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Contains fulltext : 292111.pdf (Publisher’s version ) (Open Access) INTRODUCTION: The ageing society requires physicians who can deliver integrated care, but it is unclear how they should be prepared for doing so. This scoping review aims to create an overview of educational programmes that prepare (future) physicians to deliver integrated care while addressing components and outcomes of the interventions. METHOD: We included papers from five databases that contained: (1) integrated care (2) education programme (3) medical students (4) elderly, or synonyms. We divided the WHO definition of integrated care into ten components for the concept of 'integrated care'. Data were collected with a charting template, and template analysis was used to formulate themes. RESULTS: We found 17 educational programmes in different learning settings. All programmes addressed several components of the WHO definition. The programmes primarily focused on care for individual patients (micro-level), and the outcomes suggested that experiencing the complexity of care is key. CONCLUSION: This review revealed the limited evidence on educational programmes about integrated care for the elderly. Our findings suggest that educational programmes on integrated care should not be limited to the micro-level, and that students should obtain adaptive expertise by experiencing complexity. Future research should contain an explicit description and definition of integrated care.

Introduction: Patient-reported outcome and experience measures (PROM and PREM) are used to guide individual care and quality improvement (QI). QI with patient-reported data is preferably organized around patients, which is challenging across organisations. We aimed to investigate network-broad learning for QI with outcome data. Methods: In three obstetric care networks using individual-level PROM/PREM, a learning strategy for cyclic QI based on aggregated outcome data was developed, implemented and evaluated. The strategy included clinical, patient-reported, and professional-reported data; together translated into cases for interprofessional discussion. This study’s data generation (including focus groups, surveys, observations) and analysis were guided by a theoretical model for network collaboration. Results: The learning sessions identified opportunities and actions to improve quality and continuity of perinatal care. Professionals valued the data (especially patient-reported) combined with in-dept interprofessional discussion. Main challenges were professionals’ time constraints, data infrastructure, and embedding improvement actions. Network-readiness for QI depended on trustful collaboration through connectivity and consensual leadership. Joint QI required information exchange and support including time and resources. Conclusions: Current fragmented healthcare organization poses barriers for network-broad QI with outcome data, but also offers opportunities for learning strategies. Furthermore, joint learning could improve collaboration to catalyse the journey towards integrated, value-based care.

Background: The implementation of models of integrated care for chronic conditions is not well understood. We conducted a realist evaluation to determine how and why the implementation of the National Diabetes Programme in Ireland worked (or not).Methods: Documentary analysis and qualitative interviews with a purposive sample of national stakeholders (n = 19), were used to develop an initial theory on expected programme delivery. We refined this theory using semi-structured interviews (n = 38) with professionals from different clinical disciplines involved in programme implementation.Results: Locally important contexts facilitating implementation included staff experience of delivering diabetes care, capacity, and familiarity with the intended purpose of new clinical posts. The extent to which integrated care was adopted and implemented depended on judgements made by professionals working in these contexts; specifically, judging the relative advantage of the programme and whether to engage in negotiations to legitimize their new roles in diabetes care.Conclusions: Our results highlight the need for adequate preparatory work to raise awareness of and support new roles to implement integrated care, clarification on the core components of new care models, and the development of local service infrastructures to support integrated care.

Introduction: Health care system transformations that align with the principles of integrated care require the collaborative efforts of various macro-, meso- and micro-level stakeholders. Understanding the roles of various system actors can improve collaboration in ways that support purposeful health system change. Professional associations (PAs) have considerable influence, but little is known about the strategies they use to influence health system transformation. Methods: Using a qualitative descriptive approach, eight interviews with 11 senior level leaders from local PAs were conducted to learn about the strategies used to influence the province-wide reorganization of health care into Ontario Health Teams. Results: During times of health system transformation, PAs balance: (1) supporting members, (2) negotiating with government, (3) collaborating with stakeholders, and (4) reflecting on their role. The enactment of these various functions demonstrates the strategic nature of PAs, and showcases their ability to evolve in ways that align with the dynamic nature of healthcare. Discussion: PAs are highly connected groups, deeply engaged with their members and regularly engaged with other key stakeholders and decision-makers. PAs play a critical role in influencing health system transformations, by bringing forward practical solutions to government that reflect the needs of their members, often frontline clinicians. PAs strategically seek opportunities for collaboration with stakeholders that can amplify their message. Conclusion: Insights from this work could support health system leaders, policymakers, and researchers in leveraging the role of PAs in health system transformations via strategic collaboration.

Introduction: Robust measures of integration are essential for assessment of the development, design and implementation of integration within healthcare systems. This review aimed to identify measurement instruments for integration within children and young people’s (CYP) healthcare systems (PROSPERO registration number CRD42021235383). Methods: We searched electronic databases (PubMED and Ovid Embase) using three main concepts: ‘(integrated care) AND (child population) AND (measurement)’, along with additional searches. Results: Fifteen studies describing 16 measurement instruments were eligible for inclusion. The majority of studies were conducted in the USA. There was a diversity of health conditions included in the studies. The most frequent type of assessment used was a questionnaire (11 identified), but interviews, patient data and healthcare records, and focus groups were also used. Integration outcomes assessed were quality of care coordination, quality of collaboration, continuity of care, completeness of care, structure of care, quality of communication, and local implementation of integrated care. Conclusion: A variety of instruments for the measurement of integration within CYP healthcare systems were identified. Further work on the standardisation of integrated care measures would be valuable; however, it is important that instruments and measures meet the needs of specific settings, populations and conditions being studied.

