Providing holistic end-of-life care for people with a history of problem substance use: a mixed methods cohort study of interdisciplinary service provision and integrated care.

Harmful use of illicit drugs and/or alcohol is linked to life-limiting illness and complex health and social care needs, but people who use substances and have complex needs do not receive timely palliative care and fail to achieve quality standards for a good death. They and their families often require support from multiple health and social care services which are shown to be poorly integrated and fail to deliver interdisciplinary care. This study aimed to identify the existing barriers and facilitators within and between services in providing this population with a good death. Using a mixed methods approach of survey, focus groups and semi-structured interviews, we explored the perspectives of practitioner and management staff across a range of health and social disciplines and organisations in one combined authority in a large city in the north west of England. Our findings indicate that practitioners want to provide better care for this client group, but face structural, organisational and professional boundary barriers to delivering integrated and shared care. Differences in philosophy of care, piecemeal commissioning and funding of services, and regulatory frameworks for different services, lead to poor and inequitable access to health and social care services. Ways forward for improving care are suggested as bespoke hostel-based accommodation for palliative care for this client group, and specialist link workers who can transcend professional and organisational boundaries to support co-ordination of services and support. We conclude that it is no longer adequate to call for more training, better communication and improved joint working. Complex care at the end of life requires creative and cohesive systemic responses that enable multi-disciplinary practitioners to provide the care they wish to give and enables individuals using substances to get the respect and quality service they deserve.

Mental health practices in rehabilitation for youth with physical disabilities: a chart review study.

PURPOSE: Evidence on co-occurring mental health problems in youth with physical disabilities is growing, however how services are provided remains unclear. This study examined current interprofessional rehabilitation practices for physical and mental health services. METHODS: Youth (aged 15-24) followed for a physical disability that had mental health problems were identified. Chart reviews were used to identify practices. Mental health-related diagnoses/symptoms, assessments, goals, interventions, and referrals were extracted for inductive content analysis. RESULTS: Sixty charts were reviewed. Mental health problems included anxiety (n = 53), depression (n = 25), neurodevelopmental (n = 19) and personality disorders (n = 8), often (n = 36) citing more than one. No mental health assessments were found, and in 43%, no goals or interventions were evident. Relevant goals (n = 98) targeted emotional management, autonomy/communication of needs, acceptance of physical condition, socialization, routines/energy levels, school/work supports, and leisure/calming environments. Interventions (n = 104) included emotional management, formal individual/group therapy, links with external supports, routines/activities, reflection/acceptance, and school/work support. Mental health services were received in-house (n = 24) and/or externally (n = 30), plus 18 referrals pending and 14 not referred. CONCLUSION: Many had more than one mental health problem, suggesting the complexity of their condition. While some mental health goals/interventions are documented, problems may often not be reported or addressed in this context.

Further attention can be directed to the needs of youth with physical disabilities and co-occurring mental health problems as they are not fully addressed by current interdisciplinary rehabilitation practices.Follow-up (services and referrals) should be adapted to the holistic needs of youth and their goals within the rehabilitation context.Rehabilitation professionals can be provided with training to build workforce capacity in mental health screening and have access to guidance when addressing situations related to mental health or referring to external services.

Competition, quality and integrated health care.

Integration of health care services has been promoted in several countries to improve the quality and coordination of care. We investigate the effects of such integration in a model where providers compete on quality to attract patients under regulated prices. We identify countervailing effects of integration on quality of care. While integration makes coordination of care more profitable for providers due to bundled payments, it also softens competition as patient choice is restricted. We also identify circumstances due to asymmetries across providers and/or services under which integration either increases or reduces the quality of services provided. In the absence of synergies, integration generally leads to increases in quality for some services and reductions for others. The corresponding effect on health benefits depends largely on whether integration leads to quality dispersion or convergence across services. If the softening of competition effect is weak, integration is likely to improve quality and patient outcomes.

Factors Influencing the Integration of Traditional Medicine and Mainstream Medicine in Mental Health Services in West Africa: A Systematic Review Using Narrative Synthesis.

