Tracking the Development of Community Engagement Over Time: Realist Qualitative Study.

BACKGROUND: A growing interest in engaging communities in the development of health care services and communities has not automatically led to progress or consensus as to how to engage communities successfully, despite the evidence base showing how to leverage enablers and alleviate barriers. OBJECTIVE: To bridge the gap between the evidence base and which community engagement (CE) approaches have actually been applied in practice over time, this study aims to investigate how CE approaches have changed over the past 4 years in 6 different regions in the Netherlands and citizens' and professionals' experiences underlying these changes. METHODS: For the last stage of a multiple case study following the development of CE approaches in 6 different regions in the Netherlands, a realist qualitative case study was conducted. To investigate how CE approaches had changed over the past 4 years, data from the entire 4 years of the study were used, including documents, interview transcripts, and observations. To examine citizens' and professionals' experiences underlying these changes, new interviews were conducted. The latest interview results were discussed with a panel to ensure the results had face validity. RESULTS: The regions had implemented different types of CE approaches over the past 4 years and were adapting these approaches over time. Many of the (remaining) approaches may be operating on a smaller scale. The study identified the following overarching themes along which CE had been adapted: fewer region-wide approaches and more community-focused approaches, more focus on building relationships with (already engaged) citizens and community-led initiatives, and more focus on practical and tangible health promotion and social cohesion activities and less focus on complex "abstract" programs. The study identified a further 4 overarching themes highlighting citizens' and professionals' experiences underlying these changes in the CE approaches: a lack of engagement environment, need for facilitative leadership from organizations, need for a clear and shared vision underscoring the importance of CE, and misalignment between citizens' and professionals' perspectives and motivations for CE. All participants had experienced the engagement environment as insufficient. To support CE, professionals experienced the need to develop and receive more facilitative leadership and to develop approaches better equipped to involve citizens in the decision-making process. Citizens experienced the need to better align citizens' and professionals' motivations and aims for CE approaches and to receive longer-term financial support for their community-led initiatives. CONCLUSIONS: This study suggests that CE has not yet been embedded within organizational cultures. This has arguably meant that the (remaining) CE approaches are operating on a smaller scale. To enable the further development of CE approaches, an investment in the engagement environment and a shared vision is required. Only then could CE within the regions move beyond the more seemingly smaller-scale CE approaches.

Conceptualizing learning health systems: A mapping review.

Introduction: Health systems worldwide face the challenge of increasing population health with high-quality care and reducing health care expenditure growth. In pursuit for a solution, regional cross-sectoral partnerships aim to reorganize and integrate services across public health, health care and social care. Although the complexity of regional partnerships demands an incremental strategy, it is yet not known how learning works within these partnerships. To understand learning in regional cross-sectoral partnerships for health, this study aims to map the concept Learning Health System (LHS). Methods: This mapping review used a qualitative text analysis approach. A literature search was conducted in Embase and was limited to English-language papers published in the period 2015-2020. Title-abstract screening was performed using established exclusion criteria. During full-text screening, we combined deductive and inductive coding. The concept LHS was disentangled into aims, design elements, and process of learning. Data extraction and analysis were performed in MAX QDA 2020. Results: In total, 155 articles were included. All articles used the LHS definition of the Institute of Medicine. The interpretation of the concept LHS varied widely. The description of LHS contained 25 highly connected aims. In addition, we identified nine design elements. Most elements were described similarly, only the interpretation of stakeholders, data infrastructure and data varied. Furthermore, we identified three types of learning: learning as 1) interaction between clinical practice and research; 2) a circular process of converting routine care data to knowledge, knowledge to performance; and performance to data; and 3) recurrent interaction between stakeholders to identify opportunities for change, to reveal underlying values, and to evaluate processes. Typology 3 was underrepresented, and the three types of learning rarely occurred simultaneously. Conclusion: To understand learning within regional cross-sectoral partnerships for health, we suggest to specify LHS-aim(s), operationalize design elements, and choose deliberately appropriate learning type(s).

Engaging citizens in local health policymaking. A realist explorative case-study.

