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Introduction: (short description of the SIG to include in the Conference Programme). Citizens want to feel supported in being able to participate as optimally as possible in society with the highest possible quality of life, at the lowest possible cost (triple aim) and with more meaning for care providers (quadruple aim). In the meantime, citizens' care needs are becoming increasingly complex, still mostly approached by more individual acting professionals at the same time resulting in fragmented care.The SIG ‘Evidence Based Integrated Care’ is for healthcare researchers who are interested in support healthcare professionals with joined evidence for effective interventions and evidence for effective application in Integrated Care trajectories.Background: Earlier with the members of this SIG, we debated that Integrated Care is aimed at well-organized, cost-effective processes of care delivery, provided by committed professionals which must be able to count on well-established evidence for the care interventions they provide in integrated trajectories to their patients.SIG members defined ‘Evidence Based Integrated Care’ covering the description of the care problem with the underlying working mechanisms, the test acceptance by patients and care providers, of both the concept of interventions and the (cost) effectiveness in the context where the complex interventions are provided. It also covers the organization of the complex interventions in the trajectory and the quality of life and societal participation of citizens or patients.Aims and Objectives: In research regarding evidence base integrated care, practical questions are asked about the contexts in which the care under study must be provided or to which the context under study must be adapted. As such in research for evidence base integrated care for integration knowledge there is thus a constant balance between practical orientation and theoretical orientation. This concerns the ""proof in context"" (care provision) versus the ""proof of concept"" (care content). In this session we will discuss the meaning of incorporating both the perspective of ""proof of concept"" and the ""proof in context"" in integrated care research. FormatOpening and introduction (10”)Interaction between participants aiming at discussing the perspective of ""proof of concept"" and the ""proof in context"" in integrated care research: (30”)1.How do we define ""proof of concept"" research?2.How do we define ""proof in context""?3.How does integrated ""proof of concept"" and the ""proof in context"" look like?Conclusions (10”) Key people from SIG network involved in session (this helps to avoid programme clashes)Roelof Ettema PhD

Background: Most asylum seekers experiences stress, not only due to the reason of fleeing and their travel, but also due to their compulsory stay in the asylum seeker center in the Netherlands and the asylum procedure. This often leads to self-medication and addiction which causes a lower self-esteem and lower quality of life. Many professionals working with asylum seekers often have no experience with the diverse cultural background. Adverse life events, forced migration and the prolonged asylum procedures, in addition to the complexity of the acculturation process can all contribute to higher levels of psychopathology.Objective: What are threats to well-being in terms of mental health, psychosocial and addiction problems and what are effective interventions for well-being for asylum seekers in asylum seeker centers in the Netherlands, reported in literature?Method: Following the descriptive nature of the research question and the need for identifying knowledge gaps, we created an overview of existing knowledge by executing a scoping review on influencing factors on mental health of asylum seekers.Results: We included 26 articles in this study. From literature we identified four major threats, two assessment instruments and five interventions.: The threats concern: 1. the influence of staying in the environment of an asylum seekers center with its tight regime, scanty living conditions, involuntary living together with other asylum seekers from multiple countries with subsequent differences in cultural backgrounds, and speaking other languages; 2. substance and drug abuse among asylum seekers; 3. health care professionals and employees who do not detect or underestimate the underlying suffering of asylum seekers leading to undertreatment; 4. frequent relocations of asylum seekers. Assessment instruments include the Rapid-Assessment-Response-method (RAR-method) and the Health-Information-Assessment-Tool-Asylum-Seeker-tool (HIATUS-tool). The five interventions comprise 1. therapy for asylum seekers diagnosed with PTSD (Post-Traumatic-Stress-Disorder); 2. art therapy; 3. education focused on prevention as intervention; 4. cultural interview; and 5. Mindspring, which is aimed at enabling professionals to reduce these threats.Conclusions: The knowledge on identifying and reducing threats and assessment and treatment interventions for asylum seekers living in an asylum seekers center, found in literature, provides for perspectives on improving their well-being. However, the great diversity of cultural aspects and continuous changes of the number of refugees in the Dutch asylum seekers centers which for example were recently confronted with a steep increase in Afghan refugees, disrupts the continuity of care on a large scale. The absence of guidelines and required knowledge of professionals working with these asylum seekers leads to the question of what professionals need for providing effective health care to asylum seekers with mental health and addiction problems. The Netherlands is divided when it comes to the reception of asylum seekers. This is clearly visible in politics, media and society. The result is a cost reduction in care for asylum seekers, which results in fragmentation in care, lower quality and a higher burden of disease. The shortage of well-trained and intercultural expert healthcare personnel also causes loss of knowledge and the cessation of local or non-local interventions.

IntroductionBoth in literature and in practice there is debate about defining Integrated Care. The WHO for example, defines Integrated Care as a process, not covering the perspective of (cost-) effectiveness. From the perspective of research into evidence in Integrated Care this is rather awkward. Triple aim focusses on 1) quality of life of citizens; 2) quality and continuity of care and, 3) cost effective care. Integrated Care is aimed at well-organized, cost-effective processes of care delivery, provided by committed professionals which must be able to count on well-established evidence for the care interventions they provide in integrated trajectories to their patients. Research should support them both with evidence for effective interventions and evidence for effective application. A basis for thorough research in Integrated Care is narrowed by a lack of a comprehensive definition.BackgroundSince Integrated Care is considered as sets of complex interventions targeting triple aim, together with colleagues from all over the world we discuss definitions of Integrated Care reported in literature. with a definition of complex interventions and a model for evidence based developing, testing and implementing complex interventions. This definition and the accompanied model are issued by the British Medical Research Council (MRC) in 2008 and are nowadays worldwide established.During the session at the conference, after a short introduction, we will discuss our proposal with the participants for improving a new definition of evidence based integrated care.Aims and Objectives To create support by participating in a discussion resulting in a proposal for a definition for ‘Evidence Based Integrated Care’ which covers defining the care problem with the underlying working mechanisms and the test acceptance by patients and care providers. Furthermore, it covers test effect of both the concept of interventions and the (cost) effectiveness in the context were the complex interventions are provided, the organization of the complex interventions in the trajectory and the quality of life and societal participation of citizens or patients. Format10 min Introduction cause, approach and definitions in literature (plenairy and buzz groups)15 min Discussion how we want to define Integrated Care (in groups)10 min Doing research in Integrating Care (plenary)15 min Discussion Towards an operationalisation of Evidence Based Integrated Care (in groups)10 min Wrap up and closure (plenary)Key PeopleRoelof EttemaJohn EastwoodMarlou de Kuiper

