International Journal of Integrated Care

Online ISSN: 1568-4156
Stroke care model of the stroke service Maastricht in 2004.
Content of assessment at the nursing home assessment unit.
The redesigned integrated stroke service Maastricht.
Introduction Stroke care is complex and often provided by various healthcare organisations. Integrated care solutions are needed to optimise stroke care. In this paper, we describe the development of integrated stroke care in the region of Maastricht during the last 15 years. Description of integrated care case Located in the south of the Netherlands, the region of Maastricht developed integrated stroke care to serve a population of about 180,000 people. Integration was needed to improve the continuity, coordination and quality of stroke care. The development of integrated care in Maastricht was a phased process. The last phase emphasized early discharge from hospital and assessing the best individual rehabilitation track in a specialized nursing home setting. Discussion and lessons learned The development and implementation of integrated stroke care in the region of Maastricht led to fewer days in hospital, more patients being directly admitted to the stroke unit and an earlier start of rehabilitation. The implementation of early discharge from the hospital and rehabilitation assessment in a nursing home led to some unforeseen problems and lessons learned.
Our objective was to describe the utilization and costs of services from 1985 to 2002 of a Social Health Maintenance Organization (SHMO) demonstration project providing a benefit for home-based and community-based as well as short-term institutional (HCB) care at Kaiser Permanente Northwest (KPNW), serving the Portland, Oregon area. The HCB care benefit was offered by KPNW as a supplement to Medicare's acute care medical benefits, which KPNW provides in an HMO model. KPNW receives a monthly per capita payment from Medicare to provide medical benefits, and Medicare beneficiaries who choose to join pay a supplemental premium that covers prescription drugs, HCB care benefits, and other services. A HCB care benefit of up to 12,000 dollars per year in services was available to SHMO members meeting requirement for nursing home certification (NHC). We used aggregate data to track temporal changes in the period 1985 to 2002 on member eligibility, enrollment in HCB care plans, age, service utilization and co-payments. Trends in the overall costs and financing of the HCB care benefit were extracted from quarterly reports, management data, and finance data. During the time period, 14,815 members enrolled in the SHMO and membership averaged 4,531. The proportion of SHMO members aged 85 or older grew from 12 to 25%; proportion meeting requirements for NHC rose from 4 to 27%; and proportion with HCB care plans rose from 4 to 18%. Costs for the HCB care benefit rose from 21 dollars per SHMO member per month in 1985 to 95 dollars in 2002. The HCB care costs were equivalent to 12% to 16% of Medicare reimbursement. The HCB program costs were covered by member premiums (which rose from 49 dollars to 180 dollars) and co-payments from members with care plans. Over the 18-year period, spending shifted from nursing homes to a range of community services, e.g. personal care, homemaking, member reimbursement, lifeline, equipment, transportation, shift care, home nursing, adult day care, respite care, and dentures. Rising costs per month per SHMO member reflected increasing HCB eligibility rather than costs per member with HCB care, which actually fell from 6,164 dollars in 1989 to 4,328 dollars in 2002. Care management accounted for about one-quarter of community care costs since 1992. The Kaiser Permanente Northwest SHMO served an increasingly aged and disabled membership by reducing costs per HCB member care plan and shifting utilization to a broad range of community care services. Supported by a disability-based Medicare payment formula and by SHMO beneficiaries willing to pay increasing premiums, KPNW has been able to offer comprehensive community care. The model could be replicated by other HMOs with the support of favorable federal policies.
Introduction This paper assesses the policy developments pertaining to the implementation of an integrated approach to domestic violence over the past 15 years. The contextual setting is outlined in terms of the international policy response to the problem of domestic violence based on an ecological perspective. Description of policy and case Periods of core strategic policy and related structural developments are considered illustrating the Irish experience of domestic violence policy-making and service provision. The value of adopting an integrated approach to domestic violence based on the rationale of improving strategic policy formulation, coordinating service provision and facilitating joined-up governance is set out. The core facilitators and challenges associated with such an approach are described. Analysis and conclusion The policy framework and restructured landscape of domestic violence in Ireland has undergone significant change over the past decade and a half. The paper uses a three-dimensional matrix of domestic violence policy development and service integration as a means of addressing horizontal, vertical and resource aspects of collaboration and integration. While the changes have been characterised by significant phases of fluctuation in terms of coordinated action and the situation currently appears promising, however it is too early to judge the outcomes of the most recent reforms.
Main stakeholders of the Swedish health care system and their principal duties.
