Does integrated health and care in the community deliver its vision? A workforce perspective

Purpose –The purpose of this paper is to explore and capture workforce perceptions, experiences and insights of the phenomena of integrated care (IC) in a community health and care NHS trust in England; including whether there are any associated factors that are enablers, barriers, benefits or challenges; and the level of workforce engagement in the process of integrated health and care. Design/methodology/approach – A qualitative design based on an interpretivist research paradigm was used with a purposive sampling technique. Five in-depth semi-structured interviews were conducted with community nursing, social workers and allied health professionals. Colaizzi’s (1978) descriptive phenomenological seven-step method was applied to analyse data, with the emergence of 170 significant statements, 170 formulated meanings and 8 thematic clustering of themes to reveal 4 emergent themes and 1 fundamental structure capturing the essential aspects of the structure of the phenomenon IC. Findings – This study revealed four interdependent emergent themes: (1) Insight of IC and collaboration: affording the opportunity for collaboration, shared goals, vision, dovetailing knowledge, skills and expertise. Professional aspirations of person-centred and strength-based care to improve outcomes. (2) Awareness of culture and professionalism: embracing inter-professional working whilst appreciating the fear of losing professional identity and values. Working relationships based on trust, respect and understanding of professional roles to improve outcomes. (3) Impact of workforce engagement: participants felt strongly about their differing engagement experience in terms of restructuring and redesigning services. (4) Impact of organisational structure: information technology (IT) highlighted a barrier to IC as differing IT platforms prevent interoperability with one system to one patient. Shared positivity of IC, embracing new ways of working. Originality/value – This study proposes considerations for future practice, policy and research from a local, national and global platform, highlighting the need for any IC strategy or policy to incorporate the uniqueness of the “voice of the workforce” as a key enabler to integration developments, only then can IC be a fully collaborative approach

Az integrált ellátás koncepcionális keretrendszere és az integráció lehetőségei az alapellátásban

Absztrakt Mára már több ország egészségügyi kormányzata felismerte, hogy a krónikus betegségek kezelése, komplex rehabilitációs és prevenciós ellátások biztosítása újfajta szemléletet igényel. A tanulmány célja bemutatni, hogy az egészségügyi szektorban fellelhető és azon kívüli szolgáltatások integrációjára milyen módon van lehetőség; az alapellátás esetében a szolgáltatások integrációja hogyan valósul meg; valamint a szervezetek különböző szintű integrációja hogyan alakítja át az ellátások szervezését. A téma bemutatása érdekében a szerzők áttekintik a legújabb nemzetközi szakirodalmat, valamint a 2014. szeptember 1–2-án Barcelonában megrendezésre került V. Európai Alapellátási Fórum tapasztalatait. Az integrált ellátás átfogó szemlélete, illetve a helyi közösségek igényeihez való alkalmazkodás ösztönzőleg hat az új szervezeti, szolgáltatási formák kialakítására az alapellátásban. Az integrált szolgáltatási formák alkalmasak a betegek és a közösség igényeihez jobban alkalmazkodó, széles körű ellátások biztosítására, de minden esetben kiemelten fontos a céloknak megfelelő integrációdimenziók megválasztása. Orv. Hetil., 2015, 156(22), 881–887

Can health and social care integration make long-term progress? Findings from key informant surveys of the integration Pioneers in England

Purpose All areas in England are expected by National Health Service (NHS) England to develop integrated care systems (ICSs) by April 2021. ICSs bring together primary, secondary and community health services, and involve local authorities and the voluntary sector. ICSs build on previous pilots, including the Integrated Care Pioneers in 25 areas from November 2013 to March 2018. This analysis tracks the Pioneers’ self-reported progress, and the facilitators and barriers to improve service coordination over three years, longer than previous evaluations in England. The paper aims to discuss these issues. Design/methodology/approach Annual online key informant (KI) surveys, 2016–2018, are used for this study. Findings By the fourth year of the programme (2017), KIs had shifted from reporting plans to implementation of a wide range of initiatives. In 2018, informants reported fewer “significant” barriers to change than previously. While some progress in achieving local integration objectives was evident, it was also clear that progress can take considerable time. In parallel, there appears to have been a move away from aspects of personalised care associated with user control, perhaps in part because the emphasis of national objectives has shifted towards establishing large-scale ICSs with a particular focus on organisational fragmentation within the NHS. Research limitations/implications Because these are self-reports of changes, they cannot be objectively verified. Later stages of the evaluation will look at changes in outcomes and user experiences. Originality/value The current study shows clearly that the benefits of integrating health and social care are unlikely to be apparent for several years, and expectations of policy makers to see rapid improvements in care and outcomes are likely to be unrealistic. </jats:sec

Primary care redesign for person-centred care: Delivering an international generalist revolution

