Can Project Integrate’s Evidence-Based Framework Support the Implementation of Integrated Care?

Between January and March 2016, the research undertook ‘organisational raids’ in three of the four sites where case study work was undertaken in the first phase of the Project. These included the Hospital Clinic Barcelona, Spain (COPD) on 13th January, Hospital Charité, Berlin, Germany (Geriatric Condition) on 21st January, and TioHundra, Norrtaelje, Sweden (Mental Health) on 22nd March.

The main objective of the ‘organisational raids’ were to understand the key barriers and facilitators in the implementation of integrated care experienced in each case site; to assess the key factors that managers and decision-makers need to take into account when taking forward integrated care projects in different contexts and settings; to further inform the development of the Project INTEGRATE Framework of key factors that influence the progress of integrated care; and to understand how such a framework may best be used in practice to support the implementation of integrated care strategies through evidence-based decision-making.

Beginnings

Each of the case studies demonstrate unique stories in how they were established, developed and sustained over time. In each case there were a range of stimuli that supported adoption over time and each of the case sites were on a continuing journey in their development – none would claim to have a ‘mature’ or ‘established’ programme of work. Rather, the case sites reveal that it is usually the case with integrated care programmes that they have to continually evolve.

Common issues across all the case sites in their implementation period included developing a clarity of purpose in response to common local problems in the quality and cost-effectiveness of existing care (most especially in regard to the future economic sustainability of the care system, but also in terms of quality of care and experiences).

The role of lead clinicians (and managers) in driving change forward was clearly an important driver. It was also clear that each site was helped by developing an understanding of the future organisational model of care that it wanted to apply, for example: the Chronic Care Model in Barcelona; an integrated geriatric clinic in Berlin; and a new health and social care company to plan and provide services in Norrtaelje.

Growth

For the longer-term sustainability of the programmes, each reported important points in time when the integrated care projects were ‘institutionalised’ and so became ‘core business’, so helping to promote their legitimacy across partners in care and greater management capacity. The creation of new organisational ‘units’, however, would not have been possible without a prior process of engagement and negotiation with the different partners in care, most importantly to senior clinicians and their colleagues.

The ability to provide evidence of positive impact was also a significant enabling factor. Being able to demonstrate significant improvements in quality and costs of care was crucial – for example in Barcelona, to convince stakeholders to take the next steps in the evolution of Integrated Care Services.

In terms of the reported key factors for success for integrated care delivery in practice, common elements related to multi-disciplinary working in a team-based environment supported by effective clinical engagement and professional education.

Funding issues, however, had very different trajectories and were a cause for concern to the continued support of the programmes. Overcoming clinical opposition and addressing embedded cultures that did not value team-based working also remains a common challenge. So too are issues related to poor communication related to fractured ICT systems, and governance and legal barriers at systemic level that make it hard to embed change on the ground.

Relevance of the Conceptual Framework

Despite the different country contexts and varied condition-specific approaches to integrated care, there was a marked degree of agreement on the relevance, clarity and importance of Project INTEGRATE’s framework of key dimensions and component items.

The Framework was considered as a useful tool for self-reflection amongst groups of professionals and decision-makers, a process requiring facilitation rather than being a paper-based exercise. However, managers and professionals wanted to better understand the ‘how’ of deployments of different Framework elements rather than just the ‘what’, indicating the need for implementation guidance, self-assessment capabilities, and links to possible tools, interventions and also measures to support adoption. The Framework should also not be considered as a ‘tick-box’ exercise, but as a tool for engaging partners in care to have discussions on the progress, priorities and future actions of their joint initiatives.

Comparative analysis of case sites’ standard descriptions

Between March and June 2016 the research administered an on-line survey, developed on the basis of the validated conceptual framework, to a purposive sample of case sites across the world. We collected standardized descriptions of integrated care initiatives from a variety of health systems located in Europe, United States and Australia.

The objective of this phase of the study was twofold: (a) testing the face validity of the framework; (b) exploring relationships between aspects of care integration (as articulated in the framework) and between such aspects and relevant contextual variables. The research design aimed to find evidence based on comparisons of similar and different cases. In fact, the purposive sample was explicitly intended to select case sites characterized all the possible combinations of contextual variables’ values. We had 80% response rate, enabling us to conduct most of the planned comparisins.
As far as the first objective is concerned, the collected data show good face validity, with less that less than 5% of the total responding occurrences reporting that an aspect of the framework was unclear or not relevant for care integration in general. The punctual analysis of the data suggests specific aspects (or items) on which researchers could work to imporve the framework.

Regarding the second objective, we applied four different methods of analysis of the data (correlation analysis, cluster analysis, regression analysis, and systematic comparisons bases on the most different systems design (MDSD) and most symilar systems design (MSSD). Results support the argument that there is no correspondence between the perceived priority and the level of implementation of dimensions of care integration. In particular patient-centeredness resulted the most implemented dimension, while functional integration is considered the most important dimension. This may be due to a time lag between strategy formulation and implementation, but nevetheless suggest interesting implications in terms of coherence between planning and implementation. In addition, the financing system and the leading care setting do influence the implementation approach of care integration: in particular, primary care leadership is more likely to be associated with higher patient centeredness compared with hospital leadership.

Authors:

Stefano CalciolariStefano Calciolari,
Assistant Professor of Healthcare Management,
Università della Svizzera Italiana (USI)

 

 

LauraLaura Gonzalez,
Doctoral Assistant,
Università della Svizzera Italiana (USI)

 

 

Nick Goodwin bw

Nick Goodwin,
CEO,
International Foundation for Integrated Care (IFIC)

 

 

Viktoria photoViktoria Stein,
Head of the Integrated Care Academy,
International Foundation for Integrated Care (IFIC)