Introduction Recipients of care and welfare in Western Europe are increasingly presenting themselves with complex needs due to chronic diseases which can have major consequences for how people live their lives. Multiple care demands require a new way of organizing care and welfare in an integrated manner, which meets those demands in a personalized way. Policy context and objective The reality is that care and welfare are still mainly offered in a standardized, specialized and fragmented way. This imbalance between the need of care and the supply of care not only leads to under-treatment and over-treatment and thus to less (experienced) quality, but also entails the risk of mis-treatment, which means that patient safety is at stake. It also leads to a decrease in the functioning of people and unnecessary (care) costs. To proceed in the same way in the Netherlands is financially untenable. Targeted population Elderly people with two or more chronic disorders Highlights Why is integration of health care and welfare so very difficult to achieve? First, the starting point for integrated personalized care is that patients, professionals and informal caretakers work towards common goals, which in a person’s care situation are not always compatible. Second, for the arduous creation of integrated care is a lack of cooperation between organizations. When the interventions lead to a decrease in income of professionals or organizations, this negatively affects the willingness to collaborate. Third, the number of interventions that can contribute to integrality is vast. And it is unclear what strategies and interventions work in which circumstances. The awareness that the context is important and influential to integrating personalized care is increasing. Yet, the local circumstances are yet not sufficiently taken into account in research into the (effects of) integrated care. Forth, organizing this complexity and uncertainty is a major challenge to many professionals and managers. They have often learned to reduce complexity instead of integrating more complexity. Changes are frequently introduced on a process and systematic basis. In implementation repeatedly little attention is paid to the diversity of needs in reality. The risk of failing integrated care and welfare pathways increases as complexity increases. Knowledge of implementation strategies in complex change situations is needed to achieve successful integration of health care and welfare services. Conclusions Implementing innovations becomes more complex with application of integrated care. There are still many obstacles to remove before we can speak of personalized integrated care. We need to improve knowledge of and recommend strategies and interventions within specific contexts and conditions to increase integration of healthcare and welfare. Evaluation of the effectiveness of deliberately applied implementation strategies and interventions to integrate health care and welfare from single component to multicomponent. Third phase contingency models are very usefull in this context because they combine multiple movements and take into account dynamic interactions between change and a complex environment.

Introduction In the Netherlands, skin cancer is the most common type of cancer (KWF, 2016). More than 51.000 new cases of skin cancer are diagnosed every year and over 900 fatalities are reported (RIVM, 2017). Skin cancer incidence rates increase dramatically: since 1990 the number of new patients with skin cancer quadrupled (RIVM, 2017). This increase is much higher than in other types of cancer (IKNL, 2016). It is expected that incidence rates of skin cancer will increase even further, probably with a factor 2 to 5 (RIVM, 2017). Direct costs for medical treatment of skin cancer are estimated at 325 million each year (250-400 million) (RIVM, 2017). On top of that, sick leave and premature mortality are also important indirect costs in melanoma (Brochez et al., 1999). Increasing use of more costly treatment, such as Mohs surgery and photodynamic therapy, is contributing to rising treatment costs (Hollestein et al, 2017). In addition to the costs, this growing group of patients with skin cancer will represent an important burden on the limited specialized dermatological care in the Netherlands. Subsequent early assessment of skin cancer risk is necessary for timely preventive measures in the general population. Theory/Methods 1) A systematic review of the literature on patient characteristics with a prognostic predictive value for future basal cell carcinoma, squamous cell carcinoma or melanoma (such as age, gender, presages, signs and risk behaviour). 2) A Current practice analysis on care concerning risk behaviour, presages and signs of skin cancer. 3) Prognostic modelling using existing data of over 5000 cases from the Netherlands Comprehensive Cancer Organisation (IKNL). 4) Developing risk profiles and implement these through internet and social media. Results It will provide insight in early risk behaviours in the general population. It also provide knowledge of serious presages or signs enabling these patients to be seen by their GP timely. Conclusion Basal cell carcinoma (BCC, approx. 70%), squamous cell carcinoma (SCC, approx. 20%) and melanoma (approx. 10%) are the three most common types of skin cancer. Melanoma is the most lethal type, accounting for 90% of all skin cancer fatalities. The incidence of melanoma in the Netherlands is among the highest in Europe (RIVM, 2017). Despite the fact that most non-melanoma skin cancers (BCC and SCC) can be cured, the treated lesions can be disfiguring or even lethal if not treated timely. Lessons learned Risk profiles will enable healthcare professionals and citizens both with knowledge which persons are at high risk and should be screened and insight in risk behaviour. Limitations Risk screening is costly, time consuming and it is to be expected that the adherence will be moderate. Suggestions for future research Behaviour change intervention target groups in the society as implementation research.

A shared culture for change can be achieved if there is a shared set of values which requires a shared paradigm for the exchange of research findings, assessment tools, design principles and a shared language. Systems theory, often referred to as complex adaptive system theory, may provide the framework for increased cooperation and collaboration for the development of integrated care. In this workshop we want to share knowledge and applied science of systems theory as one of the necessary elements of a culture for change. Programme outline. 10 min Welcome and introductions Dr. Roelof Ettema 20 min Complex adaptive systems characteristics and examples Marlou de Kuiper 40 min World cafe set up. Chairpersons are well suited to chair these discussion rounds with change every 10 min for the discussion of four statements: a complex adaptive care perspective contributes to designing care systems which are flexible and needs-oriented a complex adaptive care perspective contributes to self-organizing care systems which are democratic, inclusive and cost-effective a complex adaptive care perspective contributes to positive health/better self-management if integrated care is to become a success, a paradigm shift from a lineair to a systems perspective is required Dr. Roelof Ettema Marlou de Kuiper Ferdy Pluck Dr. Anneke de Jong 20 min Discussion of main findings and future plans.

