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Introduction: Multispecialty community providers (MCPs) are a proposed model of care by which the NHS can reduce pressures on hospitals and general practices whilst improving the quality and continuity of care for people with complex health problems. MCPs integrate primary, community, mental health, and social care services by linking up services virtually or geographically. This paper presents findings that focus on how heath information technology (HIT) could be used to improve services and patient care in the MCP context using a realist synthesis approach. Methods: We followed the RAMESES guidelines, which outline the following process of conducting a realist synthesis: Develop an initial programme theory for how the intervention is thought to work. To create our programme theory we met held three meetings with policymakers and service users and conducted a search for relevant policy papers in the HMIC database. Conduct a systematic and iterative search of the literature to find evidence to support or refute the initial programme theory. To find evidence, we conducted a search in four databases (MEDLINE, PsycINFO, CINHAL, and ASSIA), and screened, extracted data, and critical appraised articles by five team members with 10% of records error checked by a second person. Revise the theory based on the collated evidence and build a new (evidence-based) logic model based on the findings. Results: Forty-one primary and secondary sources were included in the synthesis. We found some evidence that HIT in MCP-like organisations support multidisciplinary team working, care planning at the population and inter-organisational level, care planning at the patient level, and reduce unplanned hospital admissions. Few studies directly linked HIT with these outcomes, but there was a great deal of conceptually rich evidence about different contexts and mechanisms that can support or hinder projects from being most effective. Discussion: We found a very clear pattern that the most effective HIT projects in new models of care were implemented based on the unique needs of the organisation, customised as needed, and included input from the health professionals that would be using the system. This, in turn, often led to staff buy-in for the projects and supported good team working. Many sources also described the difficulties in using existing healthcare technology within new models of care and provided insight as to how an ideal HIT system might be designed. Such a system would be interoperable, capable of complex data analysis, contain workflow tools, and be flexible enough to support formal and informal communication between healthcare providers. Conclusions: We found some evidence that HIT, when well designed, can support MCP-like organisations. Lessons learned: The presence of HIT does not, by itself, lead to more efficient services or better patient outcomes. HIT must be carefully designed based on organisational needs. Limitations: Studies were limited to OECD countries and published between 2014-2016. Future Research: Further primary research is required to test elements of our revised logic model. Additional review work on aspects of HIT in new models of care such as patient registries and telehealth is needed. [ABSTRACT FROM AUTHOR]

Introduction: Multispecialty Community Providers (MCPS) aim to provide horizontal coordination of care via networks of primary care providers (general practice, community health services, mental health, ambulance, etc.) and non-health services (e.g. voluntary sector, social services etc.). MCPs are also expected to improve the quality, continuity and coordination of care for people with chronic health problems. Our Realist Synthesis identified policy assumptions about how MCPs are thought to achieve outcomes and the extent to which these were supported by evidence. Improvements to patient experiences of care was also an expected outcome of MCP care. We explored the evidence for this outcome. Theory/Methods: Three stage synthesis: 1) Review of policy material to identify the underlying programme theory (PT) for MCPs. This work surfaced policy makers assumptions about how MCPs would achieve their outcomes. These were elicited from policy documents and 'think-tanks' with stakeholders. We searched Health Management Information Consortium (HMIC) database, and the King's Fund database. The elaboration of the policy-makers' assumptions about MCPs provided search terms for the second stage. 2) A systematic literature review and synthesis of secondary evidence mapped to the initial PT. We searched for evidence of the 'causal links' in the initial PT by searching databases: MEDLINE, PsycINFO, CINAHL, and ASSIA. 1319 titles/abstracts reviewed in two rounds, and 116 selected for full-text data extraction. Secondary data were extracted and synthesised into a framework reflecting causal links in the initial PT. We used the Mixed Methods Appraisal (MMAT) and the Assessment of Multiple Systematic Reviews (AMSTAR) tools to assess quality and validity. 