Search

BACKGROUND:Integrated care is the coordination of general and behavioral health and is a highly promising and practical approach to improving healthcare delivery and patient outcomes. While there is growing interest and investment in integrated care implementation internationally, there are no formal guidelines for integrated care implementation applicable to diverse healthcare systems. Furthermore, there is a complex interplay of factors at multiple levels of influence that are necessary for successful implementation of integrated care in health systems. METHODS:Guided by the Exploration, Preparation, Implementation, Sustainment (EPIS) framework (Aarons et al., 2011), a multiple case study design was used to address two research objectives: 1) To highlight current integrated care implementation efforts through seven international case studies that target a range of healthcare systems, patient populations and implementation strategies and outcomes, and 2) To synthesize the shared and unique challenges and successes across studies using the EPIS framework. RESULTS:The seven reported case studies represent integrated care implementation efforts from five countries and continents (United States, United Kingdom, Vietnam, Israel, and Nigeria), target a range of clinical populations and care settings, and span all phases of the EPIS framework. Qualitative synthesis of these case studies illuminated common outer context, inner context, bridging and innovation factors that were key drivers of implementation. CONCLUSIONS:We propose an agenda that outlines priority goals and related strategies to advance integrated care implementation research. These goals relate to: 1) the role of funding at multiple levels of implementation, 2) meaningful collaboration with stakeholders across phases of implementation and 3) clear communication to stakeholders about integrated care implementation. TRIAL REGISTRATION:Not applicable.

Physical activity is important in the self-management of long-term conditions (LTCs). However, implementing physical activity into clinical practice is challenging, due to complex barriers including access to programmes, time pressures, and transport costs, for people with comorbidities, managing multiple responsibilities. Various digital tools exist to overcome these barriers and support wide-scale implementation to help people stay physically active. We explored the experiences, needs and preferences of healthcare professionals and commissioners, regarding the use of digital tools to support people with LTCs to self-manage using physical activity. This included barriers and facilitators to implementing digital tools to support people with LTCs in NHS settings. Semi-structured interviews were conducted (April 2021 to January 2022) in Wessex, southern England, UK. Purposive sampling was used to recruit general practitioners and healthcare professionals, and convenience sampling to recruit commissioners (n = 15). Transcripts were coded to develop conceptual themes allowing comparisons between and among perspectives, with the Normalisation Process Theory (NPT)'s four constructs used to aid interpretation. Results showed that most digital tools supporting physical activity for LTCs, are not well implemented clinically. Current digital tools were seen to lack condition-specificity, usability/acceptability evidence-base, and voluntary sector involvement (i.e., NPT: coherence or 'making sense'). Healthcare professionals and commissioners were unlikely to engage with use of digital tools unless they were integrated into health service IT systems and professional networks (i.e., NPT: cognitive participation), or adaptable to the digital literacy levels of service users and staff (i.e., NPT: collective action–needs for implementation). In practice, this meant being technically, easy to use and culturally accessible (i.e., NPT: collective action–promoting healthcare work). COVID-19 changed professional attitudes towards digital tools, in that they saw them being viable, feasible and critical options in a way they had not done before the pandemic. Implementation was also influenced by endorsement and trustworthiness enhancing the perception of them as secure and evidence-based (i.e., NPT: reflective monitoring). Our findings highlight that consideration must be given to ensuring that digital tools are accessible to both healthcare professionals and patients, have usability/acceptability, and are adaptable to specific LTCs. To promote clinical engagement, digital tools must be evidence-based, endorsed by professional networks, and integrated into existing health systems. Digital literacy of patients and professionals is also crucial for cross-service implementation. [ABSTRACT FROM AUTHOR]