Introduction: Although the patient experience of integrated care has been documented for several chronic conditions, little is known in the context of rheumatic and musculoskeletal diseases (RMDs). This study provides a first overview of the patient experience of integrated care according to the perspective of people living with RMDs in Italy. Methods: A cross-sectional survey was administered to 433 participants who reported their experiences together with the importance assigned to different attributes of integrated care. Explorative factor analysis (EFA) and non-parametric ANOVA and ANCOVA statistical tests were employed to account for the differences in the answers provided by sample subgroups. Results: Two factors (namely, “Person-centred care” and “Health service delivery”) were extracted in the EFA. Participants attributed high importance to both of them. Overall positive experiences were reported only for Person-centred care. The delivery of health services instead received a poor evaluation. Significantly worse experiences were observed for women and people that were either older, unemployed, with comorbidities or lower self-reported health, or less engaged in their healthcare management. Conclusions: Italians with RMDs described integrated care as an important approach to care. However, further effort is needed to allow them to perceive an actual benefit from integrated care practices. Specific attention should be paid to disadvantaged and/or frail population groups.

Background: Health care delivery is often poorly coordinated and fragmented. Integrated care (IC) programs represent one solution to improving continuity of care. The aim of this study was to understand experiences and reported outcomes of patients and caregivers in an IC Program that coordinates hospital and home care for thoracic surgery. Methods: A process evaluation was undertaken using qualitative methods. We conducted semi-structured interviews with 10 patients and 8 caregivers who received IC for thoracic surgery and were discharged between June 2019 and April 2020. A phenomenological approach was used to understand and characterize patient and caregiver experiences. Thematic analysis began with a deductive approach complemented by an inductive approach. Results: Four major themes evolved from patient and caregiver interviews, including 1) coordination and timeliness of patient care facilitated by an IC lead; 2) the provision of person-centred care and relational continuity fostered feelings of partnership with patients and caregivers; 3) clear communication and one shared digital record increased informational continuity; and 4) impacts of IC on patient and caregiver outcomes. Conclusions: Patients and caregivers generally reported this IC Program met their health care needs, which may help inform how future IC programs are designed.

Introduction: As South Korea is fast becoming an aging society, the need for integrated care of the elderly has increased. ‘Community Integrated Care Initiatives’ have been implemented by the Ministry of Health and Welfare. However, home healthcare is insufficient to meet this need. Description: The National Health Insurance Service (NHIS) launched the initiative, ‘Patient-Centered Integrated model of Home Health Care Services in South Korea (PICS-K)’. Its purpose is to coordinate home healthcare providers by establishing a home health care support center (HHSC) in public hospitals starting in 2021. The PICS-K has six main features: integration of primary care-hospital-personal care-social services through a consortium, HHSC in hospitals with primary care collaboration, increased accessibility, interdisciplinary team (IDT), patient-centeredness, and education. Discussion: >Integrating healthcare, personal care, and social services at multiple levels is necessary. Accordingly, platforms to share participant information and service records, and institutional payment system reforms are required. Conclusion: In public hospitals, the HHSC supported primary care, which provides home healthcare. The model combined community healthcare and social services to accomplish the aging-in-place of the homebound population by focusing on their needs. This model will be applicable to other regions in Korea.

Background: Long-stay home care patients are a large population of older adults with multi-morbidity and frailty. The COVID-19 pandemic posed challenges to executing care coordination and completing in-home assessments due to provincial mandates restricting in-person care. We evaluated the implementation of the interRAI Check-Up Self-Report instrument administered by phone and video. Methods: We report on a mixed-methods study, which involved the collection and analysis of survey and focus group data. Care coordinators from two regions in Ontario who had implemented the Check-Up at least once between March 2020 to September 2021 were recruited via convenience sampling. Results: A total of 48 survey respondents and 7 focus group participants consented to the study. Advantages of completing the Check-Up over the telephone or video call included: reduced travel time, reduced risk of disease transmission, familiarity with the assessment questions, and reduced time spent administering the assessment. Limitations most frequently reported were: the inability to see the living environment, hearing impairments, inability to observe non-verbal responses or cues, language barriers, difficulty building rapport, and difficulty understanding the patient. Conclusions: The Check-Up was advantageous in providing sufficient information to create a care plan when administered over the phone and by video. Implementation of the Check-Up assessment was facilitated by familiarity and alignment with other interRAI assessments. Our results indicate that population characteristics need to be taken into consideration for administration of self-report style of assessments.

Introduction: Integrated clinical pathways should provide the best and most efficient treatment. As no study on barriers to inter-organisational collaboration has investigated the barriers to unimplemented integrated clinical care in a country with less efficiently organised health system, the study aimed to identify these barriers in the preoperative management of patients with hip or knee osteoarthritis in Slovenia. Methods: A cross-sectional study was conducted using multiple methods, including a quantitative survey with participants involved in target patient groups, and in-depth interviews with involved key actors at micro, meso and macro levels in Slovenia. Results: Respondents predominantly expressed a lack of inter-organisational collaboration. The exposed barriers are individualistic culture, the level of development of the health system, financing, administration, and regulatory frame at the macro level, shortage of staff at the meso level, and the lack of technological standards, trust, communication, and perception of pressures at the micro level. Discussion and conclusion: In addition to the barriers identified in previous studies, our study shows that individualistic culture and the level of development of the health system at the macro level, manifested as a pressure on health professionals and other actors at the micro level, are important barriers to inter-organisational collaboration.

