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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: 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]

Public-private partnerships (PPPs) are increasingly used to develop, finance, and provide public health infrastructure and service delivery [1]. They combine the strengths of private actors, e.g., innovation, technical knowledge, and entrepreneurial spirit, with the knowledge and social responsibility of public actors to develop beneficial health outcomes However, literature indicates that further research is necessary to understand the conditions and impact of such collaborations to suggest when, how and to what extent PPPs should be favored [2]. This paper presents a PPP between the Region Zealand University Hospital, Køge and Blue Ocean Robotics. The result of this innovative collaboration is the Patient Transfer and Rehabilitation (PTR) Robot that has been developed to reduce healthcare professionals' injuries and support them in their work, providing patients a higher quality of care. Hospitals spend a lot of resources on conventional patient handling procedures and manual patient handling is not an effective way to reduce injuries to caregivers, due to high risks of musculoskeletal overexertion and acute onset. Thus, the hospital looked for more efficient and flexible alternatives that would benefit both patient and caregiver and integrate rehabilitation in the daily care routines. The project began in 2016 and included a mix of methodologies that had patients and caregivers in focus. This paper presents the results collected in the last phase of the project during the introduction of the new technology into the hospital's wards. In 2021, two PTR Robots were delivered to the hospital. Two main actions were planned to onboard the users: a) introductory workshop with 211 healthcare professionals from different wards (orthopedic, surgical, and geriatric) and b) "superusers" training. Besides the need to gather qualitative feedback from real users, the workshop sessions were strategic to arouse curiosity, engagement, and motivation about the robot in their workplace. At the end of the introductory workshop, participants filled out a usability questionnaire, which was applied to quantify their experiences: • 93% of participants agreed that PTR Robot is easy to use. • 94% of participants agreed they would use PTR Robot again in their workplace. • 88% of participants agreed that PTR Robot is quick to learn. In the second stage, small groups from the hospital's staff were educated as "superusers". Based on the ethnographic approach, the "superusers" act as the key-informants of the development team, as well as "coaches" of the rest of the hospital staff. The paper gives insights into practices of a successful PPP. The results can guide healthcare institutions to better understand how to enable new collaborations and what activities have higher possibility for success. Limitations concern the applicability of the results as these are based on a single PPP with two partners from the same country focusing on the development of robotics technology. [1] Anderson, S. (2012). Public, private, neither, both? Publicness theory and the analysis of healthcare organisations. Social Science & Medicine, 74(3), 313-322. [2] Roehrich, J. K., Lewis, M. A., & George, G. (2014). Are public-private partnerships a healthy option? A systematic literature review. Social science & medicine, 113, 110-119. [ABSTRACT FROM AUTHOR]

Introduction: In the worldwide COVID-19 pandemic, healthcare workers (HCWs) caring for people with intellectual disabilities (ID) face a unique risk above the already heightened occupational risk all HCWs are exposed to, but literature on this specific group is lacking. Understanding why individuals are hesitant to be vaccinated for COVID-19 is essential in order to provide the right measures in improving vaccination numbers. This article reviews the influencing factors of COVID-19 vaccine willingness and hesitancy in HCWs who work with people with ID. Methods: CINAHL, APA PsycArticles, APA PsycInfo, Web of Science, Semantic Scolar, Prospero, Outbreak Science, Cochrane and Scopus were searched for papers including the attitudes on COVID-vaccination of HCWs in the field of ID-care. Only two papers were found on HCWs working with people with ID, therefore the search was broadened to HCWs in general. Twenty-six papers were identified containing quantitative and qualitative data on 43,199 HCWs spread over 16 countries worldwide. Socio-demographical predictors of vaccine willingness were extracted and analysed, as well as attitudes of vaccine willingness and hesitancy. Results: Medical doctors, people of older age, men, and those previously vaccinated with the influenza vaccine were most willing to take the COVID-vaccine. Health factors and ethics were drivers of vaccine willingness; characterised by perceived COVID-threat and wanting to protect family members and others. Distrust and lack of information were the most common drivers of vaccine hesitancy; characterised by concerns on side effects, vaccine safety, vaccine efficacy, and speed of vaccine development. Limiting to the two papers investigating HCWs in the care of people with ID, some similarities were found: (1) only older age was a predictor for vaccine willingness and (2) concerns about possible side effects and the fast development of the vaccine were the main drivers for vaccine hesitancy. Additionally, vaccine willingness and hesitancy in HCWs are not stable over time and are affected by information sources and contextual factors. Conclusions: To achieve the highest COVID-vaccination degree worldwide amongst HCWs, recommendations are made for interventions on distrust-topics to nursing staff, people of younger age, women, and those not previously vaccinated within the HCW-population. Implications: Additional research is needed to specify more precisely the attitudes of HCWs caring for people with ID in general and in more countries worldwide. [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]

This paper examines the proposition that temporary project-based organizations that operate across the formal boundaries and hierarchies of health and social care organizations can create 'trading zones' in which different types of knowledge can come together as new multi-disciplinary practices are constructed. The paper presents new case study evidence that shows how small project-based teams of care professionals from previously separate provider organizations were able to create dialogic 'spaces' and strong project identities that facilitated the sharing of useful knowledge. These teams included senior social care managers whose ability to make effective use of population health data was mediated and facilitated by their ability to form 'guiding coalitions' that allowed them to claim and demarcate new operating jurisdictions. Middle managers played a proactive role as 'horizontal integrators' that were able to orchestrate divergent skills and learning capabilities. Project-based teams also included supervisory grade service managers whose involvement allowed the design and subsequent routinization of new services to be directly informed by the situated knowledge and experience of those working at, or close to, the front-line of care provision. [ABSTRACT FROM AUTHOR]

The achievement of integrated care requires innovative, cross-sectoral and interdisciplinary collaboration in relation to workforce capacity and capability. Such collaboration can be furthered by collaborative, participatory health research in which people in the field under study and university researchers co-produce knowledge across different epistemologies and institutional contexts. However, co-producing knowledge across different knowledge forms and institutions faces challenges rooted in tensions. The tensions arise in the complex relational work which collaboration across disciplines and institutions necessitates. This paper is based on the assumption that critical, reflexive analysis of these tensions can further develop innovative collaboration and, in so doing, enhance workforce capacity and capability in relation to integrated care. Our research question is as follows: In collaborative research practices across institutions, how do different knowledge forms come into play, what tensions arise and with what implications for the enhancement of workforce capacity and capability in relation to integrated care?" We address this question through critical, reflexive analysis of a collective research project designed to enhance workforce capacity and capability, and more specifically, the recruitment and retention of nurses. The main collaborative research partners are junior and senior researchers from the Region Zealand and Roskilde University, including professors, associate professors, Ph.D. students and a Postdoc. The collective project consists of the following collaborative, participatory sub-projects: 1) conflict de-escalation in hospitals (Ph.D.) 2) nurses' workplace environment and satisfaction (Ph.D.) 3) nurses' choice of specialisation (Postdoc). Theoretically, our analysis draws on dialogic communication theory, Foucauldian poststructuralist theory and Bennett and Brunner (2020: 2)'s concept of a 'buffer zone': a "dynamic, contextual space and set of practices necessary to undertake collaborative research within contemporary, complex arrangements". Using the methods of discourse analysis, we analyse the following data: advertisements for the doctoral and postdoctoral posts; policy documents about the recruitment and retention of nurses; audio recordings of meetings between the collaborative research partners; email correspondence between the partners. The analysis provides insight into the tensions that arise in struggles for legitimacy across conflicting understandings of "co-production" and "intended outcomes". One main tension arises between an orientation towards outcomes designed to generate innovative solutions to complex problems and an orientation towards processes designed to provide a strong foundation for dialogic learning across difference. An orientation towards outcomes carries the risks of overly instrumentalizing co-production and reproducing the existing hierarchy of power and knowledge. An orientation towards research processes of dialogic learning and caring can face difficulties in meeting the criteria for "evidence" that dominate the practice and research fields and finding a constructive course of action leading to practice change. In conclusion, we expand on how the approach to critical-reflexive analysis illustrated in the paper represents a strategy for furthering the innovative collaboration, which enhances workforce capability and capacity and is at the core of people-centred integrated care. [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]

Introduction & Context: Population Health is a term popularised by Kindig and Stoddart in their 2003 paper which defined it as "the health outcomes of a group of individuals, including the distribution of such outcomes within the group." Its initial formulation focused on health statuses and was synonymous with the "health of the population". The paper pointed out that many (commercial and socio-ecological) factors beyond the usual biomedical determinants influence health outcomes, and encouraged a greater focus ""on health outcomes (as opposed to inputs, processes, and products) and on determining the degree of change that can actually be attributed to our work." Over time, the semantic range of the term has expanded beyond the initial tension between "a field of study" and "a concept of health", to include the actions undertaken by various agencies to improve the health status of the population (much like how the single phrase "Public Health" can connote (a) the interventions based on (b) a field of skills and knowledge for (c) desired outcomes). It would seem logical (especially to the clinically-oriented professional seeking always to improve the health of an individual whatever their current situation as presented) that the ultimate health of the population is the sum of the health of its members, and each professional and provider will do their and its bits wherever they are. In the context of unending needs and wants and limited resources however, it is not tenable to adopt the scattershot approach of multiple disparate efforts by all and sundry. The challenge is to focus not only on ""what moves the needle the most significantly" but also ""what moves the most significant needles". Disease and death are inevitable, and measuring current outcomes as "population health" data can be insightful and suggest next actions for specific problem areas but does not help design the complex "portfolio" of different interventions for multiple problems across the whole population. Method & Results: What is needed then is a way to (a) first summarise across the health of the population with clear, defined and agreed top-level objectives based on the relative disease burdens and community priorities, and then (b) systematically analyse each top level indicator for its key determinants and subdeterminants, to (c) identify and intervene intentionally on those elements that most contribute to the larger health of the population based on societal mores and national policies, and (d) monitor and evaluate progress and impact on the health and wellness of the population. This presentation will first propose a high-level population health dashboard that summates the current health outcomes and healthcare delivery, based on the paradigm that the key to the best possible health of the population is in optimising (a) disease prevention, (b) early detection and (c) clinical management. Similarly to how financial statements efficiently present a financial picture of a firm for more effective and informed decision making and enterprising planning systems enable efficient resource and process management, this dashboard will guide policy setting, portfolio design and programme implementation, and progress monitoring, to maximise the outcomes for the whole population based on intentional objectives. While illustrations will pertain to the local context, the general principles, like accounting standards, can be applied to a wide variety of constituencies and contexts. Conclusion: Healthcare is complex and adaptive, and is not susceptible to "simplistic reductionist" silver bullets. The concept of population health as defined by Kindig and Stoddart highlighted the need to move beyond the biomedical conceptualisation of health and healthcare. Implementing interventions and reforms across a fragmented or disjointed front will make some progress but will also create unintended side-effects amid potentially considerable wastage. A dashboard, analogous to financial reporting and enterprise planning systems, that is able to present an integrated and coherent construct linking macro objectives and policies with ground programmes and resource utilisation will be very useful to a coherent intentional approach to maximising the health of the population through population health action. [ABSTRACT FROM AUTHOR]

