Applying Elinor Ostrom’s Design Principles to Guide Co-Design in Health(care) Improvement: A Case Study with Citizens Returning to the Community from Jail in Los Angeles County

Increased interest in collaborative and inclusive approaches to healthcare improvement makes revisiting Elinor Ostrom’s ‘design principles’ for enabling collective management of common pool resources (CPR) in polycentric systems a timely endeavour.

Ostrom proposed a generalisable set of eight core design principles for the efficacy of groups. To consider the utility of Ostrom’s principles for the planning, delivery, and evaluation of future health(care) improvement, the autors retrospectively applied them to a recent co-design project.

Three distinct aspects of co-design were identified through consideration of the principles. These related to: (1) understanding and mapping the system (2) upholding democratic values and (3) regulating participation. Within these aspects, four of Ostrom’s eight principles were inherently observed. Consideration of the remaining four principles could have enhanced the systemic impact of the co-design process.

Reconceptualising co-design through the lens of CPR offers new insights into the successful system-wide application of such ...

Medical and Old-Age Care Integration Model and Implementation of the Integrated Care of Older People (ICOPE) in China: Opportunities and Challenges

The demand for healthy old-age care is growing rapidly in China. The traditional old-age care model can no longer meet elderly patients’ demands for medical care and old-age care. To promote the development of medical care-integrated old-age care, a solution covering multiple aspects is necessary. In the context of the global development of healthy aging, China recently issued many policies to integrate old-age care with medical care, establishing protection for a large number of disabled elderly people. The Integrated Care of Older People (ICOPE) project is an international program developed by the World Health Organization. This paper reviews China’s medical and old-age care integration model and the opportunities and challenges in implementing the ICOPE in the context of healthy aging in China.

Integrated care and outcomes in patients with atrial fibrillation and comorbidities

Integrated care for management of atrial fibrillation (AF) patients has been associated with a reduction in adverse events. The ‘Atrial fibrillation Better Care (ABC) pathway’ has been proposed to streamline such integrated management. In this paper, we analysed the impact of ABC pathway adherent clinical management on outcomes in AF patients with high?risk ‘metabolic’ comorbidities (i.e. diabetes mellitus [DM], chronic kidney disease [CKD], metabolic syndrome [MetS].

Prevalence of non-communicable chronic conditions, multimorbidity and its correlates among older adults in rural Nepal: a cross-sectional study

The population of older adults is increasing globally and is projected to increase to over 1.5 billion by 2050. A similar demographic transition is occurring in Nepal. While we celebrate longevity, health and quality of life are two crucial agendas for the older population. Older adults have a higher prevalence of non-communicable chronic conditions, and with longevity, the likelihood of experiencing more than one non-communicable chronic condition also increases.

This study’s objectives were to estimate the prevalence of major non-communicable conditions and multimorbidity among older adults in rural Nepal and examine the associated socioeconomic and behavioural risk factors.

IFIC Ireland Patient Empowerment Mini-Series with CEmPaC

The World Health Organization (WHO) defines Empowerment for Health as ‘a process through which people gain greater control over decisions and actions affecting their health. Empowerment may be a social, cultural, psychological or political process through which individuals and social groups are able to express their needs, present their concerns, devise strategies for involvement in decision-making, and achieve political, social and cultural action to meet those needs.’

Integrated health Services for Children: a qualitative study of family perspectives

There is increasing evidence that integrated care improves child related quality of life and reduces health service use. However, there is limited evidence on family perspectives about the quality of integrated care for children’s services. This study aimed to understand children, young people, and caregivers’ perceptions of a new integrated care service, and to identify essential components of integrated care for children and young people with ongoing conditions.

Comparison of Integrated Care of the Elderly in Iran with Other Selected Countries, a Comparative Study

The current situation of the population of Iran is such that at present the population has changed from the explosive situation of the child population to the increase of the elderly population. The aim of this study was to compare the integrated care of the elderly in Iran with other selected countries.

How to Ensure Referral and Uptake for COPD Rehabilitation – Part 2: A Case of Integrated Care on How to Translate Findings of Cross- Sectorial Workflow to Improve Cross-Sectorial Rehabilitation

Patients with chronic obstructive pulmonary disease (COPD) can greatly benefit from rehabilitation initiatives, but referral to rehabilitation is sparse. Before we initiated activities to ensure hospital referrals for prevention initiatives at the municipality, we investigated referral patterns and relevant factors in the cross-sectorial workflow.

This study aims to ensure referral to municipality COPD rehabilitation, by simplifying the referral procedures, and by facilitating relational coordination across the two health care settings.

Co-Creating Descriptors and a Definition for Person-Centred Coordinated Health Care: An Action Research Study

The aim of this study was to co-create a definition and generic descriptors for person-centred coordinated care for Ireland generated from service users’ narratives.

An overarching action research approach was used to engage and empower people to tangibly impact health policy and practice. Through focus groups and a qualitative survey, primary data were collected from a national sample of health services users, caregivers and health care service users’ representative groups. Thematic analysis was used to analyse the data. Three major themes were co-produced as essential care elements. These were: ‘My experience of healthcare’, ‘Care that I am confident in’ and ‘My journey through healthcare’. Through an IPPOSI partner project steering group and their membership groups’ contribution, these themes were further refined into a definition of person-centred coordinated care and nineteen related generic descriptors.

Key findings demonstrate that within complex, fragmented healthcare systems, the subjective expectations of service users should be ...

Disrupting health inequity and injustice through partnership

Integrated care for older adults during the COVID-19 pandemic in Belgium: Lessons learned the hard way

The corona pandemic challenges countries worldwide in many different ways. Due to its magnitude and impact on global health, this health crisis exposes several shortcomings in their health systems and emphasizes their shortcomings and deficiencies. These deficiencies have quickly affected the most frail citizens, such as older people. The first wave of the COVID19 pandemic in Belgium has quickly shown that nursing homes were not prepared for these kinds of crises. The nature, speed and extent gave rise to an accelerated and more extensive collaboration between various nursing homes and Ghent University Hospital. Before this crisis, the level of integrated care between nursing homes and hospitals was mostly limited. But setting up a strong collaboration model and integrated care between nursing homes and hospitals enables the nursing homes to manage this specific and complex care in their own environment. IMPLICATIONS FOR PRACTICE: This case study shows that integrated care is ...

