoral collaboration is hampered by the general practitioners' work routines and professional identity, by organisational factors and by a lack of clarity concerning the content of collaboration with regard to economic and professional incentives. [ABSTRACT FROM AUTHOR]

Objectives: This paper discusses the increasing incidence of mental health problems in Pakistan, and specifically in the Swat Valley, in relation to the growing insurgency and current violence in Pakistani society. The paper argues that the health care system's response in Pakistan is not adequate to meet the current challenges and that changes in policy are needed to build mental health care services as an important component of the basic health package at primary care level in the public sector. Method: This paper reviews the existing mental health situation in Pakistan with reference to the findings of a case study in the Swat Valley in Khyber Pukhtoonkhwa Pakistan. The figures presented in the case study are used to support the need for an integrated national mental health policy. Conclusion: Mental health care needs to be incorporated as a core service in primary care and supported by specialist services. There is a strong need to provide adequate training for general practitioners and postgraduate training for mental health professionals to meet the current demands. A collaborative network between stakeholders in the public and private sector, as well as non-governmental organisations are required that promotes mental health care and advocates for changes in mental health policy. [ABSTRACT FROM AUTHOR]

Background: Over the past years, Greece has undergone several endeavors aimed at modernizing and improving national health care services with a focus on PHC. However, the extent to which integrated primary health care has been achieved is still questioned. Purpose: This paper explores the extent to which integrated primary health care (PHC) is an issue in the current agenda of policy makers in Greece, reporting constraints and opportunities and highlighting the need for a policy perspective in developing integrated PHC in this Southern European country. Methods: A systematic review in PubMed/Medline and SCOPUS, along with a hand search in selected Greek biomedical journals was undertaken to identify key papers, reports, editorials or opinion letters relevant to integrated health care. Results: Our systematic review identified 198 papers and 161 out of them were derived from electronic search. Fifty-three papers in total served the scope of this review and are shortly reported. A key finding is that the long-standing dominance of medical perspectives in Greek health policy has been paving the way towards vertical integration, pushing aside any discussions about horizontal or comprehensive integration of care. Conclusion: Establishment of integrated PHC in Greece is still at its infancy, requiring major restructuring of the current national health system, as well as organizational culture changes. Moving towards a new policy-based model would bring this missing issue on the discussion table, facilitating further development. [ABSTRACT FROM AUTHOR]

This paper introduces an empirically-grounded theory of change in health care systems. It draws on three research projects focusing on the implementation of a mental health care reform. These projects include two evaluation studies commissioned by Belgian public health authorities and a scientific, PhD research supported by the Belgian National Fund for Scientific Research. They are based on qualitative methods, including document analysis, semi-structured interviews and focus groups. The generalisation of these research findings has recently started through ongoing projects devoted to the implementation of an integrated care model in the field of chronic diseases. This paper first draws on a realistic approach to health policy implementation (1). A particular attention is consequently paid to the context of implementation and to identify explicit and implicit mechanisms combining to give a particular direction to the change process. Moreover, the theory of change outlined in this paper importantly borrows from system and process theories (2). It emphasises the pivotal role fulfilled by repeated sequences of interactions, most of which take the form of meeting communication, between differentiated and interdependent social systems. Belgian policymakers started supporting a shift from an institution-based towards an integrated care model in the field of mental health in 2010. This shift was expanded to the field of chronic diseases in 2015. The Belgian health care system combines characteristics of the Bismarkian and Beveridgian models. It is decentralised, highly differentiated, and recognises the autonomy of health care providers and professionals. Moving towards integrated care is all the more challenging in that context. This challenge explains the preference of Belgian policymakers for soft regulation mechanisms, that is, pilot projects making room for local adaptations and depending on a phased approach to organisational change. In this framework, local coordinators are responsible for steering the implementation process, in a way to ensure consistency between local translations and global policy objectives. In-depth analysis of the mental health reform implementation evidenced a significant discrepancy between the policy programme and local adaptations. Professional cultures, organisational strategies and ideological pillars specific to the Belgian society have been identified as the main factors accounting for these discrepancies. Furthermore, inter-organisational meetings emerged as the very spaces where such influential logics of action are expressed and articulated with one another. In this respect, the main challenge lies in the stakeholders' ability to create hinges (3), defined as visions of the situation which enable to coordinate the action of different systems, without preventing them from preserving their cognitive structure. Coordinators, acting as boundary spanners (4), play a strategic role in organising and reporting on these meetings. However, coordinators lack power, managerial skills and knowledge of innovation process to cope with social influence in a way consistent with policy objectives. Therefore, this paper outlines a theory of health system transformations which put professional culture, organisational strategies and social ideologies at the forefront. It argues that assuming the social nature of these transformations would enable to improve both the design of health policy and the training of change managers. [ABSTRACT FROM AUTHOR]

Policy and System Change Context: The paper describes insights into implementation challenges associated with integrated care as a national policy component of Universal Health Care in Ireland. It addresses an international audience by linking universal and integrated care development with the policy implementation literature in complex adaptive health and social care systems. Study Design and Methods: It outlines findings from two literature reviews on change in complex health and social care systems, one of them a systematic review that situates integrated care in the universal health care policy context. We also present findings, including operational and strategic insights on the challenges and opportunities of implementing integrated care from a) a participant online survey across seven pioneer sites and at national programme level, and b) an indepth case study of integrated care implementation in Ireland over three pioneer sites. Case-data generated from November 2017 to June 2018 at national and pioneer-site levels include initial research co-design discussions, exploratory and elite interviews, workshops, documentary review, participant observation and feedback. Outline Findings: Systematic and literature review findings address methodologies, conditions and competencies for implementation (including collaboration, distributed decision-making, mindsetshifts and leadership styles in complex systems). System-level mechanisms for better patient access, information sharing, and effective functionality are also highlighted. The survey and case study research evidences similar challenges around provider skills and competencies, managing patient access and pathways, and the creation of organisational systems to underpin new service delivery designs. The question of organisational adaptability is critical here for successful system reform outcomes such as positive change management, quality of care and sustained learning for person-centered care. Practical and Policy Relevance: Learning how demonstrator (pioneer) site initiatives and discrete programmes can grow locally, as well as scale more broadly for translation as common discourses, approaches, and buy-in is critical to meet the challenges of integrated care as a key plank of universal healthcare. The paper usefully describes policy implementation challenges from a grounded, complex, wholeof- system perspective. [ABSTRACT FROM AUTHOR]

Introduction: In 2000, Japan implemented a mandatory long-term care insurance system. With the rapid growth of the system, problems became apparent. Several critical alterations were made to long-term care insurance system, particularly with respect to integrated care. Methods: This paper elucidates the policy trends that led to the reforms of the long-term care insurance system, which included new concepts of 'integrated care' and 'community-based care', an agenda of cost containment and service streamlining, and coordination with medical care. Results: Community-based integrated care, as envisaged in the long-term care policy, includes not only the integration of medical care into service provision but also the inclusion of the informal mutual aid, oversight of for-profit providers by an administration that ensures users are not exploited and coordination between systems that cover different geographical areas. Conclusions: Japan's experience in community-based care integration suggests that this project requires multi-faceted care integration in local communities. In the future, it will be necessary to conduct empirical assessments of the effectiveness of these measures. [ABSTRACT FROM AUTHOR]

