Integrated care for the
frail and elderly: a review
of the evidence by Susan
Smith and John Gale (JET
Library, Mid-Cheshire
NHS Foundation Trust)
Contents
Evidence Review .............................................................................................................................. 8
Rapid evidence review to inform the case for change: long-term conditions and frailty / Shiona
Aldridge and Alison Turner (attached file) Central Midlands Commissioning Support Unit, 2014 .... 8
Other Trusts’ projects.................................................................................................................... 8
A new and short-stay unit for frail and elderly patients ..................................................................... 8
Better care for elderly and diabetic patients ...................................................................................... 8
Age UK's integrated care pilot to be rolled out across England. ........................................................ 8
Better Care Fund Plan - Integrating Health and Social Care in Central Bedfordshire......................... 9
Birmingham and Solihull frail elderly programme plan (2012) (see attached file) ............................ 9
Burton Hospitals NHS Foundation Trust Strategic Plan – 2014-2019 (see attached file) ................... 9
Bringing together the health and care system with the fire service .................................................. 9
Effective integration of acute and community services for frail older people: South Warwickshire
NHS Foundation Trust (2012) (see attached file) ............................................................................... 9
Evaluation of complex integrated care programmes: the approach in North West London. ............ 9
High quality lifelong care .................................................................................................................. 10
Integrated Care and Support Pioneer Programme Annual Report 2014 – NHS England ................. 10
Integrated care pilots launched. ....................................................................................................... 11
Integrated care pioneer programme: annual report 2014 / NHS England (see attached file) ......... 11
Integrated care scheme for older people will roll out across England. ............................................ 11
Integrated care pilot programme: ensuring people with dementia receive joined up care ............ 12
Integrating community services for patients with multiple long-term conditions and the frail
elderly / Balmer, Jan (Mid-Nottinghamshire Integrated Care Transformation Programme) (see
attached file) ..................................................................................................................................... 12
New care models – vanguard sites – NHS England web sites........................................................... 12
Portsmouth Hospitals NHS Trust: clinical strategy 2012/13-2015/6 (2014) (see attached file) ...... 13
Solent NHS Trust: integrated business plan (see attached file)........................................................ 13
Summary of integrated care projects: Bolton, Salford and Trafford (2013) (see attached file)....... 13
The North West London Integrated Care Pilot: Innovative strategies to improve care coordination
for older adults and people with diabetes........................................................................................ 13
Transforming the care of the frail older person / The Community Programme (various bodies in
the East Midlands) (see attached file) .............................................................................................. 14
Whittington Health NHS Trust: 13/14 annual report (see attached file) ......................................... 14
The Policy Background ................................................................................................................ 14
Building the house – the House of Care toolkit ................................................................................ 14
Disability, dementia and frailty in later life – mid-life approaches to prevention............................ 14
Fit for frailty: consensus best practice guidance for the care of older people living with frailty in
community and outpatient settings / British Geriatrics Society (2014) (see attached file) ............. 14
Making our health and care systems fit for an ageing population / Oliver, David, Foot, Catherine
and Humphries, Richard (King’s Fund, 2014) (see attached file) ...................................................... 15
Person centred care made simple: what everyone should know about person-centred care. Quick
Guide. ................................................................................................................................................ 15
Safe, compassionate care for frail older people using an integrated care pathway: practical
guidance for commissioners, providers and nursing, medical and allied health professional leaders
– NHS England, South, Report (see attached file)............................................................................. 15
Think frailty: improving the identification and management of frailty – a case study report of
innovation on four acute sites in NHS Scotland / NHS Scotland (2014) (see attached file) ............. 15
Towards whole person care. ............................................................................................................. 15
European Initiatives ..................................................................................................................... 16
A Slovenian model of integrated care for older people can offer solutions for NHS services. ........ 16
Diagnostic study, design and implementation of an integrated model of care in France: a bottomup process with continuous leadership. ........................................................................................... 16
Health and social care in aging population: an integrated care institution for the elderly in Greece.
.......................................................................................................................................................... 17
Implementing the chronic care model for frail older adults in the Netherlands: study protocol of
ACT (frail older adults: care in transition) ......................................................................................... 18
Integrated care for the elderly: the background and effects of the reform of Swedish care of the
elderly. .............................................................................................................................................. 19
Integrated care for older people in Europe-latest trends and perceptions. .................................... 19
Integrated care for vulnerable older people in Denmark ................................................................. 20
Organizing integrated care for older persons: strategies in Sweden during the past decade. ........ 20
Ten years of integrated care for the older in France. ....................................................................... 21
The 2008-2012 French Alzheimer plan: a unique opportunity for improving integrated care for
dementia. .......................................................................................................................................... 22
The first general practitioner hospital in The Netherlands: Towards a new form of integrated care?
.......................................................................................................................................................... 23
Academic Research ...................................................................................................................... 24
5-year Medicaid cost savings from integrating home and community based services with a housecall practice: Elder partnership for all-inclusive care (EPAC) ............................................................ 24
A cost-effectiveness study of a patient-centred integrated care pathway ...................................... 25
A literature review to explore integrated care for older people. ..................................................... 26
A novel model of integrated care for the elderly: COPA, coordination of professional care for the
elderly ............................................................................................................................................... 26
A system of integrated care for older persons with disabilities in Canada: Results from a
randomized controlled trial .............................................................................................................. 27
A systematic review of different models of home and community care services for older persons.
.......................................................................................................................................................... 28
A systematic review of integrated working between care homes and health care services ........... 29
Accountable care organisations in the United Sates and England: testing, evaluating and learning
what works / Stephen Shortell … et al (King’s Fund, 2014) (see attached file) ................................ 30
An integrated care pathway project ................................................................................................. 31
An integrated care program for hip fracture in Singapore ............................................................... 31
Attitudes towards integrated care pathways in the UK NHS: A pilot study in one UK NHS trust .... 33
Better care for frail older people: working differently to improve care - Deloitte........................... 33
Building bonds with nursing homes / Butcher, Lola Hospitals and Health Networks May 2015 ..... 34
Care for Canada's frail elderly population: Fragmentation or integration? ..................................... 34
Caregiver satisfaction with support services: influence of different types of services. ................... 34
Care transitions for frail, older people from acute hospital wards within an integrated care system
in England: a qualitative case study / Lesley Baillie … [et al] ............................................................ 35
Case management for at-risk elderly patients in the English integrated care pilots: observational
study of staff and patient experience and secondary care utilisation.............................................. 35
Commonwealth Care Alliance. A new approach to coordinated care for the chronically ill and frail
elderly that organizationally integrates consumer involvement. ..................................................... 36
Cost-effectiveness of integrated care for elderly depressed patients in the PRISM-E study ........... 36
Developing and trial use of the new integrated care pathway for dementia in an urban city in
Japan ................................................................................................................................................. 38
Effectiveness and cost-effectiveness of a proactive, goal-oriented, integrated care model in
general practice for older people. A cluster randomized controlled trial: Integrated Systematic
Care for older People-the ISCOPE study ........................................................................................... 39
Elder partnership for all-inclusive care (Elder-PAC): 5-year follow-up of integrating care for frail,
community elders, linking home based primary care with an area agency on aging (AAA) as an
independence at home (IAH) model................................................................................................. 40
Effectiveness of community-based integrated care in frail COPD patients: a randomised controlled
trial. ................................................................................................................................................... 41
Effects of multidisciplinary integrated care on quality of care in residential care facilities for elderly
people: a cluster randomized trial. ................................................................................................... 41
Embracing integrated care by collaborating in project care with tan tock Seng hospital ................ 42
Enhancing health care in care homes: integration in practice – King’s Fund Blog Post ................... 43
Frail elderly patients. New model for integrated service delivery. .................................................. 43
Frailty pathway integrates service to provide more and better care outside of hospital – NHS
Improving Quality ............................................................................................................................. 44
Fully integrated care for frail elderly: two American models ........................................................... 45
House Calls for Seniors: Building and Sustaining a Model of Care for Homebound Seniors ............ 45
Increasing value for money in the Canadian healthcare system: new findings and the case for
integrated care for seniors................................................................................................................ 46
Innovative contracting for integrated care: what are the risks and benefits of various contracting
methods? / Ricketts, Bob (King’s Fund, 2014) (see attached file) .................................................... 46
Integrated care.................................................................................................................................. 47
Integrated care facilitation for older patients with complex health care needs reduces hospital
demand ............................................................................................................................................. 47
Integrated care for frail older people 2012: a clinical overview / Jackie Morris Journal of Integrated
.......................................................................................................................................................... 48
Integrated care for older people: examining workforce and implementation challenges / Centre
for Workforce Intelligence (2014) (see attached file) ...................................................................... 48
Integrated care for the frail elderly .................................................................................................. 48
Integrated care models for the frail older people [sic]: some international case studies and lessons
/ Kodner, Dennis L. (see attached file) .............................................................................................. 49
Integrated care summit 2015: the journey from integrated care to population health systems .... 49
Integrated models of care delivery for the frail elderly: International perspectives ....................... 49
Integrated services for dementia: The formal carer experience ...................................................... 50
Integration and continuity of care in health care network models for frail older adults ................. 51
International experiments in integrated care for the elderly: A synthesis of the evidence ............. 51
Interprofessional and integrated care of the elderly in a family health team. ................................ 52
Just for us: An academic medical center-community partnership to maintain the health of a frail
low-income senior population .......................................................................................................... 53
Managed long-term care: care integration through care coordination. .......................................... 54
Managing effective partnerships in older people's services ............................................................ 54
Medicaid-funded home care for the frail elderly and disabled: evaluating the cost savings and
outcomes of a service delivery reform. ............................................................................................ 55
Opening the black box of clinical collaboration in integrated care models for frail, elderly patients
.......................................................................................................................................................... 56
PACE: A model for integrated care of frail older patients ................................................................ 57
Person centred care 2020: calls and contributions form health and social care charities. .............. 57
Physician home visits in homebound ............................................................................................... 58
PRISMA: a new model of integrated service delivery for the frail older people in Canada ............. 59
Progress toward integrating care for seniors in Canada: "We have to skate toward where the puck
is going to be, not to where it has been."......................................................................................... 59
Randomised trial of impact of model of integrated care and case management for older people
living in the community .................................................................................................................... 60
Reducing hospital bed use by frail older people: results from a systematic review of the literature
.......................................................................................................................................................... 61
Successfully integrating aged care services: a review of the evidence and tools emerging from a
long-term care program.................................................................................................................... 62
Supporting frail seniors through a family physician and Home Health integrated care model in
Fraser Health ..................................................................................................................................... 63
Teams without walls: enabling partnerships between generalists and specialists. ......................... 64
Ten years of integrated care: backwards and forwards. The case of the province of Québec,
Canada. ............................................................................................................................................. 64
Test and learn: Working towards integrated services. ..................................................................... 65
The acute and long-term care interface. Integrating the continuum. .............................................. 66
The CareWell in Hospital program to improve the quality of care for frail elderly inpatients: results
of a before-after study with focus on surgical patients. ................................................................... 66
The contribution of geriatric medicine to integrated care for older people. ................................... 67
The effects of an integrated care intervention for the frail elderly on informal caregivers: a quasiexperimental study ........................................................................................................................... 68
The future is frail: An innovative approach to managing patients in care homes............................ 69
The Growing Pains of Integrated Health Care for the Elderly: Lessons from the Expansion of PACE
.......................................................................................................................................................... 70
The impact of an integrated care service on service users: the service users' perspective ............. 70
The short-term effects of an integrated care model for the frail elderly on health, quality of life,
health care use and satisfaction with care ....................................................................................... 71
'Trying to do a jigsaw without the picture on the box': understanding the challenges of care
integration in the context of single assessment for older people in England. ................................. 72
Using HIT to deliver integrated care for the frail elderly in the UK: current barriers and future
challenges. ........................................................................................................................................ 73
Using principles of transition management while introducing and evaluating a model of care to
improve care for frail older inpatients .............................................................................................. 73
Whole-system approaches to health and social care partnerships for the frail elderly: an
exploration of North American models and lessons. (See attached file) ......................................... 74
Working towards integrated community care for older people: Empowering organisational
features from a professional perspective ......................................................................................... 75
Evidence Review
Rapid evidence review to inform the case for change: long-term conditions and
frailty / Shiona Aldridge and Alison Turner (attached file) Central Midlands
Commissioning Support Unit, 2014
Other Trusts’ projects
A new and short-stay unit for frail and elderly patients
Southport and Ormskirk NHS Trust are already providing integrated care for the frail and elderly
http://www.gmc-uk.org/guidance/25974.asp
Better care for elderly and diabetic patients
How Imperial College Healthcare NHS Trusts are getting involved in providing care for the frail and
elderly
http://www.imperial.nhs.uk/aboutus/news/news_030246
Age UK's integrated care pilot to be rolled out across England.
Citation: Nursing standard (Royal College of Nursing (Great Britain) : 1987), Apr 2015, vol. 29, no. 35,
p. 10. (April 29, 2015)
Author(s): Comerford, Cathy
Abstract: A pioneering integrated care scheme, whereby community nurses work with trained
volunteers to co-ordinate care, has helped reduce unplanned hospital admissions among older
people by almost half.
Source: Medline
Better Care Fund Plan - Integrating Health and Social Care in Central Bedfordshire
http://plaintext.centralbedfordshire.gov.uk/Images/integrated%20care%20diagram_tcm852851.pdf#False
http://plaintext.centralbedfordshire.gov.uk/health-and-social-care/adult-care/better-carefund/better-care-fund.aspx
Birmingham and Solihull frail elderly programme plan (2012) (see attached file)
Burton Hospitals NHS Foundation Trust Strategic Plan – 2014-2019 (see attached
file)
Burton Hospitals are looking at becoming an integrated care provider (p. 34-36 of this document)
Bringing together the health and care system with the fire service
How the Fire Service is working with health and social care to provide integrated care in Manchester
http://www.nhsiq.nhs.uk/news-events/news/bringing-together-the-health-and-care-system-withthe-%EF%AC%81re-service.aspx
Effective integration of acute and community services for frail older people: South
Warwickshire NHS Foundation Trust (2012) (see attached file)
Evaluation of complex integrated care programmes: the approach in North West
London.
Citation: International journal of integrated care, Jan 2013, vol. 13, p. e006. (2013 Jan-Mar)
Author(s): Greaves, Felix, Pappas, Yannis, Bardsley, Martin, Harris, Matthew, Curry, Natasha, Holder,
Holly, Blunt, Ian, Soljak, Michael, Gunn, Laura, Majeed, Azeem, Car, Josip
Abstract: Several local attempts to introduce integrated care in the English National Health Service
have been tried, with limited success. The Northwest London Integrated Care Pilot attempts to
improve the quality of care of the elderly and people with diabetes by providing a novel integration
process across primary, secondary and social care organisations. It involves predictive risk modelling,
care planning, multidisciplinary management of complex cases and an information technology tool
to support information sharing. This paper sets out the evaluation approach adopted to measure its
effect. We present a mixed methods evaluation methodology. It includes a quantitative approach
measuring changes in service utilization, costs, clinical outcomes and quality of care using routine
primary and secondary data sources. It also contains a qualitative component, involving
observations, interviews and focus groups with patients and professionals, to understand participant
experiences and to understand the pilot within the national policy context. This study considers the
complexity of evaluating a large, multi-organisational intervention in a changing healthcare
economy. We locate the evaluation within the theory of evaluation of complex interventions. We
present the specific challenges faced by evaluating an intervention of this sort, and the responses
made to mitigate against them. We hope this broad, dynamic and responsive evaluation will allow us
to clarify the contribution of the pilot, and provide a potential model for evaluation of other similar
interventions. Because of the priority given to the integrated agenda by governments
internationally, the need to develop and improve strong evaluation methodologies remains strikingly
important.
Source: Medline
Full Text:
Available from Free Access Content in International Journal of Integrated Care
Available from National Library of Medicine in International Journal of Integrated Care
Gnosall memory clinic: the basics
http://www.gnosallsurgery.co.uk/website/M83070/files/Gnosall_Memory_Clinic__The_Basics_April_2013.pdf
High quality lifelong care
The Uniting Care Partnership: an NHS partnership responsible for providing older people’s
healthcare and adult community services across Cambridgeshire and Peterborough
http://www.unitingcare.co.uk/
‘If vanguards work the return on investment is to the wider NHS.’ / Read, Claire
How vanguard trusts are working at Salford Royal, Northumbria and Morecambe Bay
http://www.hsj.co.uk/hospitaltransformation/if-vanguards-work-the-return-on-investment-is-tothe-wider-nhs/5085295.article#.VXABms-6eUk
Integrated Care and Support Pioneer Programme Annual Report 2014 – NHS
England
http://www.local.gov.uk/documents/10180/6927502/Integrated+Care+Pioneer+Programme+Annua
l+Report+2014/76d562c3-4f7d-4169-91bc-69f7a9be481c
Integrated care pilots launched.