Introduction: Quality, accessibility and affordability in Dutch healthcare are system-goals in which the secretaries of the ministry of Healthcare, Welfare and Sports are accountable. These system-goals serve a public interest and they have to be accounted for. This only happens if the allied institutes, professionals and citizens take responsibility of their actions. Healthcare delivery becomes more and more organized in networks and alliances, where more focus is on the right care in the right place, namely integrated health service delivery. How accountability of quality of care takes place is a challenge in the system of regular healthcare as well as integrated care. Policy context and objectives: Accountability takes place in various forms and the term in itself is multi interpretable and is best described from two approaches: As subject of the term “governance”: In Dutch public governance, the ethical code consists of four elements that are related. These elements are ‘control or supervision’, ‘accountability’, ‘steering’ and ‘purchase (of healthcare)’. As three main directions of accountability: To whom is accounted for? About what is accounted for? Why is accounted for? Targeted population: Accountability of quality of care is observed on multiple perspectives. National - and local government, between board of directors and their supervisory boards, organizations and their financiers, organizations and their clients, which also have to account for their received care, which benefits to quality of care. Accountability is not only happening within (healthcare) organizations by structuring decision-making in a vertical, hierarchical sense to pursue control, but accountability takes place more and more in complex partnerships with many mutual dependencies and cross-border character. Accountability shifts from inside organizations towards outside organizations. To citizens, professionals and cooperation partners, towards integrated health service delivery. Impact and outcomes: Accountability in relation to integrated health service delivery in the Netherlands is not yet aligned. Accountability of quality of care is still institute focussed, but integrated health service delivery becomes more than delivery of just care or cure. Positive health is becoming a greater part of integrated health service. The way of accounting quality of care does not fit anymore and should shift from institutes to a holistic (integrated) focus. Transferability: This leads to the fact that new answers, of how quality of care in integrated health service delivery should be formulated to the main directions of accountability. Conclusions: Accountability of quality of care in the current sense differs much from accountability of quality of care in integrated healthcare delivery. Research questions therefor are: What is the concept of accountability in the context of integrated health service delivery? How can accountability be arranged in relation to integrated health service delivery? How can integrated health service delivery in The Netherlands be defined? What is the state of play on accountability in Dutch healthcare? How can accountability contribute to de development of integrated health service in The Netherlands? What accountability tools can be developed which can be helpful to develop integrated health service delivery in The Netherlands?

Introduction: Both in literature and in practice there is debate about defining Integrated Care. The WHO for example, defines Integrated Care as a process, not covering the perspective of (cost-) effectiveness. From the perspective of research into evidence in Integrated Care this is rather awkward. Triple aim focusses on 1) quality of life of citizens; 2) quality and continuity of care and, 3) cost effective care. Integrated Care is aimed at well-organized, cost-effective processes of care delivery, provided by committed professionals which must be able to count on well-established evidence for the care interventions they provide in integrated trajectories to their patients. Research should support them both with evidence for effective interventions and evidence for effective application. A basis for thorough research in Integrated Care is narrowed by a lack of a comprehensive definition. Theory/Methods: Since Integrated Care is considered as sets of complex interventions targeting triple aim, we compared definitions of Integrated Care reported in literature with a definition of complex interventions and a model for evidence based developing, testing and implementing complex interventions. This definition and the accompanied model are issued by the British Medical Research Council (MRC) in 2008 and are nowadays worldwide established. During the session at the conference, after a short introduction, we will discuss our proposal with the participants for improving a new definition of evidence based integrated care. Results: Our preparation resulted in a proposal for a definition for ‘Evidence Based Integrated Care’ which covers defining the care problem with the underlying working mechanisms and the test acceptance by patients and care providers. Furthermore, it covers test effect of both the concept of interventions and the (cost) effectiveness in the context were the complex interventions are provided, the organization of the complex interventions in the trajectory and the quality of life and societal participation of citizens or patients. Discussions: On one hand, the perspective of the content of the interventions moves mostly in the domain of healthcare research. On the other hand, the perspective of the organisation of Integrated Care process is predominantly moving in the domains of social sciences and healthcare business research. In order to achieve triple aim care and welfare, a third perspective of directing the content of the interventions and the way of organising the Integrated Care process is necessary. Unfortunately, this remains rather underexposed in research. Conclusions: In order to meet triple aim, research in Integrated Care should focus on three perspectives at ones: the content of the interventions; the organisation of the Integrated Care process; to strengthen both, creating synergy between content and context. Lessons learned: By directing content and context, research in Integrated Care will make a vital contribution to accomplishing triple aim Integrated Care. Limitations: This is a theoretical exercise for starting a discussion for establishing a research basis, needed for focussing research in Integrated Care. Suggestions for future research: Developing research methods for Integrated Care research covering the perspectives of content context and the direction of these.

Introduction: In March 2014, the New South Wales (NSW) Government (Australia) announced the NSW Integrated Care Strategy. The NSW Government’s Integrated Care Strategy funding enabled the establishment of an integrated care initiative called Healthy Homes and Neighbourhoods (HHAN). The Initiative was designed as a population-based, family-centered, care-coordination network that functioned across agencies to assist vulnerable families to navigate the health and social-care system, to keep themselves and their children safe, and in doing so, promote social cohesiveness. The evaluation framework is described. Methods: Since integrated care initiatives are an example of complex interventions in health and social care, we underpinned this programme of development, research and evaluation by the critical realist metatheory of science and the NSW Health Monitoring and Evaluation Framework, using the UK Medical Research Council (MRC) Framework for evaluating complex interventions.1 We adapted the iterative approach of development, feasibility/piloting, evaluation and implementation of the MRC framework to include critical realist, participatory, continuous and theory driven elements. Discussion: Both the 2008 UK Medical Research Council framework for evaluating complex interventions, and our previously reported critical realist methodology, provided the tools to enable an iterative approach to development, design, testing and continuous evaluation. The philosophical paradigms underpinning each approach are different. Both the NSW Health and MRC frameworks were developed from in the “logical positivist” inductive and deductive reasoning traditions with a strong focus on activities and outcomes but little emphasis on process. That weakness was been recognised and the MRC subsequently endorsed advice on process evaluation for complex interventions which accommodated the realist approach incorporated here. Conclusion: Integrated care initiatives are examples of complex interventions in health and social care. The interventions are multi-layered and operationalization is strongly influenced by both historical and current context. This aspect alone makes it imperative that the methodology used is post-positive and takes ontologically stratified context into account. The NSW Health Monitoring and Evaluation Framework did not make provision for assessment of context or mechanism of effect. We describe here a multilevel approach including a continuous improvement approach through constant comparison and triangulation of mixed method findings. Utilising the MRC framework for evaluating complex interventions within a critical realist methodology, enabled us to study both mechanisms of effect and context. Lessons learned: Evaluation of integrated care interventions will require a pluralist approach to methodology. It is possible to design evaluation approaches that allow study of context, mechanism, reach and efficacy in a complex layered design as used for integrated care initiatives. Limitations: The approach utilised was contrained by the requirements of the policy and funding organisation. We did not fully explore the application of Theory of Change and complexity science within the MRC framework. Suggestions for future research: We recommend that further theoretical and applied research be undertaken to advance the methods and tools available for evaluation of complex multi-layered integrated care initiatives. Reference: 1. Craig P, Dieppe P, Macintyre S, Michie S, Nazareth I, Petticrew M. Developing and evaluating complex interventions: the new Medical Research Council guidance. BMJ. 2008;337:a1655

