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Introduction: Stroke care is complex and often provided by various healthcare organisations. Integrated care solutions are needed to optimise stroke care. In this paper, we describe the development of integrated stroke care in the region of Maastricht during the last 15 years. Description of integrated care case: Located in the south of the Netherlands, the region of Maastricht developed integrated stroke care to serve a population of about 180,000 people. Integration was needed to improve the continuity, coordination and quality of stroke care. The development of integrated care in Maastricht was a phased process. The last phase emphasized early discharge from hospital and assessing the best individual rehabilitation track in a specialized nursing home setting. Discussion and lessons learned: The development and implementation of integrated stroke care in the region of Maastricht led to fewer days in hospital, more patients being directly admitted to the stroke unit and an earlier start of rehabilitation. The implementation of early discharge from the hospital and rehabilitation assessment in a nursing home led to some unforeseen problems and lessons learned. [ABSTRACT FROM AUTHOR]

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: Electronic sick leave certificates, called e-ZLA, were being implemented nationwide in Poland from 1 January 1 2016 until 30 November 30 2018. During the time of implementation doctors in Poland could issue sick leave certificates alternatively in electronic or in the paper form. Since 1 December 2018 sick leave certificates are to be issued in the whole Poland electronically only. Practice change: Paper form certificates in Medical and Diagnostic Centre (CMD) - an integrated care organization located in Siedlce (Poland) used to be prepared with the help of the registration or nurse staff. The average work time consumed for that process was calculated in CMD for 13 minutes per one paper form certificate. CMD is serving approximately 85000 patients and issues about 1500 sick leaves certificates every month. Therefore, CMD made an effort of rapid implementation of electronic sick leave certificates issuing. Aim and theory of change: The vendor of computer application for managing of health care related processes introduced in February 2018 in CMD's client application a new functionality of issuing electronic sick leave certificates. The personnel of CMD was trained adequately. Timeline: The first e-ZLA in the CMD was issued on 20February 2018. After short period of time when the correctness of sickleaves certificates issued via client application was being verified, the change was implemented in the whole organization. Highlights: The concept of having an e-certificate uploaded and stored within the system was highly appreciated by CMD staff. The average time of e-ZLA issuing and its online transmission is 2-3 min compared to 13 min for managing paper-form sick leave certificates. Between 20 February 2018 and 30 November 2018, CMD doctors used to issue about 1200 e-ZLAs monthly. The necessity of writing multiple sick leave certificates for patients having more than one employer was also eliminated. This system allows also for review the history of e-ZLAs received by the patient and thus prevent potential abuses. Conclusions: As a result of e-ZLA introduction, the registration staff and nurses were relieved from paper work related to issuing paper-form certificates and additional administrative tasks related to providing copies of sick leave certificates to health insurer branches. Decrease of paper work burden resulted in saving of time which could be sacrificed for patients. Enabling the release of electronic sick leave certificates was an important milestone on the way to better integrated care. [ABSTRACT FROM AUTHOR]

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

Introduction: Social Prescribing has an established recognition regarding the benefits provided to the health-related social needs of adults, but little is known about how the intervention addresses young people's needs. There is optimism regarding the central role of two core mechanisms that allows social prescribing to be effective, such as the empathetic role of Link Workers and the connection with community resources. This paper aims to describe the role played by Link Workers working a Social Prescribing intervention targeting young people. Description: This paper adopts a case study methodology to describe the role of Link Workers addressing young people's needs and implementing Social Prescribing scheme in Sheffield (UK). Data were collected through semi-structured interviews with four of the seven link workers of one organisation based in Sheffield. Data were analysed through an inductive approach for emerging themes. Discussion: We provided a description of the profiles and background of Link Workers and described the three models of referral pathways into the intervention. The paper also shows how Link Workers identify young people's needs and how they connect with the community. Conclusion: Based on the insights and the internationally accepted definition of Social Prescribing, we provide a visual representation of the Social Prescribing model and discuss challenges. The paper highlights lessons learned and future directions regarding the role of Link Workers from the case study. [ABSTRACT FROM AUTHOR]

