National rollout of Healthy Life Centres in Norway

Municipally-managed Healthy Life Centres staffed by multidisciplinary public health teams were established across Norway to advance local health promotion; government commitment to addressing chronic disease through strengthening health promotion provided a platform for change and fostered widespread scale-up of activities; the Healthy Life Centre concept was invented locally and continues to depend on locally-driven efforts, with municipalities given significant autonomy over activities; a structured approach to the rollout of Healthy Life Centres from the outset (including research, piloting and creation of national guidelines) ensured accountability and systematic evaluation; collaborative partnerships between primary care providers, Centre staff and patients proved integral to successfully running activities.

Effect of care management program structure on implementation: a normalization process theory analysis

Care management in primary care can be effective in helping patients with chronic disease improve their health status, however, primary care practices are often challenged with implementation. Further, there are different ways to structure care management that may make implementation more or less successful. Normalization process theory (NPT) provides a means of understanding how a new complex intervention can become routine (normalized) in practice. In this study, we used NPT to understand how care management structure affected how well care management became routine in practice.

Promoting Policy, Systems, and Environment Change to Prevent Chronic Disease: Lessons Learned From the King County Communities Putting Prevention to Work Initiative.

Initiatives that convene community stakeholders to implement policy, systems, environment, and infrastructure (PSEI) change have become a standard approach for promoting community health. To assess the PSEI changes brought about by the King County, Washington, Communities Putting Prevention to Work initiative and describe how initiative structures and processes contributed to making changes.

User-Centered Design of a Tablet Waiting Room Tool for Complex Patients to Prioritize Discussion Topics for Primary Care Visits.

Complex patients with multiple chronic conditions often face significant challenges communicating and coordinating with their primary care physicians. These challenges are exacerbated by the limited time allotted to primary care visits.

OBJECTIVE:

Our aim was to employ a user-centered design process to create a tablet tool for use by patients for visit discussion prioritization.

METHODS:

We employed user-centered design methods to create a tablet-based waiting room tool that enables complex patients to identify and set discussion topic priorities for their primary care visit. In an iterative design process, we completed one-on-one interviews with 40 patients and their 17 primary care providers, followed by three design sessions with a 12-patient group. We audiorecorded and transcribed all discussions and categorized major themes. In addition, we met with 15 key health communication, education, and technology leaders within our health system to further review the design and plan for broader implementation of the tool ...

Can chronic disease be managed through integrated care cost-effectively? Evidence from a systematic review.

The increase in demand for integrated care models to manage chronic disease is a challenge for the Irish health system, which is traditionally organised around the acute hospital services. Implementing integrated care programmes requires significant investment, and thus, their economic impact requires consideration.

AIMS:This paper updates the previous evidence on the cost-effectiveness of integrated care programmes to support the development of a cost-effective integrated care programme for chronic disease management.

METHODS: A systematic review of economic evaluations of integrated care programmes for chronic diseases (respiratory, cardiovascular, diabetes and musculoskeletal diseases) was performed using methods guided by the principles of conducting systematic reviews. The evidence was combined and summarised using a narrative synthesis. A meta-analysis of the evidence was not performed due to the heterogeneity of interventions and associated outcomes.

RESULTS: Six studies met the inclusion criteria; no study considered an integrated model of care that dealt with more than ...

The Patient Experience of Integrated Care Scale: A Validation Study among Patients with Chronic Conditions Seen in Primary Care.

Valid and comprehensive instruments to measure integrated care are required to capture patient experience and improve quality of patient care. This study aimed to validate the Patient Experience of Integrated Care Scale (PEICS), among patients with chronic conditions seen in primary care.

Personalised care for long-term conditions

 Living with multiple conditions

Mary, aged 76, has diabetes, arthritis, and macular degeneration, and she’s feeling low. She recently lost her husband, Frank, who died after a long period of dementia. She cared for him devotedly for many years, but this occupied most of her time and energy and took a heavy toll on her health and wellbeing.

Mary’s GP reminds her to attend the local diabetes clinic. The specialist nurses are concerned about her test results and urge her to try to eat a healthier diet and take more exercise. Mary nods, but in her heart knows that this advice will be difficult to follow. Her knees are painful, her eyesight is deteriorating, the local shops don’t sell much in the way of healthy food, and she doesn’t feel confident to travel far on her own.

As populations age, increasing numbers of people live with ...

Global COVID-19 Pandemic Response and Impact Grant (Global Co-RIG)

The Besrour Centre for Global Family Medicine (Besrour Centre) at the College of Family Physicians of Canada (CFPC), thanks to the generous support of the CFPC’s Foundation for the Advancement of Family Medicine (FAFM) and the Fondation Docteur Sadok Besrour, is seeking proposals for a Global COVID-19 pandemic innovation response.

The initiative is a response to how the COVID-19 pandemic is disrupting the health and economic well-being of nations. There are more than six million cases, and more than 370,000 deaths, worldwide.