Effectiveness of a pathway-driven eHealth-based integrated care model (PEICM) for community-based hypertension management in China: study protocol for a randomized controlled trial

The prevalence of hypertension is high and increasing in China in recent years. The treatment and control of hypertension calls for long-term management beyond hospital, which is hard to implement in traditional care settings. Integrated care combined with information technology can promote high-quality healthcare services across the life-course. However, few studies have applied a customized integrated care model in community-based hypertension management in China, catering to the emerging “three-manager” mode. This study aims to identify the effectiveness of a pathway-driven eHealth-based integrated model that implemented as a full-featured telehealth system to facilitate standardized management of hypertension in China.

What day is today? Cognitive capacity and the risk of incident dementia in the context of integrated care for older people (ICOPE Step 1)

Based on clinical observations, our objective was to test if the older adults who failed to recall the name of the weekday, or had a higher number of mistakes in the word recall were at higher risk of mild cognitive impairment (MCI) or dementia. Longitudinal data of the Multidomain Alzheimer Preventive Trial (MAPT) was used to retrospectively measure the cognitive capacity according to the ICOPE Step 1 tool. Incident dementia was assessed by two multidisciplinary committees independent from each other. MCI was defined as Clinical Dementia Rating scale CDR = 0.5. Failure to recall the name of the weekday had a three-fold risk of incident dementia in the next 5 years (HRa = 3.11, 95%CI: 1.18-8.17). Having two or three mistakes in the word recall carried a higher risk of incident dementia, (HRa for two mistakes = 3.50, 95% CI: 1.49-8.26; HRa for three mistakes ...

Integrated Care in Europe: Keys, Challenges and Best Practices

OPEN ARCH integrated care model: experiences of older Australians and their carers

There is worldwide recognition of the need to redesign health service delivery with a focus on strengthening primary health care and aligning health and social care through integrated models. A defining feature of integrated models is improved patient and carer experience of care. This study explored the experiences of older people and their carers enrolled in a unique model of integrated care that provides a specialist geriatric intervention in the primary care setting for older adults with complex needs in Far North Queensland. A qualitative exploratory descriptive design using semistructured interviews was used to address the study aims. Seventeen older people and nine carers took part in the study. Data were analysed inductively, guided by the principles of thematic analysis. Three themes emerged: getting by; achieving positive change; and improving and maintaining the OPEN ARCH (Older Persons ENablement And Rehabilitation for Complex Health conditions) approach. The findings indicate that enablement ...

ARIA 2019: An Integrated Care Pathway for Allergic Rhinitis in Portugal

The Allergic Rhinitis and Its Impact on Asthma (ARIA) initiative started more than 20 years ago and has developed and disseminated evidence-based guidelines and projects in the field of allergic rhinitis. This initiative is currently focused on providing patient-centred guidelines that contribute to an integrated care pathway between the various levels of care and take advantage of digital solutions, and the introduction of integrated care pathways in clinical practice has been recommended. In this article we describe the adaptation for Portugal of the ARIA Integrated Care Pathways document. After a brief review of the epidemiology and impact of allergic rhinitis in Portugal and the activities carried out in Portugal within the ARIA initiative, we describe the broad knowledge base used for the development of recommendations for the pharmacological treatment of allergic rhinitis, and these recommendations are based on the GRADE methodology, real world evidence acquired by mobile technology (mHealth) and ...

Patient Experiences of Integrated Care in Medicare Accountable Care Organizations and Medicare Advantage Versus Traditional Fee-for-Service

Health insurance design can influence the extent to which clinical care is well-coordinated. Through alternative payment models, Medicare Advantage (MA) and Accountable Care Organizations (ACOs) have the potential to improve integration relative to traditional fee-for-service (FFS) Medicare.

The Affordable Care Act: policy predictors of integrated care between Hispanic-serving and mainstream mental health organizations

The Patient Protection and Affordable Care Act increased funding for integrated care to improve access to quality health care among underserved populations. There is evidence that integrated care decreases inequities in access and quality of mental health care among Hispanic clients. Increasing integrated care at Hispanic-Serving Organizations may help to eliminate mental health service disparities among Hispanic clients.

Bridging the Gap: A Mixed Methods Study Investigating Caregiver Integration for People with Geriatric Syndrome

Transitions of care between acute hospital and community settings are points of vulnerability for people with geriatric syndrome. Routinely including informal caregivers into the transition processes may mitigate risk. Guidance for operational aspects of caregiver inclusion is currently lacking in healthcare policy and fails to address the barriers faced by caregivers and healthcare professionals.

This pilot mixed method study adopts an implementation science lens to “bridge the gap” between top-down policy recommendations and the realities experienced by healthcare professionals who provide transitional care. It explores how informal caregiver integration can be better achieved. In the past, caregiver integration literature has focused the role of nurses and case managers in this role. However, in true person-centred integrated care, discharge planning and caregiver inclusion is the responsibility of every healthcare professional. This study conducted a pilot to explore these concepts and challenges in physiotherapists at a private hospital in New South Wales ...

Implementing Integrated Care in Practice – Learning from MDTs Driving the Integrated Care Programme for Older Persons in Ireland

The importance of multidisciplinary teams (MDTs) as critical implementation drivers emerged from this case study conducted with three pioneer sites implementing integrated care for older persons in Ireland as part of the Integrated Care Programme for Older Persons (ICPOP).

The study describes the practices of MDTs learning to deliver integrated care in service delivery settings, including the framework, resourcing, strategies, challenges and barriers they encounter.

Nursing Care Coordination for Patients with Complex Needs in Primary Healthcare: A Scoping Review

Millions of people worldwide have complex health and social care needs. Care coordination for these patients is a core dimension of integrated care and a key responsibility for primary healthcare. Registered nurses play a substantial role in care coordination.

