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Introduction: After the era of paper health record, in 2002 standard questionnaires for chronic patients were collected and registered by a hospital nurse. Since then, our electronic health record has been evolving. Nowadays the same electronic health record (eHR) is shared by the whole public health system that attends 2 million people, nursing homes included. The next step forward comes with the creation of standard questionnaires within an "Integral Program Manager", this meaning that relevant information of the patient will be registered and analyzed giving identical recommendations in any setting (primary care, specialist or hospital) in a given clinical change. This will lead to "message reconciliation" in the system avoiding contradictions and helping educate and empower the patients for self-control. The creation of the personal health record and the new technologies (smartphones) will enable patients to fill the questionnaires by themselves. Description of practice change implemented: Change of paper based fragmented health record to an electronic and integrative one. Aim: Same electronic health record, questionnaires and recommendations in different settings Target population: All patients, but specially: - Pluripathological patients - Home-dependent patients - Nursing home residents - End of life patients Timeline: *Until 1996: health record on paper. *1996-2000: some reports are digitalized and the copy is carried by the patient. *2000-2009: basic electronic health record, different for primary care *Since 2002: assessment questionnaires for heart failure and COPD by phone by a case management nurse *2009-2012: health care based on an electronic health record, but different for hospital and primary care. Beginning of a electronic prescription tool (same for all) *Since 2012: creation of personal health records for patients *2012-2018: integrative electronic health record accessible for all healthcare workers, old paper reports are digitalized, warnings (allergies e.g.), same prescription tool ("Presbide"). *Since 2018: beginning of electronic application forms including those for pluripathological patients. Beginning of the "Integral Program Manager" to suggest recommendations according to clinical changes registered in the application forms. Highlights: -Creation of the electronic health record. -Computer integration: only one electronic health record -Healthcare integration: same questionnaires for all pluripathological patients (generic and specific disease related application forms). Information collected in any setting (call center, primary care physician or hospital) and creation of recommendations accordingly (by the "Integral Program Manager") leading to remote treatment adjustment, face-to-face assessment in primary care or direct hospital admission. Sustainability: The unification of theelectronic health record reduces maintenance costs and those related to the lack of coordination. Transferability: Transferable for all health services with compatible information systems. Conclusions: Integrative electronic health record and healthcare process with the same questionnaires and recommendations are desirable for a coordinated health care, especially for multipathological patients. Discussion: The new technologies should allow patients to choose the easiest way to fill in control questionnaires by themselves. Lessons learned: This process is not easy because apart from the technical difficulties requires important habit changes, but is the only way to achieve our goals. [ABSTRACT FROM AUTHOR]

Introduction: The implementation of people-centred care requires strategies that respond to local conditions and contexts, with the participation of local stakeholders in collaborative approaches such as co-design. Within this framework, the authors performed a literature review to identify the most implemented practices in health and social care services for co-designing digital solutions. Methods: The literature review was conducted following five steps: (i) Definition of the Keywords and their relations; (ii) Definition of the selection criteria; (iii) Search in PubMed; (iv) Selection of papers; and (v) Analysis of the selected papers. Results: 20 papers addressed to co-design health digital solutions with stakeholders were analysed in terms of the activities implemented and participants involved. Discussion: Previous studies using co-design methods for the deployment of health digital solutions employed a wide range of activities, most of them combining activities and/or mixed target groups. Conclusion: Co-design is the key to deliver people-centred care as it allows to involve stakeholders in the development of health digital solutions. Implementing one or more of the co-design methods identified in this literature review should be considered to better address the needs and specific projects and target groups. [ABSTRACT FROM AUTHOR]

The ambitious and wide-ranging paper on Academic Health Science Systems ['AHSS'] [1] proposed a new model for health innovation and stimulated considerable interest. The paper made three main assumptions about AHSS: i) university-based centres should play linchpin roles in health and social care innovation; ii) medical innovation cannot be achieved without links to industry; iii) innovation occurs at the scientific end of a discovery-care continuum. But the paper had a pregnant coda for the NHS, and GM devolution in particular: the authors explicitly linked their view of the need for the integration of university-based research and health care delivery to population level approaches, suggesting that vertically integrated AHSSs should ultimately transform into integrated care organisations. When Manchester's experiment in the devolution of health and social care as a place-based approach to health and social care began in 2015, Health Innovation Manchester was created as an AHSS to support innovation in the Partnership. Five years after the start of devolution, this short paper, which is based on a longer study of Health Innovation Manchester's development [2], provides an overdue reflection on the proposition advanced just over a decade ago [1]. [ABSTRACT FROM AUTHOR]

Introduction: The healthcare delivery system of Assam faces several challenges to provide affordable, accessible and quality care services. GNRC (Guwahati Neurological Research Center) is the first super-speciality hospital to address many of these gaps by delivering integrated affordable healthcare services to the populations of Assam and other parts of North-eastern India. Description & Discussion: This paper describes the implementation of a care delivery model which provides integrated care delivery services through linking hospitals to primary healthcare services, including preventive, promotive, and curative care, along with delivering easily accessible and affordable care to the people of Assam and other parts of North-eastern India. Conclusion: The proposed model is the first innovative approach from Northeastern India, Assam, to deliver affordable, accessible and patient-centric hospital led community-based preventive, promotive, and primary, secondary, and tertiary hospital-based care. It is anticipated that GNRC's "Affordable Health Mission" will help redesign and integrate the way primary, secondary and tertiary healthcare is delivered to the population of Assam in helping patients manage their own health and reduce the numbers that needs to be admitted to secondary care and tertiary care by improving patients' independence and well-being as well as dramatically reducing the cost to the overall health system. [ABSTRACT FROM AUTHOR]

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

Introduction: Despite health and care services being performed by similarly skilled professionals, using largely the same technology and with similar levels of governance, there are few specialisms where there is an exclusive 'dominant' model of high performance or high reliability unlike other sector models (e.g. automotive lean production or six sigma for the electronics sector). Competition and confusion exists in the health and care setting which obscures the benefits of one approach over another. Aim and Objectives: Adopting an improvement methodology can generate an absolute denial that any other approach is legitimate or worthy of use. This methodological fanaticism is concerning and often based on highlighting differences with other models and approaches to the detriment of staff learning. This paper presents a review of the competing approaches and methodologies employed by health and care organisations as the medium through which improvement interventions are undertaken and how there are significant gaps within and between the logic, application and potential for change offered by each approach. The study draws from 9 case studies of teams and organisations employing the lean, the theory of constraints, Value-Based Health Care, service improvement and Bevan Prudent Principles approaches to change. The case study service reviews were conducted over a 4-year period using interviews and secondary data collection. Results: The cases show how, over time, some approaches have endured only a short lifecycle of improvement and reached a 'ceiling' or stall point before either being stopped or moving towards another of the approaches. The study supports the view that there is a mastery process which underpins the journey of improvement teams and also that selecting an ineffective improvement approach can have detrimental impact on learning as well as staff willingness to engage in change in the future. The results clearly indicate without an essential model then implementation of change achieves some benefits but these are largely from 're-engineering' processes rather than from a process of continual learning. In addition, some methods are clearly confused in terms of their promotion of value generation yet their focus on cost savings. Conclusions: Improvement approaches are not the same. They have different logics, focus and lifecycles. Incorrectly selecting a method can therefore fail to deliver the benefits sought. Further, if every improvement methodology promotes the important feature of staff learning then it is illogical that organisations and teams "lock themselves" into a single model which lacks an essential logic to learning rather than emulation. Emulation involves copying others who are perceived as successful and involves "borrowing methods" from other sectors to ground the health and care approach. This paper shows how decisions are not binary and why emulated methods tend to fail because a contingent and integrated care systems approach is ignored in favour of 'point improvements" within a system. Implications for applicability/transferability: The Toyota Motor Corporation does not just make cars and its divisions operate a bespoke 'Toyota Production System'. At the heart of the system are significant skills investments "To make good products - we must first make good people". These "dialects" of improvement are seldom understood by healthcare professionals who instead emulate without contextualising the sustainability of improvement processes and how they need to be 'contextualised to the health and care setting. Only staff can innovate and locking into a single improvement solution is found to be unwise and constraining. [ABSTRACT FROM AUTHOR]

