Impact of a high-risk multimorbidity integrated care implemented at the public health system in Chile

During recent years, multimorbidity has taken relevance because of the impact of causes in the system, people, and their families, which has been a priority in the health care plan. Interventions strategies and their implementation are still an emerging topic. In this context, Centro de Innovación en Salud ANCORA UC, together with Servicio de Salud Metropolitano Sur Oriente, implemented as a pilot study High-Risk Multimorbidity Integrated Care strategy. This study aimed to evaluate the impact of this strategy in terms of health services utilization and mortality. A cohort study was conducted with high-risk patients with multimorbidity, stratified by ACG®, intervened between April 2017 and December 2019. The studied population was 3,933 patients who belonged to similar size and location primary care centers. The impact analysis was performed used generalized linear models. Results showed that intervened patients had a significantly lower incidence in mortality (OR 0.56; 95% CI 0.40–0.77), hospital admissions, length of stay, and the number of hospital emergency consultancies. With the proper barriers and facilitators of a real context intervention, the implementation process allowed the systematization and consolidation of the intervention provided in this study. The training for new roles and the constant implementation support from the Centro de Innovación en Salud ANCORA UC team were essential in the progress and success of the intervention. A complete description of the high-risk intervention strategy is provided to contribute to this emerging topic and facilitate its scale-up. We can conclude that this complex intervention was feasible to be implemented in a real context. The Ministry of Health has taken the systematization and consolidation of the conditions for the national scale-up.

Integrated Care for Seniors as a Challenge for Slovakia

Older age can be accompanied by a lot of changes in the field of health, which influence the social functioning of seniors.One of the factors influencing the quality of life of seniors is the connection of healthcare and social care, built on the interdepartmental cooperation. This approach is still absent in Slovakia.The aim of the paper is therefore to emphasize the importance and need of integrated care and to describe the barriers that prevent its implementation in Slovakia. In search of answers to the questions: “When and why was the healthcare and social care department of seniors established in Slovakia? What are the reasons persisting in this condition? What are the consequences of this divided care for the seniors in practice? What strategies use facilities for seniors to overcome this situation during the COVID-19 pandemic?” the authors used the method of the case study (Yin, 2003) focused on the Trnava self-governing region. Persistent structural, procedural, legislative and political factors have been identified as the main barriers. Specific for Slovakia is the existence of a barrier of the profession, which is caused by the low interest of social workers in the issue. The authors state that the situation in Slovakia is caused mainly by the reflection of integrated care as a political problem. In the end, the authors make several suggestions for solving the situation.

Understanding the Experience of Service Users in an Integrated Care Programme for Obesity and Mental Health: A Qualitative Investigation of Total Wellbeing Luton

Obesity is a complex public health issue with multiple contributing factors. The emphasis on joined care has led to the development and implementation of a number of integrated care interventions targeting obesity and mental health. The purpose of this study was to examine user experience in an integrated care programme for obesity and mental health in Luton, UK. Semi-structured interviews were conducted with a purposeful sample of service users (N = 14). Interview transcripts were analysed using thematic analysis. Analysis of the interviews identified six main themes for understanding service users’ experiences of integrated care: (1) ‘A user-centered system’, (2) ‘Supports behaviour change’, (3) ‘Valued social support’, (4) ‘Communication is key’, (5) ‘Flexible referral process’, and (6) ‘Positive impact on life’. These themes describe how the service is operated, evidence perceived value service users place on social support in behavior change intervention, and address which service areas work well and which require improvement. The findings of these interviews have offered a significant contribution to understanding what service users value the most in an integrated healthcare setting. Service users value ongoing support and being listened to by healthcare professionals, as well as the camaraderie and knowledge acquisition to support their own behaviour change and promote self-regulation following their participation in the programme.

A Protocol on Using the RE-AIM Framework in the Process Evaluation of the Primary Health Integrated Care Project for Four Chronic Conditions in Kenya

