Search

Accountability in health services is necessary for legitimacy, transparency, financial and managerial justification. To achieve the best possible outcomes for people at an affordable cost, healthcare services are continuously evolving. One development is the movement to person-centred integrated care to better serve people’s individual needs. This requires inter-organisational cooperation and service provision by domain-overarching networks and alliances. Accountability traditionally focuses on professionals and organisations. In the development towards inter-organisational networks, it is relevant to explore which accountability approaches are appropriate for local inter-organisational healthcare governance. Therefore, in this study we provide insight into the state of play of accountability in Dutch healthcare.MethodsFor systematically mapping and addressing the exploratory nature of the topic of accountability in healthcare in the Netherlands, we executed a scoping review. Databases were searched from January 2009 to March 2021. The following aspects of accountability are mapped: keywords of accountability, domains, stakeholders and target audiences, the aim (why), content (what) and method (how) of accountability, who is accountable to whom, and reported issues in accountability in Dutch healthcare practice. ResultsForty-one studies were included, of which twenty were in the hospital domain. Definitions of accountability were mostly absent. Involved stakeholders include mainly medical and managerial professionals in practice and supervisory boards. Most frequently reported issues were the relationship between performance management and accountability, different views of stakeholders about both accountability and perverse effects. Accountability covering integrated care was rarely described.ConclusionsAccountability is not only a method for legitimacy or transparency. It relates to how to judge performance, on what basis and towards whom. Current, accountability practice does not focus on or comply with the characteristics of integrated service delivery and is merely single profession or single organisation focussed. Issues like perverse effects, absence of trust, and preventing bureaucracy are relevant for further development of effective accountability. New guiding principles for accountability that suit integrated health-service delivery in the Netherlands should be developed.

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.

To enhance prevention and treatment of malnutrition in older adults before, during and after hospitalization, deeper understanding of older adults' and informal caregivers' perspective on nutritional care is important. One-time in-depth interviews were conducted with 15 older adults who had been discharged from hospital, and seven informal caregivers. We explored their experiences and needs regarding nutritional care provided in the periods before, during and after hospitalization. Five themes emerged from the data: (1) dietary intake, (2) food service during hospitalization, (3) nutrition-related activities, (4) whose job it is to give nutritional care, and (5) competing care priorities. Further, several opinions about nutritional issues were identified. Older adults and informal caregivers did not always experience optimal nutritional care. When discussing nutritional care, they mainly focused on the in-hospital period. When providing nutritional care and developing guidelines, older adults' and informal caregivers' perspective on nutritional care should be incorporated. Here, the periods before, during and after hospitalization should be taken into account equally.

BackgroundMost asylum seekers experience stress, not only due to the reason for 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 lower self-esteem and lower quality of life. Adverse life events, forced migration, and prolonged asylum procedures, in addition to the complexity of the acculturation process, can all contribute to higher levels of psychopathology.ObjectiveWhat are the threats to wellbeing in terms of mental health, psychosocial, and addiction problems, and what are the effective interventions for wellbeing for asylum seekers in asylum seeker centers in the Netherlands, reported in the literature?MethodFollowing the descriptive nature of the research question and the need for identifying knowledge gaps, an overview of existing knowledge was created by executing a scoping review on influencing factors on the mental health of asylum seekers. The Neuman system model was used as a guiding framework to understand the complexity of the issues this population experience and to identify the stressors and the factors which cause the imbalance and also the disease.ResultsThe literature review resulted in 26 articles that met the criteria for inclusion. The threats included the influence of staying in the environment of an asylum seekers center, drug abuse among asylum seekers, health-care professionals and employees who do not detect or underestimate the underlying suffering of asylum seekers, and frequent relocations of asylum seekers. The two assessment instruments used were the Rapid-Assessment-Response method (RAR method) and the Health Information Assessment Tool Asylum Seeker tool (HIATUS tool). Finally, the five interventions were identified: therapy for asylum seekers diagnosed with post-traumatic stress disorder (PSTD), art therapy, education focused on prevention as intervention, cultural interview, and mindspring.ConclusionThe knowledge on identifying and reducing threats, assessment, and treatment interventions for asylum seekers living in an asylum seekers center found in the literature provided perspectives on improving their wellbeing. The great diversity of cultural aspects and continuous changes in the number and origin of refugees in the Dutch asylum seekers centers disrupted the continuity of care.