Politicians in Ireland aim to radically transform access to healthcare by changing the current two-tiered system to a single-tier, universal healthcare service ensuring access to healthcare on the basis of medical need; not ability to pay. Successful implementation of this vision requires enabling a health system with the capacity to deliver in fact. Bedevilled with long waiting lists, emergency department bottlenecks, path dependent fragmentation and chronic under-resourcing of the primary and community care domains (to name a few of the challenges apparent), the Irish health system needs to forge practical paths to a level of integration greater than (although encompassing) the integrated care programmes already in train. This paper, based on initial findings of a systematic review of the 'organisational challenges of implementing universal healthcare policies in countries with a GDP per capita greater than $22,000' is oriented towards policy-makers, health system designers, enablers and providers - particularly those working in a context where health reform is focussed on implementing universal and integrated care models. Our initial search identified 1,784 papers (having removed duplicates) and after 5 screening stages resulted in 9 papers for review. These include a range of study types, and report findings from the USA, Australia, Canada, UK, Italy and Taiwan. Findings highlight the variety of policy instruments used to deliver universal healthcare, these include legislation, social health insurance and Medicare subsidies at the policy level; they also note service implementation processes, design, performance evaluation and leadership programmes aimed at greater system cohesion and integration at the practice level. The challenges and opportunities identified from our analysis relate primarily to provider practice and collaboration - both themes central to the development of integrated care. We find that providers experience better continuity of care and hence job satisfaction in some universal access settings, but also come up against systemic barriers to the shared decisionmaking, information flows and new role requirements necessary for integrated and universal access to care. The difficulty of changing role definitions and expectations is also apparent in our theme of collaboration. Getting stakeholders to engage in transparent peer-review, shifting fixed mind-sets and behaviours, optimum pacing of policy implementation for engagement, and systemic constraints that disable the renegotiation of professional differences on teams (for example) are also identified as important challenges. These findings can inform politicians and policy-makers as they express a vision and plan for the 'Future of Healthcare in Ireland' over the next 10 years (http://www.oireachtas.ie/parliament/oireachtasbusiness/committees_list/future-ofhealthcare/). More broadly they offer pertinent evidence for those eager to better understand the processes of health system transition and transformation through a practical lens. We conclude on the basis of our review that universal healthcare implies a health system designed for integrated care. Making the explicit link between universal healthcare and integrated care on the basis of the organisational challenges and opportunities inherent to both policy directions is innovative and useful for health system reformers generally. [ABSTRACT FROM AUTHOR]

Introduction: Literature reveals that integrated care is perceived to be the answer to the many issues faced by health systems in in the OECD. Research has also identified many difficulties in its implementation1. In Ireland, it has been observed that there is a disconnect between the trend of patient centred policy making and the organisational support available to health professionals and patients at the frontline in its implementation2 Description of Policy context and Objective: The context for this paper is the introduction of integrated care in Ireland through the implementation of Community Health Organisations (CHOs) in 2015/16 as outlined in the report- Report and Recommendations of the Integrated Service Area Review Group' also referred to as the Healy Report (HSE 2014). A similar policy development was introduced in Northern Ireland since 2011; with the development of an integrated health and social care policy (Transforming Your Care, Review of Health and Social Care, 2011). This paper reports on a comparative review of integrated health and social care policy in both Ireland and Northern Ireland and identifies themes that emerge from a comparative policy document analysis. It examines the contents and specific aspects of both sets of policy documents including; implementation plans, structures and governance arrangements and their potential influence on professional practice. This paper will serve as a contribution to a future study on the process of implementation of integrated care in the Republic of Ireland. Highlights: Northern Ireland has implemented structural integration of its health and social care since the 1970s. Existence of similarity in policy goals and objectives, the reform programmes, guiding principles and agenda's set out in policy documents in Northern Ireland and Republic of Ireland. The Republic of Ireland runs a risk of facing the same policy issues observed in the Northern Ireland experience of implementation based on policy recommendations. Sufficient resources need to be in place in order to have sustainable integrated care in the Republic of Ireland. Transferability: This paper describes the relevance of Northern Ireland experience and serves as a useful guide to the implementation of integrated health and social care in the Republic of Ireland. Conclusion: (Key findings, discussion and lesson learned) The main themes that emerged from the comparative review include; policy process, structural composition, governance, management and accountability, clarity of professional roles and policy goals, localism agenda and standardised pathways, frontline autonomy and decision making, stakeholder inclusion and configuration. Implementing integrated care is expensive, requires balanced configuration of management, structures and governance arrangements that supports exchange of information across professionals, shared services, involvement of users, promotion of strong working relationships and collaborations as well as more research in bridging gaps between policy aims and frontline professional practice which on the long run produces sustainable health delivery outcomes. [ABSTRACT FROM AUTHOR]

Introduction: Montenegro, a newly independent Balkan state with a population of 650,000, has a health care reform programme supported by the World Bank. This paper describes planning for integrated elderly and palliative care. Description: The current service is provided only through a single long-stay hospital, which has institutionalised patients and limited facilities. Broad estimates were made of current financial expenditures on elderly care. A consultation was undertaken with stakeholders to propose an integrated system linking primary and secondary health care with social care; supporting people to live, and die well, at home; developing local nursing homes for people with higher dependency; creating specialised elderly-care services within hospitals; and providing good end-of-life care for all who need it. Effectiveness may be measured by monitoring patient and carers' perceptions of the care experience. Discussion: Changes in provision of elderly care may be achieved through redirection of existing resources, but the health and social care services also need to enhance elderly care budgets. The challenges for implementation include management skills, engaging professionals and political commitment. Conclusion: Middle-income countries such as Montenegro can develop elderly and palliative care services through redirection of existing finance if accompanied by new service objectives, staff skills and integrated management. [ABSTRACT FROM AUTHOR]

Introduction: Long-term neurological conditions are a major cause of disability in the UK and internationally. Their successful management, in order to enhance health and well-being, requires both sophisticated organisation across a number of health, social care and other service boundaries, and the real involvement of people with neurological conditions and members of their support networks. Policy development: This paper reports on part of the preliminary scoping phase of a study designed to evaluate the impact of the National Service Framework for long-term neurological conditions on integrated care. It describes current policies in England and reports on discussions with a range of people involved in the planning, provision or use of services, which took place during the scoping exercise. These interviews inform how policy affecting people with long-term neurological conditions has been received and implemented so far. Conclusion and discussion: Findings suggest that progress towards integrated service provision is patchy and slow. In the competing priorities within government policy, neurological conditions have tended to be marginalised, within healthcare policy generally and in initiatives to support people with long-term conditions in particular. The reasons for this are explored and will inform the next stages of the research. [ABSTRACT FROM AUTHOR]

Purpose: The purpose of this paper is to examine the effects of health care policy on the development of integrated mental health services in England. Data sources: Drawing largely from a narrative review of the literature on adult mental health services published between January 1997 and February 2003 undertaken by the authors, we discuss three case studies of integrated care within primary care, secondary care and across the primary/secondary interface for people with serious mental illness. Conclusion: We suggest that while the central thrust of a raft of recent Government policies in England has been towards integration of different parts of the health care system, policy waterfalls and implementation failures, the adoption of ideas before they have been thoroughly tried and tested, a lack of clarity over roles and responsibilities and poor communication have led to an integration rhetoric/reality gap in practice. This has particular implications for people with serious mental health problems. Discussion: We conclude with suggestions for strategies that may facilitate more integrated working. [ABSTRACT FROM AUTHOR]

Purpose: The purpose of this paper is to examine the effects of health care policy on the development of integrated mental health services in England. Data sources: Drawing largely from a narrative review of the literature on adult mental health services published between January 1997 and February 2003 undertaken by the authors, we discuss three case studies of integrated care within primary care, secondary care and across the primary/secondary interface for people with serious mental illness. Conclusion: We suggest that while the central thrust of a raft of recent Government policies in England has been towards integration of different parts of the health care system, policy waterfalls and implementation failures, the adoption of ideas before they have been thoroughly tried and tested, a lack of clarity over roles and responsibilities and poor communication have led to an integration rhetoric/reality gap in practice. This has particular implications for people with serious mental health problems. Discussion: We conclude with suggestions for strategies that may facilitate more integrated working. [ABSTRACT FROM AUTHOR]