Introduction: Integrated care research often fails to adequately describe co-design methods. This article outlines the process, principles and tools to co-design an integrated health and social care Hub for families experiencing adversity. Research methods: The Child and Family Hub was co-designed in four stages: (1) partnership building and stakeholder engagement, (2) formative research, (3) persona development and (4) co-design workshops and consultations. Local families, community members and intersectoral practitioners were engaged at each stage. The co-design workshops employed a human-centred design process and were evaluated using the Public and Patient Engagement Evaluation Tool (PEET). Results: 121 family participants and 80 practitioners were engaged in the Hub’s co-design. The PEET highlighted the co-design team’s satisfaction achieved by community members working alongside practitioners to generate mutual learning. Resourcing was a key challenge. Discussion: Human-centred design offered a systematic process and tools for integrating formative evidence with lived and professional experience in the Hub’s co-design. Applying community engagement principles meant that a diverse range of stakeholders were engaged across all stages of the project which built trust in and local ownership of the Hub model. Conclusion: Co-design research with families experiencing adversity should attend to language, engagement methods, team composition and resourcing decisions.

Introduction: Integrated care is an important strategy for increasing health system performance. Despite its growing significance, detailed evidence on the measurement properties of integrated care instruments remains vague and limited. This article aims to present the Monitoring and Evaluation Framework (M&EF) used in the pilot program of coordinated primary care in Poland. It can serve as an example of Monitoring and Evaluation (M&E) concept for the countries taking their first steps in the care integration implementation or establishing PHC reforms. This article belongs to the series of publications entitled: “Highway to hell or stairway to heaven – evaluating complex integrated care models – lessons from the Primary Healthcare Plus pilot program (PHC Plus) in Poland”. Methods: The M&EF of the PHC Plus was based on the Theory of Change within which a shift was to take place in the following 4 aspects: (1) change in health outcomes among participating patients; (2) change in health care experience among participating patients; (3) change in the fragmentation of care provided for chronic diseases among participating patients; (4) change in overall spending on health services for the patients in the PHC Plus facilities. Data for the M&EF of the PHC Plus came from two main sources: the National Health Fund (national insurer) database and the results survey questionnaires. Results: Based on the established M&EF of PHC Plus it was possible to monitor and evaluate the change in patients’ health outcomes, health experience and health literacy, fragmentation of care index, and overall spending on healthcare services offered in the pilot. Some of the analyzes planned could not be carried out due errors in data reporting systems, the lack of data of adequate quality or the pandemic. However, M&E implementation process provided many insightful information supporting broader PHC reform in Poland. Inclusive process of information and data sharing, discussions with the country health stakeholders and solid analytical background allowed for better informed policy making and scaling up the pilot. Conclusion: M&E process was put in place to help identify interventions, processes and approaches that could be scaled up and implemented at the country level. This approach resulted in broader understanding and acceptance of the proposed reforms in the PHC in Poland, following PHC Plus pilot implementation. Tools and approaches available and used to evaluate care integration in the PHC setting may not fully respond to the PHC and care integration system characteristic and country capacity. Therefore, revised M&E approach should be an integral part of the health policy interventions and further development of the PHC. Care integration specific measurement tools should be considered. Integration is a complex, multidimensional concept that requires measurement at multiple levels, including the patient level, the provider (professional) level, organizational and systems level. The M&E system of care integration requires use of multidimensional approach, complexed data systems, but also active sharing process of key findings. A phased approach is recommended to help researchers define clearly where they are in the research process and show progress on the outcomes’ achievement. Some simplification of the M&EF used in the PHC Plus is recommended to increase its sustainability without loosing key analytics.

Background: Integrated care is an important initiative to respond positively to the ageing of society and information and communication technology(ICT) plays an important role in facilitating the integration of functional and normative health and social care. The scoping review aims to synthesize evidence on the experience and practice of ICT-based implementation of integrated care for older adults. Methods: This study followed the research framework developed by Arksey and O’malley for the scoping review and systematically searched for relevant studies published between 1 January 2000 and 30 March 2022 from nine electronic databases, three specialist journals, three key institutional websites, 11 integrated care project websites, google scholar and references of the studies to be included. Two reviewers independently screened and extracted data and used thematic analysis to sort out and summarize the core elements, hindrances and facilitators of ICT-based integrated care. Results: A total of 77 studies were included in this study, including 36 ICT-based practice models of integrated care with seven core elements of implementation including single entry point, comprehensive geriatric assessment, personalized care planning, multidisciplinary case conferences, coordinated care, case management and patient empowerment, which generally had a positive effect on improving quality of life, caregiver burden and primary care resource utilization for older adults, but effectiveness evaluations remained Heterogeneity exists. The barriers and facilitators to ICT-based implementation of integrated care were grouped into four themes: demand-side factors, provider factors, technology factors and system factors. Conclusion: The implementation of ICT-based integrated care for the elderly is expected to improve the health status of both the supply and demand of services, but there is still a need to strengthen the supply of human resources, team training and collaboration, ICT systems and financial support in order to promote the wider use of ICT in integrated care.

Introduction: Care integration needs to take place on different levels, including that of infrastructure and especially data infrastructure. Only integrated data allow for policy making, care planning, research, and evaluation that spans across different sectors of care and support. Methods: In the course of an EU-funded reform initiative on integrated care, the Estonian government and various agencies have developed a concept for an integrated data centre, bringing together information from social, medical, and vocational support services. The concept was developed in co-production with many stakeholders. A test data set from all covered sectors, including the pseudonymised data of 17,945 citizens of an Estonian municipality, was created and analysed as a proof-of-concept exercise. Results: The co-production approach resulted in a set of requirements and use cases as well as a specification of premises, processes, and data flows for the data centre. The analysis of the test dataset showed the principal feasibility of the dataset for the intended purposes. Conclusion: The concept development phase showed that an integrated data centre for Estonia is feasible per se and helped to specify concrete actions required for its realisation. Strategic and financial decisions from the Estonian Reform Steering Committee are now needed to create the data centre.