Introduction: Integration in health and care can improve quality and outcomes, but it is challenged by expansion of medical knowledge, social pressures on patient needs, and demands to deliver critical information. In Latin American and in other lower and middle-income countries integrated care remains in development. This paper examined the available literature on integrated care to understand how Latin American countries identify and measure integration, and what factors influence success. Methods: This integrative literature review included systematic searches in Global Health, PubMed, SciELO and BVSPsi databases for articles on integrated care in Spanish, Portuguese, and English in the period from January of 1999 to December 2020. The articles were screened for selection and assessed independently by five reviewers that used the inclusion criteria of papers about integration in health care systems. The sample excluded articles that did not deal with the integration of health care, which addressed issues related to public health campaigns, programs to control endemics and epidemics, reports on the experience of implementing health services, health promotion guidelines, food safety, oral health, and books evaluation. Results: 24 articles were included: qualitative (75%), quantitative (12,5%), and mixed-method research (4%) published between 2000 and 2017. All studies were undertaken in Brazil, and two of them were also conducted in Latin American countries. In 15 articles there was an interchangeable use between concepts of integration of services and integrated care, while nine studies did not define integration. Barriers to integration included absence of shared understanding of knowledge among members of interprofessional teams, lack of clarity on professional roles, missing consensus on a definition and measurement of integrated care, power struggles between professionals, poor institutional support, insufficient team preparation and training and unequal valuation of professions by society. Conclusion: Several types of integration and factors contributing to the success of implementation of integrated care in various contexts in Brazil were identified. The concept of integration reflected the varied local and regional realities including different health settings and levels of health and care, suggesting a need for further clarifications on its objective and components especially in LMIC contexts. [ABSTRACT FROM AUTHOR]

Introduction: The COVID-19 pandemic disproportionally impacted people experiencing homelessness, including people sleeping rough, people in temporary accommodation and those living in boarding houses. This paper reports on intersectoral responses across six health and social care agencies in Inner Sydney, New South Wales, Australia. Prior to the pandemic the six agencies had established an Intersectoral Homelessness Health Strategy (IHHS), in recognition of the need for intersectoral collaboration to address the complex health needs of people experiencing homelessness. Description: The governance structure of the IHHS provided a platform for several innovative intersectoral responses to the pandemic. A realist informed framework was used to select, describe, and analyse case studies of intersectoral collaboration. Discussion: The resultant six critical success factors (trust, shared ways of working, agile collaboration, communication mechanisms, authorising environment, and sustained momentum), align with the existing literature that explores effective intersectoral collaboration in complex health or social care settings. This paper goes further by describing intersectoral collaboration 'in action', setting a strong foundation for future collaborative initiatives. Conclusion: While there is no single right approach to undertaking intersectoral collaboration, which is highly context specific, the six critical success factors identified could be applied to other health issues where dynamic collaboration and integration of healthcare is needed. [ABSTRACT FROM AUTHOR]

Introduction: There are many challenges we must adapt to in healthcare - health inequalities, environmental concern, ageing populations and multimorbidity to name a few. The English health system has responded by restructuring into Integrated Care Systems1. These are collaborative, place-based partnerships tackling health inequalities and improving care coordination. Additional skills are likely needed for professionals to thrive in and potentiate the promise of ICSs for patients. One key component identified in the Future Doctor Report2, was cultivating generalism. This led to the inception of the Enhance programme for generalism3 - a developing multiprofessional educational offer in England. Aim and Method: Any change is best supported by academically rigorous evidence. Some published evidence was anticipated, as the generalism concept has existed for centuries and some professionals practice in this way today. Three literature searches were commissioned from the Health Education England library service around the evidence for generalism. This presentation will focus on "what are the benefits of generalism to patients, the healthcare system and healthcare professionals". A second search was performed by a HEE fellow. All included papers were critically analysed. Results: 32 papers were identified by the library service. No further papers were included from the second search due to their age (approx. 30 years). All were written in English, 19 from the UK and 13 from across Europe, Asia and Africa, published between 2017-2020. Papers were methodologically diverse, predominantly qualitative, reviews, opinion pieces or project evaluations. Common themes included doctor preparedness, CPD and skills learning. Two papers each, respectively, explored professional and patient satisfaction. A subset of 8 papers felt to be of most relevance to the question were then analysed. Article types were similar to the above, originating from the UK, Thailand or Norway. Four common themes were identified: QI; CPD; preparedness and professional satisfaction. Only one examined patient satisfaction. Interestingly, this paper's findings aligned closely with the principles and aims of the Enhance programme and ICSs - person-centred, well-coordinated care, understanding realworld causes of ill health4. Conclusion: Although there are some proponent opinion pieces and indirect evidence, no papers have been identified that examine this question directly. There is a distinct lack of robust academic exploration of the actual (as opposed to posited potential) benefits to patients, professionals other than doctors and system-wide impacts from generalism. Implications: This work highlights several new and exciting areas for future research - likely to be interdisciplinary. How best to research applying a generalist approach for its benefits to stakeholders in terms of the Institute of Medicine's 6 domains of quality may be a future key question to consider. [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]

Objective: Adults living with Type 2 diabetes (T2D) and severe mental illness (SMI) disproportionally experience premature mortality and health inequality. Despite this, there is a limited evidence-base and evaluation of non-pharmacological integrated interventions that may contribute to improved patient experience and outcomes. To improve our understanding of how to optimise integrated care for this group, this review evaluates the effectiveness, acceptability, and feasibility of non-pharmacological integrated interventions for adults with SMI and T2D. Methods: Studies from nine electronic databases were searched. Of the 6750 papers retrieved, seven papers (five quantitative and two qualitative) met the inclusion/exclusion criteria. A convergent integrated approach was used to narratively synthesise data into four main themes: effectiveness, acceptability, feasibility, integrated care. Results: There is moderate evidence to suggest non-pharmacological integrated interventions may be effective in improving some diabetes-related and psychosocial outcomes. Person-centred integrated interventions that are delivered collaboratively by trained facilitators who exemplify principles of integrated care may be effective in reducing the health-treatment gap. Conclusions: Recommendations from this review can provide guidance to healthcare professionals, commissioners, and researchers to inform improvements to nonpharmacological integrated interventions that are evidence-based, theoretically driven, and informed by patient and healthcare professionals' experiences of care. [ABSTRACT FROM AUTHOR]