Introduction The recent history of integrated health care in Sweden is explored in this article, focusing on the first decade of the 2000s. In addition, there are some reflections about successes and setbacks in this development and challenges for the next decade. Description of policy and practice The first efforts to integrate health care in Sweden appeared in the beginning of the 1990s. The focus was on integration of intra-organisational processes, aiming at a more cost-effective health care provision. Partly as a reaction to the increasing economism at that time, there was also a growing interest in quality improvement. Out of this work emerged the ‘chains of care’, integrating all health care providers involved in the care of specific patient groups. During the 2000s, many county councils have also introduced inter-organisational systems of ‘local health care’. There has also been increasing collaboration between health professionals and other professional groups in different health and welfare services. Discussion and conclusion Local health care meant that the chains of care and other forms of integration and collaboration became embedded in a more integrative context. At the same time, however, policy makers have promoted free patient choice in primary health care and also mergers of hospitals and clinical departments. These policies tend to fragment the provision of health care and have an adverse effect on the development of integrated care. As a counterbalance, more efforts should be put into evaluation of integrated health care, in order to replace political convictions with evidence concerning the benefits of such health care provision.
Conditions for cooperation. 
No buffer (situation A), a buffer without buffer management (situation B) and a buffer with buffer management (situation C); bb, bed blocker; Q, queue.
Conditions for cooperation.
Bed-blocking problems in hospitals reflect how difficult and complex it is to move patients smoothly through the chain of care. In the Netherlands, during the first decade of the 21st century, some hospitals attempted to tackle this problem by using an Intermediate Care Department (ICD) as a buffer for bed-blockers. However, research has shown that ICDs do not sufficiently solve the bed-blocking problem and that bed-blocking is often caused by a lack of buffer management. TOOL: Buffer management (BM) is a tool that endeavors to balance patient flow in the hospital to nursing home chain of care. Additional research has indicated that the absence of BM is not the result of providers' thinking that BM is unnecessary, unethical or impossible because of unpredictable patient flows. Instead, BM is hampered by a lack of cooperation between care providers. Although stakeholders recognize that cooperation is imperative, they often fail to take the actions necessary to realize cooperation. Our assumption is that this lack of willingness and ability to cooperate is the result of several impeding conditions as well as stakeholders' perceptions of these conditions and the persistence of their current routines, principles and beliefs (RPBs). We recommend simultaneously working on improving the conditions and changing stakeholders' perceptions and RPBs.
Personal and technical inputs to consultations and their links with types of continuity over time (after Freeman et al. 2003) [37].
This perspective paper makes a brief conceptual review of continuity and argues that relationship continuity is the most controversial type. Plentiful evidence of association with better satisfaction and outcomes urgently needs to be supplemented by studies of causation. The scope of these has been outlined in this paper. Evidence strongly suggests that patients generally want more relationship continuity than they are getting and that relationship continuity is linked with better patient and staff satisfaction. This is reason enough to justify improving relationship continuity for patients.
ABCD 2 risk score
ABCD2 risk score
Although the symptoms of a transient ischemic attack (TIA) by definition resolve completely, the subsequent risk of cardiovascular complications is substantial. Urgent diagnosis and start of secondary prevention can reduce these risks. In light of the potential unfavourable prognosis, especially the first days after a TIA, we have developed and implemented a 24/7 TIA-service. Patients can be referred at any time and timing of analysis is determined by means of short-term risk assessment with a validated tool. Within half a day all investigations necessary to diagnose TIA and identify risk factors take place and secondary prevention at all levels is started immediately. This service is realized through integration of workflow of different specialities at multiple levels of care. Although patient service improves, the beneficial effects of a 24/7 TIA-service need to be established before further implementation is started. A preliminary analysis on the effects of continuous TIA-care and suggestions for the development of the necessary process and outcome indicators are provided.
The early post-discharge period is a vulnerable time for older patients with complex care requirements. This paper identifies factors predicting a self-reported successful post-discharge outcome for patients aged 80 years and over by exploring factors related to the discharge process, the provision of formal home-care services, informal care and characteristics of the patients. The study reports results from survey interviews with patients admitted from home to 14 hospitals in Norway and later discharged home. Logistic regression analysis was performed to assess the impact of a number of factors on the likelihood that the patients would report that they managed well after discharge. The odds of managing well after discharge were more than four times higher (OR=4.75, p=0.022) for patients reporting that someone was present at homecoming than for those who came home to an empty house. Patients who reported receiving adequate help from the municipality had an odds four times (OR=4.18, p=0.006) higher of reporting that everything went well after discharge than those who stated the help was inadequate. Having someone at home upon return from hospital and having adequate formal home-care services are significantly associated with patient-reported success in managing well.