Introduction: The NHS England General Medical Services 2017–18 contract made it mandatory for general practices in England to identify and manage older people proactively. In response to the national policy, the Luton Framework for Frailty (LFF) programme was developed to target older residents of Luton and offer interventions according to their frailty level. The aim of this study was to gain a deeper understanding of the LFF and the factors that affect the implementation of a proactive integrated care service for older people with different frailty levels (OPDFL). Methods: We undertook document analyses and conducted semi-structured interviews with stakeholders to create a ‘thick description’ that provides insights into the LFF. Results: Healthy ageing interventions bring beneficial outcomes but to increase the uptake they should be co-produced with older people. A common electronic system within primary care and multidisciplinary team meetings (MDT) aid implementation. However, variation in implementation across Luton, different levels of buy-in for MDT, and different data systems in primary and secondary care make implementation challenging. Conclusion: The LFF is a promising initiative and lessons learned are likely to be transferable to other settings as proactive management of frailty takes on greater policy prominence in the UK and worldwide.

Introduction: Supportive care models considering inclusivity and community services to improve integrated care for cancer survivors are limited. In this case study, we described the implementation of a multidisciplinary care model employing routine distress screening and embedded integrated care pathways to integrate care across disciplines and care sectors, while remaining inclusive of the multi-ethnic and multilingual population in Singapore. We reported implementation outcomes after 18 months of implementation. Description: We reviewed the model’s process indicators from September 2019 to February 2021 at the largest public ambulatory cancer centre. Outcomes assessed included penetration, fidelity to screening protocol, and feasibility in three aspects – inclusiveness of different ethnic and language groups, responsiveness to survivors reporting high distress, and types of community service referrals. Discussion/conclusion: We elucidated opportunities to promote access to community services and inclusivity. Integration of community services from tertiary settings should be systematic through mutually beneficial educational and outreach initiatives, complemented by their inclusion in integrated care pathways to encourage systematic referrals and care coordination. A hybrid approach to service delivery is crucial in ensuring inclusivity while providing flexibility towards external changes such as the COVID-19 pandemic. Future work should explore using telehealth to bolster inclusiveness and advance community care integration.

Introduction: Ensuring access to the right information at the right time can improve the safety, effectiveness and efficiency of care. A systematic and detailed collection of patient records, commonly known as electronic health records (EHRs), forms the core of the information system architecture in integrated health systems. Description: Since January 2021, seventeen years after the German legislation to implement EHRs (elektronische Patientenakte; ePA) came into force, the sickness funds in Germany have been offering their enrollees a downloadable application with which patients can access their personal EHRs through an electronic device. Looking at the ePA adoption process, it is now safe to argue that the deployment has been anything but successful. After two years of the launch, the number of ePA users amounts to not even 1% of the insured population in Germany, failing to move the needle on integrated care and health data integration. Based on a public policy theory, this article analyses the factors that are influencing the ePA implementation and secondary use of ePA data. Discussion: As the German experience shows, the feasibility of digital health projects depends on several contextual factors: countries with a high degree of self-governance and federal structures have to manage complex coordination processes that often slow down or otherwise impede digitalisation processes. In addition, cultural peculiarities such as concerns about data protection and security can be a hindering factor for digitalisation. Whereas the new German government and European initiatives such as the European Health Data Space (EHDS) create an advantageous situation for the ePA implementation and secondary use of health data, the structural and cultural issues in Germany should be acknowledged and tackled. Conclusion: Concerning the structural factors, a further reorganisation of the board of gematik, the key organisation of digital health solutions in Germany, should be considered. Cultural factors in Germany affect especially the secondary use of data; organising information campaigns, investing in (digital) health literacy of the population and designing a user-friendly ePA application are central in this context. Zusammenfassung Einleitung: Der Zugang zu den richtigen Informationen zur richtigen Zeit kann die Sicherheit, Wirksamkeit und Effizienz der Gesundheitsversorgung verbessern. Eine systematische und detaillierte Sammlung von Patientenakten, bekannt als Electronic Health Records (EHRs), bildet den Kern der Informationssystemarchitektur in integrierten Gesundheitssystemen. Beschreibung: Seit Januar 2021, siebzehn Jahre nach Inkrafttreten der deutschen Gesetzgebung zur Einführung der elektronischen Patientenakte (ePA), bieten die Krankenkassen eine zum Download verfügbare Anwendung an, mit der Patienten über ein elektronisches Gerät auf ihre persönliche elektronische Patientenakte zugreifen können; bisher jedoch mit wenig Erfolg. Zwei Jahre nach der Inbetriebnahme beläuft sich die Zahl der ePA-Nutzer auf weniger als 1 % der gesetzlich versicherten Bevölkerung in Deutschland; es ist also nicht gelungen, die integrierte Versorgung und Datenintegration voranzutreiben. Basierend auf einer politikwissenschaftlichen Theorie, werden in dieser Studie Faktoren analysiert, welche die ePA-Einführung und die sekundäre Nutzung von ePA-Daten beeinflussen. Diskussion: Wie die Erfahrungen mit der ePA in Deutschland zeigen, hängt die Umsetzbarkeit digitaler Gesundheitsprojekte von einer Vielzahl von kontextuellen Faktoren ab: Länder mit einem hohen Maß an Selbstverwaltung und föderalen Strukturen müssen komplexe Koordinationsprozesse bewältigen, die den Digitalisierungsprozess oft verlangsamen oder anderweitig behindern. Darüber hinaus können kulturelle Eigenheiten wie Datenschutz- und Sicherheitsbedenken die Digitalisierung behindern. Obwohl die neue Bundesregierung und europäische Initiativen, wie der Europäische Gesundheitsdatenraum (European Health Data Space; EHDS), die ePA-Implementierung und die Sekundärnutzung von Gesundheitsdaten begünstigen, sollten strukturelle und kulturelle Probleme in Deutschland berücksichtigt und angegangen werden. Schlussfolgerung: Im Hinblick auf die strukturellen Faktoren sollte eine weitere Umstrukturierung der gematik, des wichtigsten Entscheidungsorgans für digitale Gesundheitslösungen in Deutschland, in Betracht gezogen werden. Kulturelle Faktoren in Deutschland beeinflussen vor allem die Sekundärnutzung von Daten; in diesem Zusammenhang sind das Organisieren von Informationskampagnen, die Förderung der (digitalen) Gesundheitskompetenz der Bevölkerung und die Gestaltung einer nutzerfreundlichen ePA-Anwendung von zentraler Bedeutung. Schlüsselwörter: Elektronische Patientenakte; Akzeptanz von Innovationen; Verwaltung von Gesundheitsdaten; Integrierte Versorgung; Datenintegration; Nationales Gesundheitssystem; Deutschland

