Shut

Search

Abstract

Purpose

Inform health system improvements by summarizing components of integrated intendance in older populations. Place key implementation barriers and facilitators.

Data sources

A scoping review was undertaken for evidence from MEDLINE, the Cochrane Library, organizational websites and cyberspace searches. Eligible publications included reviews, reports, individual studies and policy documents published from 2005 to February 2017.

Study selection

Initial eligible documents were reviews or reports concerning integrated care approaches in older/frail populations. Other documents were later sourced to identify and contextualize implementation problems.

Information extraction

Written report findings and implementation barriers and facilitators were charted and thematically synthesized.

Results of data synthesis

Thematic synthesis using 30 publications identified 8 important components for integrated care in elderly and delicate populations: (i) care continuity/transitions; (ii) enabling policies/governance; (3) shared values/goals; (4) person-centred care; (5) multi-/inter-disciplinary services; (vi) constructive communication; (seven) case management; (viii) needs assessments for care and discharge planning. Intervention outcomes and implementation bug (barriers or facilitators) tend to depend heavily on the context and programme objectives. Implementation problems in four main areas were observed: (i) Macro-level contextual factors; (ii) Miso-level organisation organization (funding, leadership, service construction and culture); (3) Miso-level intervention organization (characteristics, resource and credibility) and (four) Micro-level factors (shared values, engagement and communication).

Conclusion

Improving integration in care requires many components. However, local barriers and facilitators need to be considered. Changes are expected to occur slowly and are more probable to exist successful where elements of integrated care are well incorporated into local settings.

Background

The demographic shift towards a growing ageing population has major social and economic implications for many countries [ane]. 'Integrated care' within and between medical and social services has go a focal betoken in the delivery of quality healthcare for ageing populations and service models for integration are beingness developed and evaluated in unlike countries [2, 3]. Frail and elderly populations may particularly benefit from integrated care because their needs are complex, continuously changing, and they require a range of services provided over a long fourth dimension-frame [iv].

Integration can be simply be defined equally 'The direction and delivery of health services and then that clients receive a continuum of preventive and curative services, according to their needs over fourth dimension and beyond different levels of the health system' [5]. Yet, integration is a circuitous process and can be conceptualized in a number of ways. Horizontal integration involves linking similar levels of care (e.g. multi-disciplinary teams) and vertical integration links different levels of intendance (e.g. through illness-specific care pathways). To reach system-wide integration, different strategies are needed: (i) Systemic integration (policy, rules or regulatory frameworks); (ii) Normative integration (shared values and civilization); (iii) Organizational integration (structures, governance or relationships); (iv) Administrative integration (back-office functions, budgets or accountability) and (5) Clinical integration (coordinating services and data to focus on patient intendance within a single procedure) [six].

No single best model or guidelines exist for integrating care [7], making the commitment of integrated care for ageing populations challenging. The process of integration, therefore, requires multiple initiatives throughout different services and professions of the health system. However, integration efforts are oftentimes costly, labour-intensive and are prone to failure [iv]. Planners and providers must be aware of effective elements of integrated care, understand the needs within their own context, and apply implementation cognition to address local integration strategies.

At that place is a growing torso of literature relating to integrated care, simply few previous reviews summarize practical implementation issues across different components of integrated systems or in dissimilar care settings, to inform implementation of integrated care for older or frail populations. Our aim was, therefore, to identify important domains of integrated care systems for older or frail populations and to concisely nowadays testify on implementation issues, as a resource for implementing health system improvements.

Search Strategy and Methods of Review

First, a scoping review was conducted, according to published methods, to identify key themes in integrated intendance for older populations [eight]. Once saturation of key themes was reached through the scoping review, targeted searches were conducted to provide up-to-date bear witness relating to implementation bug (Fig. ane).

Effigy 1

Stages of searching, evidence synthesis for elements of integrated care and implementation issues in older or frail populations.

Stages of searching, show synthesis for elements of integrated care and implementation bug in older or delicate populations.

Phase 1. Scoping searches: review studies were first identified from the Cochrane database of systematic reviews and from Medline. Further targeted net searching was so carried out for governmental/organizational documents, or other prove, to fill gaps in elements of intendance or care settings. Bibliographies of included studies were screened for other potential documents. A pragmatic publication appointment cut betoken of 10 years was adopted to focus findings on more recent studies and documents. Included literature, therefore, initially spanned from 2005 to 26th January 2015. Postal service hoc inclusion criteria were adult based on increasing familiarity with the identified studies; a standard arroyo in scoping reviews [8]. Review articles from MEDLINE and the Cochrane database were included when reporting (i) intendance quality, integrated health and social intendance, or person-centred care (PCC), (two) in older or frail populations and (iii) care delivered in mainstream settings such equally hospitals, sub-astute intendance and community care. Publications focusing on terminal or terminate-of-life intendance were excluded. Potentially relevant Medline and Cochrane citations were reviewed by two researchers, using standardized inclusion criteria. The same criteria were applied to literature from other sources, simply the study design was not limited to review articles, and iterative searching was conducted past one researcher.

Stage 2. Thematic synthesis of cardinal elements of integrated care: articles were systematically read and primary themes in results/discussion were extracted. Thematic synthesis was used to identify and link common themes into categories by coding data co-ordinate to emerging themes. Findings were then narratively synthesized. The heterogeneous nature of evidence from systematic reviews, summary reviews, individual trials and policy documents fabricated quality assessment impractical and instead, relevant articles were selected until saturation of themes was achieved.

Stage 3. Focused searches: supplemental searches using Cochrane, Medline and the cyberspace were undertaken to identify evidence relating to implementation (barriers or facilitators) of integrated intendance policies or programmes. Update searches included literature published in the prior 5 years, and upwardly to January 2017.