This study explored the enablers and obstacles to the integration of traditional medicine and mainstream medicine in mental health services in West Africa. This study is a systematic review conducted in accordance with the relevant parts of the Preferred Reporting Items for Systematic reviews and Meta-analyses. Keywords searches were done in databases, and other reference lists were also searched. The Rainbow model of integrated care and a thematic analysis framework were used to account for the factors influencing the integration of traditional medicine and mainstream medicine in mental health services in West Africa. A total of 12 studies met the eligibility criteria after the evaluation of 6413 articles from databases and reference lists. The themes of: policy and implementation; different conceptualisation of mental health/referrals; trust issues, and education and training, were enablers or obstacles of integration depending on how they worked to facilitate or hinder integration. There was an indication of little integration of TM and MM at the macro, meso and micro levels in mental health services in West Africa. Though the study does cover all the West African states evenly, it is recommended that policy-makers and stakeholders interested in integration should ensure integration activities, especially policies, cut across all the levels of the rainbow model of integrated care and are planned and aligned at the macro, meso and micro levels instead of using ad hoc measures, informal initiatives or placing TM services in MM mental health services, which do not amount to integration.

Value-Based Integrated Care: A Systematic Literature Review.

BACKGROUND: Healthcare services worldwide are transforming themselves into value-based organizations. Integrated care is an important aspect of value-based healthcare (VBHC), but practical evidence-based recommendations for the successful implementation of integrated care within a VBHC context are lacking. This systematic review aims to identify how value-based integrated care (VBIC) is defined in literature, and to summarize the literature regarding the effects of VBIC, and the facilitators and barriers for its implementation. METHODS: Embase, Medline ALL, Web of Science Core Collection, and Cochrane Central Register of Controlled Trails databases were searched from inception until January 2022. Empirical studies that implemented and evaluated an integrated care intervention within a VBHC context were included. Non-empirical studies were included if they described either a definition of VBIC or facilitators and barriers for its implementation. Theoretical articles and articles without an available full text were excluded. All included articles were analysed qualitatively. The Rainbow Model of Integrated Care (RMIC) was used to analyse the VBIC interventions. The quality of the articles was assessed using the Mixed Methods Appraisal Tool (MMAT). RESULTS: After screening 1328 titles/abstract and 485 full-text articles, 24 articles were included. No articles were excluded based on quality. One article provided a definition of VBIC. Eleven studies reported-mostly positive- effects of VBIC, on clinical outcomes, patient-reported outcomes, and healthcare utilization. Nineteen studies reported facilitators and barriers for the implementation of VBIC; factors related to reimbursement and information technology (IT) infrastructure were reported most frequently. CONCLUSION: The concept of VBIC is not well defined. The effect of VBIC seems promising, but the exact interpretation of effect evaluations is challenged by the precedence of multicomponent interventions, multiple testing and generalizability issues. For successful implementation of VBIC, it is imperative that healthcare organizations consider investing in adequate IT infrastructure and new reimbursement models. Systematic Review Registration: PROSPERO (CRD42021259025).

Integrated Care Model by the Village Health Volunteers to Prevent and Slow down Progression of Chronic Kidney Disease in a Rural Community, Thailand.

INTRODUCTION: Chronic kidney disease (CKD) is a major health problem in Thailand and health behaviors are central to its risk and progression. Because of the shortage of healthcare personnel, village health volunteers (VHVs) have been collaborating in the primary health care system. However, the contribution of VHVs to CKD reduction has not been evaluated yet. This study aimed to evaluate the efficacy of the VHV-integrated model in preventing and slowing down CKD and its risk factors. METHODS: The population-based cohort study was conducted in a rural community of Thailand between 2017 and 2019. Baseline clinical and behavioral characteristics including CKD, diabetes, hypertension, and other high-risk factors of the participants were collected. The integrated care model was initiated by the multidisciplinary care team that facilitated, empowered, and trained VHVs targeting risk factors of CKD, health literacy, and health promotion. Then the participants were educated and trained for lifestyle modification and were monitored continuously for 18 months by VHVs. Changes in the CKD risk factors, and kidney functions before and after the application of integrated care model were compared. RESULTS: A total of 831 subjects participated in the study with an average age of 57.5 years, and 69.5% were female. Among them, 222 participants (26.7%) were diagnosed as having CKD, the vast majority (95%) of which were in the early stages (G1-G3 and A1-A2). CKD risk factors such as high salt intake, smoking, alcohol consumption, self-NSAID (non-steroidal anti-inflammatory drugs) use were significantly decreased after application of the care model. Also, hemoglobin A1c was significantly reduced in diabetic patients, and blood pressure was controlled better than before in the hypertensive patients. Most importantly, a decline of estimated glomerular filtration rate of the CKD group was improved and lower than the non-CKD group. CONCLUSION: The integrated care model through VHV significantly attenuated the risk factors associated with CKD in the general and high-risk population and effectively slowed down the progression of CKD.

