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Introduction: The concept of integration, although dating from the 1990s, has only recently appeared in French public health policy. It must be linked with “coordination”, which is the base of most French public policies applied to geriatrics since the 1960s. Herein, we report the French Society of Geriatrics and Gerontology working group’s findings according to three axes: definition of integration, objectives of this organisational approach and the means needed to achieve them. Discussion: Integration is a process that aims to overcome the fragmentation of services for vulnerable people. This process requires a multilevel approach, particularly concerning how to modify public policies and financing systems. Notably, all relevant levels need to develop shared processes, tools, resources, financing, interventions and action-reports on the latter. Integration must to be accompanied by a local dedicated professional (the “pilot”). Results of recent experiments showed that it is possible to implement integrative dynamics in France.

Increasingly, complexity science concepts are informing health care design and practice. The present paper describes the implementation of early complexity science principles in a Complex Care Program with the aim of strengthening the provision of integrated care. Grounded in cybernetic network theory, Stafford Beer’s Viable Systems Model [1] provided the guiding principles for the program’s redesign. The Viable Systems Model with its broadly applicable principles [1], is now the conceptual model of information management in the program. Beer’s framework has enabled a relatively small number of clinicians to coordinate care for a large cohort of patients with significant clinical complexity, and a multitude of providers, in the community setting.

Background: An aging population is one of the key drivers reshaping health care systems. In China, the complex needs of its huge aging population require integration across the health and care sectors. Policies and progress: Over the past decade, the central government of China promulgated a series of policies to promote the establishment of aftercare facilities, specify approaches to integrate health and care service delivery at institutional and community levels, pilot long-term care insurance (LTCI) as a funding mechanism, and reform administrative structures in favor of integration. Progress has been made towards organizational and clinical integration of service delivery both at institutional and community levels. LTCI has been introduced as the financing mechanism covering long term care services. Discussions and Conclusions: The experiences of China in the integration of health and care could be summarized as a top-down approach in policy formulation and implementation, the significant employment of pilots and demonstrations, and the activation of market forces. However, China is still in the initial stage of integrating health and care and is faced with system-level challenges in its financing, management, and workforce, and faces technical challenges, such as a lack of tools, and standards. In the future, these issues need to be addressed.

Introduction: Facing the challenges of aging populations, increasing prevalence of chronic diseases and health system fragmentation, decision-makers have looked towards system integration as one possible strategy to coordinate care delivery and improve care quality while avoiding cost-escalation. There have been several pilots of integrated health systems inChina during the last decade, but little is known about their structure, mechanism and effectiveness. The aim of this paper is to analyze health system integration using a case study approach and develop recommendations for achieving integration as part of health system reform, using two rural counties inWestern China. Method: Huangzhong and Hualong counties in Qinghai province are used as study sites, with only Huangzhong having implemented health system integration. A case-study method is employed with all institutions at the county level along with a stratified sample of 3 township health centers and 6 village health stations in each county, a total study sample of 29 institutions. Document analysis was used to describe social and demographic settings and health reforms. Information on between-institution relationships (patient referrals, population and patient information sharing and joint training) was collected using a modified version of Provan’s instrument. Social network analysis was employed to analyze integration, through structure measurement (density, degree of centralization, average distance between network levels, core membership and broker analysis) and effectiveness evaluation (at both participant and network levels, by doctor behavior, patient satisfaction and patient distribution among institutions before and after the reform) using questionnaires, interviews, and health insurance system records as sources of data. Results: Health system integration in Huangzhong is higher than in Hualong. The patient referral network in Hualong has more “leapfrog” referrals, which means county-level institutions don’t serve well as gatekeepers to higher levels of care. The information sharing networks in both counties are larger and based on more dense connections than the other types of networks, but core membership and broker analysis show similar institutions’ have different roles in the two counties. In the joint training network, the average distance between village health stations and county 3 World Congress on Integrated Care, Mexico City, Mexico, 19-21 November, 2015 International Journal of Integrated Care – Volume 15, 17 Nov – URN:NBN:NL:UI:10-1-117295 – http://www.ijic.org hospitals in Huangzhong is less than in Hualong, which makes it easier to conduct direct training. Meanwhile, there are deficiencies common to both county systems, including one-way patient referral. Almost all indicators of network effectiveness imply greater effectiveness in Huangzhong than in Hualong. Conclusion: Health systems in both counties have strengths and limitations regarding system integration. The information-sharing network in both counties remain limited. In regard to the relationship between structure and effectiveness, the use of medical consortia in Huangzhong has contributed to network effectiveness. In addition, the different pace towards integrated health systems in the two counties are results of system-wide contexts. Therefore, future research might consider alternative more context specific models of health system integration. As the first paper to explore county health systems inChina using social network analysis, it introduces interorganizational network analysis into health system research and provides evidence for policy development on integrated health system reforms. Conference abstract Spanish Introduccion: Los desafios del envejecimiento de la poblacion, el aumento de la prevalencia de las enfermedades cronicas y la fragmentacion del sistema de salud, han hecho que los tomadores de decisiones miren hacia la integracion de sistemas como una posible estrategia para coordinar la prestacion de servicios y mejorar la calidad de la atencion, evitando costos y escalada. Ha habido varios sistemas pilotos de salud integrados inChina durante la ultima decada, pero poco se sabe acerca de su estructura, el mecanismo y la eficacia. El objetivo de este trabajo es analizar la integracion del sistema de salud con un enfoque de estudio de casos y elaborar recomendaciones para el logro de la integracion como parte de la reforma del sistema de salud, el uso de dos condados rurales en la China Occidental. Metodo: Los condados de Huangzhong y Hualong en la provincia de Qinghai se utilizan como sitios de estudio, con la integracion del sistema de salud que solo Huangzhong habia implementado. Un metodo de estudio de casos se emplea con todas las instituciones a nivel de condado, junto con una muestra estratificada de 3 centros de salud del municipio y 6 puestos de salud del pueblo en cada condado, una muestra total del estudio de 29 instituciones. Se utilizo el analisis de documentos para describir entornos sociales y demograficos y las reformas de salud. Informacion sobre relaciones entre-institucion (referencias de pacientes, la poblacion y el intercambio de informacion de los pacientes y la formacion conjunta) se recogio mediante una version modificada del instrumento de Provan. Se empleo el analisis de redes sociales para analizar la integracion, a traves de la medicion estructura (densidad, grado de centralizacion, distancia media entre los niveles de red, de miembros del nucleo y analisis broker) y evaluacion de la eficacia (tanto a nivel de los participantes y de la red, por el comportamiento medico, la satisfaccion del paciente y paciente distribucion entre instituciones antes y despues de la reforma), utilizando cuestionarios, entrevistas y registros del sistema de seguro de salud como fuentes de datos. Resultados: la integracion del sistema de salud en Huangzhong es mayor que en Hualong. La red de derivacion de pacientes en Hualong tiene mas "saltos" en las referencias, lo que significa que las instituciones a nivel de condado no sirven asi como guardianes de los niveles superiores de atencion. Las redes de intercambio de informacion en ambos condados son mas grandes y se basan en las conexiones mas densas que los otros tipos de redes, pero miembros principales y agentes de analisis mostraron instituciones similares "tener diferentes roles en los dos condados. En la red de capacitacion conjunta, la distancia media entre estaciones de salud de las aldeas y hospitales del condado en Huangzhong es menor que en Hualong, lo que hace que sea mas facil de llevar a cabo la capacitacion directa. Mientras tanto, hay deficiencias comunes a ambos sistemas del condado, incluyendo una sola via de derivacion de pacientes. Casi todos los indicadores de la eficacia de la red implican una mayor efectividad en Huangzhong que en Hualong. Conclusion: Los sistemas de salud en ambos condados tienen fortalezas y limitaciones en cuanto a la integracion de sistemas. La red de intercambio de informacion en ambos condados permanecen limitadas. En lo que respecta a la relacion entre la estructura y la eficacia, el uso de consorcios medicos en Huangzhong ha contribuido a la red eficacia. Ademas, el diferente ritmo 3 World Congress on Integrated Care, Mexico City, Mexico, 19-21 November, 2015 International Journal of Integrated Care – Volume 15, 17 Nov – URN:NBN:NL:UI:10-1-117295 – http://www.ijic.org hacia los sistemas de salud integrados en los dos condados son resultados de contextos en todo el sistema. Por lo tanto, la investigacion futura podria considerar mas de contexto alternativos modelos especificos de la integracion del sistema de salud. Como el primer documento para explorar los sistemas de salud de los condados en China usando analisis de redes sociales, se presenta el analisis de redes entre organizaciones en la investigacion del sistema de salud y proporciona pruebas para el desarrollo de politicas sobre reformas integrales del sistema de salud.