Results

The thematic synthesis included thirty articles from the following sources: Cochrane (n = vii) [nine–xv], Medline (n = 5) [xvi–20], cyberspace searches and government websites (northward = 12) [2, 3, 21–30], articles to accost testify gaps identified by research squad-members (north = 4) [31–34], and from reference lists of already included studies (n = 2) [35, 36] (Report list in Supplementary Table). The reports could largely be grouped in two categories: (i) those reporting on full general approaches to amend quality of intendance through integrating services across the whole wellness arrangement and (ii) those focusing on one chemical element or component of integrated healthcare or focusing on care in specific setting such every bit within hospitals, sub-acute settings or in the community. Eight primal elements of integrated care were found in the thematic synthesis (Table 1). Despite the variation in included publications, mutual implementation issues were shared amid studies (Tabular array 2).

Table 1

Core components of integrated intendance for older or delicate populations, identified from a scoping review of international literature

Elements of constructive integrated healthcare Brief description
Care continuity and transitions Intendance needs for elderly or frail patients are circuitous, and span different care locations or providers. Connected service networks, and effective referral systems tin can ensure patients receive quality care and continuity when they transit between locations or providers
Policy and governance Enabling policy is needed to align stakeholder goals/outcomes and provide financing structures to facilitate integration. Processes need to be facilitated through integrated systems of care so providers can work within mutual governance or piece of work towards incentives [35]. Cooperation across care provider organizations and the integration of health and social care at the clinical level is also of import [2, 23]
Shared values and goals Meso-(organizational) or Micro-(individual) level integration of values and goals amongst different providers can facilitate staff motivation and service integration. Shared values and goals are facilitated through formal policies [ii, 23, 35] and changes in culture at clinical and managerial levels [7]
PCC Holistic and respectful care should be delivered with a focus on the individual and on enabling autonomy by empowering individuals to be involved in their own intendance [37]
Multi-/inter-disciplinary teams Providers from all services must piece of work together in a flexible way to provide coordinated care and then that patients can benefit from expertise from multiple specialties [9, 31]
Effective communication Communication is a vital component for all involved in care and extends to the communication between healthcare professionals past providing integrated electronic record direction [two, 31, 35]
Example management A named individual is identified every bit care coordinator/example manager, who has direct responsibility for supporting service users by coordinating care, engaging patients in their own care and providing care directly [2, 23, 35]
Needs assessment for intendance and belch planning Using comprehensive multi-disciplinary geriatric assessment can evaluate needs and enable care plans to be adult [ii, nine, 33, 35]. Personalized plans for patients aim to improve the efficiency and quality of healthcare surrounding the discharge procedure and ensure appropriate and coordinated services are in place to support the patient [2, 13, 35]
Elements of effective integrated healthcare Brief description
Care continuity and transitions Care needs for elderly or frail patients are circuitous, and bridge different care locations or providers. Connected service networks, and effective referral systems can ensure patients receive quality care and continuity when they transit between locations or providers
Policy and governance Enabling policy is needed to align stakeholder goals/outcomes and provide financing structures to facilitate integration. Processes need to be facilitated through integrated systems of intendance so providers can work within common governance or work towards incentives [35]. Cooperation across intendance provider organizations and the integration of health and social care at the clinical level is as well important [2, 23]
Shared values and goals Meso-(organizational) or Micro-(individual) level integration of values and goals among unlike providers tin facilitate staff motivation and service integration. Shared values and goals are facilitated through formal policies [two, 23, 35] and changes in culture at clinical and managerial levels [7]
PCC Holistic and respectful care should be delivered with a focus on the individual and on enabling autonomy past empowering individuals to be involved in their ain care [37]
Multi-/inter-disciplinary teams Providers from all services must work together in a flexible way to provide coordinated care and and so that patients can do good from expertise from multiple specialties [9, 31]
Effective communication Communication is a vital component for all involved in care and extends to the communication betwixt healthcare professionals by providing integrated electronic record management [2, 31, 35]
Case management A named individual is identified as intendance coordinator/case manager, who has direct responsibility for supporting service users by coordinating care, engaging patients in their ain intendance and providing care directly [2, 23, 35]
Needs cess for care and discharge planning Using comprehensive multi-disciplinary geriatric assessment tin evaluate needs and enable intendance plans to exist developed [two, 9, 33, 35]. Personalized plans for patients aim to improve the efficiency and quality of healthcare surrounding the belch procedure and ensure appropriate and coordinated services are in place to back up the patient [2, 13, 35]

Table 1

Core components of integrated care for older or delicate populations, identified from a scoping review of international literature