Understanding Mental Health Challenges in Cardiovascular Care.

There is a profound link between cardiovascular health and mental well-being. This narrative review shows that heart and mental health are not isolated domains but deeply interconnected, influencing each other. It describes how cardiovascular diseases (CVDs) can cause mental health issues such as stress, anxiety, and depression. It also explains how these mental conditions can, in turn, worsen or raise the risk of CVDs. In addition, it emphasizes the necessity of a holistic approach to healthcare that integrates the treatment of physical symptoms of CVDs with interventions aimed at addressing mental health issues. This approach advocates for comprehensive care strategies that include psychotherapy, pharmacological treatments, lifestyle modifications, and digital health technologies. It also highlights the significant role of family and social support in recovery and discusses barriers to integrating mental health care in cardiovascular treatment. The article argues for a paradigm shift in healthcare towards more inclusive and integrated care models. The authors hope to foster a healthcare environment that prioritizes holistic care by increasing awareness about the connection between heart and mind. The call to action includes policy changes and healthcare system reforms aimed at facilitating the integration of mental health services into cardiovascular care, ultimately leading to improved outcomes for patients with CVDs and associated mental health issues.

A call for action to include psychosocial management into holistic, integrated care for patients with atrial fibrillation.

Contemporary management of atrial fibrillation (AF) has become increasingly complex. Therefore, strong efforts have been made during the past decade to develop models for structured, integrated care for patients with AF. These have also been incorporated in international guidelines for the management of patients with AF. However, implementation of integrated care approaches in daily clinical practice is scarce and far from optimal, and it may require a re-thinking of the structure of the healthcare system. The reasons for the poor implementation are many, from limited time and economic resources to deficits in postgraduate education of healthcare professionals, lack of involvement of patients in how integrated care should be designed, and fragmentation of the healthcare system. Moreover, patients' psychological challenges, which not only impact patients' adherence to treatment but, if untreated, increase their risk of morbidity, mortality, and poor quality of life, are not given sufficient attention. It is time to start a necessary discussion of what integrated care should be, what it should contain, and what is necessary to implement it in daily clinical practice.

Perceptions and Experiences of Parents of Burn-Injured Children during Hospital Stay: A Need for Integrated Care.

Pediatric burn injuries are a critical medical condition that triggers a series of ongoing multifactorial stressors that affect both children and their families. To inform healthcare research and clinical practice, this study aimed to understand and describe the perceptions and experiences of the parents of burn-injured children during hospital stay. Forty-six parents (thirty-eight mothers) of forty-six children (eighteen girls) with a mean age of 2.28 years (SD = 1.52) answered ten open-ended questions. This qualitative study was conducted in a referral hospital in the northern region of Portugal. Qualitative data were analyzed using an inductive content analysis. Five key themes emerged from the data analysis: diving into the crisis of the child burn injury, being together and in good hands, becoming aware of an uncertain future, enhancing supportive care and environment, and finding ways to guide parents. Qualitative findings underlined the pressing need for integrated care within this context. Parents were significantly burdened and distressed during the inpatient phase. These parents should be included in the integrated care plan starting from admission. Understanding and addressing parents' healthcare needs and psychosocial adjustment difficulties is paramount to the development of future intervention programs and the delivery of suitable integrated healthcare.

Tackling social inequalities in health: Assessing contexts for implementing integrated health access for people with severe mental illness.

Social inequalities in health are a complex problem that often emerge at the interfaces between different sectors, such as health and social care, and the corresponding transitions between different provider organisations. Vulnerable people are typically in greater need of accessing different sectors of the health system and therefore often experience lack of coherence in their treatment pathway. We aimed to examine the contexts of health systems that influence initiatives concerned with integrated health access. We used the theory of Organizational Fields to study the contexts for implementing Flexible Assertive Community Treatment (FACT) in Central Denmark Region and three municipalities in the region. We collected 33 documents and conducted six qualitative interviews with professionals involved in FACT to understand the contexts of implementing integrated health access. We found that contexts for implementing FACT are highly complex, as they are divided between health and social care (horizontal complexity) and between national and the sub-national levels of the region and the municipalities (vertical complexity). This leads to conflicting demands on implementation. Local contexts of collaboration may offer a lever to handle these demands, but these are likely to vary. Analysis of how complex health system contexts influence implementation is important to understand how changes might become sustainable and help to tackle social inequalities in health.