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.

Background: The diffusion of telehealth into hospital care is still low, partially because of a lack of telehealth competence among nurses. In an earlier study, we reported on the knowledge, skills, and attitudes (KSAs) nurses require for the use of telehealth. The current study describes hospital nurses' confidence in possessing these telehealth KSAs. Method: In a cross-sectional study, we invited 3,543 nurses from three hospitals in the Netherlands to rate their self-confidence in 31 telehealth KSAs on a 5-point Likert scale, using an online questionnaire. Results: A total of 1,017 nurses responded to the survey. Nine KSAs were scored with a median value of 4.0, 19 KSAs with a median value of 3.0, and three KSAs with a median value of 2.0. Conclusion: Given that hospital nurses have self-confidence in only nine of the 31 essential telehealth KSAs, continuing education in additional KSAs is recommended to support nurses in gaining confidence in using telehealth. [ J Contin Educ Nurs. 2019;50(1):26–34.]

Item does not contain fulltext AIMS AND OBJECTIVES: To gain insight into the experiences and perceptions of hospital and home care nurses regarding nutritional care for older adults to prevent and treat malnutrition. BACKGROUND: In-depth knowledge about hospital and home care nurses' experiences and perceptions can contribute to optimise nutritional care for older adults across the care continuum between hospital and home to prevent and treat malnutrition. DESIGN: Multicentre cross-sectional descriptive study. METHOD: A validated questionnaire addressing malnutrition was used. A total of 1,135 questionnaires were sent to hospital and home care nurses. The STROBE statement was followed for reporting. RESULTS: The response rate was 49% (n = 556). Of all the nurses, 37% perceived the prevalence of malnutrition among their care recipients between 10% and 25%. Almost 22% of the nurses neither agreed nor disagreed or disagreed with the statement that prevention of malnutrition is possible. More than 28% of the nurses reported that malnutrition is a small or no problem. Over 95% of the hospital nurses and 52.5% of the home care nurses stated they screened routinely for malnutrition. The nurses considered several interventions for treating malnutrition important. Over 81% of the nurses indicated they wanted to follow further training. CONCLUSION: Most hospital and home care nurses perceived that nutritional care for older adults to prevent and treat malnutrition was important. A fair group of nurses, however, had the opposite perception. RELEVANCE TO CLINICAL PRACTICE: Raising the awareness of all hospital and home care nurses about the importance of nutritional care for older adults is pivotal to increase the chance of successfully providing nursing nutritional care. Nurses should follow training for consolidation of nutritional care. Nurses are well-positioned to take a leadership role to improve continuity and quality of nutritional care across the care continuum between hospital and home.

Background Undernutrition in surgical patients leads to a higher risk of postoperative complications like infections and delayed recovery of gastrointestinal functions, often resulting in a longer hospital stay and lower quality of life. Nurses at outpatient clinics can deliver nutritional care during outpatient preoperative evaluation of health status to ensure that patients are properly fed in preparation for hospital admission for surgery. However, nutritional nursing care was not determined in research yet. This paper describes the structural development of an Outpatient Nursing Nutritional Intervention (ONNI). Methods A project group followed the steps of the Intervention Mapping. The needs assessment included assessment of delivery of nutritional care and nutritional care needs at two anaesthesia outpatient clinics of an academic and a teaching hospital. Also, outpatient clinic nurses and patients at risk for undernutrition were interviewed. Determinants resulted from these methods were matched with theories on behaviour change and nutritional support. Results Both patients and nurses were unaware of the consequences of undernutrition, and nurses were also unaware of their roles with regard to nutritional support. The intervention goals were: 1) enabling surgical patients to improve or maintain their nutritional status before hospital admission for surgery, and 2) enabling nurses to deliver nutritional support. The ONNI was developed for outpatients at risk for or with undernutrition. A training was developed for nurses. The ONNI included the five following components: 1) identification of the causes of undernutrition; 2) provision of a nutritional care plan including general and individually tailored advice; 3) self-monitoring of nutrient intake; 4) counselling and encouragement; and 5) support during a telephone follow-up meeting. The intervention and training were tested. A multifaceted implementation strategy was used to deliver the intervention in daily practice. Conclusions Despite the unique position of the nurses at outpatient clinics, nurses were unaware of their role with regard to nutritional care. The ONNI was developed and implemented along with a training program for nurses. The test confirmed that the training can improve nurses’ knowledge, skills, and sense of responsibility for nutritional support. The intervention may empower patients to actively improve their nutritional status.

