Just a story? Leadership, lived experience and integrated care.

BACKGROUND: Integrated care is based around values of involvement and shared decision-making, but these are not often reflected within planning and implementation. Barriers include continued emphasis on professional and managerial perspectives, skills gaps on how best to engage people and communities and insufficient investment in involvement infrastructure. Despite such challenges, people with lived experience have still led changes in policy and services. DESIGN: Qualitative study involving 25 participants with lived experience from 12 countries. Participants shared their background stories and engaged in semistructured interviews relating to leadership identity, experience of influencing and personal learning. Transcripts were analysed through a framework approach informed by narrative principles. RESULTS: Participants were motivated by their own experiences and a wish to improve care for future individuals and communities. Sharing their story was often the entry point for such influencing. Participants gained skills and confidence in story telling despite a lack of support and development. Many felt comfortable being described as a leader while others rejected this identity and preferred a different title. No common alternative term to leader was identified. Influencing services required considerable personal cost but also led to new networks, skills development and satisfaction when change was achieved. DISCUSSION: Leadership within integrated care is often awarded to those with structural power related to management or clinical seniority. People with lived experience are though uniquely placed to identify what needs to change and can develop inspiring visions based around their personal stories. Claiming identity as leader can be challenging due to traditional notions of who is eligible to lead and unwillingness by professionals and managers to grant such identity. CONCLUSIONS: People with lived experience should be recognised as leaders of integrated care and have access to developmental opportunities and practical support to strengthen their skills, including that of storytelling. PATIENT AND PUBLIC CONTRIBUTION: The research was instigated on the request of a community advisory board of people with lived experience who shaped its design, contributed to the analysis and informed the conclusions and implications.

An International Competency Framework for High-Quality Workforce Development in Integrated Care (IC): A Modified Delphi Study Among Global Participants.

Introduction: There have been increasing calls in the literature recommending training in integrated care (IC) for health and social care professionals. Although studies have focused on different stakeholders' perceptions of education and training, there is no consistent definition of the key competencies or approach to implementing these competencies among health and social care providers. This study used a modified Delphi consensus-building method with global panellists with experience in delivering and designing training in IC to ascertain which competencies are important in an international framework guiding workforce development in IC. Methods: A four-step methodological process was used. First, a scoping review identified a potential list of competencies and features of education and training in IC. Second, predefined criteria were used to identify global panellists with IC education experience. Third, two anonymous iterative Delphi rounds were conducted to (1) reach a consensus on the level of importance of the competencies and key themes to be included and (2) identify existing models of training in IC. This was followed by the analysis of the Delphi study and presentation of the results. Results: A list of eight domains and 40 competencies was generated. Twenty-one panellists reviewed the competencies in the first and second round. The highest importance rankings were allocated to person-centred care, interprofessional teamwork and care coordination. The lower-ranking domains focused on professional workforce attributes. Discussion and conclusion: The study provides a global consensus on the competencies required for workforce training and development in IC and offers recommendations on how these competencies can be implemented in higher education and vocational institutions and workplace settings. The results will be useful for developing policy and curriculum by health and education providers and accreditation bodies.

Trends over time in the deficit of (instrumental) activities of daily living in the Austrian population aged 65 years and older : Results from the Austrian Health Interview Survey series.