Patient flow through the multidisciplinary Abdominal Pain Clinic.
Time since onset of pain by clinic type.
Family intention to begin recommended treatments by clinic type.
Family overall satisfaction with initial evaluation for pediatric abdominal pain by clinic type.
To assess patient and family satisfaction with evaluation received through a multidisciplinary paediatric Abdominal Pain Clinic (APC) staffed by a paediatric gastroenterologist and a paediatric psychologist as compared to a traditional gastroenterology clinic (GI) staffed by a paediatric gastroenterologist only. Two hundred and ninety-eight families (145 APC, 153 GI) with a child or adolescent aged 8-17 years seen for initial evaluation of a chronic abdominal pain completed an anonymous survey to assess understanding of the treatment recommendations made, intent to follow through with various treatment recommendations, and the overall level of satisfaction with the evaluation service provided. Family perceptions of strengths and challenges of the APC evaluation process also were explored. APC families reported being prescribed adjunctive mental health and other therapies at significantly higher rates than GI families, while the rates of medication were comparable. APC families also reported significantly greater receptivity to beginning the treatments prescribed and higher levels of overall satisfaction with the evaluation process. The contribution of integrated medical and psychological perspectives frequently was identified as a strength of the APC evaluation process. Challenges identified for the APC evaluation were few and focused on issues related to paperwork and scheduling issues. Integrative care approaches to the evaluation of paediatric abdominal pain appear well accepted by families, yielding high levels of satisfaction, and enhance receptivity to treatment recommendations. Integrative care starting at the time of first evaluation may be particularly well-tailored to enhance outcomes, reduce health care utilization, and yield financial savings within this population.
The purpose of this project was to implement the delivery of a full range of substance abuse services in a primary care setting. Implementation and logistical issues including confidentiality and communication are discussed. The delivery of services, types of patients, and contextual and policy factors that influenced project implementation are described. Substance use disorders are associated with significant morbidity and mortality worldwide. Patients with alcohol/drug problems frequently present in primary care. Effective and brief treatments are available and recommended for primary care but infrequently implemented. Institutional and provider barriers to implementation have been identified. Project documentation, data from the patient tracking system, and clinical case notes were used for description and analyses. Addressing substance abuse problems in primary care is important. Behavioral health professionals with training in substance abuse can provide a range of services that are likely to enhance the quality and quantity of care available to patients. Although contextual factors needed to be addressed, integration of services was manageable and seemed acceptable to both providers and patients in this project.
Differences in client characteristics between working procedures 
Clients experiences with the RIO, differences between procedures 
Client satisfaction with aspects of the RIOs needs assessment process a 
To determine if and how the outcome quality from a client perspective is related to process characteristics and structure of Regional Individual Needs Assessment Agencies (RIOs) regulating access to long-term care services in The Netherlands. Because of decentralised responsibilities, ultimo 1999 85 RIOs were set up. RIOs differ in their structural and process characteristics. This could lead to differences in client quality. Insight into factors relating to client quality (e.g. client satisfaction) can improve the needs assessment process. Eighteen RIOs participated in this study. These RIOs each selected 120 clients, filled in forms about their needs assessment procedures and sent them a questionnaire assessing judgements, experiences and satisfaction with the RIO. We received 1916 RIO-forms and 1062 client questionnaires. Eighty-two percent of the clients were satisfied with the RIO, the percentages not satisfied clients varied from 10 to 29% among items and working procedures. Satisfaction is mostly related to what is actually done for the client. Information aspects and providing choices are important determinants of client quality with the RIO. In improving quality seen from a client perspective, one should focus on what is actually done for the client, rather than looking at the RIOs structure.
Infant and maternal mortality rates, Costa Rica, Chile and Colombia 1
International aid-promoted health policy.
To review the evidence basis of international aid and health policy. Current international aid policy is largely neoliberal in its promotion of commoditization and privatisation. We review this policy's responsibility for the lack of effectiveness in disease control and poor access to care in low and middle-income countries. National policies, international programmes and pilot experiments are examined in both scientific and grey literature. We document how health care privatisation has led to the pool of patients being cut off from public disease control interventions--causing health care disintegration--which in turn resulted in substandard performance of disease control. Privatisation of health care also resulted in poor access. Our analysis consists of three steps. Pilot local contracting-out experiments are scrutinized; national health care records of Colombia and Chile, two countries having adopted contracting-out as a basis for health care delivery, are critically examined against Costa Rica; and specific failure mechanisms of the policy in low and middle-income countries are explored. We conclude by arguing that the negative impact of neoliberal health policy on disease control and health care in low and middle-income countries justifies an alternative aid policy to improve both disease control and health care.