An Integrated Care Pathway for depression in adolescents: protocol for a Type 1 Hybrid Effectiveness-implementation, Non-randomized, Cluster Controlled Trial.

INTRODUCTION: Our group developed an Integrated Care Pathway to facilitate the delivery of evidence-based care for adolescents experiencing depression called CARIBOU-2 (Care for Adolescents who Receive Information 'Bout OUtcomes, 2nd iteration). The core pathway components are assessment, psychoeducation, psychotherapy options, medication options, caregiver support, measurement-based care team reviews and graduation. We aim to test the clinical and implementation effectiveness of the CARIBOU-2 pathway relative to treatment-as-usual (TAU) in community mental health settings. METHODS AND ANALYSIS: We will use a Type 1 Hybrid Effectiveness-Implementation, Non-randomized Cluster Controlled Trial Design. Primary participants will be adolescents (planned n = 300, aged 13-18 years) with depressive symptoms, presenting to one of six community mental health agencies. All sites will begin in the TAU condition and transition to the CARIBOU-2 intervention after enrolling 25 adolescents. The primary clinical outcome is the rate of change of depressive symptoms from baseline to the 24-week endpoint using the Childhood Depression Rating Scale-Revised (CDRS-R). Generalized mixed effects modelling will be conducted to compare this outcome between intervention types. Our primary hypothesis is that there will be a greater rate of reduction in depressive symptoms in the group receiving the CARIBOU-2 intervention relative to TAU over 24 weeks as per the CDRS-R. Implementation outcomes will also be examined, including clinician fidelity to the pathway and its components, and cost-effectiveness. ETHICS AND DISSEMINATION: Research ethics board approvals have been obtained. Should our results support our hypotheses, systematic implementation of the CARIBOU-2 intervention in other community mental health agencies would be indicated.

"We have to change our mindsets": a qualitative study of barriers and facilitators in research collaboration across integrated care system organisations.

The introduction of Integrated Care Systems (ICS) in England aimed to increase joint planning and delivery of health and social care, and other services, to better meet the needs of local communities. There is an associated duty to undertake collaborative research across ICS partners to inform this new integrated approach, which might be challenging given that organisations span health, local authority, voluntary and community sector, and research. This study aimed to explore the appetite for collaborative Research and Innovation (R&I) across ICSs, potential barriers and solutions. This qualitative study involved semi-structured interviews with 24 stakeholders who held senior positions within organisations across two ICS areas (Staffordshire and Stoke-on-Trent; Shropshire, Telford and Wrekin). Interview transcripts were analysed using inductive and deductive analysis, first mapping to the Theoretical Domains Framework (TDF), then considering key influences on organisational behaviour in terms of Capability, Opportunity and Motivation from the COM-B Behaviour Change Wheel. There were fundamental limitations on organisational opportunities for collaborative R&I: a historical culture of competition (rather than collaboration), a lack of research culture and prioritisation, compounded by a challenging adverse economic environment. However, organisations were motivated to undertake collaborative R&I. They recognised the potential benefits (e.g., skill-sharing, staff development, attracting large studies and funding), the need for collaborative research that mirrors integrated care, and subsequent benefits for care recipients. Related barriers included negative experiences of collaboration, fear of failing and low confidence. Capability varied across organisations in terms of research skills and confidence, which reflected the range of partners (from local authorities to NHS Trusts, primary care, and academic institutions). These findings indicate a need to shift from a culture of competition to collaboration, and to help organisations across ICS to prioritise research, and share resources and skills to mitigate the limiting effects of a constrained economic environment. This could be further explored using a systems change approach, to develop the collaborative research efforts alongside the overarching move towards integrated care.

What Attributes of Integrated Health Care for Mental Health Are the Most Important to Potential Consumers? A Relative Ranking Study.