Elements of effective integrated healthcare Brief description
Care continuity and transitions Intendance needs for elderly or delicate patients are complex, and span different care locations or providers. Connected service networks, and effective referral systems tin ensure patients receive quality care and continuity when they transit between locations or providers
Policy and governance Enabling policy is needed to marshal stakeholder goals/outcomes and provide financing structures to facilitate integration. Processes need to be facilitated through integrated systems of intendance so providers tin can work within common governance or piece of work towards incentives [35]. Cooperation across care provider organizations and the integration of wellness and social care at the clinical level is also of import [ii, 23]
Shared values and goals Meso-(organizational) or Micro-(private) level integration of values and goals amongst different providers can facilitate staff motivation and service integration. Shared values and goals are facilitated through formal policies [ii, 23, 35] and changes in culture at clinical and managerial levels [seven]
PCC Holistic and respectful care should be delivered with a focus on the private and on enabling autonomy by empowering individuals to exist involved in their ain care [37]
Multi-/inter-disciplinary teams Providers from all services must work together in a flexible way to provide coordinated intendance and then that patients can benefit from expertise from multiple specialties [ix, 31]
Constructive communication Communication is a vital component for all involved in care and extends to the communication between healthcare professionals by providing integrated electronic record management [2, 31, 35]
Case management A named individual is identified as intendance coordinator/example managing director, who has straight responsibleness for supporting service users by analogous care, engaging patients in their ain care and providing care directly [2, 23, 35]
Needs assessment for care and belch planning Using comprehensive multi-disciplinary geriatric cess can evaluate needs and enable intendance plans to be developed [2, 9, 33, 35]. Personalized plans for patients aim to improve the efficiency and quality of healthcare surrounding the discharge process and ensure appropriate and coordinated services are in place to back up the patient [2, 13, 35]
Elements of effective integrated healthcare Brief description
Intendance continuity and transitions Care needs for elderly or frail patients are circuitous, and span different intendance locations or providers. Connected service networks, and effective referral systems can ensure patients receive quality care and continuity when they transit between locations or providers
Policy and governance Enabling policy is needed to align stakeholder goals/outcomes and provide financing structures to facilitate integration. Processes demand to be facilitated through integrated systems of care then providers can piece of work within common governance or work towards incentives [35]. Cooperation across care provider organizations and the integration of health and social intendance at the clinical level is too important [ii, 23]
Shared values and goals Meso-(organizational) or Micro-(individual) level integration of values and goals among different providers tin facilitate staff motivation and service integration. Shared values and goals are facilitated through formal policies [ii, 23, 35] and changes in culture at clinical and managerial levels [seven]
PCC Holistic and respectful care should be delivered with a focus on the individual and on enabling autonomy by empowering individuals to exist involved in their own care [37]
Multi-/inter-disciplinary teams Providers from all services must work together in a flexible way to provide coordinated care and so that patients can benefit from expertise from multiple specialties [ix, 31]
Effective communication Communication is a vital component for all involved in care and extends to the communication between healthcare professionals by providing integrated electronic record management [2, 31, 35]
Case direction A named individual is identified as care coordinator/case manager, who has direct responsibleness for supporting service users by coordinating care, engaging patients in their own care and providing care direct [2, 23, 35]
Needs assessment for care and belch planning Using comprehensive multi-disciplinary geriatric assessment can evaluate needs and enable care plans to be developed [ii, 9, 33, 35]. Personalized plans for patients aim to improve the efficiency and quality of healthcare surrounding the discharge process and ensure appropriate and coordinated services are in place to support the patient [two, 13, 35]

Table 2

Macro-, meso- and micro-level implementation barriers and facilitators for integrated intendance in older populations

Factor level Barriers to integrating care Facilitators for integrating care
Macro-level factors: External context

  • Cultural inertia [vii]

  • Wellness system instability [38]

  • Strategic direction for improving services [38, 39]

  • Wider wellness arrangement stability [38]

  • Laws and regulation regarding professional competency, scope of practice, intendance standards and safety [38]
Miso-level factors: System organisation Funding/finances

  • Funding silos [38]

  • Competitive funding amidst stakeholders [38]

  • Unclear financial attribution [7]

  • Common governance [35]

  • Incentives for integration [35, 38]

  • Funding realignment, ring-fencing and pooling [7]

  • Funding systems for integration [35]
Organizational leadership

  • A barrier occurs when organization leaders are not in charge of interventions and changes are implemented from outside groups [26]

  • Weakness in commissioning to support innovations and collaborative work and lack of sustained projection direction [3]

  • Ensure potent project management and ties between implementers and the arrangement where changes volition occur

  • Strong leadership and clearly communicated strategic visions [34]
Construction of existing services

  • Divides between primary and secondary or wellness and social service provision [3]

  • Fourth dimension pressure and staffing levels [17, 24, 35]

  • Complexity in the intendance organization [32]

  • System-level policies and procedures should be made that item how care works and who is eligible [2]
Philosophy/ civilisation

  • Poor institutional philosophy [17]

  • A permission-based and gamble-balky culture [3, 26]

  • Bureaucratic environment based on a command and control approach to management [32]

  • Encourage innovation [28]

  • Enable an adaptive system and focus on the system'southward chapters to self-organize [32]
Miso-level factors: Intervention organization Intervention size and complication

  • Big, multi-component interventions take longer and are harder to implement [26]

  • Complex interventions crave cooperation with multiple stakeholders—getting agreement and implementing change can have longer and is more hard [26]

  • Modest/ focused teams can make fast decisions, implement changes and drive the projection forward [26]

  • Preliminary work to promote mutual understanding and clarify roles is useful [26]
Intervention resource

  • Bereft additional resources/ extra funds means new tasks will simply be added to existing ones, staff volition not have plenty time and new tasks will non exist done [26]

  • Success can be supported past a general framework for suitable conditions and funding must exist in place [31]
Credibility

  • Interventions may lack brownie east.g. GP endorsement was critical for airplane pilot study brownie on integrated care within chief care setting in the UK [26]

  • Staff must be confident that senior direction/team leaders are strongly committed to implementing lasting change [26]
Micro-level factors: Providers and inquiry staff Shared values and understanding

  • Staff attitudes, lack of shared values and disagreement over the goals or benefits of interventions [17, 26]

  • Lack of understanding may cause staff to feel their role is existence eroded and are therefore non happy to assist with changes

  • Sites, teams and members disagree over the aims or benefits of the proposed intervention and their roles and responsibilities [26]

  • Grooming is needed on the objectives of alter

  • Joint preparation (different professional person groups) may be useful [31]

  • Staff consultation promotes feelings of involvement and understanding of aims
Engagement

  • Lack of professional engagement is a bulwark. For example a particular barrier is when GPs were not involved and committed to community interventions. Changes lacked credibility and others did not appoint in modify [26]