Types of collaboration described by Scott 2005 [2]
Overview of the sites participating in the qualitative study
WE INVESTIGATED THE EFFECTS ON COLLABORATIVE WORK WITHIN THE UK NATIONAL HEALTH SERVICE (NHS) OF AN INTERVENTION FOR SERVICE QUALITY IMPROVEMENT: informal, structured, reciprocated, multidisciplinary peer review with feedback and action plans. The setting was care for chronic obstructive pulmonary disease (COPD). THEORY AND METHODS: We analysed semi-structured interviews with 43 hospital respiratory consultants, nurses and general managers at 24 intervention and 11 control sites, as part of a UK randomised controlled study, the National COPD Resources and Outcomes Project (NCROP), using Scott's conceptual framework for action (inter-organisational, intra-organisational, inter-professional and inter-individual). Three areas of care targeted by NCROP involved collaboration across primary and secondary care. Hospital respiratory department collaborations with commissioners and hospital managers varied. Analysis suggested that this is related to team responses to barriers. Clinicians in unsuccessful collaborations told 'atrocity stories' of organisational, structural and professional barriers to service improvement. The others removed barriers by working with government and commissioner agendas to ensure continued involvement in patients' care. Multidisciplinary peer review facilitated collaboration between participants, enabling them to meet, reconcile differences and exchange ideas across boundaries. The data come from the first randomised controlled trial of organisational peer review, adding to research into UK health service collaborative work, which has had a more restricted focus on inter-professional relations. NCROP peer review may only modestly improve collaboration but these data suggest it might be more effective than top-down exhortations to change when collaboration both across and within organisations is required.
Overview of forums in the co-innovation process
Survey of interviewed respondents in phases I and II
Identified obstacles in the co-innovation process
The Tele-rehabilitation program
The aim of the Telekat project is to prevent re-admissions of patients with chronic obstructive pulmonary disease (COPD) by developing a preventive program of tele-rehabilitation across sectors for COPD patients. The development of the program is based on a co-innovation process between COPD patients, relatives, healthcare professionals and representatives from private firms and universities. This paper discusses the obstacles that arise in the co-innovation process of developing an integrated technique for tele-rehabilitation of COPD patients. Network and innovation theory. The case study was applied. A triangulation of data collection techniques was used: documents, observations (123 hours), qualitative interviews (n=32) and action research. Obstacles were identified in the network context; these obstacles included the mindset of the healthcare professionals, inter-professionals relations, views of technology as a tool and competing visions for the goals of tele-rehabilitation. We have identified obstacles that emerge in the co-innovation process when developing a programme for tele-rehabilitation of COPD patients in an inter-organizational context. Action research has been carried out and can have helped to facilitate the co-innovation process.
The main purpose of this practice paper is to describe and analyse the possibilities and complexities of integrated health care across borders. First, we portray an ideal scenario for this type of care with a case of patients suffering from rheumatoid arthritis and living in the Dutch-Belgian frontier area. It shows how cross border care enhances continuity of care/tailor-made care and the other way around. Secondly, based on different literature sources, we describe actual regulations on health care across borders. We show that these regulations can be a major hindrance to integrated care. This raises questions on the scope and content of policies directed at both cross border and integrated care.
Jeannette Shannon was 69 in 2002, and chair of March of Dimes Canada (MODC). Disabled from Polio, Jean-nette had been experiencing significant health prob-lems and concluded that people with disabilities who often experienced early ageing-related conditions were sometimes ignored by the fields of both reha-bilitation and geriatrics as they aged, and had com-plex care issues related to existing disabilities and new health concerns. Known as Mrs. March of Dimes, Ms. Shannon passed away before she could see the result of her vision: to deliver a conference on “growing older with a disability,” bringing consumers of health and social services together with practitioners, policy-makers, researchers and businesses. In 2007 and 2011 Ms. Shannon’s vision came to fruition through the establishment of the Growing Older with Disability (GOWD) conferences and the larger umbrella frame-work of which they are a central component, namely the Festival of International Conferences on Caregiv-ing, Disability, Aging and Technology (FICCDAT).
Conceptual framework.