Introduction: Health systems around the world are being redesigned to address issues of poor care coordination, weak information flows, increase in care spending, disparate safety and quality, and inequitable population health outcomes. In the past decade, Accountable Care Organizations (ACO) have risen in the health policy landscape as promising instruments to incentivize both healthcare quality and efficiency through the creation of shared accountability and shared risk delivery systems. ACO-like organizations refer to incentivized entities in the form of legal networks, including hospitals, primary care providers, specialists, community organizations and other system partners, that are financially and clinically accountable to coordinate and deliver continuums of care to attributed populations. ACOs are namely dominant in countries such as the United States, Canada, Australia, the United Kingdom and the Netherlands. More recently, ACOs are growing as potential incubators for large-system care integration. However, to this day, little research has been done on the particular challenges and opportunities arising from reforming integrated in the context of ACO-like organizations. Aims, Objectives, Theory or Methods: We aim to better understand the particular challenges and opportunities for reforming integrated in ACO-like organizations. We conducted a scoping review (Summer-Fall 2021), systematically investigating six bibliographic databases to search, screen and select relevant literature ACOs and integrated care. We screened 521 papers, then completed a full-text review of 105 identified as relevant based on title and abstract. A total of 36 papers were retained for analysis. Data were extracted and synthesised through descriptive and inductive thematic analysis. Highlights or Results or Key Findings: We identify four preliminary clusters of challenges and opportunities towards reforming integrated care in ACO-like organizations. First, numerous studies support that ACOs' shared governance and accountability models raise significant challenges towards care integration. Variability in terms of organizational maturity, institutional logics, and partner engagement strategies namely emerges as factors that would influence the capacity of ACOs to establish shared governance and accountability. Second, the slow development of digital health and data-driven patient navigation functions in ACOs currently hinders population health management capacity building that is crucial to integrated care. Third, collective incentives are still in development within ACOs. An increasing body of research supports that shared risks and rewards might not be sufficient to overcome the various boundaries (clinical, financial, technical, normative, organizational) that keep system partners disintegrated. Finally, patient and community engagement as a strategy for integrated care remains premature and rarely incentivized in ACOlike organizations. Conclusions: Challenges of reforming and delivering integrated care within ACO-like organizations namely include shared governance and accountability, digital health and patient navigation capacity, collective incentives and patient engagement. Further research should focus on how ACOs may go from offering levers (financial, technical) to support care integration at the organizational level, to conveying true integration at the point of care. Implications for applicability/transferability, sustainability, and limitations: With both integrated care systems and ACO-like organizations thriving as health system priorities, we hope to provide timely and actionable knowledge on how to build better capacity and greater accountability for integrated care system-wide. [ABSTRACT FROM AUTHOR]

Introduction: In recent years, engaging people in research has received increasing recognition as a method for improving person-centered research practice, clinical practice and healthcare. this generates a need for more transparent research, measuring how person-centered methods impacts research and the development of research-based solutions. Hence, this paper conducts a process-evaluation, examining how the involvement of health professionals, patients and their relatives impacted the development of BackTrace. BackTrace is a people-centred digital solution for patients with low-back pain. It empowers patients to engage in their own health and support a dialogue-based person-centred communication between the patients and the health professional and the inter-professional dialogue. Aim: To investigate the impacts of user involvement on development of a digital health solution BackTrace. Methods: A two-part retrospective process evaluation examines the level of user involvement (patients, relatives and healthcare professionals) in development of BackTrace. First part; describing, through the INVOLVE conceptual framework, the range and content of user involvement during the development process, using qualitative interviews with the project management. Second part; examining and identifying user input aimed at developing BackTrace through text condensation. 50 documents were screened, containing field notes from workshops and meetings with users. 30 documents were included for further analysis. 700 inputs were identified; after which they were categorized into themes. Results: The interviews are conducted and the analysis is proceeding. Initial findings show a clear description of why and how people were engaged and involved throughout the development phase of BackTrace. The analysis of inputs from users is completed. It resulted in 8 themes exemplifying areas of impact; Content, Information, General features, Treatment plan, Empowerment, Target group, Challenges and Information technology. Conclusion: The initial analysis of data, shows a decisive impact from user input to the development of BackTrace. They helped ensure relevant content that can empower patients, by engaging them as an active part in their treatment and assist professionals in making a shared treatment plan. Implications for applicability: This paper illustrates how user involvement in research can help develop person-centred solutions for healthcare. It ensures that solutions address the both health professionals and patients' needs, but also a means of empowering them in managing their health. [ABSTRACT FROM AUTHOR]

Introduction: The management of chronic diseases and multimorbidity is an important part of primary healthcare. Current disease management programs focus primarily on a single disease, while multimorbidity and social problems often co-occur. Person-centered integrated care delivered by interprofessional collaborative teamwork tailors care to the needs of the individual patient and empowers the patient to become an active participant in his own care. However, it is uncertain how healthcare professionals can be optimally equipped to deliver care and participate as team members in this contemporary approach. Objective: In this review, we explored what competencies primary healthcare professionals need to deliver high-quality person-centered integrated care, and how these competencies can be acquired. Methods: We performed a scoping review guided by the methodological framework proposed by Arksey and O'Malley. Guidelines and chronic disease management programs were searched in the Trip medical database with the following terms including their linguistic variations; a) primary care, b) integrated care, c) chronic illness, d) multimorbidity, e) shared decision making and f) competencies. Next, using the same keywords, we searched for peer-reviewed articles in the following scientific literature databases: Cinahl, Embase, PubMed, Medline, and Web of Science. Grey literature was hand-searched through websites of relevant national and international journals, scanning reference lists and through Google and Google Scholar. All titles and abstracts of both the guidelines and peer-reviewed articles were reviewed against inclusion and exclusion criteria and screened independently by two researchers. Then full text publications were retrieved and synthesized when they met the inclusion criteria. Results: The screening resulted in 17 guidelines and 89 articles to be obtained in full text. After reading full text papers, a total of 4 guidelines and 21 articles met the inclusion criteria and were included in the data synthesis. Next to several subthemes four main themes were identified; interprofessional communication, interprofessional collaborative teamwork, leadership and patient-centred communication. However, all included papers lacked a description of competencies' core concepts, such as knowledge, skills and attitudes necessary for the personcentered integrated care approach or how competencies can be acquired in addition to academic or bachelor professional training. Conclusion: This review provides an integrative view on professionals' competencies necessary for person-centered integrated care within the practice of primary care, though details on competencies' core concepts are lacking. More research is needed, on competencies and educational programs to ensure healthcare professionals in primary care are better equipped to deliver person-centred integrated care for chronic ill patients. [ABSTRACT FROM AUTHOR]

Introduction: Primary healthcare (PHC) in Sweden is under transformation following an extensive governmental reform, called "Good quality, local health care". The reform aims to re-establish PHC as 'front-line care' and to strengthen the quality of PHC, largely by integrating person-centred solutions. Digital solutions are foreseen to play a significant part in the transformation as well as stronger coordination between municipalities and regions. The suggested focus of the reform indicates areas where policy makers think changes are needed. It is important to scrutinize the "solutions" proposed, as problem representations justify or legitimise certain policies or policy solutions. Aim and method: This policy analysis aims to explore problem representations in the Swedish healthcare reform. Four main policies underpinning the reform were identified and documentations of those retrieved. To unpack the 'problems' represented in the reform, the "What is the problem represented to be" (WPR) approach developed by Bacchi was applied (1). Guided by Bacchi, the proposed solutions in the policy documents were analysed and evolved into three preliminary themes, which form the basis for the problem formulations. This paper is work under progress. Key findings: Three overarching problem formulations unfolded. First, by proposing that the development of a modern, accessible, and effective healthcare system that focus on PHC will depend upon a new definition and a common roadmap, the reform represents the 'problem' as a 'nebulous care mission and narrow health system scope'. The second 'problem' was developed based on solutions concerned with strengthening the collaboration between regional and municipal care actors. The reform locates the 'problem' primarily within the organisational realm of the health system while representing it as the 'silos of differentiated care systems and processes'. The third 'problem' builds on solutions intended to bring services closer to people and ensuring that the services are relevant to the needs, wishes and preferences of the patient(s). In this regard, the 'problem' is represented as care that is 'distant and detached from (individual) patients'. Conclusion: The problem representations developed by the policy analysis can be traced to earlier PHC reforms aiming to give the municipalities the responsibility of elderly care (2) and individual patients more power to influence their care (3). The reform is silent on equity between social groups which warrants further scrutiny. Implications to the ICIC 2022 Conference: The paper suits the first theme since personcenteredness is at the core of the reform. Being a policy proposal, it adheres especially well to the sixth pillar which directly addresses policymaking. Knowledge-sharing from Swedish healthcare may thus be useful for other countries in transition. 1. Bacchi C, Eveline J. What's the problem represented to be Mainstreaming Politics: Gendering Practices and Feminist Theory. 2010;111. 2. Edebalk PG. Den dramatiska Ädelreformen. Äldre i centrum: tidskrift för aktuell äldreforskning, 2021, 35, 111-113 3. Burström, B., Burström, K., Nilsson, G., Tomson, G., Whitehead, M., & Winblad, U. (2017). Equity aspects of the Primary Health Care Choice Reform in Sweden-a scoping review. International journal for equity in health, 2017, 16(1), 1-10. [ABSTRACT FROM AUTHOR]

Background: There is little evidence showing the effectiveness of integrated healthcare initiatives to improve population health. Moreover, current guidelines for evaluation have shortcomings that could lead to misleading conclusions. Our paper focuses on the evaluation of Gesundes Kinzigtal, a German best-practice integrated healthcare initiative previously evaluated in a quasi-experiment using propensity score matching. The challenge arises when realizing the design selectively excludes treated participants. Integrated initiatives like Gesundes Kinzigtal seek to improve health by introducing specific interventions in the whole spectrum of patients and care services, in what is known as a whole system approach. Because it is unknown where in the spectrum of patients are the biggest gains of integrated healthcare, the non-random exclusion of a portion of the sample can bias the evaluation in an unknown direction. Aim/Methods: By creating an evaluation design that overcomes previous challenges, our paper aims to correctly evaluate the effect of integrated healthcare over population health outcomes. We performed two quasi-experimental evaluations and compared their results and validity. One evaluation used the design outlined in previous literature, while the other used our new design based on entropy balancing. The evaluations compared patients enrolled in Gesundes Kinzigtal to a control group of non-enrolled patients of the region and follow them for 5 years. Claims data from 2004 to 2018 was used. Population health outcomes correspond to survival (Cox hazard ratio, Kaplan-Meier curve), mortality ratio, mean age at the time of death, and years of life lost or gained. Results: In the entropy balancing based evaluation, 9083 treated participants were compared to an equivalent control group, showing, respectively, a mortality ratio of 5.4% vs 7.5% (p < 0.05), mean age at the time of death of 80.1 vs 80.3 (p>0.05) and a gain of 0.2 years of life per person for the treatment group (p >0.05). The Cox hazard ratio (0.72; p<0.05) indicates a lower risk of death for the treated, in line with greater mean survival time (1784 vs 1768 days; p<0.05). The results of the propensity score matching-based evaluation were more favorable to the treatment group. However, when compared to the matched participants, unmatched treated participants in the propensity score design had significantly more physician visits, hospitalizations, number of prescriptions, Charlson comorbidity score, and other indicators related to greater healthcare needs. Conclusion: Gesundes Kinzigtal had a favorable effect on the mortality and survival risk of the enrolled population at the time of assessment. Previous evaluation designs might overestimate this effect by excluding patients with greater healthcare needs. Consequently, our results suggest that health gains resulting from the integrated healthcare approach diminish for patients with high healthcare needs. Implications for applicability/transferability: Our work presents readers with a robust evaluation design to evaluate the effectiveness of integrated healthcare systems over population health outcomes. Furthermore, it provides useful insights for the discussion regarding the relationship between patient's healthcare needs and integrated healthcare health gains. [ABSTRACT FROM AUTHOR]