3) Comparison (and reformulation) of original PT based on secondary evidence and identification and focus on all studies measuring patient experience as an outcome (e.g. goal setting, care planning at a patient level etc.). Results: We found supporting evidence that if MCPs implement care planning at a patient level then patient experiences of care improve. The evidence was less strong for improvements in patient experience as a consequence of diversion from in-patient care. MDTs and boundary spanning roles helped improve patient experience. There was emerging evidence that MDTs and boundary spanning roles facilitated the delivery of person centred care by improvements in care planning and access to services. Discussion: Individuals with complex needs or those with long term conditions commonly report poor experiences of care (5, 6), particularly care from multiple organisations (7). Our review suggests that MCPs can improve patient experiences of care by providing tailored and accessible coordinated care. Conclusions: Patients' experiences of care have the potential to improve if care planning at a patient level becomes prevalent and delivered through MDTs and/or professionals with boundary spanning roles. Lessons learned: MDTs and boundary spanning roles are potential mechanisms to improve the experiences of care. Limitations: Due to the large volume of material we only included studies published 2014-2016; reviews covered earlier periods. Suggestions for future research: Changes in organisational culture was a potential mechanism associated with improvements in patient experience. Primary research that explore how this works would help unpack this newly identified mechanism. [ABSTRACT FROM AUTHOR]

Introduction: Current National Health Service (NHS) policy towards care coordination in England, involving the introduction of Multi-Specialty Community Providers (MCPs), assumes that repeated unplanned admissions of older people with multiple morbidity make disproportionately heavy use of hospital bed-days, that a substantial number of these admissions are preventable, and that reducing these admissions would substantially reduce cost and access pressures on hospital services. 'Integrated' (better-coordinated) care, delivered by MCPs, is intended to reduce these admissions by partly replacing hospital care with non-hospital care, hence raising the quality and reducing the cost of care. Our study synthesised existing evidence about how to integrate care at the system-level, including management of complexity and whole system patient flow. Theory/Methods: Stage 1. From grey literature, MCPs' published logic models, and a think tank (policy makers, health-workers, patients/public), we elicited policy-assumptions ('programme theory') about what structures, working practices and services ('mechanisms') the MCPs will contain, and how these mechanisms are expected to produce the outcomes above. Stage 2. Realist review: Evidence from other 'integrated' care projects which related to the programme theory identified in stage 1 was synthesised to produce a revised, more strongly evidence-based explanation of how complex, MCP-like 'integrated' care systems function in different contexts. 3. 'Critical Analysis': The policy-makers' initial programme theory (from stage 1) was compared with the evidence from stage 2. In that way the policy-makers' initial programme theory was elaborated, qualified and revised, better to inform the development of health and social care co-ordination in England. Results: We present 1) the initial programme theory, built from NHS England policy-makers' assumptions as to what outcomes the MCP models of care integration will produce in England, and by what means, and 2) some main findingsof how different models of care co-ordination might contribute to achieving these outcomes and under what conditions. Discussions: We discuss 1) how realist review methods were used to elaborate, qualify or challenge policy-makers' assumptions about how care co-ordination by means of MCPs would achieve the desired outcomes, and 2) how these findings can inform better care co-ordination. Conclusions: We describe the main empirical strengths and weaknesses in the assumptions underlying the models of care and care coordination which inform current NHS policy, and indicate where existing evidence is weak or lacking. [ABSTRACT FROM AUTHOR]

Introduction: Background: In many countries, including England, increasing numbers of people survive into old age with multiple chronic health problems. This demographic pattern and financial pressures on health systems have stimulated a twofold substitution of care providers, namely of: 1. Primary for hospital care, where 'primary care' means home nursing services; physiotherapy and other 'allied' health professions; mental health services; and crisis-response services (out-ofhours care, ambulance, outreach etc.) besides general medical practice. Concomitantly, social care is often also required. Even when all these services are present a residual need for secondary care often remains. 