Values Underpinning Integrated, People-Centred Health Services: Similarities and Differences among Actor Groups Across Europe.

Introduction: In addition to the functional aspects of healthcare integration, an understanding of its normative aspects is needed. This study explores the importance of values underpinning integrated, people-centred health services, and examines similarities and differences among the values prioritised by actors across Europe. Methods: Explorative cross-sectional design with quantitative analysis. A questionnaire of 18 values was conducted across Europe. A total of 1,013 respondents indicated the importance of each of the values on a nine-point scale and selected three most important values. Respondents were clustered in four actor groups, and countries in four European sub-regions. Results: The importance scores of values ranged from 7.62 to 8.55 on a nine-point scale. Statistically significant differences among actor groups were found for ten values. Statistically significant differences across European sub-regions were found for six values. Our analysis revealed two clusters of values: 'people related' and 'governance and organisation'. Discussion and conclusion: The study found that all 18 values in the set are considered important by the respondents. Additionally, it revealed distinctions in emphasis among the values prioritised by actor groups and across sub-regions. The study uncovered two clusters of values that contribute to a conceptually based definition of integrated, people-centred health services.

Assessing the experience of person-centred coordinated care of people with chronic conditions in the Netherlands: Validation of the Dutch P3CEQ.

BACKGROUND: Countries are adapting their health and social care systems to better meet the needs of growing populations with (multiple) chronic conditions. To guide this process, assessment of the 'patient experience' is becoming increasingly important. For this purpose, the Person-Centred Coordinated Care Experience Questionnaire (P3CEQ) was developed in the United Kingdom, and translated into several languages. AIM: This study aimed to assess the internal and construct validity of the Dutch P3CEQ to capture the experience of person-centred coordinated care of people with chronic conditions in the Netherlands. PARTICIPANTS AND METHODS: Adults with chronic conditions (N = 1098) completed the Dutch P3CEQ, measures of health literacy and patient activation, and reported the use and perceived quality of care services. Data analysis included Principal Component and reliability analysis (internal validity), analysis of variance and Student's T-tests (construct validity). RESULTS: The two-component structure found was pretty much the same as in the UK validation study. Sociodemographic correlates also resembled those found in the United Kingdom. Women, persons who were less educated, less health-literate or less activated experienced less person-centred coordinated care. P3CEQ scores correlated positively with general practitioner performance scores and quality ratings of the total care received. CONCLUSION: The Dutch P3CEQ is a valid instrument to assess the experience of person-centred coordinated care among people with chronic conditions in the Netherlands. Awareness of inequity and more attention to communication skills in professional training are needed to ensure that care professionals better recognize the needs of women, lower educated or less health-literate persons, and improve their experiences of care. PATIENT CONTRIBUTION: The P3CEQ has been developed in collaboration with a range of stakeholders. Eighteen persons with (multiple) chronic conditions participated as patient representatives and codesign experts in (four) codesign workshops. Other patient representatives participated in cognitive testing of the English-language instrument. The usability of the P3CEQ to capture the experience of person-centred coordinated care of older persons has been examined by interviewing 228 older European service users, including 13 living in the Netherlands, as part of the SUSTAIN project. More than a thousand persons with chronic conditions participated in the validation study of the Dutch P3CEQ.

Optimising Integrated Stroke Care in Regional Networks: A Nationwide Self-Assessment Study in 2012, 2015 and 2019.