  • Staff may feel uninvolved, underprepared and 'thrown in' to projects [26]

  • Identify or engage 'champions' who act to remind and encourage staff. Champions may be more effective when they exist amid peer groups i.e. GPs to encourage GPs [26]

  • Engage workforce with a simple vision and enable people on the front line to 'feel involved' in changing the service to ensure they effectively engage

  • Some staff autonomy and being motivated helped to brand changes possible [26]
Communication

  • Bereft communication in full general is a major barrier to integrated care

  • Lack of existing working relationships between individuals/ groups [26]

  • Teams and squad-members are not located together [26]

  • Lack of robust tape sharing across services

  • Staff members are concerned about data security and who is immune to see what

  • Primary care physicians may not exist proactive in sharing information [35]

  • Staff may be unclear of purpose/ objectives of interventions and so are not motivated to engage in changes [26]

  • Staff confusion about their ain and others' roles and responsibilities [24]

  • Staff are unsure what they are permitted to do and who is working on the projection [26]

  • Allow time for relationships to develop [26]

  • Co-location increases frequency and quality of communication and gives better access to the advisable professional knowledge [31]

  • Regular, ongoing and pre-planned advice betwixt senior partners in the relevant organizations is of import for success [two, 25, 26]

  • Create rules and agreement in advance about how the partnership/ collaboration will work

  • Electronic record sharing and using an integrated information organisation for record sharing can help integration [two], with existent-time data sharing [35]

  • Preliminary work is needed to involve staff so they feel consulted and valued

  • Articulate outlines of each role/responsibility are needed. Integrated intendance pathways tin can formalize multi-disciplinary team-working and enable professionals to examine their roles and responsibilities [21]

  • Encourage staff to make decisions autonomously [26]
Factor level Barriers to integrating intendance Facilitators for integrating intendance
Macro-level factors: External context

  • Cultural inertia [seven]

  • Wellness system instability [38]

  • Strategic direction for improving services [38, 39]

  • Wider health arrangement stability [38]

  • Laws and regulation regarding professional competency, scope of practice, intendance standards and safety [38]
Miso-level factors: Arrangement organization Funding/finances

  • Funding silos [38]

  • Competitive funding among stakeholders [38]

  • Unclear financial attribution [seven]

  • Common governance [35]

  • Incentives for integration [35, 38]

  • Funding realignment, ring-fencing and pooling [seven]

  • Funding systems for integration [35]
Organizational leadership

  • A barrier occurs when organization leaders are not in charge of interventions and changes are implemented from exterior groups [26]

  • Weakness in commissioning to back up innovations and collaborative work and lack of sustained project management [iii]

  • Ensure strong projection management and ties between implementers and the organization where changes will occur

  • Potent leadership and conspicuously communicated strategic visions [34]
Structure of existing services

  • Divides betwixt primary and secondary or health and social service provision [3]

  • Time pressure and staffing levels [17, 24, 35]

  • Complexity in the care system [32]

  • System-level policies and procedures should be made that detail how care works and who is eligible [2]
Philosophy/ civilisation

  • Poor institutional philosophy [17]

  • A permission-based and risk-averse culture [iii, 26]

  • Bureaucratic environment based on a command and control arroyo to management [32]

  • Encourage innovation [28]

  • Enable an adaptive system and focus on the system's chapters to cocky-organize [32]
Miso-level factors: Intervention organisation Intervention size and complexity

  • Large, multi-component interventions take longer and are harder to implement [26]

  • Complex interventions require cooperation with multiple stakeholders—getting agreement and implementing alter can take longer and is more difficult [26]

  • Small/ focused teams can make fast decisions, implement changes and drive the projection forward [26]

  • Preliminary work to promote mutual understanding and clarify roles is useful [26]
Intervention resources

  • Insufficient additional resources/ actress funds means new tasks will just be added to existing ones, staff will not have enough time and new tasks will not exist washed [26]

  • Success can be supported by a general framework for suitable atmospheric condition and funding must be in place [31]
Credibility

  • Interventions may lack credibility e.g. GP endorsement was critical for airplane pilot study brownie on integrated intendance inside primary care setting in the Great britain [26]

  • Staff must be confident that senior management/squad leaders are strongly committed to implementing lasting alter [26]
Micro-level factors: Providers and research staff Shared values and agreement

  • Staff attitudes, lack of shared values and disagreement over the goals or benefits of interventions [17, 26]

  • Lack of agreement may cause staff to experience their function is beingness eroded and are therefore non happy to help with changes

  • Sites, teams and members disagree over the aims or benefits of the proposed intervention and their roles and responsibilities [26]

  • Preparation is needed on the objectives of change

  • Joint training (unlike professional person groups) may be useful [31]

  • Staff consultation promotes feelings of involvement and understanding of aims
Engagement

  • Lack of professional engagement is a bulwark. For example a particular barrier is when GPs were not involved and committed to community interventions. Changes lacked credibility and others did not appoint in change [26]

  • Staff may feel uninvolved, underprepared and 'thrown in' to projects [26]

  • Identify or appoint 'champions' who act to remind and encourage staff. Champions may exist more than constructive when they exist amidst peer groups i.east. GPs to encourage GPs [26]

  • Engage workforce with a simple vision and enable people on the forepart line to 'feel involved' in changing the service to ensure they effectively appoint

  • Some staff autonomy and being motivated helped to brand changes possible [26]
Communication

  • Insufficient communication in general is a major barrier to integrated care

  • Lack of existing working relationships between individuals/ groups [26]

  • Teams and team-members are not located together [26]

  • Lack of robust tape sharing across services

  • Staff members are concerned about data security and who is allowed to run across what

