Implementation of an integrated community approach in deprived neighbourhoods: a theory-based process evaluation using the Consolidated Framework for Implementation Research (CFIR).

BACKGROUND: We investigated the implementation process of an Integrated Community Approach (ICA) applied in four low socio-economic status neighbourhoods in Maastricht, the Netherlands. The ICA is a Population Health Management initiative and aims to improve population health, quality of care, professional's satisfaction and decrease costs of care. This study addresses the facilitators and barriers for implementing the ICA from a stakeholder perspective, including steering group members, professionals and citizens. METHODS: We conducted a mixed-methods study using a triangulation of methods to investigate the implementation from 1 December 2016 to 31 December 2020. The Consolidated Framework for Implementation Research guided data collection and data-analysis for evaluating the implementation process. In total, 77 interviews, 97 observations, seven focus groups, 65 collected documents and two surveys with open-ended questions were conducted. RESULTS: Facilitators for implementation were the use of citizen science to bring residents' needs into sharp focus, the integration of the ideology of Positive Health into the working routines of the professionals and leadership at the steering group level to overcome barriers in the ICA. The existing accounting and financial infrastructure obstructed combining budgets at neighbourhood level. CONCLUSIONS: Engaging citizens and professionals at an early stage is an important facilitator for implementation. The use of a shared vision on health also worked as a facilitator since it created a shared language among professionals, which is important in Population Health Management initiatives where multiple professionals are expected to collaborate. TRIAL REGISTRATION: NTR 6543; registration date, 25 July 2017.

Collaborative governance at the start of an integrated community approach: a case study.

BACKGROUND: We studied collaborative governance at the start of an integrated community approach aiming to improve population health, quality of care, controlling health care costs and improving professional work satisfaction. Our objective was to investigate which characteristics of collaborative governance facilitate or hamper collaboration in the starting phase. This question is of growing importance for policymakers and health initiatives, since on a global scale there is a shift towards 'population health management' where collaboration between stakeholders is a necessity. In addition, it is crucial to investigate collaborative governance from the beginning, since it offers opportunities for sustainability of collaboration later on in the process. METHODS: We performed a qualitative case study in four deprived neighbourhoods in the city of Maastricht, the Netherlands. An integrated community approach was implemented, involving various stakeholders from the public and private health sectors and provincial and local authorities. Data was collected from December 2016 to December 2018, with a triangulation of methods (50 observations, 24 interviews and 50 document reviews). The Integrative Framework for Collaborative Governance guided data collection and analysis. RESULTS: We focused on the dynamics within the collaborative governance regime, consisting of principled engagement, shared motivation and capacity for joint action. We found that shared goalsetting, transparency, being physically present, informal meetings, trust and leadership are key aspects at the start of collaborative governance. An extensive accountability structure can both hamper (time-consuming which hinders innovation) and facilitate (keep everybody on board) collaboration. The characteristics we found are of significance for policy, practice and research. Policymakers and practitioners can use our lessons learned for implementing similar (population health) initiatives. This case study contributes to the already existing literature on collaborative governance adding to the knowledge gap on the governance of population health approaches. TRIAL REGISTRATION: NTR6543 , registration date; 25 July 2017.

Positive Health beyond boundaries in community care: design of a prospective study on the effects and implementation of an integrated community approach.

BACKGROUND: High healthcare expenditures due to population ageing and chronic complex health complaints are a challenge on a global scale. To improve the quality of healthcare, population health, and professionals' work satisfaction and to reduce healthcare costs (Quadruple Aim), the Dutch Ministry of Health, Welfare and Sport designated nine pioneer site regions across the Netherlands. One of these pioneer sites is the integrated community approach (ICA) known as 'Blue Care'. This article describes the design of a prospective study investigating the effects of Blue Care ICA on Quadruple Aim outcomes and a process evaluation focussing on its implementation in deprived neighbourhoods. METHODS: A mixed-methods approach, combining both quantitative and qualitative research methods, is applied to yield an enriched understanding of the various processes that will take place in the neighbourhoods. A prospective, quasi-experimental study is conducted within a natural experiment. Blue Care ICA is being implemented between 2017 and 2020 and research activities are taking place parallel to the implementation process. Effects of Blue Care ICA are measured at T0 (baseline), T1 (after 1 year), T2 (after 2 years) and at T3 (after 3 years) using a questionnaire. The primary outcome measure is health-related quality of life (SF-12v2), secondary outcomes are health status (EQ-5D-5 L), resilience (RS-Scale), Positive Health (Spiderweb diagram) and quality of care (grade 0-10). As part of the process evaluation, the Consolidated Framework for Implementation Research guided the formulation of process evaluation questions. Participant observations, interviews and focus groups with all stakeholders active in the Blue Care ICA will be conducted during the whole implementation period (2017-2020). DISCUSSION: The evaluation takes into account the interconnections between content, application, context and outcomes to understand how the Blue Care ICA unfolds over time in a complex, dynamic setting. Results of the effect and process evaluation will become available in 2020. TRIAL REGISTRATION: NTR 6543 , registration date; 25 July 2017.

Citizen science in the community: Gaining insight in community and participant health in four deprived neighbourhoods in the Netherlands.

The aim of this study was to examine if citizen science contributes to gaining insight into community health and to the health of the citizen scientists themselves. Therefore, thirteen citizens in four deprived neighbourhoods were trained as citizen scientists to conduct research in their own communities. Results showed that the citizen scientists identified forty (health related) themes in their communities. The citizen scientists reported an increase in their overall self-perceived health which, however, was not significantly demonstrated in the prequestionnaire and postquestionnaire.