A 10 Step Framework to Implement Integrated Care for Older Persons
Tóm tắt
An aging population, whose multi-morbidities and risk of frailty increase with age results in significant health and social care consumption. Increasing complexity amplifies fragmentation of care and results in sub optimal care outcomes. Ireland, in keeping with other jurisdictions seeks to implement integrated care for older persons as a policy response. There is growing evidence base supporting effective service responses for older persons. These typically include multidisciplinary, community based teams providing services in or near to the older person’s home (the ‘what’). However, examples of systemic implementation are confined to smaller regions notably in Catalonia (Spain), Scotland and Singapore. This reflects the fact that the implementation of integrated care is problematic at scale. The need to attend to methods that support high autonomy professionals tasked with local implementation (the ‘who’) is a neglected area. This is especially important in light of the fact managerial and clinical leaders already have operational and clinical imperatives to attend to. Whilst ideologically committed, the change management challenge presented by integrated care is daunting as they may lack the capacity (time, resources, structures) required to test a new care model. In addition, most change methodologies fail to recognise powerful social dynamics that reflect the characteristics of a complex adaptive system (the ‘how’). This paper proposes a framework to implementing integrated care for older persons. In addition, it offers some initial empirical evidence that this approach has utility among managers and clinicians. In doing so seeks to bridge the implementation gap associated with systemic change.
Tài liệu tham khảo
Anderson, R., Crabtree, B., Steel, D., & Mc Daniel, R. (2011). 'Case Study Research: The View from Complexity Science. Qualitative Health Research, 15(5), 669–685.
Bandura, A. (2000a). Exercise of human agency through collective efficacy. Current Directions of Psychological Science, 9, 75–78.
Bandura, A. (2000b). Cultivate self-efficacy for personal and organizational effectiveness. In E. A. Locke (Ed.), The Blackwell Handbook of Principles of Organizational Behavior (pp. 120–136). Oxford: Blackwell.
Bandura, A. (2001). Social cognitive theory: An agentic perspective. Annual Review of Psychology, 52, 1–26.
Bate, P. (2004). The role of stories and storytelling in organizational change efforts: The anthropology of an intervention within a UK hospital. Intervention Research, 1(1), 27–42.
Beard, J., Alana Officer, A., de Carvalho, I., Sadana, R., Pot, A. M., Michel, J. P., Lloyd-Sherlock, P., Epping-Jordan, J., Peeters, G., Mahanani, W. R., Thiyagarajan, J. A., & Chatterji, S. (2016). The world report on ageing and health: A policy framework for healthy ageing. Lancet, 387, 2145–2154.
Begun, J. W., Zimmerman, B., & Dooley, K. (2002). Health care organizations as complex adaptive systems. In S. Mick & M. Wyltenbach (Eds.), Advances in Health Care Organization Theory (pp. 253–288). San Francisco: Jossey-Bass.
Benson, H. (2005). Chaos and complexity: Applications for healthcare quality and patient safety. Journal of Healthcare Quality, 27(5), 4–10.
Berglund, H., Blomberg, S., Duner, A., & Kjellgren, K. (2015). Organising Integrated care for older persons: strategies in Sweden during the past decade. Journal of Health Organisation and Management, 29(1), 128–151.
Best, A., Greenhalgh, T., Lewis, S., Saul, J. E., Carroll, S., & Bitz, J. (2012). Large-system transformation in health care: A realist review. Milbank Quarterly, 90(3), 421–456.
Bloom, D., Chatterji, S., Kowal, P., Lloyd-Sherlock, P., McKee, M., Rechel, B., Rosenberg, L., & Smith, J. (2014). Macroeconomic implications of population ageing and selected policy responses. The Lancet, 385(9968), 577–662.
Bluementhal, D., Cherof, B., Fulmer, T., Lumpkin, J., & Selberg, J. (2016). Caring for high cost high need patients. An urgent priority. New England Journal of Medicine, 375, 909–909.