  • Chief care physicians may not be proactive in sharing data [35]

  • Staff may be unclear of purpose/ objectives of interventions and and so are not motivated to engage in changes [26]

  • Staff confusion well-nigh their ain and others' roles and responsibilities [24]

  • Staff are unsure what they are permitted to do and who is working on the project [26]

  • Allow time for relationships to develop [26]

  • Co-location increases frequency and quality of communication and gives improve access to the appropriate professional knowledge [31]

  • Regular, ongoing and pre-planned communication between senior partners in the relevant organizations is important for success [2, 25, 26]

  • Create rules and agreement in advance about how the partnership/ collaboration will work

  • Electronic record sharing and using an integrated information arrangement for tape sharing tin can help integration [2], with real-time information sharing [35]

  • Preliminary work is needed to involve staff so they feel consulted and valued

  • Clear outlines of each function/responsibleness are needed. Integrated care pathways tin can formalize multi-disciplinary team-working and enable professionals to examine their roles and responsibilities [21]

  • Encourage staff to brand decisions autonomously [26]

Table 2

Macro-, meso- and micro-level implementation barriers and facilitators for integrated care in older populations

Factor level Barriers to integrating care Facilitators for integrating care
Macro-level factors: External context

  • Cultural inertia [seven]

  • Wellness system instability [38]

  • Strategic direction for improving services [38, 39]

  • Wider health system stability [38]

  • Laws and regulation regarding professional person competency, scope of exercise, care standards and safety [38]
Miso-level factors: Organization organization Funding/finances

  • Funding silos [38]

  • Competitive funding among stakeholders [38]

  • Unclear financial attribution [seven]

  • Mutual governance [35]

  • Incentives for integration [35, 38]

  • Funding realignment, band-fencing and pooling [7]

  • Funding systems for integration [35]
Organizational leadership

  • A barrier occurs when organization leaders are not in charge of interventions and changes are implemented from outside groups [26]

  • Weakness in commissioning to support innovations and collaborative work and lack of sustained project management [three]

  • Ensure strong project management and ties between implementers and the organization where changes will occur

  • Strong leadership and clearly communicated strategic visions [34]
Structure of existing services

  • Divides between chief and secondary or health and social service provision [iii]

  • Time pressure and staffing levels [17, 24, 35]

  • Complexity in the care organisation [32]

  • System-level policies and procedures should exist made that detail how care works and who is eligible [ii]
Philosophy/ culture

  • Poor institutional philosophy [17]

  • A permission-based and take a chance-averse culture [3, 26]

  • Bureaucratic environment based on a control and control approach to management [32]

  • Encourage innovation [28]

  • Enable an adaptive system and focus on the organization's capacity to self-organize [32]
Miso-level factors: Intervention organization Intervention size and complication

  • Big, multi-component interventions take longer and are harder to implement [26]

  • Circuitous interventions crave cooperation with multiple stakeholders—getting understanding and implementing change can have longer and is more difficult [26]

  • Small/ focused teams can brand fast decisions, implement changes and drive the project forrard [26]

  • Preliminary work to promote common understanding and clarify roles is useful [26]
Intervention resources

  • Insufficient additional resource/ extra funds ways new tasks volition but be added to existing ones, staff will not accept enough time and new tasks will non be done [26]

  • Success can be supported by a general framework for suitable weather condition and funding must be in place [31]
Credibility

  • Interventions may lack credibility e.m. GP endorsement was disquisitional for pilot report credibility on integrated care inside primary care setting in the United kingdom of great britain and northern ireland [26]

  • Staff must exist confident that senior management/team leaders are strongly committed to implementing lasting modify [26]
Micro-level factors: Providers and inquiry staff Shared values and agreement

  • Staff attitudes, lack of shared values and disagreement over the goals or benefits of interventions [17, 26]

  • Lack of understanding may crusade staff to feel their role is beingness eroded and are therefore non happy to help with changes

  • Sites, teams and members disagree over the aims or benefits of the proposed intervention and their roles and responsibilities [26]

  • Training is needed on the objectives of change

  • Joint training (different professional person groups) may be useful [31]

  • Staff consultation promotes feelings of involvement and understanding of aims
Engagement

  • Lack of professional engagement is a barrier. For example a particular barrier is when GPs were not involved and committed to community interventions. Changes lacked credibility and others did non engage in alter [26]

  • Staff may experience uninvolved, underprepared and 'thrown in' to projects [26]

  • Identify or appoint 'champions' who act to remind and encourage staff. Champions may be more effective when they be among peer groups i.due east. GPs to encourage GPs [26]

  • Engage workforce with a simple vision and enable people on the front line to 'feel involved' in irresolute the service to ensure they effectively engage

  • Some staff autonomy and existence motivated helped to make changes possible [26]
Communication

  • Insufficient communication in general is a major barrier to integrated care

  • Lack of existing working relationships between individuals/ groups [26]

  • Teams and team-members are not located together [26]

  • Lack of robust record sharing across services

  • Staff members are concerned about data security and who is allowed to run into what

  • Master intendance physicians may not exist proactive in sharing data [35]

  • Staff may exist unclear of purpose/ objectives of interventions and so are not motivated to engage in changes [26]

  • Staff confusion well-nigh their ain and others' roles and responsibilities [24]

  • Staff are unsure what they are permitted to do and who is working on the projection [26]

  • Allow time for relationships to develop [26]

  • Co-location increases frequency and quality of advice and gives better access to the appropriate professional knowledge [31]

  • Regular, ongoing and pre-planned communication betwixt senior partners in the relevant organizations is important for success [2, 25, 26]

  • Create rules and agreement in advance about how the partnership/ collaboration volition work