Intermediate care (IC) provides an integrated approach for service users at key points of transition in the system, stepping up or down from hospital. The issues intermediate care seeks to address are common across Europe but there is wide variation in the solutions being implemented. For instance, there are significant variations with the definition of IC, a clear understanding of the scopes, organisational patterns and professionals involved and the types of services users. Even within countries, service models and capacity between regions display great heterogeneities. The paper aims to understand the development of IC in Europe, providing a synthesis of the current development of IC in Europe and using benchmarking studies undertaken in the England, Catalonia Region (Spain) and Scotland to spread learning and good practice in this important area. In the UK, the provision of IC services became a national policy in 2001, whereas the first National Audit of Intermediate Care (NAIC) was conducted in 2012 to understand how IC had developed in terms of scale, scope and quality. The study was extended in 2013 to cover crisis response and social care re-ablement services, in addition to bed based and home/community based IC, and to incorporate clinical outcome and patient experience measures. The audit is now in its fourth iteration (NAIC 2015) and the results suggest IC is now well developed in the UK, although the scale and nature of provision varies considerably. The findings from NAIC 2015 deliver a range of performance indicators including, outcome measure scores over users' functional outcome from their episode of intermediate care; the access to IC services measured by the proxy of the average waiting times; the level of care integration and the development of tools to foster these processes; and, finally, the workforce employed in IC, focusing on the ratio of registered nursing compared to unregistered health staff. Further, in considering the overall need for IC, it was calculated in NAIC 2012 that intermediate care capacity in England needs to approximately double to meet potential demand. However, as in NAIC 2013 and NAIC 2014, there is no evidence in NAIC 2015 of a material increase in capacity nationally which may be due to the fragmented nature of health and social care funding arrangements in the UK. Scotland has also introduced a national policy on IC with a national framework and underpinning principles that can be tailored to local context. A community of practice and web portal to share learning and good practice case study examples support IC development. Benchmarking data is being progressed through a national health and social care data project that will link client or patient level data to allow IC activity and resources to be viewed within the whole system pathway of care. In Catalonia, IC has been homogeneously implemented, with a population-based distribution, since 1986. IC services are bed-based (convalescence and rehabilitation, palliative care, long term care), ambulatory (day hospital, outpatients) and home-based. Quality indicators for each type of service are homogeneously set, and accomplishment is associated to a % of reimbursement. Recently, in 2014, shared indicators between institutions operating across different levels of care of a same area have been introduced, to promote integrated care and common goals. Other sources of data include patient level activity data (admissions, discharges etc) and data of patients' Minimum Data Set (a simple comprehensive geriatric assessment), also matched with acute hospital data and users' satisfaction, all centrally collected and virtually available for 100% of institutions. These data are the basis for the benchmarking initiative, publicly available since 2014, which includes areas of case-mix, functional improvement, discharge destination, length of stay, satisfaction, and costs, among others. The paper intends therefore to discuss the dissemination of health policies to encourage the development of IC in Europe, providing a first rapid evidence synthesis on the current situation and a comparative analysis using benchmark and outcome data available in this field. Whereas this major strand represent a common denominator between European and Western Countries to achieve integrated care delivery system, there is a lack of consensus on the definition and purpose of IC. Where IC have been recently introduced, in fact, they result more akin to organisational adjustments and temporary solutions replacing the cuts from other services in the supply chain (hospital beds or personnel in long term care settings), but they struggle to achieve autonomous organisation in the health service delivery system. This variation in progress with IC highlights the value of comparing different experiences across Europe and sharing learning from countries with experiences in areas such as the development of performance indicators and benchmarking evaluative processes. [ABSTRACT FROM AUTHOR]

In response to increasing care needs, the development of elderly care systems has become a prominent policy concern across the OECD. Since the beginning of the 1990s, the increasing economic constraints led to the rise of policies that focus on the improvement of "coordination" and "integration" of administrations and services - in other words, policies that aim at reducing the fragmentation of health and social care system. As a result, a growing number of studies focus on innovative integrated care schemes and their transferability from one national context to another. Yet they do not systematically investigate the political, organizational, cultural and societal contexts in which they have emerged neither do they link them to the diverse conceptions of integration or coordination carried by the multiple actors concerned. In this paper, we identified three policy-making mechanisms underpinning integration policies at both national and local levels. Theory/Methods: The POLIA-INLOVE comparative research investigates integration/coordination policies in three European countries - France, Sweden and UK. Its analytical framework borrows from sociology, public policy analysis and management studies. Based on a qualitative and diachronic perspective, not presupposing the existence of any integration/coordination policy in the countries studied, it focuses on the understanding of whether, when and how the need for professional, institutional and organizational integration/coordination came to be formulated. Our approach seeks to deconstruct the meaning of integration and coordination policies led in the three countries, and to understand their institutional, organisational and historical contexts. This paper presents the first results of a literature review and an empirical survey by semi-directive interviews led since 2013 in France (n=27), Sweden (n=22) and the UK (n=28). It covers two levels: interviews with national experts at the macro level of policies developed and implemented nationally and with actors at the micro level concerning specific schemes implemented locally, to take into account the organizational particularities in each of the countries and on chosen territories. Results: The analysis of the policies in France, Sweden and UK shows the impact of both the national and the territorial contexts, which varies from one country to the other. It leads us to identify three different policy-making processes towards coordination/integration. We provisionally named them "layers", "chains" and "lineages". These logics are unequally shared out between the three countries: the layering process can be identified as a dominant trend in France whereas the chaining logic is dominant in Sweden. The lineage metaphor, finally, looks more appropriate when it comes to analyze the history of attempts for reducing fragmentation in England. Yet, further analysis including concrete solutions experimented on both national and local levels shows that there come to be a mix of logics mobilized in each concrete situation. Thus, the different logics are not directly opposed and they can be expected to work together. Discussion: Qualitative comparison raises significant challenges due to the risk of comparing schemes or elements which are not comparable, particularly for locally implemented models developed in specific territorial contexts, unless one focus on the learning and adaptation processes. Secondly, comparison between countries representing different welfare models runs the risk of reducing the observed outcomes to the same variables used for the identification of the welfare models. By putting the accent on identifying the underpinning logics of integration/coordination policies in the three countries rather than running a systematic comparison of their content, we address these challenges in two ways: - The three logics identified articulate both macro and micro analysis since they are based on the identification of the mechanisms underpinning both national policies and locally implemented measures. -The three logics are analyzed in relation to the different welfare state models and to the wider political projects they belong to. Conclusion: The next step of the research consists in identifying common cross-cutting issues in at least two of the three countries studied: -The impact of the political variable on the orientation and the content of integration/coordination policies; -Interactions between local and national levels as opportunities and constraints for integration; -The issue of New Public Management in the integration/coordination process Taken as basis for comparison, these issues can inform aspects of processes of integration/coordination that are often analyzed in one single national/local context. [ABSTRACT FROM AUTHOR]