Citation: GP: General Practitioner, 10 April 2009, vol./is. /(3-), 02688417
Language: English
Abstract: The article announces the launch of integrated care organisations in Great Britain. It is
expected that the 16 pilot projects will cost £4 million and will involve collaborations between
general practitioner (GP) practices, trusts, private providers, social services and charities for local
health needs. It points out that most of their schemes is aimed at improving services coordination
for the elderly and chronically ill.
Publication Type: Periodical
Source: HEALTH BUSINESS ELITE
Full Text:
Available from EBSCOhost in GP: General Practitioner
Integrated care pioneer programme: annual report 2014 / NHS England (see
attached file)
Integrated care scheme for older people will roll out across England.
Citation: BMJ (Clinical research ed.), Jan 2015, vol. 350, p. h2157. (2015)
Author(s): O'Dowd, Adrian
Source: Medline
Integrated care pilot programme: ensuring people with dementia receive joined
up care
Citation: Nursing times, March 2010, vol./is. 106/10(12-14), 0954-7762 (2010 Mar 16-22)
Author(s): Jones K.
Language: English
Abstract: The Department of Health's integrated care pilots, announced in April 2009, aim to
transform the way people experience health and social care. A multidisciplinary team in
Bournemouth and Poole has set up a nurse led project focusing on memory loss and dementia in
older people. This article outlines the aims, elements, challenges and benefits of working as part of a
multidisciplinary team, from a nursing perspective.
Publication Type: Journal: Article
Source: EMBASE
Full Text:
Available in NURSING TIMES at JET Library, Leighton
Integrating community services for patients with multiple long-term conditions
and the frail elderly / Balmer, Jan (Mid-Nottinghamshire Integrated Care
Transformation Programme) (see attached file)
New care models – vanguard sites – NHS England web sites
A list of the vanguard sites and the projects they are working on
http://www.england.nhs.uk/ourwork/futurenhs/5yfv-ch3/new-care-models/
Portsmouth Hospitals NHS Trust: clinical strategy 2012/13-2015/6 (2014) (see
attached file)
Pages 20-21 of the strategy talk about integrated care pathways
Solent NHS Trust: integrated business plan (see attached file)
Page 10-12 talk about developing integrated care
Summary of integrated care projects: Bolton, Salford and Trafford (2013) (see
attached file)
The North West London Integrated Care Pilot: Innovative strategies to improve
care coordination for older adults and people with diabetes
Citation: Journal of Ambulatory Care Management, July 2012, vol./is. 35/3(216-225), 0148-9917
(July-September 2012)
Author(s): Harris M., Greaves F., Patterson S., Jones J., Pappas Y., Majeed A., Car J.
Language: English
Abstract: The North West London Integrated Care Pilot (ICP) was launched in June 2011 and brings
together more than 100 general practices, 2 acute care trusts, 5 primary care trusts, 2 mental health
care trusts, 3 community health trusts, 5 local authorities, and 2 voluntary sector organizations (Age
UK and Diabetes UK) to improve the coordination of care for a pilot population of 550 000 people.
Specifically, the ICP serves people older than 75 years and those with diabetes. Although still in the
early stages of implementation, the ICP has already received national awards for its innovations in
design and delivery. This article critically describes the ICP objectives, facilitating processes, and
planned impact as well as the organizational and financial challenges that policy makers are facing in
the implementation of the pilot program. Copyright © 2012 Wolters Kluwer Health Lippincott
Williams & Wilkins.
Publication Type: Journal: Article
Source: EMBASE
Transforming the care of the frail older person / The Community Programme
(various bodies in the East Midlands) (see attached file)
Whittington Health NHS Trust: 13/14 annual report (see attached file)
Whittington Health is one of the 14 integrated-care pioneers chosen by NHS England – see page 10
of this document
The Policy Background
Building the house – the House of Care toolkit
The House of Care toolkit describes four key, interdependent components that, if implemented
together, will achieve patient-centred, co-ordinated service for people living with long-term
conditions and their carers
http://www.nhsiq.nhs.uk/improvement-programmes/long-term-conditions-and-integratedcare/long-term-conditions-improvement-programme/house-of-care-toolkit.aspx
Disability, dementia and frailty in later life – mid-life approaches to prevention
NICE guideline on preventing disability and dementia as people get older
http://www.nice.org.uk/Guidance/GID-PHG64/Documents
Fit for frailty: consensus best practice guidance for the care of older people living
with frailty in community and outpatient settings / British Geriatrics Society
(2014) (see attached file)
Integration: local-government and health leaders prefer a whole-systems
approach / Dalton, Rachel
http://www.hsj.co.uk/resource-centre/supplements/integration-local-government-and-healthleaders-prefer-a-whole-system-approach/5086572.article#.VXbO88-6eUk
Making our health and care systems fit for an ageing population / Oliver, David,
Foot, Catherine and Humphries, Richard (King’s Fund, 2014) (see attached file)
Person centred care made simple: what everyone should know about personcentred care. Quick Guide.
Citation: Health Foundation, October 2014.
Author(s): Health Foundation.
Full text: http://personcentredcare.health.org.uk/sites/default/files/resources/personcentred_care_made_simple_1.pdf
Safe, compassionate care for frail older people using an integrated care pathway:
practical guidance for commissioners, providers and nursing, medical and allied
health professional leaders – NHS England, South, Report (see attached file)
http://www.england.nhs.uk/wp-content/uploads/2014/02/safe-comp-care.pdf
Think frailty: improving the identification and management of frailty – a case
study report of innovation on four acute sites in NHS Scotland / NHS Scotland
(2014) (see attached file)
Towards whole person care.
Citation: Institute for Public Policy Research, December 2013.
Author(s): Bickerstaffe, S.
Full text: http://www.ippr.org/assets/media/images/media/files/publication/2013/11/wholeperson-care_Dec2013_11518.pdf?noredirect=1
European Initiatives
A Slovenian model of integrated care for older people can offer solutions for NHS
services.
Citation: Nursing times, Jan 2009, vol. 105, no. 49-50, p. 10-12, 0954-7762 (2009 Dec 15-2010 Jan
11)
Author(s): Jones, Helen, Wilding, Steve
Abstract: The population in Britain is ageing and creating a burden on healthcare that will require
the NHS and social care to deliver innovative strategies. This article outlines a visit to Slovenia to
view a model of care that fits in well with the Department of Health's integrated care approach to
the care of older people and those with long term conditions.
Source: Medline
Full Text:
Available in NURSING TIMES at JET Library, Leighton
Diagnostic study, design and implementation of an integrated model of care in
France: a bottom-up process with continuous leadership.
Citation: International journal of integrated care, Jan 2010, vol. 10, p. e034. (2010)
Author(s): de Stampa, Matthieu, Vedel, Isabelle, Mauriat, Claire, Bagaragaza, Emmanuel, Routelous,
Christelle, Bergman, Howard, Lapointe, Liette, Cassou, Bernard, Ankri, Joel, Henrard, Jean-Claude
Abstract: Sustaining integrated care is difficult, in large part because of problems encountered
securing the participation of health care and social service professionals and, in particular, general
practitioners (GPs). To present an innovative bottom-up and pragmatic strategy used to implement a
new integrated care model in France for community-dwelling elderly people with complex needs. In
the first step, a diagnostic study was conducted with face-to-face interviews to gather data on
current practices from a sample of health and social stakeholders working with elderly people. In the
second step, an integrated care model called Coordination Personnes Agées (COPA) was designed by
the same major stakeholders in order to define its detailed characteristics based on the local
context. In the third step, the model was implemented in two phases: adoption and maintenance.
This strategy was carried out by a continuous and flexible leadership throughout the process, initially
with a mixed leadership (clinician and researcher) followed by a double one (clinician and managers
of services) in the implementation phase. The implementation of this bottom-up and pragmatic
strategy relied on establishing a collaborative dynamic among health and social stakeholders. This
enhanced their involvement throughout the implementation phase, particularly among the GPs, and
allowed them to support the change practices and services arrangements.
Source: Medline
Full Text:
Available from Free Access Content in International Journal of Integrated Care
Available from National Library of Medicine in International Journal of Integrated Care
Health and social care in aging population: an integrated care institution for the
elderly in Greece.
Citation: International journal of integrated care, Jan 2003, vol. 3, p. e04. (2003)
Author(s): Daniilidou, Natasa V, Economou, Charalabos, Zavras, Dimitrios, Kyriopoulos, John,
Georgoussi, Eugenia
Abstract: To describe the nature of the services actually offered to the elderly in Greece by an
institution of integrated care, as opposed to those that should be offered according to the relevant
law, and to investigate the factors influencing the supply of those services. By the year 2020 about
20 million people will be aged 80 and over in the European Union. People of third age consist 16.9%
of the total Greek population. Population aging has major implications on health services,
employment and society as a whole. "Open Care Centres for the Elderly" (KAPI) is a rapidly
developing and expanding institution providing integrated care for the elderly. A questionnaire to be
completed by the staff was sent to all 370 KAPI. Response rate reached 66%. For the analysis of the
data multiple logistic regression analysis was performed using SPSS 10.0. Both medical and social
care is provided by the KAPI to the elderly with different magnitude all over the country. Factors
such as number of members, medical, paramedical and non-medical staff and fund availability in the
KAPI mainly influence the supply of services. Integrated care services are offered by the KAPI.
However, more steps need to be taken towards the direction of other European countries'
integrated care schemes, in order to improve both quality and quantity of the services provided.
Source: Medline
Full Text:
Available from Free Access Content in International Journal of Integrated Care
Available from National Library of Medicine in International Journal of Integrated Care
Implementing the chronic care model for frail older adults in the Netherlands:
study protocol of ACT (frail older adults: care in transition)
BMC Geriatr. 2012; 12: 19.
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC3464922/
Background
Care for older adults is facing a number of challenges: health problems are not consistently
identified at a timely stage, older adults report a lack of autonomy in their care process, and care
systems are often confronted with the need for better coordination between health care
professionals. We aim to address these challenges by introducing the geriatric care model, based on
the chronic care model, and to evaluate its effects on the quality of life of community-dwelling frail
older adults.
Methods/design
In a 2-year stepped-wedge cluster randomised clinical trial with 6-monthly measurements, the
chronic care model will be compared with usual care. The trial will be carried out among 35 primary
care practices in two regions in the Netherlands. Per region, practices will be randomly allocated to
four allocation arms designating the starting point of the intervention. Participants: 1200
community-dwelling older adults aged 65 or over and their primary informal caregivers. Primary care
physicians will identify frail individuals based on a composite definition of frailty and a polypharmacy
criterion. Final inclusion criterion: scoring 3 or more on a disability case-finding tool. Intervention:
Every 6 months patients will receive a geriatric in-home assessment by a practice nurse, followed by
a tailored care plan. Expert teams will manage and train practice nurses. Patients with complex care
needs will be reviewed in interdisciplinary consultations. Evaluation: We will perform an effect
evaluation, an economic evaluation, and a process evaluation. Primary outcome is quality of life as
measured with the Short Form-12 questionnaire. Effect analyses will be based on the “intention-totreat” principle, using multilevel regression analysis. Cost measurements will be administered
continually during the study period. A cost-effectiveness analysis and cost-utility analysis will be
conducted comparing mean total costs to functional status, care needs and QALYs. We will
investigate the level of implementation, barriers and facilitators to successful implementation and
the extent to which the intervention manages to achieve the transition necessary to overcome
challenges in elderly care.
Discussion
This is one of the first studies assessing the effectiveness, cost-effectiveness and implementation
process of the chronic care model for frail community-dwelling older adults.
Keywords: Chronic care model, Frailty, Elderly, Primary care, Stepped wedge cluster randomised
controlled clinical trial
Integrated care for the elderly: the background and effects of the reform of
Swedish care of the elderly.
Citation: International journal of integrated care, Jan 2000, vol. 1, p. e01. (2000)
Author(s): Andersson, G, Karlberg, I
Source: Medline
Full Text:
Available from Free Access Content in International Journal of Integrated Care
Available from National Library of Medicine in International Journal of Integrated Care
Integrated care for older people in Europe-latest trends and perceptions.
Citation: International journal of integrated care, Jan 2012, vol. 12, p. e7. (2012 Jan-Mar)
Author(s): Leichsenring, Kai
Abstract: As a researcher and consultant I have coordinated local pilots and European research
projects to analyse and improve long-term care for older people by better integrating health and
social care systems. One of my conclusions from the wide range of initiatives that have been taken
over the past two decades in Europe has been the need to treat long-term care as a system in its
own right. Long-term care systems require a discernable identity; specific policies, structures,
processes and pathways; and the leadership and resources that can underpin expectations, drive
performance and achieve better outcomes for people that are living with (and working for those
with) long-term care needs. Progress in developing LTC systems can be identified today in all
European countries. Integrated care solutions at the interface between health and social care, and
between formal and informal care, have appeared. These have been achieved partly by means of
(slow) political reforms, partly as a response to market-oriented governance, and in many cases
through pioneering community and civil society initiatives. It will depend on such initiatives, and
their ability to convince both citizens and policy-makers, whether new societal approaches to longterm care are created that meet the demands of ageing societies.
Source: Medline
Full Text:
Available from Free Access Content in International Journal of Integrated Care
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Integrated care for vulnerable older people in Denmark
Citation: HealthcarePapers, 2009, vol./is. 10/1(29-33; discussion 79-3383), 1488-917X (2009)
Author(s): Hansen E.B.
Language: English
Abstract: This paper focuses on community-based services for vulnerable older people in Denmark.
The main characteristics of the Danish case of integrated care are introduced, and the principles in
the provision of community-based services and the overall organization and responsibility of these
services are analyzed. Furthermore, the principles and the incentives behind the development of
integrated care for older people in Denmark are discussed. On the basis of the Danish experience,
the paper ends with a discussion of important characteristics of community care for vulnerable and
disabled older people and significant factors in the process of developing integrated community
care.
Publication Type: Journal: Article
Organizing integrated care for older persons: strategies in Sweden during the past
decade.
Citation: Journal of health organization and management, Jan 2015, vol. 29, no. 1, p. 128-151, 14777266 (2015)
Author(s): Berglund, Helene, Blomberg, Staffan, Dunér, Anna, Kjellgren, Karin
Abstract: Purpose - The purpose of this paper is to describe and analyse ways of organizing
integrated care for older persons in Sweden during the past decade. Design/methodology/approach
- The data consist of 62 cases of development work, described in official reports. A meta-analysis of
cases was performed, including content analysis of each case. A theoretical framework comprising
different forms of integration (co-ordination, contracting, co-operation and collaboration) was
applied. Findings - Co-operation was common and collaboration, including multiprofessional
teamwork, was rare in the cases. Contracting can be questioned as being a form of integration, and
the introduction of consumer choice models appeared problematic in inter-organization integration.
Goals stated in the cases concerned steering and designing care, rather than outcome specifications
for older persons. Explicit goals to improve integration in itself could imply that the organizations
adapt to strong normative expectations in society. Trends over the decade comprised development
of local health care systems, introduction of consumer choice models and contracting out. Research
limitations/implications - Most cases were projects, but others comprised evaluations of regular
organization of integrated care. These evaluations were often written normatively, but constituted
the conditions for practice and were important study contributions. Practical implications - Guiding
clinical practice to be aware of importance of setting follow-up goals. Social implications - Awareness
of the risk that special funds may impede sustainable strategies development. Originality/value - A
theoretical framework of forms of integration was applied to several different strategies, which had
been carried out mostly in practice. The study contributes to understanding of how different
strategies have been developed and applied to organize integrated care, and highlights some
relationships between integration theory and practice.
Source: Medline
Ten years of integrated care for the older in France.
Citation: International journal of integrated care, Jan 2011, vol. 11, p. e141. (January 2011)
Author(s): Somme, Dominique, de Stampa, Matthieu
Abstract: This paper analyzes progress made toward the integration of the French health care
system for the older and chronically ill population. Over the last 10 years, the French health care
system has been principally influenced by two competing linkage models that failed to integrate
social and health care services: local information and coordination centers, governed by the social
field, and the gerontological health networks governed by the health field. In response to this
fragmentation, Homes for the Integration and Autonomy for Alzheimer patients (MAIAs) is currently
being implemented at experimental sites in the French national Alzheimer plan, using an evidencebased model of integrated care. In addition, the state's reforms recently created regional health
agencies (ARSs) by merging seven strategic institutions to manage the overall delivery of care. The
French health care system is moving from a linkage-based model to a more integrated care system.
We draw some early lessons from these changes, including the importance of national leadership
and governance and a change management strategy that uses both top-down and bottom-up
approaches to implement these reforms.
Source: Medline
Full Text:
Available from Free Access Content in International Journal of Integrated Care
Available from National Library of Medicine in International Journal of Integrated Care
The 2008-2012 French Alzheimer plan: a unique opportunity for improving
integrated care for dementia.