BACKGROUND: To help enhance the quality of integrated stroke care delivery, regional stroke services networks in the Netherlands participated in a self-assessment study in 2012, 2015 and 2019. METHODS: Coordinators of the regional stroke services networks filled out an online self-assessment questionnaire in 2012, 2015 and 2019. The questionnaire, which was based on the Development Model for Integrated Care, consisted of 97 questions in nine clusters (themes). Cluster scores were calculated as proportions of the activities implemented. Associations between clusters and features of stroke services were assessed by regression analysis. RESULTS: The response rate varied from 93.1% (2012) to 85.5% (2019). Over the years, the regional stroke services networks increased in 'size': the median number of organisations involved and the volume of patients per network increased (7 and 499 in 2019, compared to 5 and 364 in 2012). At the same time, fewer coordinators were appointed for more than 1 day a week in 2019 (35.1%) compared to 2012 (45.9%). Between 2012 and 2019, there were statistically significantly more elements implemented in four out of nine clusters: 'Transparent entrepreneurship' (MD = 18.0% F(1) = 10.693, p = 0.001), 'Roles and tasks' (MD = 14.0% F(1) = 9.255, p = 0.003), 'Patient-centeredness' (MD = 12.9% F(1) = 9.255, p = 0.003), and 'Commitment' (MD = 11.2%, F(1) = 4.982, p = 0.028). A statistically significant positive correlation was found for all clusters between implementation of activities and age of the network. In addition, the number of involved organisations is associated with better execution of implemented activities for 'Transparent entrepreneurship', 'Result-focused learning' and 'Quality of care'. Conversely, there are small but negative associations between the volume of patients and implementation rates for 'Interprofessional teamwork' and 'Patient-centredness'. CONCLUSION: This long-term analyses of stroke service development in the Netherlands, showed that between 2012 and 2019, integrated care activities within the regional stroke networks increased. Experience in collaboration between organisations within a network benefits the uptake of integrated care activities.

Appropriate leadership in nursing home care: a narrative review.

PURPOSE: The purpose of this paper is to synthesize the existing evidence on leadership that best matches nursing home care, with a focus on behaviors, effects and influencing factors. DESIGN/METHODOLOGY/APPROACH: A narrative review was performed in three steps: the establishment of scope, systematic search in five databases and assessment and analysis of the literature identified. FINDINGS: A total of 44 articles were included in the review. The results of the study imply that a stronger focus on leadership behaviors related to the specific context rather than leadership styles could be of added value in nursing home care. RESEARCH LIMITATIONS/IMPLICATIONS: Only articles applicable to nursing home care were included. The definition of "nursing home care" may differ between countries. This study only focused on the academic literature. Future research should focus on strategies and methods for the translation of leadership into behavior in practice. PRACTICAL IMPLICATIONS: A broader and more conceptual perspective on leadership in nursing homes - in which leadership is seen as an attribute of all employees and enacted in multiple layers of the organization - could support leadership practice. ORIGINALITY/VALUE: Leadership is considered an important element in the delivery of good quality nursing home care. This study provides insight into leadership behaviors and influencing contextual factors specifically in nursing homes.

Parkinson Network Eastern Saxony (PANOS): Reaching Consensus for a Regional Intersectoral Integrated Care Concept for Patients with Parkinson's Disease in the Region of Eastern Saxony, Germany.

As integrated care is recognized as crucial to meet the challenges of chronic conditions such as Parkinson's disease (PD), integrated care networks have emerged internationally and throughout Germany. One of these networks is the Parkinson Network Eastern Saxony (PANOS). PANOS aims to deliver timely and equal care to PD patients with a collaborative intersectoral structured care pathway. Additional components encompass personalized case management, an electronic health record, and communicative and educative measures. To reach an intersectoral consensus of the future collaboration in PANOS, a structured consensus process was conducted in three sequential workshops. Community-based physicians, PD specialists, therapists, scientists and representatives of regulatory authorities and statutory health insurances were asked to rate core pathway-elements and supporting technological, personal and communicative measures. For the majority of core elements/planned measures, a consensus was reached, defined as an agreement by >75% of participants. Additionally, six representatives from all partners involved in the network-design independently assessed PANOS based on the Development Model for Integrated Care (DMIC), a validated model addressing the comprehensiveness and maturity of integrated care concepts. The results show that PANOS is currently in an early maturation state but has the potential to comprehensively represent the DMIC if all planned activities are implemented successfully. Despite the favorable high level of consensus regarding the PANOS concept and despite its potential to become a balanced integrated care concept according to the DMIC, its full implementation remains a considerable challenge.

Improving Person-Centredness in Integrated Care for Older People: Experiences from Thirteen Integrated Care Sites in Europe.

