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This rapid realist review aims to explain how and why person-centred care (PCC) in primary care works (or not) among others for people with low health literacy skills and for people with a diverse ethnic and socioeconomic background, and to construct a middle-range programme theory (PT). Peered reviewed- and non-peer-reviewed literature (Jan 2013-Feb 2021) reporting on PCC in primary care was included. Selection and appraisal of documents were based on relevance and rigour according to the Realist And Meta-narrative Evidence Syntheses: Evolving Standards (RAMESES) criteria. Data on context, mechanisms and outcomes (CMO) were extracted. Based on the extracted data, CMO configurations were identified per source publication. Configurations containing all three constructs (CMO) were included in the PT. The middle-range PT demonstrates that healthcare professionals (HCPs) should be trained and equipped with the knowledge and skills to communicate effectively (i.e. in easy-to-understand words, emphatically, checking whether the patient understands everything, listening attentively) tailored to the wishes, needs and possibilities of the patient, which may lead to higher satisfaction. This way the patient will be more involved in the care process and in the shared decision-making process, which may result in improved concordance, and an improved treatment approach. A respectful and empathic attitude of the HCP plays an important role in establishing a strong therapeutic relationship and improved health (system) outcomes. Together with a good accessibility of care for patients, setting up a personalised care plan with all involved parties may positively affect the self-management skills of patients. Good collaboration within the team and between different domains is desirable to ensure good care coordination. The coherence of items related to PCC in primary care should be considered to better understand its effectiveness.

Objective To provide an overview of the challenges of conducting mixed methods research (MMR) in the context of health services research (HSR) and to discuss a case study example of the triangulation procedures used in a MMR study on task-shifting in the Netherlands. Method A narrative literature review of publications between January 2000 and February 2020 on the use of mixed methods in the context of HSR and a description of the triangulation procedures in an HSR study with a MMR design on task shifting in the Netherlands. Results The narrative review identified eight challenges. Those related to publishing and appraisal of MMR within HSR were most frequently reported (e.g. ‘lack of MMR examples’, ‘lack of recognition’ and ‘triangulation issues’). Also, practical problems for conducting MMR within HSR were identified (e.g. ‘lack or resources’, ‘teamwork’ and ‘lack of quality criteria’). Methodological challenges (e.g. ‘sampling’ and ‘paradigm wars’) were less frequently reported as a challenge. Conclusion While increasing in popularity, there remain a range of challenges for the design, conduct and reporting of MMR designs in HSR. Using a triangulation protocol can potentially help address some of these challenges.

IntroductionEngaging public and patients in the decision-making processes is on the agenda of many healthcare systems towards sustainable healthcare delivery. While many engagement initiatives are performed face-to-face, an increasing number is conducted online. An example of the latter is the Dutch digital platform Gezonde Mening that engages patients, healthcare professionals and other stakeholders in the co-creation of healthcare innovations. This study aimed to evaluate the effectiveness of stakeholder engagement performed on Gezonde Mening by focusing on the process of planning, execution and transition of engagement activities.MethodsA mixed-methods study was performed by conducting eight semi-structured interviews with developers and funders of Gezonde Mening and an assessment of the psychometric properties of two questionnaires administrated via Gezonde Mening to seek stakeholders’ inputs. While the interviews were analysed deductively and inductively, data from the assessment of psychometric properties were analysed in a descriptive quantitative manner. Data were interpreted through triangulation.ResultsAssessment of the planning of stakeholder engagement identified needs for having more stakeholders on the platform to enable subgroup analysis and robust insights. Moreover, questionnaires administered by Gezonde Mening showed low validity and reliability. Assessment of the execution of stakeholder engagement indicated that stakeholders are sufficiently informed about engagement. Assessment of the transition of engagement activities showed needs to provide direct results to stakeholders and allow their evaluation of the platform.ConclusionGezonde Mening digital platform facilitates communication between innovators and stakeholders during engagement activities. However, the study identified room for improvement regarding the planning and transition activities.

Introduction: Violet Program (ViP) was developed to address the current home palliative service gap for individuals with life limiting non-cancer conditions residing in the Eastern part of Singapore. While its basic principles and processes have been planned and implemented, how ViP works, for whom and in what circumstances are not yet well understood. Therefore, we propose for a realist evaluation (RE) – a theory-based evaluation, to address the current knowledge gaps. Evaluation findings may guide, support further development and broader uptake of ViP.Methods and Analysis: This study will be conducted in three phases: 1. development of initial program theory (IPT), 2. testing of programme theory, and 3. refinement of IPT. First, IPT will be elicited through review of programme documents, scoping review of reviews and in-depth interviews with stakeholders involved in the conceptualization of ViP. Then, a convergent mixed method study will be conducted to assess contexts (C), mechanisms (M) and outcomes (O) to test the IPT through interviews with stakeholders, surveys and analysis of program and administrative databases. Based on findings gathered and through consultation with respective stakeholders, IPT will be refined to highlight what works (outcomes), how (mechanisms) and for whom under what conditions (contexts).

Contains fulltext : 245430.pdf (Publisher’s version ) (Open Access) INTRODUCTION: In a previous rapid realist review (RRR), an initial programme theory (PT) was established giving insight into the interrelatedness of context items, mechanisms, programme-activities, and outcomes that influence integrated care programmes (ICPs) for community-dwelling frail older people. As ICPs need to be tailored to their local setting, the objective of this study is to assess consensus on the relevance of the items identified in the RRR for the Dutch setting, and refine the PT, where appropriate. METHODS: A two-round e-Delphi study was carried out among Dutch experts to determine the relevance of 71 items. RESULTS: Consensus on relevance was reached on 57 out of 71 items (80%). Items added to refine the PT included: increasing number of older people, decreasing access to hospital beds, well-designed ICP implementation processes, case management, having a clear portfolio of patients, the role of the government, aligning existing health and social care systems, management and monitoring of care activities, strong relationship between older person and healthcare providers (HCP), and providing continuous feedback to HCPs. CONCLUSION AND DISCUSSION: The initial PT was refined for the Dutch setting. Items on which no consensus was found, need to be further investigated on the reason behind it.