Background: In the Netherlands, elderly people live longer and longer at home. Estimates show that the number of elderly people living at home will increase from 3 million (17%) in 2017 to 4,5 million (25%) in 2040. Estimates show that 15 to 25% of the elderly who receive care at home is malnourished. Causes are a reduced thirst-tingling and appetite, loneliness and bad teeth. In most cases, elderly people are not aware of becoming undernourished. Consequently physical resistance drops, resulting in an increased risk of diseases and complications. Preventing undernourishment among this population is crucial. Aims and objectives: The aim of this research is to increase the number of high-quality and meaningful life years for elderly people and thereby limiting the demand for care. For this purpose, this project aims at prevention of undernourishment of the elderly at home through a sustainable and cost-effective design of personalized preventive care with use of blockchain technology. To this end, his research combines the field of preventive care, that of blockchain technology and the field of economics. Prognostic epidemiological research of the Dutch Malnutrition Steering Group identifies predictors for imminent undernourishment amongst elderly. In this research project, these predictors are tested on feasibility in practice in close collaboration with elderly people living at home, (informal) caregivers, general practitioners, practice assistants and visiting nurses. Based on these experiences, a functional decomposition of processes and interventions is set up. To streamline data, actions, and processes, this research project applies blockchain technology. In the context of this project, several stakeholders are involved. Something like a central agency on this dossier is not available. Therefore it is essential that the stakeholders have access to a trusted technical infrastructure that enables participants to record and share relevant data in an easy and reliable way. Blockchain technology can provide this infrastructure. To determine whether this preventive care innovation is cost effective, a cost-utility analysis (CUA) is performed. This analysis is important to convince the relevant health care budget authorities to finance this preventive care innovation. In addition, a budget impact analysis (BIA) is composed. The BIA pictures the difference in expected expenditures between a scenario in which the new intervention is accepted and disseminated and the reference scenario in which that is not the case. Format: - Introduction – 15 minutes – Wil van Erp and Roelof Ettema. - Discussion on possibilities and constraints of blockchain technology in care contexts – 30 minutes discussion in small groups, followed by 10 minutes plenary wrap up – Wil van Erp, Roelof Ettema and Dennis van Kerkvoorden. - How to finance the proposed preventive care integration – 20 minutes plenary brainstorm – Wil van Erp. - Conclusion – 15 minutes – Roelof Ettema. Target audience: Health care professionals, specialized in preventive care and/or e-health technology and/or finance of (integrated) care. Learnings: After this session, the participants have knowledge of the disruptive potential of blockchain technology in the integration of care. Moreover, the participants gain new insights on how to finance innovative car integration.

Introduction: In March 2014, the New South Wales (NSW) Government (Australia) announced the NSW Integrated Care Strategy. In response, a family-centred, population-based, integrated care initiative for vulnerable families and their children in Sydney, Australia was developed. The initiative was called Healthy Homes and Neighbourhoods. A realist translational social epidemiology programme of research and collaborative design is at the foundation of its evaluation. Theory and Method: The UK Medical Research Council (MRC) Framework for evaluating complex health interventions was adapted. This has four components, namely 1) development, 2) feasibility/piloting, 3) evaluation and 4) implementation. We adapted the Framework to include: critical realist, theory driven, and continuous improvement approaches. The modified Framework underpins this research and evaluation protocol for Healthy Homes and Neighbourhoods. Discussion: The NSW Health Monitoring and Evaluation Framework did not make provisions for assessment of the programme layers of context, or the effect of programme mechanism at each level. We therefore developed a multilevel approach that uses mixed-method research to examine not only outcomes, but also what is working for whom and why. Published version

Introduction: Both in literature and in practice there is debate about defining Integrated Care. The WHO for example, defines Integrated Care as a process, not covering the perspective of cost- effectiveness. From the perspective of research into evidence in Integrated Care this is rather awkward. Triple aim focusses on 1 quality of life of citizens; 2 quality and continuity of care and, 3 cost effective care. Integrated Care is aimed at well-organized, cost-effective processes of care delivery, provided by committed professionals which must be able to count on well-established evidence for the care interventions they provide in integrated trajectories to their patients. Research should support them both with evidence for effective interventions and evidence for effective application. A basis for thorough research in Integrated Care is narrowed by a lack of a comprehensive definition.Theory/Methods: Since Integrated Care is considered as sets of complex interventions targeting triple aim, we compared definitions of Integrated Care reported in literature with a definition of complex interventions and a model for evidence based developing, testing and implementing complex interventions. This definition and the accompanied model are issued by the British Medical Research Council MRC in 2008 and are nowadays worldwide established.During the session at the conference, after a short introduction, we will discuss our proposal with the participants for improving a new definition of evidence based integrated care.Results: Our preparation resulted in a proposal for a definition for ‘Evidence Based Integrated Care’ which covers defining the care problem with the underlying working mechanisms and the test acceptance by patients and care providers. Furthermore, it covers test effect of both the concept of interventions and the cost effectiveness in the context were the complex interventions are provided, the organization of the complex interventions in the trajectory and the quality of life and societal participation of citizens or patients.Discussions: On one hand, the perspective of the content of the interventions moves mostly in the domain of healthcare research. On the other hand, the perspective of the organisation of Integrated Care process is predominantly moving in the domains of social sciences and healthcare business research. In order to achieve triple aim care and welfare, a third perspective of directing the content of the interventions and the way of organising the Integrated Care process is necessary. Unfortunately, this remains rather underexposed in research.Conclusions: In order to meet triple aim, research in Integrated Care should focus on three perspectives at ones:the content of the interventions;the organisation of the Integrated Care process;to strengthen both, creating synergy between content and context.Lessons learned: By directing content and context, research in Integrated Care will make a vital contribution to accomplishing triple aim Integrated Care.Limitations: This is a theoretical exercise for starting a discussion for establishing a research basis, needed for focussing research in Integrated Care.Suggestions for future research: Developing research methods for Integrated Care research covering the perspectives of content context and the direction of these.