BACKGROUND: Municipalities have been trying to involve citizens as citizen participation is thought to improve municipalities' accountability, the quality of services, and to align policies and services to communities' needs. This study examined citizens' participation preferences in policymaking by investigating their health policy priorities, expectations of involvement, and required support. METHODS: For this case-study the realist evaluation approach was applied to focus groups with citizens and to a workshop with a local panel consisting of professionals, citizens and citizen representatives. RESULTS: This study showed that citizens want to be involved in (health) policymaking with the aim of improving their communities' quality of life and living environment and prioritised local services and amenities (e.g. suitable housing, public transport, health and care services). Instead, professionals' priorities were focussed on singular public health issues related to prevention and lifestyle factors. The results also show that citizens felt responsible for driving citizen participation and representing community needs to the municipality, but needed the municipality to improve their communication and accessibility in order to do so successfully. Furthermore, the professionals on the panel indicated that they needed training on how to reach out to citizens. Such training should highlight how to better align their language to citizens' lived experiences. They also wanted their organisations to provide more space, flexibility and resources to build relationships with citizens in order to provide improved communication and accessibility to citizens. CONCLUSION: The difference in priorities between citizens and professionals highlights the importance of involving citizens in policymaking. Moreover, citizens' involvement can act as a lever for change to bring a wider range of services and policy sectors together and has the potential to better align policies to citizens' lived experiences and hopefully increase the democratic legitimacy of policymaking. However, to fulfil such potential municipalities will need to invest in improving their accessibility and communication with communities.

'They need to ask me first'. Community engagement with low-income citizens. A realist qualitative case-study.

BACKGROUND: Community engagement is seen as key to citizen-centred and sustainable healthcare systems as involving citizens in the designing, implementation and improvement of services and policies is thought to tailor these more closely to communities' own needs and experiences. Organizations have struggled to reach out to and involve disadvantaged citizens. This paper examines how if, why, and when low-income citizens wish to be involved. METHODS: For this qualitative realist case-study, 19 interviews (one dyad) were held with (20) low-income citizens in two Dutch municipalities. Additionally, the results were discussed with a reference panel consisting of professionals and citizens to enrich the results and to ensure the results had face validity. RESULTS: The results showed four different ways in which low-income citizens wished to be involved: (a) in a practical/volunteer way; (b) as a buddy; (c) as a lay expert; (d) not involved at all. The factors affecting citizens' interest and capacity to participate include citizens' own experiences of the services they access and their personal situations, e.g. their mental or physical health, extent of financial crisis, family situation, home environment. None of the interviewees was currently involved, but all had ideas for improving health(care) services and policies. Citizens' experiences of the services they accessed acted as a motivator for some to be involved as they wanted to ensure others would not have the same struggles, while for others their own needs and an apathetic system remained too high a barrier. To enable involvement, citizens need continued support for their own health(care) and financial situation, better communication and accessibility from services, practical support (e.g., training and bus passes) and recognition for their input (e.g., monetary compensation). CONCLUSION: The study shows that citizens' experiences of the services they accessed influenced if and how they wanted to be involved with health and care services. Despite the fact that all participants had shared solid ideas for improving services and policies, they were hindered by a bureaucratic, impersonal and inaccessible system. Organizations seem to underestimate the required investments to reach out to low-income citizens and the support required to ensure their involvement. PATIENT AND PUBLIC INVOLVEMENT (PPI) IN STUDY: Citizens as well as PPI organizations were members of the reference panel who helped formulate the research questions and recruitment strategy. The local reference panel also helped to interpret and refine the initial findings.

Safety risks among frail older people living at home in the Netherlands - A cross-sectional study in a routine primary care sample.