Despite recent studies confirming task shifting is both safe and effective, its implementation has proven difficult in practice. So too in the Netherlands, where legal barriers enforcing strict professional boundaries have historically limited task shifting. In recent years, Dutch policymakers have experimented with temporary expanded scopes of practice (ESP) for several professional groups, with the aim to facilitate task shifting in order to increase the overall effectiveness and efficiency of health care. The Clinical Technologist (CT), is an emerging new professional group that has received such a temporary ESP pending an evaluation. This paper reports the qualitative findings of the implementation process of providing CTs with an temporary ESP. Data collection consisted of 69 semi-structured interviews, 3 focus group interviews and 9 participant observations, conducted between September 2015 and October 2017. Analysis was conducted through an 'editing analysis style' whereby data were categorized using the conceptual framework of Grol & Wensing's implementation model. The study suggests that social features are of great importance when implementing task shifting. In situations with few social barriers, organizational and administrative barriers seem to be less dominant, thereby expediting the overall implementation process. Consequently, we recommend that policymakers should prioritize social features over organizational features when implementing task shifting. (C) 2019 Elsevier B.V. All rights reserved.

IntroductionIntegrated people-centred care is a modern approach for addressing healthcare issues related to demographic changes, increasing prevalence of chronic diseases, and restricted resources. By providing an overview of integrated care models for patients with rheumatoid arthritis, we aimed to offer insight into the strategies and interventions that are being used for designing and implementing integrated models of care for this patient group, and their outcomes.MethodsWe conducted a systematic literature search of peer-reviewed literature available in English and published between 2013 and 2018, using three databases: Cochrane, PubMed and EMBASE. We analysed the publications based on the Framework on integrated people-centred health services and the Triple/Quadruple Aim framework.ResultsWe identified 1271 records. After screening, 50 articles met the criteria for inclusion in the review. Approaches for improving patient empowerment, engagement and experience of care were most prevalent in the identified care profiles. Similarly, frequently reported outcomes were related to improvements in patients’ experience of care and their health status. Most of the studies we reviewed did not demonstrate notable improvements from the perspective of cost-effectiveness or benefits for the healthcare workforce.ConclusionsOur findings suggest that for rheumatoid arthritis, integrated care is in the early stages of development. Strategies focusing on patient outcomes and patient satisfaction were found to be prioritised. Future initiatives aiming to redesign rheumatology care should adopt systems thinking perspective to better address all of the building blocks of people-centred integrated care.

Item does not contain fulltext Task shifting in healthcare has mainly been initiated and studied as a way to react to/or mitigate workforce shortages. Here, we define task shifting as the structural redistribution of tasks, usually including responsibilities and competencies between different professions. As such, task shifting is commonly focused on highly specialised and trained professionals who hand-over specific, standardised tasks to professionals with lower levels of education. It is expected that this type of task shifting will lead to efficiency and cost savings to healthcare organisations. Yet, there are more benefits to task shifting, in particular its contribution to integrated patient-centred quality of care and a tailored system that meets the changing care demands in society. Hence the importance to broaden the scope of task shifting, its goals, manifestations and how task shifting plays a role in addressing both the strengths and weaknesses in the healthcare system. In this focus piece, trends and conditions for task shifting and its (un)anticipated effects are discussed. We argue that, only when designed to face specific complexities at the workplace and taking into account the balance between specialists and generalists, task shifting may substantially contribute to enhanced quality of care that meets the changing needs of society. 5 p.

Background: To help enhance the quality of integrated stroke care delivery, regional stroke services networks in the Netherlands participated in a self-assessment study in 2012, 2015 and 2019. Methods: Coordinators of the regional stroke services networks filled out an online self-assessment questionnaire in 2012, 2015 and 2019. The questionnaire, which was based on the Development Model for Integrated Care, consisted of 97 questions in nine clusters (themes). Cluster scores were calculated as proportions of the activities implemented. Associations between clusters and features of stroke services were assessed by regression analysis. Results: The response rate varied from 93.12012) to 85.52019). Over the years, the regional stroke services networks increased in ‘size’: the median number of organisations involved and the volume of patients per network increased (7 and 499 in 2019, compared to 5 and 364 in 2012). At the same time, fewer coordinators were appointed for more than 1 day a week in 2019 (35.1 compared to 2012 (45.9. Between 2012 and 2019, there were statistically significantly more elements implemented in four out of nine clusters: ‘Transparent entrepreneurship’ (MD = 18.01) = 10.693, p = 0.001), ‘Roles and tasks’ (MD = 14.01) = 9.255, p = 0.003), ‘Patient-centeredness’ (MD = 12.91) = 9.255, p = 0.003), and ‘Commitment’ (MD = 11.2 F(1) = 4.982, p = 0.028). A statistically significant positive correlation was found for all clusters between implementation of activities and age of the network. In addition, the number of involved organisations is associated with better execution of implemented activities for ‘Transparent entrepreneurship’, ‘Result-focused learning’ and ‘Quality of care’. Conversely, there are small but negative associations between the volume of patients and implementation rates for ‘Interprofessional teamwork’ and ‘Patient-centredness’. Conclusion: This long-term analyses of stroke service development in the Netherlands, showed that between 2012 and 2019, integrated care activities within the regional stroke networks increased. Experience in collaboration between organisations within a network benefits the uptake of integrated care activities.

Background To examine how the knowledge transfer processes unfolded within SCIROCCO, a EU funded project (3rd Health Programme (2014–2020)) that aimed to facilitate the process of knowledge sharing across five European regions, to speed up adoption and scaling-up of integrated care initiatives. Methods A qualitative multi-method design was used. Data collection methods included focus groups, project documents and action plans of the regions. The data was analysed using a qualitative content-analysis procedure, which was guided by the frameworks of knowledge exchange and the why, whose, what, how framework for knowledge mobilisers. Results All five components (including the themes) of knowledge exchange could be identified in the approach developed on the knowledge transfer processes. The four questions and accompanying categories of the framework of knowledge mobilisation were also identified to a large degree. Conclusions The observed incorporation of distinct forms of knowledge from multiple sources and the observed dynamic and fluid knowledge transfer processes both suggest that SCIROCCO developed a comprehensive knowledge transfer approach aiming to enable the adoption and scaling-up of integrated care. Overall, the multi-method qualitative nature of this research has allowed some new and practical insights in the knowledge transfer activities on integrated care between several European regions. To obtain a clear understanding of the content of the knowledge transfer approaches, which could assist the operationalising of models to support the evaluation of knowledge transfer activities, it is strongly recommended that further research of this type should be conducted in other research settings.