Integrated health care (IHC) is efficacious, cost-effective, and more attractive to some consumers than traditional standalone psychotherapy, but the specific characteristics of IHC that drive this enhanced attraction have yet to be explored among potential future mental health consumers. As such, this brief report documents the results of a survey of 428 US adults who were asked to rank order the relative personal importance of seven characteristics (e.g., self-stigma mitigation, prompt appointment, saving money). These seven characteristics have been characterized in the IHC literature as potential beneficial elements of seeking mental health care from a provider in certain integrated health care settings. Getting sufficient information about one's health and treatment from one's provider was rated as most important, whereas co-location of mental/medical care and treatment privacy were rated as least important. The authors found evidence for select hypothesized demographic effects (e.g., interprovider communication rated more important for older adults) on how these factors were ranked. Professionals invested in developing and improving mental health care systems that are attractive and accessible to consumers in need of mental health care can consider the present findings when making decisions about which characteristics (e.g., getting sufficient information) should be maximized in the design and marketing of such systems. Future research, particularly longitudinal studies that assess prospective treatment seeking behavior, can build on the present study by examining the degree to which these attributes attract consumers to IHC settings.

Paediatric Rheumatology Fails to Meet Current Benchmarks, a Call for Health Equity for Children Living with Juvenile Idiopathic Arthritis, Using Digital Health Technologies.

PURPOSE OF REVIEW: This critical review begins by presenting the history of Juvenile Idiopathic Arthritis (JIA) management. To move the conversation forward in addressing the current shortcomings that exist in the clinical management of children living with JIA, we argue that to date, the advancement of successful treatments for JIA has been historically slow. Factors implicated in this situation include a lack of rigorous research, JIA being considered a rare disease, and JIA's idiopathic and complex pathophysiology. RECENT FINDINGS: Despite the well-intended legislative changes to increase paediatric research, and the major advancements seen in molecular medicine over the last 30 years, globally, paediatric rheumatology services are still failing to meet the current benchmarks of best practice. Provoking questions on how the longstanding health care disparities of poor access and delayed treatment for children living with JIA can be improved, to improve healthcare outcomes. Globally, paediatric rheumatology services are failing to meet the current benchmarks of best practice. Raising awareness of the barriers hindering JIA management is the first step in reducing the current health inequalities experienced by children living with JIA. Action must be taken now, to train and well-equip the paediatric rheumatology interdisciplinary workforce. We propose, a resource-efficient way to improve the quality of care provided could be achieved by embedding digital health into clinical practice, to create an integrative care model between the children, general practice and the paediatric rheumatology team. To improve fragmented service delivery and the coordination of interdisciplinary care, across the healthcare system.

Inter-relationships between cardiovascular, renal and metabolic diseases: Underlying evidence and implications for integrated interdisciplinary care and management.

Cardiovascular, renal and metabolic (CaReMe) diseases are individually among the leading global causes of death, and each is associated with substantial morbidity and mortality. However, as these conditions commonly coexist in the same patient, the individual risk of mortality and morbidity is further compounded, leading to a considerable healthcare burden. A number of pathophysiological pathways are common to diseases of the CaReMe spectrum, including neurohormonal dysfunction, visceral adiposity and insulin resistance, oxidative stress and systemic inflammation. Because of the shared pathology and common co-occurrence of the CaReMe diseases, the value of managing these conditions holistically is increasingly being realized. A number of pharmacological and non-pharmacological approaches have been shown to offer simultaneous metabolic, cardioprotective and renoprotective benefits, leading to improved patient outcomes across the CaReMe spectrum. In addition, increasing value is being placed on interdisciplinary team-based and coordinated care models built on greater integration between specialties to increase the rate of early diagnosis and adherence to practice guidelines, and improve clinical outcomes. This interdisciplinary approach also facilitates integration between primary and specialty care, improving the patient experience, optimizing resources, and leading to efficiencies and cost savings. As the burden of CaReMe diseases continues to increase, implementation of innovative and integrated care delivery models will be essential to achieve effective and efficient chronic disease management and to ensure that patients benefit from the best care available across all three disciplines.

Evaluation of Health-Related Quality of Life in Adolescents With Obesity: A Randomized Qualitative Study Among Healthcare Professionals.