Frail older people face a range of problems and risks that could undermine their ability to live safely at home. A comprehensive overview of these risks, from a multidimensional perspective, is currently lacking. This study aims to examine the prevalence of risks in multiple domains of life among frail older people living at home. We used cross-sectional data from 824 people aged 65 years and older, who received a comprehensive geriatric assessment (the interRAI Home Care [interRAI-HC]) between 2014 and 2018, as part of routine care from 25 general practices in the region of West-Friesland, the Netherlands. The interRAI-HC identifies amenable risks related to people's clinical conditions, functioning, lifestyle and behaviour, and social and physical environment. Descriptive statistics were used to examine population characteristics (age, gender, marital status, living arrangements and presence of chronic conditions) and prevalence of risks. Most common risks were related to people's clinical conditions (i.e cardio-respiratory health, urinary incontinence, pain), functioning (i.e. limitations in instrumental activities of daily living and mood) and social environment (i.e. limitations in informal care and social functioning). More than 80% of frail older people faced multiple risks, and often on multiple domains of life simultaneously. People experiencing multiple risks per person, and on multiple domains simultaneously, were more often widowed and living alone. The multidimensional character of risks among frail older people living at home implies that an integrated approach to care, comprising both health and social care, is necessary. Insight in the prevalence of these risks can give direction to care allocation decisions.

Exploring how residential care facilities can enhance the autonomy of people with dementia and improve informal care.

BACKGROUND AND OBJECTIVES: Residential care facilities (RCFs) strive to enhance autonomy for people with dementia and to enhance informal care provision, although this is difficult. This study explored how RCF staff can enhance autonomy and improve informal care by looking at the influence of interactions (contact and approachability between residents, staff members and informal caregivers) and the physical environment, including the use of technologies. RESEARCH DESIGN AND METHODS: A realist evaluation multiple-case study was conducted using document analyses, eight semi-structured interviews with staff members and relatives and 56 hours of observations of residents across two RCFs aiming to provide person-centred care. Realist logic of analysis was performed, involving Context-Mechanism-Outcome configurations. FINDINGS: The behaviour, attitudes and interactions of staff members with residents and informal caregivers appeared to contribute to the autonomy of people with dementia and enhance informal care provision. The physical environment of the RCFs and the use of technologies were less relevant to enhancing autonomy and informal care provision, although they can support staff members in providing person-centred care in daily practice. DISCUSSION AND IMPLICATIONS: The findings add to those of other studies regarding the importance of interaction between residents, staff members and informal caregivers. The findings provide insight for other RCFs on how successfully to enhance autonomy for their residents and to improve informal care provision, as well as, more broadly, how to implement person-centred care.

How staff characteristics influence residential care facility staff's attitude toward person-centered care and informal care.

BACKGROUND: Staff members, and their attitudes, are crucial for providing person-centered care in residential care facilities for people with dementia. However, the literature on the attitudes of nursing staff regarding person-centered care is limited. The objective of this study is to explore the association between staff characteristics (age, education level, years of work experience and function, i.e., care or welfare) and staff attitudes toward perceived person-centered care provision and including informal caregivers in the caregiving process in residential care facilities. METHODS: A convenience sample of 68 care staff - nurses and nurse assistants - welfare staff members - activity counselors, hostesses, and living room caretakers - of two residential care facilities filled out a questionnaire. Staff attitudes regarding perceived person-centered care were measured with the Person-centered Care Assessment Tool (P-CAT). Staff attitudes regarding informal care provision were measured with the Attitudes Toward Families Checklist (AFC). Multiple linear regression analysis explored the association between variables age, work experience, education, and function (care or welfare). RESULTS: A higher age of staff was associated with a more negative attitude toward perceived person-centered care and informal care provision. Welfare staff had a more negative attitude toward the inclusion of informal caregivers than care staff. The perceived person-centered care provision of the care and welfare staff was both positive. Work experience and education were not associated with perceived person-centered care provision or informal care provision. CONCLUSION: This study is one of the first to provide insight into the association between staff characteristics and their attitude toward their perceived person-centered care provision and informal care provision. A higher age of both the care and welfare staff was associated with a more negative attitude toward their perceived person-centered care and informal care provision. Welfare staff had a less positive attitude toward informal care provision. Additionally, future studies, also observational studies and interview studies, are necessary to collect evidence on the reasons for negative attitudes of older staff members towards PCC and informal care giving, to be able to adequately target these reasons by implementing interventions that eliminate or reduce these negative attitudes.

