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Introduction: Action 3 of the UN Decade of Healthy Ageing plan is to deliver integrated care to improve older adults' lives. Integrated care is vital in meeting the complex needs of people with dementia but little is known about how this is or could be delivered in low and middle income countries (LMIC). This paper provides insights into previously unknown care system structures and on the potential and reality of delivering integrated care in Central America for people with dementia. Methods: A social network analysis (SNA) methodology was adopted to engage with providers of services for older adults and families with dementia in Guatemala, El Salvador, Honduras, Costa Rica and Panama. Sixty-eight (68) semi-structured interviews were completed, 57 with organisations and 11 with families. Results: Across the five countries there was evidence of fragmentation and low integration within the dementia care systems. A variety of services and types of providers are present in all five countries, and high levels of diversified connections exist among organisations of differing disciplines. However, unawareness among network members about other members that they could potentially form active links with is a barrier on the path to integration. Conclusion: This innovative and robust study demonstrates SNA can be applied to evaluate LMIC care systems. Findings provide baselines of system structures and insights into where resources are needed to fortify integration strategies. Results suggest that Central American countries have the building blocks in place to develop integrated care systems to meet the needs of people with dementia, but the links across service providers are opportunistic rather than context based coordinated integration policies. [ABSTRACT FROM AUTHOR]

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

Introduction: Team-based care can improve integrated health services by increasing comprehensiveness and continuity of care in primary healthcare (PHC) settings. Collaborative models involving providers from different professions can help to achieve coordinated, high-quality person-centred care. In Canada, there has been variation in both the timing/pace of adoption and approach to interprofessional PHC (IPHC) policy. Provinces are at different stages in the development, implementation, and evaluation of team-based PHC models. This paper describes how different policies, contexts, and innovations across four Canadian provinces (British Columbia, Alberta, Ontario, Quebec) facilitate or limit integrated health services through IPHC teams. Methods: Systematic searches identified 100 policy documents across the four provinces. Analysis was informed by Walt and Gilson's Policy Triangle (2008) and Suter et al.'s (2009) health system integration principles. Provincial policy case studies were constructed and used to complete a cross-case comparison. Results: Each province implemented variations of an IPHC based model. Five key components were found that influenced IPHC and integrated health services: patientcentred care; team structures; information systems; financial management; and performance measurement. Conclusion: Heterogeneity of the implementation of PHC teams across Canadian provinces provides an opportunity to learn and improve interprofessional care and integrated health services across jurisdictions. [ABSTRACT FROM AUTHOR]

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, underinvestigation 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. [ABSTRACT FROM AUTHOR]

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. [ABSTRACT FROM AUTHOR]