Introduction : People with diagnoses of severe mental illness (SMI) such as schizophrenia and bipolar disorder die 15-20 years earlier than the general population, mainly from natural causes. In particular, they have an increased risk of cardiovascular disease (CVD) This health inequality was reviewed in 2006 by the Disability Rights Commission in a report called ‘Equal treatment: Closing the gap’. Deprivation and lifestyle were major factors, but not sufficient to account for the health inequalities. The report proposed that ‘Diagnostic Overshadowing’, or clinical blindness to physical problems in people with mental illness was a form of inadvertent discrimination by health professionals that led to under-diagnosis, under-investigation and under-treatment of potentially preventable or treatable physical disease in people with mental illness. Challenges in integrating care across primary and secondary providers are likely to contribute to this inadvertent discrimination. Recognising that poor access to health care is key factors in determining higher death rates, the NHS in England has put in place financial incentives for both primary and secondary care providers to improve physical health screening for people with SMI. However, very different incentive schemes have been implemented for primary and secondary care and many improvement programmes do not focus on integrating care. For example, the Royal College of Psychiatrists has made recommendations to address physical health inequalities through better training of psychiatrists and better collaboration with primary care. Although there are areas of good practice, the systematic prevention and treatment of physical disease in people with SMI has received relatively little attention. Health screening using a paper based template is one possible mechanism and has been promoted by the Royal College of Psychiatrists (using the Positive Cardio-metabolic Health (Lester) Algorithm) and Rethink, a campaigning mental health charity. Furthermore, it is recognised that paper based templates may not support the behavioural changes required to achieve systematic improvements in screening and treatment: Paper templates are difficult to implement in practice busy practice and provide a barrier to collaboration between primary and secondary care. Despite the introduction of financial incentives, screening rates remain lower than for people without an SMI condition. Description of practice change implemented : This study took the step of integrating a standard health screening tool into the primary care digital information system, so it could be automated, in the hope that this would facilitate the practice of physical health screening in SMI. Secondary care providers worked in partnership with primary care to develop a physical health screening template for use within primary care information system. The impact of the tool was evaluated its introduction across the city of Bradford against standards recommended by the National Institute for Health and Care Excellence (NICE) for physical health and cardiovascular risk screening. The study examined whether SMI patients offered the template-based screening received better or worse quality care than patients who were not offered the template-based screening in a side by side comparison. Key findings : The baseline measures showed that 10% of SMI patients were excluded from the SMI register and only a third of people on the SMI register had an annual physical health check recorded. The new computer-based physical health screening template was taken up by 75% of GP practices and was associated with better quality screening than usual care, doubling the rate of cardiovascular risk recording and more than doubling the early detection of high cardiovascular risk. Uptake of the template was about 1 in 5 of all annual physical reviews, which is encouraging given that there was no incentive to use the template other than to improve quality of care. Use of the template was associated with more than double the rate of adherence to the NICE standards in relation to the calculation of cardiovascular risk. The template was also associated with more than double the rate of detection of significant cardiovascular risk. The study found that the practices that received promotion of the template to were more likely to use it, so stronger promotion of a computerised physical health check template could increase the uptake. Highlights : These findings suggest that by making a computerised health screening tool available, GP teams were aided to carry out higher quality physical health reviews and detect more patients at risk of early cardiovascular death. The computerised physical health screening template has potential to support the behavioural change identified by the Royal College of Psychiatrists required for systematic improvement in practice; both by improving screening within secondary and primary care settings and by supporting collaborative working across primary and secondary care. It is interesting that this digital template has been more successful in supporting behavioural change than the use of financial incentives alone. Further investigation of the factors contributing to success of the digital template would be relevant to other health improvement initiatives. There are a number of possible success factors in this case: The template was designed by practising clinicians, taking into account the length of a primary care appointment; it aligns to other requirements and incentives and clinicians received face to face mental health training and practical IT support to implement the template. Informal feedback has suggested that the combination of a pragmatic digital template and face to face training were essential to success. Conclusion : The digital template is now being incorporated into all of the main NHS electronic care records systems and secondary care providers are beginning to use the template to support physical health screening of inpatients. Work is underway, using Quality Improvement methodology, to enable dissemination and spread of the template and associated change in practice Work is underway to examine whether patients with positive screening findings go on to receive appropriate interventions.