Asylum seekers often have serious and complex mental health problems mostly due to experiences either in their home country or during their travel to the Netherlands. During the asylum procedure, people seek treatment from the GP or a primary health care provider. However, often their problems are more serious and complex and they need to be referred to specialized primary and secondary mental health care. Asylum seekers are, as a group, characterized by diversity and multiple cultural backgrounds. Problem statement: The consequences are mental trauma such as depression, psychotic symptoms, sleeplessness, suicidal behavior, conflicts, insufficient social support. For professionals in the first echelon of care, this group is problematic and requires resources which are not always available which is why many problems are underdiagnosed and undertreated Asielzoekersteam GGz Centraal, n.d. The problem statement provides the rationale for the design of an integrated specialized care program for asylum seekers, including first and second echelon health care providers, social work, specialized care and preventive care. At the moment, there is no national guideline for the care of these clients. At GGz Centraal, which is a large Mental Health Care Institute in the Netherlands, there are 8 facilities for refugees and asylum seekers for a total of around 3500 people "Asielzoekersteam GGz Centraal", n.d.. For people with mental health problems, a program was designed and implemented which is carried out by multidisciplinary teams of Mental Health Care professionals such as psychiatrists, Nurse Specialists, psychologists, etc. Due to a lack of a methodical evaluation, the effects of this program are unknown. Research proposal: At the moment, there are three main research questions: What are the effects of the current program on long-term symptoms and perceived quality of life of clients and what is the opinion of professionals on the different aspects of the program such as feasibility en demands on professional resources? Which are the underlying mechanisms of the outcomes in the 8 facilities of this program from a realist perspective and how can these findings be applied to the improvement of the current program with the aim to reduce long-term effects of the consequences of traumatic experiences due to forced migration in all its forms How to design an experimental research approach in which the improved design can be tested? The theoretical framework for the design of the program will be the Neuman Systems Model because of its combination of systems theory, stress-coping theory and prevention theory which suits an integrated care approach Merks, Verberk, De Kuiper, & Lowry, 2012. The research method involves both qualitative and quantitative data and the design of this research will be from a realist perspective. A theory-based evaluation from a realist perspective provides a sound basis for a study into the general design principles for integrated care programs which may provide a framework for future designs Pawson, 2006 Pawson & Tilley, 1997. This basis would need to be discussed with researchers and practicing professionals to share the possibility of collaboration around the world from a methodological perspective.

Background: Realist philosophy and methodology is increasingly being explicitly used in the field of integrated care to research the extant context, structure and mechanisms at play, and to design and evaluation interventions. Philosophic realism is the view that entities exist independently of our perception or our theories about them. While the realist philosophy underpins much of modern health and social science, it is only recently that this philosophical approach has been popularised within main stream health and social science literature. Realist research methodology is increasingly being described in research areas that are relevant to the study of integrated care, namely, organisational management, information science, social epidemiology, economics, and health services evaluation. Importantly realist approaches are increasingly being used in mixed method research designs and to elucidate the processes at play in experimental and quasi-experimental studies. Realist researchers seek to explain the underlying “cause” or mechanisms that generate observed phenomenon. The realist understanding of how the world is ontology includes the notion of a hidden or “real” domain where mechanisms generate forces that result in the phenomena which we observe. Realists also view the world as consisting of strata or layers of reality which may interact with other layers to produce new mechanism. This approach is proving useful for studying and developing theory about complex health and social care systems, and then designing and evaluating possible interventions. Over the last number of years a number of realist studies have been presented at the International Foundation of Integrated Care conferences including: realist studies of context and mechanisms; realist design of integrated care interventions; realist synthesis of literature; and realist evaluations of integrated-care interventions. The methodologies, and the dialectical debates, are complex, and therefore, deserving of special consideration within the Integrated Care community. This preliminary workshop will support evaluators and researchers to use realist methods in integrated care and other complex evaluations. Because realist evaluation was initially developed using smaller-scale programs, methods need to be modified for large scale programs, while remaining consistent with underlying methodological principles. The workshop will discuss the value of and the dilemmas involved in using realist methods for large and complex programs, and demonstrate strategies to address the dilemmas. Aims and Objectives: 1- Present and discuss the basic tenants of realist research, design and evaluation as it applies to the large scale and complex programs such as integrated care 2- Discuss the scope and purpose of a Realist Research, Design and Evaluation for Integrated Care Special Interest Group RIC-SIG 3- Modify the scope and purpose of a Realist Research, Design and Evaluation for Integrated Care - SIG Format: Group Discussion Target Audience: Integrated care practitioners and researchers who are familiar with realist research including the current focus on critical realism and realist evaluation Learning and Takeaway: The workshop will define the scope and purpose of a SIG for Realist Research, Design and Evaluation for Integrated Care