This review draws on previous theoretical work and provides a synthesis of care coordination interventions as operationalized by nurses for complex patient populations in primary healthcare.

Service Delivery Reforms for Asian Ageing Societies: A Cross-Country Study Between Japan, South Korea, China, Thailand, Indonesia, and the Philippines

Japan’s health policies to address the most advanced-aged society have been the target of focus in Asia, but no studies have investigated this issue using tools for cross-country comparisons.

A cross-country study design was used to compare healthcare reform policies with a framework in Japan, Korea, Thailand, China, Indonesia, and the Philippines. Data were collected via document reviews and key informant interviews.

Three distinctions were identified. First, all countries except for the Philippines have policy decisions regarding reforms for the existing service delivery systems for healthcare, long-term care and welfare. Second, the most extensive service delivery reform is currently being implemented in Japan, whose system is shifting to primary health care. Third, the direction of the transformation of service delivery system is different between Thailand and China despite a similar level of ageing society. China has made progress on facility-based care integration between health and social care, whereas Thailand ...

Transitional Care Experiences of Patients with Hip Fracture Across Different Health Care Settings

Transitions of care often result in fragmented care, leading to unmet patient needs and poor satisfaction with care, especially in patients with multiple chronic conditions.

This project aimed to understand how experiences of patients with hip fracture, caregivers, and healthcare providers differ across different points of transition.

An Integrated Care Strategy for Pre-schoolers with Suspected Developmental Disorders: The Optimus Co-design Project that has Made it to Regular Care

Clustering Complex Chronic Patients: A Cross-Sectional Community Study From the General Practitioner’s Perspective

A Validation Study of the Rainbow Model of Integrated Care- Measurement Tool for Patients in China

The original Rainbow Model of Integrated Care Measurement Tool (RMIC-MT) is based on the Rainbow Model of Integrated Care (RMIC), which provides a comprehensive theoretical framework for integrated care. The aim of this paper is to modify the original patient version of the RMIC-MT for the Chinese primary care context and validate its psychometric properties.

The primary care behavioral health model (PCBH) and medication for opioid use disorder (MOUD): integrated models for primary care

Recent decades have witnessed increases in (a) integrated physical and behavioral health services and (b) the treatment of opioid use disorders (OUD) in primary care settings – also known as office-based opioid treatments (OBOT) – using a combination of medication and psychosocial support. Providing these services requires a workforce trained to address addiction’s psychosocial components and interventions addressing addiction’s biological and neurological mechanisms. This paper examines the implementation factors, clinic workflow and roles, and administrative considerations of two models of integrated care in order to identify ways of increasing treatment capacity and expanding OUD treatment uptake in integrated primary care settings.

Barriers and Facilitators in the Uptake of Integrated Care Pathways for Older Patients by Healthcare Professionals: A Qualitative Analysis of the French National “Health Pathway of Seniors for Preserved Autonomy” Pilot Program

Integrated care is a particularly promising approach in geriatrics – a field in which the medical, psychological and social issues are often complex. The uptake of integrated care by healthcare professionals is essential but varies markedly.

The objective of the present study of healthcare professionals was to identify barriers to and facilitators of commitment to integrated care for seniors.

New Zealand’s Integration-Based Policy for Driving Local Health System Improvement – Which Conditions Underpin More Successful Implementation?

The System Level Framework (SLMF) is a policy introduced by New Zealand’s Ministry of Health in 2016 with the aim of improving health outcomes by stimulating inter-organisational integration at the local level.

This study aimed to understand which conditions that vary at the local level are most important in shaping successful implementation of this novel and internationally significant policy initiative relevant to integrated care.

A Contextual Analysis and Logic Model for Integrated Care for Frail Older Adults Living at Home: The INSPIRE Project

Implementation science methods and a theory-driven approach can enhance the understanding of whether, how, and why integrated care for frail older adults is successful in practice.

This study aimed to perform a contextual analysis, develop a logic model, and select preliminary implementation strategies for an integrated care model in newly created information and advice centers for older adults in Canton Basel-Landschaft, Switzerland.

The overall INSPIRE project aims to develop, implement and evaluate an integrated care model for the information and advice centers. This paper specifically addresses the development phase of INSPIRE and aims to:

• Determine the contextual factors which may influence the INSPIRE integrated care model for the IACs and implementation strategies by collecting information through various sources
• Develop a logic model to display the overall theory for the INSPIRE care model, including inputs, activities, outputs, anticipated outcomes and assumptions
• Propose preliminary implementation strategies for the INSPIRE care model

General Practitioners and Community Pharmacists’ Collaboration in Primary Care: Small Steps for a Major Change

Healthcare authorities worldwide search for ways to develop integrated care and interprofessional collaboration. In Belgium, Medical-Pharmaceutical Concertation (MPC) was introduced as a format to promote constructive dialogues between GPs and community pharmacists (CPs) with a focus on pharmacotherapy.

This study aimed to evaluate the implementation of MPC from the perspective of healthcare authorities and GPs/CPs.

Behavioral interventions in acute COVID-19 recovery: A new opportunity for integrated care

New York City was the epicenter of the 2019 coronavirus disease (COVID-19) pandemic. Critically ill patients surviving prolonged ventilation, medical complications, and protracted delirium are profoundly debilitated. In response, our hospital temporarily created a novel, hybrid inpatient medicine-rehabilitation unit for COVID-19 survivors. Patients are medically monitored and work towards rehabilitation goals with daily physical and occupational therapy (PT/OT). To our knowledge, it is the only such unit in our region. Here, we describe how neuropsychology and consultation-liaison psychiatry have collaborated to implement interventions within this unit to facilitate patients' recovery.

A journey towards integrated person-centred care: a case study of a mental health perspective in the voluntary sector

Implementing patient-centred integrated care for multiple chronic conditions Evidence-informed framework

Fifteen years ago, the term multimorbidity rarely appeared in chronic disease health care policies. Today, research has revealed very high rates of multimorbidity, leading to it being labeled the number one challenge in developed countries. Paradoxically, chronic disease prevention and management (CDPM) programs of integrated care have popped up in all health care systems but they mainly follow a single-disease approach in their interventions. In this article, we define CDPM programs broadly as any interventions intended to improve care for patients with chronic diseases and risk factors; these are added to usual care and are typically delivered by a team.