Background Shared decision making (SDM) is at the core of policy measures for making healthcare person-centred. However, the context-sensitive nature of the challenges in integrated stroke care calls for research to facilitate its implementation. This before and after evaluation study identifies factors for implementation and concludes with key recommendations for adoption. Methods Data were collected at the start and end of an implementation programme in five stroke services (December 2017 to July 2018). The SDM implementation programme consisted of training for healthcare professionals (HCPs), tailored support, development of decision aids and a social map of local stroke care. Participating HCPs were included in the evaluation study: A questionnaire was sent to 25 HCPs at baseline, followed by 11 in-depth interviews. Data analysis was based on theoretical models for implementation and 51 statements were formulated as a result. Finally, all HCPs were asked to validate and to quantify these statements and to formulate recommendations for further adoption. Results The majority of respondents said that training of all HCPs is essential. Feedback on consultation and peer observation are considered to help improve performance. In addition, HCPs stated that SDM should also be embedded in multidisciplinary meetings, whereas implementation in the organisation could be facilitated by appointed ambassadors. Time was not seen as an inhibiting factor. According to HCPs, negotiating patients’ treatment decisions improves adherence to therapy. Despite possible cognitive or communications issues, all are convinced patients with stroke can be involved in a SDM-process. Relatives play an important role too in the further adoption of SDM. HCPs provided eight recommendations for adoption of SDM in integrated stroke care. Conclusions HCPs in our study indicated it is feasible to implement SDM in integrated stroke care and several well-known implementation activities could improve SDM in stroke care. Special attention should be given to the following activities: (1) the appointment of knowledge brokers, (2) agreements between HCPs on roles and responsibilities for specific decision points in the integrated stroke care chain and (3) the timely investigation of patient’s preferences in the care process – preferably before starting treatment through discussions in a multidisciplinary meeting.

Background In previous years, many multi-faceted initiatives have been set up to improve outcomes for people with chronic diseases. Evaluation studies about the (cost-)effectiveness of these integrated care programs showed heterogeneity in outcomes. Hence, it has been suggested to use realist evaluation for the evaluation of integrated care programmes. Thus, our aim was to gain insight into whether and how existing integrated care programmes work for people with cardiovascular disease, chronic obstructive pulmonary disease, depression, diabetes and multi-morbidity, and under what conditions within the Dutch healthcare setting. Methods A rapid realist review was conducted to identify the context and mechanisms that are associated with the outcomes of integrated care programmes. From a selection of systematic reviews and meta-analyses and Dutch literature, data on the context, mechanisms and outcomes of integrated care programmes were extracted. The data were analysed by placing the extracted variables in context-mechanism-outcome configurations which showed their interrelatedness. A panel of executives from Dutch care groups assessed the face validity of the context-mechanism-outcome configurations. Results Based on the existing literature, context-mechanism-outcome configurations were compiled for all five diseases. Some configurations could be filled with more detail than others, with the configuration of integrated care for people with diabetes being the most complete. Context-mechanism-outcome configurations were completed and confirmed by executives from Dutch care groups. Conclusion The configurations together with the identified factors in them reveal the underlying preliminary program theories of integrated care programmes. These theories need to be tested in further research.

Objectives: To assess the cost effectiveness of home telemonitoring (HTM) and nurse telephone support (NTS) compared with usual care (UC) in the management of patients with chronic heart failure, from a third-party payer's perspective. Methods: We developed a Markov model with a 20-year time horizon to analyze the cost effectiveness using the original study (Trans-European Network-Home-Care Management System) and various data sources. A probabilistic sensitivity analysis was performed to assess the decision uncertainty in our model. Results: In the original scenario (which concerned the cost inputs at the time of the original study), HTM and NTS interventions yielded a difference in quality-adjusted life-years (QALYs) gained compared with UC: 2.93 and 3.07, respectively, versus 1.91. An incremental net monetary benefit analysis showed (sic)7,697 and (sic)13,589 in HTM and NTS versus UC at a willingness-to-pay (WTP) threshold of (sic)20,000, and (sic)69,100 and (sic)83,100 at a WTP threshold of (sic)80,000, respectively. The incremental cost-effectiveness ratios were (sic)12,479 for HTM versus UC and (sic)8,270 for NTS versus UC. The current scenario (including telenurse cost inputs in NTS) yielded results that were slightly different from those for the original scenario, when comparing all New York Heart Association (NYHA) classes of severity. NTS dominated HTM, compared with UC, in all NYHA classes except NYHA IV. Conclusions: This modeling study demonstrated that HTM and NTS are viable solutions to support patients with chronic heart failure. NTS is cost-effective in comparison with UC at a WTP of (sic)9000/QALY or higher. Like NTS, HTM improves the survival of patients in all NYHA classes and is cost-effective in comparison with UC at a WTP of (sic)14,000/QALY or higher.

Objective. The present study aimed to assess the costs and potential financial benefit of integrated care models for patients with chronic diseases, i.e. type 2 diabetes mellitus, schizophrenia, or multiple sclerosis respectively. Methods. A systematic search of the literature was performed using Embase, Medline, and Web of Science. Studies which conducted a cost analysis, considered at least two components of the Chronic Care Model, and compared integrated care versus standard care, were included. Results. Out of 575 articles, 26 were included. Most studies examined integrated care models for patients with type 2 diabetes mellitus (n=18) and to a lesser extent for patients with schizophrenia (n=6) or multiple sclerosis (n=2). Across the three disease groups, the incremental cost per patient per year ranged from – €3,860 to €614 ( = – €533.61, SD = €902.96 ). The incremental cost for type 2 diabetes mellitus ranged from – €1,507.49 to €299.20 ( = – €518.22, SD = €604.75), for schizophrenia from – €3,860 to €613.91 ( = – €677.21, SD = €1,624.35), and for multiple sclerosis from – €822 to €339.43 ( = – €241.29, SD = €821.26). The vast majority of studies (22/26, 84.6%) reported a positive economic impact of integrated care models, respectively for type 2 diabetes mellitus (16/18, 88.9%), schizophrenia (4/6, 66.7%), and multiple sclerosis (1/2, 50%). Conclusion. In this systematic literature review, predominantly positive economic impacts of integrated care models for patients with chronic diseases were found. The Agency for Innovation by Science and Technology provided the necessary funds for the CORTEXS (Care Organization: a Re-Thinking EXpedition in search for Sustainability) research project of which this article is a result.

Introduction: The aim of the study is to investigate the barriers and facilitators to the implementation of workforce changes implemented as part of integrated chronic care interventions. Methods: We used a qualitative multimethod design that combined expert questionnaires, a systematic literature review, and secondary analysis of two case reports. Twenty-five experts, twenty-one studies and two case reports were included in the study. Results: Most barriers related to problematic delivery structures, health professionals’ skills and enthusiasm, IT, funding, culture and cooperation and communication. Most facilitators related to health professionals’ motivation and enthusiasm, good delivery structures, communication and cooperation, IT, patients, leadership and senior management. Overall, similar categories of barriers and facilitators were found. Discussion: We recommend that future research focusses on more complex designs including multiple data sources, as these are better able to capture the complexity of interventions such as integrated care. We recommend that health managers and policy-makers should invest in delivery structures and skills and motivation of health professionals to improve the implementation of workforce changes in integrated chronic care interventions. Conclusion: The added value of the present study lies in its provision of information on which factors might mitigate the success of an intervention, which helps to prevent premature conclusions of ineffectiveness for complex interventions.