Introduction: NHS staff are no strangers to innovating practices or embracing new ways of working including technological, process innovations and improved competences to accommodate a variety of service demands. These pressures are increasing and combine with pressures to evidence positive changes in performance. The latter is a skill that few NHS staff possess, and few models exist to help guide professionals to conduct such assessments as to how contributed patients, staff, employer organisations, patient journeys across shifts and organisational hand overs have generated benefits. Aims and Objectives: This paper presents a model that has been developed to allow health and care staff to conduct and validate claims of improvement success. The paper is based on over 80 case studies of improvement that were conducted in Wales (over a 3-year period). It draws from the experiences of teams that have undertaken improvements across a wide spectrum of patient facing and support processes. The research draws from an extensive literature review, and the methodology was enacted using a training session (half day to full day of exercises and application) to introduce the methods to the improvement attendees and to allow them to calculate their savings in the form of released value and cost savings. The projects also included patients as informants to help coproduce the savings claimed. Results: The results of the practical methodology include a method of visualising the patient or service user pathway, distinguishing errors, issues and experiences of all staff, a structured project management approach and a systematic logic which relates 'time released' as the core currency of savings to a human resource constrained series of cases. Time is used to assess the combined activity cost savings for each staff member which is then converted into an annualised savings based on real demand for a service and allowing service users/staff to redirect their 'released time' towards more project and more personally rewarding higher value-added activities. The results show that no single project team (from those that voluntarily undertook the training) failed to create an output calculation of savings and typically the projects resulted in a significant payback that was many times the total annual salaries of the staff involved and have significantly improved process/patient experience performance levels as measured in terms of the 'sand cone' model (Rich et al., 2004). Conclusions: The methodology and its application have proven robust across a wide range of health and care settings. The results of the projects undertaken have been tested and validated with finance directors and their staff in terms of the usability and validity of the approach for the justification of savings. The method is therefore transferable and a means of engaging all stakeholders in improving a process. Significant savings have been achieved and validated at the team, patient pathway and national pathway approaches in Wales. Implications: The applicability and transferability of this form of assessment fills a gap in the skill sets of improvements undertaken by staff and adds another capability to innovation management processes. The 'easy to follow' method captures and allows a holistic assessment of a projects results on process performance based on a realistic 'costed time saving' which quantifies efficiency gains and staff/patient gains in a less daunting approach than other forms of costing. The approach provides a meaningful addition to the Plan-Do-Check-Act (PDCA) improvement cycle by allowing the 'check stage' to be quantified and in answering the basic questions of senior executives and directorate leaders as to what 'return' can and did we make from allocating scarce staff time to improvement activities. [ABSTRACT FROM AUTHOR]

Background: Integrated Primary Care Teams (IPCTs) have four key characteristics (intensive interdisciplinary practice; advanced nursing practice with an expanded role; group practice; increased proximity and availability) aimed at strengthening primary care in Quebec, Canada. The purpose of this paper is to examine the care experience over time of patients who have an IPCT as their primary source of care. Methods: We used a quasi-experimental longitudinal design based on a pre-andpost administered survey at a 2-year interval without a control group. We measured patient-reported accessibility, continuity, comprehensiveness, responsiveness and outcomes of care. Results: Results showed that patients who were newly registered with an IPCT had a significant increase in reported care experience, whereas patients who have been registered with an IPCT for 2 years prior to the first round of data collection had already high reported care experience that was maintained over time. Moreover, linear regression models showed statistically significant different increases in the dimensions of care experience by site and patients' characteristics. Conclusions: Our results suggest that the IPCT model is tailored to the needs of its target populations, resulting in improved Patient Reported Experience Measures. These results imply that broader implementation of innovative and flexible communitybased care models should be considered by policymakers. [ABSTRACT FROM AUTHOR]

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Background: Integrated healthcare delivery is a policy goal of healthcare systems. There is no consensus on how to measure the concept, which makes it difficult to monitor progress. Purpose: To identify the different types of methods used to measure integrated healthcare delivery with emphasis on structural, cultural and process aspects. Methods: Medline/Pubmed, EMBASE, Web of Science, Cochrane Library, WHOLIS, and conventional internet search engines were systematically searched for methods to measure integrated healthcare delivery (published -- April 2008). Results: Twenty-four published scientific papers and documents met the inclusion criteria. In the 24 references we identified 24 different measurement methods; however, 5 methods shared theoretical framework. The methods can be categorized according to type of data source: a) questionnaire survey data, b) automated register data, or c) mixed data sources. The variety of concepts measured reflects the significant conceptual diversity within the field, and most methods lack information regarding validity and reliability. Conclusion: Several methods have been developed to measure integrated healthcare delivery; 24 methods are available and some are highly developed. The objective governs the method best used. Criteria for sound measures are suggested and further developments should be based on an explicit conceptual framework and focus on simplifying and validating existing methods. [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: This paper analyses the important enablers, barriers and impacts of country-wide implementation of integrated health and social care in Scotland. It offers insights for other systems seeking to advance similar policy and practice. Description: Landmark legislation was based on a shared vision and narrative about improving outcomes for people and communities. Implementation has involved coordination of multiple policies and interventions for different life stages, care groups, care settings and local context within a dynamic and complex system. Discussion: Relational and citizen led approaches are critical for success, but it takes time to build trusting relationships, influence organisational and professional cultures and cede power. Assessing national impacts is challenging and progress at a national level can seem slower than local experience suggests, due in part to the relative immaturity of national datasets for community interventions. Five years on there are many examples of innovation and positive outcomes despite increasing demographic, workforce, and financial challenges. However, inequalities continue to increase. Conclusion: Realising the true value from integration will require a stronger focus on place-based prevention and early intervention to achieve a fairer Scotland where everybody thrives. Solidarity, equity, and human rights must guide the next phase of Scotland's story. [ABSTRACT FROM AUTHOR]

Despite an increasing share of societal income being used to deliver health and social care services, families accross the globe continue to provide upwards of 80% of the overall care delivered (Huber & Hennessy, 2005; Dieleman et al, 2016). Such carers often experience inadequate recognition of their unique and crucial role in keeping their care recipients well and at home, and in the wider scheme of sustaining national and international healthcare infrastructure. While family carers availability and willingness to provide care is crucial; stress, isolation and ill health are frequently experienced;all of which may impact on their quality of life and ability to care, and further may impact on the availability of this under resourced pool of caregivers into the future. Identifying the needs of family carers is increasingly being viewed as a key intervention in the development of fully integrated health and social care (Guberman et al, 2007). The positive impact of such assessments to carers is wide and varied, particularly in reducing their burden of stress and depressive symptoms (Guberman et al, 2003; Becker et al, 2005; Kwak et al, 2011). Internationally, Carer Needs Assessments (CNA's) have been enshrined in law in the UK for over 20 years and are significantly embedded in assessment processes; while in the US in particular- there has been some legislative initiatives to bring Family Carers closer to the centre of care. This paper discuses the Carer Needs Assessment Development Project and presents preliminary findings on Irish data from the Carer Needs Assesment international pilot study. In giving expression to the Irish National Carers Strategy which seeks to work with Family Carers as partners in care (Department of Health (IRL), 2012), the HSE Single Asessment Tool (SAT) Project established a collaborative Working Group to develop a Carer Needs Assessment for national and international use. This group comprised of HSE SAT national team members, not-for profit national Carer/Advocacy Organisations (NGOs),and the international not-for-profit organisation 'interRAI?' who specialise in evidence-based assessment systems development. The Working Group are developing a CNA, initially paper based, which is currently being piloted with adult family carers in a longitudinal study across 11 countries, including Ireland, in order to finalise the tool. Once the pilot is complete, the CNA will be available as part of the interRAI integrated suite of assessment tools which are in use Ireland and internationally in an electronic format across health care settings. The target population for the pilot study are adult family carers who are providing an ongoing and significant level of care to an older person person who is in need due to illness, disability, or frailty. A family carer can be a relative, friend or neighbour. Approximately 600 Family Carers will be recruited internationally. The final potential target population in Ireland is all Family Carers who provide significant levels of care. This initiative is innovate as it represents a first between a state health agency, a number of not-for profit agencies and a leading academic health care assessment systems design collaboration (interRAI), in developing, testing and (potentially) implementing a comprehensive standardised assessment tool. Current models of CNA have not been exposed to sufficiently comprehensive evaluation. This paper charts the progression and challenges of this initiative, using an Implementation Science Framework. There will be a discussion on the learnings from the process together with a wider assessment of the future potential for Carer Needs Assessments in general. [ABSTRACT FROM AUTHOR]

Introduction: To meet the needs of vulnerable people, the integration of services across different sectors is important. This paper presents a preliminary review of service integration across sectors in Europe. Examples of service integration between social services, health, employment and/or education were studied. A further aim of the study was to improve conceptual clarity regarding service integration across sectors, using Minkman's Developmental Model for Integrated Care (DMIC) as an analytical framework. Methods: The study methods comprised a literature review (34 articles) and a survey of practice examples across Europe (44 practices). This paper is based on a more comprehensive study published in 2016. Results: The study demonstrates that although the focus of integration across sectors is often on social services and health care, other arrangements are also frequently in place. The review shows that integration may be either tailored to a particular target group or designed for communities in general. Although systems to monitor and evaluate social service integration are often present, they are not yet fully developed. The study also highlights the importance of good leadership and organizational support in integrated service delivery. Discussion: The study shows that the DMIC can work as a conceptual framework for the analysis of service integration across sectors. However, as this is an exploratory study, further in-depth case studies are required to deepen our understanding of the processes involved in service integration across sectors. [ABSTRACT FROM AUTHOR]