Introduction: Health care demands increase over the winter period, especially for people with chronic diseases. Hospital avoidance programs have potential to address seasonal surges. Methods: An integrated care intervention was provided to patients at high risk of hospitalisation during the 2017 and 2018 winters in Northern New South Wales, Australia. Patients received increased support including general practice sick day action plans, automated admission notifications to the general practitioner, and care coordination services. Outcomes were provider and patient experience and preventable hospitalisation rates. Results: The program enrolled 1244 participating patients from 37 general practices with at least 12 months follow-up. It was associated with marked improvements in provider and patient experience. However, when compared to a propensity score matched control group there was no difference in hospital utilisation or emergency presentation rates. Discussion and Conclusion: An integrated care strategy to address chronic care needs of patients in winter was well received by practitioners and patients, but did not translate to changes in hospital utilisation or emergency presentation rates. Areas for improvement include: strengthening inter-professional engagement between hospital, specialists and primary care providers, more tailored support services for patients with complex health needs, and a more expansive set of process measures beyond hospital and emergency utilisation to assess impact.

IntroductionFragmentation of health care services remains widespread, resulting in adverse effects such as inefficient and inequal care. Networks have the potential to address those ‘wicked’ problems. However, current ways of paying seem to impede coordination and collaboration. Health-care providers are predominantly reimbursed through traditional payments models that reward volume rather than value, such as fee-for-service or diagnosis-related groups. It is believed that moving from separate provider reimbursement to joint reimbursement of networks stimulates coordination between providers and encourages flexible use of resources. Ultimately, jointly reimbursing networks through network-level payment models is assumed to lead to improved performance. Aims Objectives Theory or MethodsOur aim was to study how network-level payment models affect the performance of health-care networks. Due to the broad nature of this aim, a scoping review was conducted. Six bibliographical databases were searched, combining various terms that reflected ‘payment model’ and ‘interorganizational network’. Articles were eligible for inclusion if they described networks, payment (models), performance indicators and if it was a peer-reviewed, empirical study set in an OECD country. Network performance was defined as the ability of the network to satisfy the payment model’s objectives. We distinguish four categories of performance: spending, utilization, quality of care, and other consequences. Highlights or Results or Key Findings63 studies were included with the majority of studies stemming from the USA (N=58). Payment flows to the network were more common than payment flows in the network (N=57 vs. N=6). Global payment with add-ons (N=49) was the most common model, followed by pay-for-performance (N=7), capitation (N=4) and bundled payment (N=3). In general, the results show that payment models have mixed effects on performance. No single payment model proved able to consistently improve on all four categories of performance. However, in the majority of studies performance in terms of quality and utilization remained stable or improved. Spending was not curbed under the disease-based bundled payment model. Our results also show that the relation between payment models and performance is not necessarily stable, with several factors of importance: timing of the performance assessment, cohort entry year, and scope of services offered by the networks explain differences in performance. ConclusionsAlthough network-level payment models are still in their infancy, this review shows that these models have the potential to improve performance of networks. Given the increasing omnipresence of health-care networks, it is fruitful to keep experimenting with joint reimbursement of those networks. Implications for applicability/transferability sustainability and limitations It might prove worthwhile to develop more theory-based understanding on the contexts and mechanisms under which payment models lead to certain performance. As alternative payment models gain momentum, this understanding can enhance transferability of knowledge and subsequently support providers in preparing for future (mandatory) payment reform.

Introduction: While many different factors can undermine older people’s ability to live safely at home, safety as an explicit aspect of integrated care for older people living at home is an underexplored topic in research. In the context of a European project on integrated care, this study aims to improve our understanding of how safety is addressed in integrated care practices across Europe.Methods: This multiple case study included thirteen integrated care sites from seven European countries. The Framework Method guided content analyses of the case study reports. Activities were clustered into activities aimed at identifying and managing risks, or activities addressing specific risks related to older people’s functioning, behaviour, social environment, physical environment and health and social care receipt.Results: Case studies included a broad range of activities addressing older people’s safety. Although care providers felt they sufficiently addressed safety issues, older people were often concerned and insecure about their safety. Attention to the practical and social aspects of safety was often insufficient.Conclusions and discussion:Integrated care services across Europe address older people’s safety in many ways. Further integration of health and social care solutions is necessary to enhance older people’s perceptions of safety.