INTRODUCTION: Although person-centredness is a key principle of integrated care, successfully embedding and improving person-centred care for older people remains a challenge. In the context of a cross-European project on integrated care for older people living at home, the objective of this paper is to provide insight at an overarching level, into activities aimed at improving person-centredness within the participating integrated care sites. The paper describes experiences with these activities from the service providers' and service users' perspectives. METHODS: A multiple embedded case study design was conducted that included thirteen integrated care sites for older people living at home. RESULTS: Service providers were positive about the activities that aimed to promote person-centred care and thought that most activities (e.g. comprehensive needs assessment) positively influenced person-centredness. Experiences of service users were mixed. For some activities (e.g. enablement services), discrepancies were identified between the views of service providers and those of service users. DISCUSSION AND CONCLUSION: Evaluating activities aimed at promoting person-centredness from both the service providers' and service users' perspectives showed that not all efforts were successful or had the intended consequences for older people. Involvement of older people in designing improvement activities could ensure that care and support reflect their needs and preferences, and build positive experiences of care and support.

Comparing International Models of Integrated Care: How Can We Learn Across Borders?

INTRODUCTION: Providers, managers, health system leaders, and researchers could learn across countries implementing system-wide models of integrated care, but require accessible methods to do so. This study assesses if a common framework could describe and compare key components of international models of integrated care. THEORY AND METHODS: A framework developed for an international study of programs that address high needs high cost patients was used to describe and compare 11 case studies analyzed in two international research projects; the Implementing Integrated Care for Older Adults with Complex Health Needs (iCOACH) study in Canada and New Zealand, and the Vilans research group exploring models in the Netherlands. Comparative summaries were generated, with findings discussed at a 2019 International Conference on Integrated Care workshop. RESULTS: The template was found to be useful to compare integrated case analyses in different contexts, and stands apart from other case comparison approaches as it is easily applied and can provide practical guidance for frontline staff and managers. Areas of improvement for the template are identified and two updated versions are presented. CONCLUSIONS AND DISCUSSION: There is value to using a common template to provide guidance in international comparison of models of integrated care. We discuss the applicability of the approach to support scale and spread of integrated care internationally.

Towards a values framework for integrated health services: an international Delphi study.

BACKGROUND: In order to organize person-centered health services for a growing number of people with multiple complex health and social care needs, a shift from fragmented to integrated health services delivery has to take place. For the organization of governance in integrated health services, it is important to better understand the underlying factors that drive collaboration, decision-making and behavior between individuals and organizations. Therefore, this article focuses on these underlying normative aspects of integrated health services. This study investigates the values that underpin integrated health services delivery as a concept, by examining the extent to which an initial literature based set of underlying values underpins integrated care and the relevance of these values on the different levels of integration. METHODS: An international Delphi study with 33 experts from 13 different countries was carried out to examine the initial set of underlying values of integrated health services. In addition, the relevance of the values was assessed on the different levels of integration: personal level, professional level, management level and system level. RESULTS: The study resulted in a refined set of 18 values of integrated health services developed in three Delphi study rounds. In addition, the results provided insight into the relevance of these values on the personal level (e.g. 'trustful'), professional level (e.g. 'collaborative'), management level (e.g. 'efficient') and system level (e.g. 'comprehensive') of integration. Some of the values score consistent across the different levels of integration while other values score inconsistent across these levels. CONCLUSIONS: The Delphi study resulted in an international normative basis for integrated health services delivery as a concept. The values can be used as ingredients for a values framework and provide a better understanding of the normative aspects of integrated health services delivery. Future research could focus on associated behaviors in practice, the relationship between normative integration and governance, and differences between the value priorities of stakeholder groups.

Values of Integrated Care: A Systematic Review.

INTRODUCTION: Although substantial generic knowledge about integrated care has been developed, better understanding of the factors that drive behaviour, decision-making, collaboration and governance processes in integrated care networks is needed to take integrated care forward. To gain more insight into these topics and to understand integrated care in more depth, a set of underlying values of integrated care has been developed and defined in this study. THEORY AND METHODS: A systematic literature review was conducted to identify the underlying values of integrated care. Values theory was used as a theoretical framework for the analysis. RESULTS: This study identified 23 values in the current body of knowledge. The most frequently identified values are 'collaborative', 'co-ordinated', 'transparent', 'empowering', 'comprehensive', 'co-produced' and 'shared responsibility and accountability'. DISCUSSION AND CONCLUSION: The set of values is presented as a potential basis for a values-driven approach to integrated care. This approach enables better understanding of the behaviours and collaboration in integrated care and may also be used to develop guidance or governance in this area. The practical application of the values and their use at multiple levels is discussed. The consequences of different stakeholder perceptions on the values is explored and an agenda for future research is proposed.