This Perspective Paper explores the challenges of implementing local initiatives guided by the tenets of the Collective Impact (CI) approach. As such, it draws implications of CI for integrated health and social care efforts to improve and sustain health and social outcomes within a community-wide context, based on our efforts to deploy a CI intervention in the regional town of Muswellbrook, New South Wales (NSW) Australia. A program of health and wellbeing activities providing mental health and wellness messages and activities was implemented in the township over 2 years by the Family Action Centre (FAC), University of Newcastle, Australia. A key takeaway was the importance of authentic community engagement and active involvement as opposed to mere consultation. [ABSTRACT FROM AUTHOR]

Introduction: Co-production is more and more considered as a promising tool for dealing with the main challenges in the health sector (e.g., growing rates of chronic diseases, budget constraints, higher patients' expectations of the quality and the value of services, equity to access of care, etc.). However, there is still little evidence on coproduction determinants and impacts. Description: This research protocol aims to present a framework to assess the determinants and impacts of the co-productive approach in healthcare delivery on patients, professionals, and providers from economic, organisational, and clinical perspectives. To this end, the paper examines the co-produced outpatient parenteral antimicrobial therapy (OPAT), applied to cystic fibrosis patients in an Italian hospital. A mixed methods approach will be adopted and data will be collected through semistructured interviews and surveys of patients, caregivers, and professionals; biological samples of patients; archival sources. Then, the analyses to be performed are the following: (i) cost evaluation, (ii) content, (iii) descriptive and inferential statistical, (iv) microbiome analysis, and (v) desk analysis. Conclusion: The research protocol contributes to both theoretical and practical knowledge. It represents the first attempt to develop a systematic analytical framework for the evaluation of co-production in healthcare. Moreover, the findings gathered within the study will provide evidence to support policy makers and managers in decision-making and managerial processes within the health service. [ABSTRACT FROM AUTHOR]

Paper summary: Overcoming fragmentation in the delivery network is a critical factor in achieving better health system performance. As health systems around the world expand to meet the population's growing demand and rising expectations, the failure to address the fragmentation in care between primary care, specialists and hospital care will lead to increasing cost escalation and declining quality of care. The literature review of nearly ten years of coordinated care programs across the OECD shows that successful disease management or coordinated care efforts share a number of common design components. The paper highlights successful experiences and synthesizes the lessons learned for emerging market countries that aim to achieve greater integration. Introduction: Fragmentation is at the heart of the ineffectiveness of our increasingly chaotic efforts to achieve improvements in health systems. As health systems around the world expand to meet the population's growing demand and rising expectations, the failure to address the fragmentation in care between primary care, specialists and hospital care will lead to increasing cost escalation and declining quality of care. Methods: The paper reviews the experience across the OECD with the introduction of integrated delivery systems, or coordinated care, to address the issue of system fragmentation. The paper follows the definition of integrated delivery systems established by Shortell (1984), that defines them as "a network of organizations that provides, or organizes in order to provide, a continuum of coordinated services for a defined population, and that is accountable for its clinical and financial results and for the health status of the population served. These systems, widely participated and vertically integrated, offer an extensive range of ambulatory services, hospital, of acute and chronic, and home care". Discussion: The study shows that there are a number of common features that should be developed under any initiative for coordinated care. These range from the definition of the scope of the program to the content of the coordinated care efforts and the role of the providers in the system. The OECD experience points to a number of core components: Reference Population. Defined population and defined territory. Priority Health Needs. Based on the health needs of the population within a defined territory; Focused on the risks or pathologies of the population Scope of network of services. PHC based coordination strategy. Regulated access to specialists. Integrated and coordinated model of care. PHC based coordination strategy . Mechanisms for integration and coordination among the levels, including clinical and non-clinical coordination -- case management. Organized support systems. Electronic medical record or consultation form. The strategy of contracting (and financing) aligns incentives and strengthens the integration of the network. A system of financial management devised for the network Distribution of Roles. Mission and clear vision for the network - or specific group of patients. Have a single governance structure. Involvement of healthcare teams in the planning and management of network Measurement of impact of services. Establish system of learning and dissemination of good practices with other networks. Information systems functioning in support of the network with EMR and data exchange for all support systems (lab, diagnostics, etc). Use of performance monitoring and audit systems. Results: The experiences across the OECD show that significant improvements are possible in the decline in readmission rates, improvements in survival rates and small changes in outcomes, such as glucose levels for diabetics. These often come at slightly higher costs. Successful programs in the OECD show a number of common lessons learned. Lesson 1. Integrate for the right reasons. Successful integrated systems have grown organically; situations where top-down attempts to integrate care, for example through vertical integration or mergers of service providers, have often had less happy outcomes. The objectives of integration need to be made explicit. If they include reduction in use of hospital beds, then the implications within the current payment by results system need to be addressed. Lesson 2. Don't necessarily start by integrating organizations Integration that focuses mainly on bringing organizations together is unlikely to create improvements in care for patients. There is also the danger that integration might act only to distract local personnel. An alternative approach is to begin integration at the front line, which has a direct impact on the patient experience; the most apt organizational supports for service provision might be identified. Excessive focus on patient pathways might lead to loss of the benefits of overall service co-ordination, for example in managing comorbidities. Lesson 3. Ensure that local contexts are supportive of integration. This review identifies several key contextual elements that are important to successful integration. They include a culture of quality improvement, a history of trust between partner organizations, existing multidisciplinary teams, integration of personnel who are open to collaboration and innovation, and effective and complementary communications and IT systems. Lesson 4. Be aware of local cultural differences. Several cases reported in this review demonstrate the very significant challenge of bringing together organizational cultures that have, in many cases, evolved separately over decades. Clearly, this is an obstacle that must be considered when planning future integration. Lesson 5. Ensure that community services don't miss out. One of the most valuable potential outcomes of vertical integration is better integration of community services. King et al (2001) notes the existence of longstanding power imbalances between acute and community services which make such integration a challenge. Lesson 6. Provide the right incentives. It is important that frontline staff recognize and buy into the integration process. Shortell (2000) suggests that this requires not just persuasion from a clinical standpoint, but also financial incentives. Lesson 7. Don't assume economies of scope and scale. Significant improvements in quality of care could follow better co-ordination of previously fragmented service providers. Potential economies of scope and scale are likely to take time to achieve, however, and much evidence from the US (Burns & Pauly, 2002; Robinson, 2004) suggests that integration has seldom increased efficiency. This is due to factors such as the significantly different practices in the organizations that are to be integrated, and the steep learning curve inherent in joining with another organization. Lesson 8. Be patient. The time required to implement effective integration is a recurrent theme, and is unsurprising given the complexity. [ABSTRACT FROM AUTHOR]

Background: Providing efficient and effective aged care services is one of the greatest public policy concerns currently facing governments. Increasing the integration of care services has the potential to provide many benefits including increased access, promoting greater efficiency, and improving care outcomes. There is little research, however, investigating how integrated aged care can be successfully achieved. The PRISMA (Program of Research to Integrate Services for the Maintenance of Autonomy) project, from Quebec, Canada, is one of the most systematic and sustained bodies of research investigating the translation and outcomes of an integrated care policy into practice. The PRISMA research program has run since 1988, yet there has been no independent systematic review of this work to draw out the lessons learnt. Methods: Narrative review of all literature emanating from the PRISMA project between 1988 and 2012. Researchers accessed an online list of all published papers from the program website. The reference lists of papers were hand searched to identify additional literature. Finally, Medline, Pubmed, EMBASE and Google Scholar indexing databases were searched using key terms and author names. Results were extracted into specially designed spread sheets for analysis. Results: Forty-five journal articles and two books authored or co-authored by the PRISMA team were identified. Research was primarily concerned with: the design, development and validation of screening and assessment tools; and results generated from their application. Both quasi-experimental and cross sectional analytic designs were used extensively. Contextually appropriate expert opinion was obtained using variations on the Delphi Method. Literature analysis revealed the structures, processes and outcomes which underpinned the implementation. PRISMA provides evidence that integrating care for older persons is beneficial to individuals through reducing incidence of functional decline and handicap levels, and improving feelings of empowerment and satisfaction with care provided. The research also demonstrated benefits to the health system, including a more appropriate use of emergency rooms, and decreased consultations with medical specialists. Discussion: Reviewing the body of research reveals the importance of both designing programs with an eye to local context, and building in flexibility allowing the program to be adapted to changing circumstances. Creating partnerships between policy designers, project implementers, and academic teams is an important element in achieving these goals. Partnerships are also valuable for achieving effective monitoring and evaluation, and support to 'evidence-based' policy-making processes. Despite a shared electronic health record being a key component of the service model, there was an under-investigation of the impact this technology on facilitating and enabling integration and the outcomes achieved. Conclusions: PRISMA provides evidence of the benefits that can arise from integrating care for older persons, particularly in terms of increased feelings of personal empowerment, and improved client satisfaction with the care provided. Taken alongside other integrated care experiments, PRISMA provides further evidentiary support to policy-makers pursuing integrated care programs. The scale and scope of the research body highlights the long-term and complex nature of program evaluations, but underscores the benefits of evaluation, review and subsequent adaptation of programs. The role of information technology in supporting integration of services is likely to substantially expand in the future and the potential this technology offers should be investigated and harnessed. [ABSTRACT FROM AUTHOR]