Citation: Journal of Alzheimer's disease : JAD, Jan 2013, vol. 34, no. 1, p. 307-314 (2013)
Author(s): Pimouguet, Clément, Bassi, Valérie, Somme, Dominique, Lavallart, Benoit, Helmer,
Catherine, Dartigues, Jean François
Abstract: The 2008-2012 French Alzheimer plan has proposed measures to improve care for
dementia patients in a more personalized and graduate approach owing to patients and caregivers
needs. A key measure of the plan is the nationwide implementation of the MAIA (French acronym
for Maison pour l'Autonomie et l'Intégration des malades d'Alzheimer). The main goal is to
implement a process of integration through a network of partners involved in elderly care,
assistance, or support. The MAIA model comprises tools and mechanisms necessary to improve the
integrated care process; in particular, case management for elderly in complex situations. The
purpose of this paper is to describe the main measures from the national plan that aim to improve
care for dementia patients with an emphasis on the MAIA measure. We summarize initial results of
case management activity in one MAIA in the South West of France and we present two vignettes of
cases benefiting from case management in order to demonstrate the nature of intervention. The
French Alzheimer plan has promoted several non-pharmacological strategies for dementia patients.
Implementation of both integrated care and case management represent a challenging perspective
for the elderly and health professionals.
Source: Medline
The first general practitioner hospital in The Netherlands: Towards a new form of
integrated care?
Citation: Scandinavian Journal of Primary Health Care, March 2004, vol./is. 22/1(38-43), 0281-3432
(March 2004)
Author(s): Van Charante E.M., Hartman E., Yzermans J., Voogt E., Klazinga N., Bindels P.
Language: English
Abstract: Objective - To describe the types of patients admitted to the first Dutch general
practitioner (GP) hospital, their health-related quality of life and its substitute function. Design - A
prospective observational study. Setting - The remaining 20-bed ward of a former district general
hospital west of Amsterdam; a region with 62000 inhabitants and 26 GPs. Subjects - All patients
admitted during the 12 months between 1 June 1999 and 1 June 2000. Main outcome measures Patients' health-related quality of life (Medical Outcome Study 36-item Short Form Health Survey,
Groningen Activities Restriction Scale), GPs assessments of severity of illness (DUSOI/WONCA
Severity of Illness Checklist) and alternative modes of care. Results - In total, 218 admissions were
recorded divided into 3 bed categories: GP beds (n = 131), rehabilitation beds (n = 62) and nursing
home beds (n = 25). The mean age of all patients was 76 years. Main reasons for admission were
immobilization due to trauma at home (GP beds), rehabilitation from surgery (rehabilitation beds)
and stroke (nursing home beds). Overall, patients showed a poor health-related quality of life on
admission. If the GP beds had not been available, the GPs estimated that the admissions would have
been almost equally divided among home care, nursing home and hospital care. The severity of the
diagnosis on admission of the 'hospital-care group' appeared to be significantly higher than the
other care groups. Conclusion - The GP hospital appears to provide a valuable alternative to home
care, nursing home care and hospital care, especially for elderly patients with a poor health-related
quality of life who are in need of short medical and nursing care.
Publication Type: Journal: Article
Source: EMBASE
Full Text:
Available from EBSCOhost in Scandinavian Journal of Primary Health Care
Available from Free Access Content in Scandinavian Journal of Primary Health Care
Available from EBSCOhost in Scandinavian Journal of Primary Health Care
Academic Research
5-year Medicaid cost savings from integrating home and community based
services with a house-call practice: Elder partnership for all-inclusive care (EPAC)
Citation: Journal of the American Geriatrics Society, April 2011, vol./is. 59/(S6), 0002-8614 (April
2011)
Author(s): Kinosian B., Yudin J., Myers S., Danish A., Touzell S., Horner S., Bowman J., Gallahger J.,
O'Donnell L., Forciea M.
Language: English
Abstract: Background: Multidisciplinary housecall practices have been shown to decrease hospital
(Medicare-covered) costs by 25-30%. Impact on Medicaid covered services (HCBS and nursing home
care) are unclear, although states have pursued integrated care options with Special Needs Plans
and PACE to achieve such savings. We have operated an inter-agency, interdisciplinary team,
integrating the Area Agency on Aging (Philadelphia Corporation on Aging) provided waiver services
with an Independence-at-Home like housecall practice. Methods: We assembled a 2004 prevalence
cohort with accrual, and followed them for 5 years. We identified controls, matched by age, gender,
PCA program, zip code, and long term care assessment risk score elements. We identified death, NH
residence, and Medicaid costs (total, HCBS, NH) for both groups, and calculated Kaplan- Meier
survival. Results: There were 4360 member-months of observation for the 92 EPAC cohort members;
and 6910 member-months of observation for the 216 Waiver controls. EPAC consumers had 256
months in long-term institutional care (5.7%), compared to 1726 months for wavier controls (24.9%).
Mean survival was 47 months, with 44.3 months in the community for EPAC, and 31.9 months (24.2
in community) for waiver controls. Mean Medicaid costs were $1720 pmpm ($1448 HCBS/$271
NH)for EPAC and $2257 ($1084 HCBS/$1172 NH) for Waiver. Total 5-year Medicaid costs were
$7.5M for EPAC, and $9.8M for equivalent member-months in Waiver, and $6.7M for 92 similar
Waiver consumers,with an incremental cost/year of community survival of $190, due to the longer
survival of EPAC members. Conclusion: Integratingmedical care through a IAH-type housecall
practice with HCBS provided by a AAA can reduce Medicaid costs by 23%, driven by a 76% reduction
in nursing home months.
Publication Type: Journal: Conference Abstract
Source: EMBASE
Full Text:
Available from EBSCOhost in Journal of the American Geriatrics Society
A cost-effectiveness study of a patient-centred integrated care pathway
Citation: Journal of Advanced Nursing, August 2009, vol./is. 65/8(1626-1635), 0309-2402;1365-2648
(August 2009)
Author(s): Olsson L.-E., Hansson E., Ekman I., Karlsson J.
Language: English
Abstract: Title. A cost-effectiveness study of a patient-centred integrated care pathway. Aim. The
aim of the study was to compare costs and consequences for an integrated care pathway
intervention group with those of a usual care group for patients admitted with hip fracture.
Background. Rehabilitation for patients with hip fracture consists of training in hospital and/or in a
rehabilitation unit, and on their own at home with assistance from community care staff. It is
important for hospitals to provide methods of care that can safeguard these older patients' physical
function and potential for independent living. Methods. A consecutive sample of 112 independently
living participants, aged 65 years or older and admitted to hospital with a hip fracture, were included
in the study. Data were collected over an 18-month period in 2003-2005. A cost-effectiveness
analysis was performed to compare an integrated care pathway intervention (treatment A) with
usual care (treatment B). Results. There was a 40% reduction for each participant in the average
total cost of treatment A of 9685 vs. 15,984 for treatment B. Moreover, clinical effectiveness was
much improved. The cost-effectiveness ratio for treatment A was 14,840 vs. 31,908 for treatment B.
In addition, 75% of the participants in treatment A were successfully rehabilitated vs. 55% in
treatment B. Conclusions. The recovery trajectory for hip fracture surgery may be shortened if
nurses pay more attention to the individual patient's resources and motivation for rehabilitation.
The application of an integrated care pathway with individualized care appears to enhance both
rehabilitation outcomes and cost-effectiveness. © 2009 Blackwell Publishing Ltd.
Publication Type: Journal: Article
Source: EMBASE
Full Text:
Available from EBSCOhost in Journal of Advanced Nursing
A literature review to explore integrated care for older people.
Citation: International journal of integrated care, Jan 2005, vol. 5, p. e17. (2005)
Author(s): Reed, Jan, Cook, Glenda, Childs, Sue, McCormack, Brendan
Abstract: This paper reports on some of the findings of a literature review commissioned to explore
integrated care for older people. The process of revising included finding and selecting literature
from multidisciplinary sources, and encompassed both published papers and 'grey' literature, i.e.
material which had not been reviewed for publication. The study found that thinking has moved on
from a focus on the problems of accessing services to exploring ways in which they may function in
an integrated way. The study shows how thinking on integrated care for older people has developed,
and knowledge of micro, mezzo and macro strategies is now more available.
Source: Medline
Full Text:
Available from Free Access Content in International Journal of Integrated Care
Available from National Library of Medicine in International Journal of Integrated Care
A novel model of integrated care for the elderly: COPA, coordination of
professional care for the elderly
Citation: Aging Clinical and Experimental Research, December 2009, vol./is. 21/6(414-423), 15940667;1720-8319 (December 2009)
Author(s): Vedel I., De Stampa M., Bergman H., Ankri J., Cassou B., Mauriat C., Blanchard F.,
Bagaragaza E., Lapointe L.
Language: English
Abstract: Despite strong evidence for the efficacy of integrated systems, securing the participation
of health professionals, particularly primary care physicians (PCPs), has proven difficult. Novel
approaches are needed to resolve these problems. We developed a model - COPA - that is based on
scientific evidence and an original design process in which health professionals, including PCPs, and
managers participated actively. COPA targets very frail community-dwelling elders recruited through
their PCP. It was designed to provide a better fit between the services provided and the needs of the
elderly in order to reduce excess healthcare use, including unnecessary emergency room (ER) visits
and hospitalizations, and prevent inappropriate long-term nursing home placements. The model's
originality lies in: 1) having reinforced the role played by the PCP, which includes patient recruitment
and care plan development; 2) having integrated health professionals into a multidisciplinary
primary care team that includes case managers who collaborate closely with the PCP to perform a
geriatric assessment (InterRAI MDS-HC) and implement care management programs; and 3) having
integrated primary medical care and specialized care by introducing geriatricians into the community
to see patients in their homes and organize direct hospitalizations while maintaining the PCP
responsibility for medical decisions. Since COPA is currently the subject of both a quasi-ex
perimental study and a qualitative study, we are also providing preliminary findings. These findings
suggest that the model is feasible and well accepted by PCPs and patients. Moreover, our results
indicate that the level of service utilization in COPA was less than what is reported at the national
level, without any compromises in quality of care. ©2009, Editrice Kurtis.
Publication Type: Journal: Article
Source: EMBASE
A system of integrated care for older persons with disabilities in Canada: Results
from a randomized controlled trial
Citation: Journals of Gerontology - Series A Biological Sciences and Medical Sciences, April 2006,
vol./is. 61/4(367-373), 1079-5006 (April 2006)
Author(s): Beland F., Bergman H., Lebel P., Clarfield A.M., Tousignant P., Contandriopoulos A.-P.,
Dallaire L.
Language: English
Abstract: Background. Care for elderly persons with disabilities is usually characterized by
fragmentation, often leading to more intrusive and expensive forms of care such as hospitalization
and institutionalization. There has been increasing interest in the ability of integrated models to
improve health, satisfaction, and service utilization outcomes. Methods. A program of integrated
care for vulnerable community-dwelling elderly persons (SIPA [French acronym for System of
Integrated Care for Older Persons]) was compared to usual care with a randomized control trial. SIPA
offered community-based care with local agencies responsible for the full range and coordination of
community and institutional (acute and long-term) health and social services. Primary outcomes
were utilization and public costs of institutional and community care. Secondary outcomes included
health status, satisfaction with care, caregiver burden, and out-of-pocket expenses. Results.
Accessibility was increased for health and social home care with increased intensification of home
health care. There was a 50% reduction in hospital alternate level inpatient stays ("bed blockers")
but no significant differences in utilization and costs of emergency department, hospital acute
inpatient, and nursing home stays. For all study participants, average community costs per person
were C$3390 higher in the SIPA group but institutional costs were C$3770 lower with, as
hypothesized, no difference in total overall costs per person in the two groups. Satisfaction was
increased for SIPA caregivers with no increase in caregiver burden or out-of-pocket costs. As
expected, there was no difference in health outcomes. Conclusions. Integrated systems appear to be
feasible and have the potential to reduce hospital and nursing home utilization without increasing
costs. Copyright 2006 by The Gerontological Society of America.
Publication Type: Journal: Article
Source: EMBASE
Full Text:
Available from EBSCOhost in Journals of Gerontology Series A: Biological Sciences & Medical Sciences
A systematic review of different models of home and community care services for
older persons.
Citation: BMC health services research, Jan 2011, vol. 11, p. 93. (2011)
Author(s): Low, Lee-Fay, Yap, Melvyn, Brodaty, Henry
Abstract: Costs and consumer preference have led to a shift from the long-term institutional care of
aged older people to home and community based care. The aim of this review is to evaluate the
outcomes of case managed, integrated or consumer directed home and community care services for
older persons, including those with dementia. A systematic review was conducted of non-medical
home and community care services for frail older persons. MEDLINE, PsycINFO, CINAHL, AgeLine,
Scopus and PubMed were searched from 1994 to May 2009. Two researchers independently
reviewed search results. Thirty five papers were included in this review. Evidence from randomized
controlled trials showed that case management improves function and appropriate use of
medications, increases use of community services and reduces nursing home admission. Evidence,
mostly from non-randomized trials, showed that integrated care increases service use; randomized
trials reported that integrated care does not improve clinical outcomes. The lowest quality evidence
was for consumer directed care which appears to increase satisfaction with care and community
service use but has little effect on clinical outcomes. Studies were heterogeneous in methodology
and results were not consistent. The outcomes of each model of care differ and correspond to the
model's focus. Combining key elements of all three models may maximize outcomes.
Source: Medline
Full Text:
Available from EBSCOhost in BMC Health Services Research
Available from ProQuest in BMC Health Services Research
Available from National Library of Medicine in BMC Health Services Research
Available from BioMed Central in BMC Health Services Research
A systematic review of integrated working between care homes and health care
services
Citation: BMC health services research, 2011, vol./is. 11/(320), 1472-6963 (2011)
Author(s): Davies S.L., Goodman C., Bunn F., Victor C., Dickinson A., Iliffe S., Gage H., Martin W.,
Froggatt K.
Language: English
Abstract: In the UK there are almost three times as many beds in care homes as in National Health
Service (NHS) hospitals. Care homes rely on primary health care for access to medical care and
specialist services. Repeated policy documents and government reviews register concern about how
health care works with independent providers, and the need to increase the equity, continuity and
quality of medical care for care homes. Despite multiple initiatives, it is not known if some
approaches to service delivery are more effective in promoting integrated working between the NHS
and care homes. This study aims to evaluate the different integrated approaches to health care
services supporting older people in care homes, and identify barriers and facilitators to integrated
working. A systematic review was conducted using Medline (PubMed), CINAHL, BNI, EMBASE,
PsycInfo, DH Data, Kings Fund, Web of Science (WoS incl. SCI, SSCI, HCI) and the Cochrane Library
incl. DARE. Studies were included if they evaluated the effectiveness of integrated working between
primary health care professionals and care homes, or identified barriers and facilitators to integrated
working. Studies were quality assessed; data was extracted on health, service use, cost and process
related outcomes. A modified narrative synthesis approach was used to compare and contrast
integration using the principles of framework analysis. Seventeen studies were included; 10
quantitative studies, two process evaluations, one mixed methods study and four qualitative. The
majority were carried out in nursing homes. They were characterised by heterogeneity of topic,
interventions, methodology and outcomes. Most quantitative studies reported limited effects of the
intervention; there was insufficient information to evaluate cost. Facilitators to integrated working
included care home managers' support and protected time for staff training. Studies with the
potential for integrated working were longer in duration. Despite evidence about what inhibits and
facilitates integrated working there was limited evidence about what the outcomes of different
approaches to integrated care between health service and care homes might be. The majority of
studies only achieved integrated working at the patient level of care and the focus on health service
defined problems and outcome measures did not incorporate the priorities of residents or
acknowledge the skills of care home staff. There is a need for more research to understand how
integrated working is achieved and to test the effect of different approaches on cost, staff
satisfaction and resident outcomes.
Publication Type: Journal: Review
Source: EMBASE
Full Text:
Available from EBSCOhost in BMC Health Services Research
Available from ProQuest in BMC Health Services Research
Available from National Library of Medicine in BMC Health Services Research
Available from BioMed Central in BMC Health Services Research
Accountable care organisations in the United Sates and England: testing,
evaluating and learning what works / Stephen Shortell … et al (King’s Fund, 2014)
(see attached file)
Acute hospitals and integrated care: from hospitals to health systems.
Citation: King’s Fund, March 2015.
Author(s): Naylor, C et al.
Full text: http://www.kingsfund.org.uk/sites/files/kf/field/field_publication_file/acute-hospitalsand-integrated-care-march-2015.pdf
An integrated care pathway project
Citation: Annals of Physical and Rehabilitation Medicine, May 2014, vol./is. 57/(e400), 1877-0657
(May 2014)
Author(s): Enjalbert M., Benoit E., Ducassy B., Anuth C., Barnier-Figue G.
Language: English
Abstract: Goal.- The need to streamline care pathways led us to build up an integrated project
shared by Perpignan Hospital and different PRM facilities. Methods.- The approach has been
achieved in three steps: grouping of threePRM facilities and two medicosocial settings, creation of a
union of associations with a combination of psychiatric and geriatric institutions and, finally, setting
up a project with the Perpignan Hospital. Results.- This project thus integrated the pooling of PRM
technical platforms of the hospital centre (including geriatric network) and of the partner facilities.