Introduction: The paper examines the role and experience of a local voluntary sector provider (NGO) in meeting the challenge of enhancing levels of integration across their wide range of services. The aim has been to provide patients with continuity of their care so they experience a seamless transition between services as their needs change. At the same time the NGO has become a member of a new consortium of local public sector organisations providing health and social care (including a district acute hospital trust, mental health trust, community trust and councils) which has been formed to redesign care pathways collaboratively on a whole system basis. This paper records the opportunities and challenges of improving integrated working both within the organisation and across organisations. Practice Change: All Hallows Healthcare Trust was established as a charity 150 years ago. The Trust has expanded to meet local needs and is unique in offering a particularly wide range of health and social care to its local community. The Trust provides health and social care through their community hospital, nursing home, respite care, day care, home care, health promotion services, meals on wheels and many other community services. A particular focus of care is rehabilitation and promoting independence, health and wellbeing. The Trust offers specialist palliative care and end of life care by working jointly with the local hospice. In order to improve the service, a new culture within the Trust has been fostered to increase transparency and promote team working. This culture has been embedded by redesigned systems and procedures to improve clinical and care practice and working arrangements. Joint training and development for staff, volunteers and patient relatives has furthered integration with wider community resources, and fostered a culture of co-production with patients and their families. Joint training also means that staff are now able to work across all services, which has also increased flexibility and responsiveness. Patients appreciate the continuity of care and ease of movement between services. The Trust is now applying this learning to the new challenge of integrating with other providers across the locality within the new joint venture company of providers. The Trust has undertaken audits of its services, in order to make an informed contribution to the collaborative re-design of the service and determine its role. Key Findings: The progress towards integrating across sectors, staff and services is demonstrated in the records of the performance of the Trust. There are high levels of satisfaction recorded by staff and patients. The Trust has also been successful in receiving a national award in recognition of its achievements in integrating care. The Trust has met specific national standards such as the Gold Standards Framework for end of life care, which requires a demonstration of integrated working. The progress within the Consortium has been rapid, accelerated by the timescale required by commissioners. Commissioners have used the scope within NHS England's Strategy, "Five Year Forward View" to make this shift from procurement by competition to one of collaboration. This has enabled providers to join up to create one "Most Capable Provider," with explicit shared objectives reflecting national policy. This commission and contracting lever has transformed relationships and attitudes across providers, and engendered a strong spirit of joint working, characterised by "provider-led design" of services. Highlights: The Trust is continuing to improve its knowledge management on local resources and services and develop relationships across organisations and within the community. The Trust recognises that its sustainability requires a demonstration of integrated working across sectors, staff, patients and back office services, as it is a clear requirement by those funding and regulating the services. Commissioners also require reassurance that there is close working with patients, families, community groups, volunteers, and others. There is a long tradition of community support, and this continues to be evident. Conclusion: The Trust is well placed to share learning with its partners in the multi-provider consortium from its own systems approach to integrated working. The Trust is now participating in integration between commissioner and provider functions, between secondary and community care, between the public and the voluntary sector, and between health and social care. This paper identifies progress made in implementing and sustaining multiple types of integration. [ABSTRACT FROM AUTHOR]

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. [ABSTRACT FROM AUTHOR]

Copyright of International Journal of Integrated Care (IJIC) is the property of Ubiquity Press and its content may not be copied or emailed to multiple sites or posted to a listserv without the copyright holder's express written permission. However, users may print, download, or email articles for individual use. This abstract may be abridged. No warranty is given about the accuracy of the copy. Users should refer to the original published version of the material for the full abstract. (Copyright applies to all Abstracts.)

Introduction: During the past two decades, HIV and Sexual and Reproductive Health services in Namibia have been provided in silos, with high fragmentation. As a consequence of this, quality and efficiency of services in Primary Health Care has been compromised. Methods: We conducted an operational research (observational pre-post study) in a public health facility in Namibia. A health facility assessment was conducted before and after the integration of health services. A person-centred integrated model was implemented to integrate all health services provided at the health facility in addition to HIV and Sexual and Reproductive Health services. Comprehensive services are provided by each health worker to the same patients over time (longitudinality), on a daily basis (accessibility) and with a good external referral system (coordination). Prevalence rates of time flows and productivity were done. Results: Integrated services improved accessibility, stigma and quality of antenatal care services by improving the provider-patient communication, reducing the time that patients stay in the clinic in 16% and reducing the waiting times in 14%. In addition, nurse productivity improved 85% and the expected time in the health facility was reduced 24% without compromising the uptake of TB, HIV, outpatient, antenatal care or first visit family planning services. Given the success on many indicators resulting from integration of services, the goal of this paper was to describe "how" health services have been integrated, the "process" followed and presenting some "results" from the integrated clinic. Conclusions: Our study shows that HIV and SRH services can be effectively integrated by following the person-centred integrated model. Based on the Namibian experience on "how" to integrate health services and the "process" to achieve it, other African countries can replicate the model to move away from the silo approach and contribute to the achievement of Universal Health Coverage. [ABSTRACT FROM AUTHOR]

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. [ABSTRACT FROM AUTHOR]