Introduction: While the effectiveness of team-based care and wrap-around services for high utilizers is clear, how complex care clinics deliver effective, person-centered care to these vulnerable populations is not well understood. This paper describes how interactions among interprofessional team members enabled individualized, rapid responses to the complex needs of vulnerable patients at the Virginia Commonwealth University Health System's Complex Care Clinic. Methods: Researchers attended twenty weekly care coordination meetings, audio-recorded the proceedings, and wrote brief observational field notes. Researchers also qualitatively interviewed ten clinic team members. Emergent coding based on grounded theory and a consensus process were used to identify and describe key themes. Results: Analysis resulted in three themes that evidence the structures, processes, and interactions which contributed to the ability to provide person-centred care: team-based communication strategies, interprofessional problem-solving, and personalized patient engagement efforts. Conclusion: Our study suggests that in care coordination meetings team members were able to strategize, brainstorm, and reflect on how to better care for patients. Specifically, flexible team leadership opened an inter-disciplinary communicative space to foster conversations, which revealed connections between the physical, and socio-emotional components of patients' lives and hidden factors undermining progress, while proactive strategies prevented patient's rapid deterioration and unnecessary use of inappropriate health services. [ABSTRACT FROM AUTHOR]

Background and introduction: Although most developed countries are currently pursuing greater integration of health and social care, the current evidence base is limited by a number of key weaknesses in the existing literature. Chief amongst these is the tendency to focus on issues of process ('how well are we working together'?) not on outcomes (does it make any difference to people who use services?). As a result, there is a danger that integration can become an end in itself, rather than a means to an end (of better services and better outcomes). Understanding context, process and outcomes: To guard against this danger, this policy paper sets out a number of theoretical and conceptual frameworks to help policy makers, managers and practitioners remain focused on the outcomes that their joint work is meant to achieve. This includes different approaches to being clear about what integration is trying to deliver (outcomes), understanding where we are now (context) and how we get from where we are now to where we want to be (process). Conclusion: Rather than assume that integration is automatically a 'good thing', the frameworks presented in this paper suggest a more critical approach in which policy makers, managers and practitioners focus in more detail on what they are trying to achieve for the people they serve, viewing integration as a means to an end and never an end in itself. [ABSTRACT FROM AUTHOR]

Purpose: The purpose of this paper is to critically examine the extent of patient centrality within integrated chronic back pain management services and compare policy rhetoric with practice reality. Context: Integrated chronic back pain management services. Data sources: We have drawn on theories of integration and context specific journals related to integration and pain management between 1966 and 2006 to identify evidence of patient centrality within integrated chronic pain management services. Discussions: Despite policy rhetoric and guidelines which promote 'patient centrality' within multidisciplinary services, we argue that evaluations of these services are scant. Many papers have focussed on the assessment of pain in multidisciplinary services as opposed to the patients' experience of these services. Conclusions: A latent measure of the reality of its magnitude needs to be captured through analysis of the patient's perspectives. Capturing patients' thoughts about integrated services will promote patient centrality and support the reality rather than endorse the rhetoric. [ABSTRACT FROM AUTHOR]

Background: Integrated care that focuses on organising healthcare services around people and their communities rather than their diseases is promoted as the strategy to overcome the challenges associated with growing complexity in healthcare needs, demand for healthcare services and inadequate supply of services due to fragmentation in the provision of services. While conceptually appears to be simple, integrated care is made up of multicomponent delivery strategies targeting various levels of the healthcare system while engaging various stakeholders in their execution. Methods: We applied the complex adaptive system (CAS) perspective to two different initiatives that exemplify approaches towards integrating care in Singapore: the Regional Health System (RHS) model, implemented across healthcare institutions at the national level, and CARITAS Integrated Dementia Care implemented in the northern region of Singapore. We adopted an inductive approach in our analysis in which we studied the RHS and CARITAS Integrated Dementia Care according to the components of the CAS. We applied the typical characteristics of CAS: (i) diverse, interdependent and semi-autonomous actors (ii) self-organizing capacity and simple rules (iii) relationship with the bigger system, emergent behaviour and non-linearity in our analysis of key drivers behind the implementation of both the RHS and CARITAS integrated dementia care. Results: By considering the RHS and CARITAS as whole networks each comprising of interacting and adaptive components instead of separate entities within a bigger system, the CAS provided a new mindset in surfacing issues associated to the implementation of these integrated care networks. In addition to important actors, systems, it informed understanding of relationships and dependencies between different parts of the network - revealing the lack of homogeneity, conformity and difficulties in designing any optimal system in advance given the many moving parts. Conclusions: Drawing on the two examples of integrated care networks, this paper highlights the significance of effective collaboration built on a common focus, responsiveness to emergent behaviours, simple rules, the ability to self-organize and adapt in response to unexpected situations in further development of integrated care in the Singapore context and beyond. [ABSTRACT FROM AUTHOR]

Introduction: Emerging from the epidemiological transition and accelerated aging process, China's fragmentated healthcare systems struggle to meet the demands of the population. On Sept 1st 2017, China's National Health and Family Planning Commission encouraged all cities to learn from the Luohu model of integration adopted in Luohu as an approach to meeting these challenges. In this paper, we study the integration process, analyze the core mechanisms, and conduct preliminary evaluations of integrated policy development in the Luohu model. Policy development: The Luohu hospital group was established in Aug 2015, consists of five district hospitals, 23 community health stations and an institute of precision medicine. The group adopted a series of professional, organizational, system, functional and normative strategies for integrated care, which was provided for the residents of Luohu, especially for the elderly population and patients with chronic conditions. According to a preliminary evaluation of the past two years, the Luohu model showed improvement in the structure and process towards integrated care. New preventive programs conducted in the hospital group resulted in changes of disease incidence. Residents were more satisfied with the Luohu model. However, spending exceeded the global budget for health insurance because of short-term increases in the demand for health care. Lessons learned: First, engagement of multiple stakeholders is essential for the design and implementation of reform. Second, organizational integration is a prerequisite for integrated care in China. Third, effective care integration requires alignment with payment reforms. Fourth, normative integration could promote collaboration in an integrated healthcare system. Conclusion: Core strategies and mechanisms of the Luohu model will promote integrated care in urban China and other countries facing the same challenges. However, it is necessary to study the effects of the Luohu model over the long term and continue to strive for integrated care. [ABSTRACT FROM AUTHOR]

Taking many forms across contextually diverse and complex settings, models of health care delivery described as integrated, commonly share an assumption that the model will improve the individuals experience and enable the individual to be in a better position to self-manage their health and any related ongoing health care needs. Engaging with, and being focussed on, what is important to the individual patient is widely accepted as being foundational in realising the immediate and longer-term individual, population and health system benefits of an integrated model of health care delivery. However, the practice of co-designing person-level outcome measures, that reflect what matters and is valued at the individual patient level and applying these to shape and evaluate health care delivery, is not common practice. Objectives: To identify pragmatic approaches (that have been applied in real-life settings) to understanding how individuals construct their expectations and/or experiences of an integrated model of health care delivery across a range of settings. To identify how person-level outcomes, that describe issues and outcomes important to the individual, could shape the integrated model of health care delivery. To propose recommendations on the benefits and insights that person-level outcomes offer integrated model of health care delivery across a range of settings. Study selection: Peer-reviewed empirical studies published in English within the last 10 years from June 2018, set within the context of an integrated model of health care delivery, with participants being adults (18 years or greater) living in the community self-managing and/or having been exposed to the integrated model, the focus of inquiry was the perspective and/or experience of the participant and the data analysis explored the issues and outcomes important to that participant, rather than an attribute of or issues at the provider, service, or system level, were included. Search Strategy: The search of Ovid MEDLINE, EBSCO CINAHL, SCOPUS Elsevier and ProQuest Health & Medicine databases with selected key words, yielded 707 records. 38 records were added following review of reference lists. 61 duplicates removed, leaving 684 potentially relevant records. Initial screening excluded 490 records. Remaining 194 records were screened, excluding 121 records due to study design (68), participants (25), intervention (21) or not full text (7). Indepth review of the 73 records assessed as addressing the research question resulted in 19 records being omitted for study design and 49 for the phenomena of interest. A total of 5 papers were determined eligible and included in the review. Data Extraction: All eligible papers were qualitative studies, exploring the views of individuals using indepth interviews and focus groups. The studies originated from United Kingdom (2), Australia (1), Netherlands (1) and USA (1). Participants were all community living adults, with sample size ranging from 23 to 230. As the aim of the review was to capture how information was collected, how it was applied and the potential significance, a bespoke data extraction tool was developed. Data Synthesis and key findings: A descriptive synthesis was undertaken, and a detailed narrative summary of the key findings will be presented. [ABSTRACT FROM AUTHOR]