BACKGROUND: Difficulties in activities of daily living (ADL) and instrumental activities of daily living (IADL) in older adults are associated with diminished quality of life and increased demand for long-term care. The present study examined the prevalence of disability among individuals aged 65 years and older in Austria, using data from the Austrian Health Interview Surveys (ATHIS). METHODS: The ATHIS 2014 and 2019 surveys were used (N = 5853) for the analysis. Binary logistic regression was performed to measure the association between disability in at least one ADL or IADL limitation and independent variables adjusted for sociodemographic, health-related behavior and survey year. RESULTS: The prevalence of ADL or IADL limitations increased in both sexes during the 5­year follow-up period. For ADL limitations, the prevalence rose from 12.8% to 17.9% in men (p < 0.001) and from 19.2% to 25.7% in women (p < 0.001). The IADL limitations increased from 18.9% to 35.1% in men (p < 0.001) and from 38.2% to 50.8% in women (p < 0.001). Women reported significantly higher odds for ADL (odds ratio [OR]: 1.08, 95% confidence interval [CI]: 0.93-1.26) and IADL limitations (OR: 1.74, 95% CI: 1.53-1.98). In both sexes, participants aged 80 years and older reported higher odds for ADL (OR: 4.37, 95% CI:3.77-5.07) and IADL limitations (OR: 4.43, 95% CI: 3.86-5.09) compared to the younger group. Participants with at least one chronic disease reported higher odds for ADL (OR: 4.00, 95% CI: 3.41-4.70) and IADL limitations (OR: 4.37, 95% CI: 3.85-4.96). Primary education, single status, being born in non-EU/EFTA countries, and residing in Vienna were associated with higher odds of ADL and IADL limitations. CONCLUSION: Gender, age, education, country of birth, residence, partnership status, number of chronic diseases, noncompliance with physical activity, and nutrition recommendations had a strong association with increased vulnerability to disability. Public health policy must address these factors for disability prevention strategies.

Builder, Expert, Disruptor, Leader: The Many Roles of People with Lived Experience.

People with lived experience of health and social care, including family carers, should be at the heart of integrated care policy and practice. One of the challenges to achieving such co-production is insufficient clarity and limited understanding of the different roles that people with lived experience are asked or choose to undertake. Following research and workshops, four roles have been identified - community builder, improvement expert, disruptor/advocate, and citizen leader. Recognising the distinct contribution and demands of these roles will enable appropriate support and development for people with lived experience and the professionals and managers with whom they collaborate.

Workforce Development in Integrated Care: A Scoping Review.

INTRODUCTION: Integrated care aims to improve access, quality and continuity of services for ageing populations and people experiencing chronic conditions. However, the health and social care workforce is ill equipped to address complex patient care needs due to working and training in silos. This paper describes the extent and nature of the evidence on workforce development in integrated care to inform future research, policy and practice. METHODS: A scoping review was conducted to map the key concepts and available evidence related to workforce development in integrated care. RESULTS: Sixty-two published studies were included. Essential skills and competencies included enhancing workforce understanding across the health and social care systems, developing a deeper relationship with and empowering patients and their carers, understanding community needs, patient-centeredness, health promotion, disease prevention, interprofessional training and teamwork and being a role model. The paper also identified training models and barriers/challenges to workforce development in integrated care. DISCUSSION AND CONCLUSION: Good-quality research on workforce development in integrated care is scarce. The literature overwhelmingly recognises that integrated care training and workforce development is required, and emerging frameworks and competencies have been developed. More knowledge is needed to implement and evaluate these frameworks, including the broader health and social care workforces within a global context. Further research needs to focus on the most effective methods for implementing these competencies.

Cost and effects of integrated care: a systematic literature review and meta-analysis.

BACKGROUND: Health and care services are becoming increasingly strained and healthcare authorities worldwide are investing in integrated care in the hope of delivering higher-quality services while containing costs. The cost-effectiveness of integrated care, however, remains unclear. This systematic review and meta-analysis aims to appraise current economic evaluations of integrated care and assesses the impact on outcomes and costs. METHODS: CINAHL, DARE, EMBASE, Medline/PubMed, NHS EED, OECD Library, Scopus, Web of Science, and WHOLIS databases from inception to 31 December 2019 were searched to identify studies assessing the cost-effectiveness of integrated care. Study quality was assessed using an adapted CHEERS checklist and used as weight in a random-effects meta-analysis to estimate mean cost and mean outcomes of integrated care. RESULTS: Selected studies achieved a relatively low average quality score of 65.0% (± 18.7%). Overall meta-analyses from 34 studies showed a significant decrease in costs (0.94; CI 0.90-0.99) and a statistically significant improvement in outcomes (1.06; CI 1.05-1.08) associated with integrated care compared to the control. There is substantial heterogeneity in both costs and outcomes across subgroups. Results were significant in studies lasting over 12 months (12 studies), with both a decrease in cost (0.87; CI 0.80-0.94) and improvement in outcomes (1.15; 95% CI 1.11-1.18) for integrated care interventions; whereas, these associations were not significant in studies with follow-up less than a year. CONCLUSION: Our findings suggest that integrated care is likely to reduce cost and improve outcome. However, existing evidence varies largely and is of moderate quality. Future economic evaluation should target methodological issues to aid policy decisions with more robust evidence on the cost-effectiveness of integrated care.