Introduction: Attempts to encourage integrated care in Australia are known be made difficult by complicated funding health funding streams that come through two layers of government (Federal and State) and differing constitutional responsibilities for hospitals and other health care. This paper discusses further potential barriers to integration at a primary care level. Description of context: Primary care is predominantly funded by the Federal Government through payments to general practitioners, but there are significant contributions through State-funded community health centres and through patient out of pocket expenses. This presentation will discuss the funding structure of primary care in Australia, as well as barriers to achieving integrated care. In particular, the Australian health system does not limit patients (by regulation or financial burden) from attending multiple general practices or general practitioners in meeting their primary health care needs. There is good capacity for sharing of electronic health records within practices, but limited capacity to do so between practices. This Australian context has potential implications for the fragmentation of care and decreased delivery of continuity of care and patient centred care. Key findings: This paper uses data from an Australian Study of over 50000 patients to understand how patient preferences for general practice care are changing, and reveals increasing patient preferences for seeking care from a regular practice, rather than a particular provider. There is also a trend for patients to seek care at larger practices. Conclusion: It is hypothesised that patients are seeking to identify with a regular general practice, in order to gain some of benefits of both personal continuity of care and integrated care. By attending a regular general practice and a larger practice, these benefits can be obtained without the decreased access associated with a sole provider, and without potential fragmentation from attending multiple practices which do not share information. There are limitations to the research due to the nature of the study sample, and the use of patient recall in service usage estimations. [ABSTRACT FROM AUTHOR]

Copyright of International Journal of Integrated Care (IJIC) is the property of Ubiquity Press and its content may not be copied or emailed to multiple sites or posted to a listserv without the copyright holder's express written permission. However, users may print, download, or email articles for individual use. This abstract may be abridged. No warranty is given about the accuracy of the copy. Users should refer to the original published version of the material for the full abstract. (Copyright applies to all Abstracts.)

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 policymakers, 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 metaanalyses 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. [ABSTRACT FROM AUTHOR]

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

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. [ABSTRACT FROM AUTHOR]

Background: The Intermediate Care Services in Bolton consist of health, social care, and mental health organisations, 350 staff across 7 services and 5 different bases. In totality these services provide the step-up and step-down facilities for people at risk of hospital or long term care admission, or requiring additional support on discharge from hospital. Bolton as a Locality system identified Intermediate Care as having significant difficulties in managing flow between its services and its transition points, thereby having a negative impact on flow within the hospital system. Whilst a number of the teams were co-located, it was recognised that integration in itself was minimal, and the opportunity to maximise efficiency and effectiveness of integration hadn't been realised. As a locality we applied to one of the discovery sites for AQuA's Whole System Flow programme and undertaken a process of diagnostic, design, and implementation. Aims and Objectives: Demonstrate how application of a Whole System Flow Programme has resulted in a re-designed and improved Intermediate Care system. Demonstrate the system impact at the following levels in terms of effectiveness, efficiency, culture, system shift, mind-set change: Outline the engagement and co-production process with people and their families alongside staff, managers, voluntary sector organisations, and how the inclusion of Lived Experience has shaped the phases of diagnostic, design and implementation. Describe the challenges faced, and how these have been overcome. Outline key measures for improvement and the data to support these. Oral Paper Target audience: This workshop will be of interest to people engaged in pathway redesign and development of care systems across organisational boundaries. It will be delivered to meet the needs of patients, community representatives as well as professionals within care systems and its leaders. Learnings/Take away: How Bolton has taken the theory of Whole System Flow, and change methodologies implementing them in practice Practical examples for improving flow across a system Utilising Lived Experience in a meaningful way Challenges at a system, service, and team level and ways these have been overcome Importance of joining up the System, Service and Team for improving service delivery. [ABSTRACT FROM AUTHOR]