There is a long history of attempting to integrate health and care across Warrington, a need which has arisen due to unfavourable health outcomes for some of the population and increased financial pressures. Until recently, these attempts have been unsuccessful. Warrington Together is a partnership that was created in 2017 which works with stakeholders from across the health and care system to integrate care, improve outcomes for residents and eradicate areas of duplication. This paper reviews how an integrated model of care has been designed and implemented in partnership with colleagues from across the health and care system in Warrington and how the culture has changed to allow a more collaborative way of working. Resources have been invested in the development of relationships from across traditional organisational boundaries. Colleagues have been encouraged to work in a ‘badgeless’ way, considering the needs of the residents of Warrington over their own organisational interests. A series of workshops and development sessions have been held with leaders over the past 12 months to develop a culture of mutual respect and understanding between partners and to create a shared vision and values. Leaders from across the system have been closely involved and own the development of all key documents and processes, such as the vision, a strategic business case and governance structure. This has led to a sense of shared ownership and has created a commitment to implement integrated care. The main aims for the new model of care are: Creation of neighbourhood hubs with co-location of multi-disciplinary integrated care teams. Reducing non-elective attendances and admissions to hospital and providing care closer to home. Increased digital capacity and capability with the creation of the Warrington Care Record. Promotion of assets and asset based working within the community. Reducing dependence on health and care services and moving towards a culture of self-care and independence, where appropriate. These aims will be delivered by senior leaders thinking and working collaboratively as a system. Key signs that signal success include: The hospital trust voluntarily signing up to a ‘lite’ version of the Capped Expenditure Process. Commitment from a number of partners across the system to the development of the Warrington Care Record, a digital enabler that will enable a virtual patient record. £500k funding being awarded from the Cheshire and Merseyside Health and Care Partnership as a result of a bid written by the Warrington Together team. Commitment being given from all partners to prioritise work on frailty, including the creation of a frailty hub that involves a number of partners. Implementation of integrated community teams commencing in late 2018. Key factors in this work include giving leaders the autonomy to act and make decisions on behalf of their organisations. This has been crucial to driving change at pace. Having a diverse range of stakeholders has also proven to be an advantage as it has encouraged different ways of thinking and has resulted in collaborative, innovative solutions.

Introduction: New models of healthcare have largely focussed on adults, with increasing policy and practice interest in integrated care across many high-income countries. Integrated care models have been identified as a promising solution by children and young people (CYP), and by policy-makers, to target the gaps in healthcare delivery for CYP with on-going conditions. However, there has been limited work on developing and evaluating integrated models of child healthcare, so there is an evidence gap in this important area of policy. This systematic review and meta-analysis assessed the effects of integrated care interventions on child health, health service use, and healthcare quality for CYP with on-going conditions. Methods: Articles were eligible for the review if they 1) reported randomised controlled trials (RCTs), published between 1996 and September 2018; 2) evaluated an integrated healthcare intervention designed to improve child health; 3) included CYP (0-18 years) with an on-going health condition; 4) included at least one health-related outcome. Descriptive data on a range of outcomes was synthesised for all included papers, and data homogeneity allowed further meta-analyses to explore the effects of integrated care interventions compared with usual care, on health-related quality of life (QOL) and number of emergency department visits. Results: Twenty-three randomised controlled trials were identified, describing 18 interventions. Studies had medium risk of bias, as assessed by the Cochrane Risk of Bias tool. Improvements were found for quality of care (87% of interventions found a positive effect for intervention) and child health (39% found a positive effect for intervention). The meta-analyses found that integrated care interventions have a positive effect in improving QOL over usual care (n=5 trials; SMD = 0.24; 95% CI = 0.03, 0.44; P=0.02), but no significant difference across groups for emergency department contacts (n=5 trials; OR=0.82; 95% CI = 0.53, 1.26; p=0.37). Conclusion and Discussion: Integrated care interventions for CYP with on-going conditions may deliver improved quality of life for children, health, and quality of care. However, no conclusions can be made about the direction or magnitude of the effect for integrated care interventions on emergency department contacts in CYP with on-going conditions. However, only 23 RCTs were included in this review, which were of moderate quality, highlighting the need for more robust trials to inform current health service delivery in this area and fully establish the effectiveness of integrated healthcare interventions on CYP outcomes. In collaboration with NHS Trusts, local councils, CYP and families, the findings from this review have been used to inform a fully integrated healthcare model for CYP that will be implemented at scale, and rigorously evaluated using an RCT design.

Frailty is increasingly recognised as a public health priority due to the associated demand for acute and longer term health and social care support, and the impact on the lives of individuals, caregivers and families. Integrated care is widely considered to be most effective when applied to an older population, but there is limited data on outcomes and costs from studies of integrated care to prevent and manage frailty. This paper describes work by the ADVANTAGE Joint Action (JA), co-funded by the European Union and 22 Member States, to develop a common European approach to the prevention and management of frailty. The authors reflect on the emerging evidence and experience of implementing integrated care for frailty, and invite readers to participate in ongoing dialogue on this topic through the ADVANTAGE JA website and IFIC Academy activities.