22nd International Conference on Integrated Care. ICIC22 Odense, Denmark – May 23-25 2022

Impact of Integrated Care on the Rate of Hospitalization for Ambulatory Care Sensitive Conditions among Older Adults in Stockholm County: An Interrupted Time Series Analysis

Reducing avoidable hospital admissions is often viewed as a possible positive consequence of introducing integrated care (IC). The aim of this study was to investigate the impact of implementing IC in Norrtälje on the rate of admissions for ambulatory care sensitive conditions (ACSC).

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.

An Analysis of the Sustainability of a Collaborative Care Program Used to Deliver Integrated Mental Health Care Within a Micronesian Island State

Adequate access to mental health care is a global problem, including in the Federated States of Micronesia (FSM). The Collaborative Care Model (CoCM) offers an opportunity to deliver improved access to mental health services in primary care centers, and key factors to program sustainability have been investigated in high-income country settings. This study's objective was to evaluate how well factors associated with sustainability have been incorporated into a CoCM in Kosrae, Federated States of Micronesia. The Kosraean CoCM's strengths included its supportive leadership, team member training, and having a strong care manager and engaged primary care provider champion. Opportunities for growth included further development of its financial viability, information technology systems, change readiness, and operational procedures. Our program found that having a stable and invested staff and leveraging its current strengths were important to its viability. In an international partnership, it is also critical to develop strong relationships ...

Evaluation is Key: Providing Appropriate Evaluation Measures for Participatory and User-Centred Design Processes of Healthcare IT

The increasing availability of healthcare IT has the potential to improve the integration of health services. Existing projects developing healthcare IT mostly disregard the potential and importance of incorporating user feedback and proper evaluation measures to gain user feedback throughout the development process.

This article aims to provide methodological guidance for evaluation in a stepwise user-centred design process.

The Contribution of Case Mix, Skill Mix and Care Processes to the Outcomes of Community Hospitals: A Population-Based Observational Study

Community hospitals could address the emerging complex care needs of patients. The authors investigated which characteristics of patients and community hospitals affect patient outcomes, in order to identify who could benefit the most from community hospital care and the best skill mix to deliver this care.

Collective Impact Approaches to Promoting Community Health and Wellbeing in a Regional Township: Learnings for Integrated Care

This Perspective Paper explores the challenges of implementing local initiatives guided by the tenets of the Collective Impact (CI) approach. As such, it draws implications of CI for integrated health and social care efforts to improve and sustain health and social outcomes within a community-wide context, based on our efforts to deploy a CI intervention in the regional town of Muswellbrook, New South Wales (NSW) Australia.

A program of health and wellbeing activities providing mental health and wellness messages and activities was implemented in the township over 2 years by the Family Action Centre (FAC), University of Newcastle, Australia. A key takeaway was the importance of authentic community engagement and active involvement as opposed to mere consultation.

A Cross-European Study of Informal Carers’ Needs in the Context of Caring for Older People, and their Experiences with Professionals Working in Integrated Care Settings

Informal carers are increasingly relied on for support by older people and the health and social care systems that serve them. It is therefore important that health and social care professionals are knowledgeable about and responsive to informal carers’ needs.

This study explores informal carers’ own needs within the context of caregiving; and examines, from the informal carers’ perspective, the extent to which professionals assess, understand and are responsive to informal carers’ needs.

Realising Integrated Care

IFIC Ireland hosts and facilitates a series of six webinars titled ‘Realising Integrated Care’ which forms one of the key delivery mechanisms enabling knowledge mobilisation across all stakeholders with an interest in developing and implementing integrated care within the healthcare systems on the island of Ireland. 

Measuring Older Peoples’ Experiences of Person-Centred Coordinated Care: Experience and Methodological Reflections from Applying a Patient Reported Experience Measure in SUSTAIN

While several evaluation studies on (cost-)effectiveness of integrated care have been conducted in recent years, more insight is deemed necessary into integrated care from the perspective of service users.

In the context of a European project on integrated care for older people living at home (SUSTAIN), this paper shares the experience and methodological reflections from applying a Patient Reported Experience Measure (PREM) on person-centred coordinated care -the P3CEQ- among this population.

Reform For People: A Joint Vision For Integrating Care

Many of us will be watching closely as the NHS Bill begins its journey through Parliament and will be seeking to ensure that it meets the needs of the people we support. However, while the Bill represents an exciting opportunity, previous NHS reforms have taught us that legislation alone is not enough to improve people’s health and lives. For these reforms to be a success, and make a real difference to people and communities, we need to go further. We need to improve cultures, change behaviours, and capture hearts and minds.

National Voices, Age UK, the Richmond Group of Charities, and the King’s Fund have joined together, with input from a range of health sector partners, to produce a shared vision of what new reforms could achieve. This joint vision, ‘Reform for people’ aims to lay out a shared ambition of what integrated care and improved ways of ...

Measurement-based care in integrated health care: A randomized clinical trial

Many suggest that the next step for integrated care is widespread implementation of measurement-based care (MBC). Although the measures most associated with MBC are standardized, no randomized clinical trial has demonstrated their use to improve psychotherapeutic outcomes with embedded behavioral health providers in integrated care. Two evidence-based MBC systems have been studied in a variety of behavioral health environments, but neither system has been investigated in integrated health care. Addressing this gap in the literature, the present study evaluated the use of MBC, specifically the Partners for Change Outcome Management System, in three integrated care sites.

Integrated Care in Europe: Time to Get it Together?

Integrated care: easy in theory, harder in practice?

Integrated care (IC) is a term now commonly adopted across the world, which implies a positive attitude towards addressing fragmentation of service provision inside health systems. While the principles of IC are simple, their implementation is more controversial. The ever growing number of IC definitions is related to the increasing domains of applications, which reflect the increasing demand induced by ageing multi-morbid patients. An exhaustive definition of IC should now enclose the coordination of health and social services useful to deliver seamless care across organizational boundaries. The current debate on IC is largely fueled by the modern mismatch between the growing burden of health needs for chronic conditions from the demand side and the design of health systems still largely centered on acute care from the supply side. The major reasons of persisting IC weakness in Western European nations stem from arguable choices of health policy taken in a quite ...