Introduction: Data and digital infrastructure drive collaboration and help develop integrated healthcare systems and services. COVID-19 induced changes to collaboration between healthcare organisations, which previously often happened in fragmented and competitive ways. New collaborative practices relied on data and were crucial in managing coordinated responses to the pandemic. In this study, we explored datadriven collaboration between European hospitals and other healthcare organisations in 2021 by identifying common themes, lessons learned and implications going forward. Methods: Study participants were recruited from an existing Europe-wide community of mid-level hospital managers. For data collection, we ran an online survey, conducted multi-case study interviews and organised webinars. Data were analysed using descriptive statistics, thematic analysis and cross-case synthesis. Results: Mid-level hospital managers from 18 European countries reported an increase in data exchange between healthcare organisations during the COVID-19 pandemic. Data-driven collaborative practices were goal-oriented and focused on the optimisation of hospitals’ governance functions, innovation in organisational models and improvements to data infrastructure. This was often made possible by temporarily overcoming system complexities, which would otherwise hinder collaboration and innovation. Sustainability of these developments remains a challenge. Discussion: Mid-level hospital managers form a huge potential of reacting and collaborating when needed, including rapidly setting up novel partnerships and redefining established processes. Major post-COVID unmet medical needs are linked to hospital care provision, including diagnostic and therapeutic backlogs. Tackling these will require rethinking of the position of hospitals within healthcare systems, including their role in care integration. Conclusion: Learning from COVID-19-induced developments in data-driven collaboration between hospitals and other healthcare organisations is important to address systemic barriers, sustain resilience and further build transformative capacity to help build better integrated healthcare systems. [ABSTRACT FROM AUTHOR]

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 codesign. 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 codesign. 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. [ABSTRACT FROM AUTHOR]

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 stepup/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. [ABSTRACT FROM AUTHOR]

This paper reports on the outcomes of an intensive collaborative community-based perinatal and infant mental health (PIMH) Day Program designed to improve the emotional-social wellbeing of mothers with a moderate to severe mental illness and attachment to their infant. Coordinated by the Queensland Centre for Perinatal and Infant Mental Health, Child and Youth Mental Health, Children's Health Queensland Hospital and Health Service, the program was delivered in 2016 to twenty six mother-infant dyads through an interagency partnership between adult mental health, child and youth mental health and community child health across two Hospital and Health Service sites in Queensland, Australia. The study resulted from recommendations of a pilot project conducted in Brisbane in 2009. An infant's developmental outcomes are predicated by their earliest attachment to their caregivers. It is estimated 40% to 60% of children whose parent has a mental illness are at risk to their mental wellbeing. With more than 16% of Australian women and 10% of fathers developing a perinatal mental illness, there is an identified gap in both the availability and flexibility of services to this vulnerable population. Evidence suggests that service delivery to perinatal mothers with complex mental health issues is typically 'siloed' and that treating maternal mental health alone does not improve outcomes for infants. The unique feature of the PIMH Day Program is the collaboration of three separate health services delivering one program to mothers and infants together. Cairns and Hinterland Hospital and Health Service (HHS) and Townsville HHS are two large regional cities located in north Queensland. Clinicians from adult mental health, child and youth mental health and child health from each HHS delivered three (3) six week (one day per week) perinatal and infant mental health programs between May to November 2016 through a collaborative and integrative methodology. Multidisciplinary clinicians from the three services worked together to deliver the program using a dedicated program manual. The intervention resulted in statistically significant improvements in pre-post quantitative measures relating to mother's emotional-social wellbeing and infant attachment, positive feedback from selfreport surveys on program elements, and engagement in post referral pathways. Clinicians reported high level satisfaction with the collaborative process, resource sharing and transfer of knowledge and skills. They support the intervention as a sustainable, effective and efficient model of service. The findings support the premise that interagency collaboration between health services brings about improved mental health outcomes for mothers with a mental illness and enhanced understanding and sensitivity to their infants. The study resulted in statistically significant results in both sites supporting the results of the 2009 study. This program demonstrates that collaboration, partnerships and integration across service boundaries and professional disciplines offers a promising opportunity to deliver a service that supports parenting and an infant's emotional-social development. The Day Program translates across settings while building workforce capacity in perinatal and infant mental health. [ABSTRACT FROM AUTHOR]