Almost everyone who works in healthcare aims to create person-centered care. That is care which is accustomed to the needs and questions of the network that has to deal with a disease. But, in our day to day practices, it is hard to take time for reflection on what actually is the 'personcenteredness' in the care that we provide. This project aims to 'see' person-centered care, to 'catch' the person's behind the person with Parkinson's and their care professional, and to capture the 'essence' of their relationship. Next to more conventional qualitative methods, we used an innovative approach: we worked together with an artist. A photographer. Whether we indeed 'caught' person-centered care, we leave to the viewer. In any case, our approach yielded a powerful combination of intimate words (quotes) and imagery (portraits) that describes and ascribes key elements of person-centered care: touch, diagnostics, support, activation, time, self-image, and so on. Next to academic output in the form of a book, and two papers, the unique combination of narratives and photographs is now also used in the education of care professionals and university students. [ABSTRACT FROM AUTHOR]

Patients need better coordinated health services, and coordination has always been a part of what nurses do (1). Yet, professionally led development of coordination depends on whether this is regarded as a legitimate professional task. A central element of professional logic is to grant or deny legitimacy to actions based on the view of relevant professional problems and attached views of valid evidence (2). Thus, if coordination is not viewed as a legitimate part of nursing, no endogenous development and innovation of such tasks can be expected to take place. Thus, the object of this paper is to provide empirical insight into the professional self-concept of inter-organisational coordination (IOC) based on a qualitative case study involving 44 Danish nurses and nurse leaders from hospitals, municipal institutions and general practices. Empirical material included field observations and five focus groups. In exceptional cases, nurses interpret IOC as 'outside nursing' due to the administrative character of the work and because it did not match the nurses' general understanding of nursing. Ambivalence towards IOC was the dominating picture reflected in numerous accounts related to the demarcation of the nursing job, awareness of IOC tasks, the nursing education, the office location and finally the distribution of IOC tasks among staff members. E.g., one the one hand, the nurses themselves feel unable to explain this work to outsiders. On the other hand, the nurses criticise 'the healthcare system' for not recognising the IOC they perform. Understanding 'IOC as inside nursing' is also a rare interpretation, but some nurses express a functional based self-understanding: Since IOC is a comprehensive part of nursing work; it also becomes a natural part of what nursing is. Furthermore, the nurse leaders have a fairly clear stand on this, as they link IOC directly to nursing and even to the professional core concept of caring. Consequently, the professional self-concept of IOC can be characterised as a non-homogeneous inter-mixture of rejection, profound ambivalence and inclusion. The findings implies that an explicit link between coordination and the concept of caring can promote legitimacy. These findings do not rule out the existence of alternative interpretations of the relationship between IOC and nursing among other categories of nursing professionals (e.g. academics or educators). The Findings do imply, however, that such potential ideas have not been spread to clinical professionals at the front line of healthcare. How then can nursing be evolved to meet the patients' needs for coordinated health services? At the very least, it seems relevant to make the existing knowledge of operative coordination within nursing more visible, so that nursing students may benefit, and coordination theory from organisational science should be included in the nursing curriculum. [ABSTRACT FROM AUTHOR]

This paper outlines the evaluation strategy of the EMPOWERCARE, an EU Interreg 2 Seas funded social innovation project, which involves a partnership of local authorities, universities and nongovernmental organisations from four European countries: Belgium, France, the Netherlands and the United Kingdom. Partners are working in collaboration with local people aged 65+, and those aged 50+ with at least one chronic condition, to respond to current gaps in the care of older people. The project aims specifically to contribute to person-centred care and technology knowledge transfer whilst reducing isolation, loneliness and increasing solidarity amongst older people and their communities. During the project, partners are jointly developing a strategy for implementing good-practice models, a workforce transformation approach via shared training and a technology blueprint with emphasis on caring digital technologies to address the rising demand for health and social care services for older people. The project addresses this challenge by drawing on community assets, involving older people in decisions about their own health and wellbeing, enabling them to keep healthier and in their own homes and communities safely for longer. The project's evaluation aims to measure the impact of the EMPOWERCARE initiative across 7 pilot sites in the 4 participating countries. Given the Covid-19 pandemic, the evaluation design has been developed with a view to being agile and able to respond to complex and shifting situations, and especially so in terms of what and how data are collected. A realist synthesis approach (Pawson & Tilley, 2004) guides the evaluation within a descriptive case study design (Yin 2003) to identify and contextualise the project strategies that are influential within and across the 7 different case study sites. The evaluation uses multiple interdisciplinary methods, such as surveys, Photovoice and Social Return on Investment, to capture a range of perspectives across three timepoints, baseline (T0), mid-point (T1) and end-point (T2). Online surveys are conducted with both end-users and the workforce in all pilot sites at T0 and T2. At T1, end-users are actively involved in creating visual data through Photovoice to capture their lived experiences with local initiatives in pilot sites. Visual data are going to be displayed at pilot site exhibitions targeted to key local stakeholders and members of the workforce. Focus groups will be conducted with all participants reflecting on the visual data exhibition to explore insights about the initiative from current and future perspectives. This aspect is informed by a Social Return on Investment approach. The sequential data collection of multiple sources and longitudinal study design identify patterns of change and impact. The evaluation design will deliver a theory-driven rich explanation of what works about EMPOWERCARE and for whom, why, how and in what circumstances it works. The analysis of the evaluation findings will contribute to a more empowered person-centred approach, with more inclusive and caring digital health solutions that will allow policy makers to develop localised, efficient and social-value driven services to meet the rising needs of older people in the European regions. [ABSTRACT FROM AUTHOR]

Introduction: We analyzed the Service Models of 30 integrated care initiatives, through a systematic comparison of their Service Components and the related technological opportunities. Description: Twenty initiatives (13 full-scale Programmes and 7 pilots in EU-funded projects) belong to a sequence deployed in Badalona (Catalonia, Spain), where the joint health and social care delivery is active since year 2000. They were evolving over time to meet an increasingly extended range of integration needs between 2003 and 2015, when a pervasive, persistent ecosystem on Integrated Care was achieved. They are individually described in published papers; however, a systematic interpretation to highlight the major features of the journey was not yet available [1]. An additional set of ten initiatives comes from pilot activities performed in various EU-funded Projects. We used the toolkit named ""Service Deployment Outline"" (SDO) [2], a format to guide an expert having an active role in an initiative to perform a subjective but disciplined exploration of the Service Components of the related Service Model. Discussion: We interpreted the transformation processes carried, with the underlying vision and design strategies, according to various perspectives, such as: the evolution of the Service Components that addressed the most challenging integration needs; the roles of the technologies in the evolutionary processes; the factors influencing the adoption of the initiatives. Lessons learned and limitations: We worked out a number of factors influencing the propagation speed for different Service Models [3]: they marginally affect the spontaneous penetration of technology-oriented initiatives, slow down the spread of those with a clinical connotation, and severely limit the adoption of those with a strong organizational attitude. Most initiatives were labelled as ""Basic"": they are scalable, replicable, measurable, yielding a high Value and thus set up the foundations for a widespread ecosystem in a Region. They belong to three classes: - long-term follow-up of complex chronic conditions: - long-term follow-up of frailty and mobility impairment; - short-term follow-up after a severe health-related event. Other initiatives are ""Complementary"", i.e. they address narrow topics or they build on the Basic ones, eg. remote follow-up of implanted cardiac devices or treatment of depression. The unavoidable peculiarities of the context in any jurisdiction in a given period make it impossible to directly generalize our results; nevertheless, this study could facilitate a similar analysis in other localities. Conclusions: Similar studies, replicated to design or assess Roadmaps in other jurisdictions, could bring to a better understanding of: - the actual deployment of innovation processes on integrated care; - the priorities for service transformations; - the relations between integration needs, service components and technologies. [ABSTRACT FROM AUTHOR]

Introduction: Although many countries have been implementing integrated care, the scale-up remains difficult. Macro-level system barriers play an important role. This is also the case in Belgium, which has a complex governing system where both the federal and federated governments have responsibilities concerning health care. By selecting three key policies, which have implemented integrated care in Belgium over the last 10 years (the federal care trajectory for diabetes, the joint plan for the chronically ill and the reform of primary care in Flanders), we aim to go beyond the identification of their specific barriers and facilitators to obtain an overarching generic view. Methods: 27 participants were purposefully selected, to include all important stakeholders involved on the macro-level in chronic care in Belgium. Policymakers, public administrators, finance stakeholders, provider organisations, user and patient groups and scientific stakeholders were included. Semi-structured interviews were guided by a timeline of policies and performed by two researchers. The main topics of the interview guide were: stakeholder role, their understanding of integrated chronic care, and the barriers to and facilitators of the development and implementation of integrated care policies. The interviews were transcribed verbatim and an inductive thematic analysis was performed and repeatedly discussed within the team. Results: Stakeholders had diverse interpretations of integrated care, but agreed that implementation of integrated care in Belgium is still suboptimal. Barriers and facilitators were identified on both health care and policy level. A major barriers is the fee-for-service system, which does not stimulate cooperation nor quality of care. Within the topic of data sharing, many strategies have been formulated, but the implementation lacks, which hinders again cooperation. A last major barrier is the fragmentation of responsibilities between different levels of government. It leads to confusion, but mainly it hinders integrated care as different policy-makers head in different directions and so it is difficult to align plans, especially on the long term. Remarkably, these factors strongly interact. Conclusion: The scale-up of integrated care is influenced by multiple factors, which interact with each other. The preparedness to change at both the policy level and health care level will be key to triggering a transformation leading to integrated care. However, important barriers, are hindering a much needed change to the entire Belgian health care system and a shift towards integrated care. Implications: This paper highlights the importance of homogenization of responsibilities of governments regarding integrated care and the interdependency of policy and health care system factors. A whole system change is needed instead of the current Belgian model of prolonged search for common ground between conflicting opinions. A focus on the financing system seems important in this regard. Political commitment and citizen participation will be crucial. [ABSTRACT FROM AUTHOR]