Diverse clinical and social circumstances: developing patient-centred care for DR-TB patients in South Africa

To describe the medical, socio-economic and geographical profiles of patients with rifampicin-resistant TB (RR-TB) and the implications for the provision of patient-centred care.

RR-TB patients had diverse medical and social challenges highlighting the need for integrated, differentiated and patient-centred healthcare to better address specific needs and underlying vulnerabilities of individual patients.

Social work student reflections on training in integrated care: opportunities for social work educators

Integrated care, an approach designed to improve health/ behavioral health outcomes and increase quality of life, has received international interest. Given the important roles social workers play in this approach, American universities have begun novel training programs to better prepare social workers to work in integrated care. The aim of this study is to better understand the experiences of recent MSW trainees, and how they can inform future educational/ training programs. Focus groups of MSW students who recently completed integrated care training programs were conducted (N = 9). Content analysis of the focus group data resulted in three main themes: Gaps in Knowledge about Integrated Care, Developing Professional Identity on a Team, and Adaptation of Core Social Work Skills. Student feedback aligns with current literature, highlighting variability among placements, need for additional training resources, and value of social workers on interprofessional teams. There were also unique findings, include challenges and rewards ...

Let's Get Real: Patient Partnership to Advance Integrated Care

Integrated Care is about bringing together a collaboration of organizations and their staff to coordinate services around patients in order to improve health and well-being outcomes and overall satisfaction with services. Integration is context driven; it requires shared vision, trusting relationships, resources and alignment across health and social service ecosystems.

This webinar will bring together patient partners and health leaders who attended the first-ever North American Conference on Integrated Care and are advancing integrated people-centred health systems (#NACIC2021).

Join this patient and family advisor-led panel to learn:

1. Insights from the recent NACIC conference: what worked, how to continue to spark engagement

2. The importance of building trust and creating safer spaces-examples that worked from your experience, and

3. How patient and family advisors can partner to advance integrated care systems.

Intrinsic Capacity predicts adverse outcomes using Integrated Care for Older People screening tool in a senior community in Beijing

The World Health Organization (WHO) introduced the concept of intrinsic capacity in order to create a multidimensional model to maintain individual's functional ability. Intrinsic capacity is the composite of all the physical and mental capacities that an individual can draw on at any point in time, and represents the amount of resources one can tap into during his life(WHO, 2015). By interacting with the surrounding environment, intrinsic capacity determines functional ability largely. Considering and organizing the retrieved evidence, five domains are proposed to define the intrinsic capacity: cognition, locomotion, vitality, sensory, and psychosocial, each of which is composed of subdomains(Cesari et al., 2018). In 2017, the WHO published Integrated Care for Older People (ICOPE): Guidelines on community-level interventions to manage declines in intrinsic capacity, and highlighted the importance of focusing on intrinsic capacity to establish effective interventions(WHO, 2017). In 2019, Guidance for person-centered assessment and pathways ...

Between Social Inclusion and Exclusion: Integration of Daycare Guests in the Nursing Home Setting

In integrated daycare, community-dwelling older people in need of care join existing groups in residential care facilities during the day. This study focuses on how nursing home residents experience the integrative care approach, exploring opportunities for social inclusion and mechanisms of exclusion.

Integrated Care’s New Protagonist: The Expanding Role of Digital Health

Digital health technologies hold significant promise to advance both functional and normative health and social care integration. The COVID-19 pandemic has created a window of opportunity to rapidly advance the adoption of digital solutions which can improve activities that support integration at clinical, professional, organizational and system levels. Global examples demonstrate how the pandemic has also created opportunities to use technology to address core values of integrated care like person-centredness and coordination. However, rapid and reactive changes could lead to increased fragmentation and exacerbate health inequity. This perspective paper outlines some of the opportunities and threats to advancing integrated care presented by the rapid adoption of digital health tools, suggesting we maintain a long view to ensure the stage we set today will mean greater integration tomorrow.

Balancing Pragmatism and Sustainability: A Case Study of an Interorganisational Network to Improve Integrated Care for the Elderly

Networks constitute a promising strategy for interorganisational collaboration, but may fail due to network tensions. By investigating the activities and internal dynamics of a voluntary meso-level network operating in the intersection of health and social care, this study aims to enhance the understanding of the relationship between pragmatism and sustainability and the role network governance plays in this respect.

Treatment outcomes among adults with HIV/non-communicable disease multimorbidity attending integrated care clubs in Cape Town, South Africa

The growing burden of the HIV and non-communicable disease (NCD) syndemic in Sub- Saharan Africa has necessitated introduction of integrated models of care in order to leverage existing HIV care infrastructure for NCDs.

Teamwork: A Multidisciplinary Review

Promoting integrated care initiatives is an important approach to addressing growing gaps in access to mental health. This article presents a multidisciplinary review of essential team elements and how to optimize team performance. Fostering a collaborative team approach can produce more effective and efficient mental health ca

Co-designing an Integrated Care Network With People Living With Parkinson's Disease: From Patients' Narratives to Trajectory Analysis

An integrated care model for people living with Parkinson's disease (PD) offers the promise of meeting complex care needs in a person-centered way that addresses fragmentation and improves quality of life. The purpose of our research was to co-design a care delivery model that supports both social and medical care from the perspective of patients and care partners. In the first step of our co-design approach, participants from five countries were invited to share their experiences of living with PD during a narrative interview. A qualitative analysis of these narrative interviews based on the Corbin and Strauss model was done to map out patients' trajectories. Three typical trajectories were identified: (a) the "unpredictable" trajectory, (b) the "situated" trajectory, and (c) the "demanding" trajectory. Based on the analysis of these trajectories, we were able to integrate various patient experiences into the design of an integrated care network.

Integrated Care in England – what can we Learn from a Decade of National Pilot Programmes?