The integration of health and social care has been a constant policy goal of successive UK governments for over 40 years and is a contemporary priority now supported in Great Britain by legislation. It has been noted that the 'imperative to integrate and transform has never been greater' (NHS Confederation/Local Government Association, 2016). The main rationales for the importance of integration have also been largely accepted relating to; a holistic approach; facilitating a more person centred approach; producing a better experience and outcomes for users; reducing the complexity of organisational divisions, responding to more complex conditions and delivering more effective and efficient use of resources. Integration is also accepted as an appropriate response to increasing demands on both health and social care services. The challenges to transforming delivery are a consequence of well-established factors. Demographic change, with larger numbers of older people, changes in life expectancy, the needs of people with multiple health problems and complex conditions and large increases in the numbers of older people without a child to care for them if needed. The importance of integration has also been enhanced by the broader direction of change relating to health provision and the desirability of making a shift from acute hospital provision and institutional care to more community based provision covering community health services and social care. Integration is thus part of the envisaged transformation in care in health related areas. Other challenges have come from the impact of economic recession and austerity policy with reductions in the funding resources and increasing costs of services. The task of producing effective integrated care involves in Great Britain bringing together two separate institutional configurations, the NHS and local authority social services and also developing the delivery of integrated services and integrated practice. Numerous policy and delivery initiatives have been developed but generally progress has been piecemeal and limited. The Commission on the Future of Social Care (2014) noted the compelling case for bringing health and social care together, enabling better alignment of the two systems and leading to transformational change. In 2015 much closer integration of health and social care was identified as one of the three major challenges faced by the NHS (Ham, 2015). The Nuffield Trust (2015) has identified five factors to pursue in improving UK health care, each of which relates to integrated approaches, the NHS and social care reform; the quality of care; the workforce; new models of care delivery and older people and complex care. The existing, research on integrated care concludes that there is no one size fits all for achieving this ambition for integration, although factors such as leadership, financial incentives, clinical pathways and aligned IT systems have emerged as significant factors. This paper draws on the authors' experiences of health and social care in Northern Ireland and the Basque country to suggest the key factors that drive transformation in healthcare systems and ensure that they achieve their full potential. [ABSTRACT FROM AUTHOR]

Introduction: Internationally governments have promoted general practices and community pharmacy working together more closely. Despite examples of co-location, this has not been particularly successful for a number of reasons, including issues of territoriality. There is growing interest in clinical pharmacists working in, and for, general practices. Practice change: This is a change in the model of service delivery with the clinical pharmacist working within the multidisciplinary team of a health care home, and independent of a community pharmacy. This paper explores the changes occurring in the UK and Australia, and presents information of the roles and activities of the fledging clinical advisory pharmacist workforce in New Zealand. It includes the roles of prescribing pharmacists in primary care, using a collaborative prescribing model. A survey of these pharmacists provides information on their roles and contributions to patient care, and creates opportunities for other health care homes to incorporate this resource into their practice. Aim and theory of change: The aim of this change is to allow clinical advisory pharmacists, who by definition have postgraduate qualifications, to work to top-of-scope though working in the health care home, helping to reduce drug-related morbidity and mortality and therefore helping optimise medicines-related health outcomes. The theory of change incorporates the concepts of the power / process and medical dominance models. This requires exposure to the new service, but additionally it has required recognition that the independent clinical advisory pharmacists have a different set of knowledge and skills. Targeted populations and stakeholders: Most of the clinical advisory pharmacists in New Zealand are working in practices with vulnerable populations to improve access to optimal pharmacotherapy. This has been expanding, particularly over the last three years. Highlights: The highlight of this service is the expansion and growing workforce with acceptance of the role of clinical advisory pharmacists within a health care home team and utilising their skills to improve person and whanau care. Evaluations of the different services has shown beneficial outcomes. Sustainability, transferability: With the changing workforce and increasing multidisciplinary teams in health care homes, this model of clinical pharmacist service delivery is very transferable, although requires a transfer of funding and investment for five years to establish it fully and achieve a critical mass. Conclusions: Independent clinical advisory and prescribing pharmacists are a viable way of integrating services into the health care home. We can learn from international evidence, but also the growing evidence in New Zealand. Lessons learnt:The clinical advisory and prescribing pharmacists bring a different skill set and focus into the health care home, but exposure is required to help understand the benefits achieved. [ABSTRACT FROM AUTHOR]