Adolescent obesity constitutes a disorder with physical and psychosocial implications. Childhood and adolescent obesity rates are constantly increasing worldwide. Since adolescent obesity is a chronic disease, which is part of noncommunicative degenerative diseases, its holistic approach decisively includes the assessment of its impact on quality of life. The use of the tools Pediatric Quality of Life Inventory 4.0 (PedsQL4.0) and The Impact of Weight on Quality of Life for Kids (IWQOL-Kids), the familiarity of health professionals with them, their applicability, and relevance in clinical practice, are a cornerstone in the promotion of health services in adolescent obesity. The present randomized qualitative study aimed to highlight the attitudes and preferences of pediatricians on the assessment of health-related quality of life (HRQoL), among obese adolescents. The sample consists of 120 pediatricians, randomly selected from the totality of municipality-registered pediatricians (Municipality of Thessaloniki, Greece) who were interviewed in a semi-structured way, regarding their attitudes in the assessment of health-related quality of life, as measured by the PedsQL4.0 and IWQOL-Kids tools. The interviews revealed that most participants gained insight into the HRQoL assessment process during the present study interview with the researchers. Only eight (n=8/120) participants were familiar with the explored tools, PedsQL4.0 and IWQOL-KIDS. The remaining sample (n=112/120) was unfamiliar with both the two questionnaires and their content as well. Among the referred barriers to the usage of the tools, lack of time was stated as the pivotal factor hindering the implementation of the tools in clinical practice. There was no consensus on the preferred questionnaire among the participating healthcare professionals. All participants stated that the use of one or both questionnaires would have added significant value to the support and care of adolescents with obesity. Tools assessing HRQoL present low familiarity among pediatricians in real-world data. Focus on the engagement of the healthcare providers in the evaluation of obesity-related quality of life is unequivocal, in order to improve health care status in adolescents with obesity.

Norwegian community midwives' experience of interdisciplinary collaboration in care of pregnant women with vulnerabilities.

AIM: The aim of this study was to investigate Norwegian community midwives(CMs) experience of collaboration when caring for pregnant women with vulnerabilities. We wanted to determine which professionals and services are considered important and with whom they have written agreements and good lines of communication. Furthermore, which tools are used in collaboration and if any background factors enhance collaboration. BACKGROUND: Vulnerable pregnant women may require more than standard antenatal care, involving interdisciplinary collaboration. Outcomes can improve if vulnerable pregnant women are offered additional support. The introduction of multi-disciplinary teams in Norway has shown promising results, as in many other countries. A Norwegian report concluded that there is need for more research to improve the quality and availability of interdisciplinary care. METHODS: A cross-sectional, descriptive study, using data from a questionnaire that approximately 700 CMs in Norway were invited to answer online from May-August 2020. Data were analysed using the statistical software SPSS 26. RESULTS: One third (257) of the invited CMs participated in the survey. They reported that professionals involved in standard antenatal care, such as those at the maternity unit and PHNs, were the most important collaborative partners when caring for vulnerable pregnant women. The CMs reported poor communication with general practitioners, child welfare-, drug welfare- and mental health-services. The most frequent methods for accessing collaboration were phoning and electronically through patient record systems, while there was limited use of the personal care plan, patient coordination meetings and regular meetings with collaborative partners/services. CMs with more than ten years as a CM and "Early Start" training were more frequently involved in patient coordination meetings and counselling and debriefing sessions compared to inexperienced CMs who had not attended a special training program. CONCLUSION: Experience and completed the Early Start education/training increased the use of interprofessional collaborating meetings including CMs. This study suggests interdisciplinary training programmes to improve collaboration, which are expected to benefit vulnerable pregnant women, their babies and families. IMPLICATION FOR PRACTICE AND RESEARCH: We recommend education and training in both the educational system and among involved professionals in communities to improve collaboration in the care of vulnerable women. In order to measure the effectiveness of collaboration in the care of vulnerable pregnant women, both the targeted group and the collaborating professionals should be asked to provide feedback. More research on communication and collaboration is needed.

Spatio-temporal modelling of referrals to outpatient respiratory clinics in the integrated care system of the Morecambe Bay area, England.