Background: The use of digital pain management interventions has grown since the Covid 19 pandemic. The aim of this study was to systematically review and synthesise evidence from qualitative studies regarding the experiences of individuals with chronic pain participating in digital pain management interventions in primary care and community settings. Methods: Fourteen databases were searched, as well as citation tracking and hand-searching reference lists of included articles. The latest search was completed by 07/07/2023. Qualitative studies of patient and carer perspectives of digital pain management interventions for adults aged 18 and over with non-malignant chronic pain were included. All studies were appraised for quality using the Critical Appraisal Skills Programme Qualitative Checklist. A narrative synthesis approach was used to synthesise the findings. Normalisation Process Theory was used to understand how individuals with chronic pain make sense of digital pain management interventions and incorporate knowledge, skills and strategies learnt into their day-to-day lives. Results: Eleven studies, encompassing both digital applications for use on smartphones/ mobile devices and user-directed online modular programmes, were included in the synthesis. Three main themes and related subthemes were identified from the included studies: 1) Making sense of the digital intervention (Subthemes: Tailoring to user's needs; Human contact and support; Accessibility of the digital intervention; Personal and environmental factors affecting engagement with digital interventions); 2) Initiating and Maintaining Behaviour Change (Subthemes: Planning activity; Being active); and 3) Personal Growth (Subthemes: Gaining understanding and skills; Gaining and acting on feedback; Negotiating a new relationship with pain). Conclusion: Recommendations. The key recommendations from our findings are that digital pain management interventions should provide: Specific and tailored information for individual participants. Focus on changing attitudes and behaviours and reframing perceptions of pain. Structured goal setting with prompts to review goals. Potential healthcare professional support alongside the digital intervention. Limitations of the review. To reduce bias, it would have been preferable for more than one author to independently fully analyse each paper and to identify themes and sub-themes. Instead, the identified themes and sub-themes were discussed with two other authors in the team (ES, LW) to reach a consensus view on final themes and sub-themes. One author (JS) received a Research Internship and Research Initiation Award funded by NIHR Applied Research Collaboration (ARC) Wessex (https://www.arc-wx.nihr.ac.uk/) and NHS England (https://www.england.nhs.uk/). The protocol for this review was registered with the National Institute of Health Research (NIHR) PROSPERO international database for registering systematic reviews (PROSPERO Registration Number CRD42021257768). [ABSTRACT FROM AUTHOR]

To explore older adult's perceptions of early rehabilitation and recovery after hip fracture, as a complement to the UK standards for acute physiotherapy after hip fracture. In-depth semi-structured interviews with 15 adults aged 60 years or more in hospital after hip fracture surgery. A thematic analysis approach with interpretation informed by Bury's biographical disruption theoretical framework. Participants voiced the importance of self-determination, professional support, meaningful feedback, and social capital after hip fracture. Collaborative working with staff was required for meeting the UK standards. Participants voiced anxieties about their hip fracture when considered in conjunction with their age and co-existing conditions, anticipating a disruption to their previous physical and social activities. This new, more dependent, life situation was not acceptable to participants. This study suggests hip fracture alone, was not perceived as a biographical disruption by older adults although it is presented as a potential tipping point in the loss of independence, contributing to the wider disruption of advancing age and co-existing conditions. For successful implementation of the UK standards, goal setting should consider patients in the wider context of their advancing age and co-existing conditions to empower them to define a fresh narrative of self. Hip fracture was perceived as a potential tipping point in the loss of independence, contributing to the wider disruption of advancing age and co-existing conditions. Participants expressed uncertainty over their ability to recover their previous identity in the absence of professional support and/or social capital. Healthcare professionals need to educate and empower older adults to take charge of their own recovery. For successful implementation of the UK standards for acute physiotherapy, there is a need to contextualize goal setting to empower patients to define a fresh narrative of self. [ABSTRACT FROM AUTHOR]

