Search

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

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

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

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

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

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

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

Introduction: In 2000, Japan implemented a mandatory long-term care insurance system. With the rapid growth of the system, problems became apparent. Several critical alterations were made to long-term care insurance system, particularly with respect to integrated care. Methods: This paper elucidates the policy trends that led to the reforms of the long-term care insurance system, which included new concepts of 'integrated care' and 'community-based care', an agenda of cost containment and service streamlining, and coordination with medical care. Results: Community-based integrated care, as envisaged in the long-term care policy, includes not only the integration of medical care into service provision but also the inclusion of the informal mutual aid, oversight of for-profit providers by an administration that ensures users are not exploited and coordination between systems that cover different geographical areas. Conclusions: Japan's experience in community-based care integration suggests that this project requires multi-faceted care integration in local communities. In the future, it will be necessary to conduct empirical assessments of the effectiveness of these measures. [ABSTRACT FROM AUTHOR]

The Regional Council of Lombardy Region (legislative body) launched an enquiry to understand the integrated care (IC) challenges and their strategic role in light of the forthcoming regional health service reform. The contribution therefore represents the policy paper which takes the offering of such an inquiry on examines the Lombard case study of IC. The paper synthetises the IC policies and services' delivered in Lombardy hitherto and discussed the lessons learnt on three assets. Firstly, IC policies and interventions in force in Lombardy are presented and analysed in depth, to value their scopes, targets, volume, costs and the legislative scenario over IC, which states the role of departments (health and social), the financing systems and the legal regulation compared to the national one. Secondly, to evaluate the outcomes of IC, domiciliary care is analysed in depth and compared with three other Italian Regions, conceived among the best performers nationally. The comparison holds a key role to understand the results achieved in Lombardy against other solutions applied in similar contexts. Finally, the third part exploits the previous towards: on the one hand, evaluate the impacts of different policies, managerial strategies and institutional assets can have over the services' delivery system, as for the case of domiciliary care. On the other, the lesson learnt are synthesised in light of the first part to clearly stated recommendations of short, medium and long term objectives for the Regional Council if IC has to be developed and prioritised in the forthcoming reform. [ABSTRACT FROM AUTHOR]

Purpose: To explore the integration of health and social care in the UK through policy and clinical guidelines and to examine how partnership working and case management enables policy to be embedded into local practice. Context: The UK Department of Health policy document (White Paper 2006) Our Health, Our Care, Our Say: a new Direction for Community Services [1] focused on a new direction for the whole health and social care system. Description: The paper and subsequent action plans targeted the way services are provided, placing greater choice and control in the hands of people who use them. Health and Social Care services were tasked with becoming better integrated to meet the needs and wishes of individuals with chronic illness and long-term needs. The UK's National Service Frameworks and NICE guidelines are being implemented at local level to achieve management of chronic illness through effective case management and roles are being evaluated to show the effect of interventions [2]. The Government report Our NHS, Our Future [3] encourages a response to the , needs of local communities through integrating care to ensure that services are shaped around the user not the organisation. Discussion: We know that people with chronic illness are intensive users of services; that repeat admissions to hospital cause untold distress and that this vulnerable group is increasing as our population ages. We also know that inappropriate and increased use of services causes a financial burden in both primary and secondary care. Managed care through effective case management, if adopted flexibly, presents an opportunity to focus on reducing costs whilst appropriately managing the health needs of the target population. [ABSTRACT FROM AUTHOR]

Introduction: The Dutch Solid Start program aims to improve the collaboration between the medical and social sector to offer every child the best start in life. Municipalities form local coalitions of partners within the medical and social sector to support parents and children during the first thousand days. The aim of this study was to develop an indicator set for coalitions to monitor their local Solid Start program. Methods: A modified Delphi study with three rounds was carried out among Dutch experts in Solid Start practice, policy and research (n = 39) to reach consensus. Results: The indicator set included 19 indicators covering the three phases of the Solid Start program: preconception, pregnancy and after birth (up to two years). Prioritized indicators included both social and medical topics, among which poverty, psychological/ psychiatric problems, stress, smoking, cumulation of risk factors, preconception care, low literacy, premature birth, and intellectual disability. Additionally, a development agenda was established with topics and indicators that lacked data or clear operationalization (e.g. stress, unintended pregnancy, loneliness). Discussion and conclusion: The developed indicator set enhances the conversation between policymakers, managers, professionals and other stakeholders about the local situation and developments in order to prioritize interventions and policies. Next, the indicator set needs evaluation to assess its usefulness. [ABSTRACT FROM AUTHOR]