Introduction: Despite continuing efforts by national and local policy-makers, the French health and social care system still remains fragmented, often resulting in many problems for the users, their family, as well as the local managers and providers of care (Bloch, 2013; Bloch and Hénaut, 2014). Most of the recent attempts to overcome fragmentation regarding elderly care took the form of pilot projects. In this paper, based on literature and ethnographic materials, we argue that integration has been difficult to achieve because pilots have been launched, at the national level, by siloed and competing administrations, and circumscribed, on sites, to either health or social care providers. However, new trends in policy piloting seem to be able to change the course of that story. First, some pilot project managers have been able to work with local managers and care providers in order to achieve what we call "integrative piloting". Second, the rise of a social movement among integrated care pilot project managers is impacting the development of integrated care policies both at the local and national levels. Methods: The paper is based on literature and ethnographic materials. First, complementing the work of Somme and de Stampa (2011), we traced the history of coordination and integration policies for the elderly in France thanks to a systematic literature review of more than 300 documents produced by scholars or policy-makers. Second, we conducted an in-depth analysis of three major coordination schemes that have been implemented across the country after several years of piloting: _CLIC, Réseaux_ and _MAIA_. Interviews and observations have been done in four sites (center of Paris, North East suburb of Paris, Marseille, Ile de la Reunion). Interviews focused on the work of pilot project managers and front-line professionals involved in coordination schemes (N=45), local policy makers (N=15), and leaders of newly created associations or networks related to the different pilots (N=4). Finally, we attended assemblies and training sessions arranged for the managers of the three coordination schemes. Results: At the level of national policy-makers, each administration (social affairs, health care, long term care, and social security) tried to overcome fragmentation by developing its own coordination scheme. The lack of interaction and the on-going competition between administrations, along with the inability to conduct or use public policy evaluations, resulted at the local level in a never-ending struggle against fragmentation. The paper presents the complex web of competing and overlapping coordination schemes in the settings that have been investigated. While most professionals had a limited view of health and social care providers for dependent elderly persons, and of coordination schemes, some project managers succeeded in developing local integration by implementing what we call "integrative piloting". They got other managers and providers on board thanks to the display of relational and entrepreneurial skills. They also took advantage of calls for applications offered by different administrations to channel new funds and build innovative collaborative schemes. In addition, our study shows the increasing role of the newly created associations and networks of the project managers who are piloting and managing coordination schemes in the development of best practice guides. They are in the process of combining their efforts in order to attract the attention of national policy-makers on several "local success stories". Discussion: Centrifugal forces take place both at the national and local levels. Because of the lack of learning process, policy-makers have been creating layers of coordination schemes. However, in-depth case studies reveal that it is possible to redesign the different pilots depending on the local context and convert the layers into integrative schemes. The role of the newly created associations of project managers as part of a new centripetal force can be discussed. Conclusion: There is no doubt that national administrations should intervene in a more coordinated way. Moreover, on the face of it, the management of the complexity of the health and social care system can also benefit from local initiatives, and from meso-level organizations such as the association of networks of coordination schemes managers. Only time will tell if these new trends will become perennial. [ABSTRACT FROM AUTHOR]

Introduction: The integration of Mental Health services is a prominent feature of government health policies. Whilst there is a substantial literature promoting the benefits of rural integrated mental health services, there is little detail of how those services function, or how and to what extent those services are integrated. This research described a rural Nurse Practitioner (NP) led primary healthcare mental health service within the context of rural mental health (MH) service policy in Australia and the literature on integrated mental health services. Theory/Methods: Data were collected from documentary evidence and quantitative evidence in one small town with a Mental Health NP. Qualitative individual and group semi structured interviews, and a 'stakeholder meeting' were conducted. A case-study design was used. Results: The NP mental health service was regarded by most participants as a viable solution to address the drug and alcohol and mental health needs of a high needs community. The service showed some evidence of government and non-government organisations working effectively together to provide a service to the community over the duration of the NPs employment. Integration was described at several levels including at the organisational level, between the mental health and other health and non-health related services and within the community. Discussions: The study provided a detailed description of how integration is demonstrated in a primary healthcare NP-led service. It illustrated the potential benefit to small communities and the significance of the role of a NP in leading this service. The NP service in this primary care setting provided an innovative solution to the fragmented MH and drug and alcohol service that was previously provided by visiting mental health and drug and alcohol services to this small rural town. It reduced the numbers of mental health and/or drug and alcohol related crises and provided links with other services enabling better continuity of care and improved capacity for early intervention. Conclusions: This service demonstrated key features of local integration which was community driven, led by a number of government and non-government agencies, supported by a steering committee as well as a partnership agreement. It also highlighted the substantial challenges to integration of a rural NP-led MH service. Lessons learned: This study is relevant to health care planners and policy makers and to small rural towns. This paper identified and described a NP role in a primary health care setting. It has the potential to influence the development of NP roles in similar settings. Limitations: The case is not necessarily representative of similar cases and therefore the results of the research are not generalisable. Suggestions for future research: Further research in other services such as child and family health could enhance knowledge of the key components of integration and further studies representing the clients' perspective of receiving integrated services. Further areas for research have been identified in the literature to inform integration of mental health services, particularly in a primary health care setting. This research should focus on the scarcity of evidence around qualified NPs coordinating care within this model. [ABSTRACT FROM AUTHOR]

Background: Integrated care has gained popularity in recent decades. This study aims to explore its global progress, current foci, and future trends. Methods: We conducted a scientometric analysis. Data (including subject categories, countries/territories, institutions, journals, citations, and author keywords) were exported from the Web of Science database. Publication number and citations, co-authorship between countries and institutions, co-occurrence of author keywords and cluster analysis were calculated with Histcite12.03.07 and VOSviewer1.6.4. Results: A total of 6127 articles were retrieved from 1997 to 2016. Results indicate the following: (1) The USA, UK, and Canada led research with the most publications, citations, and productive institutions. (2) The top 10 cited papers and journals (such as BMC Health Services Research) are crucial for the knowledge distribution. (3) The 50 author keywords were clustered into five groups, including digital medicine and e-health, community health and chronic disease management, primary health care and mental health, health care system for infectious diseases, health care reform and qualitative research, social care and health policy services. Conclusions: This paper confirmed that integrated care is undergoing rapid development with more categories involved and additional collaboration networks established. Various research foci are forming like economic incentives mechanism for integration, e-health data mining, systematically quantitative study. Moreover, an urgent need exists for the development of the performance measurement for policies and models. [ABSTRACT FROM AUTHOR]

Background: In the wake of demographic changes, with a growing and aging population living with a diversity of long-term and complex conditions, there is an urgent need for costeffective care. Concurrent ideological voices, advocating greater citizen involvement, autonomy and freedom of choice and the bolstering of private markets for social care services and products, raise a number of competing and contradictory demands. In the face of these global challenges, Swedish healthcare, like that in many other countries, has undergone a number of reforms. The changes made, aiming to improve effectiveness and quality, have rather led to increased specialization, division of roles and responsibilities, making it hard to see how integrated care services that bridge institutional borders can be supported. To meet the increasing burden of cancer treatment and the need for better coordination and integration of the different clinical aspects involved in cancer care, the Swedish government recently launched a national reform to standardize cancer patient pathways. Prostate cancer is one of five cancer diagnoses for which a clinical chain of care was introduced in early 2015, operationalized as a standardized package. In this paper, we illustrate the dilemmas that arise and the conflicting demands that need to be managed with the introduction of a standardized patient pathway for prostate cancer patients. The aim was to describe how patients diagnosed with prostate cancer experienced their pathway through the healthcare system and to compare with the journey described in healthcare policy documents. Methods: Fourteen individual interviews were conducted with patients who had undergone treatment for prostate cancer at a mid-sized hospital in southeast Sweden. As a basis for the interviews, a template with a generic scheme for a standardized cancer patient pathway was used. Interviews were audio-recorded, transcribed verbatim and analyzed using qualitative content analysis. Results: We found that the clinical view of the standardized cancer pathway as a 'straight line' through the health care system was rather experienced as 'riding an undesirable rollercoaster' from the patients' point of view. Lack of personalized and timely, coordinated information was the most common experience. Although lead times between test and diagnosis or between diagnosis and treatment were shortened within standardized frames, the patients' experiences of 'waiting' were of an existential nature: a matter relating to life and death. Patients described being left in a void between planned visits to the hospital. Integration of support from professionals or other caregivers was not sufficiently included in the standardized cancer pathways. Discussion: This study highlights that implementation of standardized care pathways for specific patient groups, such as prostate cancer patients, aimed to make care more efficient, may not be compatible with other ideological incentives, such as personalization, integration and equity of care for all patient groups. [ABSTRACT FROM AUTHOR]