Introduction: Current descriptions of pooled budgets in the literature pose challenges to good quality evaluation of their contribution to integrated care. Addressing this gap is increasingly important given the shift from early models of integrated care targeting segments of the population, to more recent approaches that aim to target 'places', broader geographically defined populations. This review draws on the current international evidence to describe practical examples of pooled health and social care budgets, highlighting specific place-based approaches. Methods: We initially conducted a scoping review, a systematic database search ('Medline', 'Embase', 'Econ Lit' and 'Google Scholar') complemented by further snowballing for academic and 'grey literature' publications (1995 – 2020). Results were analysed thematically according to budget characteristics and macro-environment, with additional specific case studies.Results: Thirty-six primary studies were included, describing ten broad models of pooled budgets across seven countries. Most budgets targeted specific sub-populations rather than an entire geographically defined population. Specific budget structures varied and were generally under-described. The closest place-based models were for small populations and implemented in a national health system, or insurance-based with natural geographical boundaries.Conclusion: Despite their increasing relevance in the current political debate, pooled place-based budgets are still at an early stage of implementation and research. Adequate description is required for future meta-analysis of effectiveness on outcomes.

Introduction: Multidisciplinary team (MDT) meetings could facilitate coordination of care for individuals living with multimorbidity, yet there is limited evidence on their effectiveness. We hence explored the common characteristics of MDT meetings in primary care and assessed the effectiveness of interventions that include such meetings, designed to improve outcomes for adults living with multimorbidity. Methods: A systematic review of literature was conducted using MEDLINE and EMBASE. A narrative synthesis was performed, extracting study and MDT meeting characteristics, in addition to any outcomes reported. Results: Four randomised controlled trials that were conducted in the United States of America were identified as eligible, recruiting a total of 3,509 adults living with multimorbidity. Common MDT meeting themes include regular frequency of discussion, the absence of patient involvement and the participation of three or four multiprofessionals. Significant improvements were observed in response to interventions with an MDT component across most measures, yet this trend did not extend to physical health outcomes. Discussion: It is unclear if the results in this review are sufficient to support the widespread implementation of MDT meetings in primary care, for adults living with multimorbidity. Due to the paucity of studies collated, further research is required to inform widespread implementation.

[EN] Introduction: In the face of a growing ageing population and rising care needs, compassionate communities seek to visualize the community as an equal partner in the complex task of providing quality social and health care at the end of life. Description: Getxo Zurekin is a social innovation example for the creation of a compassionate community in Getxo, one of the most populated cities in the province of Biscay, with 25.46% of its population aged over 65. Mixed methodologies have been applied, active listening and co-creation of actions and strategies towards improving care and quality of life for people and families facing advanced disease and end of life situations, with more than 80 people interviewed to conform the basis for a collective sense making. The initiative has reached more than 1,000 people in Getxo. Discussion: Following a systemic approach, horizontal relationships and cross-sectoral collaborations have allowed engaging the active involvement of local agents in the collective sense making and co- creation process. Conclusion: Getxo Zurekin represents an example of a participatory action research model, which has shown to be effective to meet initial targets towards creation of a compassionate community.

Introduction: A provincial strategy to expand care coordination and integration of care for children with medical complexity (CMC) was launched in Ontario, Canada in 2015. A process evaluation of the roll-out examined the processes, mechanisms of impact, and contextual factors affecting the implementation of the Complex Care for Kids Ontario (CCKO) intervention strategy.Methods: This process evaluation was conducted and analyzed according to the United Kingdom Medical Research Council (UK-MRC) process evaluation framework. To evaluate the implementation of the CCKO intervention, a multi-method study design was used, including semi-structured interviews with 38 key informants and 10 families of CMC involved in CCKO. To further understand implementation details across regional sites, provincial-level implementation plans, and process documents were reviewed.Discussion: Strengths of CCKO included novel collaborations and partnerships between complex care teams, community partners and regional sites. Issues relating to communication and coordination across care sectors created challenges to holistic care coordination objectives. Provincial system fragmentation limited the ability of CCKO to provide seamless care coordination due to the multiple care sectors involved.Conclusion: This study adds to the understanding of the processes involved in a population-level care coordination intervention for CMC. Lessons learned through CCKO can help facilitate reproducibility and necessary adjustments of the intervention in different settings.

Aim: To review the available evidence on asynchronous communication models between primary care professionals and patients in different countries around the world in order to analyse the added value that this model brings to patients and professionals.Design: A rapid literature review was conducted using the World Health Organisation guidance to include a variety of studies on the concept of asynchronous communications between primary care and patients in different countries.Data sources: The search for articles was carried out in PubMed and Google Academics and with the contribution of telemedicine experts from the Catalan Institute of Health.Selection of studies: The review included 271 articles. The inclusion criteria were: publications from 2010 onwards, in English, Spanish or Catalan, focused on asynchronous communications between primary care professionals and patients to improve patient management. After discarding duplicates and applying the exclusion criteria (255 articles), 16 were included for further review.Data extraction: The rapid literature review was conducted by an evaluator; detecting 5 main general themes: reduction of face-to-face visits, available services and most frequent uses, characteristics and perceptions of primary care professionals, characteristics and perceptions of users, and barriers and facilitators for the implementation of asynchronous teleconsultation.Results: A total of sixteen studies were included, including seven quantitative studies, seven qualitative studies and two mixed studies.Conclusions: The high degree of satisfaction of both users and professionals, the outbreak of COVID-19 and the effectiveness and efficiency of asynchronous remote communications are key factors for the implementation and improvement in the management of the different healthcare systems across the world.