Contains fulltext : 202257.pdf (Publisher’s version ) (Closed access) AIMS AND OBJECTIVES: To evaluate the effects of preoperative nutritional support using a regular diet for undernourished surgical patients at the outpatient clinic. BACKGROUND: Undernutrition (or malnutrition) in surgical patients has severe consequences, that is, more complications, longer hospital stay and decreased quality of life. While systematic reviews show the effects of oral nutritional supplements (ONS), enteral and parenteral nutrition in surgical patients, the effects of normal foods and regular diets remain unclear. DESIGN: A systematic review. METHODS: PubMed, CINAHL, Web of Science, PsycINFO, Cochrane Library and EMBASE were searched up to July 24, 2017. Studies on undernourished patients receiving nutritional support using regular or therapeutic diet, performed preoperatively at the outpatient clinic, were considered eligible. Risk of bias was assessed using the Cochrane Risk of Bias tool. Two reviewers independently performed study selection, quality assessment and data extraction. RESULTS: Six studies with moderate risk of bias were included. Interventions were preoperatively performed in mainly oncological outpatients by dieticians and aimed to reach nutrient requirements. Interventions included consults for counselling and advice, follow-up meetings and encouragements, and ONS. Nutritional status, nutrient intake and quality of life improved in supported patients. Improvements were better in counselled patients compared to patients using supplements. Unsupported patients experienced worse outcomes. CONCLUSION: Frequent consults with counselling and advice as nutritional support for undernourished patients before surgery result in improvements to nutritional status, intake and quality of life. This statement is supported by weak evidence due to few studies and inadequate methods. RELEVANCE TO CLINICAL PRACTICE: Nutritional support should be provided to all undernourished surgical patients during preoperative course. Nurses are in key position to provide nutritional support during outpatient preoperative evaluations.

Background In recent years there has been much emphasis on ‘research waste' caused by poor question selection, insufficient attention to previous research results, and avoidable weakness in research design, conduct and analysis. Little attention has been paid to the effect of inadequate development of interventions before proceeding to a full clinical trial. Objective We therefore propose to enrich the development phase of the MRC Framework by adding crucial elements to improve the likelihood of success and enhance the fit with clinical practice Methods Based on existing intervention development guidance and synthesis, a comprehensive iterative intervention development approach is proposed. Examples from published reports are presented to illustrate the methodology that can be applied within each element to enhance the intervention design. Results A comprehensive iterative approach is presented by combining the elements of the MRC Framework development phase with essential elements from existing guidance including: problem identification, the systematic identification of evidence, identification or development of theory, determination of needs, the examination of current practice and context, modelling the process and expected outcomes leading to final element: the intervention design. All elements are drawn from existing models to provide intervention developers with a greater chance of producing an intervention that is well adopted, effective and fitted to the context. Conclusion This comprehensive approach of developing interventions will strengthen the internal and external validity, minimize research waste and add value to health care research. In complex interventions in health care research, flaws in the development process immediately impact the chances of success. Knowledge regarding the causal mechanisms and interactions within the intended clinical context is needed to develop interventions that fit daily practice and are beneficial for the end-user.

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.