A Scoping Review of Alternative Payment Models in Maternity Care: Insights in Key Design Elements and Effects on Health and Spending.

INTRODUCTION: Although effects of alternative payment models on health outcomes and health spending are unclear, they are increasingly implemented in maternity care. We aimed to provide an overview of alternative payment models implemented in maternity care, describing their key design elements among which the type of APM, the care providers that participate in the model, populations and care services that are included and the applied risk mitigation strategies. Next to that, we made an inventory of the empirical evidence on the effects of APMs on maternal and neonatal health outcomes and spending on maternity care. METHODS: We searched PubMed, Embase and Scopus databases for articles published from January 2007 through October 2020. Search key words included 'alternative payment model', 'value based payment model', 'obstetric', 'maternity'. English or Dutch language articles were included if they described or empirically evaluated initiatives implementing alternative payment models in maternity care in high-income countries. Additional relevant documents were identified through reference tracking. We systematically analyzed the initiatives found and examined the evidence regarding health outcomes and health spending. The process was guided by the Preferred Reporting Items for Systematic Reviews and Meta-Analysis (PRISMA) to ensure validity and reliability. RESULTS: We identified 17 initiatives that implemented alternative payment models in maternity care. Thirteen in the United States, two in the United Kingdom, one in New Zealand and one in the Netherlands. Within these initiatives three types of alternative payment models were implemented; pay-for-performance (n = 2), shared savings models (n = 7) and bundled payment models (n = 8). Alternative payment models that shifted more financial accountability towards providers seemed to include more strategies that mitigated those risks. Risk mitigation strategies were applied to the included population, included services or at the level of total expenditures. Of these seventeen initiatives, we found four empirical effect studies published in peer-reviewed journals. Three of them were of moderate quality and one weak. Two studies described an association of the alternative payment model with an improvement of specific health outcomes and two studies described a reduction in medical spending. CONCLUSIONS: This study shows that key design elements of alternative payment models including risk mitigation strategies vary highly. Risk mitigation strategies seem to be relevant tools to increase APM uptake and protect providers from (initially) bearing too much (perceived) financial risk. Empirical evidence on the effects of APMs on health outcomes and spending is still limited. A clear definition of key design elements and a further, in-depth, understanding of key design elements and how they operate into different health settings is required to shape payment reform that aligns with its goals.

Supporting Older People to Live Safely at Home - Findings from Thirteen Case Studies on Integrated Care Across Europe.

INTRODUCTION: While many different factors can undermine older people's ability to live safely at home, safety as an explicit aspect of integrated care for older people living at home is an underexplored topic in research. In the context of a European project on integrated care, this study aims to improve our understanding of how safety is addressed in integrated care practices across Europe. METHODS: This multiple case study included thirteen integrated care sites from seven European countries. The Framework Method guided content analyses of the case study reports. Activities were clustered into activities aimed at identifying and managing risks, or activities addressing specific risks related to older people's functioning, behaviour, social environment, physical environment and health and social care receipt. RESULTS: Case studies included a broad range of activities addressing older people's safety. Although care providers felt they sufficiently addressed safety issues, older people were often concerned and insecure about their safety. Attention to the practical and social aspects of safety was often insufficient. CONCLUSIONS AND DISCUSSION: Integrated care services across Europe address older people's safety in many ways. Further integration of health and social care solutions is necessary to enhance older people's perceptions of safety.

Advancing integrated care evaluation in shifting contexts: blending implementation research with case study design in project SUSTAIN.