Introduction: Integrated primary care (IPC) models have empirical support for improving access to and quality of behavioral health care and can be effectively implemented in a diverse range of formats1. Various studies have demonstrated that primary care service providers tend to positively endorse IPC models of pediatric behavioral health care, especially in comparison to traditional, non-integrated care2-3. However, there is a paucity of research evaluating parent perceptions and attitudes towards behavioral health care, especially when delivered in an IPC setting. The present paper describes a survey tool designed to better understand and meet patient care needs. Methods and Aims: The Parent Acceptance of Pediatric Integrated Care Survey (PAPICS) was developed by a multidisciplinary panel of integrated care experts at the University of Michigan Medicine to evaluate parent perceptions and acceptance of integrated primary care (IPC) models for treatment of behavioral health problems in children. In response to the COVID-19 pandemic, the PAPICS was expanded to include more items focused on virtual services in IPC and revised to address items with poor factor loadings. Methods include Exploratory Factor Analysis (EFA) and Confirmatory Factor Analysis (CFA) to analyze and validate the survey. Results: The original 35-item PAPICS was distributed to parents pre-pandemic with children under 18 across the United States and was completed by 422 respondents4. Items on this survey largely pertained to face-to-face care within the clinic and an EFA only was conducted to analyze the data. Parents overwhelming favored an IPC model and supported learning skills to help their child. More variability was evidenced for parents' perceptions of one-on-one talk therapy between their child and the psychologist. Some parents had concerns about stigma and privacy, but agreement was more inconsistent. After the World Health Organization (WHO) declared COVID-19 a global pandemic, Michigan Medicine's IPC clinics converted to 100% virtual care. The PAPICS was revised using patient feedback data for applicability to virtual care delivery and was completed by 875 respondents. Conclusions: Data collection from the revised PAPICS was completed in December 2021. Exploratory Factor Analysis (EFA) and Confirmatory Factor Analysis (CFA) are presently be conducted and will be reviewed at ICIC22. Results will provide insight into parent perceptions of virtual IPC and allow for comparison to those for face-to-face care. Implications for applicability/transferability, sustainability, and limitations: The PAPICS survey provides a template for assessing beliefs and preferences of families to provide high-quality, patient-centered behavioral health care in an IPC setting. Though certain items on the survey may not be applicable in some settings, the scale can be adapted as needed. [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]

Background: Patient reported outcomes and experience measures (PROM and PREM) provide an opportunity to prioritize patients' health goals in care decisions and quality improvement. In perinatal care, the use of PROM and PREM is scarce and limited to research and quality purposes. The International Consortium of Health Outcomes Measurement (ICHOM) published an outcome set for pregnancy and childbirth (PCB set), including PROM and PREM. In the Netherlands, the PCB set was implemented in a pilot project with the primary goal to integrate its PROM and PREM in clinical practice over the full course of pregnancy and postpartum care. To ensure continuity of care, the project was explicitly organized within integrated obstetric care networks (OCN): collaborating with all care professionals and organizations involved. Objectives: This study aimed to report first outcomes, experiences, and practice insights of implementing the PCB set in clinical practice of perinatal care. We assessed compliance to the PROM and PREM questionnaires, outcomes per domain, and clinical use of threshold values. Methods: Seven OCN across the Netherlands, each consisting of one or two hospitals and multiple community midwifery practices (2 - 18), implemented the PROM and PREM of the PCB set as part of clinical routine. This observational study included all women participating in the clinical project who gave informed consent for research purposes. The PROM and PREM were assessed with questionnaires at five timepoints: two during pregnancy and three postnatally until six months postpartum. Clinical threshold values (alerts) supported physicians interpretating the answers, indicating worrisome outcomes per domain. Data collection took place from February 2020 till September 2021. Questionnaires were assessed mostly digital - in one site on paper. Data analysis included missing (pattern) analysis, sum scores, alert rates, and sensitivity analysis. Results: In total 1923 questionnaires were collected across the five timepoints: 816 at T1 (first trimester), 793 at T2 (third trimester), 125 at T3 (maternity week), 170 at T4 (6 weeks postpartum) and 19 at T5 (6 months postpartum). Of these, 84% were filled out completely. Missing items per domain ranged from 0 to 13%, with highest missing rates for depression, pain with intercourse and experience with pain relief at birth. No notable missing patterns were found. Relatively high alert rates were found for urine incontinence (27%), pain with intercourse (25%), breastfeeding selfefficacy (23%) and mother-child binding (45%). Regarding PREM domains, most alerts were found for birth experience (23%), shared decision making (11%) and discussing pain relief antepartum (41%). Some domains showed very little clinical variation: mother role and satisfaction with care. Conclusions: The PCB set is a useful and acceptable tool to assess patient reported outcomes that need to be addressed over the whole course of pregnancy and childbirth. Our findings reveal a window of opportunity to improve and personalize perinatal care. Furthermore, based on our findings we could propose several recommendations about the methods and timeline of PROM and PREM measurement based. This study supports further implementation of the PCB set in clinical practice and the transformation towards patient centred value driven care. [ABSTRACT FROM AUTHOR]

Introduction: The healthcare journey to create integrated care in Ontario, Canada, was bolstered in 2019 by the creation of Ontario Health Teams(OHTs). These newly formed meso-level networks of providers are collectively responsible for providing appropriate, coordinated, effective and efficient health services for an attributable population. These "self-determined and fit for purpose" OHTs are developing governance structures to enable partnership among community-based organizations, patients/caregivers, primary care and home and hospital providers. This study describes the different governance structures and pathways adopted by three OHTs, detailing factors that enable OHTs to take steps towards their maturity and highlighting the lessons learned from the experience. Methods: This paper is aimed to assess the diverse governance models, their pathways to maturity and intended advantages and challenges across the OHTs. This study aims to understand how OHTs set up their governance structures based on their population need and context. The study follows a mixed-methods design. An initial survey was used to collect data across all 50 OHTs to describe governance structures and processes adopted (council membership, joint decisionmaking, separate legal entities). The qualitative study will use a cross-case comparative design amongst three OHTs to compare and study the different governances adopted by OHTs. The three OHTs were selected to allow variability in governance structures; for example, OHTs formed a separate legal entity or enacted a joint-decision making or a collaborative agreement. This phase will collect data from interviews (leadership/collaborative council and management team members) and document review (key documents, meeting minutes) across three OHTs and will be analyzed using thematic network analysis. Highlights: We intend to interview 7-9 decision-makers across each selected OHT, who are council members or have been involved in the governance setup. Using a three-stage network development and change cycle, we will assess initial readiness and activation, current stabilization and routinization practices and finally, efforts towards stability and sustainability across each OHT. The key governance themes that will be explored with the OHTs are partner composition and engagement, legal form, role and functioning of governing bodies, decision-making authority and dynamics funding and accountability. A thematic network analysis will enable a methodical systematization of the textual data and help depict graphical web-like nets of the themes. Enabling a richer understanding of an issue and facilitating disclosure on researchers' analysis process and a more precise understanding for the reader. [ABSTRACT FROM AUTHOR]

In Canada, the average costs to treat mental illness varies greatly depending upon the type of disorder. In 2012, the total direct cost of treating psychotic disorders to the Ministry of Health in Ontario, Canada was around 2.1 billion Canadian dollars. Psychiatric hospitalizations, followed by long-term care needs, contributed to the high cost of care. As of 2017-2018 schizophrenia and psychotic disorders were costliest to treat, with an estimated average cost of 12,971 Canadian dollars per hospital stay (CIHI, 2019). Bundled care models refer to a single payment for a full scope of care, are based on timely and highest quality of care, within an integrated care pathway provided to a patient during a defined episode of care. The results are a seamless transition experience and consistency in care for patients across providers and care settings. Bundled care models have been successfully created and implemented in other acute episodes of care, however within mental health and addictions and specifically within the specialized psychiatric setting are relatively new, as defining and articulating the episode of care across the chronicity of one's lifetime has proven challenging. In this paper, we describe our experiences with designing a proof-ofconcept bundled care model for patients with schizophrenia, implementing the model in the hospital setting, measuring adherence, and calculating the accompanying financial model. The comprehensive, evidenced based care elements that comprise optimal care for those with schizophrenia (in accordance with best practices and Health Quality Ontario's Quality Standards) were mapped into a 61-day proof of concept pathway by taking into consideration - (a) daily nursing care activities (b) clinical care and treatment activities reflective of Quality Ontario's governed quality standards for schizophrenia care (i.e. access to Family Intervention Therapy [FIT] and cognitive behavior therapy for psychosis [CBTp]) and (c) identification of exceptions to care. The financial model leveraged data retrieved from the electronic health record on a sample of 142 inpatients with a diagnosis of schizophrenia and reflective of the resources required to deliver the care elements and activities. Statistical analysis were conducted to identify areas of opportunity to standardize practice and align practices in quality improvement initiatives to increase adherence to the proof-of-concept model and pathway. Initial learnings included the identification of the variable risk factors that impact complexity and care. Next steps in this work include the definition and design of risk-adjusted, personalized pathways to further refine the model and reflect personalized care. By taking into consideration the complexity factors, both from a treatment perspective and population health focus with the social determinants of health, personalized pathways can be identified to ensure timely, quality, evidence-based and efficient care during the course of admission. Work is currently underway to develop formalized partnerships across care settings (acute care, specialized mental health care and community settings) to further broaden the model and support a seamless experience across care settings. Further learnings from this work have funding model implications and will inform mental health bundled care policies to support similar mental health clinical pathways. [ABSTRACT FROM AUTHOR]

Introduction: Congregate settings in the province of Ontario, Canada supports a vulnerable patient population that requires coordination across health and care systems. These settings are a wideranging category of supportive housing facilities where people live, stay overnight, and use shared spaces. The global pandemic has reinforced the need for person-centred care for these vulnerable patients. The highlighted complexity and multidimensional care needs of this population lie outside of the traditional health system. Researchers have called for a focus on relationships across providers and a system shift from a patient specific illness state to a person-centred approach that coordinates care across multiple providers. Methods: This paper reflects the first module of the Precede-Procede model. The research aim, what are the system level factors that influence the ability to deliver person-centred care across health and care providers A patient interview and literature review are combined to consider the patient, professional, leadership, and system factors influencing an ideal state. The most relevant facet of the literature review where the terms 'leadership' and 'person centred' as well as considering executive and management functions, styles and theories. The patient was "BB" a retired career educator who advanced to the highest level of leadership who is also a steadfast and integral leader and advocate for patient co-design and person central care. Results: Research identified several factors that impact the ability provide person-centred care for patients will complex care needs. The degree of complexity may itself impact the ability for patients to be part of the care design as well as the behaviours and values of the care providers themselves. Patients own level of knowledge and education also influence their capacity to be involved in system level decision making. Predisposing, enabling and reinforcing factors were considered at the micro (patient and provider), meso (leadership), and macro (system) level of impact. The focus on individual professional expertise was found to lead to a lack of person-centred care, and a lack of investment across providers means and absence of shared values and investment in patientcentres care. Reductionism and oversimplification of both the patients care needs as well as the system complexities, coupled with command-and-control hierarchical leadership structures result in a lack of patient-centred care. Conclusion: To be able to have trust in the system and a commitment to patient and personcentred care there is a need to address the lack of relationships spanning the boundaries of individual professionals and providers. The lack of relationship means there is also not shared values, which erodes sustainable trust. Implications: Person-centred care requires the direct commitment and involvement of leaders that are present and part of the local community. In addition, there is need to focus on partnerships across organizations, active trust building, and acknowledgment of the complex adaptive nature of health and care. [ABSTRACT FROM AUTHOR]