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. [ABSTRACT FROM AUTHOR]

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 crosssectional 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. [ABSTRACT FROM AUTHOR]

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 modif ied 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 represent ed "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. [ABSTRACT FROM AUTHOR]

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 micropolit ical 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 coordination, 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. [ABSTRACT FROM AUTHOR]

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

Introduction: In addition to the functional aspects of healthcare integration, an understanding of its normative aspects is needed. This study explores the importance of values underpinning integrated, people-centred health services, and examines similarities and differences among the values prioritised by actors across Europe. Methods: Explorative cross-sectional design with quantitative analysis. A questionnaire of 18 values was conducted across Europe. A total of 1,013 respondents indicated the importance of each of the values on a nine-point scale and selected three most important values. Respondents were clustered in four actor groups, and countries in four European sub-regions. Results: The importance scores of values ranged from 7.62 to 8.55 on a nine-point scale. Statistically significant differences among actor groups were found for ten values. Statistically significant differences across European sub-regions were found for six values. Our analysis revealed two clusters of values: 'people related' and 'governance and organisation'. Discussion and conclusion: The study found that all 18 values in the set are considered important by the respondents. Additionally, it revealed distinctions in emphasis among the values prioritised by actor groups and across sub-regions. The study uncovered two clusters of values that contribute to a conceptually based definition of integrated, people-centred health services. [ABSTRACT FROM AUTHOR]

Introduction: Programs that fill gaps in fractured health and social services in response to local needs can provide insight on enacting integrated care. Grassroots programs and the changing roles of paramedics within them were analyzed to explore how the health workforce, organizations and governance could support integrated care. Methods: A study was conducted following Arksey and O'Malley's method for scoping reviews, using Valentijn's Rainbow Model of Integrated Care as an organizing framework. Qualitative content analysis was done on clinical, professional, organizational, system, functional and normative aspects of integration. Common patterns, challenges and gaps were documented. Results: After literature search and screening, 137 documents with 108 unique programs were analysed. Paramedics bridge reactive and preventative care for a spectrum of population needs through partnerships with hospitals, social services, primary care and public health. Programs encountered challenges with role delineation, segregated organizations, regulation and tensions in professional norms. Discussion: Five concepts were identified for fostering integrated care in local systems: single point-of-entry care pathways; flexible and mobile workforce; geographicallybased cross-cutting organizations; permissive regulation; and assessing system-level value. Conclusion: Integrated care may be supported by a generalist health workforce, through cross-cutting organizations that work across silos, and legislation that balances standardization with flexibility. [ABSTRACT FROM AUTHOR]

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. [ABSTRACT FROM AUTHOR]

Introduction: Three peak organisations in Queensland, Australia partnered with consumers and other health and social sector partners to co-design and pilot the first known integrated, health navigation model to improve outcomes for children and young people in care in Australia. Description: An Organisational Learning theoretical lens has been used to present a narrative case study of findings structured as key learnings from the Navigate Your Health pilot to inform quality improvement, scalability and program sustainability. A developmental evaluation was completed whereby semi-structured interviews, focus groups, surveys, chart reviews, database excerpts and economic modelling was completed alongside project documentation analyses to create an evaluation framework. Discussion: Findings highlighted the agency partners' drive to foster a more integrated and person-centred approach to care. The pilot's aim of improving health outcomes for a vulnerable population were achieved through a co-designed process which provided additional insights regarding partnerships, improvement, scalability and sustainability. Conclusion: Inter-agency responses to system fragmentation provide significant organisational learning opportunities. System integration is achievable through strengthened partnerships that can be sustained beyond a pilot phase to improve health outcomes for vulnerable/priority populations. [ABSTRACT FROM AUTHOR]