© La Trobe University. Person-centred primary care is a priority for patients, healthcare practitioners and health policy. Despite this, data suggest person-centred care is still not consistently achieved-and indeed, that in some areas, care may be worsening. Whole-person care is the expertise of the medical generalist-an area of clinical practice that has been neglected by health policy for some time. It is internationally recognised that there is a need to rebalance specialist and generalist primary care. Drawing on 15 years of scholarship within the science of medical generalism (the expertise of whole-person medical care), this discussion paper outlines a three-tiered approach to primary care redesign describing changes needed at the level of the consultation, practice set up and strategic planning. The changing needs of patients living with complex chronic illness has already started a revolution in our understanding of healthcare systems. This paper outlines work to support that paradigm shift from disease-focused to person-focused primary healthcare

Improving outcomes for people with COPD by developing networks of general practices: evaluation of a quality improvement project in east London

BACKGROUND: Structured care for people with chronic obstructive pulmonary disease (COPD) can improve outcomes. Delivering care in a deprived ethnically diverse area can prove challenging. AIMS: Evaluation of a system change to enhance COPD care delivery in a primary care setting between 2010 and 2013 using observational data. METHODS: All 36 practices in one inner London primary care trust were grouped geographically into eight networks of 4-5 practices, each supported by a network manager, clerical staff and an educational budget. A multidisciplinary group, including a respiratory specialist and the community respiratory team, developed a 'care package' for COPD management, with financial incentives based on network achievements of clinical targets and supported case management and education. Monthly electronic dashboards enabled networks to track and improve performance. RESULTS: The size of network COPD registers increased by 10% in the first year. Between 2010 and 2013 completed care plans increased from 53 to 86.5%, pulmonary rehabilitation referrals rose from 45 to 70% and rates of flu immunisation from 81 to 83%, exceeding London and England figures. Hospital admissions decreased in Tower Hamlets from a historic high base. CONCLUSIONS: Investment of financial, organisational and educational resource into general practice networks was associated with clinically important improvements in COPD care in socially deprived, ethnically diverse communities. Key behaviour change included the following: collaborative working between practices driven by high-quality information to support performance review; shared financial incentives; and engagement between primary and secondary care clinicians

Models for Treatment of Patients with Complex Medical-Psychiatric Conditions

Patients with co-morbidity and multi-morbidity have worse outcomes and greater healthcare needs. Co-morbid depression and other long-term conditions present health services with challenges in delivering effective care for patients. We provide some recent evidence from the literature to support the need for collaborative care, illustrated by practical examples of how to deliver a collaborative/integrated care continuum by presenting data collected between 2011 and 2012 from a London Borough clinical improvement programme that compared co-morbid diagnosis of depression and other long-term conditions and Accident and Emergency use. We have provided some practical steps for developing collaborative care within primary care and suggest that primary care family practices should adopt closer collaboration with other services in order to improve clinical outcomes and cost-effectiveness.publishersversionpublishe

Population-level impact of diabetes integrated care on commissioner payments for inpatient care among people with type 2 diabetes in Cambridgeshire: a postintervention cohort follow-up study

Objectives Few studies have estimated the effect of diabetes integrated care at a population level. We have assessed the impact of introducing a community service-led diabetes integrated care programme on commissioner payments (tariff) for inpatient care in rural England.Methods The Diabetes Integrated Care Initiative was delivered by a separate enhanced community diabetes service, increasing specialist nursing, dietetic, podiatry and medical support to primary care and patients, while linking into other diabetes specialist services. Commissioner data were provided by the local authority. The difference in area between the two overlapping distribution curves of inpatient payments at baseline and follow-up (at 3 years) was used to estimate the effect of integrated care on commissioner inpatient payments on a population level.Results Over the 3-year period, reduced inpatient payments occurred in 2.7% (1.3% to 5.8%) of patients with diabetes aged more than 70 years in the intervention area. However, reduced diabetes inpatient payments occurred in 3.20% (1.77% to 7.20%) of patients aged <70 years and 4.1% (2.3% to 7.9%) of patients =70 years in one of the two adjacent areas.Conclusion This enhanced community diabetes services was not associated with substantially reduced inpatient payments. Alternative diabetes integrated care approaches (eg, with direct primary and secondary care collaboration rather than with a community service) should be tested

Harm Reduction as "Continuum Care" in Alcohol Abuse Disorder

Alcohol abuse is one of the most important risk factors for health and is a major cause of death and morbidity. Despite this, only about one-tenth of individuals with alcohol abuse disorders receive therapeutic intervention and specific rehabilitation. Among the various dichotomies that limit an effective approach to the problem of alcohol use disorder treatment, one of the most prominent is integrated treatment versus harm reduction. For years, these two divergent strategies have been considered to be opposite poles of different philosophies of intervention. One is bound to the search for methods that aim to lead the subject to complete abstinence; the other prioritizes a progressive decline in substance use, with maximum reduction in the damage that is correlated with curtailing that use. Reduction of alcohol intake does not require any particular setting, but does require close collaboration between the general practitioner, specialized services for addiction, alcohology services and psychiatry. In patients who reach that target, significant savings in terms of health and social costs can be achieved. Harm reduction is a desirable target, even from an economic point of view. At the present state of neuroscientific knowledge, it is possible to go one step further in the logic that led to the integration of psychosocial and pharmacological approaches, by attempting to remove the shadows of social judgment that, at present, are aiming for a course of treatment that is directed towards absolute abstention