Introduction: The care needed at end of life can go beyond what services can offer. This is where volunteers can make a difference, however the nature of their support can vary. Dodd et al. [1] recognised two types of input: 'being there' and 'doing for'. Similarly, Burbeck et al. [2] examined the volunteer role and found three themes; the distinctness, characteristics and experience of the role. Here, a volunteer can be mediating between patients and staff, sometimes acting as a surrogate family member. Such complexity requires further study and more detailed information about the impact on care recipients, and the volunteers themselves, would greatly assist the training and development of volunteers as well as decisions on how to maximise the use of volunteers to achieve the most benefit. Compassionate Isle of Man (IOM) has been developing the role of volunteers as Palliative Care Companions in the community. This evaluation aims to capture the impact and experience of volunteers and care recipients and examine the explicit and implicit needs for palliative care that they address. This paper will report on the pilot of the methods and initial findings. Aims: To use capability measures, qualitative and other data to identify the implicit and explicit needs for volunteer support, the short-term impact(s) on care recipients and volunteers and the implications for the training of volunteers. Methods: A prospective study will enrol care recipients and their carers at the outset of Compassionate IOM support. Baseline data will include stated needs as well as the ICEpop CAPability (ICECAP) measures [3] and interviews. Data collection will be repeated at 6 and 12 weeks and will include specially designed questionnaires and interviews to elicit perceptions of impact, satisfaction and details of the support experience. This information will be set within a cost-benefit framework to quantify the extent to which declared and undeclared needs are met, at what cost and with what benefits to care recipients and volunteers. The initial pilot study will test the methods and include at least 10 care recipients, their main carers and the related volunteers. Conclusion and implications: This pilot study will form the basis for a longer-term study which will provide essential information on the potential scope of volunteer support and their place in the overall service delivery of palliative care in the community. [ABSTRACT FROM AUTHOR]

Introduction: The field of low back pain (LBP) is a prime example of patient-experienced incoherence. Individuals often have year-long care pathways, moving in loops between hospital, municipal and private health care providers. They are also often in contact with municipal job centres that sometimes have goals that conflict with those of the health system (Rossen et al 2021). To accommodate these challenges, an interdisciplinary team has developed the first version of the digital solution 'BackTrace', in collaboration with health professionals, representatives from municipal job centres, individuals with LBP and their relatives. The solution currently consists of a smartphone app that allows patients to share self-reported data about their condition and activity with the different professionals they are in contact with. Professionals can also access the reported data through a professional user interface. Methods: A pilot test of the first version of BackTrace runs from October 2021 to February 2022. Here, 300 individuals with LBP test BackTrace. The present research project samples participants from the pilot test participants. To secure a spread in participants' gender, age, and health status, participants are sampled through different channels such as private health care providers, the hospital, and municipal rehabilitation units. The project has three objectives: 1) to explore how BackTrace affects participants' experience of cross sectoral coherence and empowerment 2) to explore participants' perceptions of the patientprofessional collaboration with the use of BackTrace and 3) to explore barriers for using BackTrace, as experienced by participants (e.g. technical, ethical, personal). This is investigated using a mixed methods design, combining ethnographic methods with quantitative survey data, into an integrated analysis. Results: The preliminary results after BackTrace has been pilot-tested are presented, with a focus on the ethnographic part of the study. Findings from interviews and observations with 10 participants and a workshop with 20 additional research participants are presented. The paper presents the experiences of using BackTrace from the point of view of the individual with LBP: their thoughts and experiences of using BackTrace in their everyday life, how it affects their sense of empowerment and engagement, and the quality of their collaboration with professionals in their trajectory. It is examined, if patients with BackTrace take more charge of their own treatment and recovery process; if they experience a stronger sense of agency and confidence in their trajectory; and what (new) kinds of patient/user roles are made possible (and which are limited) with the introduction of BackTrace. Conclusions: The development of BackTrace is based on inputs from individuals with LBP, their relatives, and other relevant stakeholders. It will be discussed to what degree this user-involvement approach can be said to actually create solutions that accommodate the needs of the individual living with LBP. Implications: As BackTrace is developed bottom-up and through continuous collaborative activities, inputs from individuals with LBP will both inform future research questions and the further development of BackTrace. The insights from this project can also be useful for the development of digital solutions for other patient groups. [ABSTRACT FROM AUTHOR]

Introduction: All hospitals, laboratories, pharmacies, municipalities, physiotherapists, general and specialist practitioners etc. in Denmark routinely use MedCom -communication in their daily work. MedCom's standards are built into more than 150 IT systems and approx. 6.5 million MedCom - standards are exchanged monthly. The present infrastructure is based on Value-added Networks (VANS), which was created in the 1990s. The messages in the VANS network have standardised content, and the message format is mainly based on EDIFACT. To meet the future needs of the Danish healthcare sector, the national eHealth strategy contains a priority on implementing a fundamental modernisation of both MedCom's standards and the associated infrastructure. Aims, Objectives: The Danish healthcare system is facing organisational changes that call for a paradigm shift in the MedCom communication, namely: Fewer, highly specialised hospitals with short courses of treatment and quick handing-over of patients to municipality and general practice. Thus, close and parallel collaboration between municipality, general practice and specialists at hospitals on treatment and care is, therefore, essential. The purpose of the modernisation is firstly to make relevant data available for online sharing at the request of health profesisonalsprofessionals; and secondly to support a fast, stable and secure transmission of relevant data sets at the time, the patient responsibility unequivocally shifts between sectors. Highlights, Results or Key Findings: Consequently, the internationally preferred standard, HL7 FHIR®, will replace EDIFACT. The choice was made in close collaboration with IT vendors and representatives from all parts of the healthcare sector. It has been crucial to - secure an upgrade based on known technologies and supported by available development tools - support globalisation of Danish health -IT development - simplify future revisions of MedCom's standards in conjunction with the user/business needs HL7 FHIR® underpins transmission of information between IT systems, as known in the original MedCom communication, as well as data sharing between IT systems. In 2020, the Danish Health Data Authority published a target architecture for future message communication, which pointed at EU's eDelivery solution to replace VANS for point-to-point message communication in the health domain, including increased security in the exchange using modern technology and standards. In addition, there will be the possibility to add document sharing of messages through the National Service Platform. Conclusions: A well-functioning MedCom -communication is critical for the daily activities across the whole health system. Consequently, many organisations must maintain the current and new technical solution in a multi-annual transition period. Additionally, the MedCom -communication is still growing and must be upheld in parallel with the introduction of new standards and new infrastructure. Implications for applicability/transferability, sustainability, and limitations: With the introduction of the EDIFACT -communication years ago, the Danish healthcare sector has already harvested the apparent gains from replacing paper-based workflows with digital data exchange. FHIR® is still a new technology for many IT vendors, and an initial investment to make the transition is required from both vendors and customers. [ABSTRACT FROM AUTHOR]

Introduction: Low back pain (LBP) is the most common disability worldwide (1). Each year, app. 900,000 adult struggle with LBP in Denmark. Creating numerous contacts to the healthcare system across sectors and care providers (2). As a result of increased sectoral division in the Danish healthcare system, many people in need of healthcare experience their treatment trajectory as fragmented with conflicting information. They experience to be asked the same health-related questions each time they consult a new health care professional, instead of professionals sharing their knowledge of the patient trajectory. Thus, patients struggle with the additional burden of being the primary information mediator between professionals. This dissonance causes patients to feel powerless and frustrated, experiencing a lack of empowerment (3). Digitalisation in healthcare has the potential to support cross sectoral coherence. In reality however, the IT-systems are not designed to share the individual's data across the different sectoral IT-systems (4). Therefore, important knowledge about people with LBP is not continually shared across the professionals and may get lost. Objective: To overcome this challenge, we have over the past two years developed the first version of a new and innovative digital solution, called BackTrace. This paper focuses on the development process of BackTrace. Methods: The development of BackTrace is an iterative bottom-up process where user involvement and scientific knowledge is central. BackTrace is developed by a multidisciplinary team of relevant collaborators: people with LBP, their relatives, healthcare professionals, job centre employees, researchers and IT-developers. With this diverse team, in a workshop based method, we have developed a digital solution which may facilitate integrated and person-centred trajectories. Findings: The development has been governed by the needs of the collaborators and the contextual frames under which the professionals work. This work revealed that it is crucial for BackTrace to support: 1) sharing of all relevant data across sectors and professions. 2) rethinking of user-centricity by giving people with LBP access and the opportunity to share all relevant data with the professionals of choice. 3) presenting data from different individual records in a clear form that is understandable and applicable for professionals across sectors. 4) empowering the individual with LBP by facilitating that relevant knowledge is available, and that the individual gain more insight into their own condition. 5) good, equal and qualified dialogue between people with LBP and the health professional These findings, have guided the works of IT-developers designing BackTrace. Conclusion: We have succeeded in identifying and collaborating with relevant collaborators, facilitating transdisciplinary dialogue. This dialogue has through an innovative and iterative process resulted in a user-oriented digital solution which is currently being pilot tested. Implications: The evaluation of the pilot testing will provide future direction for the research and the development of BackTrace. Based on the thorough development of the digital BackTrace solution, adaptation to other relevant patient groups is easily available. The project is funded by the Ministry of Health. 1. Hartvigsen et al. 2018. 2. Flachs et al. 2015. 3. Rossen et al. 2021. 4. Sundhedsdatastyrelsen. 2018. [ABSTRACT FROM AUTHOR]

Introduction: How have we progressed and where are the gaps of integrated care in Singapore? Social-health care provision in the context of an ageing population is critical in the city-state's management of the unprecedented demand as the proportion of seniors with multiple complex medical needs has almost doubled in the past decade. The concept of integrated health and social care has been increasingly discussed due to its role in advancing the Quadruple Aims of healthcare. Aims & Methods: Using the SCIROCCO Exchange tool, this paper explores the maturity of the overall integration of Singapore's health and social care system, identifies strengths and gaps and recommends follow-up actions. The SCIROCCO Exchange tool consists of 12 domains necessary for the provision of integrated care. A three-step mixed method Delphi study was used to derive expert consensus. At each iteration, participants rated each of the twelve domains of the SCIROCCO Exchange tool on a six-point ordinal and provided justifications for each rating. Criteria from the RAND UCLA appropriateness method and thematic analysis were adopted for the analysis. The six-point scale was tiered into maturity levels - "Initial", "Progressing", "Optimising" and "Uncertain", based on the median and distribution of responses. Findings: All 12 participants completed the study and reached agreement on the maturity level for most domains over three rounds of Delphi study. The study found that five domains of integrated care are in "Initial" maturity level and five domains in "Progressing" maturity level. Participants had split responses in two remaining domains, viz Breadth of Ambition and Capacity Building. For the former, the split responses suggested that participants adopted varying interpretations and expectations of integrated care, where the latter seemed to suggest the absence of a systematic building of capacity for integrated care, with social-health care remaining in silos. Conclusion: In participants' justifications for their ratings, the absence of a systematic approach for integrated care was the most common subtheme across all dimensions. Coordination is limited to programme-or disease-specific, due to operational challenges because of separate socialhealth ministries and limited digital infrastructure to support data-sharing. Implications: Depending on the role they play in the provision of integrated care, participants appeared to have different responses because of different vantage points and interpretations of integrated care. The common subtheme of the felt absence of a systematic approach for integrated care is foundational and suggests where the current gaps areThe findings reflect that there is a sequence to the domains, where certain domains are foundational to lead the progress of other domains. When the foundational domains are weak, the progress in other domains becomes limited. The development of a population health roadmap which spans social-health care sectors could be favourable, as it would guide policymakers, healthcare and social care professionals to consider a systematic and strategic approach that could further strengthen the design and deployment of social-healthcare in Singapore. Future thoughts on approaches to restructure the governance of social-health care agencies and citizens' consultation on integrated care are warranted. [ABSTRACT FROM AUTHOR]