Introduction: Care transitions between specialist and primary healthcare services for people with concurrent substance abuse and mental health problems are characterised by vulnerability and arbitrariness. Objectives: By studying factors that influence integration in a Norwegian context, this study aims to investigate, from a municipal perspective, why care transitions are still tricky after the introduction of the key Coordination Reform. Methods: This study has an explorative approach based on interviews with managers and front-line professionals in primary care. We applied the conceptual framework of functional and normative integration of the Rainbow Model. Results: The municipal actors emphasise that integration is hampered by limited cooperation with general practitioners in referrals to hospital, challenges of communication and loss of meeting points. They experienced close cooperation with sociomedical polyclinics for substance abuse, while challenges in cooperation with district psychiatric centres indicated an interdependence of functional and normative integration. Questioning hospital discharge of patients to primary care was a recurring theme for the municipal actors. Thus, the governing framework of the Coordination Reform has coexisted with fragmentation in organisational structures and divided professional cultures. Conclusions: The coexistence of the new and the old regimes seems to hamper functional and normative integration in care transitions. [ABSTRACT FROM AUTHOR]

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. [ABSTRACT FROM AUTHOR]

Introduction: Despite evidence that people with serious mental illness benefit from receiving primary care within mental health care settings, there is little research on this type of integration. The objective of this study was to characterize how providers and patients experienced implementation of primary care into specialty mental health services. Methods: During site visits, study team members interviewed staff and conducted focus groups with patients at 10 United States community mental health centres then beginning to integrate primary into their practices. One year later, follow up phone interviews with key centre staff informants validated and updated findings. Data analysis included thematic coding of results from staff interviews and patient focus groups. Results: Findings included the importance of the scope of primary care services provided on site, given limited alternatives available to patients; rapid scale-up; overcoming challenges in provider recruitment and retention; and adaptations to engage patients as well as to improve communication between mental health and primary care providers. Conclusion: Providers and patients perceived improvements through integrated care. However, the majority of patients were uninsured, and the funding was short term. The long-term viability of integrated care for community mental health centre patients may hinge on adequate, predictable public funding. [ABSTRACT FROM AUTHOR]

Introduction: Nursing home residents are a vulnerable and frail segment of the population, characterised by their complex and palliative care needs. To ensure an integrated approach to palliative care for this target group, working on a collaborative basis with multiple providers across organisational boundaries is necessary. Considering that coordinators of palliative networks support and coordinate collaboration, the research question is: 'how do network coordinators perceive the process of collaboration between organisations in Flemish palliative networks?'. Methods: A dual-phase sequential mixed-methods design was applied. First, the coordinators of each of the fifteen palliative networks in Flanders completed a survey in which they evaluated ten aspects of collaboration for two types of cooperation: between nursing homes and home care, and between nursing homes and hospitals. Next, the survey results thus obtained were discussed to improve understanding in a focus group composed of the above coordinators, and which was analysed on the basis of content analysis. Results: In both forms of cooperation, the 'formalisation' and 'governance' were the aspects that yielded the lowest mean scores. The coordinators in the focus group expressed a need for more formalised interaction among organisations with regard to palliative care, the establishment of formal channels of communication and the exchange of information, as well as the development of shared leadership. Conclusions: The perspectives of the coordinators on inter-organisational collaboration are a valuable starting point for interventions directed at the stronger integration of palliative care for residents of long term-care facilities. [ABSTRACT FROM AUTHOR]