BACKGROUND: Despite many studies evaluating the effectiveness of integrated care, evidence remains inconsistent. There is increasing commentary pointing out the mismatch between the ability to capture the somewhat 'illusive' impact of integrated care initiatives and programmes, and the most appropriate way to do this. Focusing on methodology, this paper describes and critically reviews the experiences of SUSTAIN, a Horizon 2020 funded project (2015-2019) with the purpose of advancing knowledge and understanding of cross-European integrated care evaluation. SUSTAIN sought to improve integrated care initiatives for older people in seven countries, and to maximise the potential for knowledge transfer and application across Europe. The methods approach drew from implementation research, employing the participative Evidence Integration Triangle (EIT) and incorporating a mixed method, multiple embedded case study design. A core set of qualitative and quantitative indicators, alongside context and process data, were created and tested within four key project domains (person-centredness, prevention-orientation, safety and efficiency). The paper critically discusses the overall approach, highlighting the value of the EIT and case study design, and signalling the challenges of data collection with frail older people and stakeholder involvement at the sites, as well as difficulties developing the core set of indicators. CONCLUSIONS: Lessons learned and recommendations for advancing integrated care evaluation are put forward that focus on the status of integrated care as a complex intervention and a process. The use of implementation research methods and case study design are recommended as an additional evaluation approach for researchers to consider, alongside suggested ways of improving methods of data collection with frail populations and cost analysis.

Cross-Sector Collaboration for a Healthy Living Environment-Which Strategies to Implement, Why, and in Which Context?

BACKGROUND: Working toward a healthy living environment requires organizations from different policy domains and nongovernment partners involved in public health and the living environment to collaborate across sectors. The aim of this study is to understand how this cross-sector collaboration for a healthy living environment can be achieved. METHODS: The realist evaluation approach was used to investigate what strategies can be used in which contexts to achieve cross-sector collaboration. The "Collaborative Adaptive Health Networks" framework was used as a theoretical framework. Seventeen partners of three Dutch projects collaborating for a healthy living environment in different regions were interviewed about their experiences during the initiating phase of their projects. RESULTS: Seven themes for achieving cross-sector collaboration were identified, namely creating a feeling of equivalence, building trust, bridging different perspectives, providing clarity regarding roles and tasks, creating commitment, creating active engagement, and understanding whom to engage and when. For each theme, the strategies that were used, and why, were specified. CONCLUSION: This study provides new insights in how cross-sector collaboration for a healthy living environment can be achieved in different contexts. Whether the start of a cross-sectoral collaboration is successful is largely influenced by the choice of leadership and the interorganizational relations.

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.

Implementing population health management: an international comparative study.

PURPOSE: The purpose of this paper is to gain insight into how population health management (PHM) strategies can successfully integrate and reorganize public health, health care, social care and community services to improve population health and quality of care while reducing costs growth, this study compared four large-scale transformation programs: Greater Manchester Devolution, Vancouver Healthy City Strategy, Gen-H Cincinnati and Gesundes Kinzigtal. DESIGN/METHODOLOGY/APPROACH: Following the realist methodology, this explorative comparative case-study investigated PHM initiatives' key features and participants' experiences of developing such initiatives. A semi-structured interview guideline based on a theoretical framework for PHM guided the interviews with stakeholders (20) from different sectors. FINDINGS: Five initial program theories important to the development of PHM were formulated: (1) create trust in a shared vision and understanding of the PHM rationale to establish stakeholders' commitment to the partnership; (2) create shared ownership for achieving the initiative's goals; (3) create shared financial interest that reduces perceived financial risks to provide financial sustainability; (4) create a learning environment to secure initiative's credibility and (5) create citizens' and professionals' awareness of the required attitudes and behaviours. ORIGINALITY/VALUE: The study highlights initial program theories for the implementation of PHM including different strategies and structures underpinning the initiatives. These insights provide a deeper understanding of how large-scale transformation could be developed.

Addressing safety risks in integrated care programs for older people living at home: a scoping review.