Introduction: LBP is a leading cause of disability and exerts a considerable burden on healthcare systems. Management is frequently inconsistent with clinical guidelines, which advocate a demedicalised approach in primary care settings for most patients, with easy access to specialised care when necessary. Integrated care pathways have potential to enhance care quality and costeffectiveness through bridging the evidence-practice gap and optimising resource use. Care integration across the primary-secondary care continuum aims to address care fragmentation, reduce duplication, improve clinical outcomes and enhance cost-effectiveness. This review aimed to synthesise the evidence for integrated care pathways for LBP from primary to specialised care. Methods: This review was reported in accordance with Preferred Reporting Information for Systematic reviews and Meta-Analyses (PRISMA) guidelines. Electronic database searches (CINAHL, MEDLINE, Cochrane Library, EMBASE) were conducted (2006 onwards) with further manual and citation searching. Search results were exported to Covidence (systematic review software). Two independent reviewers conducted eligibility assessment and data extraction, as well as quality appraisal using the Effective Public Health Practice Project (EPHPP) Quality Assessment Tool for Quantitative Studies or the Critical Appraisal Skills Programme (CASP) qualitative studies checklist. A narrative synthesis of findings is presented. Results: From 18,443 identified studies, 28 papers met inclusion criteria. LBP pathways were reported from high-income countries, primarily to address over-burdened secondary care services with long wait-times for consultant appointments. Pathways almost universally re-organised care using non-consultant interface services to manage the primary-secondary care boundary by triaging patients for surgical opinion or conservative management. Interface services aim to optimise use of the multidisciplinary workforce to ensure judicious use of surgical clinics. Accordingly, evaluation of healthcare resource use and patient flow predominated, with reports of enhanced service efficiency through decreased wait-times and appropriate use of consultant appointments. Interface services were evenly represented across community and hospital settings. Using a model that conceptualises care integration on a five-level continuum, the included pathways demonstrated the two most basic levels of integration, 'full segregation' or 'linkage'. Low quality study designs, heterogenous outcomes and insufficient comparative data precluded definitive conclusions regarding clinical and cost-effectiveness of pathways. Conclusions: Interface services, delivered by non-consultant multidisciplinary team members, to ensure appropriate referrals to specialised care dominated the LBP integrated care pathway literature with enhanced efficiency of care delivery reported. Pathways demonstrated the most basic levels of care integration, 'full segregation' and 'linkage', across traditional healthcare boundaries. Implications: Further exploration of the potential of care pathways as a model for the delivery of integrated, cost-effective, person-centred, guideline-concordant care which improves clinical outcomes for patients with LBP is required, with patient involvement in integrated care pathway development. [ABSTRACT FROM AUTHOR]

Introduction: As in many other countries, the challenges in the health status of the population and in the healthcare system persist in the Netherlands, despite longstanding reforms and integration efforts. This raises questions about the long-term sustainability of the system. As more and more studies describe the implementation of whole system transformation initiatives, approaches such as Population Health Management (PHM) gain traction. This study aims to contribute to the growing area of research by exploring the knowledge in recent literature about these kind of initiatives worldwide, focussing on the different levels of integrated care. Methods: A scoping review was performed using the six-stage methodological framework from Arksey and O'Malley. The electronic databases Embase, PubMed and Academic Search Premier were searched for papers published between January 2016 and January 2021. Structuring of the data was done from a realist analysis perspective, identifying context, mechanism and outcome (CMO) items describing what works for whom under what circumstances. Secondly, these items were then allocated to the levels of the Rainbow model of integrated care to identify the level to which the transformation item pertains. Finally, six topic clusters were formed, which constitute key elements of PHM. This resulted in a matrix of items corresponding to the levels of integrated care, the CMO structure and the six elements of PHM. Results: The literature search generated 531 articles, of which 11 were included. Structuring the data showed that most reported items were normative and functional items on the organizational level about 'accountable regional organization'. Also containing a high number of functional items are 'cross domain business model' and 'emergent implementation strategy', both on system and organizational levels. In contrast to that, items on the clinical level and normative items were overall underreported. The PHM elements 'co-designing workforce and community', 'integrated data infrastructure' and 'population health data analysis' contained overall the lowest number of items. Items that were mentioned by four or more articles were: Data availability, IT infrastructure, additional funding or monetary resources, and financial incentives aligned with system goals. Conclusions: This scoping review demonstrated that recent literature mainly reports on context, mechanisms and outcomes on system and organizational level of integrated care when it comes to PHM initiatives. And while the need for data availability and IT infrastructure are frequently specified, there is limited consideration for the normative side of integration in this regard. Implications for applicability/transferability, sustainability, and limitations: One of the limitations of this study is that many initiatives are not published in scientific literature, and therefore there may be items that are missing in the overview. However, the resultant matrix gives a first comprehensive overview of what needs to be done on what level to achieve what outcome. It also shows the lack of involvement of and attention to providers and patients within these initiatives. [ABSTRACT FROM AUTHOR]

Introduction: This programme evolved from the Complex Case and Recovery Management Framework (The CCaRM1), developed within Merseycare Specialist LD Services. •This value-based platform was being used by the Specialist Support Team (SST) to support people in the community with Learning Disability and Autism diagnosis with complex needs. •With lockdown constraints, the service became reliant on working indirectly through family and carers. Aims & Hypothesis, Theory/Methods: Despite the challenges posed by the COVID-19 epidemic, several resourceful initiatives were implemented, across the clinical landscape The Self-guided CCaRM Programme was developed under QI framework as a format for on-line workshops with those concerned. The expectation was to reframe support already there and streamline further support to best effect Pre-workshop exercise was shared for each attendee A skype-based workshop practised Explored areas of strengths, concerns, & possible fresh approaches towards the themes Collaborative care plans were refreshed. Key Findings: PDSA 1-ONLINE CCARM Workshop 2020: A skype-based workshop was convened for all relevant parties. In advance, attendees reviewed concerns using the 6 self-guided CCaRM headings, in line with the original CCaRM, as follows: Having a good circle of support Having a good shared understanding Having clear problem areas thought about Social Participation and Living a Good Life Keeping people safe and well Making progress. For each theme, areas of strengths, concerns, and possible fresh approaches were explored. Subsequently, collaborative care plans were refreshed accordingly. PDSA 2-ONLINE Complex case management workshop 2021-TRAINEEES &TRAINERS: 60-minute slot is proposed, on the end of the NWLD Northwest monthly academic teaching forum meetings, starting from June 2021 The structure of the workshop will borrow the informality and spirit of support from Balint groups. Each session will conclude with an evaluation discussion of workshop usefulness. There were 8 such workshops conducted over the lockdown in PDSA1 and 6 workshops conducted for PDSA 2 Participants included support staff and family members, though no service users in the first PDSA cycle. Second PDSA cycle included educators professionals and trainees of Psychiatry Excellent feedback: that the experience helped with understanding and confidence in roles and generated fresh ideas to try. Conclusions: We consider that the online workshops is a great success in creating competent and well-rounded MDT professionals and the ID psychiatrist in Northwest region of England Implications: Our paper outlines the impact of value-based complex case management workshops in Intellectual Disability and Autism Care to ensure better outcomes in challenging times •By Analysing the potential impact of the COVID-19 pandemic on Intellectual Disability complex case management. •By strengthening self-management capabilities for complex care needs •By developing expertise as a collaborative project •By Coping with Diagnostic Overshadowing •By developing a value-based case management process. [ABSTRACT FROM AUTHOR]

Introduction: Intersectoral coordination and collaboration give rise to many well-known challenges. One central challenge is how to create a shared understanding of, and a common platform for, coordination and collaboration across sectors, organisations and professions. Health care organisations and managers often draw on the concept of organizational culture to establish a shared meaning as a pathway to effective coordination and collaboration. However, such a topdown approach is problematic as shared meaning often comes about from the bottom-up, in the context of day-to-day professional practice. Aims, Objectives and Methods: The aim of this paper is to open the 'black box' of how and why organizational culture binds organisations together as some kind of social glue and how this can help understand processes of intersectoral coordination and collaboration. The specific objective is to draw on the conceptual framework of 'boundary work' and 'boundary objects' to gain a more thorough insight into how organizational culture paves the way for intersectoral coordination and collaboration. The study is based on observations and qualitative interviews with health professionals engaged in two cross sectoral projects developing and providing health promotion services for women with gestational diabetes mellitus (GDM). Key Findings: Our study shows that boundary work revolves around negotiations about how to jointly define, understand and act on the diagnosis of GDM. This diagnosis has the characteristics of a 'boundary object', as it is more loosely structured in general terms, but more strongly structured in local settings, where organizations and health professionals are dependent on relatively unambiguous images to act in efficient ways. Boundary objects helps connecting different professionals and facilitating collaboration, and our analysis shows, how the introduction of time and the concept of 'lifelong health promotion' helps to transgress existing boundaries between strongly structured local definitions of the diagnosis. It builds a bridge across organizational and professional boundaries, by allowing for a shared meaning that embraces values and goals of the professionals from across the different sectors. This helps reconciling diverging notions of a diagnosis and creating shared meaning about life-long health promotion. Conclusions: Our analysis shows how organizational culture emerges from negotiating, determining and agreeing on shared notions of how people, things and concepts are defined. These processes take place in concrete relational processes between health professionals rather than through top-down definitions of shared concepts and meanings. Implications for applicability/transferability, sustainability: The study encourages health professionals and managers to use seemingly divisive boundary objects as a lever to maintaining and developing everyday practices of cross sectoral coordination and collaboration. The strong theoretical underpinnings of the study support applicability across a wide range of settings. [ABSTRACT FROM AUTHOR]