Background: In England, 70% of people who were homeless on admission to hospital were discharged back to the street without having their care and support needs addressed (Department of Health, 2013). Furthermore they experienced high hospital readmission rates and often resorted to inappropriate use of the Emergency Department. Following these data, Government funding was provided to enable hospitals to work with local partners to develop specialist integrated homeless hospital discharge schemes, including intermediate or step-up/step-down care. In this paper we report preliminary findings from a realist evaluation which explored the effectiveness of the different schemes established. Schemes took many different formats, and tended to be either uniprofessional, comprising housing workers, or multi-professional, comprising: GPs; occupational therapists; nurses; social workers; housing workers; and peer navigators. Methods: The study was carried out in England between September 2015 and February 2018. It was funded by the National Institute of Health Research (NIHR). It employs a realist evaluation methodology, comparing sites with specialist integrated care (n=4) to those with standard care (n=2). Realist evaluation is designed to explore the relationship between the local context, the mechanisms and resources deployed and the outcomes. The overall aim is to generate hypotheses about ‘what works for whom, in what circumstances and why’. Across the six study sites in-depth observational fieldwork was undertaken. This encompassed interviews with 60 practitioners and stakeholders, and 60 people who were homeless on admission to hospital. People who were homeless were interviewed shortly after discharge and again three months later. An economic evaluation and ‘data linkage’ (across a total of 20 sites) were also undertaken to interrogate the emerging realist hypotheses. Preliminary Results: Our emerging hypothesis is that there is no ‘magic bullet’ or single most effective solution. Findings so far indicate that improving hospital discharge arrangements for people who are homeless requires action on many different fronts to weave together a range of potentially effective mechanisms and resources. To illustrate this, we will present examples of different local configurations evolving over time, in rural and urban contexts, mapping the advantages and disadvantages of each. We will pinpoint a number of key attributes of effective systems (e.g. clear protocols for the discharge of people who are homeless, discharge co-ordination and intermediate care) and the factors that may explain why these are necessary and workable in some but not all locations. Throughout, we will tease out the concept of ‘specialist integrated care’ and whether this is indicative of improved quality or further fragmentation. Limitations and future research: The limitations of the research are that it is focused on England. We hope that during the conference we can engage with international colleagues with a view to scoping ideas for future comparative research in the field of integrated care transitions. Reference: 1. Department of Health. Homeless Hospital Discharge Fund. London: Department of Health. 2013

Offender mental ill health is a major societal challenge. In Europe, there are unacceptably high numbers of people in contact with the criminal justice system who have mental health issues with almost 9 out of 10 prisoners demonstrating signs of at least one mental disorder. This is far higher than the average population level of mental illness and as such represents an area of severe health inequality within the EU. This is attributable to less than optimum levels of organisational and professional integration between mental health (MHS) and criminal justice systems (CJS). In this paper we introduce an EU funded project exploring levels of integration and collaborative practices between the mental health and criminal justice systems in the Norwegian context. This knowledge will contribute to the development of a pedagogical framework to underpin training that prepares professionals in both systems to deliver collaborative practice in the interest of the mental health of the offender population. We focus here specifically on the development of the research framework underpinning this study, borrowing from techniques that guide a narrative synthesis, to combine key theoretical perspectives from innovation, collaboration, integration and competency based education disciplines. The overarching research framework and its operationalization through specific research questions, potential research designs, methods and sampling structure are then presented and future research directions discussed.

Introduction: An estimated 50 million people in Europe suffer from multiple chronic diseases. The complex health care problems of these patients and their need for continuous and multidisciplinary care poses a great challenge to health systems and social services. Integration lies in the core of care innovation. The main aim is to describe and analyze the role of integration as a tool for innovating care in the context of multimorbidity. In particular the study addresses interand intraorganizational multi-actor and multiprofessional collaboration as a core of integration processes. The study is a part of the international ICARE4EU project (www.icare4eu.org), which aims to improve the care for people suffering from multiple chronic conditions. Theory/Methods: Theoretical background consists of the integration approaches (e.g. Lawrence & Lorsch 1967, Sinkkonen & Jaatinen 2003, Pieper 2006, Antunes & Moreira 2011, Nolte & Pitchforth 2014). The data was collected during the first half of 2014 within the ICARE4EU programme through a survey in 31 European countries. An on-line questionnaire was targeted to project managers of integrative programmes focusing on providing care for adult people with two or more medically diagnosed chronic or long lasting diseases. Data consists of structured questions focusing on changes in structures and processes, competencies required in care provision and collaboration issues. The final data includes 144 filled questionnaires. Data analysis is currently in process. Results: The preliminary findings show the crucial significance of integration in innovating the care for people of multimorbidity. In particular, the findings address the factors promoting or hindering multiprofessional collaboration. The final findings will be presented in the conference paper. Discussion and conclusions: Integration and multidisciplinary collaboration are key issues when planning the care for people with multimorbidity. The implications of the research results for the management of the care for people with multimorbidity will be discussed. International Journal of Integrated Care – Volume 15, 27 May – URN:NBN:NL:UI:10-1-116977 – http://www.ijic.org/ 15th International Conference on Integrated Care, Edinburgh, UK, March 25-27, 2015 2 Limitations, suggestions for future research: The study focused on the development programmes. In future research focusing on perspectives of professionals and managers working in the care field is needed.