Background: There has been a rapid increase in morbidity and mortality arising from non-communicable diseases (NCDs). The Academic Model Providing Access to Healthcare (AMPATH) program has established a chronic disease management program in collaboration with the Ministry of Health (MoH) in Kenya at over 150 health facilities in western Kenya. The primary health integrated care for chronic (PIC4C) disease project seeks to deliver preventive, promotive, and curative care for diabetes, hypertension, cervical and breast cancers at the primary health care level. We apply the RE-AIM framework to conduct a process evaluation of the integrated PIC4C model. This paper describes the protocol we are using in the PIC4C process evaluation planning and activities.Methods and Analysis: This evaluation utilizes clinic reports as well as primary data collected in two waves. Using mixed methods (secondary data, observation, semi-structured interviews, and focus group discussions), the process evaluation assesses the reach, effectiveness, adoption, implementation and maintenance of the PIC4C model in Busia and Trans Nzoia Kenya. The evaluation captures the PIC4C process, experiences of implementers and users, and the wishes of those using the PIC4C services. We will analyse our data across the RE-AIM dimensions using descriptive statistics and two-sample t-test to compare the mean scores for baseline and end line. Qualitative data will be analyzed thematically.Discussion: The process evaluation of the PIC4C model in Kenya allows implementers and users to reflect and question its implementation, uptake and maintenance. Our experiences thus far suggest practicable strategies to facilitate primary health care can benefit extensively from deliberate process evaluation of the programs undertaken. Furthermore, integrating the RE-AIM framework in the process evaluation of health programs is valuable due to its pragmatic and reporting usefulness.

Patients’ Perceptions of Integrated Care Among Medicare Beneficiaries by Level of Need for Health Services

Requirements for integrating care across providers, settings, and over time increase with patients’ needs. Health care providers’ ability to offer care that patients experience as integrated may vary among patients with different levels of need. We explore the variation in patients’ perceptions of integrated care among Medicare beneficiaries based on the beneficiary’s level of need using ordinary least square regression for each of four high-need groups: beneficiaries (a) with complex chronic conditions, (b) with frailties, (c) below 65 with disability, and (d) with any (of the first three) high needs. We control for beneficiary demographics and other factors affecting integrated care, and we conduct sensitivity analyses controlling for multiple individual chronic conditions. We find significant positive associations with level of need for provider support for self-directed care and medication and home health management. Controlling for multiple individual chronic conditions reduces effect sizes and number of significant relationships.

Tuberculosis and Diabetes in India: Stakeholder Perspectives on Health System Challenges and Opportunities for Integrated Care

Background India has a dual burden of tuberculosis (TB) and diabetes mellitus (DM). Integrated care for TB/DM is still in the early phase in the country and can be considerably enhanced by understanding and addressing the challenges identified from stakeholders’ perspectives. This study explored the challenges and opportunities at individual, health system and policy level for integrated care of TB/DM comorbidities in India. Methods We used an outlier case study approach and conducted stakeholder interviews and focus group discussions with relevant program personnel including field staff and program managers of TB and DM control programs as well as officials of partners in Indian states, Kerala and Bihar. Results The integrated management requires strengthening the laboratory diagnosis and drug management components of the two individual programs for TB and DM. Focused training and sensitization of healthcare workers in public and private sector across all levels is essential. A district level management unit that coordinates the two vertical programs with a horizontal integration at the primary care level is the way forward. Substantial improvement in data infrastructure is essential to improve decision-making process. Conclusion Bi-directional screening and management of TB/DM comorbidities in India requires substantial investment in human resources, infrastructure, drug availability, and data infrastructure.

Development of a Blueprint for Integrated Care for Vulnerable Pregnant Women

Purpose 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. Description Within the consortium, vulnerability is defined as the presence of psychopathology, psychosocial problems, and/or substance use, combined with a lack of individual and/or social resources. Three studies focussing on population characteristics, organisation of care and knowledge, skills, and attitudes of professionals regarding vulnerable pregnant women, were carried out. Outcomes were discussed in three field consultations. Assessment The outcomes of the studies, followed by the field consultations, resulted in a blueprint that was subsequently adapted to local operational care pathways in seven obstetric collaborations (organisational structures that consist of obstetricians of a single hospital and collaborating midwifery practices) and their collaborative partners. We conducted 12 interviews to evaluate the adaptation of the blueprint to local operational care pathways and its’ embedding into the obstetric collaborations. Conclusion Practice-based research resulted in a blueprint tailored to the needs of maternal and child health care professionals and social care professionals and providing structure and uniformity to integrated care provision for vulnerable pregnant women.

A critical systems evaluation of the introduction of a ‘discharge to assess’ service in Kent

Discharge to Assess (D2A) models of care have been developed to expedite the process of discharging hospital patients as soon as they are medically fit to leave, thereby improving the efficiency and effectiveness of the healthcare system. This article focuses on the implementation of a D2A model in Kent, England, which formed a case study for a European research programme of improvements in integrated care for older people. It uses the Critical Systems Heuristics framework to examine the implementation process and focuses in particular on why this improvement project proved to be so difficult to implement and why the anticipated outcomes were so elusive. The analysis highlights the value in using critical systems thinking to better evaluate integrated care initiatives, in particular by identifying more explicitly different stakeholder perspectives and power relationships within the system and its decision environment.