BackgroundCare recipients in care and welfare are increasingly presenting themselves with complex needs (Huber et al., 2016). An answer to this is the integrated organization of care and welfare in a way that personalized care is the measure (Topol, 2016). The reality, however, is that care and welfare are still mainly offered in a standardized, specialized and fragmented way. This imbalance between the need for 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 (Berwick, 2005). It also leads to a reduction in the functioning of citizens and unnecessary healthcare cost (Olsson et al, 2009).Integrated CareIntegrated care is the by fellow human beings experienced smooth process of effective help, care and service provided by various disciplines in the zero line, the first line, the second line and the third line in healthcare and welfare, as close as possible (Ettema et al, 2018; Goodwin et al, 2015). Integrated care starts with an extensive assessment with the care recipient. Then the required care and services in the zero line, the first line, the second line and / or the third line are coordinated between different care providers. The care is then delivered to the person (fellow human) at home or as close as possible (Bruce and Parry, 2015; Evers and Paulus, 2015; Lewis, 2015; Spicer, 2015; Cringles, 2002).AimSupport societal participation, quality of live and reduce care demand and costs in people with complex care demands, through integration of healthcare and welfare servicesMethods (overview)1. Create best healthcare and welfare practices in Slovenia, Poland, Austria, Norway, UK, Finland, The Netherlands: three integrated best care practices per involved country 2. Get insight in working mechanisms of favourable outcomes (by studying the contexts, mechanisms and outcomes) to enable personalised integrated care for meeting the complex care demand of people focussed on societal participation in all integrated care best practices.3. Disclose program design features and requirements regarding finance, governance, accountability and management for European policymakers, national policy makers, regional policymakers, national umbrella organisations for healthcare and welfare, funding organisations, and managers of healthcare and welfare organisations.4. Identify needs of healthcare and welfare deliverers for creating and supporting dynamic partnerships for integrating these care services for meeting complex care demands in a personalised way for the client.5. Studying desired behaviours of healthcare and welfare professionals, managers of healthcare and welfare organisations, members of involved funding organisations and national umbrella organisations for healthcare and welfare, regional policymakers, national policy makers and European policymakersInvolved partiesAlma Mater Europaea Maribor Slovenia, Jagiellonian University Krakow Poland, University Graz Austria, Kristiania University Oslo Norway, Salford University Manchester UK, University of Applied Sciences Turku Finland, University of Applied Sciences Utrecht The Netherlands (secretary), Rotterdam Stroke Service The Netherlands, Vilans National Centre of Expertise for Long-term Care The Netherlands, NIVEL Netherlands Institute for Health Services Research, International Foundation of Integrated Care IFIC.References1. Berwick DM. The John Eisenberg Lecture: Health Services Research as a Citizen in Improvement. Health Serv Res. 2005 Apr; 40(2): 317–336.2. Bruce D, Parry B. Integrated care: a Scottish perspective. London J Prim Care (Abingdon). 2015; 7(3): 44–48.3. Cringles MC. Developing an integrated care pathway to manage cancer pain across primary, secondary and tertiary care. International Journal of Palliative Nursing. 2002 May 8;247279.4. Ettema RGA, Eastwood JG, Schrijvers G. Towards Evidence Based Integrated Care. International journal of integrated care 2018;18(s2):293. DOI: 10.5334/ijic.s22935. Evers SM, Paulus AT. Health economics and integrated care: a growing and challenging relationship. Int J Integr Care. 2015 Jun 17;15:e024.6. Goodwin N, Dixon A, Anderson G, Wodchis W. Providing integrated care for older people with complex needs: lessons from seven international case studies. King’s Fund London; 2014.7. Huber M, van Vliet M, Giezenberg M, Winkens B, Heerkens Y, Dagnelie PC, Knottnerus JA. Towards a 'patient-centred' operationalisation of the new dynamic concept of health: a mixed methods study. BMJ Open. 2016 Jan 12;6(1):e010091. doi: 10.1136/bmjopen-2015-0100918. Lewis M. Integrated care in Wales: a summary position. London J Prim Care (Abingdon). 2015; 7(3): 49–54.9. Olsson EL, Hansson E, Ekman I, Karlsson J. A cost-effectiveness study of a patient-centred integrated care pathway. 2009 65;1626–1635.10. Spicer J. Integrated care in the UK: variations on a theme? London J Prim Care (Abingdon). 2015; 7(3): 41–43.11. Topol E. (2016) The Patient Will See You Now. The Future of Medicine Is in Your Hands. New York: Basic Books.