Introduction: Increasing demand for interprofessional collaboration has raised the interest in the influence of different conditions. However, we know little about the magnitude of interactions between conditions. This is important, as it enables identifying the most important conditions. This paper aims to develop and adapt an existing framework based on a study of homecare services for elderly in Denmark. Theory: The Context and Program Conditions for interprofessional collaboration in integrated care (CPC)-framework conceptualises relationships between program and context conditions at professional and organisational levels; and measures the interrelationships between the conditions in addition to the conditions influence on the quality and effectiveness of communication. Program conditions directly relate to the collaboration model, while context conditions surround the collaboration. Methods: This was a sequential mixed-methods study, conducted between August and December 2021 in Herning and Holstebro municipality. A pilot-study helped to validate the adapted questionnaires. Subsequently, a multilevel cross-sectional survey study was conducted. The study focused on interprofessional collaboration between home care and home nursing units. The study population was all frontline staff in the units, and their managers. To analyse data CBSEM was used, based on prior hypothesised relationships and indexes. Results: Preliminary results indicate that the questionnaires have appropriate psychometric properties and satisfy the assumptions of the CPC-framework. This makes the CPC-framework well-suited for assessing how different types of conditions influence the quality and effectiveness of communication in interprofessional collaborations in a Danish primary care setting. Discussions: Our study stresses the importance of interactions between different types and levels of conditions on a broad scale. Additionally, our study argues that there exists no single, 'goldenstandard' framework for examining conditions for collaborations in integrated care. However, it is not conducive either to develop a unique framework each time a researcher examines a new setting. Instead, the goal should be to design a flexible framework with explicit aims and measurement strategies. This is to ensure the validity and reliably of studies each time the framework is applied to a new setting. Conclusions: The CPC-framework can be used as a diagnostic tool to identify the most important conditions for primary care collaborations in Denmark, and subsequently to help improve existing interprofessional collaborations. Lessons learned: This study demonstrated how to identify the most important conditions in an analytically stringent way. This can help leaders to identify and work with conditions as part of their continuous efforts to sustain collaborations in integrated care initiatives. Limitations: Although this study has tested the CPC-framework for its reliability and validity, future studies using the framework should follow the same measurement strategy. Further, we can expect there are additional paths and variables in the final SEM-model (e.g. patient and system level conditions). We have excluded these variables for valid analytical reasons, but the interpretation of results should have this in mind. Future research: Future research should help consolidate the literature on conditions, by further exploring how different types of conditions across analytical levels interact with each other and affect outcome-measures in different types of collaborations and settings. [ABSTRACT FROM AUTHOR]

Introduction: After several years of promoting integrated care pathways (ICP), in 2020 Osakidetza published the corporate document for the design, implementation and evaluation of corporate integrated care pathways (CICP) throughout its network of integrated care organisations (ICOs). This paper describes its elaboration, contrast and some reflections on its extension. Aims, Objectives: integrated care continues to be one of Osakidetza's strategic challenges, after having completed the integration of primary care and hospital care throughout the entire service in thirteen ICOs over the past decade. The ICPs are intended to be the operative space in which the various fundamental elements of integrated care come together. It is necessary to standardise the use of this tool in the ICOs as a whole, and to this end it was decided to draw up a reference guide for the entire network. Highlights: Definition of ICP: one of the first issues to be resolved was the concept of ICP, which is often confused with terms like clinical practice guideline, protocol, etc. The definition developed takes a dual perspective, from the professional-managerial point of view and from the point of view of the patient and their relatives. Differential elements of ICP: the proposed concept of ICP inherently entails: - agreement among all actors, including patients and relatives, - explicit description of the goals and key elements of treatments and care based on evidence, best practices and the expectations of patients and their relatives, - coordination of the care process - recording, monitoring and evaluation of variability and outcomes. Checklist: a tool is proposed to enable ICOs to assess their existing ARs and to guide the design of new ICPs. This checklist is composed of 18 questions with a Likert scale of 1 to 7 grouped into six domains: - ICP rationale, shared leadership and institutional momentum - Constitution, functioning, independence of the ICP Elaboration Group - Pathway design (scope, usability and external review) - Incorporation of evidence into the ICP Training, dissemination and implementation - Monitoring and evaluation. Conclusions: The checklist was piloted with the COPD care pathways that several ICOs had been working with previously. The usefulness of the corporate document and its checklist has been confirmed, with both the Corporate level and ICOs stating that they will use it for the design and implementation of new ICPs or for the adaptation of existing ICPs. Implications For Applicability And Limitations: one of the reflections provoked by this process is the as yet unresolved issue of extending the use of this guide to the whole of the Osakidetza's network of ICOs. There are two main alternatives, with intermediate possibilities between, depending on which criterion is given more weight: 1. Under a more centralised and standardising criterion for the creation of CICPs, the development of corporate ICPs to be implemented locally by the ICOs. 2. Under a criterion of greater autonomy for each organisation but based on common characteristics set out in this corporate guide, local ICP developed directly by each ICO. [ABSTRACT FROM AUTHOR]

Introduction: Integrated care programmes (ICPs) for community-dwelling frail older people work for some, but not for others. Why and how ICPs work, is rather unknown because the 'mechanisms' and the 'context' often remain underexposed. The study objectives are 1) to identify the relationships between the context in which ICPs are applied, the mechanisms by which ICPs do (not) work, and the outcomes resulting from this interaction, and 2) to analyse to what extent the World Health Organization (WHO) framework on integrated people-centred health services (IPCHS) is applied in ICPs. Methods: A rapid realist review was conducted to identify the mechanisms of ICPs that operate in particular contexts to generate outcomes. Peer-reviewed (reviews and meta-analyses) and nonpeer-reviewed literature reporting on integrated care for community-dwelling frail older people (= 60 years) was included. Selection and appraisal of documents was based on relevance and rigour according to the Realist And Meta-Narrative Evidence Syntheses: Evolving Standards (RAMESES) criteria. Data on context, mechanisms, and outcomes were extracted. Per source publication, context-mechanism-outcome configuration(s) (CMOc(s)) were aimed to be identified. Factors were categorized into the five strategies of the WHO-IPCHS framework. Results: 27 papers were included. The most prevalent WHO-IPCHS strategies as part of ICPs are "creating an enabling environment", followed by "strengthening governance and accountability". For ICPs to demonstrate positive effects on the functionality of older people, satisfaction of older people, informal caregivers and healthcare providers (HCPs), and a delayed placement in a nursing home, it is essential to establish multidisciplinary teams of competent HCPs (by means of education and training) providing person-centred care, closely working together and communicating effectively with other stakeholders. Heterogenous effects were however found for hospital-related outcomes, quality of life, healthcare costs, and use of healthcare services. Older people and informal caregivers should be involved in the care process in order to get a better picture of the patient's wishes and needs, and shared decision-making should be established. Financial support, efficient use of information technology, and organisational alignment were found essential. Conclusion and discussion: ICPs for older people are still in development, as most ICPs do not address all WHO-IPCHS strategies. To optimize ICPs for frail older people the comprehensiveness of the WHO-IPCHS framework and the interaction between items should be taken into account from different perspectives (system, organisation, service delivery, HCP, and patient). Within this study, data on context, mechanisms, and outcomes may show overlap, which is often considered an interpretative challenge within realist research. Additional realist research is needed to establish more comprehensive and detailed relationships of items related to ICPs for frail older people. [ABSTRACT FROM AUTHOR]

Introduction: Demographic and epidemiological shifts have made age-related and chronic illness a large part of healthcare expenditure. Episodic hospital and speciality care dominate in most health systems. Yet the shifts in consumer needs warrant a greater convergence of all levels of health and social care to improve consumer experience, health outcomes and cost inflation. Unlike traditional care approaches, New Care Models (NCMs) seek to better coordinate these three elements to meet the so-called 'Triple Aim' objectives. Aims and Methods: This paper provides the findings from a research report that sought to examine how health and life insurers can adopt NCMs to influence care at all life stages seamlessly and to keep cost in check. It is organised in three parts: •an outline of the evidence for NCMs on health and cost outcomes, based on a non-systematic literature review; •a summary of key insights from 15 high-level interviews with key informants from the health and life insurance industry; and •implications for the future of the insurance sector derived from the literature review and interviews. Key Findings [1]: There is good evidence that NCMs can support improved care experiences, favourably influence health outcomes and limit the rise in costs of care. The advent of Accountable Care Organisations (ACOs) has been associated with financial savings of between 6-25% when compared to standard practice. In part, this success has been as a result of new insurer/payer and provider models that support risk-sharing arrangements. However, varying implementation contexts make it harder to infer how consistently positive results can be generated. Interviews with stakeholders demonstrated a limited move towards the uptake of new governance and contracting models that might support NCMs. Specifically, consumer and provider benefits of NCMs needed greater articulation whilst the transactional nature of traditional distribution channels acted as a barrier to diversification. Interviewers recognised the need for service innovation, but pointed to a need to address regulatory environments, data integration, risk-averse leadership cultures, and payment reform. Conclusions: Insurers need to go beyond simplistic notions of choice and convenience to promote value to consumers, distributors, and providers. Insurers need to become 'strategic payers' to ensure favourable supply-side conditions, share risks, and shift towards value-based payments. A cradle-to-grave joint health-life service proposition should be encouraged. Implications: By moving away from being a passive claims processor to become a 'strategic payer', insurers can correct the common misalignments found between financial flows and provider incentives. Many of these purchasing approaches reward value over volume by balancing care between costly hospitals and speciality clinics and less costly primary/community-based settings. [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]

The issue of integrated care and inter-sectoral collaboration is on the health policy agenda in many countries. Yet, there is limited knowledge about the effects of the different policy instruments used to achieve this. This paper studies co-location as a driver for cross-sectoral collaboration with general practitioners (GPs) acting as coordinators in a municipal health centre. The purpose of the health centre, which is staffed by health professionals from municipal, regional and private sectors, is to provide primary health services to the citizens of the municipality. Co-locating these professionals is supposed to benefit e.g., elder citizens and patients with chronic diseases who frequently require services from health professionals across administrative sectors. Methodologically, the analysis is based on qualitative data in the form of semi-structured interviews with the health professionals employed at the health centre and with administrative managers from municipal and regional government levels. The study finds that co-location does not function as a driver for cross-sectoral collaboration in a health centre when GPs act as coordinators. Cross-sectoral collaboration is hampered by the general practitioners' work routines and professional identity, by organisational factors and by a lack of clarity concerning the content of collaboration with regard to economic and professional incentives. [ABSTRACT FROM AUTHOR]