Introduction: Patients experiencing acute ischemic stroke should access treatment as soon as possible to increase their chances for survival without severe disability. Given the increased complexity of stroke treatment from the provider and patient perspective, this study provides an overview of the pathways followed by stroke patients during in-hospital treatment.Methods: This qualitative study combined twenty-seven observations and fifteen staff interviews at a German comprehensive stroke center providing endovascular treatment (“EVT hospital”). Analysis was based on the COMIC Model for the comprehensive evaluation of complex health care interventions and a grounded theory approach.Results: The patient pathways during in-hospital treatment span the phases (1) admission to hospital, (2) receiving recanalization therapies, and (3) in-patient treatment. Before admission to the EVT hospital, interactions between staff members from the EVT hospital and patients take place as part of the telestroke consultations during which the EVT hospital’s ED neurologist meets the patient via a video- and audio-based connection. During the second phase, when IVT and/or EVT are provided to the patient, three teams (ED, neuroradiology and ICU team) with direct patient interactions intersect at the angiography suite until mechanical recanalisation treatment ends and the patient is transferred to the SU or ICU. In the third phase, the patients are treated on the SU or ICU and staff members interact with them according to a pre-defined schedule as well as based on individual needs.Discussion: Our results show that most direct staff-patient interactions are focussed within one phase, with a smaller number of interactions extending to other phases, and no professional (group) with direct patient interactions cover more than two phases of the acute stroke pathway. Future research should investigate how the pathways described here are experienced from the patient perspective, including how the organisation of visible care processes may influence patient satisfaction. Findings can be translated to accessible patient information resources as well as input for digitalisation efforts, provider orientation and training.

Introduction: Violet Program (ViP) was developed to address the current home palliative service gap for individuals with life limiting non-cancer conditions residing in the Eastern part of Singapore. While its basic principles and processes have been planned and implemented, how ViP works, for whom and in what circumstances are not yet well understood. Therefore, we propose for a realist evaluation (RE) – a theory-based evaluation, to address the current knowledge gaps. Evaluation findings may guide, support further development and broader uptake of ViP.Methods and Analysis: This study will be conducted in three phases: 1. development of initial program theory (IPT), 2. testing of programme theory, and 3. refinement of IPT. First, IPT will be elicited through review of programme documents, scoping review of reviews and in-depth interviews with stakeholders involved in the conceptualization of ViP. Then, a convergent mixed method study will be conducted to assess contexts (C), mechanisms (M) and outcomes (O) to test the IPT through interviews with stakeholders, surveys and analysis of program and administrative databases. Based on findings gathered and through consultation with respective stakeholders, IPT will be refined to highlight what works (outcomes), how (mechanisms) and for whom under what conditions (contexts).

Integrated care programs have been developed to deliver care across providers, settings, and support systems to meet the needs of community-dwelling older adults. This research asks how these programs are being used to combat issues of fragmentation in a home care sector fundamentally reshaped by neoliberalism. Data was collected through 118 key informant interviews in five Canadian integrated care programs and interpreted using a thematic analysis informed by Feminist Political Economy. This dissertation argues that integrated care programs are most useful as a policy solution to fragmented home care when they adopt policy techniques that promote equitable processes and outcomes.

Background: Professional support and communication stimulates the professional-patient relationship and supports the recovery of stroke patients.Objectives: To describe the perspectives of patients with stroke regarding communication, professional support, and their ability to participate in processes and integrated care with health providers.Methods: A qualitative study was conducted. A purposeful sampling and snowball-technique were used. Patients diagnosed with moderate or severe stroke in the post-acute or chronic stage of the disease were included. Data collection consisted of in-depth interviews and researcher field notes. A thematic analysis was performed.Results: Thirty-one patients were included. Three themes were identified: 1) Providing support, with four categories, professional behavior, personalized attention, the heart of the professional and building a bond with the patient; 2) Facilitating communication, with three categories, the patient as the recipient, the content of the message and the channel, and the professional as the person that conveys the message; and 3) Promoting participation, with two categories, barriers, and incentives to participate.Conclusions: When providing support, professionals should consider communicating information and encouraging the participation of stroke patients for integrated care.

Introduction: The study explores regional approaches to integrated care, focusing on regions with regular municipality-based and integrated unified health and social care administration. The aim is to describe a governance approach that supports care integration in the regions.Methods: The study draws on analysis of integrated care governance using an extensive collection of administrative documents (n = 176) on regional health and social services within 20 specialised care authorities. The document data were supplemented with interviews of national health and social system evaluation officers. In our analysis, we used deductive content analysis and identified conceptual approaches of social and health care integration according to elements of integrated care governance.Results: Overall, integrated care governance was relatively well advanced. All regional authorities had established at least some preconditions for integrated governance. The stage of integration varied in the different elements of integrated care governance. The regions with unified integrated administrations enabled the more advanced models of integrated care.Conclusions: Various models for cooperation between regional health and social care authorities have emerged in the regions to identify good integrated care practices. The study suggests that the applied theoretical framework and presented elements of integrated care governance can be used to monitor development of care integration.

Background: Integrated care pathways (ICPs) could improve the organisation and delivery of care for community dwelling older adults. An ICP was developed and implemented in Québec to support home care processes. This study explores the perspectives of home care staff on the use of an ICP to support the organisation and delivery of health and social care to community-dwelling older adults with complex needs. Theory and Methods: A case study based on eleven semi-structured interviews and analysis of documents was carried out in an urban home care unit. The Normalization Process Theory was used for mixed thematic analysis. Results: While its capacity to store data and enhance interprofessional information exchange was appreciated by home care staff, the broad scope, and automated features of the ICP tool were often problematic. Concerns about increased provider workloads, disruption to provider-client relationships during clinical encounters, and difficulties engaging clients in decision-making were main obstacles in the use of the ICP. Conclusion: Given the importance of ICPs in advancing clinical integration, it is critical to continuously adjust their design to align with providers’ realities in order to optimize their potential in real life contexts.