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

Introduction: The lack of integration of care in Portugal is perceived as a major constrain to the health system and, consequently, to the quality of care provided to patients. The improvement of integration is seen as a more effective way to provide quality care and to optimize scarce resources available. There were identified more than 175 definitions published in scientific papers (Armitage et al., 2009), and consensually adopted the WHO (2008) definition of integrated service delivery: "The management and delivery of health services so that clients receive a continuum of preventive and curative services, according to their needs over time and across different levels of the health system." From this point, the group established a theoretical framework of four dimensions of integration of care: structural (horizontal and/or vertical), functional, normative and systemic (clinical, information, financing and administrative perspective), in order to justify the recommendations on integration. Policy context and objective: Since 2011 the Portuguese Health Ministry has promoted technical Working Groups to study the integration of care. Several reports have been elaborated on this topic, identifying strategic initiatives to be implemented by the Government and public entities. The focus on the study of integration of care cannot be disconnected of the financial crisis that Portugal suffered and the goals established by the intervention of the International Monetary Fund, European Central Bank and the European Union. By order of the Secretary of State Assistant to the Minister of Health (9567/2013, 22 of July) a Work Group responsible for the elaboration of a report on the integration of the different health care levels in Portugal (Primary Care, Hospital and Palliative Care) was nominated. This Work Group was composed by multidisciplinary profiles with different professional background and work places, in order to reduce some bias derived from the personal experiences and influences. The document "Report of Integrated Care in the Portuguese Health System: Recommendations for the future" was produced in a six month period, and the members of the Work Group participated on a non- paid partial time regimen. Target population: The Final Report of the Work Group aims to the Health Ministry policy makers, as well as the responsibles for the delivering of care in the Portuguese NHS. The measures defined should be promoted by the Health Ministry, but they can be applied locally, having a firm connection to a broader framework (regional or national). Highlights (innovation, Impact and outcomes): The Work Group established a focus on tangible recommendations, being aware of the financial context that Portugal is subjected, and the need to improve the efficiency of the system as well as the quality of care provided. All the recommendations were presented with a rationale, with the conditions for operationalization, the estimated impact and the scientific evidence found for each one: • Introduce the concept of case management; • Create and implement a national referral management system; • Implement integrated guidelines, protocols and clinical pathways; • Create functional units shared by different levels of care (levels of decision); • Financial model based on capitation (risk adjustment) plus pay for performance (same objectives for different units); • Integrate administrative functions and procedures (for example: payroll salaries; logistics); • Integrate cost accounting systems. Conclusions: In Portugal, despite the focus on this topic the Working Group found an almost non existing evidence on integration of care, and the experiences identified, promoted locally by the providers revealed a more personal commitment and single initiatives rather than a national, or regional framework or a medium long term perspective. The recommendations of the Work Group where based on the real and theoretical diagnosis of the current state, and on the discussion based in evidence on this topic. Due to the nature of the recommendations, there is the need to develop the definition and the application of some of them, being estimated that they can be implemented with success in a medium/long term. [ABSTRACT FROM AUTHOR]

Background: An aging population is one of the key drivers reshaping health care systems. In China, the complex needs of its huge aging population require integration across the health and care sectors. Policies and progress: Over the past decade, the central government of China promulgated a series of policies to promote the establishment of aftercare facilities, specify approaches to integrate health and care service delivery at institutional and community levels, pilot long-term care insurance (LTCI) as a funding mechanism, and reform administrative structures in favor of integration. Progress has been made towards organizational and clinical integration of service delivery both at institutional and community levels. LTCI has been introduced as the financing mechanism covering long term care services. Discussions and Conclusions: The experiences of China in the integration of health and care could be summarized as a top-down approach in policy formulation and implementation, the significant employment of pilots and demonstrations, and the activation of market forces. However, China is still in the initial stage of integrating health and care and is faced with system-level challenges in its financing, management, and workforce, and faces technical challenges, such as a lack of tools, and standards. In the future, these issues need to be addressed. [ABSTRACT FROM AUTHOR]