For more than a decade the English NHS has pursued integrated care through three national pilot programmes. The three pilot programmes shared the aim of better coordination between hospital and community-based health services and between health and social care. Each programme recruited local pilot sites that designed specific interventions to support inter-professional and inter-organisational collaboration.

Integrated Health and Social Care in England: Ten Years On

As part of major policy reforms begun in 2010, England introduced a wave of initiatives to encourage more integrated care between health and social care. These built on previous attempts which sought to achieve similar objectives through a focus on better partnership working. This article provides an overview and critical commentary on integrated care policy in England from 2010–2020. The experience of England suggests that greatest progress is made when integrated care focusses on tangible issues and when there is a clear understanding of how success will be measured. 

The Advantages and Disadvantages of Integrated Care Implementation in Central and Eastern Europe – Perspective from 9 CEE Countries

Health and social care systems in Central and Eastern European (CEE) countries have undergone significant changes and are currently dealing with serious problems of system disintegration, coordination and a lack of control over the market environment. The increased health needs related to the ageing society and epidemiological patterns in these countries also require funding needs to increase, rationing to be reformed, sectors to be integrated (the managed care approach), and an analytical information base to be developed if supervision of new technological approaches is to improve. 

Designing a person-centred integrated care programme for people with complex chronic conditions: a case study from Catalonia

The prevalence of people with complex chronic conditions is increasing. This population’s high social and health needs require person-centred integrated approaches to care. We developed an evidence-based integrated care programme tailored to high-need patients combining input from patients, caregivers, and healthcare and social care professionals. Patients’ and caregivers’ main priorities were to ensure (a) comprehension of information provided by healthcare professionals; (b) coordination between patients, caregivers, and professionals; (c) access to social services; (d) support to caregivers in managing situations; (e) perceived support throughout the healthcare process; (f) home care, when available; and (d) a patient-centred approach

Workforce Development in Integrated Care: A Scoping Review

Integrated care aims to improve access, quality and continuity of services for ageing populations and people experiencing chronic conditions. However, the health and social care workforce is ill equipped to address complex patient care needs due to working and training in silos. This paper describes the extent and nature of the evidence on workforce development in integrated care to inform future research, policy and practice.

What does Success Look Like for Leaders of Integrated Health and Social Care Systems? a Realist Review

Health and social care services in England are moving towards greater integration, yet little is known about how leadership of integrated care teams and systems can be supported and improved. This realist review explores what works about the leadership of integrated care teams and systems, for whom, in what circumstances and why. This review has generated new perspectives on the leadership of integrated care teams and systems that can be built upon, developed, and tested further.

Older Adults’ Demand for Integrated Care and Its Influencing Factors: A Scoping Review

Integration has become a major concern for governments, healthcare and aged care systems in many countries. However, the research on and implementation of integrated care in China started relatively late, and there is no review on the needs of older adults with regard to integrated care and the influencing factors. Therefore, this paper aims to provide a scoping review by searching, evaluating, and summarizing the Chinese and international literature on the need for and the factors influencing integrated care for older people. In addition, this review highlights evidence of the gap between China and the world in integrated care.

Care Integration in Primary Dementia Care Networks: A Longitudinal Mixed-Methods Study

Currently, care integration for community-dwelling persons with dementia is poor and knowledge on how to effectively facilitate development of integrated dementia care is lacking. The DementiaNet program aims to overcome this with a focus on interprofessional collaboration. The DementiaNet approach enables a transition towards more mature networks. Identified success factors provide better understanding of how network maturity can be achieved and gives guidance to future care integration strategies.

UN Decade of Healthy Ageing – The Platform

The United Nations has proclaimed 2021–2030 the Decade of Healthy Ageing, with WHO leading international action to improve the lives of older people, their families and communities. The UN Decade of Healthy Ageing is a global collaboration that brings together diverse sectors and stakeholders including governments, civil society, international organizations, professionals, academic institutions, the media and the private sector to improve the lives of older people, their families and communities. The collaboration focuses on four action areas that are strongly interconnected:

Area 1. Combatting Ageism: changing how we think, feel and act towards age and ageing;

Area 2. Age-friendly Environments: developing communities in ways that foster the abilities of older people;

Area 3. Integrated Care: delivering person centred integrated care and primary health services responsive to older people; and

Area 4. Log-term Care: providing older people who need it with access to long-term care. To make the Decade of ...

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.

1st All-Ireland Conference on Integrated Care “Transforming Health and Social Care across Ireland: Delivering Lifelong People-centred Care”

IFIC Ireland in association with the International Foundation for Integrated Care (IFIC) presents “Transforming Health and Social Care across Ireland: Delivering Lifelong People-centred Care” on Thursday, 10 March 2022 in O’Reilly Hall University College Dublin. 

The forum is attended by up to 300 delegates from across the island of Ireland and includes Health and Social Care Services Mangers, Clinicians and System leads, Academics leading in the field of integrated care, and a wide range of not for profit patient representative organisations and private sector providers of care services. 

A number of policy frameworks have recently been developed to support the movement towards a more coordinated and holistic approach to improving population across the island of Ireland. The?Sla?intecare?report, a ten-year strategy for health care and health policy in Ireland, emphasises the importance of integrated care and shifting care out of hospitals and into the primary and community ...

Integrated People-Centred Care in Canada – Policies, Standards, and Implementation Tools to Improve Outcomes

Despite the national and international policy commitment to implement integrated health systems, there is an absence of national standards that support evidence-based design, implementation, and monitoring for improvement. This manuscript outlines the policy context and the process taken to develop the IPCHS standard. Implementing integration strategies requires that we create and sustain a culture of continuous improvement and learning.

WONCA Europe Conference: Innovating Family Medicine Together for a Sustainable Future

WONCA Europe 2022 Conference takes place from 28 June to 1 July 2022 and will be held conjointly with RCGP (Royal College of General Practitioners) 2022 Annual Conference as one event.