Introduction Increasing demand for interprofessional collaboration in health care settings has increased focus on the influence of conditions, but we know little about the magnitude of interactions between conditions. Conditions are determinant factors that can affect interprofessional collaboration. This paper aims to examine the relationships of intervention conditions and context conditions at the professional and organizational levels and analyze how they influence the staff's perceived success of interprofessional collaboration. Intervention conditions relate directly to integrated care models (e.g. strategy, clarity of roles and tasks). Context conditions do not directly relate to interventions, but they surround interprofessional collaboration (e.g. management support, trust amongst staff). Theory/Methods This study develops an analytical framework drawing on the RMIC-framework to operationalize intervention conditions and the iCoach-framework to operationalize context conditions. The study was conducted as a multilevel cross-sectional survey in March of 2019 in the second largest municipality in Denmark (Aarhus). The study population was all frontline-staff members and managers in nursing homes, home care units and health care units. The final sample consisted of 498 staff members and 27 managers. Confirmatory path analysis was used to analyze the data. Results The results indicate that context conditions greatly influence intervention conditions at the professional and organizational levels and that the professional and organizational levels moderately co-variate. Professional level context conditions have the biggest influence on staff's perceived success, partly because some of its influence is confounded by intervention conditions. Discussions Our study stress the importance of opening the 'black box' surrounding context as a condition type. Based on our results we would expect that: conditions in general are a good predictor of the success of collaborations; context conditions are the most influential condition type with an indirect effect confounded by intervention conditions; conditions on different analytical levels co-variate. However, this raises questions about variation across country, sector, and case. For example, the most important individual context conditions may vary depending on setting. Nevertheless, the most important context conditions in the present study are well known in much of the literature, which might indicate low variance across settings. Conclusions Practice and research in health service delivery need to move from a broad understanding of context as unchangeable and inconsequential, to an understanding of context as an active condition type, which requires closer attention. Lessons learned Political and administrative decision-makers can purposely mould context conditions. In the present study, the four context conditions at the professional level are far from unchangeable. This means that leaders should analyze and work with context conditions as part of designing and implementing integrated care initiatives. Limitations Firstly, although the analytical framework is drawing on validated frameworks, it is not a thoroughly validated measurement tool itself. Secondly, the outcome measure is a proxy-variable. Lastly, there can be hypothesized additional paths and variables in the final path analysis model (e.g. patient and system level conditions). Future research Future research should open the 'black box' of context, by further exploring how different types of conditions on different analytical levels play out in different settings. [ABSTRACT FROM AUTHOR]

Introduction: Mexico has been one of the countries most affected by the international public health emergency brought on by COVID-19 (short for corona virus disease 2019), at the end of June 2021, the country has had 2.642.068 confirmed cases and 236.015 deaths. In response to the pandemic, governments around the world have reacted by implementing a wide variety of public health policies with a wide range of nuances and huge heterogeneity that make them difficult to compare and assess in view of scaling up some of them, as well as it complicates the possibility of making global recommendations. The aim of this paper is to analyze the decision making of the Mexican health system in the governance of the COVID-19 pandemic, and to assess its strengths according to the WHO guide for COVID-19 Strategic Preparedness and Response Plan (SPRP). We conducted a qualitative investigation based on semi-structured interviews of 41 key actors of the health system, from June to November, 2020. Interviews were audio-recorded, organized into categories following the framework of the COVID-19 SPRP and the ""health policy triangle"", using ATLAS.ti-v.9 software. Conclusions: The health policy response focused on intersectoral communication between the health sector and other sector such as education, economy or public security; advice of expert in health policies; portability of health-care services, equitable policies, and improving the information system (Epidemiological Stoplight); which allowed an intermediate response to COVID-19. Implications: Strengthening an effective response of the Mexican health system to face COVID-19, according to the WHO guide for COVID-19-SPRP, requires the prompt formulation of evidencebased policies, such as restrictions on international movement, efficient testing policy and contact tracing, in addition to the intersectoral, equitable, collaborative, and responsible policies currently implemented. [ABSTRACT FROM AUTHOR]

Introduction: The Australian National Disability Insurance Scheme (NDIS) offers an approach to disability support that is personalised via the provision of an individual budget which can then be used to 'purchase' services by NDIS service providers who compete for NDIS clients as part of a social care market. The scheme is prefaced on the concepts of 'choice and control' with individuals at the centre of decision making in relation to their budgets. However, individuals with complex needs themselves may be unable to organise their own care because of the situation they are in, or they may need supports that go beyond the boundaries of the NDIS, or they cannot purchase services because services do not exist in the market to meet their needs. This means that those individuals have a higher need for integration or are at higher risk of negative social and health outcomes. Aims and objectives: This paper will reflect on the example of the Integrated Service Response (ISR) which was a highly structured add-on to the NDIS created by the New South Wales State Government in Australia to increase inter-agency collaboration around the needs of people with extremely complex needs who were in a crisis situation that could not be easily resolved. The program aimed to 1) meet the needs of the individual and 2) join up the system to make it work more collaboratively going forwards. The ISR program involved a 3-month service which aimed to connect those services and agencies relevant to the individual and situation and develop a strategy to meet their needs. Highlights: We will describe the program and examine its effectiveness at meeting its aims by drawing on process observation and interview data. We will pay close attention to the validity of ISR and ISR-like programs that act at a systemic level to address client needs, but do not actually engage with the client/patient themselves beyond their consent to participate. Is this saving the client from being drawn into fixing a mess imposed by the system, or is it cutting the client out of decision making and therefore the antithesis of personalisation? Conclusions: We will look at the possibilities posed by these types of programs in operation in Australia more generally and their sometimes-complex relationship with the personalisation agenda of the NDIS and similar programs. [ABSTRACT FROM AUTHOR]

Background: Introduction and diffusion of new disease management programs in healthcare is usually slow, but active theory-driven implementation seems to outperform other implementation strategies. However, we have only scarce evidence on the feasibility and real effect of such strategies in complex primary care settings where municipalities, general practitioners and hospitals should work together. The Central Denmark Region recently implemented a disease management program for chronic obstructive pulmonary disease (COPD) which presented an opportunity to test an active implementation model against the usual implementation model. The aim of the present paper is to describe the development of an active implementation model using the Medical Research Council's model for complex interventions and the Chronic Care Model. Methods: We used the Medical Research Council's five-stage model for developing complex interventions to design an implementation model for a disease management program for COPD. First, literature on implementing change in general practice was scrutinised and empirical knowledge was assessed for suitability. In phase I, the intervention was developed; and in phases II and III, it was tested in a block- and cluster-randomised study. In phase IV, we evaluated the feasibility for others to use our active implementation model. Results: The Chronic Care Model was identified as a model for designing efficient implementation elements. These elements were combined into a multifaceted intervention, and a timeline for the trial in a randomised study was decided upon in accordance with the five stages in the Medical Research Council's model; this was captured in a PaTPlot, which allowed us to focus on the structure and the timing of the intervention. The implementation strategies identified as efficient were use of the Breakthrough Series, academic detailing, provision of patient material and meetings between providers. The active implementation model was tested in a randomised trial (results reported elsewhere). Conclusion: The combination of the theoretical model for complex interventions and the Chronic Care Model and the chosen specific implementation strategies proved feasible for a practice-based active implementation model for a chronic-disease-management-program for COPD. Using the Medical Research Council's model added transparency to the design phase which further facilitated the process of implementing the program. [ABSTRACT FROM AUTHOR]

Introduction: Formal pathways models outline that patients should receive information in order to experience a coherent journey but do not describe an active role for patients or their relatives. The aim of this is paper is to articulate and discuss the active role of patients during their cancer trajectories. Methods and theory: An in-depth case study of patient trajectories at a Danish hospital and surrounding municipality using individual interviews with patients. Theory about trajectory and work by Strauss was included. Results: Patients continuously took initiatives to organize their treatment and care. They initiated processes in the trajectories, and acquired information, which they used to form their trajectories. Patients presented problems to the healthcare professionals in order to get proper help when needed. Discussion: Work done by patients was invisible and not perceived as work. The patients' requests were not sufficiently supported in the professional organisation of work or formal planning. Patients' insertion and use of information in their trajectories challenged professional views and working processes. And the design of the formal pathway models limits the patients' active participation. When looking at integrated care from the perspective of patients, the development of a more holistic and personalized approach is needed. [ABSTRACT FROM AUTHOR]

Objectives: The aim of follow-up visits by the general practitioner and district nurse (within a week after discharge from hospital) is to reduce hospital readmissions and improve the overall wellbeing of the patient. There is strong evidence that these programmes are effective, but are difficult to implement because of a number of organizational obstacles, including co-ordination between the organizations involved in the process. In this paper we look at the factors that affect motivation to participate in a cross-sectoral programme in Copenhagen, Denmark, implementing follow-up home visits to elderly persons. Theory and methods: The analysis is based on inter-organizational network theory in an attempt to explain the role of motivation in network formation between organizational systems. The empirical findings are based on focus groups and in-depth interviews with hospital staff, general practitioners, and district nurses. Results: Care providers are motivated to collaborate by a number of factors. The focus of collaboration needs to be clearly defined and agreed upon, there needs to be a high degree of equality between the professionals involved, and there has to be a will to co-operate based on a shared understanding of values and learning potentials. Conclusions: The study concludes that we need to focus on specific care fields and actors to reduce complexity in the area and more fully understand what motivates care providers to participate in cross-sectoral activities, such as a follow-up home visit programme. One lesson for current policy is that motivational factors need to be addressed in future collaborative programmes in order to fully exploit the potential health benefits. [ABSTRACT FROM AUTHOR]

The abstract presents results of the "InterQuality Project - International Research Project on Financing Quality in Healthcare" funded by the 7th Framework Programme (FP7) for Research and Technological Development of the European Union. Grant Agreement No: HEALTH-F3-2010-261369 Objective: To assess reliability, validity and completeness of data on pharmaceutical benefit financing components of health care in United States, United Kingdom, Denmark, Germany, Italy and Poland Theory: Information and guidance used by authorities for decision making in the financing of pharmaceutical care should be reliable, valid and complete. Methods: A systematic review of literature published in the last 10 years, found electronically in Medline, Embase, the Cochrane Library and SCOPUS, supplemented by a manual search, was conducted. Quality of publications was critically appraised using PRISMA [1], MOOSE [2] and STROBE [3] checklists. Contents of found literature were assessed in terms of consistency, coherence and strength. Results: In total, 439 full text publications were included, of which 198 papers were assessed for quality. Of these, 24,6%, 31,2% and 22,1% publications presented high levels of: consistency, coherence and strength, respectively, and 4,3% presented concurrently high levels of all assessed areas. Several areas of weak data availability were identified. Discussion: No comparable analyses were found. Credible data were often unavailable. A questionnaire and a template helpful to collect data where more information is needed were developed, validated and will be sent to experts from InterQuality Consortium countries. Conclusion: To improve the quality of information available to decision makers, so that it is more credible, multiple sources should be used. [ABSTRACT FROM AUTHOR]

Promoting coordination between primary and secondary health care has been a great challenge and at the core of Danish health policy for decades. The latest and most comprehensive Danish administrative reform (2007) trying to address grey zones, silo-style-thinking and unclear division of responsibility can hardly be labeled as any sort of resounding success in terms of improving the coherence in the health system. Coordination of health care cannot be solved simply by administrative restructuring. In Denmark we must experience the limits of an advanced and developed welfare state, where the dysfunctions take the form of: Complexity, opacity, silo barriers, underutilization of the working and learning environments for knowledge workers, and low total performance. As a result we need a massive strengthening of the development of cross-cutting organization and management in health care. In short it means some important implications for interorganizational management, which among others emphasize: * The absence of positional power and management of many dilemmas * The managing of horizontal processes * The creation of trust and appropriate formalization This implies a boundary-transgressing organizational logic that can contribute to second order development of existing hybrid organizational and management forms and that have the potential to become the cornerstone of the organizations of tomorrow. The paper will further explore these inter-organizational implications for managing health care cross sectors, professions and political levels with a point of departure in several of our own current and previous studies. [ABSTRACT FROM AUTHOR]