The purpose of this study was to explore and identify inter-organisational and inter-professional controversies that emerge when telehomecare technology is implemented across healthcare sectors. A combined inter-organisational and inter-professional perspective constitutes the conceptual framework for this study. The case study approach was applied as the overall methodology of the study. A triangulation of data collection techniques was used in order to provide multiple sources of evidence for exploring and identifying controversies (documents, participant observation, qualitative interviews, focus group interviews). During the design and implementation phases of a telehomecare system, several types of controversies emerged as part of the inter-organisational and inter-professional agenda. These controversies involved competing claims of jurisdiction, controversies over knowledge technologies, or differences in network visions and network architecture. The identification of such controversies and differences in the design and implementation process of the concept of home hospitalisation for heart patients by means of telehomecare technology can contribute to the uncovering of new knowledge. These issues should be taken into account when initiating a telehomecare project and implementing telehomecare technology. Technology in a network and across inter-professional relations poses a challenge to this new field. There is a particular need to precisely define the claims of jurisdiction, and the accompanying controversies that can arise related to knowledge technologies, network visions and network architecture.
Governance and coordination models
Provincial and regional governance context
Governance models
Governance and coordination models
Modes of governance were compared in ten local mental health networks in diverse contexts (rural/urban and regionalized/non-regionalized) to clarify the governance processes that foster inter-organizational collaboration and the conditions that support them. Case studies of ten local mental health networks were developed using qualitative methods of document review, semi-structured interviews and focus groups that incorporated provincial policy, network and organizational levels of analysis. Mental health networks adopted either a corporate structure, mutual adjustment or an alliance governance model. A corporate structure supported by regionalization offered the most direct means for local governance to attain inter-organizational collaboration. The likelihood that networks with an alliance model developed coordination processes depended on the presence of the following conditions: a moderate number of organizations, goal consensus and trust among the organizations, and network-level competencies. In the small and mid-sized urban networks where these conditions were met their alliance realized the inter-organizational collaboration sought. In the large urban and rural networks where these conditions were not met, externally brokered forms of network governance were required to support alliance based models. In metropolitan and rural networks with such shared forms of network governance as an alliance or voluntary mutual adjustment, external mediation by a regional or provincial authority was an important lever to foster inter-organizational collaboration.
Telehealthcare deployment across the countries studied
Organisation and incentive schemes in eight countries
Health care systems are struggling to deal with the increasing demands of an older population. In an attempt to find a solution to these demands, there has been a shift towards integrated care supported by information and communication technologies. However, little is understood about the role played by incentives and reimbursement schemes in the development of integrated care and information and communication technologies uptake. The objective of this paper is to investigate this question, specifically as regards telehealthcare. In order to identify the deployment of telehealthcare applications and their role in supporting integrated care, a case study approach was used. A clustering exercise was carried out and eight European countries were selected for in-depth study: Denmark, Estonia, Germany, France, Italy, the Netherlands, Spain and the UK. In total, 31 telehealthcare initiatives across eight countries involving over 20,000 patients were investigated. Reflecting on specific examples in each initiative, drivers promoting integrated care delivery supported by telehealthcare mainstreaming and associated incentive mechanisms were identified. Attention was also paid to other factors which acted as barriers for widespread deployment. Trends towards telehealthcare mainstreaming were found in Denmark, the UK, and in some regions of Spain, Italy and France. Mainstreaming often went hand-in-hand with progress towards integrated care delivery and payment reforms. A general trend was found towards outcomes-based payments and bundled payment schemes, which aimed to promote integrated care supported by telehealthcare deployment. Their effectiveness in achieving these goals remains to be seen. In addition, a form of outpatient diagnostic-related group reimbursement for telehealthcare services was found to have emerged in a few countries. However, it is questionable how this incentive could promote integrated care delivery on its own. This research suggests that incentives which align social, primary and hospital care are rare and there is a need to design new payment paradigms. Finally, eHealth penetration, interoperability, governance, availability of evidence and reorganisation of services represent additional factors which can act as drivers or barriers for integrated care delivery.