Methodological Quality of Economic Evaluations in Integrated Care: Evidence from a Systematic Review.

INTRODUCTION: The aim of this review is to systematically assess the methodological quality of economic evaluations in integrated care and to identify challenges with conducting such studies. THEORY AND METHODS: Searches of grey-literature and scientific papers were performed, from January 2000 to December 2018. A checklist was developed to assess the quality of economic evaluations. Authors' statements of challenges encountered during their evaluations were qualitatively coded. RESULTS: Forty-four articles were eligible for inclusion. The review found that study design, measurement of cost and outcomes, statistical analysis and presentation of data were the areas with most quality variation. Authors identified challenges mostly related to time horizon of the evaluation, inadequate or lack of comparator group, contamination bias, and a post-hoc evaluation culture. DISCUSSION: Our review found significant differences in quality, with some studies showing poor methodological rigor; challenging conclusions on the cost-effectiveness of integrated care. CONCLUSION: It is essential for evaluators to use best-practice standards when planning and conducting economic evaluations, in order to build a reliable evidence base for decision-making in integrated care.

The Core Dimensions of Integrated Care: A Literature Review to Support the Development of a Comprehensive Framework for Implementing Integrated Care.

OBJECTIVE: As part of the EU-funded Project INTEGRATE, the research sought to develop an evidence-based understanding of the key dimensions and items of integrated care associated with successful implementation across varying country contexts and relevant to different chronic and/or long-term conditions. This paper identifies the core dimensions of integrated care based on a review of previous literature on the topic. METHODOLOGY: The research reviewed literature evidence from the peer-reviewed and grey literature. It focused on reviewing research articles that had specifically developed frameworks on integrated care and/or set out key elements for successful implementation. The search initially focused on three main scientific journals and was limited to the period from 2006 to 2016. Then, the research snowballed the references from the selected published studies and engaged leading experts in the field to supplement the identification of relevant literature. Two investigators independently reviewed the selected articles using a standard data collection tool to gather the key elements analyzed in each article. RESULTS: A total of 710 articles were screened by title and abstract. Finally, 18 scientific contributions were selected, including studies from grey literature and experts' suggestions. The analysis identified 175 items grouped in 12 categories. CONCLUSIONS: Most of the key factors reported in the literature derive from studies that developed their frameworks in specific contexts and/or for specific types of conditions. The identification and classification of the elements from this literature review provide a basis to develop a comprehensive framework enabling standardized descriptions and benchmarking of integrated care initiatives carried out in different contexts.

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.

[Economic aspects of allergies: status and prospects for Austria]. / Volkswirtschaftliche Aspekte von Allergien. Ausgangslage und Ausblick für Osterreich.

According to epidemiological studies there has been an increase of allergic diseases and corresponding costs. Health economics analyses intend to offer decision guidance towards a more efficient and effective resource distribution, in the conflicting relationship of medicine and economics. In analogy with the "Global Initiative for Asthma (GINA)-study", one arrives at costs of Euro 227.7-455.4 million for the Austrian health system in 2004 for asthma. Direct costs of allergies in general are in part available from health insurance carriers. Between 1998 and 2005 the number of nasal preparations and antiobstructive therapies prescribed rose by 15% and 50% respectively, whilst the costs of these drugs dramatically increased by 96% and 70% respectively. Expenditure on anti-histamines rose by 31% between 2002 and 2004, whereas costs of topical and systemic anti-allergic drugs remained constant. Costs of allergies also include additional costs carried by the individuals affected, which must be added to those covered by the national health insurance carriers. Furthermore, patients with allergies more frequently turn to alternative and complimentary medicine to treat their condition (above all homeopathic remedies, massages and ointments) than people not suffering from allergies. Indirect costs due to allergies are, for instance, those caused by sick leave and loss of productivity. A continual systematic evaluation of available data on allergies in Austria could contribute to more effective implementation of medicines.