Mental health services have undergone radical transformation in the past 30 years. A community based care model has largely replaced the acute and long term care provided in large institutions. This research seeks to examine the transformation of mental health services in England and the relevance to current policy with particular emphasis on the integration of health and social care within mental health services. Through the use of a comprehensive survey of a range of professionals, and interviews with local and national leaders across England involved in both mental health provision and social care, along with a review of published literature, this paper seeks to explore the context and factors that are affecting integration between health and social care in mental health. In 1999, the Government launched a major programme of change and modernisation in mental health services within England with the NSF for Mental Health. What has followed was an expansion of mental health services and an increasing focus on both service user experience and quality of provision. Through numerous iterations of public policy in the subsequent 15 years, there has been a coming together of health and social care provision within mental health firstly facilitated by section 31 of the 1999 Health Act and subsequently by section 75 of the National Health Service Act 2006. Combined, both Acts facilitated the transfer or secondment of social care staff to NHS bodies and the transfer of health related functions of local authorities to NHS bodies that are "'likely to lead to an improvement in the way in which those functions are exercised‟. Throughout England services have generally moved closer together through various levels of integration, ranging from co-location, shared management and information systems without formal s75 agreements to full integration with formal s75 agreements and governance. The objective was to deliver enhanced service experience to service users, improving the quality of care and reducing isolated or silo working. The experience of integration has been as varied as the numerous locations affected. Over the past decade new statutory duties of local authorities have emerged along with changing policy: Mental Capacity Act 2005 followed by the Deprivation of Liberty Safeguards, policies relating to adult safeguarding subsequently enshrined into duties within the 2014 Care Act and the drive to personalisation, prevention and recovery. All these are against a background of significant cuts to local authority budgets. Within mental health services there has been the emergence of Payment by Results (PbR), of enhanced patient safety and quality measures centred on Care Programme Approach, of an increasingly competitive environment between providers and an approximate 8% cut to NHS mental health funding (BBC News March 2015). This changing policy and economic environment has placed significant tensions on local working arrangements between the NHS and local authorities in mental health services, leading to numerous revisions of arrangements, with uncertain outcomes.

When implementing strategies to improve integration, it is useful to have measures capable of assessing it. Informed by Singer et al.’s Integrated Care Framework (2011), we developed a 21-item questionnaire of Provider and Staff Perceptions of Integrated Care (PSPIC) according to the Framework's seven constructs: 1) care coordination within clinic, 2) coordination with external providers, 3) coordination with community resources, 4) familiarity with patients, 5) contacting patients between office visits, 6) patient-centered care, and 7) shared responsibility. Each construct was represented within the PSPIC by domains containing three questions; each question had five ordinal responses (Strongly Disagree=1, Disagree=2, Neither Disagree or Agree=3, Agree=4 and Strongly Agree=5). To develop the PSPIC we reviewed care integration literature, undertook pre-testing, and obtained feedback from research partners and clinicians via group meetings focused on the face validity and potential utility of the PSPIC. This paper discusses the development and testing of the PSPIC administered as part of a cross-sectional survey of providers and staff at federally-qualified health centers and other safety net clinics in the US. The MidWest Clinicians’ Network (MWCN; a network of federally-qualified health centers and other safety net clinics) provided investigators with a list of all health providers and staff at 101 health centers affiliated with the MWCN in 10 Midwestern states: Illinois, Iowa, Indiana, Kansas, Minnesota, Michigan, Missouri, Nebraska, Ohio, and Wisconsin. Questionnaires were mailed to all personnel. We aimed to determine, by undertaking exploratory factor analysis (EFA), whether the PSPIC had an underlying latent structure which may be useful in understanding care integration. Following EFA, confirmatory factor analysis (CFA) was undertaken. Item analyses were undertaken to examine the convergent and divergent properties of the questions within each of the seven Integrated Care Framework domains. Questionnaires were sent to 2,604 providers and staff from 101 health centers. Following repeated mail-outs, 781 (30%) people from 97 health centers responded. Of these, 380 were randomly allocated to the EFA group and 401 to the CFA group. The EFA suggests four latent factors. Factor 1 was labelled as ‘Teams and Care Continuity’; Factor 2 as ‘Patient Centeredness’; Factor 3 as ‘Coordination with External Providers’, and Factor 4 as ‘Coordination with Community Resources’. The CFA model confirmed these factor groupings. For the total sample, Cronbach’s alpha exceeded 0.7 for each latent factor (α=0.82, α=0.87, α=0.75 and α=0.88 respectively). Additionally, descriptive responses to each of the 21 PSPIC questions appear to have potential in identifying areas that providers and staff recognize as care integration strengths, and areas that may warrant improvement. For example, most respondents were not strongly agreed that they: coordinated care effectively with external providers (12% strongly agreed); were well-informed about patients’ social needs (8.4%), or routinely helped patients manage their chronic conditions (9.2% ). Opportunity for improvement appeared to exist across all PSPIC 21 items. The Integrated Care Framework, and findings from the PSPIC measure, support the current emphasis on improving the patient-centeredness of health services, together with ongoing care coordination efforts, in providing services that are truly integrated for patients.

