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Introduction: The public Basque Health System is undergoing a transformation process towards more integrated care. A cornerstone of this process was the creation of 13 integrated healthcare organizations (IHOs), starting in 2010. In order to assess changes in performance on integrated care, a scoreboard of quantitative indicators was selected and analysed. Methods: For the selection of indicators, the following steps were taken: - An international literature review on most commonly used indicators. - Interviews with 19 key informants on the integration process in the public Basque Health System. - Available data sources were identified. - A team of 13 regional experts was consulted on the list of indicators in the scoreboard. Based on the Donabedian model, the following categories of indicators were selected: structure, process, and (intermediary and final) results. Control variables were also identified. Trends in indicators over the 2010-2017 period were analysed, both at IHO and at whole system level. Results: A list of 49 indicators was identified and analysed. Most structural indicators showed improvement along the integration process, providing evidence of efforts made in areas such as the development of new coordination roles, and electronic information and communication tools. Process indicators showed increased efforts in improving the continuity of care for pluripathological patients and access to care at home, as well as on the assessment of functional dependency among older patients and the registration and follow-up of end-of-life patients. Some improvements were also found in the adequacy of prescription. Improvements in GP access to some diagnostics tests (eg: colonoscopies) was found. Generalised evidence of reduction in visits to especialised outpatient care could not be found. Regarding indicators of intermediary results, positive trends were found in several indicators for pluripathological patients, as well as on the reduction in potentially avoidable hospitalizations for people over 39. In most IHOs no reduction in 30-day emergency hospital readmissions was found. Regarding population health results, trends are difficult to link to integration initiatives, given their multifactorial nature. Positive developments were found in the control of diabetic patients, while only in a few IHOs diminishing trends in amenable mortality could be identified. Professionals’ perception of interprofessional collaboration between care levels was measured with a questionnaire validated elsewhere(1). While the chronic patient experience was measured using the IEXPAC Scale. Conclusions: In those groups of patients where integration initiatives have particularly focused, such as pluripathological patients, positive trends can already be identified in process and intermediary results’ indicators. Improvements in comprehensive indicators are more difficult to identify in most organisations. Lessons learned: It is useful to combine indicators more closely related to implemented interventions and targeted patients’ groups, with more comprehensive indicators that allow assessing their relative impact at system-level. Limitations: In most cases, identified trends cannot be unequivocally assigned to progress on integrated care. Trends were not statistically analysed. Nuño-Solinís R, Berraondo Zabalegui I, Sauto Arce R, San Martín Rodríguez L, Toro Polanco N. Development of a questionnaire to assess interprofessional collaboration between two different care levels.

Introduction: The public Basque Health System is undergoing a transformation process towards more integrated care. A cornerstone of this process was the creation of 13 integrated healthcare organizations (IHOs), starting in 2010. As part of a wider evaluation, a qualitative study on the views of frontline health professionals on changes experienced in relation to the integration process was conducted. Methods: A dialogical approach based on individual interviews and focus groups was used. Interviews with 19 key informants allowed identifying organisational and health professional’s characteristics which could potentially influence a health professionals’ “integration experience”. These findings influenced the composition of the four focus groups which took place in October and November 2018. Trying to cover the maximum array of professional profiles, participants in the focus groups were selected based on a theoretical sampling strategy. According to it, participating professionals’ profile heterogeneity was based upon several features: field of practice (primary care/hospital care), professional discipline (doctors/nurses), gender, years of practice, medical specialty (cardiology, endocrinology, internal medicine, pneumology …), community versus biomedical approach, liaison responsibilities, IHO size … Four focus groups were organised as follows: one group of primary care level professionals, two groups of hospital level professionals and one mixed group with both primary and hospital care level professionals. The integration model followed in the public Basque Health Service explicitly aims at integrated care for patients and is based on three main change levers: culture and values, governance, and development of a population health approach. The focus group discussions gathered views and perceptions on changes in these three potential levers as well as on the perceived impact, to date, of the integration process on patients’ care. All four group discussions were digitally recorded and transcribed verbatim. A thematic analysis was conducted. Results: Frontline health professionals in the focus groups mentioned several elements related to the management model: the development of electronic information and communication tools (such as the shared electronic clinical record, electronic prescription and consultations…), new coordination professional roles, the role of emergencies and hospitalisation at home services, and the increased development of shared care pathways between primary and hospital care professionals. Regarding changes in the organisational structure, the perceived benefits and disadvantages of the creation of the IHOs were also explored. As regards interprofessional collaboration, participants reported improved communication between primary and hospital care professionals as well as increased efforts by managers to facilitate opportunities to meet. Views on the leadership role of primary care professionals in the delivery of integrated care were also gathered. A key area identified regarding the development of a population health approach was the necessary cooperation and collaboration between social care and health care professionals and organisations. A generalised view among health professionals in the focus groups is that changes introduced with the integration process are benefiting patients, particularly chronic patients.