Health systems around the globe implement integrated care interventions to address the Triple Aim of simultaneously improving population health, patient experiences and cost-efficiency. However, the underlying definitions and conceptualisations of integrated care often differ considerably, which makes uniform measurement and comparison difficult. Rather than agreeing on one definition of integrated care, we argue that a universal typology of integrated care interventions should be developed to enable the comparison of interventions that are based on different understandings of integrated care. This universal typology should combine rankable and intangible components with unrankable and tangible sub-components, and be conceptually sound and flexible. The content of the typology should be developed by an international consortium of relevant stakeholders.

Policy Points: Investigations on systematic methodologies for measuring integrated care should coincide with the growing interest in this field of research. A systematic review of instruments provides insights into integrated care measurement, including setting the research agenda for validating available instruments and informing the decision to develop new ones. This study is the first systematic review of instruments measuring integrated care with an evidence synthesis of the measurement properties. We found 209 index instruments measuring different constructs related to integrated care; the strength of evidence on the adequacy of the majority of their measurement properties remained largely unassessed. Context Integrated care is an important strategy for increasing health system performance. Despite its growing significance, detailed evidence on the measurement properties of integrated care instruments remains vague and limited. Our systematic review aims to provide evidence on the state of the art in measuring integrated care. Methods Our comprehensive systematic review framework builds on the Rainbow Model for Integrated Care (RMIC). We searched MEDLINE/PubMed for published articles on the measurement properties of instruments measuring integrated care and identified eligible articles using a standard set of selection criteria. We assessed the methodological quality of every validation study reported using the COSMIN checklist and extracted data on study and instrument characteristics. We also evaluated the measurement properties of each examined instrument per validation study and provided a best evidence synthesis on the adequacy of measurement properties of the index instruments. Findings From the 300 eligible articles, we assessed the methodological quality of 379 validation studies from which we identified 209 index instruments measuring integrated care constructs. The majority of studies reported on instruments measuring constructs related to care integration (33%) and patient-centered care (49%); fewer studies measured care continuity/comprehensive care (15%) and care coordination/case management (3%). We mapped 84% of the measured constructs to the clinical integration domain of the RMIC, with fewer constructs related to the domains of professional (3.7%), organizational (3.4%), and functional (0.5%) integration. Only 8% of the instruments were mapped to a combination of domains; none were mapped exclusively to the system or normative integration domains. The majority of instruments were administered to either patients (60%) or health care providers (20%). Of the measurement properties, responsiveness (4%), measurement error (7%), and criterion (12%) and cross-cultural validity (14%) were less commonly reported. We found

Background Accessibility to efficient and person-centered healthcare delivery drives healthcare transformation in many countries. In Singapore, specialist outpatient clinics (SOCs) are commonly congested due to increasing demands for chronic care. To improve this situation, the National University Health System (NUHS) Regional Health System (RHS) started an integrated care initiative,the Right-Site Care (RSC) program in 2014. Through collaborations between SOCs at the National University Hospital and primary and community care (PCC) clinics in the western region of the county, the program was designed to facilitate timely discharge and appropriate transition of patients, who no longer required specialist care, to the community. The aim of this study was to evaluate the implementation fidelity of the NUHS RHS RSC program using the modified Conceptual Framework for Implementation Fidelity (CFIF), at three distinct levels; providers, organizational, and system levels to explain outcomes of the program and to inform further development of (similar) programs. Methods A convergent parallel mixed methods study using the realist evaluation approach was used. Data were collected between 2016 and 2018 through non-participatory observations, reviews of medical records and program database, together with semi-structured interviews with healthcare providers. Triangulation of data streams was applied guided by the modified CFIF. Results Our findings showed four out of six program components were implemented with low level of fidelity, and 9112 suitable patients were referred to the program while 3032 (33.3%) declined to be enrolled. Moderating factors found to influence fidelity included: (i) complexity of program, (ii) evolving providers’ responsiveness, (iii) facilitation through synergistic partnership, training of PCC providers by specialists and supportive structures: care coordinators, guiding protocols, shared electronic medical record and shared pharmacy, (iv) lack of organization reinforcement, and (v) mismatch between program goals, healthcare financing and providers’ reimbursement. Conclusion Functional integration alone is insufficient for a successful right-site care program implementation. Improvement in relationships between providers, organizations, and patients are also warranted for further development of the program.

Background To cope with rising demand for healthcare services in Singapore, Regional Health Systems (RHS) comprising of health and social care providers across care settings were set up to integrate service delivery. Tasked with providing care for the western region, in 2012, the National University Health System (NUHS) – RHS developed a transitional care program for elderly patients with complex healthcare needs who consumed high levels of hospital resources. Through needs assessment, development of personalized care plans and care coordination, the program aimed to: (i) improve quality of care, (ii) reduce hospital utilization, and (iii) reduce healthcare-related costs. In this study, recognizing the need for process evaluation in conjunction with outcome evaluation, we aim to evaluate the implementation fidelity of the NUHS-RHS transitional care program to explain the outcomes of the program and to inform further development of (similar) programs. Methods Guided by the modified version of the Conceptual Framework for Implementation Fidelity (CFIF), adherence and moderating factors influencing implementation were assessed using non-participatory observations, reviews of medical records and program databases. Results Most (10 out of 14) components of the program were found to be implemented with low or moderate level of fidelity. The frequency or duration of the program components were observed to vary based on the needs of users, availability of care coordinators (CC) and their confidence. Variation in fidelity was influenced predominantly by: (1) complexity of the program, (2) extent of facilitation through guiding protocols, (3) facilitation of program implementation through CCs’ level of training and confidence, (4) evolving healthcare participant responsiveness, and (5) the context of suboptimal capability among community providers. Conclusion This is the first study to assess the context-specific implementation process of a transitional care program in the context of Southeast Asia. It provides important insights to facilitate further development and scaling up of transitional care programs within the NUHS-RHS and beyond. Our findings highlight the need for greater focus on engaging both healthcare providers and users, training CCs to equip them with the relevant skills required for their jobs, and building the capability of the community providers to implement such programs. Electronic supplementary material The online version of this article (10.1186/s12913-019-3980-x) contains supplementary material, which is available to authorized users.