Characteristics of the study sample
Factor analysis, item-rest correlation and Cronbach's alpha of the CCAENA items
Spearman correlation coefficients between scalesa
Differences in scores between subgroups
The CCAENA questionnaire was developed to assess care continuity across levels from the patients' perspective. The aim is to provide additional evidence on the psychometric properties of the scales of this questionnaire. Cross-sectional study by means of a survey of a random sample of 1500 patients attended in primary and secondary care in three health care areas of the Catalan health care system. Data were collected in 2010 using the CCAENA questionnaire. To assess psychometric properties, an exploratory factor analysis was performed (construct validity) and the item-rest correlations and Cronbach's alpha were calculated (internal consistency). Spearman correlation coefficients were calculated (multidimensionality) and the ability to discriminate between groups was tested. The factor analysis resulted in 21 items grouped into three factors: patient-primary care provider relationship, patient-secondary care provider relationship and continuity across care levels. Cronbach's alpha indicated good internal consistency (0.97, 0.93, 0.80) and the correlation coefficients indicated that dimensions can be interpreted as separated scales. Scales discriminated patients according to health care area, age and educational level. The CCAENA questionnaire has proved to be a valid and reliable tool for measuring patients' perceptions of continuity. Providers and researchers could apply the questionnaire to identify areas for health care improvement.
Integrated care has moved from the small niche it traditionally occupied in academia, accessible only to experts in the field and applied merely on a project specific or pilot effort basis, now onto the radar of politicians and health system planners the world over.
The 2004 Children Act in the UK saw the introduction of integrated working in children's services. A raft of change followed with processes designed to make joint working easier, and models and theories to support the development of integrated work. This paper explores the links between key concepts and practice. A practitioner action research approach is taken using an autoethnographic account kept over six months. The research question was, to what extent is this group collaborating? When the architecture of practice was revealed, differences between espoused and real practice could be seen. Whilst understanding and displaying the outward signs of an effective multi professional group, the individuals did not trust one another. This was exhibited by covert interprofessional issues. As a result, collaborative inertia was achieved. This realisation prompted them to participate in further developmental and participative action research. The paper concludes that trust and relational agency are central to effective leadership of multi professional teams.
To describe the potential role of the Internet as a vehicle for improving integration of care through activating chronic kidney disease patients and their family members. Also, to describe how that potential is being developed through a website sponsored by the Medicare program in the United States. The Internet is expanding at a rapid rate, and health-related websites are one of its most popular features. Efforts to promote integration of care have focused mainly on providers up to now, and more emphasis is needed on the potential roles of patients. Chronically ill patients have particular needs for improved education about their conditions and enhanced involvement in care planning and treatment decisions. Medicare developed the Dialysis Facility Compare website to serve those goals for people with chronic kidney disease. We conducted qualitative research with 140 chronic kidney disease patients and family members, and 130 renal care professionals to evaluate and improve the Dialysis Facility Compare website. A series of 19 focus groups, 13 triads (small focus groups), and 56 individual interviews were conducted in four regions of the United States and by telephone. We found that the Dialysis Facility Compare website has the potential to improve integration of care for people with chronic kidney disease in at least three ways. First: by expanding the roles of patients as members of the multi-disciplinary team of caregivers treating their disease. Second: through better integration of the informal care provided in the home and community with the formal care provided by health professionals. Third: by improving coordination of between care provided in the pre-dialysis and dialysis phases of the disease. We developed recommendations for revising and enhancing the Dialysis Facility Compare website in a number of ways to better promote patient activation and integration of care. The unique features of the Internet, such as its different dimensions of interactivity, and applications of behavioural theories for website design should also be further explored.
The three diversity enactment stances.
The diversity enactment process in the MN case.
We are looking at the process of structuring an integrated care system as an innovative process that swings back and forth between the diversity of the actors involved, local aspirations and national and regional regulations. We believe that innovation is enriched by the variety of the actors involved, but may also be blocked or disrupted by that diversity. Our research aims to add to other research, which, when questioning these integrated systems, analyses how the actors involved deal with diversity without really questioning it. The empirical basis of the paper is provided by case study analysis. The studied integrated care system is a French healthcare network that brings together healthcare professionals and various organisations in order to improve the way in which interventions are coordinated and formalised, in order to promote better detection and diagnosis procedures and the implementation of a care protocol. We consider this case as instrumental in developing theoretical proposals for structuring an integrated care system in light of the diversity of the actors involved. We are proposing a model for structuring an integrated care system in light of the enacted diversity of the actors involved. This model is based on three factors: the diversity enacted by the leaders, three stances for considering the contribution made by diversity in the structuring process and the specific leading role played by those in charge of the structuring process. Through this process, they determined how the actors involved in the project were differentiated, and on what basis those actors were involved. By mobilising enacted diversity, the leaders are seeking to channel the emergence of a network in light of their own representation of that network. This model adds to published research on the structuring of integrated care systems.