Background: integrated Rehabilitation and EnAblement Program (iREAP) is an innovative redesign of the traditional day rehabilitation model, providing an anticipatory, early assessment and intervention program that manages care of community-dwelling older people with complex needs. It coordinates access to disciplines across medical, allied health and nursing, with a self-management focus, partnering with primary health in an integrated approach. Objective: This observational study reviews the effectiveness of iREAP on frailty, patient activation, quality of life and physical outcome measures on older people at risk of, or experiencing falls and frailty, or with neurodegenerative conditions, including Parkinson's Disease. Methods: 99 participants completed the eight-week multidisciplinary program. Patient outcome measures included Rockwood Clinical Frailty Scale, quality of life measures, Patient Activation Measure, Timed Up and Go, 6 Minute Walk Test and Berg Balance Scale. Results: On completion of iREAP, participants displayed improvements in their Rockwood Clinical Frailty Scores (mildly frail to vulnerable), 'patient activation' (55.08 to 60.61), quality of life (Parkinson's Disease Questionnaire-39, 49.93 to 47.16; WHO Quality of Life – Bref physical domain, 21 to 22.7) and physical measures including balance (44 to 49/56 Berg Balance scale) and mobility (294 m to 336 m, 6-minute walk test). Falls were not reduced at twelve months post-program (3.40 to 2.01). Conclusion: iREAP is an interdisciplinary, early assessment and intervention program with the potential to reverse frailty and improve quality of life for complex older patients. This paper offers a platform for future research, given the paucity of evidence reviewing the efficacy of integrated anticipatory models of care in older adults with complex needs. [ABSTRACT FROM AUTHOR]

Introduction: In this paper, we use the Rainbow Model of Integrated Care (RMIC) framework to evaluate the effectiveness of integrated care in terms of enhancing the outcomes of chronic conditions such as diabetes mellitus type 2 (DMT2), cardiovascular diseases (CVD), chronic respiratory diseases (CRD), or their combinations. Methods: The data extracted from randomized controlled trials (RCT) of integrated care interventions for DMT2, CVD, and CRD (follow-up ≥ 3 months) in 11 databases were analysed using random-effects meta-analysis. Results: A total of 54 eligible studies covering 12,976 participants, with a mean follow-up of 54 weeks, were included. In moderate-quality evidence, integrated care interventions reduced mortality for CVD, adverse events for CVD and DMT2, and improved quality of life for CVD and DMT2, physical and mental functioning, self-management, and blood pressure control. Conclusion: Integrated care can reduce all-cause mortality, adverse events, and improve quality of life, physical and mental functioning, self-management and blood pressure control in chronic disease patients. However, available evidence for some outcomes (e.g., all-cause hospital admissions) remains uncertain. [ABSTRACT FROM AUTHOR]

Introduction: The absence of a coordinated approach to health and social care compromises the ability of health systems to provide universal, equitable, high-quality, and financially sustainable care. Transferring evidence-based practices focused on digitally-enabled integrated care to new contexts can overcome this challenge if implementation is satisfactory. This paper presents the scaling-out methodology that JADECARE has designed to spread effective innovative practices across Europe. Methodology: The scaling-out methodology pretends to guide the Next Adopters in the transfer and adoption of practices, whereas increasing their implementation capacity and providing an evaluation framework to assess impact and success. Discussion: JADECARE scaling-out effort is based on guiding principles found in the literature such as the balance between fidelity to the original practice and the degree of adaptation required to fit the new context, the need for capacity building in implementation to bridge the gap between research and routine practice and the focus on explaining why, for whom and in what circumstances an intervention works. Conclusion: The JADECARE scaling-out methodology is theory-driven and pragmatic and aims to facilitate the transfer of complex interventions across different contexts. [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: This paper describes 'Project 8', a campaign that aims to reduce glycated haemoglobin (HbA1c) to 8% or more among patients with diabetes mellitus, utilising healthcare professionals and local community residents and focusing on education and support. The study is based in Uonuma—a small rural city in Japan with a declining population and an increased number of older people. Description: 'Project 8' began in Uonuma's Koide Hospital in 2008. The Uonuma School for Community Health and Social Care was established in 2011 with the cooperation of a clinic's general practitioner. Medical students, trainees, doctors, and health care professionals have been holding 'open schools' (daytime lectures) and 'night schools' (evening lectures) to educate the community residents about various health issues. Through repeated lectures, the residents have been made aware of lifestyle-related diseases, including diabetes, and the meaning of 'Project 8'. Discussion: Over the last decade, the hospital's campaign has expanded within the community, showing a statistically significant reduction of diabetic patients with HbA1c ≥ 8%, which successfully deferred the start of dialysis for many of them. Conclusion: Well-integrated community care requires interprofessional education, collaborative practice, and the participation of community residents in health education. [ABSTRACT FROM AUTHOR]