Objective Lack of access to mental health services during the perinatal period is a significant public health concern in the UK. Barriers to accessing services may occur at multiple points in the care pathway. However, no previous reviews have investigated multilevel system barriers or how they might interact to prevent women from accessing services. This review examines women, their family members' and healthcare providers' perspectives of barriers to accessing mental health services for women with perinatal mental illness in the UK. Design A systematic review and meta-synthesis of qualitative studies. Data sources Qualitative studies, published between January 2007 and September 2018, were identified in MEDLINE, PsycINFO, EMBASE and CINAHL electronic databases, handsearching of reference lists and citation tracking of included studies. Papers eligible for inclusion were conducted in the UK, used qualitative methods and were focused on women, family or healthcare providers working with/or at risk of perinatal mental health conditions. Quality assessment was conducted using the Critical Appraisal Skills Programme for qualitative studies. Results Of 9882 papers identified, 35 studies met the inclusion criteria. Reporting of emergent themes was informed by an existing multilevel conceptual model. Barriers to accessing mental health services for women with perinatal mental illness were identified at four levels: Individual (eg, stigma, poor awareness), organisational (eg, resource inadequacies, service fragmentation), sociocultural (eg, language/cultural barriers) and structural (eg, unclear policy) levels. Conclusions Complex, interlinking, multilevel barriers to accessing mental health services for women with perinatal mental illness exist. To improve access to mental healthcare for women with perinatal mental illness multilevel strategies are recommended which address individual, organisational, sociocultural and structural-level barriers at different stages of the care pathway. [ABSTRACT FROM AUTHOR]

Abstract: This article examines the process of training informal carers on stroke units using the lens of power. Care is usually assumed as a kinship obligation but the state has long had an interest in framing the carer and caring work. Training carers in healthcare settings raises questions about the power of the state and healthcare professionals as its agents to shape expectations and practices related to the caring role. Drawing on Foucault's notion of disciplinary power, we show how disciplinary forms of power exercised in interactions between healthcare professionals and carers shape the engagement and resistance of carers in the process of training. Interview and observational field note extracts are drawn from a multi‐sited study of a training programme on stroke units targeting family carers of people with stroke to consider the consequences of subjecting caring to this intervention. We found that the process of training informal carers on stroke units was not simply a matter of transferring skills from professional to lay person, but entailed disciplinary forms of power intended to shape the conduct of the carer. We interrogate the extent to which a specific kind of carer is produced through such an approach, and the wider implications for the participation of carers in training in healthcare settings and the empowerment of carers. [ABSTRACT FROM AUTHOR]

Objectives: Stroke is a sudden-onset condition with long-term consequences. Self-management could help address long-term consequences of stroke. Stroke survivors' and health professionals' views of selfmanagement may vary, limiting the successful introduction of self-management strategies. This paper explores stroke survivors' and physiotherapists' views of self-management, focusing on what selfmanagement means, and factors perceived to enable and hinder self-management after stroke, to draw out implications for policy, practice and future research. Design: Qualitative study using semistructured interviews and a thematic analysis approach. Setting: Stroke unit and community strokerehabilitation services in London, UK. Participants: 13 stroke survivors (8 men and 5 women; aged 53-89 years) admitted to a London stroke unit. 13 physiotherapists: 8 working in an inpatient stroke unit and 5 in community rehabilitation. Results: Key differences were evident in how selfmanagement was understood between these groups. Stroke survivors were unfamiliar with the term selfmanagement, but most could provide their own definition and relate to the term, and understood it as care of the self: 'doing things for yourself' and 'looking after yourself'. They did not recognise selfmanagement as part of their care, but valued therapists as encouraging experts in supporting their recovery after stroke. Physiotherapists commonly understood self-management as a process in which stroke survivors were expected to take an active role in their rehabilitation and manage their recovery and health, with different understandings of self-management among physiotherapists shaped by the context in which they worked. They reported that individual, social and organisational factors enable and hinder self-management after stroke, with individual and organisational barriers particularly evident in the early stages. Conclusions: If self-management support approaches are to be used, further work is required to explore the language and strategies used by professionals to support self-management, and the barriers to supporting self-management at different time points after stroke. [ABSTRACT FROM AUTHOR]