ObjectiveTo identify the relationships between the context in which integrated care programmes (ICPs) for community-dwelling frail older people are applied, the mechanisms by which the programmes do (not) work and the outcomes resulting from this interaction by establishing a programme theory.DesignRapid realist review.Inclusion criteriaReviews and meta-analyses (January 2013–January 2019) and non-peer-reviewed literature (January 2013–December 2019) reporting on integrated care for community-dwelling frail older people (≥60 years).AnalysisSelection and appraisal of documents was based on relevance and rigour according to the Realist And Meta-narrative Evidence Syntheses: Evolving Standards criteria. Data on context, mechanisms, programme activities and outcomes were extracted. Factors were categorised into the five strategies of the WHO framework of integrated people-centred health services (IPCHS).Results27 papers were included. The following programme theory was developed: it is essential to establish multidisciplinary teams of competent healthcare providers (HCPs) providing person-centred care, closely working together and communicating effectively with other stakeholders. Older people and informal caregivers should be involved in the care process. Financial support, efficient use of information technology and organisational alignment are also essential. ICPs demonstrate positive effects on the functionality of older people, satisfaction of older people, informal caregivers and HCPs, and a delayed placement in a nursing home. Heterogeneous effects were found for hospital-related outcomes, quality of life, healthcare costs and use of healthcare services. The two most prevalent WHO-IPCHS strategies as part of ICPs are ‘creating an enabling environment’, followed by ‘strengthening governance and accountability’.ConclusionCurrently, most ICPs do not address all WHO-IPCHS strategies. In order to optimise ICPs for frail older people the interaction between context items, mechanisms, programme activities and the outcomes should be taken into account from different perspectives (system, organisation, service delivery, HCP and patient).

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

Many countries are experimenting with new models to better integrate care; yet, innovative care models are often implemented as time-limited, localised projects with limited impact on service delivery more broadly. This paper seeks to understand the processes behind successful projects that achieved some form of ‘routinisation’ and informed system-wide integrated care strategies. It draws on detailed case studies of three integrated care experiments: the ‘Integrated effort for people living with chronic diseases’ project in Denmark; the Gesundes Kinzigtal network in Germany; and Zio, a care group in the Maastricht region in the Netherlands. It explores how they were developed, implemented and sustained, and how they impacted the wider system context. All three models implicitly or explicitly adopted processes shown to be conducive to the dissemination of innovations, including dedicated time and resources, support and advocacy, leadership and management, stakeholder involvement, communication and networks, adaptation to local context and feedback. Each showed robust evidence of improvements on a number of service and patient outcomes and these findings were central to their wider impacts, shaping country-wide integrated care polices. However, the wider dissemination of projects occurred in an incremental and somewhat haphazard way. To further redesign health and social care a more formal strategy, alongside resources, may thus be needed to provide funders and providers with genuine incentives to invest in new business models of care. There remains a crucial need for better understanding of specific local conditions that influence implementation and sustainability to enable translation to other contexts and settings.

Rationale, aims and objectives The delivery of integrated care is a priority in many countries' efforts to improve health outcomes for people at risk of or with diabetes. This study aims to provide an overview of the different types of integrated care interventions for type 2 diabetes and to report their outcomes. Methods A systematic literature search was conducted in PubMed and Cochrane for the period 2003–2013. Article selection and data extraction were performed independently by three researchers and results were discussed together. The chronic care model (CCM) was used to describe intervention types. Results Forty-four articles met the inclusion criteria. Most interventions included all CCM components and a variety of sub-components. Most studies reported positive patient, process and health service utilization measures. The information on costs was limited and inconsistent. The low number of articles reporting comparable outcome measures made it difficult to make meaningful statements about an association between intervention type and outcomes. Conclusions Future research would benefit from a more uniform understanding of integrated care as well as intermediate outcome measurements that allow for the establishment of a chain of evidence from specific intervention types to specific outcomes achieved. It is expected that such a comprehensive approach will reveal important insights as to which integrated care intervention types and settings are most conducive to successful implementation and would thereby be of relevance to policy makers and practitioners involved in the financing, management and delivery of integrated care.

Background: Worldwide healthcare systems are piloting new integrated delivery and payment models to effectively manage care for the rising number of people with chronic diseases [1-11]. However, information about how clinical, professional, organizational, functional, normative and system elements influence the uptake of integrated care across different countries is currently lacking [12,13]. This poses significant challenges for stakeholders to support the effective deployment and evaluation of integrated care and its implementation in daily practice [14-16]. Therefore, the aim of this study is to characterize and compare the key elements that influence the implementation of integrated care initiatives across countries using the Rainbow Model of Integrated Care RMIC [17]. Methods: A cross-sectional survey study design will be used. A convenience sample of participants of the 18th International Conference on Integrated Care ICIC will be invited to participate in an online survey study. The Rainbow Model of Integrated Care Measurement Tool RMIC-MT [18,19] will be used to measure: four drivers person-centered care, service coordination, professional coordination, and organizational coordination, and four enablers community-centeredness, technical competence, cultural competence; and healthcare policy of the implementation of integrated care. Descriptive statistics mean, standard deviation, percentages will be used to compare countries. Results: Results of the study will be presented during a workshop at the 18th International Conference on Integrated Care in Utrecht, The Netherlands. The results can help stakeholders to make informed decisions about how to effectively implement integrated care programs across different cultural and organizational contexts. It is anticipated that the findings will be disseminated through a peer-reviewed publication and presented in a variety of policy and science forums.