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: 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

Summary Background Telehealth is viewed as a major strategy to address the increasing demand for care and a shrinking care professional population. However, most nurses are not trained or are insufficiently trained to use these technologies effectively. Therefore, the potential of telehealth fails to reach full utilization. A better understanding of nursing telehealth entrustable professional activities (NT-EPAs) and the required competencies can contribute to the development of nursing telehealth education. Method In a four-round Delphi-study, a panel of experts discussed which NT-EPAs are relevant for nurses and which competencies nurses need to possess to execute these activities effectively. The 51 experts, including nurses, nursing faculty, clients and technicians all familiar with telehealth, were asked to select items from a list of 52 competencies based on the literature and on a previous study. Additionally, the panelists could add competencies based on their experience in practice. The threshold used for consensus was set at 80%. Results Consensus was achieved on the importance of fourteen NT-EPAs, requiring one or more of the following core competencies; coaching skills, the ability to combine clinical experience with telehealth, communication skills, clinical knowledge, ethical awareness, and a supportive attitude. Each NT-EPA requires a specific set of competencies (at least ten). In total, 52 competencies were identified as essential in telehealth. Discussion/Conclusion Many competencies for telehealth, including clinical knowledge and communication skills, are not novel competencies. They are fundamental to nursing care as a whole and therefore are also indispensable for telehealth. Additionally, the fourteen NT-EPAs appeared to require additional subject specific competencies, such as the ability to put patients at ease when they feel insecure about using technology. The NT-EPAs and related competencies presented in this study can be used by nursing schools that are considering including or expanding telehealth education in their curriculum.

Contains fulltext : 220931.pdf (Publisher’s version ) (Closed access) AIMS AND OBJECTIVES: To identify interventions to prevent and treat malnutrition in older adults, which can be integrated in nursing care, and to evaluate the effects of these interventions on outcomes related to malnutrition. BACKGROUND: Older adults are at great risk for malnutrition, which can lead to a number of serious health problems. Nurses have an essential role in nutritional care for older adults. Due to a lack of evidence for nursing interventions, adequate nursing nutritional care still lags behind. DESIGN: Systematic review. METHOD: We searched for and included randomised controlled trials on interventions, which can be integrated in nursing care for older adults, to prevent and treat malnutrition. We assessed the risk of bias with the Cochrane tool and evidence for outcomes with the GRADE. The PRISMA statement was followed for reporting. RESULTS: We included 21 studies of which 14 studies had a high risk of bias. Identified interventions were oral nutritional supplements, food/fluid fortification or enrichment, dietary counselling and educational interventions. In evaluating the effects of these interventions on 11 outcomes related to malnutrition, significant and nonsignificant effects were found. We graded the certainty of evidence as very low to moderate. CONCLUSION: Although slight effects were found in protein intake and body mass index, there is no convincing evidence about the effectiveness of the four identified interventions. There seems no harm in using these interventions, although it should be kept in mind that the evidence is sparse. Therefore, there is a need for high-quality research in building evidence for interventions in nursing nutritional care. RELEVANCE TO CLINICAL PRACTICE: Nurses can safely provide oral nutritional supplements and food/fluid fortification or enrichment, and give dietary counselling and education to older adults, as they are well placed to lead the essential processes of nutritional care to older adults.

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?