This provided a fluid pathway between acute care and post-acute and rehabilitation care. It also
contributed to develop the downstream networks: nursing care, homecare, long lasting care and
nursing homes. Conclusions.- The efficiency of care management relies on the development of
pathways from acute care, to post-acute care and rehabilitation, social and medical downstream
networks.
Publication Type: Journal: Conference Abstract
Source: EMBASE
Full Text:
Available from Free Access Content in Annals of Physical and Rehabilitation Medicine
An integrated care program for hip fracture in Singapore
Citation: Osteoporosis International, December 2013, vol./is. 24/(S588), 0937-941X (December
2013)
Author(s): Chan W., Rajamoney G.N., Ramason R., Chua S., Azellarasi J., Koo W.
Language: English
Abstract: Aims: To improve the care and outcomes of hip fracture patients using an integrated
model of care of these patients from acute care at Tan Tock Seng Hospital, Singapore to the
inpatient rehabilitation facilities and the community rehabilitation centres. Methods: The Integrated
Hip Fracture Care Workgroup at Tan Tock Seng Hospital (TTSH), Singapore was formed in 2010 to
plan and implement a new program that addresses the needs of these patients from acute care to
inpatient rehabilitation and community care. The proposal for The Integrated Hip Fracture Care
Program was supported by the Ministry of Health, Singapore, with funding from Health Services
Development Program since 2011. Key Performance Indicators (KPI) were conceptualised based on
various evidence-based clinical practice guidelines around the world, measuring clinical processes
and patient outcomes of the program such as time from admission to dedicated orthopaedic ward,
time to surgery, complication rates, functional outcome and mortality. Recruitment of patients age
60 years or older admitted to TTSH with acute hip fractures to the program commenced in October
2011. All patients are managed by the orthopaedic surgeons and well supported by a team of orthogeriatricians, other specialists and a multidisciplinary team of allied health professionals.
Appropriate patients are referred to inpatient rehabilitation facilities and/or day rehabiltation
centres. Care is coordinated by 3 integrated care managers based in TTSH and the patients are
followed up for 1 year fromadmission. Results: About 560 patients were admitted to the program in
the first year, with 1-year follow-up data for the first 9 months available for analysis.We report the
outcomes and challenges we face in the first 2 years of the program, and future plans to enhance
the effectiveness of the program. Conclusions: The Integrated Hip Fracture Care Program at TTSH
demonstrates the challenges and opportunities in integrating care of patients with significant
impairments and disabilities.
Publication Type: Journal: Conference Abstract
Source: EMBASE
Full Text:
Available from EBSCOhost in Osteoporosis International
Available from ProQuest in Osteoporosis International
Attitudes towards integrated care pathways in the UK NHS: A pilot study in one
UK NHS trust
Citation: Journal of Integrated Care Pathways, April 2005, vol./is. 9/1(13-20), 1473-2297 (April 2005)
Author(s): Parker D., Claridge T., Cook G.
Language: English
Abstract: Background: Integrated care pathways (ICPs) offer an increasingly common approach to
the standardization and integration of health-care practice in hospitals. The questionnaire study
reported here was the final phase in a systematic investigation of the attitudes of health-care
professionals towards ICPs in one acute UK NHS Trust. Method: A total of 314 health-care
professionals working in a medium-sized NHS hospital in the UK completed a survey questionnaire,
representing 34% of those approached. Results: Ten dimensions of attitude to ICPs were uncovered.
Junior staff had less positive attitudes than senior staff on all dimensions. Across all professional
groups (doctors, nurses, professions allied to medicine), staff were more unhappy with the idea of
ICPs than with the evidence they are based on or the quality of the documentation itself.
Conclusions: The investigation provided information about how widespread the dislike of ICPs was in
the Trust and details of what was giving rise to staff unease. This enabled the authors to make
recommendations to the Trust about the future development and implementation of ICPs in the
Trust. The most central of these was that investing time and effort in changing the presentation of
ICPs will not meet with success until more fundamental aspects of staff unease have been
addressed. Overall, respondents from this Trust felt uneasy about ICPs because they do not like the
idea of being told what to do. Therefore, if the ICP development programme is to continue at this
hospital and be successful, the hearts and minds of those expected to use ICPs must be won over.
© The Royal Society of Medicine Press 2005.
Publication Type: Journal: Article
Source: EMBASE
Better care for frail older people: working differently to improve care - Deloitte
http://www2.deloitte.com/content/dam/Deloitte/de/Documents/life-sciences-health-care/LSHCbetter-care-for-frail-older-people-14.pdf
Building bonds with nursing homes / Butcher, Lola Hospitals and Health Networks
May 2015 (see attached file)
Care for Canada's frail elderly population: Fragmentation or integration?
CMAJ. 1997 Oct 15; 157(8): 1116–1121.
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC1228270/
Budget constraints, technological advances and a growing elderly population have resulted in major
reforms in health care systems across Canada. This has led to fewer and smaller acute care hospitals
and increasing pressure on the primary care and continuing care networks. The present system of
care for the frail elderly, who are particularly vulnerable, is characterized by fragmentation of
services, negative incentives and the absence of accountability. This is turn leads to the
inappropriate and costly use of health and social services, particularly in acute care hospitals and
long-term care institutions. Canada needs to develop a publicly managed community-based system
of primary care to provide integrated care for the frail elderly. The authors describe such a model,
which would have clinical and financial responsibility for the full range of health and social services
required by this population. This model would represent a major challenge and change for the
existing system. Demonstration projects are needed to evaluate its cost-effectiveness and address
issues raised by its introduction.
Caregiver satisfaction with support services: influence of different types of
services.
Citation: Journal of aging and health, Feb 2006, vol. 18, no. 1, p. 3-27, 0898-2643 (February 2006)
Author(s): Savard, Jacinthe, Leduc, Nicole, Lebel, Paule, Beland, Francois, Bergman, Howard
Abstract: This article examines factors influencing satisfaction with support services of caregivers of
frail older adults and determines what types of support services are associated with greater
satisfaction, controlling for frail individual and caregiver characteristics. The study includes 291 frail
older adults-caregiver dyads from Montreal in which caregivers receive support services. The Client
Satisfaction Questionnaire-8 is used to measure caregiver satisfaction with these services. Caregivers
receiving information, advice, or emotional support, and those caring for seniors receiving
integrated care are more likely to be highly satisfied. Other factors increasing satisfaction are fewer
number of health problems of frail individuals, caregiver being the spouse of the frail person, as well
as greater caregiver perceived health, autonomy in instrumental activities of daily living, and
available social support. The results support the importance of integrated care for frail seniors and
informational services for their caregivers.
Source: Medline
Care transitions for frail, older people from acute hospital wards within an
integrated care system in England: a qualitative case study / Lesley Baillie … [et al]
International Journal of Integrated Care 14 (January-March 2014)
http://www.ijic.org/index.php/ijic/article/view/1175/2382
Case management for at-risk elderly patients in the English integrated care pilots:
observational study of staff and patient experience and secondary care utilisation.
Citation: International journal of integrated care, Jul 2012, vol. 12, p. e130. (2012 Jul-Sep)
Author(s): Roland, Martin, Lewis, Richard, Steventon, Adam, Abel, Gary, Adams, John, Bardsley,
Martin, Brereton, Laura, Chitnis, Xavier, Conklin, Annalijn, Staetsky, Laura, Tunkel, Sarah, Ling, Tom
Abstract: In 2009, the English Department of Health appointed 16 integrated care pilots which
aimed to provide better integrated care. We report the quantitative results from a multi-method
evaluation of six of the demonstration projects which used risk profiling tools to identify older
people at risk of emergency hospital admission, combined with intensive case management for
people identified as at risk. The interventions focused mainly on delivery system redesign and
improved clinical information systems, two key elements of Wagner's Chronic Care Model.
Questionnaires to staff and patients. Difference-in-differences analysis of secondary care utilisation
using data on 3646 patients and 17,311 matched controls, and changes in overall secondary care
utilisation. Most staff thought that care for their patients had improved. More patients reported
having a care plan but they found it significantly harder to see a doctor or nurse of their choice and
felt less involved in decisions about their care. Case management interventions were associated with
a 9% increase in emergency admissions. We found some evidence of imbalance between cases and
controls which could have biased this estimate, but simulations of the possible effect of unobserved
confounders showed that it was very unlikely that the sites achieved their goal of reducing
emergency admissions. However, we found significant reductions of 21% and 22% in elective
admissions and outpatient attendance in the six months following an intervention, and overall
inpatient and outpatient costs were significantly reduced by 9% during this period. Area level
analyses of whole practice populations suggested that overall outpatient attendances were
significantly reduced by 5% two years after the start of the case management schemes. Case
management may result in improvements in some aspects of care and has the potential to reduce
secondary care costs. However, to improve patient experience, case management approaches need
to be introduced in a way which respects patients' wishes, for example the ability to see a familiar
doctor or nurse.
Source: Medline
Full Text:
Available from Free Access Content in International Journal of Integrated Care
Available from National Library of Medicine in International Journal of Integrated Care
Commonwealth Care Alliance. A new approach to coordinated care for the
chronically ill and frail elderly that organizationally integrates consumer
involvement.
Citation: The Journal of ambulatory care management, Oct 2003, vol. 26, no. 4, p. 355-361, 01489917 (2003 Oct-Dec)
Author(s): Master, Robert, Simon, Lois, Goldfield, Norbert
Abstract: While medical care is becoming more effective, our health care system is becoming
increasingly fragmented from both a care and a financing perspective. This article summarizes our
experience with integrating the delivery of care for catastrophically ill and frail elderly. We argue
that true integration can only be done within a framework of a financing mechanism that gives all
providers the financial incentive to deliver integrated care. Under such a financial arrangement,
nurse practitioners and social workers provide much of the care within the home environment. This
results in a higher quality care delivery system within a limited budget.
Source: Medline
Full Text:
Available from EBSCOhost in Journal of Ambulatory Care Management
Cost-effectiveness of integrated care for elderly depressed patients in the PRISM-E
study
Citation: Journal of Mental Health Policy and Economics, December 2009, vol./is. 12/4(205213+217+220), 1091-4358 (December 2009)
Author(s): Wiley-Exley E., Domino M.E., Maxwell J., Levkoff S.E.
Language: English
Abstract: Background: One proposed strategy to improve outcomes associated with depression and
other behavioral health disorders in primary care settings is to strengthen collaboration between
primary care and specialty mental health care through integrated care (IC). Aims: We compare the
cost-effectiveness of IC in primary care to enhanced specialty referral (ESR) for elders with
behavioral health disorders from the Primary Care Research in Substance Abuse and Mental Health
study, which was a randomized trial conducted between 2000 and 2002, using a societal
perspective. Methods: The IC model had a behavioral health professional co-located in the primary
care setting, and the primary care provider continued involvement in the mental health/substance
abuse care of the patient. The comparison model, enhanced specialty referral (ESR), required
referral to a behavioral health provider outside the primary care setting, and the behavioral health
provider had primary responsibility for the mental health/substance abuse needs of the patient.
Costs and clinical outcomes for 840 elders with depression were analyzed using incremental costeffectiveness ratios, the net benefits framework, cost-effectiveness planes, and acceptability curves.
Outcomes were measured by the Center for Epidemiologic Studies Depression Scale (CES-D) and
converted to depression-free days and Quality Adjusted Life Years (QALY). A variation on depression
free days was proposed as an improvement on current methods. Separate analyses were conducted
for Veteran's Affairs (n=365; n=175 in IC and n=190 in ESR) and non-Veteran's Affairs (n=475; n=242
in IC and n=233 in ESR) settings. Results: ESR participants in the non-VA sample exhibited lower
average CES-D scores (i.e., an improvement in depressive symptoms) than did IC participants (beta =
2.8, p< 0.01), no such difference was noted in the VA sample (p > 0.05). Mean costs were $6,338 for
VA IC participants; $7,007 for VA ESR participants; $3,657 for non-VA IC participants; and $3,673 for
non-VA ESR participants. Although the cost-effectiveness planes suggest some uncertainty about the
cost-effectiveness of the intervention, more than 75% of the bootstrap draws were considered costeffective due to a decrease in total costs for IC in the full Veteran's Affairs sample. Discussion: The
findings indicate that IC is likely to be a cost-effective intervention in contrast with ESR in the
Veteran's Affairs setting. In the non-Veteran's Affairs settings, IC is not a more cost-effective
intervention in comparison with ESR. In the VA setting, the greater clinical improvement associated
with IC coupled with the variation in costs and outcomes were such that IC was determined to be
more cost-effective than ESR with a probability of 73-80%. Among non-VA participants, the lower
clinical outcomes combined with no discernable differences in costs translated with a low probability
that IC was more cost-effective than ESR, at any of the estimated values of clinical improvements.
This suggests the importance of clinical setting in determining the clinical and cost effectiveness of IC
for mental health. Limitations: Our analyses were restricted to a six-month period, based on selfreport, and did not include societal costs related to lost productivity and future costs. Implications:
These results suggest that general integration has its advantages and, when such integration exists,
further integrating behavioral health care into primary care might be considered as one way to
improve depression in elders. The finding that ESR may be cost effective in some settings is also
policy relevant. Further research is needed to analyze the components of the costs of ESR in non-VA
settings and the effectiveness of IC in VA settings. Copyright &#xa9; 2009 ICMPE.
Publication Type: Journal: Article
Source: EMBASE
Full Text:
Available from Free Access Content in Journal of Mental Health Policy and Economics
Developing and trial use of the new integrated care pathway for dementia in an
urban city in Japan
Citation: Alzheimer's and Dementia, July 2014, vol./is. 10/(P577), 1552-5260 (July 2014)
Author(s): Takahashi M., Nakamura N., Yanaba R., Oishi S., Miyaoka H.
Language: English
Abstract: Project Description: Elderly people increase very rapidly in Japan, and caring the people
with dementia becomes a big issue. Elderly people in big cities like Tokyo or Osaka increases around
one million in 2025 compared in 2005. Japanese government had planned to establish medical
centers for dementia in each prefecture and it was achieved last year. Sagamihara city is an
ordinance-designated city in Kanagawa prefecture nearby Tokyo. Sagamihara city medical center for
dementia was placed in Kitasato University East Hospital in April 2012. This center aims at consulting
for therapy and care of demented people, early diagnosis and intervention, treating for the
behavioral and psychological symptoms of dementia, holding the regular meetings among related
departments, and education about dementia for specialists as well as citizens. For developing the
best information transfer system among the family, medical and care staff of patients, many
specialists discussed the problems at present and developed the integrated care pathway in
community, named "Sasaetecho" means supporting note. This pathway has used since October 2012
in order to grow up a good support system around the patient and family. We applied this pathway
on 15 patients for one year. In this study we overview the process of developing the integrated care
pathway and investigate how this pathway supports the patients and family. After the first version of
"Sasaetecho" accomplished, information meeting were held several times for local medical and care
staffs. Then we started to apply this pathway. Fifteen user's average age was 73 years old (range 5287), 5 male and 10 female. Their diagnoses were 10 Alzheimer's disease, 3 mixed type dementia, 1
dementia with Lewy bodies, and 1 mild cognitive impairment. Four patients live alone and the other
live with their family. Nine patients have hypertension, six have hyperlipidemia, and three have
diabetes mellitus. Overviewed their records, "Sasaetecho" was used very frequently in two cases,
which their local care manager earnestly wrote comments in it. In conclusion, local staff education
and motivation were important for the effective use of this tool.
Publication Type: Journal: Conference Abstract
Source: EMBASE
Effectiveness and cost-effectiveness of a proactive, goal-oriented, integrated care
model in general practice for older people. A cluster randomized controlled trial:
Integrated Systematic Care for older People-the ISCOPE study
Citation: European Journal of General Practice, September 2014, vol./is. 20/3(227), 1381-4788
(September 2014)
Author(s): Blom J.W., Den Elzen W.P.J., Van Houwelingen A.H., Heijmans M., Stijnen T., Van Den
Hout W.B., Gussekloo J.
Language: English
Abstract: Background: Care for older persons with a combination of somatic, functional, mental
and/or social problems in general practice needs to shift from vertical disease-oriented care aiming
at improvement of outcomes per disease, to horizontal goal-oriented care. Research Question: What
is the feasibility and costeffectiveness of a pro-active and integrated way of working for older people
in general practice with regard to functioning of the older people? Method: Cluster randomized trial
including all persons aged > 75 years in 59 general practices (30 interventions, 29 controls),
introducing a horizontal care plan for participants with a combination of problems, as identified with
a structured postal questionnaire with 21 questions on four health domains. For participants with
problems on > 3 domains, general practitioners (GPs) made an integral care plan using a functional
geriatric approach. Control practices continued care as usual. Outcome measures: These were i)
competence to perform activities of daily living independently, ii) quality of life (QoL), iii) satisfaction
with delivered healthcare and iv) cost-effectiveness of the intervention, at 1-year follow-up. Results:
Of the 11 476 registered eligible older persons, 7 285 (63%) participated in the screening, 1 921
(26%) had problems on > 3 domains. For 225 randomly chosen persons, a care plan was made. No
beneficial effects were found on patients ' functioning, QoL or healthcare use/ costs. GPs
experienced better overview of care needs and stability in the care for individual patients.