BACKGROUND: Many older people live at home, often with complex and chronic health and social care needs. Integrated care programs are increasingly being implemented as a way to better address these needs. To support older people living at home, it is also essential to maintain their safety. Integrated care programs have the potential to address a wide range of risks and problems that could undermine older people's ability to live independently at home. The aim of this scoping review is to provide insight into how integrated care programs address safety risks faced by older people living at home - an area that is rather underexplored. METHODS: Safety was conceptualised as preventing or reducing the risk of problems, associated with individual functioning and behaviour, social and physical environments, and health and social care management, which could undermine older people's ability to live independently at home. For this scoping review a systematic literature search was performed to identify papers describing integrated care programs where at least one intervention component addressed safety risks. Data were extracted on the programs' characteristics, safety risks addressed, and the activities and interventions used to address them. RESULTS: None of the 11 programs included in this review explicitly mentioned safety in their goals. Nevertheless, following the principles of our conceptual framework, the programs appeared to address risks in multiple domains. Most attention was paid to risks related to older people's functioning, behaviour, and the health and social care they receive. Risks related to people's physical and social environments received less attention. CONCLUSION: Even though prevention of safety risks is not an explicit goal of integrated care programs, the programs address a wide range of risks on multiple domains. The need to address social and environmental risks is becoming increasingly important given the growing number of people receiving care and support at home. Prioritising a multidimensional approach to safety in integrated care programs could enhance the ability of health and social care systems to support older people to live safely at home.

Reorganizing and integrating public health, health care, social care and wider public services: a theory-based framework for collaborative adaptive health networks to achieve the triple aim.

OBJECTIVE: Population health management (PHM) refers to large-scale transformation efforts by collaborative adaptive health networks that reorganize and integrate services across public health, health care, social care and wider public services in order to improve population health and quality of care while at the same time reducing cost growth. However, a theory-based framework that can guide place-based approaches towards a comprehensive understanding of how and why strategies contribute to the development of PHM is lacking, and this review aims to contribute to closing this gap by identifying the key components considered to be key to successful PHM development. METHODS: We carried out a scoping realist review to identify configurations of strategies (S), their outcomes (O), and the contextual factors (C) and mechanisms (M) that explain how and why these outcomes were achieved. We extracted theories put forward in included studies and that underpinned the formulated strategy-context-mechanism-outcome (SCMO) configurations. Iterative axial coding of the SCMOs and the theories that underpin these configurations revealed PHM themes. RESULTS: Forty-one studies were included. Eight components were identified: social forces, resources, finance, relations, regulations, market, leadership, and accountability. Each component consists of three or more subcomponents, providing insight into (1) the (sub)component-specific strategies that accelerate PHM development, (2) the necessary contextual factors and mechanisms for these strategies to be successful and (3) the extracted theories that underlie the (sub)component-specific SCMO configurations. These theories originate from a wide variety of scientific disciplines. We bring these (sub)components together into what we call the Collabroative Adaptive Health Network (CAHN) framework. CONCLUSIONS: This review presents the strategies that are required for the successful development of PHM. Future research should study the applicability of the CAHN framework in practice to refine and enrich identified relationships and identify PHM guiding principles.

Unknown makes unloved-A case study on improving integrated health and social care in the Netherlands using a participatory approach.

Many initiatives integrating health and social care have been implemented in order to provide adequate care and support to older people living at home. Further development of existing initiatives requires iterative processes of developing, implementing and evaluating improvements to current practice. This case study provides insight into the process of improving an existing integrated care initiative in the Netherlands. Using a participatory approach, researchers and local stakeholders collaborated to develop and implement activities to further improve collaboration between health and social care professionals. Improvement activities included interprofessional meetings focussing on reflection and mutual learning and workplace visits. Researchers evaluated the improvement process, using data triangulation of multiple qualitative and quantitative data sources. According to participating professionals, the improvement activities improved their communication and collaboration by establishing mutual understanding and trust. Enabling factors included the safe and informal setting in which the meetings took place and the personal relationships they developed during the project. Different organisational cultures and interests and a lack of ownership and accountability among managers hindered the improvement process, whereas issues such as staff shortages, time constraints and privacy regulations made it difficult to implement improvements on a larger scale. Still, the participatory approach encouraged the development of partnerships and shared goals on the level of both managers and professionals. This case study highlights that improving communication between professionals is an important first step in improving integrated care. In addition, it shows that a participatory approach, in which improvements are co-created and tailored to local priorities and needs, can help in the development of shared goals and trust between stakeholders with different perspectives. However, stakeholders' willingness and ability to participate in such an improvement process is challenged by many factors.