Introduction: The objective of this paper was to describe the vision of death from the perspective of families of children who experienced palliative care, and team members working in one unit, and to explore the roles of healthcare clowns in working with life and death. The major research of which this paper is part was a requirement of one healthcare clown organization, that since 2008 works as members of the palliative care unit in a public hospital in Chile.Description: Using a qualitative methodology, and an emergent and descriptive design, 26 people, including mothers and team members of one palliative care unit, participated in in-depth interviews and discussion groups separately. Data analysis was performed using grounded theory and critical discourse analysis techniques.Results: The roles played by healthcare clowns in palliative care were accompanying, mediating between team members and families, facilitating to process death, provision of humane care using socioemotional competences, promotion of social relationships, and being complementary therapy.Conclusion: The six roles of healthcare clowns identified by this research have implications for public policies and actions in palliative care. There is also a need to expand this type of work to other public health services in Chile.

Introduction: The integrated county healthcare consortium (ICHC) is becoming an important measure to improve the capacity of primary-level medical services and to achieve grading diagnosis and treatment system in China. However, it is not clear whether health professionals are satisfied with this reform and what are the problems with it. This study aimed to understand the satisfaction of healthcare professionals to the ICHC in Zhejiang Province, China, and analyze the problems and improvement measures of the ICHC.Methods: A cross-sectional study was carried out in the 11 pilot counties (cities and districts) implementing the construction of the ICHC in Zhejiang in November 2019. Healthcare professionals from the leading county-level hospital, three township health centers (THCs) or community health centers (CHCs) in each ICHC were invited to participate in this survey.Results: A total of 3531 healthcare professionals were included, 85.92% of the participants agreed that the integration of the Centers for Disease Control and Prevention (CDC) and other professional public health institutions into the construction of ICHC could actively promote basic public health work. The most severe problem was the lack of financial guarantee fund input (severity score: 2.92 ± 1.76). The most crucial measure to promote the construction of the ICHC was to increase government financial input and improve the security mechanism (importance score: 4.81 ± 0.47). The satisfaction of the healthcare professionals to the ICHC was 89.41%. The satisfaction of healthcare professionals from county-level hospitals was 2.37 (95% CI: 1.760–3.238) times higher than that of healthcare professionals from the township health centers (THCs) or community health centers (CHCs). The satisfaction of health professionals with a college degree or below was 3.215 (95%CI: 1.413–6.786) times higher than that of health professionals with a master’s degree or above.Conclusions: Zhejiang Province has taken adequate measures to promote the construction of the ICHC. However, there are still some problems. Appropriate and effective policies should be implemented to enhance policy coordination and promote competition among ICHCs, as well as to strengthen medical service quality management and improve performance appraisal scheme.

Objective: We aimed to describe the acute seizure care pathway for pediatric patients and identify barriers encountered by those involved in seizure care management. We also proposed interventions to bridge these care gaps within this pathway.Methods: We constructed a process map that illustrates the acute seizure care pathway for pediatric patients at Boston Children’s Hospital (BCH). The map was designed from knowledge gathered from unstructured interviews with experts at BCH, direct observation of patient care management at BCH through a quality improvement implemented seizure diary and from findings through three studies conducted at BCH, including a prospective observational study by the pediatric Status Epilepticus Research Group, a multi-site international consortium. We also reviewed the literature highlighting gaps and strategies in seizure care management.Results: Within the process map, we identified twenty-nine care gaps encountered by caregivers, care teams, residential and educational institutions, and proposed interventions to address these challenges. The process map outlines clinical care of a patient through the following settings: 1) pre-hospitalization setting, defined as residential and educational settings before hospital admission, 2) BCH emergency department and inpatient settings, 3) post-hospitalization setting, defined as residential and educational settings following hospital discharge or clinic visit and 4) follow-up BCH outpatient settings, including neurology, epilepsy, and primary care provider clinics. The acute seizure care pathway for a pediatric patient who presents with seizures exhibits at least twenty-nine challenges in acute seizure care management.Significance: Identification of care barriers in the acute seizure care pathway provides a necessary first step for implementing interventions and strategies in acute seizure care management that could potentially impact patient outcomes.

This study analyzes the potential effects of a reform based on community integrated care in Korea, which is experiencing a high rate of population aging, and a specific method for financial integration. We first analyze the size and trend of funds used for the care for the elderly out of Korea's health insurance, long-term care insurance, and national budget. We then analyze the amount of financial resources required and the cost-saving effect when the related financial resources are converted into local community care funds. This approach sheds light on the possibility of harmonizing healthcare policy for the elderly and integrated care under the existing insurance system and suggests a direction for reform in policies pertaining to healthcare for the elderly. Given that the same services are provided, we find that combining the finances from the insurance and the national budget would result in a fund of KRW 2.6 trillion to KRW 4.7 trillion. This approach also confirms that health care costs for the elderly can be reduced by 1-5% in the long term, which we estimate to be between KRW 1 trillion to KRW 4 trillion by 2050. We find that by tapping into the national budget to manage the pre-medical stage care, we can utilize an efficient operation mechanism unlike insurance. We also confirm that information exchange and harmonious operation between the national budget and state-run insurance as well as feedback and incentives through performance management are necessary for these results to become a reality.