Introduction: The growing prevalence of dementia is of concern in Singapore as it poses significant health, social and economic burden on individuals, families and the healthcare system. While it widely known that dementia is best managed by a multidisciplinary team of healthcare providers working together across different healthcare settings, dementia care has been primarily delivered by tertiary hospitals in Singapore. Hospital-centric dementia care is insufficient because needs of persons with dementia PWDs and their caregivers extend beyond medical needs and are best provided for in the community. As demand continues to rise, the healthcare system now faces the challenges of ensuring sustainability, appropriateness and quality of dementia care. To cope with these, the CARITAS network was established in 2012 to foster integrated, person centered care across different healthcare settings through i formation of primary care and community PCC providers network ii empowerment of PCC to manage PWD in the community iii empowerment of caregivers and iv integration between tertiary hospital and PCC through clinical, professional and functional integration. With these strategies, the CARITAS aims to provide a comprehensive, accessible, responsive, individualized, trans-disciplinary, accountable and seamless care for PWDs in the northern part of Singapore within their community. Methods: To support further development of the CARITAS network, this study was designed as a formative evaluation. Using sequential exploratory mixed methods, we aim to examine the degree of care integration within the CARITAS network, identify moderating factors that affect its implementation by taking into consideration the context in which it operationalized so as to identify areas for improvements. Guided by the Rainbow Model of Integrated Care RMIC, the RMIC measurement tool RMIC-MT was first administered to 100 healthcare providers within the CARITAS network. Then, based on the findings from the RMIC-MT, 30 healthcare providers and caregivers were invited to participate in interviews to gather insights into the moderating factors of the implementation of the CARITAS network. Data from the various sources will initially be analyzed according to their data types and subsequently triangulated according to the RMIC. Recommendations for improvements will then be made. Results & Discussions: The results which will be presented at the conference have significant implications on a few levels. It will potentially i provide information for improvement of the CARITAS network, ii provide insights to other countries that are experimenting with new models of dementia care and iii contribute significantly to the international literature on improvement science. Lessons Learned: In the evaluation of complex healthcare intervention such as the CARITAS network, it is essential to conduct process evaluation in conjunction with outcome evaluation so as to account for variability in implementation. Without process evaluation, it would be difficult to determine actions to take for improving the intervention. Limitations: As this is a single site study, findings gathered from this study needs to be interpreted with consideration of the context in which the CARITAS network is implemented. Suggestions for future research Future research should be conducted to examine the effectiveness of the CARITAS network in improving its intended outcomes.

Introduction : Frequent admitters FA, defined as patients with three or more inpatient acute hospital admissions within one year, account for about 27% of episodes and incur high healthcare costs. National University Health System Regional Health System NUHS-RHS Integrated Interventions and Care Extension NICE, launched in 2014, targeted FA with the aim of reducing avoidable hospital utilisation. NICE patients were assigned a case manager who customised their care plan based on holistic needs assessment. NICE provided post-discharge home visits and/or phone calls to monitor patients’ progress, appropriate referrals to community health and social services, and consolidated care under one team. We retrospectively evaluated NICE’s effect on reducing utilisation over 1-year post-enrolment: all-cause admissions ADM, emergency admissions EM, emergency department visits ED, specialist outpatient clinic visits SOC, and total inpatient length of stay LOS. Methods : NICE patients enrolled between June 2014 to December 2015 were grouped as cases n=668. Unenrolled patients who were FA during the same period were designated as potential controls n=5,714, taking their third admission date during this period as proxy date of enrolment. Propensity score matching was conducted with the following: gender, race, age, residential housing type, number of comorbidities at enrolment, date of enrolment and pre-enrolment utilisation 1-year prior. This resulted in 604 matched case-control pairs. As the variance of each measure of utilisation is greater than its mean, negative binomial regression was used to model post-enrolment utilisation, adjusting for log-transformed pre-enrolment levels and matching propensity score, with an offset term to account for potential mortality during follow-up. We report incidence rate ratios IRR of cases to controls, with 95% confidence intervals 95%CI. Results : Cases unadjusted mean=6.7 had significantly fewer post-enrolment SOC than controls unadjusted mean=8.6, IRR=0.86 95%CI: 0.77-0.97. No statistically significant differences were observed for post-enrolment ADM, EM, ED, and LOS. Discussion : The results suggest that NICE provided adequate post-discharge follow-up care that patients would otherwise seek from SOC, thus potentially decreasing patients’ time and cost burden. For a significant proportion of patients in both groups, post-enrolment ADM, EM, ED, and LOS may have regressed to a low mean following an acute period of high admissions, resulting in floor effects which limit any further reductions in a 1-year period. Conclusion : NICE had an impact in reducing patients’ SOC post-discharge. Lessons Learned : The higher than expected variability in the utilisation patterns suggest FA are a heterogeneous group, and stratification could allow for more targeted interventions that better cater to care needs. Limitations : Patients were not randomised into cases and controls, but inherent bias from confounding factors was mitigated with matching. Different patient profiles and needs possibly also led to implementation inconsistencies. Suggestions for Future Research : Future research could stratify FA into subgroups and explore programme effects in reducing readmissions within patient subsets over a longer follow-up period. Targeted interventions for various subsets could be tested and inform future iterations of such programmes. Cost-benefit analysis should be conducted to determine if the savings from reduced SOC that are attributable to NICE outweighs the cost to run the programme.

Introduction: To make effective use of integrated initiatives and rapidly increase their wide-scale impact to benefit more people on a lasting basis, large-scale implementation is desirable. However, an understanding of what elements are related with successful implementation of integrated care initiatives on a larger scale remains largely unknown. WHO/ExpandNet argue that ‘’strategic planning for the expansion and institutionalization of successfully tested health systems innovations is essential’’[1]. Flexible, but intentional, scale-up strategies can help guide system changes [2]. This literature review aims to explore what scaling-up strategies for integrated care initiatives are described in literature, to describe to what extent these are theory-based, and how they match the framework for scaling-up, as defined by WHO [3]. Methods: PubMed Medline and Web of Science were consulted to collect data. A combination of three concepts are used as search strategy: 1 search terms describing “integrated care”; 2 search terms related to “scaling-up”; and 3 search terms related to “strategy”. Papers focusing on scaling-up and/or expansion of integrated care initiatives and reporting a strategy for expansion between January 2007 and December 2017 are identified. After the articles are retrieved, the framework for scaling-up, as defined by WHO, is used as a guide to extract the data. The guide includes the types of scaling-up i.e. vertical; horizontal; diversification; spontaneous, the steps for developing a scaling-up strategy for integrated care i.e. scalability; capacity of user organization; environment and planning actions; capacity of resource team; choices for vertical scaling-up; choices for horizontal scaling-up; role of diversification; actions for spontaneous scaling-up; and identification of next steps including the strategic choices made i.e. dissemination and advocacy; organizational process; costs/ resource mobilization; monitoring and evaluation. Results: A number of 6,222 articles were identified in the two databases, after removing duplicates, a total of 5,568 potentially relevant articles have been reviewed based on title. After papers are included based on the title selection, the abstracts will be reviewed. Next, the included papers will be up for full text review. The reference lists of the full papers will also be checked to include additional relevant papers for final review. The data-analysis is ongoing at this moment Dec 2017. Discussion: The framework for scaling-up does not specifically focus on scaling-up integrated care initiatives, however, since it is widely used and one of the few available comprehensive frameworks in scaling-up health interventions it has huge promise for the field of integrated care. We hypothesize to find a blend of types, strategic choices and steps for the scaling-up of integrated care. Conclusion: This literature review will yield information around scaling-up strategies aimed at the transfer and scaling-up of successful integrated care initiatives. The insights on the usage of and potential gaps in scaling-up strategies will be useful to guide the further development, implementation and evaluation of scaling-up strategies. The literature search is currently being undertaken, therefore, it is too early to report on lessons learned, these will be presented at the conference. Limitations: This review will select English articles which may result in language bias.