Bodenheimer, T., & Berry-Millet, R. Care Management of Patients with complex health care needs, research synthesis report no. 19. Princeton: Robert Wood Johnson Foundation Dec, 2009.
Booker, C., Turbutt, A., & Fox, R. (2015; Apr). Models of care for a changing healthcare system: are there foundational pillars for design? Australian Health Review, 40(2), 136–140.
Booth, B. J., Zwar, N., & Harris, M. F. (2013). Healthcare improvement as planned system change or complex responsive processes? A longitudinal case study in general practice. BMC Family Practice, 14, 51–62.
Boult, C., Reider, L., & Leff, L. (2011; March). The Effect of Guided Care Teams on the Use of Health Services: Results from a Cluster-Randomized Controlled Trial. Archives of Internal Medicine, 171(5), 460–466.
Breton, M., Lamonthe, L., & Denis, J. L. (2014). How Healthcare Organisations can act as institutional entrepreneurs in a context of change. Journal of Healthcare Management, 28(1), 77–95.
Buchanan, D. A. (2003). Getting the story straight: Illusions and delusions in the organizational change process. Tamara Journal of Critical Organisation Inquiry, 2, 7–21.
Carswell, P. TeWhiringa Ora: person-centred and integrated care in the Eastern Bay of Plenty, New Zealand, Special issue, International Journal of Integrated Care, Integrating care to older people and those with complex needs, Examining the lessons from International care studies, 2015;Vol. 16, (6), pp.
Coffey, A., Leahy-Warren, P., Savage, E., Hegarty, J., Cornally, N., Day, M. R., Maher, B., Browne, J., Sahm, L., O’Caoimh, R., Flynn, M., Hutton, S., O’Mahony, A., & Arenella, K. (2015). A Systematic Literature Review on Tackling Delayed Discharges in Acute Hospitals Inclusive of Hospital (Re) admission Avoidance. Dublin: Department of Health and children.
Connors, J. (2016). Irelands changing demographic profile; implications for public expenditure. Irish Government evaluation of Expenditure: Department of Public.
Cooke, J. (2018) Waterford Integrated Care Older Person, Network Day Presentation, www.wicop.ie (reproduced with permission).
Cooperrider, D. (2000) Collaborating for change, published by Phoenix books, Essex.
Counsell, S. R., Callahan, C. M., & Clark, D. (2007; Dec). Geriatric Care Management for Low-income Seniors: A Randomized Controlled Trial. Journal of the American Medical Association, 298(22), 2623–2633.
CSO (2011) http://www.cso.ie/en/census/census2011reports. (Accessed 5.12.16).
Curry, N. Ham, C. Clinical and service Integration. The route to improved outcomes, 2010; The Kings Fund London,
Davies, S., Goodman, C., Bunn, F., Victor, C., Dickinson, A., Iliffe, S., Gage, H., Martin, W., & Frogatt, K. (2011). A systematic review of integrated working between care homes and health care services. BMC Health Services Research, 11, 320.
Department of Health and Children, (2016) Health in Ireland, Key Trends, Department of Health.
Dixon-Woods, M., Bosk, C. L., Aveling, E. L., Goeschel, C. A., & Pronovost, P. J. (2011). Explaining Michigan: Developing an ex post theory of a quality improvement program. Milbank Quarterly, 89(2), 167–205.
Dixon-Woods, M., McNicol, S., & Martin, G. (2012). Ten challenges in improving quality in healthcare: Lessons from the Health Foundation’s programme evaluations and relevant literature. BMJ Quality and Safety, 21, 876–884.
Edgren, L. Barnard, K. (2009) Applying a complex adaptive system approach to the management of integrated care, Conference abstract, International Journal of Integrated Care, Applying a complex adaptive systems approach to the management of integrated care,
Ellis, G., Whitehead, M. A., Robinson, D., O’Neill, D., & Langhorne, P. (2011; Oct 27). Comprehensive geriatric assessment for older adults admitted to hospital: meta-analysis of randomised controlled trials. BMJ, 343.