  • Electronic record sharing and using an integrated information arrangement for tape sharing can help integration [2], with existent-time information sharing [35]

  • Preliminary piece of work is needed to involve staff so they experience consulted and valued

  • Clear outlines of each role/responsibleness are needed. Integrated care pathways can formalize multi-disciplinary team-working and enable professionals to examine their roles and responsibilities [21]

  • Encourage staff to make decisions autonomously [26]
Factor level Barriers to integrating care Facilitators for integrating intendance
Macro-level factors: External context

  • Cultural inertia [7]

  • Health organisation instability [38]

  • Strategic direction for improving services [38, 39]

  • Wider health system stability [38]

  • Laws and regulation regarding professional person competency, scope of exercise, care standards and safe [38]
Miso-level factors: Organization organization Funding/finances

  • Funding silos [38]

  • Competitive funding among stakeholders [38]

  • Unclear fiscal attribution [7]

  • Common governance [35]

  • Incentives for integration [35, 38]

  • Funding realignment, ring-fencing and pooling [7]

  • Funding systems for integration [35]
Organizational leadership

  • A barrier occurs when organization leaders are not in charge of interventions and changes are implemented from outside groups [26]

  • Weakness in commissioning to support innovations and collaborative work and lack of sustained project management [3]

  • Ensure strong projection management and ties between implementers and the organisation where changes will occur

  • Stiff leadership and clearly communicated strategic visions [34]
Construction of existing services

  • Divides between primary and secondary or health and social service provision [3]

  • Time pressure and staffing levels [17, 24, 35]

  • Complication in the intendance system [32]

  • Organization-level policies and procedures should be made that detail how intendance works and who is eligible [2]
Philosophy/ civilization

  • Poor institutional philosophy [17]

  • A permission-based and hazard-averse civilization [iii, 26]

  • Bureaucratic environment based on a command and control approach to management [32]

  • Encourage innovation [28]

  • Enable an adaptive system and focus on the system's chapters to self-organize [32]
Miso-level factors: Intervention arrangement Intervention size and complication

  • Large, multi-component interventions accept longer and are harder to implement [26]

  • Complex interventions require cooperation with multiple stakeholders—getting agreement and implementing modify can take longer and is more than difficult [26]

  • Pocket-sized/ focused teams can make fast decisions, implement changes and drive the project forward [26]

  • Preliminary work to promote mutual understanding and clarify roles is useful [26]
Intervention resource

  • Insufficient additional resources/ actress funds means new tasks will simply be added to existing ones, staff will not have plenty time and new tasks will non be done [26]

  • Success tin exist supported past a general framework for suitable conditions and funding must be in place [31]
Credibility

  • Interventions may lack credibility e.m. GP endorsement was critical for airplane pilot study credibility on integrated care within chief care setting in the UK [26]

  • Staff must be confident that senior management/team leaders are strongly committed to implementing lasting change [26]
Micro-level factors: Providers and inquiry staff Shared values and agreement

  • Staff attitudes, lack of shared values and disagreement over the goals or benefits of interventions [17, 26]

  • Lack of agreement may cause staff to feel their role is beingness eroded and are therefore not happy to assistance with changes

  • Sites, teams and members disagree over the aims or benefits of the proposed intervention and their roles and responsibilities [26]

  • Training is needed on the objectives of change

  • Articulation training (different professional groups) may be useful [31]

  • Staff consultation promotes feelings of interest and agreement of aims
Engagement

  • Lack of professional date is a barrier. For case a particular barrier is when GPs were not involved and committed to community interventions. Changes lacked credibility and others did not engage in alter [26]

  • Staff may feel uninvolved, underprepared and 'thrown in' to projects [26]

  • Place or appoint 'champions' who human activity to remind and encourage staff. Champions may be more than effective when they be among peer groups i.eastward. GPs to encourage GPs [26]

  • Engage workforce with a simple vision and enable people on the front line to 'feel involved' in changing the service to ensure they effectively engage

  • Some staff autonomy and being motivated helped to brand changes possible [26]
Communication

  • Insufficient communication in full general is a major barrier to integrated care

  • Lack of existing working relationships between individuals/ groups [26]

  • Teams and team-members are not located together [26]

  • Lack of robust record sharing beyond services

  • Staff members are concerned about data security and who is allowed to come across what

  • Main care physicians may non exist proactive in sharing data [35]

  • Staff may be unclear of purpose/ objectives of interventions and then are not motivated to engage in changes [26]

  • Staff confusion nearly their own and others' roles and responsibilities [24]

  • Staff are unsure what they are permitted to do and who is working on the project [26]

  • Allow time for relationships to develop [26]

  • Co-location increases frequency and quality of communication and gives better access to the advisable professional noesis [31]

  • Regular, ongoing and pre-planned communication between senior partners in the relevant organizations is of import for success [2, 25, 26]

  • Create rules and agreement in advance well-nigh how the partnership/ collaboration will work

  • Electronic record sharing and using an integrated information system for record sharing tin help integration [two], with real-time data sharing [35]

  • Preliminary work is needed to involve staff so they feel consulted and valued

  • Clear outlines of each function/responsibility are needed. Integrated care pathways can formalize multi-disciplinary team-working and enable professionals to examine their roles and responsibilities [21]

  • Encourage staff to make decisions autonomously [26]

Developing and evaluating integrated programmes

The continuing priority for integration of health services, amidst many governments, means the need to develop and evaluate methods remains a key outcome [40]. There are several established approaches to inform evolution and evaluation of integrated care models such as the 'Development model for integrated care', 'INTERLINKS framework' and 'COMIC model' [28, 41, 42]. These approaches are all likely to be informative in developing and evaluating integrated intendance programmes considering they are multi-component, focus on quality PCC and consider, or may exist adapted to, private, professional, organizational and arrangement levels.