Introduction: It is anticipated that by 2030 the number of older people and people living with long term conditions will have significantly increased. At the same time, it is expected that there will be a shift to providing more health care in the community. Browning et al [1] using a prospective 16- year longitudinal study of 1000 older Australians described three ageing groups (i) ageing well (30%); initially ageing well then deteriorating (50%); consistently ageing poorly (20%). Understanding the predictors of services use in older people is important in planning and providing quality care. Predictors of general practice service use from a small community-based studies have included: lower age, fewer medical conditions, restful sleep, good nutrition, decreased stress, being a non-smoker and good social support [2]. Using our existing data linkage resource, the Central and Eastern Sydney Primary and Community Health Cohort/Resource (CES-P&CH), which includes questionnaire data, primary care records, prescribing information, hospital records, emergency department records, cancer registry, and vital statistics on over 30,000 participants in CES aged 45 years and over (over 250,000 in NSW for comparison) we identified the predictors of service use (including general practice, pharmaceuticals, emergency departments, hospitalisations) amongst people aged over 75 years. Methods: A record linkage study using 45 and Up Study questionnaire data, MBS claims, PBS claims, Emergency Department visits, hospitalisations and deaths was undertaken. Participant characteristics at baseline (2006-2009) included demographics, health behaviours, social capital, functional status, and health conditions. Service characteristics included type of service, length of stay, location. Predictive models were developed to examine the participant/service characteristics with higher/lower service use over time. Results and Discussion: We identified 6,067 participants who were aged over 75 years in CES at baseline. Of these 59.0% had seen a GP 8 times or more in 2008, 19.6% had seen a specialist 8 times or more, 26.7% had attended an ED at least once, and 44.2% had been hospitalised at least once. In 2014 rates of GP use, specialist use and hospital admissions remained the same however ED visits had increased by 5%. This paper will discuss the different predictive models that were developed to describe service use. This paper will also provide the results from the predictive models and how this information is being/can be used to better plan and provide quality care for older people in CES. Limitations and suggestions for future research: Because the research study used an existing record linkage resource we were limited to the participant and service characteristics that were available. This research study would benefit from the inclusion on non-admitted data such as outpatient, community services and aged care services. [ABSTRACT FROM AUTHOR]

Introduction: In Finland large planned reform would integrate all health and social service under responsibility of 18 counties now 300 municipalities. The aim of the reform has been to comprise economic development by creating new, larger and stronger organizations as well as to build integrated services and service chains. On the other hand, one aim is to increase customers' choice of provider and to increase the number of service providers and to have competition in the market. Education of health and social care professionals is mostly based on strong professions, but new service system challenges this. Service integration can be seen as making the process between components of services smoother using multi-professional collaboration, organizational integration or case managers. In earlier studies interpersonal communication, collaboration, systems thinking and holistic assessment have been noticed as core competences in integrated care. In this paper we analyze service integration in three districts, which have already made their own integration reforms. Municipalities in large areas have built organizations, which are in responsibility of purchasing services as well as providing most of services. Examples of service integration, crucial elements and competencies are presented. The experiences from these forerunner organizations can be applied in future national reform as well as internationally. Methods: The study is a part of a large Cope-project which aims to evaluate the competencies needed in future integrated health and social care. This paper is based on individual and group interviews of 81 top and middle managers and 26 frontline managers. The data was collected from three large health and social care districts. One district has been in action for several years, one has just launched the new organization and one is being planned. The data was analyzed using inductive content analysis. Results: The first results showed that care integration is implemented using three strategies: 1 collecting services into same organizational departments from hospitals, primary care and social services, 2 improving co-operation between organizational units and professionals and 3 using care integrators or case managers. These strategies vary in different sectors and districts. Same districts may use all strategies. Market orientation and increasing number of private firms is seen as contradictory to care integration. For example understanding the services needs of customers in more holistic way larger than view of own work and understanding the service system better is needed. There is a need to create multiprofessional work, and to build trust and understanding between professionals. Managing multiprofessional groups and inter-organizational collaboration will demand new skills and new integrative management orientation. Conclusion: The first results of the study showed that service integration is a strong emphasis in all participant organizations, but the means of integration differ. There are several generic competencies which should be at better level among managers as well as employees in future. In education of all professions more integrated learning between health and social care is needed. Case managers need a special training combining both health and social care. Education at work places should be integrated to development of working culture. [ABSTRACT FROM AUTHOR]

Introduction: The Patient Narrative Project was initiated in 2016 to position the voice of patients and service users centrally in the design and implementation of Integrated Care. This paper presents the findings from Phase Two; the piloting of a qualitative survey tool called 'Your Voice Matters' (YVM) to capture a high volume of patient experiences and analysing these to find out the extent to which the person centred coordinated care indicators were made real during 2017. Methods: YVM utilises the SenseMaker® software tool and is underpinned by a partnership approach between service users and providers. The framework is dynamic and can be used to provide real time feedback to inform changes at local levels. The YVM framework consists of: - An online survey that utilizes the SenseMaker® software programme - Engagement plan to maximize service user participation, knowledge and empowerment - Analysis of data by staff and service users together - Identification of key themes and actions to influence the design and delivery of services The survey was available online, in a paper copy or through an app for smartphone or tablet. Results: There were 584 responses. 52% patients/service users and 45% carers, family/friends. 63.8% of respondents were female. A national workshop of service users and providers was held to review, analyse and interpret the data from the pilot together and identify key themes using a Quantitative Evaluation Matrix. The key issues that impact on successful implementation of integrated care were identified as: Limited joined up communication between patients and healthcare staff and between healthcare settings Limited evidence of partnership approach in healthcare Challenges in accessing services is a concern for service users Patient Experience is a driver for sustainable quality health and social care services Person-centred co-ordinated care is not yet a lived reality for patients and service users despite the rhetoric in health and social care strategy Discussions: The results from Phase 2 give a clear direction of travel for person centred integrated care and show that the approach being taken currently is attempting to address the issues raised. The results also challenge us to move more rapidly towards co-production Conclusions (comprising key findings): The journey towards person centred coordinated care has only begun and although much progress has been made, there is much more to be done and more rapidly. There is a real appetite among patients, carers and healthcare professionals to co-produce solutions. Lessons learned: Clear governance and the need for senior buy is very important. Although often stated, it is not always apparent in actions. Regular communication with key stakeholders and local buy in is key to success. Limitations: There were only 584 responses. More responses will be required to inform the design and operation of health and social care at local levels. Future research: A more detailed analysis of the outputs from Phase 2 is planned which will inform Phase 3. A collaboration involving several countries in the use of this technology would be a positive development. [ABSTRACT FROM AUTHOR]

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

Introduction: Research plays an important role in supporting integrated care (IC). However, IC networks may lack the capacity to leverage research. Moreover, many health system organizations (HSOs) struggle to identify and implement relevant research in a timely fashion. Embedded research is a promising strategy to align data with system priorities, increase the relevance and timeliness of evidence, and build capacity to conduct and use research. This study reviews two Canadian postdoctoral training programs that embed researchers in HSOs. We describe the programs, report on early lessons learned, and discuss implications for IC. Background: •IC is a priority in many Canadian jurisdictions. For example, Ontario Health Teams (OHTs) were introduced in 2019 to organize care in a more integrated way. •Embedded research requires different skills than traditional research. In response, new training programs have developed such as the Health System Impact Fellowship (HSIF) and the OHT Impact Fellows (OHTIF) programs. Aims: This paper describes the HSIF and OHTIF models and presents early lessons learned. Through surveys, program data, and interviews with participants, we identify key challenges and opportunities. Combined with insights from program leads, we provide an in-depth look at the design and implementation of these programs and how embedded research can support IC initiatives. Highlights: The HSIF program was launched in 2017 and has embedded more than 200 fellows in over 100 HSOs across Canada. Host organizations determine research priorities and are matched with fellows. Distinctive features include a focus on impact-oriented research, co-supervision with health system and academic leaders, professional development, protected time for academic research, and a national cohort that fosters networking and collaboration. Promising outcomes include advancement of HSO goals, increased system capacity for research, and enhanced leadership skills and early career success among fellows. The OHTIF program is modeled on HSIF and places researchers directly in OHTs where they support local projects and learning across organizations. Launched in 2021, the program saw strong demand from OHTs and trainees interested in IC research. Distinctive features include its focus on IC, intensive training activities, and ongoing mentorship for fellows. Early feedback is promising but also suggests areas for attention, including the unique needs of rural and remote regions and the multiple, often competing demands that fellows encounter. Both programs involve patients and caregivers on their advisory panels and offer training in patient engagement. Conclusions: Embedded research is a promising strategy to support IC and health system research. Data from two Canadian training programs show strong interest from HSOs keen to embed research talent within their teams, and from applicants interested in using their research skills to address real-world challenges. Early evidence also highlights the importance of matching, onboarding, and ongoing training for fellows, mentors, and host organizations to build a highperforming embedded research workforce. Implications: Our experience suggests embedded research programs provide important benefits both in augmenting the research and evidence translation capabilities of HSOs and in providing valuable training experiences for fellows, augmenting the research and evaluation skills gained in their graduate education. [ABSTRACT FROM AUTHOR]