Introduction: Elder abuse represents a threat to the physical, social and mental health of older people. The main forms of abuse are physical, psychological, discriminatory, sexual, financial and neglect or acts of omission. Despite increasing recognition of the epidemic of elder abuse there remains a paucity of robust evidence supporting intervention. Furthermore, where a systems level response to elder abuse is in place, there is a need for greater participation of older people in the co-design, implementation and evaluation of interventions. Elder abuse is a complex phenomenon often involving multiple forms of abuse occurring simultaneously and requiring intervention from the perspectives of health, social and legal policy and service provision. It is generally agreed that elder financial abuse is under-reported and is particularly difficult to recognise or detect. This form of elder abuse is often concurrent with and indicative of other types of abuse particularly discriminatory and/or psychological abuse. This paper describes the process of engaging public peer representatives as co-creators of an intervention to empower older people to protect themselves from financial abuse. The discussion of this grounded up and people-centred approach to intervention development highlights the key learning for activating citizens/patients and supporting their participation in the co-production of integrated health and social care services. Description of practice change: With funding from the Irish Health Service Executive, the National Centre for the Protection of Older People (NCPOP), at UCD undertook to develop a campaign to support older people to be empowered against financial abuse. On foot of this initiative, The Older People's Empowerment Network (OPEN) was established in spring 2013. OPEN is composed of peer representatives of older people as well as members of the NCPOP research team. During the summer and autumn of 2013, OPEN held regular meetings and consultations with experts in the fields of elder financial and social protection. These meetings helped the group understand the key issues relevant to elder financial protection in Ireland. The group was also informed by current research evidence on elder abuse prevention and intervention. Finally, a panel of experts in the areas of legal, financial and social protection was established to provide advice on the design and content of the campaign. Findings: This work culminated in Keep Control; a multi-media educational and information campaign developed by older people for older people. The three pillars of the campaign are: a website, a DVD and a resource or information pack. Through these pillars, information and resources are provided within five critical areas for financial self-protection: making a Will, implementing enduring powers of attorney, opening joint accounts and authorising signatures, making decisions at critical life events and protecting oneself on the doorstep. Furthermore, information about the forthcoming assisted decision-making (capacity) legislation in Ireland is provided. This information focuses on the potential implications of the legislation for the financial protection of older people who have reduced decision-making capacity. Highlights: The transferable learning, identified from the development process of the Keep Control campaign, include: engaging active participation from relevant citizens/patients from the earliest point possible in the process of intervention development; establishing a project steering group with a critical mass of citizen/patient representatives and which is organised in a non-hierarchical manner; having a defined objective with designated deliverable outcomes which are discussed and agreed upon by the steering group from the outset of project development; ensuring there is adequate knowledge exchange between steering group members and ensuring that professional knowledge is transferred and disseminated throughout the steering group in an accessible way and finally; activating the citizen/patient steering group representatives as the 'public faces' of the initiative for the purposes of implementation and dissemination. These key learning points are considered critical to engaging active citizen/patient participation in the co-creation of integrated health and social care services. Conclusion: The participatory development process which informed the co-creation of the Keep Control campaign has provided the model for a further integrated care initiative in Ireland which engaged family carers and care recipients in the co-design of a palliative care learning resource. A next phase for the project is to transfer this model for citizen engagement in the co-design of integrated care to other areas of health and social care. Examples of potential areas for application of this model include other forms of elder and/or vulnerable adult abuse as well as clinical and healthcare practice settings. Furthermore, the methodological challenges of evaluating the efficacy of citizen/patient involvement and measuring the public and user experience of the campaign present exciting areas for further innovative exploration. [ABSTRACT FROM AUTHOR]

Introduction: Elderly people may be affected by a decline in functioning that usually involves the reduction and discontinuity in daily routines and a worsening in the quality of life. Recently, solutions have been proposed to unobtrusively monitor activities of elderly people [1]. Tele-assistance systems that rely on a conjunction of sensors -each one devoted to monitor a specific status or activity- are normally used [2]. In this paper, we present our experience in monitoring 9 elderly people for 5 months through eKauri, a tele-assistance system. The Solution: eKauri is composed of a set of sensors: presence-illumination-temperature sensors (i.e., TSP01 Z-Wave PIR), to identify the room where the user is and the movement from a room to another (one sensor for each room); and a presence-door-illuminationtemperature sensor (i.e., TSM02 Z-Wave PIR), to detect when the user enters/exits the premises. They send the retrieved data to a gateway (based on Raspberry-pi) that collects and securely redirects them to the cloud to be stored, processed, mined, and analyzed by an intelligent system. Therapists and caregivers receive notifications, summaries, statistics, and general information belonging to the monitored users through a Web application. From a microscopic perspective, the system is able to recognize if the user is at home or away and if s/he is alone. It is also able to detect the following events: leaving home; going back to home; receiving a visit; remaining alone after a visit; going to the bathroom; going to sleep; and awaking from sleep. From a macroscopic perspective, therapists and caregivers become aware about habits and may detect unusual situations. Results: eKauri has been installed in Barcelona in 9 elderly people' homes (7 women) over 65 years old. To test eKauri, we asked monitored users to daily answer to a questionnaire composed of 20 questions (12 optional). Moreover, they daily received a phone-call by a caregiver who manually verifies the data. This information has been used as baseline to evaluate the performance of the system. We calculated the accuracy in recognizing if: the user is at home (98%), s/he is alone (68%), and s/he is sleeping (78%). All detected events are shown in the Web applications and revised by therapists and caregivers. Feedback from them has been used to improve the interface and add functionality. Lessons Learned: Although, at least at the beginning, users were a little bit reticent, during the monitored period they felt comfortable with the services provided by eKauri. They really appreciate, on the one hand, the fact that it is not-intrusive and that it allows them to follow their normal lives; and, on the other hand, to be called by phone. In other words, it is important to provide a system that may become part of the home without losing social interactions. Thus, a tele-assistance system does not substitute the role of caregivers. Therapists/caregivers recognize eKauri as a support to detect users' habits helping in diagnosing user's conditions and her/his decline, if any. Finally, let us mentions two real cases. _Case-1_. A user, woman with Alzheimer and heart problems needs continuously assistance and, thus, a caregiver visits her daily. One day, eKauri detected that no visits were received, an alarm was generated and the caregiver called. The caregiver confirmed that she did not go to visit the user that day. _Case-2_. During the afternoon, a user is accustomed to go out for a walk. One day, she stayed in the bedroom. eKauri detected the change in her habit and a caregiver called her. Actually, she had a problem with a knee and she cannot walk. A physiotherapist was asked to go to visit her. Conclusions: The goal of eKauri is twofold: helping and supporting elderly people that live alone at home; and constantly providing a feedback to therapists/caregivers about the evolution of the status of each monitored user. The experience obtained in Barcelona progressed knowledge about methods, interventions, tools and devices and pave the path to scale-up model and solutions to the rest of Europe and the world. [ABSTRACT FROM AUTHOR]