The population in Singapore is ageing, adding pressure to community care as the health and social needs of its residents increase. This has accelerated the pace at which Regional Health Systems adopt and deliver its population health strategies from early prevention, chronic disease management, crisis care to end-of-life care. To this end, the Central Health Integrated Care Network (ICN) began its journey to develop Communities of Care (CoCs) with other health and social care partners to meet the needs of residents in the Central Zone of Singapore. This paper describes the processes and steps taken by Central Health ICN to build partnerships with other agencies and organisations to build place-based models of care in the local neighbourhoods. The faciliating factors and the barriers faced in the implementation of CoCs were described to allow sharing of such learnings on large scale change. Strategies in overcoming some of the challenges were also presented to demonstrate the iterative processes required in building integrated place-based models of care to meet the needs of the residents in different communities. [ABSTRACT FROM AUTHOR]

Introduction: Telemonitoring has been proposed as an effective method to support integrated care for older people with hypertension and type 2 diabetes. This paper examines acceptability of telemontioring, its role in supporting integrated care, and identifies scale-up barriers. Methods: A concurrent triangulation mixed-methods study, including in-depth interviews (n = 29) and quantitative acceptability tool (n = 55) was conducted among individuals who underwent a 12-month telemonitoring routine. The research was guided by the Theoretical Framework of Acceptability. Interviews were analysed using template content analysis (TCA). Results: TCA identified seven domains of acceptability, with twenty-one subthemes influencing it positively or negatively. In the quantitative survey, acceptability was high across all seven domains with an overall score of 4.4 out of 5. Urban regions showed higher acceptability than rural regions (4.5 vs. 4.3), with rural participants perceiving initial training and participation effort as significantly more burdensome than their urban counterparts. Discussion: Patients described several instances where telemonitoring supported self-management, education, treatment, and identification elements of the integrated care package. However, there were barriers that may limit its further scale-up. Conclusion: For further scale-up, it is important to screen patients for monitoring eligibility, adapt telemonitoring devices to elderly needs, combine telemonitoring with health education, involve family members, and establish follow-up programmes. [ABSTRACT FROM AUTHOR]

Introduction: Development and implementation of the Townsville Lung Cancer Referral Pathway [TLCRP] aims to reduce delays and improve referral patterns of people with suspected lung cancer in north Queensland, Australia. Reported in this paper is the experiences and perspectives of general practitioners [GPs] and specialists of the TLCRP. Methods: This was a descriptive qualitative study nested within a larger project evaluating TLCRP, utilising a broader implementation science framework. In-depth, semi-structured interviews with GPs and specialists were conducted. An iterative, inductive thematic analysis of interview transcripts was used to derive key codes, then grouped into themes regarding participant experiences and perceptions. Results: Data analysis identified two major themes and several sub-themes. The major themes were variation in the uptake of TLCRP and enhancing coordinated care and communication. Discussion: Several enablers and barriers to implementing TLCRP were identified. Barriers to adaptation of TLCRP included lack of clinical time, resistance to changing referral patterns, lack of familiarity or experience with HealthPathways and technology issues. Conclusion: Emerging themes from this study may be used to reduce the barriers and improve uptake of TLCRP and other health care pathways in the local health service and may have wider relevance in other settings. [ABSTRACT FROM AUTHOR]

Introduction: This paper analyses and discusses the models and tools in the Finnish health and social care system to identify the individuals who might benefit from integrated multidisciplinary care. Description: The analysis and discussion of the paper is based on a study which mapped and studied the models and tools in practice or under development for identification in the Finnish health and social care organizations. The study used electric survey and structured interviews as research methods. Discussion: There are several different established models of identification in Finland and the experiences of using them are mainly positive. However, only every third of health and social care organizations in Finland have defined a common model or tool. The identification practices and criteria vary by region, municipality and/or organization. The identification is in general unsystematic and insufficient in practice that may inhibit the individuals to access the integrated care they might benefit from. Conclusions: Models and tools are needed for founding and identifying individuals who are outside the service system, those whose client-ship has just begun, and those who already access services. The identification of individuals for integrated multidisciplinary care and the assimilation and understanding of different identification models and tools requires the development of basic and further competence in the different fields of health and social care. Multidisciplinary collaboration requires shared concepts and positive attitudes on the development of integrated professional environments, identification models and services. It is therefore also a question of shared working culture. [ABSTRACT FROM AUTHOR]