Introduction: The importance of integration across the continuum of care is not limited to the health care sector. Coordinating client care between sectors and including supportive services such as education and social services is considered an essential part of building a fully integrated health system. Building on previous integration research, this study is a part of a comprehensive systematic review focused on identifying indicator and measures of the key principles of integration. We identified 16 indicator domains through a modified Delphi process using an expert panel of policy-makers, decision-makers, providers, and researchers. Intersectoral collaboration was identified as one of two indicator domains for the first principle of successful health systems integration, Comprehensive Services across the Continuum of Care. Methods: Search terms were generated for intersectoral collaboration to identify tools in the peer-reviewed and targeted gray literature. Tools were identified through a rigorous review process including abstract review, relevancy ratings, identifying additional articles in reference lists, quality ratings, and extraction. To avoid duplication of tools, only “tool development” articles were included in data extraction. If an article was found which used but did not develop an appropriate tool, the original article reporting the development and testing of the tool was identified and data was extracted from this source only. Notable exceptions included articles where the original tool was modified to measure intersectoral collaboration. Results: A review of 650 abstracts identified 14 tools which measure intersectoral collaboration. Most of the tools were questionnaires or checklists and were created or tested in a health care setting or with health related outcomes. The tools collected information from organizations in different sectors in a number of differed ways. Distributing a questionnaire or checklist to multiple organizations to measure the perceived level of mutual collaboration was the most common way. Network analysis was also used and one tool measured intersectoral collaboration as a quadrant using a balanced scorecard approach. The variables identified to measure intersectoral collaboration include identifying “high and low structure” between partnering organizations; a low level of connectivity represented “cooperation and coordination” and a high level of connectivity represented “collaboration and consolidation”. Other variables included looking at social networks, assessing interagency linkages, measuring the depth of integration in a model of human services integration, and system integration and change. All the tools came from medium-high to high quality empirical papers where in most cases the tools were tested and the psychometric properties were reported. Only one tool came from the gray literature. Discussion: Only a small number of tools have been identified, but the diversity among these tools was substantial. Ranging from simple questionnaires to complicated network analyses a number of options were found to capture ways to measure these intersectoral relationships. Some tools not only measured intersectoral collaboration but also provided a blueprint for how to use and build collaborative relationships across health care sectors and the community. For instance, Browne’s Human Services Network Integration model and measure highlights the model and how integration between sectors can be facilitated and measured. This study has a number of strengths and limitations. The review is strengthened by its thorough methodological approach. The fact that intersectoral collaboration is one indicator domain which is a part of the larger, comprehensive knowledge synthesis allows the results to contribute to the greater picture of healthcare integration. The size of the knowledge synthesis is a strength and a limitation. Given the size of the knowledge synthesis and the breadth of the topic areas, it is possible that articles and tools may have been missed despite extensive search and review strategies. Conclusion: A lot of emphasis has been put on the importance of integrated health care systems; however, there are few ways to identify and measure indicators and outcomes related to health services integration. It is not only important to identify key dimensions or principles of integrated care but also to be able to measure progress towards these integrated systems. Intersectoral collaboration is an important indicator domain contributing to building and sustaining health care integration. Valid and reliable tools to measure collaboration are essential. As such, this knowledge synthesis provides a number of appropriate tools for users including researchers, policy- and decision-makers, and providers across a wide range of health care systems. In this study we focused on measuring the presence but not the impact of intersectoral collaboration; this is an area we hope to investigate in future research.

Introduction : The Department of Health (DH) is currently funding several integrated care pilots in England, so called Integration Pioneers. Some local areas, however, are implementing programmes of integrated care without DH support. This paper reports preliminary findings of a longitudinal study of an integrated care programme without DH support in an urban setting in the North of England. The programme is unique in focusing solely on children's care, comprising health and social care organisations in the primary, secondary and tertiary sector. Children's services are different from adults' services by virtue of their universal funding and the holistic care approach. Nevertheless, children's health care suffers from similar organisational fragmentation and silo delivery. Our study evaluated a 5 year integration improvement programme in an urban area in the North of England under the leadership of the local CCG. The CCG combined more than 90 GP practices, a large children’s hospital with emergency, in and out patient services, and several community care trusts including CAMHS. The integration programme is being facilitated through the work of 5 thematically defined steering groups, comprising strategic and operational staff from all participating organisations. Members of steering groups were self-selecting or were co-opted. Each working group was self-directed in defining and implementing a programme of work around integration of children's services. Themes around which steering groups clustered were 'First 1000 days' (early intervention); 'Transition'; 'Mental Health/CAMHS', 'Models of Care'; 'IT and Governance'. The programme is funded and led by a local CCG which provides administrative assistance. The programme aims to lead to the formulation of business cases for additional investment in the sector by the CCG by end 2016. Theory/ Methods : The research study asked what the views and opinions of professional stakeholders in the programme were and how their attitudes changed over time as the programme progressed. It also explored to what extent staff from different organisations shared goals and objectives of the programme as they embarked on a multi-agency programme implementation. Whilst the study focused on the role of multi-agency working groups and their role in the definition and formulation of business cases for future investment, it took a novel approach in using a longitudinal methodology to investigate and monitor factors identified in the literature as contributory to multi-agency success, such as goal sharing, programme commitment and leadership, as well as perceptions of problem solving capacity. We used an observational study design to measure attitudes of stakeholders of the programme and detect changes over time. A literature review and a series of semi-structured interviews with a purposively selected group of respondents (n=12) from organisations involved with the programme was conducted at the start of the programme in January and February 2015. Interviews were conducted face to face or via phone. They were audio-recorded with consent of the interviewee and transcribed verbatim for analysis. Transcripts were coded for themes by two independent researchers. Emerging themes were discussed to ensure consensus. The purpose of the interviews was to provide key concepts of integration programme practices to be included in the survey instrument. Key themes were grouped into 3 investigative domains. The initial survey was to provide baseline data of staff's views and opinions on multi-agency collaboration and was repeated at 5 months with a simplified survey schedule to measure changes in attitudes. Respondents had to be members of one of the working groups to receive the survey request. All surveys were administered online with SurveyMonkey (SurveyMonkey Inc. ® (2014) Palo Alto, California, USA). Email addresses were obtained from the programme manager with the consent of all participants of working groups (n=115). Survey data were extracted from survey monkey and fed into Excel and SPSS for further analysis. Responses were descriptively analysed and cross tabulations were produced to investigate response patterns for specific professional categories or care sectors. Associations were tested using the Chi Square test. Three domains (A-C) were investigated within the programme context: how respondents perceived the capacity of the programme to solve problems (A), whether they thought to have common programme goals (B); and what they thought the impact of the programme on current multi-agency practices was (C). Problem solving capacity was defined as ‘ability to address existing barriers’ and ‘achieving pre-defined outcomes’. Sharing goals was operationalized as ‘share the same vision what to achieve’, ‘share the same goals’ and ‘agreement on how to achieve things’. Impact on current practice was defined as ‘providing increased opportunities to meet staff from other organisations’; ‘increased collaborative work’; ‘increased information exchange’; and ‘increased awareness of other organisations and their processes’. Results: Twenty one semi-structured interviews were conducted and responses to two rounds of the online survey were analysed (response rate 45 percent). Respondents were based in the following care sectors: Health 73%; Local Authorities 8%; Education 13%; Charities/Third Sector 6%. Findings indicate that commitment and enthusiasm for collaborative work was initially high amongst participants and remained so throughout the first year. Skepticism about the problem solving capacity of multi-agency work was however significant amongst respondents which contrasts with their enthusiasm for collaborative work. Staff from non-NHS organisations showed particularly high levels of pessimism about the programme's ability to improve service quality and service outcomes. Discussion : Over the last two decades scholars have developed a plethora of frameworks, often followed by little empirical testing (10). Two of the more promising ones are Cohen’s five organising constructs and Valentijn’s model of integration. Whilst Cohen’s constructs aim to structure the field and activities of integration, Valentijn’s model outlines a taxonomy of integration efforts assisting in categorisation and differentiation of integration programmes. Where Cohen’s constructs offer a simple 5 item overview, Valentijn’s model comprises 3 main categories, 8 integration subdomains with 21 individual features. The present study can be located within Cohen’s organising constructs in the fifth domain, exploring the shared understanding of goals and vision as part of determining the model of integration, and within Valentijn’s taxonomy of integration as a service or professional integration, with due nods to person focused care and guided by normative aspirations. Profession led integration pays particular attention to interdisciplinary service delivery and value added for the individual professional, leading to the formulation of a system service delivery strategy with attempts to design care plans or care pathways. The main emphasis is however on articulating, implementing and sustaining a shared vision of collaborative practice (what Valentijn calls normative integration). The findings of the study indicate that, whilst enthusiasm for collaborative work is high amongst strategic and operational staff in multi-agency programmes for integrated care, they view the ability of the programme's problem solving capacity differently, depending on which organisation they work in. This may affect the programme's transformational capacity which appears to depend on extraneous factors such as leadership within individual organisations. It also points to the 'skin-deep' character of many integration efforts unable to challenge or transform effectively organisational cultures and sectoral fragmentation. In our study, respondents appeared to be acutely aware of this limitation, whilst continue to place hope into the programme's ability to succeed. Conclusion : The study's findings have some important implications for programmes of service integration in the children's sector as well as general vertical or horizontal integration efforts in the adult sector. It appears that sharing goals, high levels of aspiration to overcome service fragmentation, as well as organisational commitment to improve service delivery contrast with significant levels of skepticism that integration can effectively challenge sectoral and professional fragmentation. Stakeholders appear to view organisational structures as immutable, resisting even concerted multi-agency efforts to integrate. This raises questions about the scope and depth of integration programmes (or lack thereof) as well as questions about perceptions of transformational capacity by stakeholders.