Registration, programme and further information

Integrated healthcare services for HIV, diabetes mellitus and hypertension in selected health facilities in Kampala and Wakiso districts, Uganda: A qualitative methods study

Abstract

The Leadership of Co-Production in Health and Social Care Integration in Scotland: A Qualitative Study

The involvement of citizens in the production and creation of public services has become a central tenet for administrations internationally. In Scotland, co-production has underpinned the integration of health and social care via the Public Bodies (Joint Working) (Scotland) Act 2014. We report on a qualitative study that examined the experiences and perspectives of local and national leaders in Scotland on undertaking and sustaining co-production in public services. By adopting a meso and macro perspective, we interviewed senior planning officers from eight health and social care partnership areas in Scotland and key actors in national agencies. The findings suggest that an overly complex Scottish governance landscape undermines the sustainability of co-production efforts. As part of a COVID-19 recovery, both the implementation of meaningful co-production and coordinated leadership for health and social care in Scotland need to be addressed, as should the development of evaluation capacities of those working across health ...

Integrated Care in Aotearoa New Zealand 2008–2020

Ten years ago, progress towards integrated care in Aotearoa New Zealand was characterised as slow. Since then, there has been a patchwork of practices occurring under the broad umbrella of integrated care. These include: collective planning approaches (i.e., alliancing), agreed pathways of care, chronic care management initiatives, shared patient information systems, co-located centres and indigenous models of holistic care (e.g., Whanau Ora).

What Makes Integration of Chronic Care so Difficult? A Macro-Level Analysis of Barriers and Facilitators in Belgium

Although many countries have been implementing integrated care, the scale-up remains difficult. Macro-level system barriers play an important role. By selecting three key policies, which have implemented integrated care in Belgium over the last 10 years, we aim to go beyond the identification of their specific barriers and facilitators to obtain an overarching generic view.

Integrated care in practice: ensuring systems deliver for people, places and populations

This virtual conference will explore the vision and journey of established integrated care systems (ICSs) and consider how place-based partnerships, newly established relationships and system leadership can deliver a step change in health and wellbeing outcomes in population health.

Online Learning: Certificate in Integrated Care

The Certificate in Integrated Care has been designed using IFIC’s 9 Pillars of Integrated Care as a module based course of online learning. The accessible, high quality programme is offered through our digital, innovative and dynamic online learning platform. This comprehensive introductory level self-managed Certificate in Integrated Care accredited by CPD Standards UK delivered 100% online and in the comfort of your own home.

The course is based on The 9 Pillars of Integrated Care with the 5 modules as follows:

Integrated Care for Multimorbidity Population in Asian Countries: A Scoping Review

The complex needs of patients with multiple chronic diseases call for integrated care (IC). This scoping review examines several published Asian IC programmes and their relevant components and elements in managing multimorbidity patients. In the IC programmes for patients with multimorbidity in Asia, service delivery, leadership, and workforce were most frequently mentioned, while the financing component was least mentioned.

Integrated care in Western Europe: a wise solution for the future?

Integrated care (IC) is a term commonly adopted across the world underpinning a positive attitude against fragmentation of healthcare service provision. While the principles supporting IC are simple, their implementation is more controversial.

Factors Impacting Primary Care Engagement in a New Approach to Integrating Care in Ontario, Canada

In 2019, Ontario’s Ministry of Health (the Ministry) introduced Ontario Health Teams to provide population-based integrated healthcare. Primary care was foundational to this approach. This study sought to identify factors that impacted primary care engagement during Ontario Health Teams formation from different perspectives.

The Care Coordinator’s Tasks During the Implementation of an Integrated Care Pathway for Older Patients: A Qualitative Study Based on the French National “Health Pathway of Seniors for Preserved Autonomy” Pilot Program

Although integrated care and care coordination are known to be beneficial for older adults’ population, the specific tasks of a Care Coordinator (CC) for integrated care pathways for this population have not been studied in detail. In this study, the CC’s tasks in an integrated care pathway for older adults shows that the CC’s overall workload was greater than expected and appreciated by healthcare professionals.

Oral health-related interdisciplinary practices among healthcare professionals in Saudi Arabia: Does integrated care exist?

There is a bidirectional relation between oral and general health, therefore collaboration between healthcare providers is needed. This study investigated current interdisciplinary practices and the associated factors among healthcare professionals in Saudi Arabia.

Development of a Blueprint for Integrated Care for Vulnerable Pregnant Women

There has been increasing awareness of perinatal health and organisation of maternal and child health care in the Netherlands as a result of poor perinatal outcomes. Vulnerable women have a higher risk of these poor perinatal outcomes and also have a higher chance of receiving less adequate care. Therefore, within a consortium, embracing 100 organisations among professionals, educators, researchers, and policymakers, a joint aim was defined to support maternal and child health care professionals and social care professionals in providing adequate, integrated care for vulnerable pregnant women.

Evaluation of the North West London Diabetes Foot Care Transformation Project: A Mixed-Methods Evaluation

Diabetes foot ulceration presents an enormous burden to those living with diabetes and to the local health systems and economies. There is an increasing interest in implementing integrated care models to enhance the quality of care for people living with diabetes and related complications and the value of co-production approaches to achieve sustainable change.

This paper aims to describe the evaluation methodology for the North West London Diabetes Foot Care Transformation project.

Integrated care systems need to be different - but how exactly?

ICSs are intended to be a fundamental departure from previous NHS structures with a different type of leadership based on partnership, in which local partner organisations hold collective responsibility for resource use and outcomes. However, as ICSs take on statutory responsibilities for the first time later this year (assuming the Heath and Care Bill gains parliamentary approval) there is a risk of recreating established ways of working within the new structures. To live up to their promise, what are the things that should be ‘different’ about ICSs?

First, the concept of equal partnership between the NHS, local government, voluntary sector and others needs to be at the core of how these reforms are implemented. ICSs started their lives as informal partnerships operating through soft power and influence. The Health and Care Bill changes this by putting ICSs on a statutory footing, but partnership-working and collective responsibility need to remain at ...

IFIC Scotland Integrated Care Matters: Webinar Series 6

IFIC Scotland and partners have launched series 6 of IFIC Integrated Care Matters webinars. The series kicked off with some webinars led by IFICs SIGs then begin to explore how we can work together to promote health and wellbeing, inclusion and participation in communities. This builds on IFIC`s plenary session at ICIC21 – you can view that session here.