Introduction: In 2020, the National Rehabilitation University Hospital (NRH) in Ireland, a complex specialist rehabilitation hospital transitioned to a new building. This transition presented a unique opportunity to explore interdisciplinary team dynamics, integration, connections and relationships within and across teams. Part of a larger project, this paper presents the results of a co-operative inquiry with the Medical Consultants. Aims and objectives: To assess the value of co-operative inquiry as a vehicle for supporting learning. The specific questions to be addressed were: •How can we as medical leaders facilitate transition to the new hospital with an improved staff and patient experience? •How might we develop the leadership skills to do this? Methodology: Action research (AR) was chosen because, similar to the biopsychosocial model of rehabilitation, it supports a collaborative, democratic approach to research based organisational change and improvement. Cooperative inquiry (CI) an experiential, participatory articulation of action research, was chosen as it has a solid evidence base in professional development in healthcare. In this articulation, small groups of co-researchers engage, in a non-hierarchical manner, multiple ways of knowing through cycles of action and reflection to explore areas of shared concern. Data generation: Data was generated from 6 action research cycles, with participants engaging in an 'extended epistemology' of experiential, presentational, propositional and practical ways of knowing. An integrative triangulation approach incorporated the first, second and third person inquiries. As there were multiple cycles of inquiry, there was a continuous process of innovation and data generation. A process folio approach was taken, to document, describe and analyze the data using a 10-step cyclical framework. Data analysis was ongoing, cyclical and reflexive, with participants engaging in the sense-making process at each session. Results: Through cycles of action and reflection, 2 key themes emerged; Communication and teamwork. Actions taken included the identification and creation of physical space to come together physically (Coffee room, informal get togethers) and virtual spaces (WhatsApp; Virtual meetings). These enhanced discovery, development, diffusion, and disruption connections. WhatsApp content analysis revealed an active dynamic exchange of diverse information that became a network of collaborative learning. These activities were supported by senior management through the 3rd person inquiry. 75% of participants felt our objectives were met. Through a process of abductive reasoning, colleagues felt they had learned to communicate better, trust, share and learn together and also patience and friendship. There was a commitment to continue as an action learning set. Conclusions: Cooperative inquiry, with a focus on action and shared reflection, facilitated the 'inpowerment' of a diverse group of colleagues to work together to develop practice in areas of mutual concern. CI was an effective vehicle for supporting learning which resulted in the stated goals of improved communication and teamwork. Implications and limitations: This study found that CI is a useful developmental method for teams engaging the collaborative dynamics of action and inquiry and the outcome of actionable knowledge. Although this approach was tested with 1 group, the approach is being extended to other groups within the organisation. [ABSTRACT FROM AUTHOR]

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

The paper presents a comparative analysis of three models of transitional care units that have been set up in Italy in the last three years within the processes of Regional Healthcare Services and healthcare organisations' reforms. The comparative analysis is worth of providing interesting insights and generalizable lessons learnt from integrated care in practice. The three cases of transitional care units belong to a similar background wherein greater needs for care coordination across the supply chain have risen, but the implementation has brought to different organizational solutions to meet the contextual features. The common base-line scenario can be described by four fundamentals: 1) the merge and establishment of larger Local Health Authorities, serving a population of 1.2mln inhabitants on average; 2) the set-up of integrated care models between hospital care and primary care (as intermediate care, rehab., residential care, palliative care, home care or hospital at home); 3) the use of clinical governance tools and methods (as Integrated care pathways (ICPs), clinical networks), exploiting approaches deriving from the population health management (PHM); 4) the efforts to strengthen the integration between health and social care, foremost by using tools and targeted case management models for the most fragile persons. From this scenario, three different models of transitional care units rose, in Veneto Region, in Tuscany and in Lombardy, to build up integrated care by streamline ICPs across the supply chain of services and professionals within the newly established LHAs. The paper discusses comparatively the three cases of transitional care units. It analyses in depth three cases, one from each Region, based on different healthcare organization unit. The case study analysis allows to tackle out the organizational, professional and operational tools applied distinctively, based on the data collection of their initial activities and interviews with the key players. From the comparisons, lesson learnt can be drawn for generalization, detangling the contextual organizational features and service design's needs (the path and resources dependency of each model) from more general observations and tips that could foster the sustainability and efficacy of similar services. [ABSTRACT FROM AUTHOR]

Introduction: Use of substances during pregnancy is a global health concern. Interprofessional care teams can provide an optimal care approach to engage individuals who use substances during the perinatal period. The purpose of this scoping review is to provide a comprehensive summation of published literature reporting on interprofessional care models for perinatal individuals who use substances. Methods: We conducted a systematic search for articles from health-related databases. The Preferred Reporting Items for Systematic Reviews for Scoping Reviews (PRISMA-ScR) was followed. Data were extracted and synthesized to identify the interprofessional care team roles, program and/or provider characteristics, and care outcomes of these models. Results: We screened 645 publications for full text eligibility. Eleven articles met full inclusion criteria and were summarized. Programs were built on co-location of services, partnership with other agencies, available group/peer support and approaches inclusive of cultural care, trauma informed care, and harm reduction principles. Discussion: There is growing evidence supporting integrated care models that are inclusive of relational care providers from multiple health care professions to achieve wraparound care. Conclusions: Many of the interprofessional care models studied have successfully blended social, primary, pregnancy, and addictions care. The success and sustainability of programs varies, and more work is needed to evaluate program and patient outcomes. [ABSTRACT FROM AUTHOR]

Background: Despite its overall good performance, the Belgium healthcare system scores less well in providing equal access to healthcare compared to other European countries. This increases the risk of people worse off to receive late diagnosis and to get complications of chronic diseases. Methods: This study aims to achieve a deeper understanding of how people with complications of a chronic disease – diabetes type 2 – experience care in the Belgium health system through semi-structured interviews with extreme case study sampling of people with advanced diabetes, and inductive analysis. Results: The results show that most respondents were diagnosed late in the course of their disease. There are variations in treatment and type of provider. People appreciate the personal and long-lasting contact with a medical doctor, while the contact with and role of paramedical providers was less recognized. Disease management has a significant impact on their financial budget and some respondents experienced barriers to obtain additional financial support. Discussion: Non-medical costs are not reimbursed, presenting a high burden to people. Self-management is tedious and hampered by other worries that people may have, such as financial constraints and coping with important life events. To conclude this study highlighted the need to improve diabetes screening. We suggest to enhance the role of paramedical professionals, integrate a social care worker, reduce financial constraints, and increase health literacy through more patient-centered, goal-oriented care. [ABSTRACT FROM AUTHOR]

Background: Patient reported outcomes (PROMs) have been increasingly on the agenda of a number of European governments. In the UK these have been associated with postoperative collection of patient reported data since April 2009. The move towards centralizing the patient in the care process as well as quantifying outcomes important to the patient have led to calls for widespread use of these instruments by 3rd party payers. There are considerable barriers to implementing routine collection of data using traditional paper based methods. However, digital approaches hold promise in addressing such barriers. This paper will report the development of and results generated using a web based PROM/PREM collection system (CareResponse (CR)) specifically for use in MSK patients attending community based outpatient services. Methods: Care Response was developed as a tool to facilitate the routine collection of PROMs and other questionnaire based information directly from patients. The following components were identified as useful for supporting patients undergoing care and physicians in practice - Reducing or removing the need for input from clinical organizations in requesting patients to complete follow up assessments. - Maintaining flexibility for clinicians to ask patients to complete questionnaires when clinically indicated - for example during a formal case review. - Providing patients and clinicians instant access to their completed assessment forms - Scoring PROM forms and presenting practitioners results in an easy to interpret graphical format suitable for discussion with patients - Enabling clinicians to compare collated results from their patients with anonymized collated results from all users of the system. Thus providing benchmarking against which to judge their service. CR accomplishes these goals through the use of a cloud based relational database. Consenting patients are entered using their name, date of birth, and email address. In its routine use in clinical practice CR generates a 'pre examination' questionnaire containing questions preselected by the clinical organization. CR can send an email to the patients with a link to its database allowing patients to complete questions on any computing device able to access the internet. Alternatively patients may opt to complete the assessment either on paper (to be keyed in later by organizational staff) or more usually on a tablet while in the waiting area upon initial consultation. Follow up questionnaires can be generated automatically at timed intervals or specifically at time points according to clinical need. Results: At present 159 organisations delivering MSK care in the private sector are using this system. To date 25053 patient records have been collected. Conclusion: A web based approach to collecting PROMs and PREMs has generated large data sets in MSK patients that effectively describe service provision, patient outcomes and experiences. We believe this is a proven and innovative way to provide the data needed to monitor and assess the success and satisfaction of patients receiving health care provision in this and the wider health care sector. [ABSTRACT FROM AUTHOR]