Introduction : There is increasing recognition that collaborative and integrated working is needed to meet the challenges faced in UK health and care and other public funded services. Alliances and alliance contracts have generated interest as a possible tool that commissioners can use to drive collaboration. There are examples in healthcare from New Zealand and recent alliance developments in services in England. In adopting alliance methodologies for the context of public sector commissioning and provision it is imperative to consider the evidence for creating successful alliances. This literature review was undertaken to identify the key components. Theory/Methods : A literature search was conducted in the summer 2015 commencing with Google Scholar searches for variations on the word alliance and alliance contracts. The reference lists of papers identified and requests to specialists in alliancing yielded further materials. The literature was analysed to draw out the key components that influence successful outcomes in alliances. Results : The search revealed over 80 references relevant to performance in alliancing and alliance contracting. Alliances can take many forms and in the literature overall there is a dominant representation of project alliances as used for public service capital build projects (e.g. construction and infrastructure) and strategic alliances across industries often seen in the private sector. Next to these well-defined types of alliances variations have emerged to cater for particular needs. Alliance success is also broadly defined. Traditional economic measures and achievement of objectives are commonly used but other benefits are described including creation of new skills and capabilities, durable relationships and competitive advantage. Analysis to identify themes defined four interrelated dimensions to successful alliancing. a. Trust and loyalty between parties Trust substitutes for hierarchical control. Partner selection and strategic, goal and incentive congruence are critical. Uncertainty about partner behaviour hinders the establishment of trust. Reducing the risk of partner opportunism requires attention to differences in economic benefits, cultural diversity and the time horizon for return on the investment for each partner. b. High quality decision making processes Alliances create a unique context for decision-making with unanimity and participatory processes. Appropriate governance arrangements are needed as well as trust and reciprocity between partners and the ability to employ various means to co-ordinate interactions and activities over time. Constraints are multiple decision making centres, uncertainty about partners, ambiguity about the evolution of the alliance and political and micropolitical actions. c. Alliance management capability and skills The multiparty context of alliances requires distinct skills for co-ordination of joint tasks, communication with sharing of relevant knowledge and information and a bonding process for social integration. Proactiveness and ability to modify the alliance activities over time are positive aspects. All these are self-reinforcing, building management effectiveness as experience grows. Challenges arise when there are divided authority structures, information asymmetries and underdeveloped personal relationships. d. Flexibility and dynamism Alliances are, by design, flexible and must evolve to accommodate contextual changes. The co-ordination, social norms, planning and capabilities must all reflect this and the leadership and management need to be able to function with ambiguity and uncertainty. Discussion : There was a wealth of material on performance in alliances and components of success from basic research, observational studies and enquiry and theoretical frameworks. The multitude of contexts, different meanings of alliances and definitions of success limits direct comparisons. However there are commonalities in findings and four themes emerge as critical for alliance success. These are trust and loyalty between parties, high quality decision making, alliance management capability and skills, flexibility and dynamism. The emphasis on partner selection, goal congruence and early relationship formative processes stands out. Specific focus needs to be given to creating trust, robust decision making, adequately resourced co-ordination and management and ensuring those in leadership and key management roles can operate with uncertainty and ambiguity so that they are able to flex and adapt as the alliance evolves. Conclusion : The interdependent four dimensions and the concepts within them provide those developing alliances in new environments with important lessons. Success does not happen by chance. Active management is required throughout the life cycle of an alliance to ensure there is a maximum chance of achieving success. We can now apply these findings to alliancing in health and care sectors. Although we focused on alliances specifically, they have relevance to all forms of collaborative and partnership working.