Eurostat (2016) http://ec.europa.eu/eurostat/web/population-demography-migration-projections/deaths-life-expectancy-data (Accessed 5.12.16).
Evans, J., Grudniewicz, A., Ross Baker, G., & Wodchis, W. (2016). Organisational context and capabilities for integrating care. International Journal of Integrated Care, 16(3), 15.
Fearon, P., & Langhorne, P. (2012; Sep). Services for reducing duration of hospital care for acute stroke patients. Cochrane Database Systematic Review, 12(9).
Goodman, C., Drennan, V., Manthorpe, J., Gage, H., Travedi, D., Shah, D., Shabel, F., Poltowski, L., Handly, M., Nash, A., & Ififfe, S. (2012). A study of the effectiveness of interprofessional working for community dwelling older people. Final Report, NIHR, Service delivery and organisation Programme. NHS.
Goodwin, N. (2013). Understanding integrated care, a complex process, a fundamental principle. International Journal of Integrated Care, 13(1).
Goodwin, N. Smith, J. (2011). The evidence base for integrated care, resource pack, the kings fund, https://www.kingsfund.org.uk/sites/files/kf/Evidence-base-integrated-care2.pdf, 2011; (Accessed 12.5.16).
Greenhalgh, T., Humphrey, C., Hughes, J., MacFarlane, F., Butler, C., & Pawson, R. (2009). How do you modernize a health service? A Realist Evaluation of Whole-Scale Transformation in London. Milbank Quarterly, 87, 391–416.
Greenhalgh, T., MacFarlane, F., Barton-Sweeney, C., & Woodard, F. (2012). If we build it, will it stay?’ A Case Study of the Sustainability of Whole-System Change in London. Milbank Quarterly, 90, 516–547.
Gullery, C., & Hamilton, G. (2015). Towards integrated person centred-care, the Canterbury experience. Future Hospital Journal, 2(2), 111–116.
Halloran, O., & A. (2017). Risk stratification based on frailty prevalence, Tilda. Trinity College Dublin: Irish Longitudinal study on aging.
Halpern, D. (2015). Inside the nudge unit, how small change can make a big difference. Published by WH Allen.
Ham, C., & Walsh, N. (2013). Making integrated care happen at scale and pace, lessons from experience. Kings Fund London.
Harnett, PJ. (2018) Improvement attributes in healthcare; implications for integrated care (accepted and in press, International Journal for Quality Assurance in Healthcare ).
Hebert, R. Durand, P. Dubuc, N. Touringy, A. PRISMA: a new model of integrated service delivery for the frail older people in Canada. International Journal of Integrated Care, 2003;Jan-March.
Hendry, A. (2015). Reshaping Care Pathways for Older People, Joint Improvement Team. Scotland: Conference Presentation.
Holden, L. M. (2005). Complex adaptive systems: Concept analysis. Journal of Advanced Nursing, 52, 651–657.
HSE (2016) National Service Plan, www.hse.ie/eng/services/publications/corporate/sp2015.pdf(Accessed 4.1.16).
Hutt, R., Rosen, R., & McCauley, J. (2004). Case-managing long-term conditions: What impact does it have in the treatment of older people? London: The King’s Fund.
Keong, H. Mun, W. Feng, L. Huang, J. Cheah, J. Singapore programme for integrated care for the elderly, International Journal of Integrated Care, 2013; July-Sept (12) Supp. 13.
Khangura, S., Konnyu, K., Cushman, R., Grimshaw, J., & Moher, D. (2012). Evidence summaries: The evolution of a rapid review approach. Systematic Reviews, 1, 10.
Klinga, C., Hansson, J., Hasson, H., & Sachs, A. (2016; May 23). Co-leadership- A management solution to integrated health and social care. International Journal of Integrated Care, 16(2), 7.
Kodener, D., & Spreeuwenberg, C. (2002). Integrated care, meaning, logic, application and implication, a discussion paper. International Journal of Integrated Care, 2.