Objective: Changes in models of health care are required to better meet the needs of diverse, underserved patient populations. Collaboration among providers is one way to promote accessible, comprehensive and continuous care in healthcare organizations. This paper describes the quantitative findings from two time points that examined providers' views of collaboration among a sample of diverse personnel (e.g. clinical nurses, social workers, dental providers, mental health providers, clerical staff, medical assistants, public health staff, and administrators) within a federally qualified nurse managed health care centre in the United States. Methods: The quantitative arm of a mixed-method study is presented in this paper. Two instruments, the Collaboration and Satisfaction About Care Decisions Scale and the University of the West of England Interprofessional Questionnaire (comprised of 4 subscales-Communication and Teamwork Scale, Interprofessional Learning Scale, Interprofessional Interaction Scale, and Interprofessional Relationships Scale) were administered to providers at baseline and three to eight months following six same discipline focus group discussions on collaboration, in order to evaluate whether participating in the focus group discussions changed providers' views of collaboration. A summary of the focus group data which were published elsewhere is additionally summarized to help provide insight to the quantitative findings. Thirty-nine staff participated. Results: Paired t-tests revealed that only one scale out of the five, Collaboration and Satisfaction About Care Decisions Scale (33.97 at time one and 37.45 at time two), significantly and positively changed after the focus group discussion (p=0.046). Providers' views on collaboration ranged from positive to moderate views of collaboration; most measures revealed a non-significant improvement after the focus group discussions. Staff with some graduate school reported the greatest satisfaction with decisions for the patient, and those with high school reported the lowest satisfaction with decisions for the patient. Respondents with a graduate degree had the most positive views of interprofessional relationships, whilst those with either a high school degree or bachelor's degree had the most negative views of interprofessional relationships. ANOVAs by professional role revealed the least positive views of collaboration for provider groups with lower levels of education, with upper administration reporting the most positive views on collaboration. Conclusion: Although the discussion generated by the focus groups was expected to facilitate communication, and research has suggested that communication between providers facilitates collaboration, only one subscale evaluating providers' views of collaboration positively and significantly changed after the focus group discussion. The wide range of views on collaboration suggests there are diverse perspectives on collaboration among the staff based on professional roles and levels of education, with upper administration and those with higher levels of education reporting the most positive views of collaboration and staff with lower levels of education reporting more negative views of collaboration. A major limitation of this study was a low time two return among support staff, comprised of primarily African American women. Due to their marginalized professional and racial status, future research needs to explore the perspectives of this important and often overlooked group of staff. [ABSTRACT FROM AUTHOR]

Purpose: This paper reports the findings of the evaluation of the Supporting People Health Pilots programme, which was established to demonstrate the policy links between housing support services and health and social care services by encouraging the development of integrated services. The paper highlights the challenges of working across housing, health and social care boundaries. Method: The evaluation of the six health pilots rested on two main sources of data collection: Quarterly Project Evaluation Reports collected process data as well as reporting progress against aims and objectives. Semi-structured interviews--conducted across all key professional stakeholder groups and agencies and with people who used services--explored their experiences of these new services. Results: The ability of pilots to work across organisational boundaries to achieve their aims and objectives was associated not only with agencies sharing an understanding of the purpose of the joint venture, a history of joint working and clear and efficient governance arrangements but on two other characteristics: the extent and nature of statutory sector participation and, whether or not the service is defined by a history of voluntary sector involvement. In particular the pilots demonstrated how voluntary sector agencies appeared to be less constrained by organisational priorities and professional agenda and more able to respond flexibly to meet the complex needs of individuals. Conclusion and discussion: The pilots demonstrate that integrating services to support people with complex needs works best when the service is determined by the characteristics of those who use the service rather than pre-existing organisational structures. [ABSTRACT FROM AUTHOR]

Introduction: Western health care is under pressure from growing demands on quality and efficiency. The development and implementation of information technology, IT is a key mean of health care authorities to improve on health care infrastructure. Theory and methods: Against a background of theories on human-computer interaction and IT-mediated communication, different empirical studies of IT implementation in health care are analyzed. The outcome is an analytical discernment between different relations of communication and levels of interaction with IT in health care infrastructure. These relations and levels are synthesized into a framework for identifying tensions and potential problems in the mediation of health care with the IT system. These problems are also known as unexpected adverse consequences, UACs, from IT implementation into clinical health care practices. Results: This paper develops a conceptual framework for addressing transformations of communication and workflow in health care as a result of implementing IT. Conclusion and discussion: The purpose of the conceptual framework is to support the attention to and continuous screening for errors and unintended consequences of IT implementation into health care practices and outcomes. [ABSTRACT FROM AUTHOR]

Purpose: The paper contributes to the conceptualisation of ''integrated care'' in heterogeneous work practices. A dynamic perspective is developed, emphasising how integrated care is malleable, open, and achieved in practice. Furthermore, we explore the role of nursing plans in integrated care practices, underscoring the inherent difficulties of building one common infrastructural system for integrated care. Methods: Empirically, we studied the implementation of an electronic nursing plan in a psychiatric ward at the University Hospital of North Norway. We conducted 80 hours of participant observation and 15 interviews. Results: While the nursing plan was successful as a formal tool among the nurses, it was of limited use in practice where integrated care was carried out. In some instances, the use of the nursing plan even undermined integrated care. Conclusion: Integrated care is not a constant entity, but is much more situated and temporal in character. A new infrastructural system for integrated care should not be envisioned as replacing most of the existing information sources, but rather seen as an extension to the heterogeneous ensemble of existing ones. [ABSTRACT FROM AUTHOR]

Introduction: Receiving client feedback is crucial for providers to identify gaps and improve services. Surveys are typically used to collect client input for quality improvement (QI) consideration - but was this enough? We did not think so. The ASBHNHH conducted client surveys in 2019 and 2020 revealing that clients with YOD and their care partners have unique needs. Embracing client engagement as a framework allows clients to be empowered decision makers who direct what services they need. This paper will focus on our recent shift to empowerment through a co-design investigative project and outcomes for persons with YOD and care partners. Aims Objectives Theory or Methods: With improved client engagement as a QI Plan indicator, the objectives of this project were to engage persons living with YOD and their care partners to identify gaps in service using codesigned, investigative strategies that promote people as partners in care. Qualitative research methods, including focus group discussions and semi-structured interviews, were used to examine the potential use of the co-design method in designing and delivering improved services. A YOD Advisory Group was assembled and meetings then took place through Zoom with the use of guiding questions, open dialogue, and Google Jam Board. Highlights or Results or Key Findings: The YOD Advisory Group identified two service gaps to improve and increase: support needs for YOD in general, and resources at the time of receiving a diagnosis. The findings informed the subsequent development of a resource guide outlining "everything to know" when one is diagnosed; and a peer support group for persons with YOD and another for their care partners. Evaluation was also co-designed to better inform the success of these projects. The co-design process was reported to have been significantly empowering for the YOD Advisory Group and staff involved. All reported having benefited from the experience and contributing to the solutions from their own perspectives. Our client engagement efforts through co-design resulted in the development of new programs and resources that now fill the identified service gaps. Conclusions: This work demonstrates the importance and value of establishing meaningful partnerships with YOD clients through engagement to ensure quality and relevance of services. Lived experience is viewed as a form of expertise and client engagement that is reflected in performance indicators related to the QI Plan for the ASBHNHH. Implications for applicability/transferability sustainability and limitations: It was evident that client engagement contributed to enhanced quality improvement. Lessons learned from the experience of the ASBHNHH can inspire other service providers to engage their clients through co-design and QI projects. Anecdotal accounts of QI planning can be references to inform many other community service contexts. [ABSTRACT FROM AUTHOR]

This paper concerns an on-going telecare project where a participative, co-design, approach was taken to specify, deliver and evaluate an information service that would enable older people, ranging in age from 57 to 98 with more than 50% over 80, to maintain their independence, quality of life and sense of well-being. In addition the project served to explore the potential such a service has for enabling the housing provider to provide the support required by the older people. The project is part of the HOST EU initiative and partners in Italy and France are exploring similar issues. In the UK digital TV was explored as a method to provide information (alongside TV channels). TV was chosen as a mechanism for providing access to information because it was assumed that older people were familiar with it. Information included health information, alerts to events, travel information and messaging and video communication with family, friends and other contacts such as housing service providers. This paper firstly reports on the initial user requirements phase of the project where a, participative, co-design approach was taken working with older people in the supported housing project in Newark. This initial phase helped to identify the information needs of the older people and the design of the interface to enable access to the range of information and tools. This, for example, included working with the older people to develop the icons that would enable the selection of categories of information. Identifying and prioritising information needswas achieved through the use of participative techniques that are recognised as enabling and encouraging community participation. This included agreeing how to work together, confidence building, group work, brainstorming, drawing, use of post-it notes, collaborative ranking and ordering of topics etc. An outline of the methods deployed and the findings of this particular stage in the project will be given, including the categories of information need and the icon designs. However, the focus of this paper will be the results of a survey of the older people with regard to their views, both positive and negative, on the participative process and the challenges that were experienced. This will also include their evaluation of the product/service and will attempt to indicate the impact that the service, and their involvement in the project, has had on the older people. Furthermore, although credence has generally been given to the co-design and participative approach, and it was generally well received by the older people there was still some resistance and challenges associated with this approach. These challenges relate to working with older people but also working with others, such as service providers and technologists. This paper will therefore highlight these challenges and make suggestions as to how they can be addressed by future co-design projects, particularly those involving older people, housing providers and technologists. [ABSTRACT FROM AUTHOR]