Guest panelists from different systems will share insights and challenge us to create age friendly, compassionate, healthy communities that leave no one behind. Each webinar is accompanied by a topic resource with links to further information. All who register will receive links to the recordings and topic resources. 
 

Paediatric integrated care in the primary care setting: A scoping review of populations served, models used and outcomes measured

Paediatric integrated care (PIC), which involves primary care and behavioural health clinicians working together with patients and families, has been promoted as a best practice in the provision of care. In this context, behavioural health includes behavioural elements in the care of mental health and substance abuse conditions, chronic illness and physical symptoms associated with stress, and addressing health behaviours. Models of and contexts in which PIC has been applied vary, as do the outcomes and measures used to determine its value. Thus, this study seeks to better understand (1) what paediatric subpopulations are receiving integrated care, (2) which models of PIC are being studied, (3) what PIC outcomes are being explored and what measures and strategies are being used to assess those outcomes, and (4) whether the various models are resulting in positive outcomes. These questions have significant policy and clinical implications, given current national- and state-level efforts aimed ...

Models of integrated care for older people with frailty: a horizon scanning review

Frailty, a multifaceted geriatric condition, is an emerging global health problem. Integrated care models designed to meet the complex needs of the older people with frailty are required. Early identification of innovative models may inform policymakers and other stakeholders of service delivery alternatives they can introduce and locally adapt so as to tackle system fragmentation and lack of coordination. This study used horizon scanning methodologies to systematically search for, prioritise and assess new integrated care models for older people with frailty and investigated experts’ views on barriers and facilitators to the adoption of horizon scanning in health services research.

Heterogeneity in preferences for outcomes of integrated care for persons with multiple chronic diseases: a latent class analysis of a discrete choice experiment

For an integrated care programme to be successful, preferences of the stakeholders involved should be aligned. The aim of this study is to investigate to which extent outcomes beyond health are valued and to study the heterogeneity of preferences of those involved in integrated care.

Enhancing inter-organisational partnerships in integrated care models for older adults: a multiple case study

The purpose of this paper was to develop deeper insights into the practices enacted by entrepreneurial healthcare managers to enhance the implementation of a partnership logic in integrated care models for older adults.

Putting the ‘I’ Back into Integrated Care

Charlotte Augst, CEO of National Voices, reflects on progress with integrated care since the charity co-produced the I statements with people with lived experience of health and social care services.

Summer School Population Health Management 2022 (online)

Are you interested in a more proactive approach in health care? Do you want a key role in a more integrated health care system? Then this Summer School is a good introduction. It offers a thorough overview of the various components in Population Health Management.

An ageing population, epidemiological challenges, rising healthcare costs, and technical developments in the medical sector are some of the topics that will be covered during the 5 day Summer School (from 4 until 8 July 2022) on Population Health Management. You will learn strategies and acquire new competences to understand and deal with these current issues and developments in healthcare.

Join the Summer School Population Health Management 2022 for an inspiring and scientific introduction to the fundamentals of Population Health Management at the LUMC-Campus The Hague  for professionals (and students) working in and around healthcare. The keynote speakers and professors during the course are experts ...

Integrated Maternal Care Strategies in Low- and Middle-Income Countries: A Systematic Review

Ineffective organisation of care leads to increased morbidity and mortality in neonates and their mothers. We aimed to identify and describe strategies used in low- and middle-income countries that attempt to deliver coherent, coordinated, and continuous services (i.e., integrated care) and how the various strategies affect the organisation of care.

Integrated Care Components in Transitional Care Models from Hospital to Home for Frail Older Adults: A Systematic Review

Frail older adults frequently experience transitions from hospital to home due to their complex care needs. Transitional care models (TCMs) are recommended to tackle adverse outcomes in frail patients. This review summarizes the use of integrated care components in addressing transitional care from hospital to home, provides an overview on reported outcomes and describes the impact of identified components on the outcomes hospital readmission and emergency department visit.

Health Centres 75+ as a New Model to Improve Care for Older People in Poland

According to a recent national audit, the cost of treating patients in geriatric wards is 20-30% less compared to those treated in internal medicine wards. Yet, geriatric care remains largely underdeveloped in Poland, with few human, material, and financial resources. Despite numerous attempts to raise the profile of geriatrics over the years, little progress has been achieved. In 2019, experts under the President of Poland proposed the creation of a network of Health Centres 75+ as the first pillar of geriatric care. These are meant to provide ambulatory services for older people and coordinate provision of other health and social care services at the county level. The goal is to create a community model of care, whereby older people would receive needed services close to their place of residence, allowing them to live independently for as long as possible. Although the proposal has been welcomed by the geriatric community and ...

How can Big Data Analytics Support People-Centred and Integrated Health Services: A Scoping Review

Frail older adults frequently experience transitions from hospital to home due to their complex care needs. Transitional care models (TCMs) are recommended to tackle adverse outcomes in frail patients. This review summarizes the use of integrated care components in addressing transitional care from hospital to home, provides an overview on reported outcomes and describes the impact of identified components on the outcomes hospital readmission and emergency department visit.

Barriers for Inter-Organisational Collaboration: What Matters for an Integrated Care Programme?

Inter-organisational collaboration is challenging but essential in managing the complex and comprehensive needs of frail older people. Therefore, there is a need to investigate the influence of different barriers to inter-organisational collaboration when implementing an integrated care programme. The aim of this study was to investigate both inpatient and outpatient staff views on the factors they deemed to be influential to inter-organisational collaboration for an integrated care programme.

Integrated care in every community

Our health and care needs are changing, with more people living longer often with multiple long term conditions. This animation explains the challenges facing the health and care system and how partnerships are being formed between the NHS, local government and the third sector to integrate care and better meet our health and care needs now and in the future. A BSL (British Sign Language) version of this video can be found here: https://youtu.be/b51AdiQf1w4

What is Integrated Care?

A video of the National Council for Mental Wellbeing.