Kodner, D. All together now, a conceptual exploration of integrated care, healthcare quarterly, 2009;special issue, Vol. 13, Oct,
Leijten, F. R. M., Struckmann, V., van Ginneken, E., Czypionka, T., Kraus, M., Reiss, M., & Tsiachristas, A. (2018 Jan). Boland M6 de Bont A, Bal R, Busse R, Mölken MR; the SELFIE framework for integrated care for multi-morbidity: Development and description. Health Policy, 122(1), 12–22. https://doi.org/10.1016/j.healthpol.2017.06.002.
Leutz, W. (1999). Five laws for integrating medical and social services:lessons from the US and the United Kingdom. Millbank Quarterly, 77(1), 77–110.
Leviton, L. (2011). Reconciling complexity and classification in quality improvement research. BMJ Quality and Safety, 20, i25–i28.
Ling, T., Brereton, L., Conklin, A., Newbould, J., & Roland, M. (2012). Barriers and facilitators to integrated care: experiences from the English Integrated Care Pilots. International Journal of Integrated Care, 12, 1–12.
Locket, A., Currie, G., Waring, J., Finn, R., & Martin, G. (2012). The role of institutional entrepreneurs in reforming healthcare. Social Science, 74, 356–363.
Lyon, D., Lancaster, G. A., Taylor, S., Dowrick, C., & Chellaswamy, H. (2007). Predicting the likelihood of emergency admission to hospital of older people: Development and validation of the emergency admission risk likelihood index (EARLI). Family Practice, 24(2), 158–167.
Massoud, R. Barry, D. Murphy, A. Albrecht, Y. Sax, S. Parchman, B. M. How do we learn about improving healthcare, the call for a new epistemological paradigm. International Journal for Quality in Healthcare, 2016;April, 1–5.
May, C. (2013). Agency and implementation: Understanding the embedding of healthcare innovations in practice. Social Science and Medicine, 78, 26–33.
Mc Adam, M (2008) Framework of integrated care for the elderly: A systematic review, Canadian Policy Research Network, April.
Mc Cormack, B. Kitson, A. Harvey,G. Rycroft, J. Titchen, A. Seers, K. Getting evidence into practice: the meaning of 'context'. Journal of Advanced Nursing, 2002; 38, 1, pp 94–104.
Mc Farlane, F. Barton-Sweeney, C. Woodard, F. Greenhalgh, T. Achieving and sustaining profound institutional change in healthcare: Using neo-institutional theory. Social Science and Medicine, 2013;, 80,pp10–18.
Minkman, M. (2015) Effectively organising integrated care, the developmental model of integrated care, EU Observatory Summer school,
Mitchell, G., Burridge, L., Zhang, J., Donald, M., Scott, I., Dart, J., & Jackson, C. (2015). Systematic review of integrated models of health care delivered at the primary-secondary interface: How effective is it and what determines effectiveness. Australian Journal of Primary Care, 21(4), 391–408.
Muskat, E. Sylvester, D. Being disruptive, how open growth is delivering effective social change at a fast pace. Technology Innovation Management Review, (2012) July, 16–20.
Naylor, M. D., Brooten, A., & Campbell, R. L. (2004; May). Transitional Care of Older Adults Hospitalized with Heart Failure: A Randomized, Controlled Trial. Journal of the American Geriatrics Society, 52(5), 675–684.
Nicholson, C., Jackson, C., & Marley, M. (2016). A Governance Model for Integrated primary/secondary care for the health reforming first world- a systematic review. BMC, Health Services Research, 13, 528.
Nolte, E. (2012). National evaluation of the Department of Health Integrated Care Pilots. RAND Europe: Final report.
O’Shea, E. (2015). Prevalence and projections of dementia in Ireland. Mullingar: Report prepared for Genio Ltd.
Oliver, D., Foot, C., & Humphries, R. (2014). Making our health and care system fit for an aging population. London: The Kings Fund.
Open App. ED attendance, admission and bed days used by people > 75 yrs, Personal correspondence, 2017.
Ovretveit, J. (2011). Understanding the conditions for improvement: research to discover which context influences affect improvement success. BMJ Quality and Safety, 20, i18–ii2.