Despite over two decades of international experience and research on health systems integration, integrated care has not developed widely. We hypothesized that part of the problem may lie in how we conceptualize the integration process and the complex systems within which integrated care is enacted. This study aims to contribute to discourse regarding the relevance and utility of a complex-adaptive systems (CAS) perspective on integrated care. In the Canadian province of Ontario, government mandated the development of fourteen Local Health Integration Networks in 2006. Against the backdrop of these efforts to integrate care, we collected focus group data from a diverse sample of healthcare professionals in the Greater Toronto Area using convenience and snowball sampling. A semi-structured interview guide was used to elicit participant views and experiences of health systems integration. We use a CAS framework to describe and analyze the data, and to assess the theoretical fit of a CAS perspective with the dominant themes in participant responses. Our findings indicate that integration is challenged by system complexity, weak ties and poor alignment among professionals and organizations, a lack of funding incentives to support collaborative work, and a bureaucratic environment based on a command and control approach to management. Using a CAS framework, we identified several characteristics of CAS in our data, including diverse, interdependent and semi-autonomous actors; embedded co-evolutionary systems; emergent behaviours and non-linearity; and self-organizing capacity. One possible explanation for the lack of systems change towards integration is that we have failed to treat the healthcare system as complex-adaptive. The data suggest that future integration initiatives must be anchored in a CAS perspective, and focus on building the system's capacity to self-organize. We conclude that integrating care requires policies and management practices that promote system awareness, relationship-building and information-sharing, and that recognize change as an evolving learning process rather than a series of programmatic steps.
Comparison of the virtual wards in Croydon, Devon and Wandsworth 
This retrospective study will assess the extent to which multidisciplinary case management in the form of virtual wards (VWs) leads to changes in the use of health care and social care by patients at high risk of future unplanned hospital admission. VWs use the staffing, systems and daily routines of a hospital ward to deliver coordinated care to patients in their own homes. Admission to a VW is offered to patients identified by a predictive risk model as being at high risk of unplanned hospital admission in the coming 12 months. STUDY DESIGN AND DATA COLLECTION METHODS: We will compare the health care and social care use of VW patients to that of matched controls. Controls will be drawn from (a) national, and (b) local, individual-level pseudonymous routine data. The costs of setting up and running a VW will be determined from the perspectives of both health and social care organizations using a combination of administrative data, interviews and diaries. Using propensity score matching and prognostic matching, we will create matched comparator groups to estimate the effect size of virtual wards in reducing unplanned hospital admissions. THIS STUDY WILL ALLOW US TO DETERMINE RELATIVE TO MATCHED COMPARATOR GROUPS: whether VWs reduce the use of emergency hospital care; the impact, if any, of VWs on the uptake of primary care, community health services and council-funded social care; and the potential costs and savings of VWs from the perspectives of the national health service (NHS) and local authorities.
Emergency compulsory admissions per 10,000 inhabitants by neighborhoods in Rotterdam (2000).
Number of days between hospital discharge and the next outpatient contact (in a one year follow-up period).
Patient characteristics and admission criteria for first emergency compulsory admissions by integration of psychiatric services*, and by differences over the 1991-1993 and 2001-2003 periods (change % in brackets)
Over recent years, the number of compulsory admissions in many countries has increased, probably as a result of the shift from inpatient to outpatient mental health care. This might be mitigated by formal or collaborative relationships between services. In a retrospective record linkage study, we compared two neighboring districts, varying in level of service integration. Two periods were combined: 1991-1993 and 2001-2003. We included patients aged 18-60, who had a first emergency compulsory admission (n=830). Their psychiatric history was assessed, and service-use after admission was monitored over a 12-month follow-up. Over a 10-year period, compulsory admission rates increased by 47%. Difference in relative increase between the integrated and non-integrated services was 14%. Patient characteristics showed different profiles in the two districts. Length of stay was >10 days shorter in the integrated district, where the proportion of involuntary readmissions decreased more, and where aftercare was swift and provided to about 10% more patients than in the non-integrated district. Services outcomes showed better results where mental healthcare was more integrated. However, limited effects were found and other factors than integration of services may be more important in preventing compulsory admissions.