Ongoing cross-site comparison studies, for structured approaches to integrate intendance, will likely explicate how or what makes programmes successful overall, such equally in project INTEGRATE [43]. All the same, robust evidence for the most benign or constructive approaches for integration may remain elusive, equally programmes are both complex and diverse, as in the case of the INTERLNKS report [41]. Targeted procedure evaluations, such as from the perspective of certain professional groups, may inform almost which components contribute to the process of integration and may be particularly useful in illuminating how integration occurs in unlike settings [4]. Each group of researchers may, therefore, wish to tailor their evaluation tools to encounter specific project objectives.

Core components of integrated intendance for frail or elderly populations

Continuity in intendance and effective transitions

In that location are often large divides between primary and secondary services or between health and social services and improving coordination, such as streamlining services (improve efficiency) or edifice networks, will improve the quality of care [3]. Transitions from inpatient to community care are hindered by ineffective communication, confusion over provider roles and responsibility and a diluted sense of individual responsibility when care spans many providers [44].

Sub-astute services, or hospital at home schemes, that bridge the gap between inpatient and general community care, have provided (weak) evidence of effectiveness in terms of clinical and service employ outcomes [11, 33]. Yet, success may depend more on targeting ideal patients rather than the setting or intensity of interventions [25]. In specific situations, early belch schemes appear extremely effective in lowering readmission rates, which supports the view that targeting ideal patients and providing comprehensive services may lead to improvements in care [33].

Formal policy and governance

Formal policy is recognized as important for integrating intendance then that providers can coordinate services and piece of work inside common governance [2, 23, 35]. Policy or guidelines may facilitate professional appointment, leadership, credibility and shared values, all of which are identified every bit essential for successful service integration [26]. Although integrated care policies are important, those that are designed to permit autonomy and adaption within the system may be more effective, so practices and procedures can develop over time to suit the environment [32, 35]. Key barriers to implementing policy for integration include operational complexity, regulatory challenges, unclear financial contribution and cultural inertia [seven]. Governmental leadership tin can facilitate integration through (i) realigning funding, (ii) formulating multi-stakeholder, representative leadership coalitions and (iii) developing models or frameworks for the leadership coalitions to follow [seven].

Shared values and common goals

Having common goals or feeling involved in changes is important in private health professional credence towards integrated care. For example, lack of community doctor engagement, the feeling of personal role erosion, feeling underprepared, uninvolved and unsure nigh what each person is permitted to do, and a strong permission culture are barriers to change [26]. Shared values tin can exist facilitated past clear guidelines of the purpose of changes, giving individual'southward permission to instigate changes, engaging, encouraging, providing leadership, developing skills, changes in culture at clinical and managerial levels, and through formal policies [2, 7, 23, 35].

Person-centred care

Recent policy rhetoric frequently endorses patient centredness as a desirable attribute of the care system [29] but evidence is lacking nigh how to successfully implement PCC [36]. Bear witness of potent benefits for clinical outcomes or satisfaction, when adopting a PCC approach, is weak but implementation barriers oftentimes preclude models being fully adopted [27, 36]. Staff shortages, in addition to a strong focus on the biomedical model in care, are considered significant barriers to implementing PCC [34].

Multi- and inter-disciplinary services

Having multi- or inter-disciplinary teams volition probable contribute to the procedure of horizontal integration through developing common goals or values and through improved advice. Existing community service construction is often circuitous and a uncomplicated design of services, based around multi-disciplinary master care teams and designed according to the natural local geography may facilitate integration [45]. Co-location, where example managers and other professionals occupy the same work space, tin assistance newly integrated teams because people take better access to the appropriate professional cognition by increasing communication frequency and quality [26].

Constructive advice

Maintaining regular, ongoing and pre-planned communication between senior partners in the relevant organizations is important for success in integrated care interventions [26]. Between medical and care staff, regular meetings and articulation training sessions can promote cooperation and information sharing, while a mutual database will aid the menstruum and exchange of information [31]. However, a common barrier to advice can be concerns surrounding information security, sharing and privacy [26, 38].

Example management

Case managers, oft a nurse or social worker, are the cardinal coordinator in effective multi-disciplinary teams for integrated services [2, 19, 35]. Instance management is associated with promising results for clinical outcomes, time to institutionalization or hospitalization, improved function, improved utilise of advisable medication and increased use of customs services [19, 27]. Example direction may be more effective when information technology is loftier intensity, includes effective advice between services, and when specialists are included in the intendance of circuitous cases [24]. Barriers to implementing effective case management include: a misunderstanding about the responsibilities of case managers, poor advice between health professionals, a lack of geriatric grooming, poor integration of case management services in the existing care system, high case manager turnover, different locations of case managers and master physicians, large caseloads and time constraints [24].

Comprehensive cess to inform care and belch plans

Assessments are considered integral to planning and delivering quality care and show supports service reorganization to provide comprehensive geriatric assessments (CGA) [ix] in order to provide needs-matched individualized care. CGA in hospitals may have beneficial outcomes, including the proportion of patients living at home, institutionalization rates and cognitive function. Studies recommend that assessments should be conducted past experienced or trained staff, in multi-disciplinary teams and be multi-dimensional [9, 31, 33].

Discharge plans aim to amend care efficiency and quality by reducing discharge filibuster, facilitating transport to the post-belch setting, providing patients with appropriate information on their condition and outlining mail service-discharge support needs [13]. Goal setting and discharge planning will be more successful when resources for treatment or rehabilitation exist [9]. Effective discharge planning is adamant past standardized and policy-driven protocols. Additionally, clarifying the roles of health professionals, having a designated coordinator, empowering nurses to participate in the process and communicating more with patients and their intendance-givers may facilitate the belch planning process and provide integrated, needs-matched intendance [30].