Introduction: This article explores the impact of the creation of a new integrated delivery organisation on the evolution of interprofessional collaboration between primary and secondary care levels. In particular, the case of the Bidasoa Integrated Healthcare Organisation is analysed. Theory and methods: The evolution of interprofessional collaboration is measured through a validated Spanish questionnaire, with 10 items and a 5-point Likert scale, based on the D’Amour’s model of collaboration [20]. The final sample included 146 observations (doctors and nurses). Results: The questionnaire identified a significant improvement on the mean scores for interprofessional collaboration of 0.57 points before and after the intervention. A significant improvement was also found in the two dimensions of the measure of interprofessional collaboration used, with the size of the change being higher for the dimension related to the organisational setting (0.63) than for interpersonal relationships (0.47). Conclusions: Before and after the creation of the Bidasoa Integrated Healthcare Organisation, an improvement in the perceived degree of interprofessional collaboration between primary and secondary care levels was observed. This finding supports the benefit of a multilevel and multidimensional approach to integration, as in the described Bidasoa case. Discussion: Results on the two dimensions of the measure of interprofessional collaboration used, seem to point to the longer time required for interpersonal relationships to change, compared to the organisational setting.

Introduction: This article explores the impact of the creation of a new integrated delivery organisation on the evolution of interprofessional collaboration between primary and secondary care levels. In particular, the case of the Bidasoa Integrated Healthcare Organisation is analysed.Theory and methods: The evolution of interprofessional collaboration is measured through a validated Spanish questionnaire, with 10 items and a 5-point Likert scale, based on the D’Amour’s model of collaboration [20]. The final sample included 146 observations (doctors and nurses). Results: The questionnaire identified a significant improvement on the mean scores for interprofessional collaboration of 0.57 points before and after the intervention. A significant improvement was also found in the two dimensions of the measure of interprofessional collaboration used, with the size of the change being higher for the dimension related to the organisational setting (0.63) than for interpersonal relationships (0.47).Conclusions: Before and after the creation of the Bidasoa Integrated Healthcare Organisation, an improvement in the perceived degree of interprofessional collaboration between primary and secondary care levels was observed. This finding supports the benefit of a multilevel and multidimensional approach to integration, as in the described Bidasoa case.Discussion: Results on the two dimensions of the measure of interprofessional collaboration used, seem to point to the longer time required for interpersonal relationships to change, compared to the organisational setting.

Introduction. This paper reports the development and validation of a questionnaire to assess collaboration between clinical professionals from two different care levels (primary and specialised care), according to the clinicians' own perceptions. This questionnaire has been elaborated to be used as part of the monitoring and evaluation process of the integrated care pilots in the public Basque Health Service.Methods. The process was carried out in four phases: development of the first version of the questionnaire, validation of the content, pre-testing, and evaluation of its construct validity and homogeneity in a sample of doctors and nurses. This last phase involved confirmatory factor analysis, as well as the calculation of Cronbach's α and various correlation coefficients.Results. The process demonstrated that the theoretical content of the questionnaire was appropriate, and also that its items were clear, relevant and intelligible. The fit indices for the confirmatory factor analysis were: c2 of 45.51 (p = 0.089), RMSEA of 0.043, RMR of 0.046, GFI of 0.92 and CFI of 0.99.Discussion. The statistics indicate a good fit between the data and a conceptual two-factor structure, in which both personal relationships between professionals and characteristics of the organisational environment are understood to underlie interprofessional collaboration.Conclusion. The end-product is a new instrument with good validity to assess the degree of interprofessional collaboration between clinicians working at two different levels of care.

Introduction. This paper reports the development and validation of a questionnaire to assess collaboration between clinical professionals from two different care levels (primary and specialised care), according to the clinicians' own perceptions. This questionnaire has been elaborated to be used as part of the monitoring and evaluation process of the integrated care pilots in the public Basque Health Service. Methods. The process was carried out in four phases: development of the first version of the questionnaire, validation of the content, pre-testing, and evaluation of its construct validity and homogeneity in a sample of doctors and nurses. This last phase involved confirmatory factor analysis, as well as the calculation of Cronbach's α and various correlation coefficients. Results. The process demonstrated that the theoretical content of the questionnaire was appropriate, and also that its items were clear, relevant and intelligible. The fit indices for the confirmatory factor analysis were: c2 of 45.51 (p = 0.089), RMSEA of 0.043, RMR of 0.046, GFI of 0.92 and CFI of 0.99. Discussion. The statistics indicate a good fit between the data and a conceptual two-factor structure, in which both personal relationships between professionals and characteristics of the organisational environment are understood to underlie interprofessional collaboration. Conclusion. The end-product is a new instrument with good validity to assess the degree of interprofessional collaboration between clinicians working at two different levels of care.