Illustration of steps in the coding process 
Integrated framework of core phenomenon, process categories and subcategories illustrating adolescents' transitional process from paediatric to adult diabetes care 
The purpose of this study was to explore how care providers handle the transition process from paediatric to adult diabetes outpatient clinic and to describe their perception of adolescents' needs during this process. Participant observations of patient visits to nurses and physicians and 10 semi-structured interviews with care providers in two paediatric and two adult clinics in Sweden were carried out. Data were analysed using the constant comparative method developed in the grounded theory tradition. The integrated framework developed in the analysis consists of subcategories, process categories and a core phenomenon. The preparation phase showed in this study that preparing transition requires modified strategies. The transition phase implied transferring responsibility and changing care relations while the evaluation phase revealed that care providers are creating mutual understanding through appraisal. All categories are related to the generated core phenomenon: enabling integration through professional meetings. The way care providers construct meeting arenas has a crucial impact on the possibility to bridge uncertainty, insufficient knowledge, routines and strategies. The way participating clinics handle transition greatly influences the process. Professional meetings appeared to be of vital importance to enable the building of bridges between paediatric and adult diabetes care in this study.
Community services are playing an increasing role in supporting older adults who are discharged from hospital with ongoing non-acute care needs. However, there is a paucity of information regarding how community services are involved in the discharge process of older individuals from hospital into the community. Twenty-nine databases were searched from 1980 to 2012 (inclusive) for relevant primary published research, of any study design, as well as relevant unpublished work (e.g. clinical guidelines) which investigated community services' involvement in the discharge of older individuals from hospital into the community. Data analysis and quality appraisal (using McMaster critical appraisal tools) were undertaken predominately by the lead author. Data was synthesised qualitatively. Twelve papers were eligible for inclusion (five randomised controlled trials, four before and after studies and three controlled trials), involving a total of 8440 older adults (>65 years). These papers reported on a range of interventions. During data synthesis, descriptors were assigned to four emergent discharge methods: Virtual Interface Model, In-reach Interface Model, Out-reach Interface Model and Independent Interface Model. In each model, the findings were mixed in terms of health care and patient and carer outcomes. It is plausible that each model identified in this systematic review has a role to play in successfully discharging different cohorts of older adults from hospital. Further research is required to identify appropriate population groups for various discharge models and to select suitable outcome measures to determine the effectiveness of these models, considering all stakeholders' involved.
Quality requirements (QRs)
Introduction Long-term neurological conditions are a major cause of disability in the UK and internationally. Their successful management, in order to enhance health and well-being, requires both sophisticated organisation across a number of health, social care and other service boundaries, and the real involvement of people with neurological conditions and members of their support networks. Policy development This paper reports on part of the preliminary scoping phase of a study designed to evaluate the impact of the National Service Framework for long-term neurological conditions on integrated care. It describes current policies in England and reports on discussions with a range of people involved in the planning, provision or use of services, which took place during the scoping exercise. These interviews inform how policy affecting people with long-term neurological conditions has been received and implemented so far. Conclusion and discussion Findings suggest that progress towards integrated service provision is patchy and slow. In the competing priorities within government policy, neurological conditions have tended to be marginalised, within healthcare policy generally and in initiatives to support people with long-term conditions in particular. The reasons for this are explored and will inform the next stages of the research.
Prevalence of individual care plans in relation to municipality characteristics
Distribution of collaboration activity and documentation tools in working with individual care plans in municipalities (n=61)
A mandatory multidisciplinary plan for individual care, the 'Individual care Plan', was introduced by law in Norway in 2001. The regulation was established to meet the need for improved efficiency and quality of health and social services, and to increase patient involvement. The plan was intended for patients with long-term and complex needs for coordinated care. The aim of this study was to elaborate on knowledge of such planning processes in Norwegian municipalities. A piloted questionnaire was sent to 92 randomly selected municipalities in 2005-2006, addressing local organization and participation in the work with individual care plans. Local political governance, size of the population, funds available for health care, and problems related to living conditions were indicators for analysing the extent to which the individual care plan was used five years after the regulation was introduced. Our results showed that 0.5% as opposed to an expected 3% of the population had an individual care plan. This was independent of the political, social and financial situation in the municipalities or the way the planning process had been carried out. The planning process was mostly taken care of by local health and social care professionals, rather than by hospital staff and general practitioners. The low number of care plans and the oblique responsibility among professionals for planning showed that the objectives of the national initiative had not been achieved. More research is needed to determine the reasons for this lack of success and to contribute to solutions for improved multidisciplinary cooperation.
Top-cited authors
Dennis L Kodner
Cor Spreeuwenberg
  • Maastricht University
Pim P Valentijn
  • Maastricht University
Marc A Bruijnzeels
  • Jan van Es instituut
Sanneke Schepman
  • Nivel – Research for better care