Introduction: Evidence based care for COPD involves patients obtaining timely access to an integrated network of evidence based services delivered by staff with different skills working across different settings. Patient needs for these different services can vary over time as the status of their condition changes or they suffer sudden health crises. The primary care team (GPs and practice nurses) have a key role as a provider of and referrer to care but their awareness and use of evidence based care has been questioned [1]. This paper describes the nature and impacts of an innovative training programme that aimed to improve the quality and integration of care by increasing the primary care team's awareness and use of needed services. Intervention: Key characteristics of the training initiative included: targeting practices where COPD was most common; providers describing evidence based services that were available locally to support diagnosis through to end of life care; patients and carers presenting their experiences of living with COPD; practice based projects being used to pilot service improvement ideas. Evaluating the impacts of the training intervention: Qualitative assessment of the impacts of the training intervention is examining practitioners' views on its relevance, content and any factors that facilitate or constrain the adoption of good practice. Quantitative assessment is monitoring changes in care delivery processes and hospital admission rates. Results: Evaluation results to date have confirmed the need for the training initiative and the relevance of its content. Using local speakers facilitated knowledge about evidence based services that were currently under-used (e.g. for pulmonary rehabilitation) and prompted actions to increase referral rates. Patient and carer led sessions were probably most influential in changing professional behaviour and promoting a more patient centred approach to the delivery and integration of services. As one participant stated, "Remembering the individual and their journey of COPD and the impact it has on their life is the most important aspect the Health Worker should consider in providing supportive care" Conclusions: Efforts to increase the continuity and co-ordination of care for chronic conditions should include initiatives to ensure that existing evidence based services are used by health staff. Use of local speakers led to primary care staff having greater knowledge about available community based services thereby promoting better integration of care for patients. "Patient power" (patients and carers presenting their lived experiences) provided insight into the patient journey and the benefits of an integrated service response. [ABSTRACT FROM AUTHOR]

This Covid-19 pandemic has been a trying time for all countries, governments, societies, and individuals. The physical, social, and organizational infrastructure of healthcare systems across the world is being stressed. This pandemic has highlighted that the healthcare of the country is as strong as its weakest link and that no aspect of life, be it social or economic, is spared from this pandemic. The authors would like to highlight some of the lessons learned from Singapore's management of the Covid-19 pandemic. During the Singaporean Covid-19 pandemic, public health policy planning was all encompassing in its coverage, involving various stakeholders in government and society. The important role of individuals, governments, industry, and primary healthcare practitioners when tackling COVID-19 are highlighted. Singapore's management of the Covid-19 pandemic involved an approach that involved the whole of society, with a particular focus on supporting the vulnerable foreign worker population, which formed the majority of Covid-19 cases in the country. Hopefully amidst the trying times, valuable lessons are learnt that will be etched into medical history and collective memory. We hope to highlight these lessons for future generations, both for members of the public and fellow healthcare practitioners. [ABSTRACT FROM AUTHOR]

In 1999, Conrane Consulting in collaboration with a US managed care company and a large GP practice in the North West implemented the first UK pilot in holistic, anticipatory, case management of older people with complex needs and co-morbidities. The senior GP partner at the practice Castlefields in Runcorn was then Dr David Colin-Thome later to become Director of Primary Care for the Department of Health in the UK. The practice pilot was a success in both qualitative and economic terms and was extended to end of life care and mental health with equally successful results. Over the next 10 year Conrane went on to roll-out this programme in multiple NHS localities placing over 100 case managers into the practice. This included one the largest projects in the UK in Surrey and Sussex and NW London, designed and implemented with Imperial College. The outcomes delivered at Castlefields were replicated in some of these new localities but not all. In this paper the Director of these implementation programmes, Dr David Cochrane will explore the essential learning and distill the key success factors which differentiate the successful from the less successful programmes. This will be supported by more recent evidence emerging from the US Medicare/Medicaid programmes including the Johns Hopkins Guided Care model whose prescriptions for a best practice are convergent with those of the Conrane programmes. Key areas of interest are locality structures, mechanisms for social and health care collaboration, individualised care planning, the central role of the patient and carers, pro-active versus re-active staff skills and competences, the role of informatics, how to secure full GP participation through primary-care co-location and the scope for return on investment in a cost-constrained system. [ABSTRACT FROM AUTHOR]