The description of case management in research and clinical practice is highly variable which impedes quality analysis, policy and planning. Case management makes a unique contribution towards the integration of health care, social services and other sector services and supports for people with complex health conditions. There are multiple components and variations of case management depending on the context and client population. This paper aims to scope and map case management in the literature to identify how case management is described in the literature for key complex health conditions (e.g., brain injury, diabetes, mental health, spinal cord injury). Following literature searches in multiple databases, grey literature and exclusion by health condition, community-based and adequate description, there were 661 potential papers for data extraction. Data from 79 papers (1988-2013) were analysed to the point of saturation (no new information) and mapped to the model, components and activities. The results included 22 definitions, five models, with 69 activities or tasks of case managers mapped to 17 key components (interventions). The results confirm the significant terminological variance in case management which produces role confusion, ambiguity and hinders comparability across different health conditions and contexts. There is an urgent need for an internationally agreed taxonomy for the coordination, navigation and management of care. [ABSTRACT FROM AUTHOR]

Inter-disciplinary team working is an essential mechanism for the delivery of integrated care. This paper summarises a narrative review of the research on the ‘work’ that teams do to develop inter-disciplinary practices, addressing the question ‘How do interdisciplinary teams ‘become’ in the context of models of integrated care?’. The narrative review identities a gap in our understanding of the active boundary work that different disciplines working together to deliver care integration engage in when creating new interdisciplinary knowledge, creating an inter-disciplinary team identity and negotiating new social and power relations. This gap is particularly significant in relation to the role played by patients and care-givers. This paper presents a way of examining inter-disciplinary working as a process of creating knowledge, identity and power relations both in terms of a theoretical lens, circuits of power, and a methodology, institutional ethnography. An explicit focus on understanding power relations within inclusive inter-disciplinary teams in care integration will contribute to our understanding of the gap between theory and implementation of care integration by focusing on the ‘work’ that teams do to create new knowledge. [ABSTRACT FROM AUTHOR]

Introduction: Non-communicable diseases, such as arterial hypertension (HTN) and type-2 diabetes (T2D), pose a global public health problem. Integrated care with focus on person-centred principles aims to enhance healthcare quality and access. Previous qualitative research has identified facilitators and barriers for scaling-up integrated care, however the lack of standardized terms and measures hinder cross-country comparisons. This paper addresses these gaps by presenting a generic codebook for qualitative research on integrated care implementation for HTN and T2D. Description: The codebook serves as a tool for deductive or deductive-inductive qualitative analysis, organizing concepts and themes from qualitative data. It consists of nine first level and 39 second level themes. First level codes cover core issues; and second level codes provide detailed insights into facilitators and barriers. Discussion: This codebook is more widely applicable than previously developed tools because it includes a broader scope of stakeholders across micro, meso, and macro levels, and the themes being derived from highly diverse health systems across highand low-income countries. Conclusion: The codebook is a useful tool for implementation research on integrated care for HTN and T2D at global scale. It facilitates cross-country learning, contributing to improved implementation, scale-up and outcomes. [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: Action 3 of the UN Decade of Healthy Ageing plan is to deliver integrated care to improve older adults' lives. Integrated care is vital in meeting the complex needs of people with dementia but little is known about how this is or could be delivered in low and middle income countries (LMIC). This paper provides insights into previously unknown care system structures and on the potential and reality of delivering integrated care in Central America for people with dementia. Methods: A social network analysis (SNA) methodology was adopted to engage with providers of services for older adults and families with dementia in Guatemala, El Salvador, Honduras, Costa Rica and Panama. Sixty-eight (68) semi-structured interviews were completed, 57 with organisations and 11 with families. Results: Across the five countries there was evidence of fragmentation and low integration within the dementia care systems. A variety of services and types of providers are present in all five countries, and high levels of diversified connections exist among organisations of differing disciplines. However, unawareness among network members about other members that they could potentially form active links with is a barrier on the path to integration. Conclusion: This innovative and robust study demonstrates SNA can be applied to evaluate LMIC care systems. Findings provide baselines of system structures and insights into where resources are needed to fortify integration strategies. Results suggest that Central American countries have the building blocks in place to develop integrated care systems to meet the needs of people with dementia, but the links across service providers are opportunistic rather than context based coordinated integration policies. [ABSTRACT FROM AUTHOR]

Introduction: Population Health Management (PHM) focusses on keeping the whole population as healthy as possible. As such, it could be a promising approach for longterm health improvement in type 2 diabetes. This scoping review aimed to examine the extent to which and how PHM is used in the care for people with type 2 diabetes. Methods: PubMed, Web of Science, and Embase were searched between January 2000 and September 2021 for papers on self-reported PHM initiatives for type 2 diabetes. Eligible initiatives were described using the analytical framework for PHM. Results: In total, 25 studies regarding 18 PHM initiatives for type 2 diabetes populations were included. There is considerable variation in whether and how the PHM steps are operationalized in existing PHM initiatives. Population identification, impact evaluation, and quality improvement processes were generally part of the PHM initiatives. Triple Aim assessment and risk stratification actions were scarce or explained in little detail. Moreover, cross-sector integration is key in PHM but scarce in practice. Conclusion: Operationalization of PHM in practice is limited compared to the PHM steps described in the analytical framework. Extended risk stratification and integration efforts would contribute to whole-person care and further health improvements within the population. [ABSTRACT FROM AUTHOR]