Introduction: Shortened hospital stays raise questions about collaboration between residential and ambulatory care with its different types of services and 'integration' of activities. This project focused on the implementation of effective discharge management of patients admitted in a general hospital. The aim of the case study is to identify the content and organization of discharge management and to determine the characteristics of effective discharge management. Theory/Methods: A literature review was conducted on issues related to discharge management from hospitals. The study was carried out in a geriatric ward of a University Hospital in Brussels, Belgium. Data was collected during August and September 2013. Qualitative research methods were used: participative observation, interviews and document analysis. Data from the different sources were triangulated and the analysis was done by two researchers and discussed with supervisors (researcher triangulation). 4 weeks of participative observations were carried out on a geriatric ward. The observations were supported by a thematic observation protocol to focus on tasks and roles in the discharge management process. The document analysis focussed on relevant hospital documents (protocols, procedures, information letters) handling issues of discharge from the geriatric ward, such were collected and analysed. Semi-structured interviews, using a topic list, were conducted with health professionals involved in the discharge of patients The interviews were carried out at reserved places in the hospital, according to subjects' availability and choice, respecting anonymity. The research protocol was approved by an ethical review committee (Committee of Ethics and Research of the hospital). Results: The discharge process can analytically be disentangled in five processes: administration, communication, medication policy, care and logistics and emotional support. Key processes in daily practice are communication and medication policy. Administration and care and logistics are more supportive to the transfer. Emotional support is very little embedded in daily discharge management. The effectiveness of discharge management seems to be determined by: (1) organization and coordination of discharge activities (2) inter-professional collaboration and (3) communication and interactions with the patient. An interesting observation is that the daily practice is not always congruent with what is found on the discharge procedures developed on paper. With regard to the coordination of discharge activities we observed that the task differentiation and role attributes of professionals on the ward has grown rather organically rather than as standardized working procedures throughout the ward. A similar process can be observed with regard to the multidisciplinary consultations. These are considered as the junction of the discharge process. Here different disciplines assess the physical, social, functional and cognitive readiness of the patient for discharge, and they provide their assessment. In this process however, the medical assessment is decisive for the discharge decision. Interactions and communication with the patient start from admission and last until the discharge. This communication and preparation of the patient is integrated in other activities. Interestingly is that the preparation of the patient for discharge is mentioned in procedures and protocols of the ward. The communication is mostly oral; exceptionally supported by written information. Patient participation on how to prepare discharge is limited, while participation of the family network is bigger: probably the effect of being on a geriatric ward plays a role. Discussion & Conclusion: Methodologically this research is limited to one case study. We are very aware of the limitation of this type of research, and we are aware that we did not contextualise the practice of one ward in the more broader hospital strategy. We did not discuss at this stage on how the discharge is coordinated with the place of destination, which is a limitation to understand integration of care. However, the use of qualitative research methods enabled us to develop an in depth understanding of daily practice. The observation learned that discharge management on the ward is more a "practice by doing" than a systemised approach. Some efforts are needed to develop a more systematic insight and coordination between professionals (role attributes and task identification). Moreover a key agenda is still to be tackled with regard to communication processes and patient participation. [ABSTRACT FROM AUTHOR]

Summary: This study aims to analyse and define the role of the case manager (CM) in Spain. The qualitative technique of semi-structured interviews together with the literature review technique have been chosen for the information gathering process. This study constitutes the first of the several stages of a broader research project whose ultimate goals are to create a Network of Integrated Care professionals (NIC) and to reach some conclusions about the CM role in Spain. The rise of chronic diseases, partly caused by demographic changes and increased longevity, requires the development of new strategies on health and social care policies. High levels of dependency associated to chronic patients imply that health care and social problems need to be addressed through coordinated actions of these two public services. The implementation of the CM seek to respond to this need. CM for chronic patients usually undertake coordination tasks within different levels of the health care system and between the health care and social systems. This coordination substantially enhances the continuity of care. Case management enables the integration of the social and health care systems and, therefore, the integrated and needs-centered health care service that patients require. The definition of the role played by the CMs is highly ambiguous; pluripathologies management, single collective (fragile elderly) and single disease management, to name only a few, are amongst them. Nevertheless, there have been also identified some of the CM most basic elements including; patients identification, problems and need assessments, care plan setting, etc. Methodology: Through the usage of an explorative methodology, the numerous roles played by the CM in Spain will be identified and classified. More concretely we will be looking at the main similarities and differences, and analysing impact results. Ultimately patterns and potential scenarios will be considered. This methodology is composed by various stages; 1-Semi-structured interviews and literature review techniques will be used to gather information from professional interviewees (professional profiles, services offered, population target, etc). In addition, a theoretical framework will support the information provided by these professionals. The objective of this first stage is to obtain an initial document which describes and simplifies the complexity that characterises the practices related to the CM. 2-Focus group; the next step will involve naming a group of professionals from the social and health care sectors to discuss the different ideas appearing in the initial document. The purpose of this stage is to reach some conclusions on the CM different realities. The resulting document will ultimately serve as a basis from which the NIC will be created. Bearing in mind that the ultimate goal of this study will only be reached in the mid -term, the main purpose of this initial paper is to elaborate a document which will serve as the basis for following stages of the research project. Preliminary results: The CM is characterised by a significant lack of homogeneity in its implementation, both within and between Spanish regions. - Despite the CM presence in most Spanish regions, its characteristics and functions vary considerably. The main differences are found in the professional profile, services offered, and duties carried by the CM, and its relationship with inner and outer professionals. These variances occur within and between regions. - The different CM functions will be categorised using the five-stages model (case finding, assessment, care planning, care coordination and case closure) based on Ross.S et al (2011). CM functions have been intuitively obtained by applying an explorative methodology in a number of CM experiences. - In Spain it is possible to observe different levels of policy development regarding the CM role (design, pilot, implementation process...). For instance, in Catalonia, Castile y Leon and the Basque Country, the role of the CM has been considerably successful whereas in Navarra no implemented practice, related to this specific actor, was found. Similarly, whilst a number of experiences where the CM has been especially dedicated to coordinate a specific treatment process, others have been implemented, in a broader sense. - Furthermore, the consequences resulting from these practices widely differ depending on the context and, a part of in the case of Andalucía, there are no major publications on the consequences of these practices. As an example, in Andalusia the CM has supposed a sort of driving force for change towards a broader model of integrated care where new roles and new ways of care management have arisen. [ABSTRACT FROM AUTHOR]

Introduction: Between 2012 and 2032 it is estimated that the populations of 65-84 years old and those over 85 in the United Kingdom will increase by 39 and 106% respectively (Kings Fund 2013). Recent figures suggest that people over the age of 65 account for almost 51% of gross local authority spending on adult social care (Oliver et al 2014). Current projections indicate that a growing proportion of older people will, in the future, be living on their own and will require formal care (King's Fund 2014). While these demographic changes have significant implications for adult social care policy they also draw attention to the pressing need for sufficient and appropriate housing that enables older people to live independently (Atkinson et al 2014). Practice: Not surprisingly the provision of appropriate housing is a key element of UK government policy (Garwood 2015). Various models of housing with care have emerged in recent years with Extra Care Housing (ECH) offering the potential to combine housing and social care in the same setting. Indeed the integration of personal housing alongside individualised care means that Extra Care Housing is viewed by many to be 'a viable alternative to and possible replacement for residential care' (Beach 2015:7). Extra Care Housing, compared to other models of housing, has several characteristics: it is primarily for older people; accommodation is almost always self-contained; social care can be delivered flexibly, usually by staff based on the premises; support staff are available on the premises 24 hours a day; domestic care is available; communal facilities and services are available; meals are usually available and charged for when taken; it aims to be a home for life and finally, it offers security of tenure (Laing and Buisson 2010). Key findings: Drawing on results from the Adult Social Services in Environmental Settings (ASSET) project (https://assetproject.wordpress.com/) and initial findings from our longitudinal study of Extra Care Housing (both funded by the National Institute for Health Research, School for Social Care Research) this paper will consider what potential the integration of housing and care has for older people living in the UK. It will consider the different models of integrating social care within housing and the advantages, as well as some of the challenges therein. The implications of integrating housing and care will be considered from the perspective of those managing schemes as well as from care workers and older people themselves. Conclusion: Despite the potential of Extra Care Housing to provide integrated care for older people the current economic context of the UK threatens to undermine the model. Reduced public spending and increased targeting of social care on those people thought most in need could weaken the preventive aims of Extra Care Housing. [ABSTRACT FROM AUTHOR]