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

Introduction: Lessons captured from interviews with 12 European regions are represented in a new instrument, the B3-Maturity Model (B3-MM). B3-MM aims to assess maturity along 12 dimensions reflecting the various aspects that need to be managed in order to deliver integrated care. The objective of the study was to test the content validity of B3-MM as part of SCIROCCO (Scaling Integrated Care into Context), a European Union funded project. Methods: A literature review was conducted to compare B3-MM’s 12 dimensions and their measurement scales with existing measures and instruments that focus on assessing the development of integrated care. Subsequently, a three-round survey conducted through a Delphi study with international experts in the field of integrated care was performed to test the relevance of: 1) the dimensions, 2) the maturity indicators and 3) the assessment scale used in B3-MM. Results: The 11 articles included in the literature review confirmed all the dimensions described in the original version of B3-MM. The Delphi study rounds resulted in various phrasing amendments of indicators and assessment scale. Full agreement among the experts on the relevance of the 12 B3-MM dimensions, their indicators, and assessment scale was reached after the third Delphi round. Conclusion and discussion: The B3-MM dimensions, maturity indicators and assessment scale showed satisfactory content validity. While the B3-MM is a unique instrument based on existing knowledge and experiences of regions in integrated care, further testing is needed to explore other measurement properties of B3-MM.

Introduction For telemonitoring to support care coordination, a sound business model is conditional. The aim of this study is to explore the systemic and economic differences in care coordination via business-to-business and business-to-consumer models for telemonitoring patients with chronic diseases. Methods We performed a literature search in order to design the business-to-business and business-to-consumer telemonitoring models, and to assess the design elements and themes by applying the activity system theory, and describe the transaction costs in each model. The design elements are content, structure, and governance, while the design themes are novelty, lock-in, complementarities, and efficiency. In the transaction cost analysis, we looked into all the elements of a transaction in both models. Results Care coordination in the business-to-business model is designed to be organized between the places of activity, rather than the participants in the activity. The design of the business-to-business model creates a firm lock-in but for a limited time. In the business-to-consumer model, the interdependencies are to be found between the persons in the care process and not between the places of care. The differences between the models were found in both the design elements and the design themes. Discussion Care coordination in the business-to-business and business-to-consumer models for telemonitoring chronic diseases differs in principle in terms of design elements and design themes. Based on the theoretical models, the transaction costs could potentially be lower in the business-to-consumer model than in the business-to-business, which could be a promoting economic principle for the implementation of telemonitoring.

Developed health systems want to avoid unnecessary hospital admissions by addressing the needs of chronically ill older adults throughout acute episodes of illness. Transitional care (TC) is a set of actions designed to ensure the coordination and continuity of health care as patients transfer between different locations or different levels of care within the same location, of which the main outcome of interest is avoiding hospital readmission. Implementation of TC is complex because it entails different actions to put multiple care components into practice, with various degrees of flexibility of adapting the intervention. Furthermore, the outcome involves behaviour change required by those delivering or receiving the intervention. Although there are examples of promising interventions, the possible variations in conceptualization and implementation present a real challenge for the adaptation of efficacious TC interventions from trial to 'real-world' settings. There is a lack of a theoretical basis or explicit logic model for why adapted interventions should work. This study provides conceptual approaches for the implementation and evaluation of TC programmes. It describes a framework of (1) conceptualization - with respect to the components in an intervention and the population of interest; (2) manner and context of implementation; and (3) evaluation - how these processes of implementation impact health outcomes.

Introduction : Lessons learned from an observational study and based on unstructured interviews with twelve European health regions are represented in a new instrument, the B3-Maturity Model (B3-MM). B3-MM aims to assess maturity along 12 dimensions (i.e. Breadth of Ambition, Capacity Building, Citizen Empowerment, Evaluation Methods, Finance & Funding, Information & eHealth services, Innovation Management, Population Approach, Readiness to Change, Removal of Inhibitors, Standardisation & Simplification and Structure & Governance) reflecting the various activities that need to be managed in order to deliver integrated care. The current situation of a health care region is assessed by considering a progress or ‘maturity’ measure (on a 0-5 scale) along each dimension thereby revealing areas of strength, further attention and improvement. Usage of these insights and comparing the findings with those of other regions should enable healthcare regions to be matched in order for them to exchange knowledge and experiences to ultimately make faster progress towards maturity. Content validity of B3-MM was tested as part of a larger EU funded project SCIROCCO (Scaling Integrated Care into Context). Methods : A literature review was conducted to compare the 12 dimensions and their measurement scales of B3-MM with existing measures and instruments focusing on maturity of integrated care. Subsequently, a three survey round international Delphi study with experts in the field of integrated care was performed to test the relevance of 1) the dimensions, 2) the maturity indicators and 3) the rating scale used in B3-MM. Results : The literature search consisted of two parts. Firstly, 7 out of 300 articles were selected from a recent systematic review on measurement properties of instruments measuring integrated care of Bautista et al. (2016). Secondly, to broaden the scope of the review, 4 additional articles were retrieved from a narrative search in Google, Google Scholar and IDEAS. The 11 included articles confirmed all dimensions as described by the original version of B3-MM. The Delphi rounds resulted in various phrasing amendments of dimensions and indicators. Full agreement among experts on the relevance of the 12 dimensions and their indicators and rating scale of B3-MM was found after the third Delphi round. Discussion : The small number of relevant articles indicates that the maturity measurement in integrated care is not yet strongly developed. Notwithstanding the pragmatic nature of the initial development of the B3-MM, our study provides the first phase of validation of B3-MM. Additional testing is needed to evaluate the robustness of B3-MM as a tool to measure the maturity of integrated care. Conclusion : The dimensions, maturity indicators and rating scale of B3-MM showed satisfactory content validity. Although there exists no universal agreed indicator set nor best approaches of integrated care development, B3-MM is a unique instrument based that intends to function as a practical and easy to use self-assessment tool for European regions revealing strengths and areas for improvement in the provision of integrated care. The tool needs further validation in supporting the matching of European regions to exchange knowledge and experiences. Limitations : The different backgrounds and fields of expertise of the experts may have influenced the interpretation of the instrument. To obtain an adequate understanding of the instrument among its future users, a clear manual explaining the meaning and application of the instrument is needed. Suggestion for further research : To enhance the methodologic quality of B3-MM, further testing is needed to explore its psychometric properties to become a robust instrument in measuring the maturity of integrated care. References : 1. Bautista, M., Nurjono, M., Lim, Y., Dessers, E., & Vrijhoef, H. Instruments measuring integrated care: a systematic review of measurement properties. The Milbank Quarterly. 2016.