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

Summary of speech: o In the context of the Government's QIPP agenda and Jeremy Hunt's challenge to the NHS to be paperless by 2018, scanning paper medical records has gained in popularity as Trusts seek to solve seemingly mutually exclusive challenges - remove a unsustainable paper process, improve the quality of patient care, enhance operational productivity while reducing cost. 엯 A variety of approaches have been taken to try to achieve this: 엯 Some Trusts have invested heavily creating in-house scanning bureaus; 엯 Others have digitised the whole record but paid little attention to navigation so clinicians are faced with hundreds of pages of notes in an unwieldy PDF. 엯 With 86,000 emergency admissions every year, 330,000 outpatient visits and 77,000 inpatient day cases - some 4,200 paper files moved daily - Aintree University Hospital couldn't 100% guarantee availability with clinicians complaining that finding information took too long. 엯 To address this, the Trust has implemented an electronic medical records system to provide clinicians instant access to patient information, guarantee notes availability, improve efficiency, and reduce the costs, risks and space associated with paper handling and storage. 엯 The EDMS solution cost £1.5 million, with the Trust realising annual savings of £1 million. o Professor Mike Pearson, consultant physician and the clinical lead on the project, will talk about the project - its goals, the solution deployed, what has been achieved, and how the project was successfully managed so that others - both clinicians and operational staff - can benefit from Aintree's experience. 엯 Ultimately it is not the actual software or the underlying technologies which have ensured success, but the careful application of them along with an understanding of the accompanying organisational and medical processes. This mandates a partnership between the suppliers and the Trust as all have to deliver which has been the case on this project. 엯 Outlined below is comprehensive detail which it is hoped the King's Fund will find useful as it selects speakers for the International Digital Health and Care Congress 2014 [Innovations in technology category]. Project goals: 엯 Aintree University Hospital recognised that it needed to implement a solution which offered two key things: 1. Addressed the issue of legacy patient records and all the problems associated with a paper management and delivery process; 2. Provided a platform for the future which had clinical support. 엯 All project goals have all been met which are summarised as follows: o Save money; 엯 Provide fast access to health records; 엯 Improve patient care through 100% records availability; 엯 Improve clinical effectiveness and safety; 엯 Provide multiple user access; 엯 Offer 24/7 multi-site access - even from home 엯 Be simple, dependable and secure to use; 엯 Have the support of clinicians; 엯 Be built on standards-based best-of-breed technology; 엯 Provide intelligent document searching; 엯 Provide future expandability; Solution 엯 Aintree University Hospital has stopped using paper health records in clinical practice. It has installed CCube Solutions' electronic document management software (EDMS) and custom portal to provide clinicians a digital version. Outsourced scanning services have been provided by Capita Total Document Solutions powered by Kodak production scanners and Capture Pro imaging software. 엯 To ensure system acceptance by around 3,000 health professionals who use it every day, the following was carried out: 엯 A clinical team was involved in helping define the functionality of the software which CCube Solutions has incorporated into the user interface design work. 엯 Workshops were also set up so that staff could engage with a prototype system and provide feedback to the project managers. Groundbreaking IT 1. 1st NHS Trust to successfully use forms recognition technology including OCR to automate the process of recognising pre-printed forms - which make up 95% of the paper file - when digitising records. This ensures contents are correctly indexed even if forms are incorrectly filed in the physical records. This is in contrast to other Trusts where staff manually go through the paper files prior to scanning to check and order contents. Forms recognition technology allows the system to automatically "find" forms in the scanned patient record rather than clinicians having to "search" for them. 2. 1st NHS Trust to successfully work with a third party using a scan-on-demand approach to outsource the huge task of scanning its records library. Capita Total Document Solutions (TDS) is providing this service using Kodak production scanning hardware and software to ensure high quality image capture. Data is then sent via a secure FTP link back to Aintree. 엯 282,000 patient files will be scanned which equates to 45 million pages. 엯 As outpatient case notes are used - on average - 21/2 times a year, once a person's file is scanned, the notes are available digitally for subsequent visits. Project management 엯 The project took 15 months and was completed on budget and to acceptable timescales. o A staggered rollout was adopted to: 엯 Minimise risk in contrast to a 'big bang' approach which would have meant the whole clinical community switching from paper to computers and changing working methods over night. 엯 Allow the project team to measure, learn, and improve each time a new department went live. 엯 Staff access the EDMS via the Trust's Patient Management System (PMS) when they login. Various IT solutions are integrated including pathology and radiology results, pharmacy, prescribing and theatre systems. o By linking the EDMS to other systems, Aintree University Hospital has ensured that information is sensibly integrated so that EDMS doesn't just become an archive, but directly improves sharing documents and collaboration among staff thereby enhancing organisational efficiency. 엯 Prior to starting the project, Aintree University Hospital ensured that its IT infrastructure was capable of supporting the new EDMS system and allowing remote access to it. Return on Investment: Financial & operational benefits 1. This is an 'invest to save' initiative and in line with the Government's QIPP agenda to improve the quality of care and make £20 billion of efficiency savings by 2014/2015. £1.5 million was spent on software, scanning hardware, and services with Aintree University Hospital saving £1 million annually based on reducing labour, transport and storage costs. 