Conclusion: This study indicates that GPs prefer proactive integrative care in general practice.
Horizontal care using care plans for older people with complex problems can be a valuable tool in
general practice. However, since no direct beneficial effect was found for older persons, we cannot
recommend this intervention to improve patient outcomes in general practice.
Publication Type: Journal: Conference Abstract
Source: EMBASE
Elder partnership for all-inclusive care (Elder-PAC): 5-year follow-up of integrating
care for frail, community elders, linking home based primary care with an area
agency on aging (AAA) as an independence at home (IAH) model
Citation: Journal of the American Geriatrics Society, April 2010, vol./is. 58/(S6), 0002-8614 (April
2010)
Author(s): Kinosian B., Meyer S., Yudin J., Danish A., Touzel S.
Language: English
Abstract: Background: Pennsylvania's Integrated Care Initiative seeks to link AAA-administered
home and community based services (HCBS) with medical care through Special Needs Plans (SNPs).
EPAC has provided integrated, interdisciplinary team-directed care for frail elders for the past
decade.Whether the initial savings have been maintained are unknown. Methods: We assembled a
cohort of 2004 E-PAC consumers, with accrual, and followed them for 5 years.We compared
community survival with local PACE programs, and HCBS benchmarks using Kaplan-Meier methods.
We obtained care plan costs, medical costs using the HCC model with frailty, and estimated savings
from adjusted state PACE payments and medical savings for a subsample of consumers enrolled in a
Medicare Advantage plan. Results: There were 92 consumers in the cohort (mean age 82; 86%
female). Over 97% of available months were spent in the community for the cohort. Nursing home
placement was 4.7/1000 member months, 5-year community survival 36%, with median community
survival of 4.5 years; and cumulative mortality 43%. K-M 5-year estimates were not significantly
different than PA PACE benchmarks, but were 25% greater than HCBS benchmarks (p<.01). Mean
care plan costs were $24,290/member, nearly $9250 less than adjusted PACE payments. Projected
medical expenditures were $25,550/member (HCC+frailty=3.13) with annual savings of $6130, or
nearly $2,096,400 over 5 years (4104 member-months). Under the IAH allocation, this would save
CMS $525,000 compared to FFS, and $3.1M compared to SNP payments. Conclusion: Integrated,
IDT-directed all-inclusive care is a state of mind, not a single organizational form, with structures
adhering to PACE principles achieving outcomes comparable to PACE, at nearly 30% lower cost. The
ten-year Elder-PAC experience supports modifying Pennsylvania's Integrated Care Initiative to
include housecall provider groups.
Publication Type: Journal: Conference Abstract
Source: EMBASE
Full Text:
Available from EBSCOhost in Journal of the American Geriatrics Society
Effectiveness of community-based integrated care in frail COPD patients: a
randomised controlled trial.
Citation: NPJ primary care respiratory medicine, Jan 2015, vol. 25, p. 15022. (2015)
Author(s): Hernández, Carme, Alonso, Albert, Garcia-Aymerich, Judith, Serra, Ignasi, Marti, Dolors,
Rodriguez-Roisin, Robert, Narsavage, Georgia, Carmen Gomez, Maria, Roca, Josep, NEXES
consortium
Abstract: Chronic obstructive pulmonary disease (COPD) generates a high burden on health care,
and hospital admissions represent a substantial proportion of the overall costs of the disease.
Integrated care (IC) has shown efficacy to reduce hospitalisations in COPD patients at a pilot level.
Deployment strategies for IC services require assessment of effectiveness at the health care system
level. The aim of this study was to explore the effectiveness of a community-based IC service in
preventing hospitalisations and emergency department (ED) visits in stable frail COPD patients. From
April to December 2005, 155 frail community-dwelling COPD patients were randomly allocated
either to IC (n=76, age 73 (8) years, forced expiratory volume during the first second, FEV1 41(19) %
predicted) or usual care (n=84, age 75(9) years, FEV1 44 (20) % predicted) and followed up for 12
months. The IC intervention consisted of the following: (a) patient's empowerment for selfmanagement; (b) an individualised care plan; (c) access to a call centre; and (d) coordination
between the levels of care. Thereafter, hospital admissions, ED visits and mortality were monitored
for 6 years. IC enhanced self-management (P=0.02), reduced anxiety-depression (P=0.001) and
improved health-related quality of life (P=0.02). IC reduced both ED visits (P=0.02) and mortality
(P=0.03) but not hospital admission. No differences between the two groups were seen after 6
years. The intervention improved clinical outcomes including survival and decreased the ED visits,
but it did not reduce hospital admissions. The study facilitated the identification of two key
requirements for adoption of IC services in the community: appropriate risk stratification of patients,
and preparation of the community-based work force.
Source: Medline
Effects of multidisciplinary integrated care on quality of care in residential care
facilities for elderly people: a cluster randomized trial.
Citation: CMAJ : Canadian Medical Association journal = journal de l'Association medicale
canadienne, Aug 2011, vol. 183, no. 11, p. E724. (August 9, 2011)
Author(s): Boorsma, Marijke, Frijters, Dinnus H M, Knol, Dirk L, Ribbe, Miel E, Nijpels, Giel, van Hout,
Hein P J
Abstract: Sophisticated approaches are needed to improve the quality of care for elderly people
living in residential care facilities. We determined the effects of multidisciplinary integrated care on
the quality of care and quality of life for elderly people in residential care facilities. We performed a
cluster randomized controlled trial involving 10 residential care facilities in the Netherlands that
included 340 participating residents with physical or cognitive disabilities. Five of the facilities
applied multidisciplinary integrated care, and five provided usual care. The intervention, inspired by
the disease management model, consisted of a geriatric assessment of functional health every three
months. The assessment included use of the Long-term Care Facility version of the Resident
Assessment Instrument by trained nurse-assistants to guide the design of an individualized care
plan; discussion of outcomes and care priorities with the family physician, the resident and his or her
family; and monthly multidisciplinary meetings with the nurse-assistant, family physician,
psychologist and geriatrician to discuss residents with complex needs. The primary outcome was the
sum score of 32 risk-adjusted quality-of-care indicators. Compared with the facilities that provided
usual care, the intervention facilities had a significantly higher sum score of the 32 quality-of-care
indicators (mean difference - 6.7, p = 0.009; a medium effect size of 0.72). They also had significantly
higher scores for 11 of the 32 indicators of good care in the areas of communication, delirium,
behaviour, continence, pain and use of antipsychotic agents. Multidisciplinary integrated care
resulted in improved quality of care for elderly people in residential care facilities compared with
usual care. www.controlled-trials.com trial register no. ISRCTN11076857.
Source: Medline
Embracing integrated care by collaborating in project care with tan tock Seng
hospital
Citation: Annals of the Academy of Medicine Singapore, February 2011, vol./is. 40/2 SUPPL. 1(S37),
0304-4602 (February 2011)
Author(s): Ramalingam V.
Language: English
Abstract: Due to the rapidly ageing population, Singapore is expected to see an increase in the
number of end-of-life care cases in nursing homes. Nursing homes have the special privilege and
responsibility to help older people finish their final journey with respect, dignity, and to die in a place
of their choice. Death is an unavoidable journey for all. However, the concern is how it is being
managed and executed with minimal sufferings for the residents. Promoting and improving quality
end-of-life care in nursing homes involve multiple issues such as pain management, symptom
control, psycho-social and spiritual care, ethical considerations, advance care planning, staff training,
family participation and partnership with acute hospitals to provide integrated care for residents.
With these values and beliefs, Lions Home for the Elders and 6 other nursing homes have embarked
on "Project Care" with Tan Tock Seng Hospital since January 2010. The project has provided a
consistent approach to the identification and management of residents requiring end-of-life care. It
also helped to reduce the number of residents with chronic conditions being transferred back to
hospital unnecessarily, thus, decreasing the number of residents who otherwise would have died in
an unfamiliar environment such as the acute hospital or the Accident and Emergency Department.
Publication Type: Journal: Conference Abstract
Source: EMBASE
Full Text:
Available from Free Access Content in Annals of the Academy of Medicine - Singapore
Enhancing health care in care homes: integration in practice – King’s Fund Blog
Post
http://www.kingsfund.org.uk/blog/2015/05/enhancing-health-care-care-homes-integration-practice
Frail elderly patients. New model for integrated service delivery.
Can Fam Physician. 2003 Aug; 49: 992–997.
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC2214268/
PROBLEM BEING ADDRESSED: Given the complex needs of frail older people and the multiplicity of
care providers and services, care for this clientele lacks continuity. OBJECTIVE OF PROGRAM:
Integrated service delivery (ISD) systems have been developed to improve continuity and increase
the efficacy and efficiency of services. PROGRAM DESCRIPTION: The Program of Research to
Integrate Services for the Maintenance of Autonomy (PRISMA) is an innovative ISD model based on
coordination. It includes coordination between decision makers and managers of different
organizations and services; a single entry point; a case-management process; individualized service
plans; a single assessment instrument based on clients' functional autonomy, coupled with a casemix classification system; and a computerized clinical chart for communicating between institutions
and professionals for client monitoring. CONCLUSION: Preliminary results on the efficacy of this
model showed a decreased incidence of functional decline, a decreased burden for caregivers, and a
smaller proportion of older people wishing to enter institutions.
Frailty pathway integrates service to provide more and better care outside of
hospital – NHS Improving Quality
http://www.nhsiq.nhs.uk/media/2570535/ltc_case_study_lincolnshire_frailty_pathway.pdf
• Many frail elderly people in hospital could be cared for more effectively in the community, or could
avoid admission altogether if more robust preventative services were in place
• Lincolnshire West CCG led the creation of an integrated frailty pathway, supported by a wider
range of services including a community response team, to enable the frail elderly to remain healthy
and safe at home
• The Canadian Frailty Scoring Tool was used to identify people at risk of unnecessary hospital
admissions so that they can receive appropriate care planning and proactive support
• Following the introduction of the new pathway, unscheduled hospital admissions and excess bed
days for the over 75s have fallen and people are more likely to be cared for at home by the clinician
best placed to help them
Effectiveness of community-based integrated care in frail COPD patients: a randomised controlled
trial – NPJ Primary Care Respiratory Medicine Article
Background: Chronic obstructive pulmonary disease (COPD) generates a high burden on health care,
and hospital admissions represent a substantial proportion of the overall costs of the disease.
Integrated care (IC) has shown efficacy to reduce hospitalisations in COPD patients at a pilot level.
Deployment strategies for IC services require assessment of effectiveness at the health care system
level.
Aims: The aim of this study was to explore the effectiveness of a community-based IC service in
preventing hospitalisations and emergency department (ED) visits in stable frail COPD patients.
Methods: From April to December 2005, 155 frail community-dwelling COPD patients were
randomly allocated either to IC (n=76, age 73 (8) years, forced expiratory volume during the first
second, FEV1 41(19) % predicted) or usual care (n=84, age 75(9) years, FEV1 44 (20) % predicted)
and followed up for 12 months. The IC intervention consisted of the following: (a) patient's
empowerment for self-management; (b) an individualised care plan; (c) access to a call centre; and
(d) coordination between the levels of care. Thereafter, hospital admissions, ED visits and mortality
were monitored for 6 years.
Results: IC enhanced self-management (P=0.02), reduced anxiety-depression (P=0.001) and
improved health-related quality of life (P=0.02). IC reduced both ED visits (P=0.02) and mortality
(P=0.03) but not hospital admission. No differences between the two groups were seen after 6
years.
Conclusion: The intervention improved clinical outcomes including survival and decreased the ED
visits, but it did not reduce hospital admissions. The study facilitated the identification of two key
requirements for adoption of IC services in the community: appropriate risk stratification of patients,
and preparation of the community-based work force.
Click here to access
Fully integrated care for frail elderly: two American models
Int J Integr Care. 2000 Oct-Dec; 1: e08.
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC1533997/
Purpose
Integrated care for the frail elderly and other populations with complex, chronic, disabling
conditions has taken centre stage among policymakers, planners and providers in the United States
and other countries. There is a growing belief that integrated care strategies offer the potential to
improve service co-ordination, quality outcomes, and efficiency. Therefore, it is critical to have a
conceptual understanding of the meaning of integrated care and its various organisational models,
as well as practical examples of how such models work. This article examines so-called “fully
integrated” models of care in detail, concentrating on two major, well-established American
programs, the social health maintenance organisation and the program of all-inclusive care for the
elderly.
Theory
A major challenge to understanding the performance and outcomes of fully integrated care and
other organisational models is the lack of a meaningful, analytical paradigm. This article builds upon
the work of Walter Leutz, to develop a framework by which new and existing programs can be
analysed. This framework is then applied to the two American models that are the focus of this
article.
Methods
Existing data about integrated care in general, and the two model programs in particular, were
collected and analysed from reports published by governmental and non-governmental
organisations, and journal articles retrieved from Medline, HealthStar and other sources.
Results and conclusions
This analysis strongly suggests that fully integrated models of care, such as the social health
maintenance organisation and program of all-inclusive care for the elderly, are not only feasible, but
offer significant potential to improve the delivery of health and social care for frail elderly patients.
In addition, the authors identify the factors that are the most critical to the success of fully
integrated care, and offer lessons for their development and implementation. Finally, issues are
raised concerning the transferability of this complex model to other countries, as well as the vital
importance of evidence-based evaluation research in furthering the evolution of integrated care.
Keywords: integrated care, managed care, frail elderly, chronic care, social health maintenance
organisation, program of all-inclusive care for the elderly
House Calls for Seniors: Building and Sustaining a Model of Care for Homebound
Seniors
J Am Geriatr Soc. 2009 Jun; 57(6): 1103–1109.
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC4036097/
Homebound seniors suffer from high levels of functional impairment and are high-cost users of
acute medical services. This article describes a 7-year experience in building and sustaining a
physician home visit program. The House Calls for Seniors program was established in 1999. The
team includes a geriatrician, geriatrics nurse practitioner, and social worker. The program hosts
trainees from multiple disciplines. The team provides care to 245 patients annually. In 2006, the
healthcare system (62%), provider billing (36%), and philanthropy (2%) financed the annual program
budget of $355,390. Over 7 years, the team has enrolled 468 older adults; the mean age was 80,
78% were women, and 64% were African American. One-third lived alone, and 39% were receiving
Medicaid. Reflecting the disability of this cohort, 98% had impairment in at least one instrumental
activity of daily living (mean 5.2), 71% had impairment in at least one activity of daily living (mean
2.6), 53% had a Mini-Mental State Examination score of 23 or less, 43% were receiving services from
a home care agency, and 69% had at least one new geriatric syndrome diagnosed by the program. In
the year after intake into the program, patients had an average of nine home visits; 21% were
hospitalized, and 59% were seen in the emergency department. Consistent with the program goals,
primary care, specialty care, and emergency department visits declined in the year after enrollment,
whereas access and quality-of-care targets improved. An academic physician house calls program in
partnership with a healthcare system can improve access to care for homebound frail older adults,
improve quality of care and patient satisfaction, and provide a positive learning experience for
trainees
Increasing value for money in the Canadian healthcare system: new findings and
the case for integrated care for seniors.
Citation: Healthcare quarterly (Toronto, Ont.), Jan 2009, vol. 12, no. 1, p. 2-12, 1710-2774 (2009)
Author(s): Hollander, Marcus J, Miller, Jo Ann, MacAdam, Margaret, Chappell, Neena, Pedlar, David
Abstract: Given the recent economic climate and increasing costs in the Canadian healthcare
system, we must ensure that we are getting the best value for money possible. This article presents
new findings and a broad weight of evidence to make the case that it is possible to obtain better
value for money in our healthcare system by adopting models of integrated care delivery for seniors
and others with ongoing care needs.
Source: Medline
Innovative contracting for integrated care: what are the risks and benefits of
various contracting methods? / Ricketts, Bob (King’s Fund, 2014) (see attached
file)
Integrated care
The King’s Fund page on integrated care
http://www.kingsfund.org.uk/topics/integrated-care
Integrated care facilitation for older patients with complex health care needs
reduces hospital demand
Citation: Australian health review : a publication of the Australian Hospital Association, August 2007,
vol./is. 31/3(451-461; discussion 449-450), 0156-5788 (Aug 2007)
Author(s): Bird S.R., Kurowski W., Dickman G.K., Kronborg I.
Language: English
Abstract: OBJECTIVE: The evaluation of a new model of care for older people with complex health
care needs that aimed to reduce their use of acute hospital services. METHOD: Older people (over
55 years) with complex health care needs, who had made three or more presentations to a hospital
emergency department (ED) in the previous 12 months, or who were identified by community health
care agencies as being at risk of making frequent ED presentations, were recruited to the project.