BACKGROUND: Promoting integrated care is a key goal of the NHS Long Term Plan to improve population respiratory health, yet there is limited data-driven evidence of its effectiveness. The Morecambe Bay Respiratory Network is an integrated care initiative operating in the North-West of England since 2017. A key target area has been reducing referrals to outpatient respiratory clinics by upskilling primary care teams. This study aims to explore space-time patterns in referrals from general practice in the Morecambe Bay area to evaluate the impact of the initiative. METHODS: Data on referrals to outpatient clinics and chronic respiratory disease patient counts between 2012-2020 were obtained from the Morecambe Bay Community Data Warehouse, a large store of routinely collected healthcare data. For analysis, the data is aggregated by year and small area geography. The methodology comprises of two parts. The first explores the issues that can arise when using routinely collected primary care data for space-time analysis and applies spatio-temporal conditional autoregressive modelling to adjust for data complexities. The second part models the rate of outpatient referral via a Poisson generalised linear mixed model that adjusts for changes in demographic factors and number of respiratory disease patients. RESULTS: The first year of the Morecambe Bay Respiratory Network was not associated with a significant difference in referral rate. However, the second and third years saw significant reductions in areas that had received intervention, with full intervention associated with a 31.8% (95% CI 17.0-43.9) and 40.5% (95% CI 27.5-50.9) decrease in referral rate in 2018 and 2019, respectively. CONCLUSIONS: Routinely collected data can be used to robustly evaluate key outcome measures of integrated care. The results demonstrate that effective integrated care has real potential to ease the burden on respiratory outpatient services by reducing the need for an onward referral. This is of great relevance given the current pressure on outpatient services globally, particularly long waiting lists following the COVID-19 pandemic and the need for more innovative models of care.

Differences in Covid-19 mortality among persons 70 years and older in an integrated care setting in region Stockholm: a multi-level analysis between March 2020-February 2021.

BACKGROUND: In Norrtälje municipality, within Region Stockholm, there is a joint integrated care organisation providing health and social care, which may have facilitated a more coordinated response to the covid-19 pandemic compared to the otherwise decentralised Swedish system. This study compares the risk of covid-19 mortality among persons 70 years and older, in the municipalities of Stockholm, Södertälje, and Norrtälje, while considering area and individual risk factors. METHODS: A population-based study using linked register data to examine covid-19 mortality among those 70 + years (N = 127,575) within the municipalities of interest between the periods March-August 2020 and September 2020-February 2021. The effect of individual and area level variables on covid-19 mortality among inhabitants in 68 catchment areas were examined using multi-level logistic models. RESULTS: Individual factors associated with covid-19 mortality were sex, older age, primary education, country of birth and poorer health as indicated by the Charlson Co-morbidity Index. The area-level variables associated were high deprivation (OR: 1.56, CI: 1.18-2.08), population density (OR: 1.14, CI: 1.08-1.21), and usual care. Together, this explained 85.7% of the variation between catchment areas in period 1 and most variation was due to individual risk factors in period 2. Little of the residual variation was attributed to differences between catchment areas. CONCLUSION: Integrated care in Norrtälje may have facilitated a more coordinated response during period 1, compared to municipalities with usual care. In the future, integrated care should be considered as an approach to better protect and meet the care needs of older people during emergency situations.

Integrated physical and mental management for China's elderly: insights from Long-gang District, Shenzhen.

China is in a period of rapid population aging. The total population of the elderly aged 60 and above in mainland China was 264 million in 2020, and is the country with the largest elderly population in the world, which is home to 1/5 of the world's older people. The urgency of actively coping with the aging population has never been greater, and China has raised it to the height of national strategy. To this end, China has issued several plans and projects on aging work. Many of them include multiple overlapping components. The management of physical illness and mental illness in the elderly is over-differentiated and segmented. However, it is common for older adults with complex health problems. The body and mind are inherently integrated and interact with each other, and should not be separated. There is an urgent need for integrated healthcare services for the physical and mental health of the elderly population. The national basic public health services play an important role in early detection and awareness of health problems for the elderly in community health services. This paper introduces the elderly health management services, one of the national basic public health projects, and the psychological care project for the elderly in Shenzhen, Guangdong Province, China. Taking Long-gang District's exploration of the joint management of physical and mental health of the elderly as an example, this review discusses the difficulties of the elderly health work, and the feasibility of integrating the elderly mental health and physical health in medical care. We outlook to build an integrated platform for physical and mental health of the elderly in China. Focus on the needs of older population, strengthen community health services, build a integrative team, fully publicize and improve health literacy of the elderly, link up and down and work together, improve coordination between providers of medical care and social services. It is of great significance to construct a strong public health system for the elderly and promote the realization of the grand goal of Healthy China.