Introduction: In the Netherlands, skin cancer is the most common type of cancer KWF, 2016. More than 51.000 new cases of skin cancer are diagnosed every year and over 900 fatalities are reported RIVM, 2017. Skin cancer incidence rates increase dramatically: since 1990 the number of new patients with skin cancer quadrupled RIVM, 2017. This increase is much higher than in other types of cancer IKNL, 2016. It is expected that incidence rates of skin cancer will increase even further, probably with a factor 2 to 5 RIVM, 2017. Direct costs for medical treatment of skin cancer are estimated at 325 million each year 250-400 million RIVM, 2017. On top of that, sick leave and premature mortality are also important indirect costs in melanoma Brochez et al., 1999. Increasing use of more costly treatment, such as Mohs surgery and photodynamic therapy, is contributing to rising treatment costs Hollestein et al, 2017. In addition to the costs, this growing group of patients with skin cancer will represent an important burden on the limited specialized dermatological care in the Netherlands. Subsequent early assessment of skin cancer risk is necessary for timely preventive measures in the general population. Methods: 1- A systematic review of the literature on patient characteristics with a prognostic predictive value for future basal cell carcinoma, squamous cell carcinoma or melanoma such as age, gender, presages, signs and risk behaviour. 2- A Current practice analysis on care concerning risk behaviour, presages and signs of skin cancer. 3- Prognostic modelling using existing data of over 5000 cases from the Netherlands Comprehensive Cancer Organisation IKNL. 4- Developing risk profiles and implement these through internet and social media. Results: It will provide insight in early risk behaviours in the general population. It also provide knowledge of serious presages or signs enabling these patients to be seen by their GP timely. Conclusion: Basal cell carcinoma BCC, approx. 70%, squamous cell carcinoma SCC, approx. 20% and melanoma approx. 10% are the three most common types of skin cancer. Melanoma is the most lethal type, accounting for 90% of all skin cancer fatalities. The incidence of melanoma in the Netherlands is among the highest in Europe RIVM, 2017. Despite the fact that most non-melanoma skin cancers BCC and SCC can be cured, the treated lesions can be disfiguring or even lethal if not treated timely. Lessons learned: Risk profiles will enable healthcare professionals and citizens both with knowledge which persons are at high risk and should be screened and insight in risk behaviour. Limitations: Risk screening is costly, time consuming and it is to be expected that the adherence will be moderate. Suggestions for future research: Behaviour change intervention target groups in the society as implementation research

Introduction: Healthcare institutions in The Netherlands are faced with the facts of increasing extent of internal and external accountability. This is related to the fact that healthcare institutions and their professionals are obliged to register a full set of indicators which are required input to effect this accountability. This is also known as governance. One of the definitions is: to control and to account for Minderman 2008 or controlling accountability Hoek 2007. On the one side in integrated care, care pathways are characterized by the delivery of care interventions proof of concept and on the other side pathways are characterized by the organization of the delivery of care interventions proof in context. Both concept and context of care are related to governance and performance measurement in healthcare. In general governance in healthcare in The Netherlands focuses on control, accountability and controlling the boards, mostly within one care organisation. However in integrated care governance and performance measurement should ideally be on cooperation and trust between the organizations. Governance therefore includes various forms of accountability, concerning several areas: from government national and local, to organizations and commissioners, to organizations and their supervisory boards, to organizations and their financiers and the patient. Healthcare organisations must be accountable to e.g.: The Dutch Healthcare Inspectorate, The care insurance companies and The National Healthcare Institute. Furthermore, healthcare institutions have to account for their efforts to deliver quality of healthcare. The way this is done is through a system administrating their internal performance indicators. In this respect, one can ask how indicators are administrated within healthcare organisations and how external accountability is designed. Different gaps of governance and accountability can thus be found e.g.: A gap between what accountancy data in care institutions is collected, their network and what is externally justified to the involved parties. The gap between governance and is the ones accountable to people and municipals are involved in decentralization. Gap of citizens and governance. Theory/Methods: A systematic review of literature on what is the current knowledge on governance in integrated care, and an extensive case study which will be conducted in Dutch healthcare organisations and healthcare network organisations. One of the characteristics of case study method is: a narrow domain with several research units, in depth rather than a broad view, the supposed concerns in many cases the entire research area instead of a few variables like in a survey study. Discussion: What should governance as an accountability tool look like within the context of evidence-based integrated care and what knowledge is gained and how can this knowledge be used to meet accountability issues?

Background: Realist philosophy and methodology is increasingly being explicitly used in the field of integrated care to research the extant context, structure and mechanisms at play, and to design and evaluation interventions. Philosophic realism is the view that entities exist independently of our perception or our theories about them. While the realist philosophy underpins much of modern health and social science, it is only recently that this philosophical approach has been popularised within main stream health and social science literature. Realist research methodology is increasingly being described in research areas that are relevant to the study of integrated care, namely, organisational management, information science, social epidemiology, economics, and health services evaluation. Importantly realist approaches are increasingly being used in mixed method research designs and to elucidate the processes at play in experimental and quasi-experimental studies. Realist researchers seek to explain the underlying “cause” or mechanism(s) that generate observed phenomenon. The realist understanding of how the world is (ontology) includes the notion of a hidden or “real” domain where mechanisms generate forces that result in the phenomena which we observe. Realists also view the world as consisting of strata or layers of reality which may interact with other layers to produce new mechanism. This approach is proving useful for studying and developing theory about complex health and social care systems, and then designing and evaluating possible interventions. The methodologies, and the dialectical debates, are complex, and therefore, deserving of special consideration within the Integrated Care community. This workshop will support evaluators and researchers to use realist methods in large scale and complex evaluations. Because realist evaluation (RE) was initially developed using smaller-scale programs, methods need to be modified for large scale programs, while remaining consistent with underlying methodological principles. The workshop will discuss the value of and the dilemmas involved in using realist methods for large and complex programs, and demonstrate strategies to address the dilemmas. Aims and Objectives: 1- Present and discuss the basic tenants of realist research, design and evaluation as it applies to the large scale and complex programs such as integrated care 2- Discuss the scope and purpose of a Realist Research, Design and Evaluation for Integrated Care Special Interest Group (RIC) 3- Modify the scope and purpose of a Realist Research, Design and Evaluation for Integrated Care - SIG Format: Timing 60 minutes, Two speakers, Group Discussion, Summation Target Audience: Integrated care practitioners and researchers who are familiar with realist research including the current focus on critical realism and realist evaluation Learning and Takeaway: The participants will learn some of the philosophical and academic foundations of realist research and evaluation as it applies to the design and evaluation of complex interventions including integrated care The workshop will define the scope and purpose of a SIG for Realist Research, Design and Evaluation for Integrated Care