Introduction: Patients with psychiatric illnesses require both medical as well as supportive psychosocial treatments in order to prevent a relapse (1). The Institute of Mental Health conducts an 8th week rehabilitation program to ensure successful transition and integration of patient to community living. This paper discusses the rehabilitation case manager Os(CM) role in the rehabilitation program and outcomes. Method: From Jan 2012 to Dec 2012, 307 patients were referred for rehabilitation. The CM performed bio-psychosocial assessments on patients suitability for the program. He coordinated and collaborated with the Multidisciplinary team(MDT) on the acute and rehabilitation ward on the transition of care and the discharge plan with the family. Outcomes of this input was collected and analyzed using Microsoft Excel program Findings 59% of the patients referred were accepted and with fairly equal numbers of males (55%) and females (45%). The majority (90%) were diagnosed with Schizophrenia. 80% were Chinese with 64% aged between 31yrs old to 40yrs old. Psycho-education, supportive counseling and linkages were done. 56% were successfully discharged home and 46% to step-down care. Conclusion: Together with the MDT, the case manager has an important role in the ensuring the successful transition and integration of patient to community living.

This paper describes the interim evaluation analysis undertaken by two of five inCASA project pilot sites. inCASA is an EU co-funded pilot project which aims at developing an integrated health and social service model supported by innovative technology solutions to enable an ageing and frail population to stay well in their own homes for longer. The aim of the UK pilot located in Chorleywood, West Hertfordshire has been to bring together primary and social care in order to improve referral, sharing of information and identification of those patients in need. Similarly, the main objective of the Konstantopouleio General Hospital of Nea Ionia Greek pilot in the inCASA project is to develop an integrated healthcare service for patients suffering from Heart Failure.

Background: Recent studies show adolescent health-related behaviours to co-occur synergistically. This paper describes the study design for an exploratory trial on the effects of a comprehensive, whole-school health promoting school intervention. This intervention tackles seven different behavioural domains simultaneously via a combination of education, creating a healthy environment and introducing healthy behavioural policies. Additionally, extensive partnerships are formed between schools, parents, neighbourhoods and youth health authorities to coordinate health promotion efforts.Study design and data collection methods: The intervention will be implemented at two secondary schools. Results will be compared with two control schools (n≈1500). The intervention's effectiveness in changing student behaviours as well as physical and psychosocial health status along with qualitative lessons learned on the integration of youth health care services and school health education practices are the main aimed outcomes of this study. Data are collected via a mixed methods design combining an annual youth health (behaviour) monitor with a qualitative process evaluation via interviews with key stakeholders.Data analysis: A multilevel analysis is performed combined with a systematic analysis of qualitative interview data.Conclusions: This study will produce an evaluation of a comprehensive health promoting school intervention that combines an integrated approach of schools, neighbourhoods, families and youth health services to improve adolescent health.

Background: Recent studies show adolescent health-related behaviours to co-occur synergistically. This paper describes the study design for an exploratory trial on the effects of a comprehensive, whole-school health promoting school intervention. This intervention tackles seven different behavioural domains simultaneously via a combination of education, creating a healthy environment and introducing healthy behavioural policies. Additionally, extensive partnerships are formed between schools, parents, neighbourhoods and youth health authorities to coordinate health promotion efforts.Study design and data collection methods: The intervention will be implemented at two secondary schools. Results will be compared with two control schools (n≈1500). The intervention's effectiveness in changing student behaviours as well as physical and psychosocial health status along with qualitative lessons learned on the integration of youth health care services and school health education practices are the main aimed outcomes of this study. Data are collected via a mixed methods design combining an annual youth health (behaviour) monitor with a qualitative process evaluation via interviews with key stakeholders.Data analysis: A multilevel analysis is performed combined with a systematic analysis of qualitative interview data.Conclusions: This study will produce an evaluation of a comprehensive health promoting school intervention that combines an integrated approach of schools, neighbourhoods, families and youth health services to improve adolescent health.

Objectives: The Wirral Assistive Technology Programme (WAT) has operated across the whole population of the Borough for 3 years. It includes the installation of telecare technologies such as falls alerts and movement sensors to prolong users’ independence and reduce use of secondary care. Qualitative evaluation of user and carer perspectives indicated a reduction in admissions as a result of the technology and we sought to demonstrate this at a population level. Methods: Secondary care episodes for A&E, admissions and outpatients were temporally analysed to identify changed trend in secondary care usage as a result of installation for 400 users. Primary diagnoses at point of secondary care engagement were categorised to discern those that might have been mediated by WAT (e.g. falls and fractures) from those likely to be incidental (e.g. infection). The nature of the WAT service made the identification of a control group challenging and it was necessary to try and establish the counterfactual of secondary care usage in an equivalent group of patients not engaged with WAT. We used Patients at Risk of Re-Hospitalisation (PARR) scores which are routinely assigned to every patient discharge in Wirral to identify an equivalent group of patients not engaged with WAT and compared trends of secondary care usage as above. Controls were selected on the basis of an equivalent PARR score to an AT user on the same date as that user’s final discharge before installation of AT. Results: A&E and inpatient episodes showed regression to the mean around the point of AT installation, both for AT-related and unrelated diagnoses (between 660 days pre-installation and 240 days post-). Outpatient episodes showed a stable trend. We found no evidence that AT installation reduced the average number of secondary care episodes per patient, reduced the average PARR score or reduced the average length of hospital stay in comparison to controls. Conclusions: Although conceptually and qualitatively WAT should be impacting secondary care episodes, we could find no evidence of this. This has important implications for the way the programme is currently integrated with other local re-ablement schemes, how it is monitored and what incentives there are in the discharge system to promote its use. This paper will outline actions taken to embed the programme since the evaluation was completed (September 2011).