In 2013, a 4-year research project on integrated care in Flanders (Belgium) was launched: “Care Organisation: a Re-Thinking EXpedition in search for Sustainability” (CORTEXS). The multidisciplinary research team focuses on the challenge of how to organize care integration. Numerous studies convincingly demonstrate the need for care integration, and several conceptual models and evaluation frameworks have been published. However, far less is known about systematic approaches to organizing care integration. CORTEXS developed a social systems based approach for redesigning care systems. A system consists of components that relate to each other, and has a certain openness to its environment. A care system is a social system, of which the elements are activities. Grouping and linking those activities forms the central focus of redesigning care systems. Splitting up care processes in specialized activities, grouped in specialized sectors, organizations, organizational units and occupations, leads to highly fragmented care systems. The number of interactions and dependencies between the many care processes and activities then becomes so high that delivering integrated care becomes virtually impossible. The mere introduction of additional coordination mechanisms leaves the underlying fragmentation untouched, and risks to increase complexity even more. From a social systems perspective, the far-driven fragmentation of processes and activities itself must be tackled. The ‘law of requisite variety’ (Ashby 1957) posits that variety can only be managed with variety. In other words: the variety a care system offers must be equal to or greater than the variety of care demands. The enormous variety of individual care demands can be reduced to a manageable range of groups of people with comparable care needs. Then, the variety of the care system can be increased by clustering activities in parallel streams for each target group. In order to further reduce the complexity of care systems, it is important to avoid ending up interlinking everything again at the end. The objective is to vest the decision-making power at the level where it is most needed, facilitating that any problems can be resolved as soon as they arise. We can assume that a care system for people with chronic care needs will often consist of multiple care organizations and professionals. In line with the reasoning developed above, such an organizational network should always be focused on achieving concrete added value for the identified target group, by being built around the care processes and activities that are needed for that target group. It should also be noted that people with a chronic care need are not regarded as passive users of the care system. Not only is it appropriate for them to be involved in the redesign exercise, but also to become an active part of the care processes, as co-managers and potential carriers of activities. Evidently, the opportunities for redesigning care systems are limited by the environment in which they operate. We discuss contextual preconditions in terms of legislation, financial incentives, information technology and competence development. The main priority of the redesign is to ensure that care systems can address the chronic care needs of their target groups, and contribute to the well-known Triple Aim. In addition, it is advisable that the redesign also contributes to improving the quality of working life of the care professionals. We will demonstrate how the proposed redesign approach could contribute to this Quadruple Aim. This social systems based approach already offers a theoretical and empirically substantiated framework for the redesign of care systems for people with chronic care needs. Further steps include the application of this generic approach to specific challenges in the field of policy and practice.

Introduction: Patients with multiple morbidities and complex needs are putting a strain on the resources of the health system, particularly on hospitals. The current fragmented hospital and disease centric care is unable to cope with the growing healthcare needs facing the modern day health system [1,2]. Therefore, integrated care interventions have been developed to improve the quality and efficiency of care by coordinating healthcare services in a person-centric manner with the aims of reducing health and social burden on the healthcare systems including hospitals [2]. However, the methods and outcomes of interventions used are different and evidence of the effectiveness of the interventions are not consistent. There is also a lack of understanding on why and how integrated care interventions work or do not work under certain circumstances. Based on the CMO (context, mechanism and outcomes) [3] model, we aim to summarise and compare the existing evidence of the context, mechanism and outcomes of hospital-led integrated care interventions from published peer-reviewed systematic reviews. Methods: A review of existing systematic reviews is being conducted to find out what works, for whom, and under what circumstances hospitals can provide effective integrated care interventions. The review will address the following questions: (1) what are the programmes available? (2) Who is the target population? (3) In what respect of integrated care (i.e., patient, system, organisation)? (4) What are the outcomes measured (e.g. healthcare utilizations, healthcare outcomes (QoL, quality of care mortality rates, etc.), costs) and how effective are they? (5) If they are effective, how do they work in different settings and for different populations? (6) What are the underlying mechanisms of these interventions? (7) What causes the heterogeneity in outcomes of hospital-led integrated care programmes? Based on the WHO definition of integrated care [4] and Rainbow Model of Integrated Care (RMIC) definition of system and organisation integration [5], articles are searched through PubMed, Scopus, Web of Science and Cochrane Database of Systematic Reviews for the period 2006-2016 (N=2290). A systematic review is included if it describes hospital-led interventions that involve system or organisation integration, involve an acute care setting as the lead, and have the outcomes of the interventions evaluated. Titles for inclusion are screened independently by three reviewers using predetermined criteria. Data are extracted and quality of review is assessed according to the Joanna-Briggs Institute guidelines.[6] Findings on context and mechanism are analysed to explain about outcomes. Complete findings will be presented during ICIC17. Discussion: The findings from the review will help inform policy-makers and healthcare professionals on the design of integrated care programmes that will most likely yield their desired outcomes, based on their target populations and context of the health system. The review will also provide an overview of how to bridge the gap between the development of interventions and successful implementation of hospital-led integrated care [2]. For researchers, the review will indicate the strength of existing evidence and identify directions for future research.

Background: The purpose of this study is to assess the Business-to-Consumer (B2C) model for telemonitoring patients with Chronic Heart Failure (CHF) by analysing the value it creates, both for organizations or ventures that provide telemonitoring services based on it, and for society.Methods: The business model assessment was based on the following categories: caveats, venture type, six-factor alignment, strategic market assessment, financial viability, valuation analysis, sustainability, societal impact, and technology assessment. The venture valuation was performed for three jurisdictions (countries) – Singapore, the Netherlands and the United States – in order to show the opportunities in a small, medium-sized, and large country (i.e. population).Results: The business model assessment revealed that B2C telemonitoring is viable and profitable in the Innovating in Healthcare Framework. Analysis of the ecosystem revealed an average-to-excellent fit with the six factors. The structure and financing fit was average, public policy and technology alignment was good, while consumer alignment and accountability fit was deemed excellent. The financial prognosis revealed that the venture is viable and profitable in Singapore and the Netherlands but not in the United States due to relatively high salary inputs.Conclusions: The B2C model in telemonitoring CHF potentially creates value for patients, shareholders of the service provider, and society. However, the validity of the results could be improved, for instance by using a peer-reviewed framework, a systematic literature search, case-based cost/efficiency inputs, and varied scenario inputs.