The widespread use of telehealth, providing healthcare remotely, is hampered by various barriers. Dutch nurses currently working in practice never received education in this new way of healthcare delivery. Education is frequently suggested as a strategy to overcome barriers in telehealth use. However, the nature and effectiveness of such education has not yet been specified and tested in practice. In a previous study, we identified 14 nursing telehealth activities and accompanying competencies. In the current study, we established the effectiveness of training in these competencies on nurses' subjective knowledge, self-efficacy and usage of telehealth. A two-day tailored training program in nursing telehealth activities was evaluated in a Dutch context among 37 participants across three settings: (a) twelve primary care (PC), (b) fourteen homecare (HC) and (c) eleven hospital (H) nurses. In each team, telehealth knowledge significantly increased during the training sessions. In each team, nurses' telehealth self-efficacy also significantly increased 6–10 weeks after the training. After the training, the number of remote consultations increased from 2 to 12 in primary care, 12 to 35 in homecare and decreased from 28 to 17 in the hospital setting. We conclude that training nurses in telehealth activities contributes to their knowledge and self-efficacy.

Objective Delirium is an impactful, frequently occurring complication in older hospital patients. Consequently, risk stratification of delirium was included in a set of mandatory safety measures in general hospitals in the Netherlands. This risk stratification contains three consensus-based questions that have not been validated. Therefore, we evaluated their predictive performance and examined whether other routinely collected patient data can improve the prediction of delirium. Method Using data from a continuous data registry from a general hospital, the prediction of the three questions was compared with the occurrence of delirium in 3786 older patients. Regression models were fitted that included other patient-related delirium risk factors. The performance was expressed by discrimination and calibration. Results Delirium occurrence was 16.8%. The three questions, a regression model with the three questions, a full model and a reduced model – including the three questions, age, use of glasses, number of medications and Katz-ADL – showed sensitivities of 0.88, 0.88, 0.92 and 0.91 and specificities of 0.52, 0.52, 0.53 and 0.54, when treated as dichotomous models respectively. The three risk models had C-statistics of 0.81, 0.86 and 0.86, with excellent p-values of the U-statistics. Conclusion The three risk-stratification questions show promising results but substantial overprediction (49% predicting positive). Further validation should be done outside the Netherlands, given the potential bias as a result of clinical activities following the risk stratification. The reduced model shows excellent calibration performance, indicating good prediction in each individual patient. In clinical practice, this advantage adds to clinical reasoning.

Malnutrition in older adults is a frequent and major problem. Despite the fact that nurses have an essential role in nutritional care, they fail to ensure appropriate delivery in preventing and treating malnutrition. For improvement, it is necessary to understand the perspective of nurses about malnutrition. The aim of this study was to gain insight into nurses’ opinions and beliefs about malnutrition in older adults. A cross-sectional study was conducted where nurses working in different health care settings were asked to fill in a survey with twelve questions regarding different aspects of malnutrition. Nurses (n = 557) frequently observe malnutrition in older care recipients, and they consider this as a serious health problem. They believe that prevention and treatment of malnutrition is important and they see screening of malnutrition as a relevant nursing activity. They also consider nutritional care as multidisciplinary. Nurses state their need for education to give adequate nutritional care. Nurses’ opinions and beliefs about malnutrition in older adults is positive, which enhances nurses’ behavior to give sufficient nutritional care to older adults. To gain more benefit in improving nursing activities within nutritional care for older adults, more education is needed targeting nurse professionals and nurse students.

Background and aim: In older patients undergoing elective cardiac surgery, timely identification and preparation of patients at risk for frequent postoperative hospital complications provides for the opportunity reducing their risk. We developed an evidence based multi component nursing intervention (PREDOCS-Program) to improve patients’ physical and psychosocial condition in order to reduce their risk on postoperative complications and we tested the PREDOCS-program on its feasibility and estimated theoretical cost savings. Method and material: In a team of researchers, experts, cardiac surgeons, cardiac surgery nurses and patients, the first phase of the revised guidelines for developing and evaluating complex interventions of the Medical Research Council (MRC) were followed. Subsequently, in a mixed-methods multicenter study, following the second phase of the MRC guidelines, we tested the feasibility in three hospitals and calculated theoretical cost savings. Results: PREDOCS-program is administered during a consult by the nurse, two to four weeks before the surgery procedure. Twenty one females and 49 males out of the 114 eligible patients completed the intervention. Patients were equally satisfied with the usual care and the PREDOCS-program (satisfaction rates on a scale from 1–10 respectively: 7.5 (95%CI: 6.4–8.7) and 7.6 (6.6–8.6)). The PREDOCS-program will be cost-effective when postoperative complications are prevented in six to sixteen of 1,000 cardiac surgery patients. Conclusion: In creating transparency in the assumed working mechanisms, an extended stepwise multi-method procedure was used to develop the PREDOCS-program, which will be already cost-effective when postoperative complications are prevented in six to sixteen of 1000 cardiac surgery patients.