Introduction : (comprising background and problem statement) In Singapore, as in other parts of the world, the healthcare system is undergoing reform. The thrust towards this is motivated by the global shared experience of a rapidly ageing population, an increasing burden of chronic diseases, decreasing old-age support across the nation, increasing healthcare costs, and a rising demand for healthcare. In response to these changes, and amongst many integrated policies and approaches, the government has looked to global partners, and has explored different approaches to integrated care that have been adopted by countries with similar experiences. This lesson-drawing from other countries, known as policy transfer, provides a framework to understand how integrated care is being developed in Singapore to address the problems that it faces. It refers to the notion of improving policy making by looking abroad and adopting policies from elsewhere as a stock response to addressing policy issues. In Singapore, where this Project is based, the Regional Health Systems (RHSs) were created in 2010, and they are tasked with implementing the integrated care policy through innovative methods of care coordination. Within this, there is an expectation that the RHSs will demonstrate public sector entrepreneurism and lead in the development of health systems to enhance the quality of care at reduced costs. This same leadership is expected of the other policy agents, such as the Voluntary Welfare Organisations and General Practitioners in the RHSs, which provide services at the community level. However, it is unclear how integrated care is being developed at the RHS level in Singapore, and the extent to which policy transfer in integrated care has taken place. This is likely to be due to the fact that policy transfer of integrated care is largely undocumented, which makes evaluating the policy problematic. The associated challenges in the development of integrated care are also unknown. Some of these challenges may include the influence of the political economy of integrated care, which is often not explicitly considered. The role of constructivism in the micro-political environment of the organisation is also yet to be explored in the local context. Such local political, cultural, social, economic and administrative contexts are however central to the thesis on policy transfer and for appropriate policy adoptions. The aim of the research is thus to understand how integrated care is being developed specifically at the Outram RHS in Singapore, the extent to which this reflects processes of policy transfer, and the associated challenges involved. Theory/Methods: This study adopts a qualitative approach as the primary theoretical methodological approach to address the research questions. The qualitative approach could help unravel micro-macro interactions between individuals and social structures and institutions, and connect generic and abstract questions with the individuals' specific experiences. As policy actors, state, and non-state actors are involved in developing policy ideas on integrated care, the study will adopt an actor-based approach, utilising a two-pronged method to answer the research question. It will involve semi-structured interviews with these policy agents, which constitute an elite group, and document reviews of the existing materials internal to their organisation in relation to integrated care development. The prospective respondents will be purposively sampled with maximum variation from five distinct clusters of policy agents. They include government officials, Singapore Health Services, service providers (Outram RHS), professional associations, and academic institutions/think-tanks. The data will be analysed using interpretative phenomenological analysis and documentary analysis. The documentary analysis component consists of a two-fold analytic approach: content and textual analyses. Results :(or 'progress report' where results not yet available) Fieldwork will begin in December 2015. Preliminary ideas from the findings will be shared at the conference. Discussion: Policy transfer as a theoretical framework facilitates the examination of barriers and enablers in the study of integrated care development in Singapore. It goes beyond the institutional-structural concerns, to understanding the global and systemic influences, and their roles and limitations. It furthers the exploration and understanding of the nation-state's interests and history, socio-cultural values, and politico-administrative structure on integrated care development. Conclusion: (key findings to date, lessons learned, limitations, suggestions for future research). This paper, which is part of a PhD work, advances policy transfer as an arguably novel approach to explaining integrated care development; this is distinct from the existing approaches in integrated care theories and frameworks. It seeks to make useful contributions to the debate over the development of integrated care, with specific reference to Singapore, and to wider arguments on integrated care development in other parts of the world. [ABSTRACT FROM AUTHOR]

The Regional Council of Lombardy Region (legislative body) launched an enquiry to understand the integrated care (IC) challenges and their strategic role in light of the forthcoming regional health service reform. The contribution therefore represents the policy paper which takes the offering of such an inquiry on examines the Lombard case study of IC. The paper synthetises the IC policies and services' delivered in Lombardy hitherto and discussed the lessons learnt on three assets. Firstly, IC policies and interventions in force in Lombardy are presented and analysed in depth, to value their scopes, targets, volume, costs and the legislative scenario over IC, which states the role of departments (health and social), the financing systems and the legal regulation compared to the national one. Secondly, to evaluate the outcomes of IC, domiciliary care is analysed in depth and compared with three other Italian Regions, conceived among the best performers nationally. The comparison holds a key role to understand the results achieved in Lombardy against other solutions applied in similar contexts. Finally, the third part exploits the previous towards: on the one hand, evaluate the impacts of different policies, managerial strategies and institutional assets can have over the services' delivery system, as for the case of domiciliary care. On the other, the lesson learnt are synthesised in light of the first part to clearly stated recommendations of short, medium and long term objectives for the Regional Council if IC has to be developed and prioritised in the forthcoming reform. [ABSTRACT FROM AUTHOR]

Introduction: Noncommunicable diseases (NCDs) are the major global cause of morbidity and mortality. In Mongolia, a number of health policies have been developed targeting the prevention and control of noncommunicable diseases. This paper aimed to evaluate the extent to which NCDrelated policies introduced in Mongolia align with the World Health Organisation (WHO) 2008-2013 Action Plan for the Global Strategy for the Prevention and Control of NCDs. Description: We conducted a review of policy documents introduced by the Government of Mongolia from 2000 to 2013. A literature review, internet-based search, and expert consultation identified the policy documents. Information was extracted from the documents using a matrix, mapping each document against the six objectives of the WHO 2008-2013 Action Plan for the Global Strategy for the Prevention and Control of NCDs and five dimensions: data source, aim and objectives of document, coverage of conditions, coverage of risk factors and implementation plan. 45 NCD-related policies were identified. Key findings: Prevention and control of the common NCDs and their major risk factors as described by WHO were widely addressed, and policies aligned well with the objectives of the WHO 2008-2013 Action Plan for the Global Strategy for the Prevention and Control of NCDs. Many documents included explicit implementation or monitoring frameworks. It appears that each objective of the WHO 2008-2013 NCD Action Plan was well addressed. Specific areas less well and/or not addressed were chronic respiratory disease, physical activity guidelines and dietary standards. Conclusions: The Mongolian Government response to the emerging burden of NCDs is a population-based public health approach that includes a national multisectoral framework and integration of NCD prevention and control policies into national health policies. Our findings suggest gaps in addressing chronic respiratory disease, physical activity guidelines, specific food policy actions restricting sales advertising of food products, and a lack of funding specifically supporting NCD research. The neglect of these areas may hamper addressing the NCD burden, and needs immediate action. Future research should explore the effectiveness of national NCD policies and the extent to which the policies are implemented in practice. [ABSTRACT FROM AUTHOR]