* The response to such a threat must be rapid and effective to minimize the harmful impact of a virus that is highly transmissible and that is affecting the most vulnerable worldwide. The primary care response to COVID-19 must support innovation that targets and protects highly vulnerable populations that lack access to primary care.

The goal of this initiative is to have the greatest impact for reducing ...

Telemonitoring and continuity of care for older subjects: comparing experience an identifying common solutions

The COVID19 pandemic highlighted some structural – organizational and cultural – limitations of our dominant model of (health)care. One of these is the need to identify and adopt newer instruments for the continuity of care for the large number of patients with chronic disease who live in low-density population areas  (200 million or 27% of EU population) and experience inequality to access (health)care because of the distance between community and healthcare structures. Notably, the onset of multimorbidity occurs 10–15 years earlier in people living in the most deprived areas compared with the most a?uent.

The Workshop aims at facilitating knowledge acquisition (including existing Projects and adopted solutions) and at fostering collaboration and standardization of best practice, including health literacy and patients and caregivers empowerment, in order to impact on the adoption of innovative digital solutions able to boost people's health and quality of life and enable more ...

Quantitative evaluation of an outreach case management model of care for urban Aboriginal and Torres Strait Islander adults living with complex chronic disease: a longitudinal study

Chronic diseases are the leading contributor to the excess morbidity and mortality burden experienced by Aboriginal and Torres Strait Islander (hereafter, respectfully, Indigenous) people, compared to their non-Indigenous counterparts. The Home-based Outreach case Management of chronic disease Exploratory (HOME) Study provided person-centred, multidisciplinary care for Indigenous people with chronic disease. This model of care, aligned to Indigenous peoples’ conceptions of health and wellbeing, was integrated within an urban Indigenous primary health care service.

Implementing Mobile Health?Enabled Integrated Care for Complex Chronic Patients: Intervention Effectiveness and Cost-Effectiveness Study

Integrated care can generate health and social care efficiencies through the defragmentation of care and adoption of patient-centered preventive models. eHealth can be a key enabling technology for integrated care.

Pathway-Driven Coordinated Telehealth System for Management of Patients With Single or Multiple Chronic Diseases in China: System Development and Retrospective Study

Integrated care enhanced with information technology has emerged as a means to transform health services to meet the long-term care needs of patients with chronic diseases. However, the feasibility of applying integrated care to the emerging "three-manager" mode in China remains to be explored. Moreover, few studies have attempted to integrate multiple types of chronic diseases into a single system.

A Digital Health Platform for Integrated and Proactive Patient-Centered Multimorbidity Self-management and Care (ProACT):Protocol for an Action Research Proof-of-Concept Trial

Multimorbidity is defined as the presence of two or more chronic diseases and associated comorbidities. There is a need to improve best practices around the provision of well-coordinated, person-centered care for persons with multimorbidities. Present health systems across the European Union (EU) focus on supporting a single-disease framework of care; the primary challenge is to create a patient-centric, integrated care ecosystem to understand and manage multimorbidity. ProACT is a large-scale project funded by the European Commission under the Horizon 2020 programme, that involved the design, development, and evaluation of a digital health platform to improve and advance home-based integrated care, and supported self-management, for older adults (aged ≥65 years) living with multimorbidity.

The European Health Data Space: A step towards digital and integrated care systems

In December 2021, EGIDE, the Expert Group for integrated Care and Digital Health Europe, has launched a paper ‘The European Health Data Space: A step towards digital and integrated care systems’.

The paper aims to represent the views of the chronic disease community. It provides a unique combination of perspectives from academia, healthcare professionals, patients and industry. The authors acknowledge too many patients across Europe are experiencing fragmented and delayed care. COVID-19 has highlighted the weaknesses of our healthcare systems and the need for rapid transformation. The European Health Data Space can act as a catalyst for change in several important areas.

Policy by Pilot? Learning From Demonstration Projects for Integrated Care; Comment on “Integration or Fragmentation of Health Care? Examining Policies and Politics in a Belgian Case Study”

Analysis of policy implementation for chronic disease in Belgium highlights the difficulties of launching experiments for integrated care in a health system with fragmented governance. It also entreats us to consider the inherent challenges of piloting integrated care for chronic disease. Sociomedical characteristics of chronic disease –political, social, and economic aspects of improving outcomes – pose distinct problems for pilot projects, particularly because addressing health inequity requires collaboration across health and social sectors and a long-term, life-course perspective on health. Drawing on recent US experience with demonstration projects for health service delivery reform and on chronic disease research, I discuss constraints of and lessons from pilot projects. The policy learning from pilots lies beyond their technical evaluative yield. Pilot projects can evince political and social challenges to achieving integrated chronic disease care, and can illuminate overlooked perspectives, such as those of community-based organizations (CBOs), thereby potentially extending the terms of policy ...

The Winter Strategy – a Multifaceted Integrated Care Intervention to Support People with Chronic and Complex Care Needs during the Australian Winter Period

Health care demands increase over the winter period, especially for people with chronic diseases. Hospital avoidance programs have potential to address seasonal surges.