BACKGROUND: Today's nursing school applicants are considered “digital natives.” This study investigated students' views of new health care technologies. METHOD: In a cross-sectional survey among first-year nursing students, 23 common nursing activities and five telehealth nursing activities were presented along with three statements: “I consider this a core task of nursing,” “I look forward to becoming trained in this task,” and “I think I will do very well in performing this task.” RESULTS: Internet-generation nursing students (n = 1,113) reported a significantly (p ⩽ .001) less positive view of telehealth activities than of common nursing activities. Median differences were 0.7 (effect size [ES], −0.54), 0.4 (ES, −0.48), and 0.3 (ES, −0.39), measured on a 7-point scale. CONCLUSION: Internet-generation nursing students do not naturally have a positive view of technology-based health care provision. The results emphasize that adequate technology and telehealth education is still needed for nursing students. [J Nurs Educ. 2017;56(12):717–724.] Nursing curricula are regularly updated to respond to changes in society and health care practice. Current nurse educators must respond to an increasing use of health care technology in nursing practice. Health care technologies, such as telehealth care (i.e., the remote provision of health care using technologies such as videoconferencing or equipment to monitor vital signs), typically do not provide direct, face-to-face contact (Shea & Chamoff, 2012). This limits the possibility to observe patients and their environments directly and requires additional digital competencies for contact through technology. Inadequately trained professionals are considered a barrier to the effective provision of telehealth care (Brewster, Mountain, Wessels, Kelly, & Hawley, 2014; Kort & van Hoof, 2012; Sharma & Clarke, 2014; van Houwelingen et al., 2015). An earlier study identified 14 distinct nursing telehealth activities (van Houwelingen, Moerman, Ettema, Kort, & ten Cate, 2016) or professional activities that can be performed by nurses to support patients using technologies (e.g., triaging incoming calls and alarms, or independently double-checking high-risk medication via videoconferencing). All of the telehealth activities required a specific set of knowledge, skills, and attitudes. Nurses cannot be entrusted with these activities without receiving adequate training in these additional required competencies. Specific competencies for health care technologies have become a significant part of published nursing curriculum guides (e.g., American Nurses Association, 2010; Australian Qualifications Framework, 2013; Steeringgroup Bachelor of Nursing 2020, 2015; Tuning Project, 2011). These curricular adjustments contribute to overcoming barriers caused by inadequately trained nurses in telehealth care. Nurses currently working in this domain need additional skills to be able to integrate technology applications in practice. However, today's applicants for nursing education are part of a generation known as “digital natives” (Prensky, 2001). This generation, referred to as Generation Z by Glass (2007), knows no world without the Internet, and its members commonly are characterized by their wide experience with and skills in using the Internet and communication technologies. For these students, the use of health care technology may feel normal because they are already immersed in a world of technology through the use of smartphones, tablets, and social media, both privately and at primary and secondary schools. The question that is being asked by schools of nursing is, “How much technology-based nursing education is necessary for the current new generation of future nurses to provide telehealth care?”

Nurses play an important role in the prevention and treatment of malnutrition in older adults. However, research shows that nurses lack the motivation to give adequate nutritional care. In order to change this motivation a learning intervention about nutrition in older adults targeted at nurses would be desirable. The aim of this study was to assess the development, validation, and reliability of a learning intervention about nutrition in older adults. The results show that this learning intervention has a good construct and content validity, and is psychometrically sound. Questions of the learning intervention can be presented at once or in a snack-sized way, where the questions are presented over a period of time. This learning intervention can be used for developers of similar interventions, and as part of educating programs for nursing professionals and nursing students about nutritional care for older adults.

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

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