The Wessex Health Innovation and Education Cluster (HIEC) programme included a commitment to promote the use and uptake of telecare and telehealth in the region. A marker of success established in April 2011 was for more telehealth to be deployed in Wessex either directly or indirectly as a result of HIEC interventions. The work stream was discussed and developed at a conference of senior health and social care leaders in June 2011. The key objectives they identified were * Demonstrations of effective telehealth services * Provide networking opportunities and shared learning experiences * Developing inter organisational and integrated systems * Promotional events and workshops In establishing these objectives a number of barriers to implementation were identified: * costs being accrued in one organisation while the savings went to another, * fear of data being lost or misused, * a fractured market, * limited proof of savings along with additional costs to set up a new service * leadership - changes in the commissioning landscape * cultural. The HIEC established a number of work streams and in the last two years has run over 16 events, managed a regular newsletter and provided local consultancy and advice to address these issues. This work has included conferences, workshops, education sessions, bi-weekly newsletters, academic sessions, work with industry on topics such as procurement, bringing key partners together to work on integration and service development. This paper will review the outcomes from this work and identify the most useful methods for enabling local telehealth/care take up by local services, and addressing the key challenges posed by the adoption of telehealth/care technology. The paper will give examples of the work it has completed such as a series of seminars on topics relating to implementation, work that is in progress such as a project with a local acute trust to raise awareness among clinicians and managers of the opportunities around telehealth and work that may be undertaken under the auspices of the emerging Academic Health Science Network (AHSN) to use information and information systems to transform health and deliver better outcomes. The key findings will discuss: * How telehealth/care has become more formally recognised in the region * The importance of networking skills and interests across the region * The role of sharing information and expertise * Enabling links with telehealth/care providers away from the direct procurement interface * The development of specialised training materials * The problems with current procurement exercises * Difficulties in managing the roll-out of local programmes * The opportunities created by new internet based telehealth/care services * The linkage to the 'Digital by Default' programme The paper will conclude with recommendations based on these findings of how telehealth and telecare can be more effectively promoted, managed and delivered in the future. [ABSTRACT FROM AUTHOR]

Background: Family carers, as a "shadow workforce", are foundational to the day-to-day integration of health service delivery for older family members living with complex health needs. This paper utilises Haggerty's model of continuity of care to explore the contribution of family carers' to the provision of care and support for an older family member's chronic condition within the context of health service delivery. Methods: We analysed data from interviews of 13 family carers in a case study of primary health care in New Zealand -- a Maori Provider Organisation -- to determine the alignment of family caregiving with the three levels of continuity of care (relational continuity, informational continuity, and management continuity). Results: We found alignment of family caregiving tasks, responsibilities, and relationships with the three levels of continuity of care. Family carers 1) partnered with providers to extend chronic care to the home; 2) transferred and contributed information from one provider/service to another; 3) supported consistent and flexible management of care. Discussion: The Maori Provider Organisation supported family carer-provider partnership enabled by shared Maori cultural values and social mandate of building family-centred wellbeing. Relational continuity was the most important level of continuity of care; it sets precedence for family carers and providers to establish the other levels -- informational and management -- continuity of care for their family member cared for. Family carers need to be considered as active partners working alongside responsive primary health care providers and organisation in the implementation of chronic care. [ABSTRACT FROM AUTHOR]

Introduction: The aim of this paper is to report on the development of surveys to explore integration of care for children living with complex care needs across the European Union (EU) and European Economic Area (EEA). Theory and methods: Each survey consists of a vignette and questions adapted from the Standards for Systems of Care for Children and Youth with Special Health Care Needs and the Eurobarometer Survey. A Country Agent in each country, a local expert in child health services, will obtain data from indigenous sources. Results: We identified 'in-principle' complex problems and adapted surveys to capture care integration. We expect to get rich data to understand perceptions and to inform actions for a number of complex health issues. Conclusion: The study has the potential to make a wide contribution to individual countries of the EU/EEA to understand their own integration of services mapped against responses from other member states. Early results are expected in Spring 2017. [ABSTRACT FROM AUTHOR]

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

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

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

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

Introduction: In this paper, we provide a detailed and explicit description of the processes and decisions underlying and shaping the emergent multimethod research design of our study on workforce changes in integrated chronic care. Theory and methods: The study was originally planned as mixed method research consisting of a preliminary literature review and quantitative check of these findings via a Delphi panel. However, when the findings of the literature review were not appropriate for quantitative confirmation, we chose to continue our qualitative exploration of the topic via qualitative questionnaires and secondary analysis of two best practice case reports. Results: The resulting research design is schematically described as an emergent and interactive multimethod design with multiphase combination timing. In doing so, we provide other researchers with a set of theory- and experience-based options to develop their own multimethod research and provide an example for more detailed and structured reporting of emergent designs. Conclusion and discussion: We argue that the terminology developed for the description of mixed methods designs should also be used for multimethod designs such as the one presented here. [ABSTRACT FROM AUTHOR]

Introduction: An increasing group of patients with multiple chronic conditions are living at home. However, rapid changes in health status are common within this group, causing a need for health care services across a broad range of professions and settings. Such "transitional care" typically requires access to relevant, accurate and timely information for all providers involved in the care of the affected individual in order to ensure high quality and safe care. Several studies have shown, however, that the information exchange needed to support such transitions is challenging. Introduction and use of electronic patient records (EPRs) has proven to facilitate the provision of care. In Norway, where the current study was conducted, hospitals and home care settings have different EPR systems that are not compatible. To overcome this shortcoming, face-toface communication, use of telephone and ordinary mail has been the traditional ways to support exchange of patient information across health care settings. In 2011, national initiatives were taken to facilitate electronic communication between hospitals and home health care and general practitioners in the municipalities. An electronic messaging system (emessages) was introduced and implemented in the EPRs. The e-message system is designed to support communication and exchange of information between providers in different care settings and during the phases of a hospital stay. Moreover, the e-messages provide a set of specific messages for targeted purposes; some messages are standardized and aimed for exchanging specific information while so-called dialogue messages are aimed for interactive collaboration. Our research question was: how has information exchange between hospitals and home health care throughout a patient's transition from admission to discharge changed over the last ten years?. Methods: This paper departs from three explorative studies addressing exchange of information between hospital and home health care during patients' transition between the two. All three studies were conducted in Norway. Data were collected by semi-structured interviews in 2005, 2011/12 and 2014. Of the total 136 providers in both hospital and home health care services who were interviewed, 21 were interviewed in 2005, 74 in 2011/12, and 41 in 2014. Data were analysed by applying a deductive-inductive approach. Results: The analysis showed two overall findings. The first overall finding was that the mode of information exchange changed across the three data sets. The most remarkable change was the transition from using mainly paper-based and oral information exchange in 2005, via using hybrid systems combining e-messages with paper and oral communication in 2011/12, to routinely using e-messages in 2014. However, use of oral communication was considered to be significant for discussions and clarifications of some of the patients' problems. The second overall finding was that the "distance" between hospital and home health care diminished from 2005 to 2014. At the point of the first data collection there was little attention to the need for exchanging information between the providers. With the introduction of e-messages, the exchange of information and an awareness of the other part went from being almost absent to being the normal practice in 2014. However, information exchange can still fail if health care providers do not follow the guidelines that describe when to inform each other and what kinds of information should be exchanged. Discussion and conclusion: For the 10 last years the authorities in Norway have launched recommendations and strategies for building systems aimed to improve the information gap when patients are transferred across health care settings. Our study shows that changes have occurred from the first initiative in 2005 to the present practice. The change that has had the most evident impact on ensuring information exchange between healthcare professionals at different care settings has been the introduction of e-messages. They have contributed to enhanced quality of care as well as representing a more secure way of transferring information. Not only does e-messages work as a tool for exchanging information but it also serves as a catalyst for the health care providers' awareness and reflection on what information collaborators need to receive to care for the patients. However, we identified that the latter is still a professional challenge to overcome. The providers struggle with deciding and agreeing on what is accurate and relevant information for the receiver. In addition, information exchange can still fail if the guidelines are not followed. The findings indicate a need for increased awareness on professional, organisational and technological improvements in future development of collaboration across the health care settings. [ABSTRACT FROM AUTHOR]