Ovretveit, J., Leviton, L., & Parry, G. J. (2011). Increasing the generalisability of improvement research with an improvement replication programme. BMJ Quality and Safety, 20, i87–i91.
Parker, S. G., Peet, S. M., McPherson, A., Cannaby, A. M., Abrams, K., Baker, R., Wilson, A., Lindesay, J., Parker, G., & Jones, D. R. (2002). A systematic review of discharge arrangements for older people. Health Technology Assessment, 6(4), 1–183.
Pike, B., & Mongan, D. (2014). The integration of health and social care services. Ireland: Health Research Board.
Prince, M. J., Wu, F., Robledo, L., & O’Donnell, M. (2015). The burden of disease in older people and implications for health policy practice. The Lancet, 385(9967), 549–562.
Radnor, Z., & Osbourne, S. (2012). Lean. A failed theory for public services. Public Management Review, 13, 265–287.
Roland, M., Lewis, R., Stevenson, A., Abel, G., Adams, J., Bardsley, A., Breraton, L., Chitnis, X., Conklin, A., & Staetsky, L. (2012). Case management for at-risk elderly patients in the English integrated care pilots: Observational study of staff and patient experience and secondary care utilisation. International Journal of Integrated Care, 12, 1–21.
Rouse, W. ‘Healthcare as a complex adaptive system, Implications for Design and Management’;, The Bridge, National Academy of Engineering, 2008; ol 28, No1, Spring.
Seligman, M., & Seligman, M. E. P. (1991). Learned optimism. New York.
Sheppard, S. Lannin, N. Clemson, L. Mc Cluskey, C. Cameron, I. Barras, S. Discharge planning from hospital to home, Cochrane database of systematic reviews, 2013;Issue 1.
Shortt, J. O Malley, G. Heffernan, M (2016) Improving the quality of care for frail older people, Sligo University Hospital.
Silvester, K., Mohammed, M., Harriman, P., Girolami, A., & Downes, T. (2014). Timely care for frail older people referred to hospital improves efficiency and improves mortality without the need for extra resources. Age and Aging, 4(43), 472–477.
Smyth, B. Kavanagh,P. Marsden, P. Donoghue, F. Kitching, A. Ryan, A. Cullen, C. (2016), Planning for health, projected demographic effect on health service costs 2017, Health and Wellbeing Division, Health Service Executive.
Stewart, M., Georgiou, A., & Westbrook, J. (2013). Successfully integrating aged care services: a review of the evidence emerging from a long term care programme. International Journal of Integrated Care Jan-March, 13.
Stokes, J., Panagioti, M., Alam, R., Cheraghi-sohi, S., & Bower, P. (2015). Effectiveness of case management for ‘at risk’ patients in primary care: A systematic review and meta-analysis. PLoS One, 10(7).
Trivedi, D., Goodman, C., & Gage, H. (2013). The effectiveness of inter-professional working for older people living in the community: A systematic review. Health and Social Care in the Community., 21(2), 113–128.
Tsasis, P., Evans, J., Rush, L., & Diamond, J. (2012). Learning to learn; towards a relational and transformational model for improved integrated care delivery. Administrative Sciences, 3, 9–31.
Valentijn, P. (2015). Rainbow of Chaos: A study into the Theory and Practice of Integrated Primary Care. International Journal of Integrated Care, 16(2).
Valentijn, P., Shepman, S., Opheji, W., & Bruijnzeels, M. (2013; Jan-Mar). Understanding integrated care: a complex process, a fundamental principle. International Journal of Integrated Care, 13.
Valentijn, P., Biermann, C., & Bruijnzeels, M. (2016). Value based integrated (renal) care: Setting a development agenda for research and implementation strategies. BMC Health Services Research, 16, 330.
Wodchis, W., Dixon, A., Anderson, G., & Goodwin, N. (2015). Integrating care for older people with complex needs: key insights and lessons from a seven-country cross-case analysis. International Journal of Integrated Care, 16, 6.