2. Informal care (self-care and/or care by spouse, other family members, friends) for formal care. In pursuit of marketisation policies, the UK government is simultaneously attempting to involve voluntary, 'social enterprise' and corporate providers. Problem statement: These changes make it increasingly necessary for someone to actively 'integrate' the care of such patients - more exactly, to co-ordinate the care provided by a range of formal and informal providers so as to promote continuity of care. In theory the GP coordinates a person's health care, but in practice other organisations or individuals sometimes take on this role. That raises the question of how methods and patterns of care coordination differ, when different organisations or individuals fulfil the coordinating role. Theory:Following Donabedian, we assume that health system organisational structures constrain the methods of care integration available to practitioners at local level, and the available methods of care integration constrain what health care outcomes (e.g. continuity of care) are achievable. Methods: Design: Nested case studies tracing the methods and consequences of different care coordination methods from patient level to the organisational context and preconditions at provider level, and from provider to health system level. Sample: Five English localities selected for maximum variety in the types of organisational structures available for integrating patient care. In each locality, a sample (n=68) of patients satisfying a set of clinical criteria for multiple chronic conditions was selected for study. Analysis: 1. Categorisation of care coordination methods and their consequences at patient level, inducted from patient interviews and systematic data extraction from patient medical records 2. Categorisation of organisational factors impeding and assisting care coordination for each type of care coordination method, inducted from (1) and from interviews with healthcare professionals and managers. Results: Provisionally (research continues), we found four main methods of care coordination at patient level: 1. GP as care coordinator (standard English model). GP input was uneven. Liaison and informational continuity with other health services was often problematic, but patients often looked to the GP as care coordinator. Often one or more of the following arrangements coexisted with (1): 2. Other health professions as coordinator, including ad-hoc care coordinating bodies, although these were hard to sustain, and case-management schemes. 3. Patients self-coordinate their care. The more complex their health problems were, the less capable patients often became of coordinating their own care. Patients often under-estimated the severity of their condition and the range of services needed. 4. Third-party integrating organisations, for instance charities such as Age Concern. However, financial pressures made it increasingly hard for health services to support them financially. Conclusions and discussion: These findings derive from small numbers of sites and patients in one country, so great caution is required in generalising empirically from them. They tend to confirm both that the structural separation of general practice from other primary and community care providers compounds the difficulties of care integration; and that it is practically difficult to substitute for the GP's coordinating role for this particular care group. [ABSTRACT FROM AUTHOR]

Background: Problem statement: Care for individuals who are marginalised and have complex needs is poor due to both reduced access and poor continuity. Improved access to treatment requires to improvement to both. Previously access has usually been measured quantitatively while there has been a trend to seeing continuity as an 'experience' encompassing relationship, flexibility and organisation of care. Purpose: To develop a causal model for barriers and facilitators of access to and continuity of healthcare care for individuals with complex needs using data from offenders as an exemplary group. Methods: Design: Mixed-method, exploratory synthesis utilising a Realistic Evaluation framework to describe outcomes of interest (access and continuity)and then examine data streams to identify causal influences. Data: Three related data and analysis streams: quantitative analysis of data about care from structured interviews with 200 offenders ; qualitative (pre-coded and thematic) analysis of 25 offender interviews and three focus groups; and two whole-organisation case studies and six mini 'best-practice' case studies from England. Setting: Health and criminal justice systems covering two local authorities in the south west and south east of England and six additional case study sites. Participants: 200 offenders and 35 practitioners and managers. Results: Healthcare was reported as disrupted, with barriers to access and ongoing care; there was quantitative evidence of continuity for those with substance misuse but not for those with mental health problems. In the new model developed from the data, continuity was conceptualised as a continuation of access with the same practitioner, a different practitioner in the same team, or a different team. In contrast we described how organisational and practitioner factors contribute to both initial and ongoing continuity of access. Services needed well engineered access arrangements as well as to demonstrate they have treatments worth receiving to sceptical clients; initial distrust needed to be overcome with skilful practitioner interactions in order to promote continuity; and organisational integrating functions such as liaison, pathways, data sharing and colocation could all play a part in creating continuity but practitioners need to be empowered to be flexible. Conclusions: Access and continuity are best seen as a continuum. By considering organisational and interpersonal factors that contribute to ongoing access, those who provide and commission care for people with complex conditions and from marginalised communities can use the model to specify practitioner behaviours and service configurations which are likely to be helpful in different contexts. [ABSTRACT FROM AUTHOR]