The participants were allocated a "care facilitator" who provided assistance in identifying and
accessing required health care services, as well as education in aspects of self management. Data for
the patients who had been participants on the project for a minimum of 90 days (n=231) were
analysed for their use of acute hospital services (ED presentations, admissions and hospital beddays) for the period 12-months pre-recruitment and post-recruitment. A similar analysis on the use
of hospital services was conducted on the data of patients who were eligible and who had been
offered participation, but who had declined (comparator group; n=85). RESULTS: Post recruitment,
the recruited patients displayed a 20.8% reduction in ED presentations, a 27.9% reduction in hospital
admissions, and a 19.2% reduction in bed-days. By comparison, the patients who declined
recruitment displayed a 5.2% increase in ED presentations, a 4.4% reduction in hospital admissions,
and a 15.3% increase in inpatient bed-days over a similar timeframe. CONCLUSION: A model of care
that facilitates access to community health services and provides coordination between existing
services reduces hospital demand.
Publication Type: Journal: Article
Source: EMBASE
Full Text:
Available from Free Access Content in Australian Health Review
Available from ProQuest in Australian Health Review
Integrated care for frail older people 2012: a clinical overview / Jackie Morris
Journal of Integrated Care 20(4) 257-264
http://search.proquest.com/docview/1095698217?pq-origsite=gscholar
Integrated care for older people: examining workforce and implementation
challenges / Centre for Workforce Intelligence (2014) (see attached file)
Integrated care for the frail elderly
Citation: HealthcarePapers, 2011, vol./is. 11/1(62-68; discussion 86-6891), 1488-917X (2011)
Author(s): Heckman G.A.
Language: English
Abstract: Chronic disease management initiatives have thus far focused on single disease entities.
The challenge of an aging population is the occurrence of multiple diseases, complicated by geriatric
syndromes, in the same person. The term frailty is used to denote such persons, who are more
vulnerable to poor health outcomes when challenged by a health stressor. In this paper, it is argued
that frailty is a chronic condition and thus requires a chronic disease management approach.
Hospital-based and community interventions for managing frail seniors are discussed, with a focus
on enhancing primary care, and with appropriate and targeted support from geriatric specialists in
the form of capacity building as well as direct clinical service. Finally, a model for integrating
individual geriatric interventions into a broader system is proposed.
Publication Type: Journal: Note
Source: EMBASE
Integrated care models for the frail older people [sic]: some international case
studies and lessons / Kodner, Dennis L. (see attached file)
Integrated care summit 2015: the journey from integrated care to population
health systems
A summit on integrated care at the King’s Fund on the 13th October
http://www.kingsfund.org.uk/events/integrated-care-summit2015?utm_source=The+King%27s+Fund+Events&utm_medium=email&utm_campaign=5759350_J2
96+IC+Summit+Call+for+Papers+-+IC+Bulletin+++290515&utm_content=ICSummit_FirstPara&dm_i=21AF,3FFXY,GCG0N2,C9PVX,1
Integrated models of care delivery for the frail elderly: International perspectives
Citation: Gaceta Sanitaria, December 2011, vol./is. 25/SUPPL. 2(138-146), 0213-9111;1578-1283
(December 2011)
Author(s): Beland F., Hollander M.J.
Language: English
Abstract: Introduction: Interest is growing in integrated systems of care for the frail elderly. Few
such systems have been both documented and evaluated in a rigorous manner. The present article
provides an international review of such systems. Methods: The literature on integrated care
covered the period from 1997 to 2010, inclusive. Some 2,496 citations were identified from Age Line,
PsycINFO, CINAHAL and MedLine and were reviewed. To be included in this paper, articles had to
provide a good description of the care delivery system and good quality evaluations. Only nine
articles were retained. Most of the articles reviewed described some form of coordinated care
without evaluation. Results: There were essentially two types of models of integrated care delivery
for the frail elderly. One was a smaller, community-based model that relied on cooperation across
care providers, focused on home and community care, and played an active role in health and social
care coordination. The second type of model was a large-scale model that could be applied at a
national/provincial/state, or large regional health authority, level, had a single administrative
authority and a single budget, and included both home/community and residential services.
Discussion: Integrated care delivery can be achieved in various ways. Irrespective of which model is
adopted, some of the key factors to be considered are how care can be coordinated effectively
across different types of services, and how all the care provider organizations can be coordinated to
ensure continuity of care for frail elderly persons. &#xa9; 2011 SESPAS.
Publication Type: Journal: Short Survey
Source: EMBASE
Full Text:
Available from Free Access Content in Gaceta Sanitaria
Integrated services for dementia: The formal carer experience
Citation: Alzheimer's and Dementia, July 2013, vol./is. 9/4 SUPPL. 1(P528), 1552-5260 (July 2013)
Author(s): Woolrych R., Sixsmith J.
Language: English
Abstract: Background: Concerns over the rising costs of healthcare and a globally ageing population
has led to calls for change in how we deliver services to older people. Policy has been re-directed to
the need for integrated care, particularly for those living with dementia, where care requirements
fluctuate over time and there is a need for flexible and seamless service provision. Various different
models of integrated care have been proposed, yet the central tenets of co-ordination, continuing
care and responsiveness are common to all. In delivering this type of care, the role of the formal
carer has often been overlooked and is thus poorly defined and articulated. The aim of this paper is
to understand the experiences of formal carers working with the context of an integrated dementia
service by exploring findings from a research-based evaluation conducted of an integrated dementia
service in the UK. Methods: The integrated dementia service consisted of daycare, respite and
outreach delivered by a single organisation. Each client was able to be signposted into and out of the
different services as required. A qualitative, ethnographic approach was undertaken to capture the
views of carers, including: observations in day care, domiciliary and respite care contexts (total 9
hours); semi-structured interviews with formal carers (n=6); and two focus groups with formal carers
(n=9 across both groups). Results:Working with an integrated service and delivering flexible and
responsive service provision presents individual, interpersonal and organisational challenges to the
formal carer. These include: freedom to deliver person-centred care, managing flexibility, lack of
appropriate knowledge and training, and clashes with traditional ways of working. Conclusions: To
facilitate the successful delivery of integrated care, the emerging role of the formal carer needs to be
more clearly articulated and supported within a service context. This requires providing formal
training, role freedom and a supportive cross-organisational culture such that services can be
delivered as and when older people with dementia need them.
Publication Type: Journal: Conference Abstract
Source: EMBASE
Integration and continuity of care in health care network models for frail older
adults
Rev Saude Publica. 2014 Apr; 48(2): 357–365.
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC4206139/
A detailed review was conducted of the literature on models evaluating the effectiveness of
integrated and coordinated care networks for the older population. The search made use of the
following bibliographic databases: Pubmed, The Cochrane Library, LILACS, Web of Science, Scopus
and SciELO. Twelve articles on five different models were included for discussion. Analysis of the
literature showed that the services provided were based on primary care, including services within
the home. Service users relied on the integration of primary and hospital care, day centers and inhome and social services. Care plans and case management were key elements in care continuity.
This approach was shown to be effective in the studies, reducing the need for hospital care, which
resulted in savings for the system. There was reduced prevalence of functional loss and improved
satisfaction and quality of life on the part of service users and their families. The analysis reinforced
the need for change in the approach to health care for older adults and the integration and
coordination of services is an efficient way of initiating this change.
Keywords: Frail Elderly, Health Services for the Aged, Comprehensive Health Care, Quality of Health
Care, Review
International experiments in integrated care for the elderly: A synthesis of the
evidence
Citation: International Journal of Geriatric Psychiatry, March 2003, vol./is. 18/3(222-235), 0885-6230
(01 Mar 2003)
Author(s): Johri M., Beland F., Bergman H.
Language: English
Abstract: Background: The OECD countries have recently promoted policies of deinstitutionalisation
and community-based care for the elderly. These policies respond to common cost pressures
associated with population aging, and the challenge of providing improved care for the elderly. They
aim to substitute less costly services for institutional ones, to improve patient satisfaction and
decrease expenses. However, views concerning their success are mixed. We took a comparative
cross-national approach to examine the evidence, to identify common features of an effective
system of integrated care, and to examine the potential of such models to positively affect care of
the elderly, and public finances. Methods: We conducted a systematic review of recent
demonstration projects testing innovative models of care for the elderly in OECD countries. Projects
included aimed to create comprehensive integration of acute and long-term care services, and were
evaluated using a comparison group. Results: For each project, we report available results on rates
of hospitalisation, long term care institutionalisation, utilisation and costs, impact on process of care,
and health outcomes. In addition, the following common features of an effective integrated system
of care were identified: a single entry point system; case management, geriatric assessment and a
multi-disciplinary team; and use of financial incentives to promote downward substitution.
Conclusions: Community-based care can impact favourably on rates of institutionalisation and costs.
Comprehensive approaches to program restructuring are necessary, as cost-effectiveness depends
on characteristics of the system of care. Expansion of successful programmes to achieve widespread
use remains a critical challenge. Copyright &#xa9; 2003 John Wiley & Sons, Ltd.
Publication Type: Journal: Review
Source: EMBASE
Full Text:
Available from EBSCOhost in International Journal of Geriatric Psychiatry
Interprofessional and integrated care of the elderly in a family health team.
Citation: Canadian family physician Médecin de famille canadien, Aug 2012, vol. 58, no. 8, p. e436.
(August 2012)
Author(s): Moore, Ainsley, Patterson, Christopher, White, Joy, House, Shelly T, Riva, John J, Nair,
Kalpana, Brown, Allison, Kadhim-Saleh, Amjed, McCann, David
Abstract: Family physicians provide most of the care for the frail elderly population, but many
challenges and barriers can lead to difficulties with fragmented, ineffective, and inefficient services.
To improve the quality, efficiency, and coordination of care for the frail elderly living in the
community and to enhance geriatric and interprofessional skills for providers and learners. The
Seniors Collaborative Care Program used an interprofessional, shared-care, geriatric model. The
feasibility of the program was evaluated through a pilot study conducted between November 2008
and June 2009 at Stonechurch Family Health Centre, part of the McMaster Family Health Team. The
core team comprised a nurse practitioner, an FP, and a registered practical nurse. Additional team
members included a pharmacist, a dietitian, a social worker, and a visiting geriatrician. Twenty-five
seniors were evaluated through the pilot program. Patients were assessed within 5 weeks of initial
contact. Patients and practitioners valued timely, accessible, preventive, and multidisciplinary
aspects of care. The nurse practitioner's role was prominent in the program, while the geriatrician's
clinical role was focused efficiently. The family health team is ideally positioned to deliver shared
care for the frail elderly. Our model allowed for a short referral time and easy access, which might
allow seniors to remain in their environment of choice.
Source: Medline
Just for us: An academic medical center-community partnership to maintain the
health of a frail low-income senior population
Citation: Gerontologist, April 2006, vol./is. 46/2(271-276), 0016-9013 (April 2006)
Author(s): Yaggy S.D., Michener J.L., Yaggy D., Champagne M.T., Silberberg M., Lyn M., Johnson F.,
Yarnall K.S.H.
Language: English
Abstract: Purpose: To promote health and maintain independence, Just for Us provides financially
sustainable, in-home, integrated care to medically fragile, low-income seniors and disabled adults
living in subsidized housing. Design and Methods: The program provides primary care, care
management, and mental health services delivered in patient's homes by a multidisciplinary,
multiagency team. Results: After 2 years of operation, Just for Us is serving nearly 300 individuals in
10 buildings. The program is demonstrating improvement in individual indices of health. Medicaid
expenditures for enrollees are shifting from ambulances and hospital services to pharmacy, personal
care, and outpatient visits. The program is not breaking even, but it is moving toward that goal. The
program's success is based on a partnership involving an academic medical center, a community
health center, county social and mental health agencies, and a city housing authority to coordinate
and leverage services. Implications: Just for Us is becoming a financially sustainable way of creating a
"system within a nonsystem" for low-income elderly persons in clustered housing. Copyright 2006 by
The Gerontological Society of America.
Publication Type: Journal: Article
Source: EMBASE
Full Text:
Available from EBSCOhost in Gerontologist
Managed long-term care: care integration through care coordination.
Citation: Journal of aging and health, Feb 2003, vol. 15, no. 1, p. 223-245, 0898-2643 (February
2003)
Author(s): Fisher, Holly Michaels, Raphael, Terrie G
Abstract: The New York State managed long-term care demonstration program combines traditional
home, community, and institutional long-term care services with other benefits integral to
maximizing overall well-being for a frail elderly population. A distinguishing feature of the model is
the responsibility to coordinate both covered and noncovered services. This article, a case study of
VNS CHOICE, a managed long-term care plan that serves 2,500 New York City residents, describes
the program's operating structure, service delivery model, and care management strategies. By
providing a capitated Medicaid long-term care benefit, VNS CHOICE can utilize a broad array of
services, offer significant flexibility to care management staff, and support member and family
involvement in care planning. Its broad care coordination responsibility allows it to achieve
integrated care without integrated financing.
Source: Medline
Managing effective partnerships in older people's services
Citation: Health and Social Care in the Community, September 2006, vol./is. 14/5(391-399), 09660410;1365-2524 (September 2006)
Author(s): Nies H.
Language: English
Abstract: The integration of older people's services is a challenge to all countries with an ageing
population. Although it is widely acknowledged that acute care, long-term care, social care, housing,
leisure, education and other services should all operate in a more 'joined-up manner', achieving this
in practice remains extremely difficult. Against this background, the European Union (EU) Care and
Management of Services for Older People in Europe Network (CARMEN) project set out to explore
the management of integrated care in 11 EU countries. Summarising key themes from the project,
this paper explores the management of integrated care, the skills required, the mechanisms which
aid successful integrated approaches, and future research priorities. Although very challenging, the
concept of integrated care is still a promising way forward when seeking to meet the challenges of
an ageing society. &#xa9; 2006 Blackwell Publishing Ltd.
Publication Type: Journal: Article
Source: EMBASE
Full Text:
Available from EBSCOhost in Health & Social Care in the Community
Available from EBSCOhost in Health & Social Care in the Community
Available in HEALTH AND SOCIAL CARE IN THE COMMUNITY at JET Library, Leighton
Medicaid-funded home care for the frail elderly and disabled: evaluating the cost
savings and outcomes of a service delivery reform.
Health Serv Res. 1996 Oct; 31(4): 489–508.
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC1070133/
OBJECTIVES: In response to rising demand and increased costs for home care services for frail elderly
and disabled Medicaid clients, New York City implemented cluster care, a shared-aide model of
home care. Our objective: to evaluate the effects of cluster care on home care hours and costs,
client functioning, depressive symptoms, and satisfaction. DATA SOURCES: Client interviews,
conducted prior to implementation and again 16 months later; Medicaid claims records; home
attendant payroll files; and vendor agency records. STUDY DESIGN: The study employed a
pretest/posttest design, comparing 229 clients at the first seven demonstration sites to 175 clients
at four comparison sites before and after cluster care implementation. Regression methods were
used to analyze pre and post-intervention data. PRINCIPAL FINDINGS: Cluster care reduced costs by
about 10 percent. Most savings occurred among the more vulnerable clients (those with five or
more ADL/IADL limitations). Clients at cluster care sites who started out with fewer than five
limitations appeared to decline somewhat more slowly than similarly impaired clients at comparison
sites, while those with more than five ADL/IADLs tended to decline more rapidly. This difference was
small-less than one limitation per year. Cluster care is associated with a significant decline in
satisfaction but appears unrelated to depressive symptoms. CONCLUSIONS: Cluster care appears
benign for home care clients with fewer limitations. For the more vulnerable, we recommend
experimentation with low-cost interventions that might augment service and improve outcomes
without reverting to traditional one-on-one care.
Opening the black box of clinical collaboration in integrated care models for frail,
elderly patients
Citation: The Gerontologist, April 2013, vol./is. 53/2(313-325), 1758-5341 (Apr 2013)
Author(s): de Stampa M., Vedel I., Bergman H., Novella J.L., Lechowski L., Ankri J., Lapointe L.
Language: English
Abstract: The purpose of the study was to understand better the clinical collaboration process
among primary care physicians (PCPs), case managers (CMs), and geriatricians in integrated models
of care. METHODS : We conducted a qualitative study with semistructured interviews. A purposive
sample of 35 PCPs, 7 CMs, and 4 geriatricians was selected in 2 integrated models of care for frail
elderly patients in Canada and France: System of Integrated Care for Older Patients of Montreal and
Coordination of Care for Older Patients of Paris. Data were analyzed using a grounded theory
approach. The dynamics of the collaboration process develop in three phases: (1) initiating
relationships, (2) developing real two-way collaboration, and (3) developing interdisciplinary
teamwork. The findings suggest that CMs and geriatricians collaborated well from the start and
throughout the care management process. Real collaboration between the CMs and the PCPs
occurred only later and was mostly fostered by the interventions of the geriatricians. PCPs and
geriatricians collaborated only occasionally. The findings provide information about PCPs'
commitment to the integrated models of care, the legitimization of the CM's role among PCPs, and
the appropriate positioning of geriatricians in such models.
Publication Type: Journal: Article
Source: EMBASE
Full Text:
Available from EBSCOhost in Gerontologist
PACE: A model for integrated care of frail older patients
Citation: Geriatrics, June 1998, vol./is. 53/6(62-73), 0016-867X (June 1998)
Author(s): Lee W., Eng C., Fox N., Etienne M.