Background: Systematic screening helps increase family planning uptake through integration with other services, including immunization. Though successfully demonstrated at health facilities, this strategy has not been demonstrated in communities. This study assessed the effectiveness of systematic screening to increase postpartum family planning use during community health days in India without adversely affecting immunization services. Methods: The study was conducted during 180 individual Village Health and Nutrition Days in Jharkhand, India. All health workers were trained in postpartum family planning counseling. Intervention providers were also trained in systematic screening. 217 postpartum women aged 15-49 years participated in baseline and endline exit interviews and routine service statistics were analyzed from 2,485 facility visits at affiliated health centers. Results: No difference in family planning service use was found in the intervention group, but significantly fewer interviewed women reported receiving family planning services at endline in the comparison group (p = 0.014). Family planning acceptance at affiliated health centers increased significantly in intervention areas (p < 0.001) but not in comparison areas, while immunization service use increased in both groups (p = 0.002 intervention, p < 0.001 comparison). Conclusions: The use of the postpartum systematic screening tool appears to increase acceptance of family planning services when integrated with community-based services in Jharkhand. [ABSTRACT FROM AUTHOR]

Background: Despite far reaching support for integrated care, conceptualizing and measuring integrated care remains challenging. This knowledge synthesis aimed to identify indicator domains and tools to measure progress towards integrated care. Methods: We used an established framework and a Delphi survey with integration experts to identify relevant measurement domains. For each domain, we searched and reviewed the literature for relevant tools. Findings: From 7,133 abstracts, we retrieved 114 unique tools. We found many quality tools to measure care coordination, patient engagement and team effectiveness/performance. In contrast, there were few tools in the domains of performance measurement and information systems, alignment of organizational goals and resource allocation. The search yielded 12 tools that measure overall integration or three or more indicator domains. Discussion: Our findings highlight a continued gap in tools to measure foundational components that support integrated care. In the absence of such targeted tools, "overall integration" tools may be useful for a broad assessment of the overall state of a system. Conclusions: Continued progress towards integrated care depends on our ability to evaluate the success of strategies across different levels and context. This study has identified 114 tools that measure integrated care across 16 domains, supporting efforts towards a unified measurement framework. [ABSTRACT FROM AUTHOR]

This study aimed to assess interprofessional collaboration between general physicians and emergency departments in the French speaking regions of Belgium. Eight group interviews were conducted both in rural and urban areas, including in Brussels. Findings showed that the relational components of collaboration, which are highly valued by individuals involved, comprise mutual acquaintanceship and trust, shared power and objectives. The organizational components of collaboration included out-of-hours services, role clarification, leadership and overall environment. Communication and patient's role were also found to be key elements in enhancing or hindering collaboration across these two levels of care. Relationships between general physicians and emergency departments' teams were tightly linked to organizational factors and the general macro-environment. Health system regulation did not appear to play a significant role in promoting collaboration between actors. A better role clarification is needed in order to foster multidisciplinary team coordination for a more efficient patient management. Finally, economic power and private practice impeded interprofessional collaboration between the care teams. In conclusion, many challenges need to be addressed for achievement of a better collaboration and more efficient integration. Not only should integration policies aim at reinforcing the role of general physicians as gatekeepers, also they should target patients' awareness and empowerment. [ABSTRACT FROM AUTHOR]

Background: There is no single definition of a community hospital in the UK, despite its long history. We sought to understand the nature and scope of service provision in community hospitals, within the UK and other high-income countries. Methods: We undertook a scoping review of literature on community hospitals published from 2005 to 2014. Data were extracted on features of the hospital model and the services provided, with results presented as a narrative synthesis. Results: 75 studies were included from ten countries. Community hospitals provide a wide range of services, with wide diversity of provision appearing to reflect local needs. Community hospitals are staffed by a mixture of general practitioners (GPs), nurses, allied health professionals and healthcare assistants. We found many examples of collaborative working arrangements between community hospitals and other health care organisations, including colocation of services, shared workforce with primary care and close collaboration with acute specialists. Conclusions: Community hospitals are able to provide a diverse range of services, responding to geographical and health system contexts. Their collaborative nature may be particularly important in the design of future models of care delivery, where emphasis is placed on integration of care with a key focus on patient-centred care. [ABSTRACT FROM AUTHOR]