2. 30% space gain in a new £45 million building now used for clinical activities not paper storage - a £13.5 million estate benefit as a whole floor has become available. 3. 100% scanning of paper case notes by June 2012 which will allow Aintree University Hospital to close its records library. Paper files will not be provided to clinicians. 4. Headcount reduced by 50 with salary costs saved. Staff numbers have reduced through natural wastage and redeployment of some people to other vacancies. 5. The innovative use of forms recognition technology to index records automatically rather than having people do it is one of the reasons so much money is saved. 6. Aintree University Hospital measures the success of its medical records process using two metrics: a. Availability of records - 100% with the new EDMS solution. With paper, it was 97%. While a 3% non-delivery might appear low, this adds up to a considerable number of patient consultations given the thousands seen each year. b. Error rates converting paper to digital- 0. 4% working with Capita TDS to provide scanning services against a target of 1%. Clinical benefits 1. The fundamental principle of good records management is that the right patient file should be available at the right time for the right clinician. This has been achieved. Immediate access to the scanned notes improves the clinical experience and care provided to patients. 2. Integration with the Trust's PMS- clinicians don't have to use different systems to access historical records. 3. Innovative indexing means navigating is as quick or faster than with paper - the system allows "three or four clicks" to information. 4. Cleverly designed portal makes the record easy to use: a. Each section of the record is split by specialty; b. An innovative 'timeline' tool shows a patient's journey over time and what has happened to them. It lists all specialties seen with clinicians able to drill down to review what has occurred, when, treatment provided, by whom, and recent medical episodes - this is key for chronic disease management given patients tend to see more than one specialty; c. Fast access to actual test results such as X-rays, ECGs and respiratory function tests in addition to written notes. 5. Enhanced collaboration among clinicians who can access notes irrespective of their location using secure remote access technology. 6. Provision of all historical notes to clinicians whereas with paper only the current volume could be provided. This has helped clinicians diagnose patients who have had health issues spanning many years. 7. Easier exporting of information between Trusts if patients are referred elsewhere for specialist care. 8. Easier provision of medical information following legal requests as data can be provided electronically rather than via paper which has time/cost impact to process. An award-winning project The EDMS project at Aintree University Hospital has been recognised as being innovative winning a variety of industry awards over the past two years, as below: o Computer Weekly's European User Awards for Enterprise Software - public sector project of the year 2013; o eHealth Insider's Best use of IT to support healthcare business efficiency 2013; o Document Manager magazine's Gold project of the year 2012; o Techworld - shortlisted in the 2012 enterprise project of the year category; o UK IT Industry Awards 2012 - high commended in the best not for profit IT project category. Why should the King's Fund select Aintree to speak at the conference? o Digitising health records is not only an invest to save initiative, but it gets crucial patient information to the point of care automatically so people have a better clinical experience. The welldesigned solution deployed does just this and means Aintree University Hospital has stopped transporting paper files and trying to manage an unmanageable logistics operation. 엯 The challenge with any NHS IT project is getting computers to work the way medicine works rather than the other way round. Aintree University Hospital and its project partners have worked hard to successfully achieve this. 엯 To meet the QIPP agenda, the real temptation in a lot of NHS organisations is to find savings by not changing working methods. Aintree University Hospital has have not taken the easy route. It has completely re-engineered a mission-critical process, and saved money and improved patient care as result. In terms of a successful project, this is everything it could have wished for and what has been achieved. 엯 The project team would like to share its experiences within the health service both in the UK and internationally - health organisations who will have similar if not exactly the same issues with medical records management. KEY QUOTES CLINICAL: Professor Mike Pearson, consultant physician, says, "It's been hard work but now we've finished the project, we have a solution which is already saving the NHS money. The key innovation is the indexing so that data can be retrieved quickly and easily. This has defeated other projects in the past but we've managed to solve this working closely with our software partner. Our system is applicable to any hospital in the country and is a significant contribution to meeting the Government's target of hospitals being paper light. " Professor Pearson says, "Trusts must recognise that projects like this involve more than just buying a software package. It's implementing a system to process and digitise all your records while at the same time teaching staff how to manage them in the electronic new world. This must be done while keeping the service operational, so it's rather like changing an engine on an aircraft while it's flying." IT/OPERATIONS: Ward Priestman, the former IT lead on the project says, "This type of project is risky, difficult, and we went out on a limb to do it. We didn't just buy off-the shelf software, but created the solution in partnership with our IT suppliers such that we are at the vanguard of using this technology in the NHS. It means we are one of the first Trusts in the country to truly get legacy records management right - forms recognition, timeline view, and quick access to information to deliver a streamlined and modern solution which clinicians accept and like." [ABSTRACT FROM AUTHOR]