Language: English
Abstract: The Program of All-inclusive Care for the Elderly (PACE) is a model of care that pools
Medicare and Medicaid funds to provide acute and long-term care services for older patients
through the use of interdisciplinary teams. Services include physician visits, prescription drugs,
rehabilitation services, personal care workers, hospitalization, and nursing home care, if needed.
PACE programs may also offer social services intervention, case management, respite care, or
extended home care nursing. The PACE site assumes financial responsibility for all services. Now that
PACE programs can become permanent providers under Medicare, their number is expected to
grow.
Publication Type: Journal: Review
Source: EMBASE
Full Text:
Available from Free Access Content in Geriatrics
Person centred care 2020: calls and contributions form health and social care
charities.
Citation: National Voices, February 2015.
Author(s): National Voices.
Full text:
http://www.nationalvoices.org.uk/sites/www.nationalvoices.org.uk/files/2015_national_voices_
position_statement_update.pdf
Physician home visits in homebound
Citation: Journal of the American Geriatrics Society, April 2015, vol./is. 63/(S80), 0002-8614 (April
2015)
Author(s): Ang S., Liew Y.
Language: English
Abstract: Background: Physician home visits (HVs) are an important model of care for the
homebound. This is a descriptive pilot study of a physician HVs for the homebound older adults who
have difficulties accessing healthcare services in Brunei. Objective: To describe the complexity of
homebound older adults. Methods: Home healthcare nurses identified clients who required
ambulance services to attend outpatient clinic for the physician HVs. Demographic and clinical data
were collected prospectively from a standardized physician home visit notes from June 2009 to
August 2012. Patients younger than 60 years old were excluded in this study. Statistical analysis was
undertaken using Microsoft Excel and SPSS Version 16.0. Categorical data were presented as
frequencies using percentages and continuous data as mean or median. Results: There were 44 HVs
made during the study period. Thirty-seven (84%) HVs were made to homebound older adults.
Twenty-six (70%) were first time visits. Most patients were Malays race (86%), 51% were woman.
Mean age was 78.6 +/-7.6 years (Median 79 years). Each older adult had a median of 4 documented
medical conditions, most suffered from cerebrovascular accident (65%) and hypertension (56%).
They had a median of 6 medications. All were dependent on their ADLs and IADLs; 22 (59%)
employed caregiver. Twenty-one (57%) patients were on artificial feeding, 13 using nasogastric tube
and 8 had percutaneous endoscopic gastrostomy. These patients were mostly bedbound (84%),
18/36(50%) have pressure ulcers. The physician reviewed and prescribed all medications, addressed
an average of 5 care plans during each visit. The median duration of each visit was 40 minutes.
Discussions: Physician HVs is a supplanted but an essential healthcare for the homebound older
adults. This pilot study described the complexity of homebound older adults, similar to nursing home
residents, bedbound and dependent. They have multiple co-morbidities and psychosocial issues. The
care of this cohort of older adults required an integrated care team approach similar to the
Independence at Home Demonstration project. Even though HVs are time-consuming, this can be
reduced with an efficient interdisciplinary team. We believe that physician HV model of care can
provide high quality cost effective care to the homebound older adults.
Publication Type: Journal: Conference Abstract
Source: EMBASE
PRISMA: a new model of integrated service delivery for the frail older people in
Canada
Int J Integr Care. 2003 Jan-Mar; 3: e08.
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC1483944/
Purpose
PRISMA is an innovative co-ordination-type Integrated Service Delivery System developed
to improve continuity and increase the efficacy and efficiency of services, especially for older
and disabled populations.
Description
The mechanisms and tools developed and implemented by PRISMA include: (1) coordination between decision-makers and managers, (2) a single entry point, (3) a case
management process, (4) individualised service plans, (5) a single assessment instrument
based on the clients' functional autonomy, and (6) a computerised clinical chart for
communicating between institutions for client monitoring purposes.
Preliminary results
The efficacy of this model has been tested in a pilot project that showed a decreased
incidence of functional decline, a decreased burden for caregivers and a smaller proportion of
older people wishing to be institutionalised.
Conclusion
The on-going implementation and effectiveness study will show evidence of its real value
and its impact on clienteles and cost.
Keywords: health services for the aged, integrated service delivery systems, frail elderly,
programme evaluation
Progress toward integrating care for seniors in Canada: "We have to skate toward
where the puck is going to be, not to where it has been."
Citation: International journal of integrated care, Jan 2011, vol. 11 Spec Ed, p. e016. (January 2011)
Author(s): Macadam, Margaret
Abstract: Integrating care is a developing feature of provincial health delivery in Canada for those
with chronic conditions. The purposes of this project were to review the conceptual understandings
underlying integrated care, examine the features of models of cost-effective care for the elderly, and
then ascertain to what extent Canadian provinces were implementing these features. These goals
were accomplished through a review of the integrated care literature followed by a survey of the
Canadian provinces. A pretested questionnaire was sent to each of the 10 provincial Ministries of
Health in 2008. The questionnaire collected basic background information and then asked a series of
open- and close-ended questions about each of the best practice features of integrated care as
found in the literature review. System improvements in integrating care for the elderly are being
implemented in Canadian provincial health care systems. There has been substantial improvement
in the delivery of case management services but the supply of some community services could be
improved. As well, the linkages amongst primary, acute and community care remain weak. Providing
an adequate supply of services is an ongoing issue in many provinces and could be the result of
either inadequate funding and/or poor targeting of scarce resources. While it is promising that so
many provinces are starting to break down the silos amongst types of health care service providers,
much remains to be accomplished. These issues are at the core of integrating care and are among
the challenges being faced by other countries.
Source: Medline
Full Text:
Available from Free Access Content in International Journal of Integrated Care
Available from National Library of Medicine in International Journal of Integrated Care
Randomised trial of impact of model of integrated care and case management for
older people living in the community
Citation: British Medical Journal, May 1998, vol./is. 316/7141(1348-1351), 0959-8146 (02 May 1998)
Author(s): Bernabei R., Landi F., Gambassi G., Sgadari A., Zuccala G., Mor V., Rubenstein L.Z.,
Carbonin P.
Language: English
Abstract: Objective: To evaluate the impact of a programme of integrated social and medical care
among frail elderly people living in the community. Design: Randomised study with 1 year follow up.
Setting: Town in northern Italy (Rovereto). Subjects: 200 older people already receiving conventional
community care services. Intervention: Random allocation to an intervention group receiving
integrated social and medical care and case management or to a control group receiving
conventional care. Main outcome measures: Admission to an institution, use and costs of health
services, variations in functional status. Results: Survival analysis showed that admission to hospital
or nursing home in the intervention group occurred later and was less common than in controls
(hazard ratio 0.69; 95%, confidence interval 0.53 to 0.91). Health services were used to the same
extent but control subjects received more frequent home visits by general practitioners. In the
intervention group the estimated financial savings were in the order of and 1125 ($1800) per year of
follow up. The intervention group had improved physical function (activities of daily living score
improved by 5.1%, v 13.0% loss in controls; P < 0.001). Decline of cognitive status (measured by the
short portable mental status questionnaire) was also reduced 13.8% v 9.4%; P < 0.05). Conclusion:
Integrated social and medical care with case management programmes may provide a cost effective
approach to reduce admission to institutions and functional decline in older people living in the
community.
Publication Type: Journal: Article
Source: EMBASE
Full Text:
Available from EBSCOhost in BMJ: British Medical Journal
Available from ProQuest in British Medical Journal
Reducing hospital bed use by frail older people: results from a systematic review
of the literature
Int J Integr Care. 2013 Oct-Dec; 13: e048.
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC3860583/
Introduction
Numerous studies have been conducted in developed countries to evaluate the impact of
interventions designed to reduce hospital admissions or length of stay (LOS) amongst frail older
people. In this study, we have undertaken a systematic review of the recent international literature
(2007-present) to help improve our understanding about the impact of these interventions.
Methods
We systematically searched the following databases: PubMed/Medline, PsycINFO, CINAHL, BioMed
Central and Kings Fund library. Studies were limited to publications from the period 2007-present
and a total of 514 studies were identified.
Results
A total of 48 studies were included for full review consisting of 11 meta-analyses, 9 systematic
reviews, 5 structured literature reviews, 8 randomised controlled trials and 15 other studies. We
classified interventions into those which aimed to prevent admission, interventions in hospital, and
those which aimed to support early discharge.
Conclusions
Reducing unnecessary use of acute hospital beds by older people requires an integrated approach
across hospital and community settings. A stronger evidence base has emerged in recent years
about a broad range of interventions which may be effective. Local agencies need to work together
to implement these interventions to create a sustainable health care system for older people.
Keywords: older people, hospital bed use, admissions avoidance, integrated care, systematic review
Successfully integrating aged care services: a review of the evidence and tools
emerging from a long-term care program.
Citation: International journal of integrated care, Jan 2013, vol. 13, p. e003. (2013 Jan-Mar)
Author(s): Stewart, Michael J, Georgiou, Andrew, Westbrook, Johanna I
Abstract: Providing efficient and effective aged care services is one of the greatest public policy
concerns currently facing governments. Increasing the integration of care services has the potential
to provide many benefits including increased access, promoting greater efficiency, and improving
care outcomes. There is little research, however, investigating how integrated aged care can be
successfully achieved. The PRISMA (Program of Research to Integrate Services for the Maintenance
of Autonomy) project, from Quebec, Canada, is one of the most systematic and sustained bodies of
research investigating the translation and outcomes of an integrated care policy into practice. The
PRISMA research program has run since 1988, yet there has been no independent systematic review
of this work to draw out the lessons learnt. Narrative review of all literature emanating from the
PRISMA project between 1988 and 2012. Researchers accessed an online list of all published papers
from the program website. The reference lists of papers were hand searched to identify additional
literature. Finally, Medline, Pubmed, EMBASE and Google Scholar indexing databases were searched
using key terms and author names. Results were extracted into specially designed spread sheets for
analysis. Forty-five journal articles and two books authored or co-authored by the PRISMA team
were identified. Research was primarily concerned with: the design, development and validation of
screening and assessment tools; and results generated from their application. Both quasiexperimental and cross sectional analytic designs were used extensively. Contextually appropriate
expert opinion was obtained using variations on the Delphi Method. Literature analysis revealed the
structures, processes and outcomes which underpinned the implementation. PRISMA provides
evidence that integrating care for older persons is beneficial to individuals through reducing
incidence of functional decline and handicap levels, and improving feelings of empowerment and
satisfaction with care provided. The research also demonstrated benefits to the health system,
including a more appropriate use of emergency rooms, and decreased consultations with medical
specialists. Reviewing the body of research reveals the importance of both designing programs with
an eye to local context, and building in flexibility allowing the program to be adapted to changing
circumstances. Creating partnerships between policy designers, project implementers, and academic
teams is an important element in achieving these goals. Partnerships are also valuable for achieving
effective monitoring and evaluation, and support to 'evidence-based' policy-making processes.
Despite a shared electronic health record being a key component of the service model, there was an
under-investigation of the impact this technology on facilitating and enabling integration and the
outcomes achieved. PRISMA provides evidence of the benefits that can arise from integrating care
for older persons, particularly in terms of increased feelings of personal empowerment, and
improved client satisfaction with the care provided. Taken alongside other integrated care
experiments, PRISMA provides further evidentiary support to policy-makers pursuing integrated care
programs. The scale and scope of the research body highlights the long-term and complex nature of
program evaluations, but underscores the benefits of evaluation, review and subsequent adaptation
of programs. The role of information technology in supporting integration of services is likely to
substantially expand in the future and the potential this technology offers should be investigated
and harnessed.
Source: Medline
Full Text:
Available from Free Access Content in International Journal of Integrated Care
Available from National Library of Medicine in International Journal of Integrated Care
Supporting frail seniors through a family physician and Home Health integrated
care model in Fraser Health
Int J Integr Care. 2014 Jan-Mar; 14: e001.
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC3956084/
Background
A major effort is underway to integrate primary and community care in Canada's western province
of British Columbia and in Fraser Health, its largest health authority. Integrated care is a critical
component of Fraser Health's planning, to meet the challenges of caring for a growing, elderly
population that is presenting more complex and chronic medical conditions.
Description of integrated practice
An integrated care model partners family physicians with community-based home health case
managers to support frail elderly patients who live at home. It is resulting in faster response times to
patient needs, more informed assessments of a patient's state of health and pro-active identification
of emerging patient issues.
Early results
The model is intended to improve the quality of patient care and maintain the patients’ health
status, to help them live at home confidently and safely, as long as possible. Preliminary pilot data
measuring changes in home care services is showing positive trends when it comes to extending the
length of a person's survival/tenure in the community (living in their home vs. admitted to
residential care or deceased).
Conclusion
Fraser Health's case manager–general practitioner partnership model is showing promising results
including higher quality, appropriate, coordinated and efficient care; improved patient, caregiver
and physician interactions with the system; improved health and prevention of acute care visits by
senior adult patients.
Keywords: integrated care for frail seniors, family physician–case manager partnership, home
health–primary care integration, integrated primary and community care
Teams without walls: enabling partnerships between generalists and specialists.
Citation: Clinical medicine (London, England), Feb 2009, vol. 9, no. 1, p. 74-75, 1470-2118 (February
2009)
Author(s): Steel, Jonathan, Burnham, Rodney
Abstract: This one-day conference for senior clinicians and NHS managers was a partnership
between the King's Fund, Royal College of Physicians (RCP) and Royal College of General
Practitioners (RCGP). It explored clinical partnerships and integrated care by examining how to
develop constructive and workable relationships between generalists and specialists that harness
clinical skills, support professional practice and deliver excellent care to patients.
Source: Medline
Full Text:
Available in CLINICAL MEDICINE at JET Library, Leighton
Available from Highwire Press in Clinical Medicine
Ten years of integrated care: backwards and forwards. The case of the province of
Québec, Canada.
Citation: International journal of integrated care, Jan 2011, vol. 11 Spec Ed, p. e004. (January 2011)
Author(s): Vedel, Isabelle, Monette, Michele, Beland, François, Monette, Johanne, Bergman, Howard
Abstract: Québec's rapidly growing elderly and chronically ill population represents a major
challenge to its healthcare delivery system, attributable in part to the system's focus on acute care
and fragmented delivery. Over the past few years, reforms have been implemented at the provincial
policy level to integrate hospital-based, nursing home, homecare and social services in 95 catchment
areas. Recent organizational changes in primary care have also resulted in the implementation of
family medicine groups and network clinics. Several localized initiatives were also developed to
improve integration of care for older persons or persons with chronic diseases. Québec has a history
of integration of health and social services at the structural level. Recent evaluations of the current
reform show that the care provided by various institutions in the healthcare system is becoming
better integrated. The Québec health care system nevertheless continues to face three important
challenges in its management of chronic diseases: implementing the reorganization of primary care,
successfully integrating primary and secondary care at the clinical level, and developing effective
governance and change management. Efforts should focus on strengthening primary care by
implementing nurse practitioners, developing a shared information system, and achieving better
collaboration between primary and secondary care.
Source: Medline
Full Text:
Available from Free Access Content in International Journal of Integrated Care
Available from National Library of Medicine in International Journal of Integrated Care
Test and learn: Working towards integrated services.
Citation: Nursing older people, Aug 2014, vol. 26, no. 7, p. 16-20, 1472-0795 (August 2014)
Author(s): Hunt, Louise
Abstract: By 2018 the government expects integrated health and social care to become the norm in
England. From next April a £3.8 billion pooled budget called the Better Care Fund will be launched to
support service redesign for integrated care. The overall aim of the integration policy is to shift more
care into the community to address the challenges of an ageing population by preventing delayed
discharges and avoiding emergency hospital admissions. Across England, there are as many different
approaches to attaining this holy grail as there are interpretations of the word integration. Nursing
Older People visited one pilot site in south east London to explore how integration works in practice
and what effect it is having on community nursing services.
Source: Medline
Full Text:
Available in NURSING OLDER PEOPLE at JET Library, Leighton
Available from EBSCOhost in Nursing Older People
The acute and long-term care interface. Integrating the continuum.
Citation: Clinics in geriatric medicine, Aug 1995, vol. 11, no. 3, p. 481-501, 0749-0690 (August 1995)
Author(s): Phillips-Harris, C, Fanale, J E
Abstract: Acute and long-term care traditionally have been distinctly different health care services,
separated by reimbursement mechanisms, types and numbers of providers, and overall approach to
the management of chronic illness. Considerable effort has been made of late, primarily due to
financial incentives, to integrate these two levels of care into a "seamless" continuum. Barriers to
such an integration process must first be identified. Physician and other health care providers will
need to develop the tools and resources necessary to manage frail, chronically ill patients in settings
other than the traditional acute care hospital, as well as to develop information systems that allow
communication to flow easily between all levels of care. As subacute or transitional care becomes a
central piece of a health care delivery system, those tools become critical to the provision of quality,
integrated care.
Source: Medline
The CareWell in Hospital program to improve the quality of care for frail elderly
inpatients: results of a before-after study with focus on surgical patients.