Measuring Regional Quality of Health Care Using Unsolicited Online Data: Text Analysis Study.

BACKGROUND: Regional population management (PM) health initiatives require insight into experienced quality of care at the regional level. Unsolicited online provider ratings have shown potential for this use. This study explored the addition of comments accompanying unsolicited online ratings to regional analyses. OBJECTIVE: The goal was to create additional insight for each PM initiative as well as overall comparisons between these initiatives by attempting to determine the reasoning and rationale behind a rating. METHODS: The Dutch Zorgkaart database provided the unsolicited ratings from 2008 to 2017 for the analyses. All ratings included both quantitative ratings as well as qualitative text comments. Nine PM regions were used to aggregate ratings geographically. Sentiment analyses were performed by categorizing ratings into negative, neutral, and positive ratings. Per category, as well as per PM initiative, word frequencies (ie, unigrams and bigrams) were explored. Machine learning-naïve Bayes and random forest models-was applied to identify the most important predictors for rating overall sentiment and for identifying PM initiatives. RESULTS: A total of 449,263 unsolicited ratings were available in the Zorgkaart database: 303,930 positive ratings, 97,739 neutral ratings, and 47,592 negative ratings. Bigrams illustrated that feeling like not being "taken seriously" was the dominant bigram in negative ratings, while bigrams in positive ratings were mostly related to listening, explaining, and perceived knowledge. Comparing bigrams between PM initiatives showed a lot of overlap but several differences were identified. Machine learning was able to predict sentiments of comments but was unable to distinguish between specific PM initiatives. CONCLUSIONS: Adding information from text comments that accompany online ratings to regional evaluations provides insight for PM initiatives into the underlying reasons for ratings. Text comments provide useful overarching information for health care policy makers but due to a lot of overlap, they add little region-specific information. Specific outliers for some PM initiatives are insightful.

Exploring improvement plans of fourteen European integrated care sites for older people with complex needs.

Integrated care programmes are increasingly being put in place to provide care to older people living at home. However, knowledge about further improving integrated care is limited. In fourteen integrated care sites in Europe, plans to improve existing ways of working were designed, implemented and evaluated to enlarge the understanding of what works and with what outcomes when improving integrated care. This paper provides insight into the existing ways that the sites were working with respect to integrated care, their perceived difficulties and their plans for working towards improvement. The seven components of the Expanded Chronic Care Model provided a conceptual framework for describing the fourteen sites. Although sites were spread across Europe and differed in basic characteristics and existing ways of working, a number of difficulties in delivering integrated care were similar. Existing ways of working and improvement plans mostly focused on three components of the Expanded Chronic Care Model: delivery system design; decision support; self-management. Two components were represented less frequently in existing ways of working and improvement plans: building healthy public policy; building community capacity. These findings suggest that broadly-based prevention efforts, population health promotion and community involvement remain limited. From the Expanded Chronic Care Model perspective, therefore, opportunities for improving integrated care outcomes may continue to be restricted by the narrow focus of developed improvement plans.

Assigning a Prominent Role to "The Patient Experience" in Assessing the Quality of Integrated Care for Populations with Multiple Chronic Conditions.

In response to growing populations of citizens with multiple chronic conditions, integrated care models are being implemented in many countries. Based on our experiences from three EU co-funded actions (ICARE4EU, SUSTAIN, JA-CHRODIS), we notice that users' experiences are not always taken into account when assessing the quality of integrated care, whereas research shows that it is in this particular domain that quality improvement is most evident. The greatest value of integrated care for people with multiple chronic conditions may not lie in its potential to improve their health or reduce their use of services, but in its potential to improve their care experience, by strengthening person-centred decision-making and delivering care and support accordingly. Collaborations of care providers, (representatives of) people with multiple chronic conditions and researchers need to develop appropriate methods and measures to include users' experiences in quality assessment of integrated care.