Background: The integration of system-wide health and social care policies and services has long been seen as the answer to improved efficiency and outcomes for consumers of health and social care services. Recent Government reviews[1] , however, have failed to find substantial evidence that integration lead to better outcomes for patients or financial savings or reduced hospital activity. For example, there was no evidence that the widely population multidisciplinary team approach is unlikely to achieve widespread efficiencies and anticipated outcomes in constrained financial settings. Barriers identified include misaligned financial incentives, workforce challenges and reticence over information sharing. Despite these reservations optimism is widespread that integration and social care can address the challenges facing society with increasing chronic illness, mental illness, disability, homelessness, ageing and marginalised traumatised populations. The answers may not lie with large scale government policies but rather with local initiatives between primary health care, community or 3rd sector providers and hospitals. The challenge advanced by the UK Audit Office as to establish an evidence base for what works in integrating health and social care as a priority. Aims and Objectives: 1- Discuss definitions and scope for Integrating Health and Social Care 2- DIscuss the scope and purpose of an Integrating Health and Social Care Special Interest Group (IHASC SIG) 3- Modify the Scope and Purpose Document for the Integrating Health and Social Care (IHASC SIG) Format: Timing 60 minutes, One Speaker, Group work at tables, Feed back from tables, Discussion and Summation Target Audience: Health, disability, education and social care practitioners and researchers who are interested in aspects of integrated health and social care. Learnings and Takeaway: The participants will learning some of the policy and academic foundations of Integrating Health and Social Care, The workshop will define the scope and purpose of a SIG for Integrating Health and Social Care

Introduction: Malnutrition is an increasing problem among community-dwelling elderly (1) and reported prevalence data are up to 50% (2). Malnutrition is associated with depression, lower cognitive and functional status, infections, comorbidities, a higher use of home care facilities and mortality (3, 4). In older community-dwelling people malnutrition may result from poor appetite, difficulties with chewing, swallowing or tasting, wrong food choices, psychosocial problems (loneliness, mourning), financial problems (low budget) and/or may be associated with disease (6). Malnutrition increases the costs of healthcare (7). At a European level malnutrition is estimated to cost healthcare systems €170 billion/y (8). In this study we will develop risk profiles for malnutrition which are sensitive on individual patient level. Based on these profiles malnutrition risk screening can be applied more effectively. Methods: 1- A systematic review of the literature on of interventions to optimize nutritional status in older patients. 2- Prognostic modelling using the data filled out by 2000 older adults themselves at www.goedgevoedouderworden.nl, on risk factors for malnutrition (SCREEN) and malnutrition (SNAQ65+) will provide up-to-date Dutch data. 3- Developing risk profiles and implement these through internet and social media. Results: The risk profiles fit the in the framework of the Population Screening Act (WBO) and are to be used for policy purposes and both the prognostic and diagnostic sets of patient characteristics with a predictive value for malnutrition are to be used by professionals and older community dwelling people and their informal care givers. This contributes to detect malnutrition in the older community dwelling population before there are consequences of the malnutrition. Conclusion: The use of tools to screen for malnutrition increases the recognition of malnutrition by 30% (9). While screening is important for the prevention and consecutive treatment of malnutrition, screening takes place in only a quarter of home care clients, which indicates that this activity is not yet standard of care (2). Lessons learned: Narrowing down malnutrition screening to those at higher risk could be an effective intervention to increase malnutrition awareness, screening and treatment in the community. Using risk profiles that indicate older adults who are at risk of development of malnutrition in future, may prevent malnutrition at an earlier stage.Health care resources will be better used when healthcare professionals (GP’s, GP practitioners, home care and district nurses) limit malnutrition screening to the higher risk population, herewith decreasing workload and increasing sensitivity of screening . Limitations: To increase reliability of screening for malnutrition in community-dwelling elderly the use of screening instruments validated for individual patients is necessary. However the currently mostly used screening tools like SNAQ65+ (10) or MNA-SF (11) are validated on population level and not on individual patient level. Moreover, these tools identify patients who are already malnourished, while screening for risk factors may lead to earlier identification of those who will become malnourished in the future. Suggestions for future research: Behaviour change intervention target groups in the society as implementation research

Introduction: In the Netherlands, skin cancer is the most common type of cancer (KWF, 2016). More than 51.000 new cases of skin cancer are diagnosed every year and over 900 fatalities are reported (RIVM, 2017). Skin cancer incidence rates increase dramatically: since 1990 the number of new patients with skin cancer quadrupled (RIVM, 2017). This increase is much higher than in other types of cancer (IKNL, 2016). It is expected that incidence rates of skin cancer will increase even further, probably with a factor 2 to 5 (RIVM, 2017). Direct costs for medical treatment of skin cancer are estimated at 325 million each year (250-400 million) (RIVM, 2017). On top of that, sick leave and premature mortality are also important indirect costs in melanoma (Brochez et al., 1999). Increasing use of more costly treatment, such as Mohs surgery and photodynamic therapy, is contributing to rising treatment costs (Hollestein et al, 2017). In addition to the costs, this growing group of patients with skin cancer will represent an important burden on the limited specialized dermatological care in the Netherlands. Subsequent early assessment of skin cancer risk is necessary for timely preventive measures in the general population. Methods: 1- A systematic review of the literature on patient characteristics with a prognostic predictive value for future basal cell carcinoma, squamous cell carcinoma or melanoma (such as age, gender, presages, signs and risk behaviour). 2- A Current practice analysis on care concerning risk behaviour, presages and signs of skin cancer. 3- Prognostic modelling using existing data of over 5000 cases from the Netherlands Comprehensive Cancer Organisation (IKNL). 4- Developing risk profiles and implement these through internet and social media. Results: It will provide insight in early risk behaviours in the general population. It also provide knowledge of serious presages or signs enabling these patients to be seen by their GP timely. Conclusion: Basal cell carcinoma (BCC, approx. 70%), squamous cell carcinoma (SCC, approx. 20%) and melanoma (approx. 10%) are the three most common types of skin cancer. Melanoma is the most lethal type, accounting for 90% of all skin cancer fatalities. The incidence of melanoma in the Netherlands is among the highest in Europe (RIVM, 2017). Despite the fact that most non-melanoma skin cancers (BCC and SCC) can be cured, the treated lesions can be disfiguring or even lethal if not treated timely. Lessons learned: Risk profiles will enable healthcare professionals and citizens both with knowledge which persons are at high risk and should be screened and insight in risk behaviour. Limitations: Risk screening is costly, time consuming and it is to be expected that the adherence will be moderate. Suggestions for future research: Behaviour change intervention target groups in the society as implementation research