Implementation bug

Overall, cardinal implementation issues in four main areas were observed: (i) Macro-level contextual factors; (2) Miso-level system organization (funding, leadership, service construction and culture); (three) Miso-level intervention system (characteristics, resources and credibility); and (iv) Micro-level factors (shared values, date and communication) (Table 2).

Understanding the broad structural, political, economic and cultural context when implementing and scaling upwards integrated care models is essential [38]. However, although macro-level (external context) and meso-level (organizational) integration is important in the process, increasing attention is being given to interventions focused on micro-level (provider/patients) integration [4, 38]. Integration is a complex and not-linear process and such micro-level operational activities, such equally, teamwork, knowledge exchange and communication, take more recently become the focus of research [4].

Having well-funded multi-disciplinary teams, that participate in frequent communication and share common values, was ofttimes identified as a necessary feature for successful integration of services [9, 11, thirty, 33, 35]. Integration is achieved past careful planning and financing, shared vision and a focus on providing care centred around patient needs [7]. A strong factor in determining whether programmes are successful is the identification and targeting of suitable patient populations [7]. Funding allocation is also a core factor in facilitating integration of services, and can incentivize and reward stakeholders that meet established criteria [seven, 38]. Funding should exist realigned, pooled and ring-fenced to facilitate integration of services [7].

When interventions or planned changes are large, changes will inevitably exist slower to take effect. Greater investment in preliminary piece of work will, therefore, be required, in which mutual understanding of aims and roles is accomplished among all participants, to avoid confusion. Risk-averse or permission-based cultures may also inhibit innovation and staff motivation towards changes [3, 26], and it is, therefore, besides important that those involved in delivering interventions are encouraged to take democratic deportment to improve services [9, eleven, 30, 33, 35]. Implementing changes may also be facilitated through preparation stakeholders on the potential pitfalls of the implementation process [46]. Thus, stakeholders may be empowered to identify and accost mutual barriers as they are encountered. In terms of implementing programmes to intendance for older patients, building flexibility into programmes was found to be benign so that professionals take selection on which actions to take, based on patient needs [46], and thus care can be tailored around the patient. Additional facilitators include suitable it infrastructure and appropriate methods for programme evaluation [7].

Give-and-take

Integrating care for older people requires some common elements, irrespective of the care setting or system, and globally, at that place is a drive to deliver better and more efficient intendance by integrating services. It is challenging to identify single successful elements of integrated care because programmes frequently include multiple components, study designs may be poorly reported and intervention success depends heavily on the context [2, 23]. Many reviews conclude that no single model or approach for integrating care exists [2, 33, 35]. Providers may benefit from focusing on how best to combine successful features of models to amend care [27], and allow services to develop over time [35]. Thus, in this review, we summarize mutual features of integrated service models, rather than provide detailed descriptions of existing models (for comprehensive descriptions of care models, please refer to existing reports [2, 35]). Our review draws together the of import elements for integrating healthcare services for older populations and also focuses on practical implementation features that can facilitate or hinder success.

The rapid and less-formal methodology adopted in scoping reviews, every bit compared to systematic reviews, is a articulate limitation and it is possible that key elements of integrated care or important implementation issues were non captured. Yet, studies were sought until theme saturation was achieved. Scoping reviews are a relatively new methodology, and no universal definition or procedure for conducting such reviews, exists [47]. Scoping reviews aim to present an overview of a potentially big and heterogeneous body of literature [47]. Given the variety in existing literature pertaining to integrated care, a scoping review methodology was selected equally a practical way to summarize key themes in integration. An additional limitation is the lack of report quality criteria, which may decrease confidence in findings. However, standard quality assessments may have limited awarding when testify is fatigued from heterogeneous sources.

The core components of integrated care programmes nosotros identified are inter-linked and all focus on integrating care at service, organizational, clinical and/or private levels, and by placing the patient at the centre of intendance. Because effectiveness, barriers and facilitators for interventions appear to depend heavily on the context, we eagerly expect findings from big (multi-site/multi-intervention) studies in integrated care, such as the SUSTAIN programme [48]. This integrated care plan across several European settings aims to identify what works, for whom, in what context. Until then, and even if robust evidence is generated from this study, implementing changes to improve integrated intendance will likely do good from using both local and international prove. Though it may not be possible to determine which components within complex interventions are constructive, we recommend that studies study on the logic and evolution of their integrated care programmes, in addition to comprehensive evaluation of both intervention outcomes and implementation processes.

Conclusion

The step of inquiry in the field of integrated intendance, and how best to implement changes, continues to increase. There are at present many established resources bachelor, to inform the development and evaluation of integrated intendance programmes. Treat elderly and delicate persons may be improved through integration by: (i) agreement the levels and modes through which integration may take place; (ii) agreement the key components of integrated care for older populations and (3) anticipating implementation issues, in society to effectively make changes inside different care contexts and settings.

Supplementary material

Supplementary textile is available at International Periodical for Quality in Health Intendance online.

Funding

This work was undertaken every bit office of a commissioned study that was fully funded by a grant from the Health and Medical Research Fund of the Food and Wellness Bureau in Hong Kong and the Research Grants Quango of Hong Kong.

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© The Author 2017. Published by Oxford University Press in association with the International Society for Quality in Wellness Intendance. All rights reserved. For permissions, delight e-mail: journals.permissions@oup.com

© The Author 2017. Published by Oxford University Press in association with the International Society for Quality in Health Care. All rights reserved. For permissions, please electronic mail: journals.permissions@oup.com

    • Supplementary data