Introduction: The lack of integration of care in Portugal is perceived as a major constrain to the health system and, consequently, to the quality of care provided to patients. The improvement of integration is seen as a more effective way to provide quality care and to optimize scarce resources available. There were identified more than 175 definitions published in scientific papers (Armitage et al., 2009), and consensually adopted the WHO (2008) definition of integrated service delivery: "The management and delivery of health services so that clients receive a continuum of preventive and curative services, according to their needs over time and across different levels of the health system." From this point, the group established a theoretical framework of four dimensions of integration of care: structural (horizontal and/or vertical), functional, normative and systemic (clinical, information, financing and administrative perspective), in order to justify the recommendations on integration. Policy context and objective: Since 2011 the Portuguese Health Ministry has promoted technical Working Groups to study the integration of care. Several reports have been elaborated on this topic, identifying strategic initiatives to be implemented by the Government and public entities. The focus on the study of integration of care cannot be disconnected of the financial crisis that Portugal suffered and the goals established by the intervention of the International Monetary Fund, European Central Bank and the European Union. By order of the Secretary of State Assistant to the Minister of Health (9567/2013, 22 of July) a Work Group responsible for the elaboration of a report on the integration of the different health care levels in Portugal (Primary Care, Hospital and Palliative Care) was nominated. This Work Group was composed by multidisciplinary profiles with different professional background and work places, in order to reduce some bias derived from the personal experiences and influences. The document "Report of Integrated Care in the Portuguese Health System: Recommendations for the future" was produced in a six month period, and the members of the Work Group participated on a non- paid partial time regimen. Target population: The Final Report of the Work Group aims to the Health Ministry policy makers, as well as the responsibles for the delivering of care in the Portuguese NHS. The measures defined should be promoted by the Health Ministry, but they can be applied locally, having a firm connection to a broader framework (regional or national). Highlights (innovation, Impact and outcomes): The Work Group established a focus on tangible recommendations, being aware of the financial context that Portugal is subjected, and the need to improve the efficiency of the system as well as the quality of care provided. All the recommendations were presented with a rationale, with the conditions for operationalization, the estimated impact and the scientific evidence found for each one: • Introduce the concept of case management; • Create and implement a national referral management system; • Implement integrated guidelines, protocols and clinical pathways; • Create functional units shared by different levels of care (levels of decision); • Financial model based on capitation (risk adjustment) plus pay for performance (same objectives for different units); • Integrate administrative functions and procedures (for example: payroll salaries; logistics); • Integrate cost accounting systems. Conclusions: In Portugal, despite the focus on this topic the Working Group found an almost non existing evidence on integration of care, and the experiences identified, promoted locally by the providers revealed a more personal commitment and single initiatives rather than a national, or regional framework or a medium long term perspective. The recommendations of the Work Group where based on the real and theoretical diagnosis of the current state, and on the discussion based in evidence on this topic. Due to the nature of the recommendations, there is the need to develop the definition and the application of some of them, being estimated that they can be implemented with success in a medium/long term. [ABSTRACT FROM AUTHOR]

Setting: North West London (NWL), an urban area composed of 8 boroughs with a highly diverse population of 2.2m. In October 2013, NWL was selected as one of 14 NHS Integration Pioneers. Background: NWL have been integrating physical, mental and social care provision for elderly and diabetic patients since 2011, with citizen engagement through a Patients, Carers, Users Group. From September 2013 we have been planning to widen the scope and scale of the initiative to a 'Whole System' approach, to be implemented in 2014. We intended to co-design the new system from the start with patients/users/carers and other citizens. Method: The design structure included five workstreams (Populations and Outcomes, GP Networks, Provider Networks, Commissioning and Finance, Informatics) plus a cross-cutting Lay Partners Advisory Group of 20, which was recruited from among patients/carers/users who already had experience of acting in a representative role and had the capability, capacity and commitment to take on an active role. Some were drawn from the existing Group, others were nominated via each borough's Clinical Commissioning Group, Healthwatch, Adult Social Services, primary care patient participation groups and patient charities. A full day of training for potential Lay Partners was commissioned from the Centre for Patient Leadership, a patient-led organisation. Expenses incurred by Lay Partners were remunerated. Outcome: All the design workstreams and the overarching programme board have had 1-3 Lay Partners as full members from the first meeting. Lay Partners attended on average eight hours of meetings per month, plus reading and commenting on discussion papers. They developed a 'Co- Production Touchstone' setting out principles and best practice, which was accepted by the Board. Some have been asked to co-chair their workstream. Their major impact has been to keep the focus on designing patient-centred accessible, pro-active and high quality care. They act as 'guardians of the vision.' [ABSTRACT FROM AUTHOR]

Introduction: Evidence based care for COPD involves patients obtaining timely access to an integrated network of evidence based services delivered by staff with different skills working across different settings. Patient needs for these different services can vary over time as the status of their condition changes or they suffer sudden health crises. The primary care team (GPs and practice nurses) have a key role as a provider of and referrer to care but their awareness and use of evidence based care has been questioned [1]. This paper describes the nature and impacts of an innovative training programme that aimed to improve the quality and integration of care by increasing the primary care team's awareness and use of needed services. Intervention: Key characteristics of the training initiative included: targeting practices where COPD was most common; providers describing evidence based services that were available locally to support diagnosis through to end of life care; patients and carers presenting their experiences of living with COPD; practice based projects being used to pilot service improvement ideas. Evaluating the impacts of the training intervention: Qualitative assessment of the impacts of the training intervention is examining practitioners' views on its relevance, content and any factors that facilitate or constrain the adoption of good practice. Quantitative assessment is monitoring changes in care delivery processes and hospital admission rates. Results: Evaluation results to date have confirmed the need for the training initiative and the relevance of its content. Using local speakers facilitated knowledge about evidence based services that were currently under-used (e.g. for pulmonary rehabilitation) and prompted actions to increase referral rates. Patient and carer led sessions were probably most influential in changing professional behaviour and promoting a more patient centred approach to the delivery and integration of services. As one participant stated, "Remembering the individual and their journey of COPD and the impact it has on their life is the most important aspect the Health Worker should consider in providing supportive care" Conclusions: Efforts to increase the continuity and co-ordination of care for chronic conditions should include initiatives to ensure that existing evidence based services are used by health staff. Use of local speakers led to primary care staff having greater knowledge about available community based services thereby promoting better integration of care for patients. "Patient power" (patients and carers presenting their lived experiences) provided insight into the patient journey and the benefits of an integrated service response. [ABSTRACT FROM AUTHOR]

Purpose: To explore the integration of health and social care in the UK through policy and clinical guidelines and to examine how partnership working and case management enables policy to be embedded into local practice. Context: The UK Department of Health policy document (White Paper 2006) Our Health, Our Care, Our Say: a new Direction for Community Services [1] focused on a new direction for the whole health and social care system. Description: The paper and subsequent action plans targeted the way services are provided, placing greater choice and control in the hands of people who use them. Health and Social Care services were tasked with becoming better integrated to meet the needs and wishes of individuals with chronic illness and long-term needs. The UK's National Service Frameworks and NICE guidelines are being implemented at local level to achieve management of chronic illness through effective case management and roles are being evaluated to show the effect of interventions [2]. The Government report Our NHS, Our Future [3] encourages a response to the , needs of local communities through integrating care to ensure that services are shaped around the user not the organisation. Discussion: We know that people with chronic illness are intensive users of services; that repeat admissions to hospital cause untold distress and that this vulnerable group is increasing as our population ages. We also know that inappropriate and increased use of services causes a financial burden in both primary and secondary care. Managed care through effective case management, if adopted flexibly, presents an opportunity to focus on reducing costs whilst appropriately managing the health needs of the target population. [ABSTRACT FROM AUTHOR]

In 1999, Conrane Consulting in collaboration with a US managed care company and a large GP practice in the North West implemented the first UK pilot in holistic, anticipatory, case management of older people with complex needs and co-morbidities. The senior GP partner at the practice Castlefields in Runcorn was then Dr David Colin-Thome later to become Director of Primary Care for the Department of Health in the UK. The practice pilot was a success in both qualitative and economic terms and was extended to end of life care and mental health with equally successful results. Over the next 10 year Conrane went on to roll-out this programme in multiple NHS localities placing over 100 case managers into the practice. This included one the largest projects in the UK in Surrey and Sussex and NW London, designed and implemented with Imperial College. The outcomes delivered at Castlefields were replicated in some of these new localities but not all. In this paper the Director of these implementation programmes, Dr David Cochrane will explore the essential learning and distill the key success factors which differentiate the successful from the less successful programmes. This will be supported by more recent evidence emerging from the US Medicare/Medicaid programmes including the Johns Hopkins Guided Care model whose prescriptions for a best practice are convergent with those of the Conrane programmes. Key areas of interest are locality structures, mechanisms for social and health care collaboration, individualised care planning, the central role of the patient and carers, pro-active versus re-active staff skills and competences, the role of informatics, how to secure full GP participation through primary-care co-location and the scope for return on investment in a cost-constrained system. [ABSTRACT FROM AUTHOR]