Introduction: Spain is one of the leading countries in the application of proactive and personalised telecare to help support frail and vulnerable service users to live independently in their own homes for longer*. Concern was however noted regarding potential impacts on ambulance mobilisations as time in the service, and mean age at cessation, increased by 1.3 years. Aims, Objectives, Theory and Methods: The purpose of this study was to investigate these impacts. A longitudinal study of a telecare service user population in Spain (n=202.1k to 247.9k) was undertaken using anonymised operational data collected in the delivery of proactive and personalised telecare services by Televida Servicios Sociosanitarios over the period 2014-18. The population was subject to change over time as new service users became eligible to register for the service, and others ceased the service. Each of these factors were also studied to assess potential confounding or covariate factors in the population also influencing the mobilisation of ambulances. Key Findings: For the studied population, ambulance mobilisation on a per-person/per-annum (pp/pa) basis reduced over the period despite the increasing age profile at cessation and with the characteristics of the population at registration remaining otherwise similar over the period. Overall mobilisations reduced by 27.9% (0.665 to 0.479 pp/pa) over the period whilst for ambulances there was a reduction of 33.3% (0.461 to 0.307 pp/pa). There were also smaller reductions in the number for family and state security mobilisations. The study identified the positive correlation coefficient between ambulance mobilisations and service user's dependency levels, and marginal negative correlation in older age bands. We are aware of no other studies which have investigated the impact on ambulance mobilisations of advanced proactive telecare and the increasing age of the services users supported to continue living independently. We believe this paper, therefore, contributes new insight which extends the existing research literature. Conclusions: The increasing age at cessation has not correlated with an increased proportion of higher dependency service users. The share of those over 85 years in the high dependency level decreased. This indicates that the changes in the telecare service contributing to increased time living independently may also have helped service users remain in lower risk bands. Limitations: There is a risk that use of mean annual measures may obscure important variations within the data. Changes in levels of proactivity, personalisation and increased use of sophisticated monitoring sensors of the telecare services are not the subject of this paper, but addressed in part in allied research. [ABSTRACT FROM AUTHOR]

Addressing new population needs, many countries are moving toward tighter integration of health and social care. Research has made considerable progress in identifying the core dimensions of integrated care, emphasising, for instance, the need for close provider relationships and coordinating care practices around patients' needs [1]. While these dimensions are widely known, we lack insight into how they emerge and change over time. Without a deep understanding of these dynamics, however, we cannot explain why initiatives fail or succeed. This paper explores the dynamics of integrated care, addressing an important gap in the literature [2]. To explore the dynamics of integrated care, the paper draws on pragmatist organisation studies [3]. Adopting a process ontology, pragmatism is well suited for this purpose. From this perspective, core dimensions of integrated care emerge and change as inter-dependent actors experience local break-downs, problems, or opportunities in their everyday work and care practices and continuously adapt these practices in communication-based deliberation [3]. The paper draws on a longitudinal single-case study conducted in the Swiss healthcare sector. It describes the emergence and change of a cutting-edge outpatient primary care centre, in which legally autonomous primary care and specialist providers jointly refer, diagnose and care for patients with complex needs. It includes data from 19 interviews, three days of non-participant observation, and 37 archival records, analysing how provider relations and care coordination emerged and changed over thirteen years. The data show that inter-dependent actors included not only a paediatrician turning quality problems in his practice into an opportunity to found the centre, but also architects, investors and other service providers. Over time, they experienced a series of problems including fragmented care, restrictive land use regulations, sceptical peers, cash drain, and rapid growth. They addressed this steady stream of problems in cycles of deliberation, recurrently restoring order from disruption, gradually building relationships, and increasingly coordinating care around patients' needs. Deliberation was typically based on bilateral conversations between the founder and other actors. While this communicative practice was initially helpful, it started impairing actors' problem-solving capacity as the founder became overwhelmed by the rapid growth of the centre, stalling advances in care coordination and straining provider relationships. The paper contributes to research by exploring the dynamics of integrated care, theorising the emergence and change of its core dimensions as grounded in inter-dependent actors' everyday work and deliberation practices amid a steady stream of problems and opportunities. The findings are relevant for theorists and policy makers alike, offering new glimpses into the "black box" of complex care integration [1, 2]. [ABSTRACT FROM AUTHOR]