Service Integration Across Sectors in Europe: Literature and Practice.

INTRODUCTION: To meet the needs of vulnerable people, the integration of services across different sectors is important. This paper presents a preliminary review of service integration across sectors in Europe. Examples of service integration between social services, health, employment and/or education were studied. A further aim of the study was to improve conceptual clarity regarding service integration across sectors, using Minkman's Developmental Model for Integrated Care (DMIC) as an analytical framework. METHODS: The study methods comprised a literature review (34 articles) and a survey of practice examples across Europe (44 practices). This paper is based on a more comprehensive study published in 2016. RESULTS: The study demonstrates that although the focus of integration across sectors is often on social services and health care, other arrangements are also frequently in place. The review shows that integration may be either tailored to a particular target group or designed for communities in general. Although systems to monitor and evaluate social service integration are often present, they are not yet fully developed. The study also highlights the importance of good leadership and organizational support in integrated service delivery. DISCUSSION: The study shows that the DMIC can work as a conceptual framework for the analysis of service integration across sectors. However, as this is an exploratory study, further in-depth case studies are required to deepen our understanding of the processes involved in service integration across sectors.

The SUSTAIN Project: A European Study on Improving Integrated Care for Older People Living at Home.

INTRODUCTION: Integrated care programmes are increasingly being put in place to provide care to older people who live at home. Knowledge of how to further develop integrated care and how to transfer successful initiatives to other contexts is still limited. Therefore, a cross-European research project, called Sustainable Tailored Integrated Care for Older People in Europe (SUSTAIN), has been initiated with a twofold objective: 1. to collaborate with local stakeholders to support and monitor improvements to established integrated care initiatives for older people with multiple health and social care needs. Improvements focus on person-centredness, prevention orientation, safety and efficiency; 2. to make these improvements applicable and adaptable to other health and social care systems, and regions in Europe. This paper presents the overall structure and approach of the SUSTAIN project. METHODS: SUSTAIN uses a multiple embedded case study design. In three phases, SUSTAIN partners: (i) conduct interviews and workshops with stakeholders from fourteen established integrated care initiatives to understand where they would prefer improvements to existing ways of working; (ii) collaborate with local stakeholders to support the design and implementation of improvement plans, evaluate implementation progress and outcomes per initiative, and carry out overarching analyses to compare the different initiatives, and; (iii) translate knowledge and experience to an online roadmap. DISCUSSION: SUSTAIN aims to generate evidence on how to improve integrated care, and apply and transfer the knowledge gained to other health and social care systems, and regions. Lessons learned will be brought together in practical tools to inform and support policy-makers and decision-makers, as well as other stakeholders involved in integrated care, to manage and improve care for older people living at home.

The development of integrated diabetes care in the Netherlands: a multiplayer self-assessment analysis.

BACKGROUND: Since recent years Dutch diabetes care has increasingly focused on improving the quality of care by introducing the concept of care groups (in Dutch: 'zorggroepen'), care pathways and improving cooperation with involved care professionals and patients. This study examined how participating actors in care groups assess the development of their diabetes services and the differences and similarities between different stakeholder groups. METHODS: A self-evaluation study was performed within 36 diabetes care groups in the Netherlands. A web-based self-assessment instrument, based on the Development Model for Integrated Care (DMIC), was used to collect data among stakeholders of each care group. The DMIC defines nine clusters of integrated care and four phases of development. Statistical analysis was used to analyze the data. RESULTS: Respondents indicated that the diabetes care groups work together in well-organized multidisciplinary teams and there is clarity about one another's expertise, roles and tasks. The care groups can still develop on elements related to the management and monitoring of performance, quality of care and patient-centeredness. The results show differences (p < 0.01) between three stakeholders groups in how they assess their integrated care services; (1) core players, (2) managers/directors/coordinators and (3) players at a distance. Managers, directors and coordinators assessed more implemented integrated care activities than the other two stakeholder groups. This stakeholder group also placed their care groups in a further phase of development. Players at a distance assessed significantly less present elements and assessed their care group as less developed. CONCLUSIONS: The results show a significant difference between stakeholder groups in the assessment of diabetes care practices. This reflects that the professional disciplines and the roles of stakeholders influence the way they asses the development of their integrated care setting, or that certain stakeholder groups could be less involved or informed.