Background: Realist research methodology is increasingly being used for the design and evaluation of integrated care initiatives. Much of current realist research and evaluation is qualitative in nature and yet many realist methodologists, including Pawson, Tilley, Sayer and Olsen, have argued for the use of mixed methods. There remains much debate regarding the role of quantitative methods, including statistics, within a critical realist philosophical framework. For many realist researchers the use of quantitative methods is both a philosophical and methodological stumbling block. Yet quantitative methods can contribute to realist theory building,, design and theory testing through their ability to use observable events to infer the existence of underlying mechanisms and to detect changes in both context and outcomes. This workshop will examine debates about the use of quantitative methods in realist research and evaluation, either as part of a mixed-method design or on their own. Examples of their use for both theory development and theory testing will be provided. The workshop will provide practical demonstration of the use of quantitative methods for both small and large scale studies. Knowledge, techniques and practices to be addressed include: The philosophical debates concerning the use of quantitative methods for realist research and evaluation Quantitative methods used for explanatory theory building research Construction of quantitative tools from qualitative data Quantitative methods used for evaluation and theory testing Application of quantitative methods within realist mixed method study designs Practical application of quantitative analysis to infer mechanistic action. By the conclusion of the workshop, participants should be able to: Understand the philosophical rejection of quantitative methods for both natural and social scientific realms Determine how to interpret quantitative methods and incorporate them into realist research and evaluation while maintaining a distinction between method and methodology Describe quantitative methods for inclusion in realist mixed method research and/or evaluation study designs Undertake practical realist analysis of quantitative study data using simple statistical methods. Aims and Objectives: 1) To examine debates about the use of quantitative methods in realist research and evaluation, either as part of a mixed-method design or on their own. 2) To demonstrate the use of realist quantitative methods for both integrated care design and evaluation. Format: 90 minutes, one speaker and facilitator, Group work at tables using problem-based learning. Discussion, debate and learning resources. Target Audience: Integrated care design and evaluation practitioners and researchers. Qualitative and quantitative researchers. Mixed methodologists. Learning and Takeaway: Increased understanding of how quantitative methods can be appropriately used with realist methodology. Introduction to the use of advanced quantitative methods for design and evaluation of integrated care initiatives including latent class analysis, latent variable pathways, and discontiuity quasiexperimental designs.

Background: The integration of system-wide health and social care policies and services has long been seen as the answer to improved efficiency and outcomes for consumers of health and social care services. Recent Government reviews[1] , however, have failed to find substantial evidence that integration lead to better outcomes for patients or financial savings or reduced hospital activity. For example, there was no evidence that the widely population multidisciplinary team approach is unlikely to achieve widespread efficiencies and anticipated outcomes in constrained financial settings. Barriers identified include misaligned financial incentives, workforce challenges and reticence over information sharing. Despite these reservations optimism is widespread that integration and social care can address the challenges facing society with increasing chronic illness, mental illness, disability, homelessness, ageing and marginalised traumatised populations. The answers may not lie with large scale government policies but rather with local initiatives between primary health care, community or 3rd sector providers and hospitals. The challenge advanced by the UK Audit Office as to establish an evidence base for what works in integrating health and social care as a priority. Aims and Objectives: 1) Discuss definitions and scope for Integrating Health and Social Care 2) DIscuss the scope and purpose of an Integrating Health and Social Care Special Interest Group (IHASC SIG) 3) Modify the Scope and Purpose Document for the Integrating Health and Social Care (IHASC SIG) Format: Timing 60 minutes, One Speaker, Group work at tables, Feed back from tables, Discussion and Summation Target Audience: Health, disability, education and social care practitioners and researchers who are interested in aspects of integrated health and social care. Learnings and Takeaway: The participants will learning some of the policy and academic foundations of Integrating Health and Social Care, The workshop will define the scope and purpose of a SIG for Integrating Health and Social Care References: 1- National Audit Office. Health and social care integration, Department of Health, Department Communiites and Local Government and NHS England. National Audit Office, London, UK, 2017

Introduction: Both in literature and in practice there is debate about defining Integrated Care. The WHO for example, defines Integrated Care as a process, not covering the perspective of (cost-) effectiveness. From the perspective of research into evidence in Integrated Care this is rather awkward. Triple aim focusses on 1) quality of life of citizens; 2) quality and continuity of care and, 3) cost effective care. Integrated Care is aimed at well-organized, cost-effective processes of care delivery, provided by committed professionals which must be able to count on well-established evidence for the care interventions they provide in integrated trajectories to their patients. Research should support them both with evidence for effective interventions and evidence for effective application. A basis for thorough research in Integrated Care is narrowed by a lack of a comprehensive definition. Theory/Methods: Since Integrated Care is considered as sets of complex interventions targeting triple aim, we compared definitions of Integrated Care reported in literature with a definition of complex interventions and a model for evidence based developing, testing and implementing complex interventions. This definition and the accompanied model are issued by the British Medical Research Council (MRC) in 2008 and are nowadays worldwide established. During the session at the conference, after a short introduction, we will discuss our proposal with the participants for improving a new definition of evidence based integrated care. Results: Our preparation resulted in a proposal for a definition for ‘Evidence Based Integrated Care’ which covers defining the care problem with the underlying working mechanisms and the test acceptance by patients and care providers. Furthermore, it covers test effect of both the concept of interventions and the (cost) effectiveness in the context were the complex interventions are provided, the organization of the complex interventions in the trajectory and the quality of life and societal participation of citizens or patients. Discussions: On one hand, the perspective of the content of the interventions moves mostly in the domain of healthcare research. On the other hand, the perspective of the organisation of Integrated Care process is predominantly moving in the domains of social sciences and healthcare business research. In order to achieve triple aim care and welfare, a third perspective of directing the content of the interventions and the way of organising the Integrated Care process is necessary. Unfortunately, this remains rather underexposed in research. Conclusions: In order to meet triple aim, research in Integrated Care should focus on three perspectives at ones: the content of the interventions; the organisation of the Integrated Care process; to strengthen both, creating synergy between content and context. Lessons learned: By directing content and context, research in Integrated Care will make a vital contribution to accomplishing triple aim Integrated Care. Limitations: This is a theoretical exercise for starting a discussion for establishing a research basis, needed for focussing research in Integrated Care. Suggestions for future research: Developing research methods for Integrated Care research covering the perspectives of content context and the direction of these.