Citation: American journal of surgery, Nov 2014, vol. 208, no. 5, p. 735-746 (November 2014)
Author(s): Bakker, Franka C, Persoon, Anke, Bredie, Sebastian J H, van Haren-Willems, Jolanda,
Leferink, Vincent J, Noyez, Luc, Schoon, Yvonne, Olde Rikkert, Marcel G M
Abstract: The objective of this study was to evaluate implementation of an innovative intervention
designed to prevent complications and stimulate early rehabilitation among frail elderly inpatients.
The program was implemented in April 2011. A mixed-methods process evaluation and before-after
study were performed. Primary effect outcomes included incidence of hospital-acquired delirium,
cognitive decline, and decline in activities of daily living (ADL) during hospital stay. Secondary
endpoints included ADL performance 3 months postdischarge, readmission, and caregiver burden.
One hundred ninety-one preintervention and 195 postintervention patients aged 70 years or older
were included. Overall, no significant differences in primary endpoints were found. Mean ADL
between discharge and follow-up improved (3.2 vs 5.7, P = .058). Caregivers rated burden of care
lower at 3 months postdischarge (.5 vs -.6, P = .049). The CareWell in Hospital program was
implemented satisfactorily. Although the low baseline delirium incidence (11%), higher comorbidity,
and an increasing learning curve during a restricted implementation period potentially influenced
the overall effects, this integrated care program may have beneficial effects on outcomes among
frail elderly surgical patients. Copyright © 2014 Elsevier Inc. All rights reserved.
Source: Medline
Full Text:
Available from ProQuest in American Journal of Surgery, The
Available from EBSCOhost in American Journal of Surgery
Available from Elsevier in American Journal of Surgery, The
The contribution of geriatric medicine to integrated care for older people.
Citation: Age and ageing, Jan 2015, vol. 44, no. 1, p. 11-15 (January 2015)
Author(s): Philp, Ian
Abstract: to describe contribution of geriatric medicine to the development of integrated care for
older people and to suggest future directions for the further development of integrated care for
older people. literature review and case studies. geriatricians have made a significant contribution to
the development of integrated care for older people. The feasibility of this approach has been
shown in demonstration projects. Although there is only limited evidence from randomised
controlled trials, integrated care seems likely to be beneficial. There is an opportunity to develop
new approaches to integrated care for older people in prevention and provision of community
alternatives to hospital care. the principles and practice of geriatric medicine have been shown to
underpin the successful development of integrated care for older people and should continue to do
so as new challenges emerge. © The Author 2014. Published by Oxford University Press on behalf of
the British Geriatrics Society. All rights reserved. For Permissions, please email:
journals.permissions@oup.com.
Source: Medline
The effects of an integrated care intervention for the frail elderly on informal
caregivers: a quasi-experimental study
Citation: BMC geriatrics, 2014, vol./is. 14/(58), 1471-2318 (2014)
Author(s): Janse B., Huijsman R., de Kuyper R.D., Fabbricotti I.N.
Language: English
Abstract: This study explored the effects of an integrated care model aimed at the frail elderly on
the perceived health, objective burden, subjective burden and quality of life of informal caregivers. A
quasi-experimental design with before/after measurement (with questionnaires) and a control
group was used. The analysis encompassed within and between groups analyses and regression
analyses with baseline measurements, control variables (gender, age, co-residence with care
receiver, income, education, having a life partner, employment and the duration of caregiving) and
the intervention as independent variables. The intervention significantly contributed to the
reduction of subjective burden and significantly contributed to the increased likelihood that informal
caregivers assumed household tasks. No effects were observed on perceived, health, time
investment and quality of life. This study implies that integrated care models aimed at the frail
elderly can benefit informal caregivers and that such interventions can be implemented without
demanding additional time investments from informal caregivers. Recommendations for future
interventions and research are provided. Current Controlled Trials http://ISRCTN05748494.
Registration date: 14/03/2013.
Publication Type: Journal: Article
Source: EMBASE
Full Text:
Available from EBSCOhost in BMC Geriatrics
Available from National Library of Medicine in BMC Geriatrics
Available from BioMed Central in BMC Geriatrics
Available from ProQuest in BMC Geriatrics
The future is frail: An innovative approach to managing patients in care homes
Citation: Age and Ageing, January 2012, vol./is. 41/(i22), 0002-0729 (January 2012)
Author(s): Shaw L., Cowie D., Dornan M., Bainbridge L., Crabtree L.
Language: English
Abstract: Background An increasing frail population in care homes is coupled with increasing acute
hospital admissions. Although attempts have been made to improve this, little collaborative working
exists due to fragmented, poorly coordinated services with immense communication difficulties. The
NHS fails to provide a proactive, coordinated, costeffective service for a cohort of patients that are
due to expand in numbers significantly over the next 20 years. Innovation An innovative nursing role
was introduced to provide clinical care and education/ training for care home staff targeting 5 care
homes in Gateshead with the highest hospital admission rates. A joint working arrangement with
care home staff, a GP with an interest in Geriatrics and a Community Geriatrician was quickly
established. Patients were case managed ensuring they all received a Comprehensive Geriatric
Assessment and subsequently a personalised care plan and action plan. Weekly multidisciplinary
team discussions coupled with family forum meetings helped implement care plans, provide
treatment and allow an opportunity for learning. evaluation Clinical audit was undertaken to capture
the impact of the role and demonstrated a reduction in hospital admissions of 45.5%, saving 440 bed
days with an estimated cost saving of 243,146 compared to admission data in the previous 12
months. Qualitatively, overwhelming support was demonstrated from staff, patients and families
who had all worked collaboratively over the course of the pilot. Conclusions This innovative role to
provide proactive care in care homes resulted in fewer hospital admissions producing associated
savings. Our pilot suggests a cost saving approach to a new integrated care pathway for care home
patients, which could be expanded upon to develop a comprehensive frailty service with an ethos of
patient centeredness at its core. Further studies are needed to confirm our findings and assess the
full impact on other outcomes such as quality of life and mortality.
Publication Type: Journal: Conference Abstract
Source: EMBASE
Full Text:
Available from Highwire Press in Age and Ageing
Available from EBSCOhost in Age & Ageing
The Growing Pains of Integrated Health Care for the Elderly: Lessons from the
Expansion of PACE
Milbank Q. 2004 Jun; 82(2): 257–282.
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC2690172/
The early success of the demonstration Program of All-Inclusive Care for the Elderly (PACE) led to its
designation as a permanent Medicare program in 1997. But the growth in the number of programs
and enrollment has lagged and does not meet expectations. This article offers insights into the
mechanisms influencing the expansion of PACE, from information obtained in interviews and surveys
of administrators, medical directors, and financial officers in 27 PACE programs. Sixteen barriers to
expansion were found, including competition, PACE model characteristics, poor understanding of
the program among referral sources, and a lack of financing for expansion. This experience offers
important lessons for providing integrated health care to the frail elderly.
The impact of an integrated care service on service users: the service users'
perspective
Citation: Journal of health organization and management, 2014, vol./is. 28/4(495-510), 1477-7266
(2014)
Author(s): Hu M.
Language: English
Abstract: The purpose of this paper is to examine the effects of an integration programme on service
users from users' own perspective. Multi-method approach was used. Both quantitative and
qualitative data collection and analysis were employed to uncover and examine service users' views
of the impact of the integration programme. An improvement in the physical functioning of one in
three occupational equipment users; a rise in the level of satisfaction of 85 per cent of occupational
health and 82 per cent of physiotherapy users; older people with complex problems and high-level
needs were able to be helped to live at home; and waiting times for both assessment and for
services within two weeks and four weeks were below the national achievement and ministerial
targets. The impact of the integration programme on users was complex. Positive outcomes were
achieved for some user groups and individuals but not for others. A lack of change outcomes in
social care, and service users' low level of satisfaction with social care services appears to be
associated with the impact of agency work and the predominant aim in social work of achieving
maintenance and prevention outcomes. This paper contributes to knowledge on what and how the
total integration in Cambridgeshire has benefited users.
Publication Type: Journal: Article
Source: EMBASE
Full Text:
Available from ProQuest in Journal of Health Organization and Management
The short-term effects of an integrated care model for the frail elderly on health,
quality of life, health care use and satisfaction with care
Int J Integr Care. 2014 Oct-Dec; 14: e034.
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC4259147/
Purpose
This study explores the short-term value of integrated care for the frail elderly by evaluating the
effects of the Walcheren Integrated Care Model on health, quality of life, health care use and
satisfaction with care after three months.
Intervention
Frailty was preventively detected in elderly living at home with the Groningen Frailty Indicator.
Geriatric nurse practitioners and secondary care geriatric nursing specialists were assigned as case
managers and co-ordinated the care agreed upon in a multidisciplinary meeting. The general
practitioner practice functions as a single entry point and supervises the co-ordination of care. The
intervention encompasses task reassignment between nurses and doctors and consultations
between primary, secondary and tertiary care providers. The entire process was supported by
multidisciplinary protocols and web-based patient files.
Methods
The design of this study was quasi-experimental. In this study, 205 frail elderly patients of three
general practitioner practices that implemented the integrated care model were compared with 212
frail elderly patients of five general practitioner practices that provided usual care. The outcomes
were assessed using questionnaires. Baseline measures were compared with a three-month followup by chi-square tests, t-tests and regression analysis.
Results and conclusion
In the short term, the integrated care model had a significant effect on the attachment aspect of
quality of life. The frail elderly patients were better able to obtain the love and friendship they
desire. The use of care did not differ despite the preventive element and the need for assessments
followed up with case management in the integrated care model. In the short term, there were no
significant changes in health. As frailty is a progressive state, it is assumed that three months are too
short to influence changes in health with integrated care models. A more longitudinal approach is
required to study the value of integrated care on changes in health and the preservation of the
positive effects on quality of life and health care use.
Keywords: frail elderly, integrated care, short-term effects
'Trying to do a jigsaw without the picture on the box': understanding the
challenges of care integration in the context of single assessment for older people
in England.
Citation: International journal of integrated care, Jan 2007, vol. 7, p. e25. (2007)
Author(s): Wilson, Rob, Baines, Susan, Cornford, James, Martin, Mike
Abstract: Demographic ageing is one of the major challenges for governments in developed
countries because older people are the main users of health and social care services. More joinedup, partnership approaches supported by information and communications technologies (ICTs) have
become key to managing these demands. This article discusses recent developments towards
integrated care in the context of one of the arenas in which integration is being attempted, the
Single Assessment Process (SAP) to support the care for older people in England. It draws upon
accounts of local SAP implementations in order to assess and reflect upon some of the successes and
limitations of service integration enabled by ICTs. At the Department of Health in England, policy and
strategy are directed at the integration of services through a 'whole systems' approach, with services
that are interdependent upon one another and organised around the person that uses them. The
Single Assessment Processes (SAP) is an instance of inter-organisational and cross-sectoral sharing of
information intended to improve communication and coordination amongst professions and
agencies and so support more integrated care. The aim of SAP is to ensure that older people receive
appropriate, effective and timely responses to their health and social care needs and that
professionals do not duplicate each others efforts. This article examines examples from two
programmes of work within the context of SAP in England: one with the direction coming from local
government social services, the other where the momentum is coming from the National Health
Service (NHS). Both examples show that the policy and practice of ICT-supported integration
continues to represent a significant challenge. Although the notion of integrated care underpinned
by ICT-enabled information sharing is persuasive, it has limitations in practice. The notion of an
'open systems' approach is proposed as an alternative way of improving communication and
coordination across the domains of health and social care.
Source: Medline
Full Text:
Available from Free Access Content in International Journal of Integrated Care
Available from National Library of Medicine in International Journal of Integrated Care
Using HIT to deliver integrated care for the frail elderly in the UK: current barriers
and future challenges.
Citation: Work (Reading, Mass.), Jan 2012, vol. 41 Suppl 1, p. 4490-4493 (2012)
Author(s): Waterson, Patrick, Eason, Ken, Tutt, Dylan, Dent, Mike
Abstract: In this paper we briefly describe the results of a 3 year project examining the use of Health
Information Technologies (e.g., electronic patient record systems) to deliver integrated care. In
particular, we focus on one group of patient (the frail elderly) and efforts to design an e-health
supported healthcare pathway (the frail elderly pathway--FEP). The aim of FEP is to bring together
clinicians and staff from health and social care and allow them to share patient information. Our
findings show that progress in delivering a fully-supported and working FEP has been slow, not least
because of the difficulties experienced by healthcare staff in using current IT systems. In addition,
there are many strategic and technical issues which remain unresolved (e.g., systems
interoperability).
Source: Medline
Using principles of transition management while introducing and evaluating a
model of care to improve care for frail older inpatients
Citation: European Geriatric Medicine, September 2012, vol./is. 3/(S109-S110), 1878-7649
(September 2012)
Author(s): Bakker F., Persoon A., Schoon Y., Olde Rikkert M.
Language: English
Abstract: Introduction.- Health care should be fundamentally reformed in order to realize efficient
integrated care for older people. Question is how to both implement and integrate complex models
of care in order to embed them in current practices, and to evaluate them scientifically. The Medical
Research Council (MRC) established a framework for development and evaluation of complex
interventions, but does not satisfactory cover influences of a changing complex adaptive care
environment. Transition management focuses especially on processes of permanent practice
change. Methods.- A transition management approach complementary to theMRCframework is
being used to develop, implement and evaluate a complex intervention to improve care for frail
older inpatients. Principles of transition management especially used in addition to MRC are: clear
responsibilities of important actors and involvement of an independent transition manager;
integration in existing structures as a final goal; and guiding the transition by closely monitoring and
evaluating implementation processes. Results.- The CareWell in Hospital program, which is an
adapted Hospital Elder Life Program (HELP), is developed as an innovative model of care to improve
care for frail older inpatients by using a proactive geriatric consultation team and a team of trained
volunteers. It is being implemented and evaluated with help of monthly and weekly structural
meetings with important actors and a thorough process evaluation. Conclusion.- Both for the
implementation and scientific evaluation of a complex intervention, a transition management
approach added to the MRC framework for complex interventions is found useful in guiding change
and understanding of scientific results.
Publication Type: Journal: Conference Abstract
Source: EMBASE
Whole-system approaches to health and social care partnerships for the frail
elderly: an exploration of North American models and lessons. (See attached file)
Citation: Health & social care in the community, Sep 2006, vol. 14, no. 5, p. 384-390, 0966-0410
(September 2006)
Author(s): Kodner, Dennis L
Abstract: Irrespective of cross-national differences in long-term care, countries confront broadly
similar challenges, including fragmented services, disjointed care, less-than-optimal quality, system
inefficiencies and difficult-to-control costs. Integrated or whole-system strategies are becoming
increasingly important to address these shortcomings through the seamless provision of health and
social care. North America is an especially fertile proving ground for structurally oriented wholesystem models. This article summarises the structure, features and outcomes of the Program of AllInclusive Care for Elderly People (PACE) programme in the United States, and the Système de soins
Intégrés pour Personnes Agées (SIPA) and the Programme of Research to Integrate Services for the
Maintenance of Autonomy (PRISMA) in Canada. The review finds a somewhat positive pattern of
results in terms of service access, utilisation, costs, care provision, quality, health status and
client/carer satisfaction. It concludes with the identification of common characteristics which are
thought to be associated with the successful impact of these partnership initiatives, as well as a call
for further research to understand the relationships, if any, between whole-system models, services
and outcomes in integrated care for elderly people.
Source: Medline
Full Text:
Available from EBSCOhost in Health & Social Care in the Community
Available from EBSCOhost in Health & Social Care in the Community
Available in HEALTH AND SOCIAL CARE IN THE COMMUNITY at JET Library, Leighton
Working towards integrated community care for older people: Empowering
organisational features from a professional perspective
Citation: Health Policy, January 2015, vol./is. 119/1(1-8), 0168-8510;1872-6054 (01 Jan 2015)
Author(s): Janssen B.M., Snoeren M.W.C., Van Regenmortel T., Abma T.A.
Language: English
Abstract: Although multi-disciplinary cooperation between professionals is a prerequisite to provide
integrated care in the community, this seems hard to realise in practice. Yet, little is known about
the experiences of professionals who implement it nor about the organisational features
professionals identify as empowering during this cooperation process. Therefore, a case study of a
multi-disciplinary geriatric team was performed. The data-collection included observations of
meetings, in-depth interviews and focus groups with professionals (. N=. 12). Data were analysed
inductively and related to the three organisational levels within the model of organisational
empowerment of Peterson and Zimmerman. Signs of empowering organisational features on the
intraorganisational level were mutual trust and clear working routines. On the interorganisational
level important features included improved linkages between participating organisations and
increased insight into each other's tasks. Tensions occurred relating to the inter- and the
extraorganisational level. Professionals felt that the commitment of the management of involved
organisations should be improved just as the capacity of the team to influence (local) policy. It is
recommended that policymakers should not determine the nature of professional cooperation in
advance, but to leave that to the local context as well as to the judgement of involved professionals.
Publication Type: Journal: Article
Source: EMBASE