Healthcare system reforms are pushing beyond primary care to more holistic, integrated models of community based primary health care (CBPHC) to better meet the needs of the population. Across the world CBPHC is at varying stages of development and few standard models exist. In order to scale up and spread successful models of care it is important to study what works and why. The first step is to select 'appropriate' cases to study. In this commentary we reflect on our journey in the selection of CBPHC models for older adults, revealing the limited utility of sourcing the empirical literature; the difficulty in identifying "successful" models to study when outcomes of importance differ across stakeholders; the value of drawing on clinical and organisational networks and experts; and the association between policy context and ease of case selection. Such insights have important implications for case study methodology in health services and policy research. [ABSTRACT FROM AUTHOR]

Introduction: Many studies have investigated the process of healthcare implementation to understand better how to bridge gaps between recommended practice, the needs and demands of healthcare consumers, and what they actually receive. However, in the implementation of integrated communitybased and integrated health care, it is still not well known which approaches work best. Methods: We conducted a systematic review and metanarrative synthesis of literature on implementation frameworks, theories and models in support of a research programme investigating CBPHC for older adults with chronic health problems. Results: Thirty-five reviews met our inclusion criteria and were appraised, summarised, and synthesised. Five metanarratives emerged 1) theoretical constructs; 2) multiple influencing factors; 3) development of new frameworks; 4) application of existing frameworks; and 5) effectiveness of interventions within frameworks/models. Four themes were generated that exposed the contradictions and synergies among the metanarratives. Person-centred care is fundamental to integrated CBPHC at all levels in the health care delivery system, yet many implementation theories and frameworks neglect this cornerstone. Discussion: The research identified perspectives central to integrated CBPHC that were missing in the literature. Context played a key role in determining success and in how consumers and their families, providers, organisations and policy-makers stay connected to implementing the best care possible. Conclusions: All phases of implementation of a new model of CBPHC call for collaborative partnerships with all stakeholders, the most important being the person receiving care in terms of what matters most to them. [ABSTRACT FROM AUTHOR]

Introduction: China's organised health system has remained outdated for decades. Current health systems in many less market-oriented countries still adhere to traditional administrative-based directives and linear planning. Furthermore, they neglect the responsiveness and feedback of institutions and professionals, which often results in reform failure in integrated care. Complex adaptive system theory (CAS) provides a new perspective and methodology for analysing the health system and policy implementation. Methods: We observed the typical case of Qianjiang's Integrated Health Organization Reform (IHO) for 2 years to analyse integrated care reforms using CAS theory. Via questionnaires and interviews, we observed 32 medical institutions and 344 professionals. We compared their cooperative behaviours from both organisational and inter-professional levels between 2013 and 2015, and further investigated potential reasons for why medical institutions and professionals did not form an effective IHO. We discovered how interested parties in the policy implementation process influenced reform outcome, and by theoretical induction, proposed a new semi-organised system and corresponding policy analysis flowchart that potentially suits the actual realisation of CAS. Results: The reform did not achieve its desired effect. The Qianjiang IHO was loosely integrated rather than closely integrated, and the cooperation levels between organisations and professionals were low. This disappointing result was due to low mutual trust among IHO members, with the main contributing factors being insufficient financial incentives and the lack of a common vision. Discussion and Conclusions: The traditional organised health system is old-fashioned. Rather than being completely organised or adaptive, the health system is currently more similar to a semi-organised system. Medical institutions and professionals operate in a middle ground between complete adherence to administrative orders from state-run health systems and completely adapting to the market. Thus, decision-making, implementation and analysis of health policies should also be updated according to this current standing. The simplest way to manage this new system is to abandon linear top-down orders and patiently wait for an explicit picture of IHO mechanisms to be revealed after complete and spontaneous negotiation between IHO allies is reached. In the meantime, bottom-up feedback from members should be paid attention to, and common benefits and fluid information flow should be prioritised in building a successful IHO. [ABSTRACT FROM AUTHOR]