Integrated Care Matters ➢ Webinar Series and Topic Resources www.integratedcarefoundation.org/scotland ➢ Special Interest Groups (SIGs) hosted on IFIC website: o Polypharmacy and Adherence o Intermediate Care o Palliative & End of Life Care o Self Management and Co-production o Compassionate Communities o Frailty ➢ https://integratedcarefoundation.org/ific-membersnetwork/groups/ A movement for change
Thank You anne.hendry@lanarkshire.scot.nhs.uk IFICscotland@integratedcarefoundation.org www.advantageja.eu A movement for change
WHAT IS SUSTAIN? Caroline Baan National Institute for Public Health and the Environment (RIVM)
The SUSTAIN-project: supporting integrated care in Europe C A R O L I N E B A A N O N B E H A L F O F T H E S U S T A I N C O N S O R T I U M
The SUSTAIN consortium
Challenges of health systems Increasing number of people with chronic conditions and/or health and social care demands → increasing need for health and social care. Health systems often poorly planned and coordinated → health and social care needs are commonly insufficiently addressed. Self-responsibility, self-efficacy, and self-management are increasingly important → people involved in decisions affecting their health and treatment (patient-centred care). 12-3-2019
Integrated care to optimize health systems Proact ctiv ive Involvin lving g Multi tiple le Set et of Coordina nation on assessmen sment older people disciplines ines interventions ntions CORE ELEMENTS INTEGRATED CARE
Challenges related to integrated care • Best way to design integrated care? • Effective? • How to implement integrated care? • How to make integrated care sustainable? • How to transfer successful initiatives?
SUSTAIN aims 1. To support and monitor improvements to established integrated care initiatives for older people living at home with multiple health and social care needs; 2. To contribute to the adoption and application of these improvements to other health and social care systems, and regions in Europe.
SUSTAIN core domains Person- Prevention- centredness orientation Efficiency Safety
Overall structure
Rehabilitative care Proactive primary care Careworks Berlin (DE) Geriatrics Osona (CAT) Surnadal Holistic Patient Care at Home Social/healthcare integration Sabadell (NO) (CAT) KV RegioMed Zentrum Templin (DE) Geriatric Care Model (NL) Søndre Nordstrand Holistic Care at Home Over 75 Service (UK) (NO) Dementia care Gerontopsychiatric Centre (AT) Transitional care Home nursing Good in one go (NL) Alutaguse Care Centre (EST) Swale home first (UK) Medendi (EST)
Main deliverable Roadmap Improved integrated care Tips and tricks Solutions for implementation issues Indicators/data collection tools Good practices Instruments to develop improvement project
The value of international collaboration Access to experiences of other countries • Learning from experiences of other countries • Get to know and understand other countries • Insight into generic vs. context-specific factors • Knowledge and uniformity of indicators for evaluating • integrated care Translating scientific knowledge to practical recommendations • Ultimately: better care and support services, and better outcomes across the EU!
Enjoy Today!
IMPROVING INTEGRATED CARE INITIATIVES ACROSS EUROPE: THE SUSTAIN FRAMEWORK Jenny Billings University of Kent
Phases of SUSTAIN and Methodology J E N N Y B I L L I N G S O N B E H A L F O F T H E S U S T A I N C O N S O R T I U M
Phase Ph ase 2 Phas Ph ase e 1 Impl mpleme ementat ntation ion resea search ch to imp mprove e Preparat ration ion exist sting ing integr egrat ated ed care e initiativ iatives es at (6 mon onth ths) s) select ected d sites es (12 2 month nths) s) WP3 WP3 WP4 WP4 WP5 WP5 Prep epar arati ative e Overar rarching hing Implemen lementation tation activ ivities ities to analyses yses of and evaluation ation improve e experiences periences of of impr provem ement nts s existing isting all integrat egrated ed of int nteg egrat ated ed integrat egrated ed care init itiat iativ ives es care init itiat iativ ives es care init itiat iativ ives es
Implementation Science Evidence Integration Triangle (Glasgow 2013) Intervention Improvements to integrated care services Evidence Practical Measures: Case study design Stakeholders Participatory Qualitative and Implementation Process quantitative indicators, Feedback Stakeholder engagement; cyclical evaluation Process evaluation Multi-Level Context
Phase 1: Preparation Stakeholder analysis at the 14 sites Initial assessments and stakeholder workshops Identification of Development of Setting up of projects for improvement steering group improvement plan Develop evaluation Establishing working method and practical relationships measures
Phase 2: Implementation and Evaluation Case Study Design (Yin 2009) Qualitative indicators: Quantitative indicators surveys to users (n=210) and (set of 14 per site) staff (n=140-280) SUSTAIN UNIT OF Dyad (n=168) or single ANALYSIS: interviews with users Interviews with (n= 84) and carers (n= managers (n=14) SET OF IMPROVEMENTS 84) FOR INTEGRATED CARE INITIATIVE Focus groups: Documents: care plans (n= professionals/agency 84) and steering group representatives (n=84- discussions (all) 140)
SUSTAIN propositions Integrated care activities will maintain or enhance person-centredness, prevention orientation, safety and efficiency in care delivery Explanations for succeeding in improving existing integrated care initiatives will be identified How and Why? why? What What What doesn’t can we works rks? work? rk? transf ansfer? er?
Qualitative indicators Control over organising health care, contacting Perceived Control of Health Care(users) and communicating workers, organising care in the future Person Centred Goal setting, Experiences independence and of Coordinated Care empowerment, care (users) coordination, involvement in decision making Team Climate Inventory Vision, task orientation, (professionals) support for innovation
Quantitative Indicators per SUSTAIN theme PERSON-CENTREDNESS Users with a needs assessment Care plans with activities already actioned or being actioned See Word- File „Follow -up Interview CPC“ Care plans shared across different professionals Care plans shared across different organisations Carers with a needs assessment PREVENTION-ORIENTATION Users receiving a medication review Users received or receiving advice on medication adherence Users received or receiving advice on self-management and how to maintain independence SAFETY Users received safety advice (home security, falls prevention) Users with falls recorded in the care plan EFFICIENCY Emergency hospital admissions of user (during evaluation period) Length of stay per emergency admission of user (during evaluation period) Hospital readmissions of the user (during evaluation period) Staff hours dedicated to initiative (per staff member)
Overview of what was collected when Timeline Team Climate Inventory (TCI); quantitative indicators Phase 1: 0-6 months Discussion with steering group: 6 months Assessment and planning User and Document P3CEQ, PCHC, carer analysis/ Phase 2 : Quantitative indicators 6-12 interviews care plans months EIT: Evidence Feedback to steering group: 12 months Assessment and planning User/ Document P3CEQ, PCHC, TCI Focus Manager carer analysis/ 12-18 months Quantitative interview group interview care plans indicators EIT: Evidence Feedback for 18 months final assessment and future planning
Approach to analysis (Yin 2009) Step 1 All data a sources s analyse ysed d separat rately Step 2 Data reduced ced to a series s of thematic atic statements ements Struct cture ured d analytical ytical frame meworks rks and guida dance nce for each data ta source provided ided Step 3 Pattern Pa rn-mat matching ching across s the data a using ng the thematic atic stateme ements nts and our propo positio sitions ns Search h for rival al explanatio anations ns
Accommodating the methods
Complex interventions and the developmental nature of methods Test est and and Le Lear arn
Coffee Break Join us outside & discover the SUSTAIN sites! The SUSTAIN project is funded under Horizon 2020 – the Framework Programme for Research and Innovation (2014-2020) from the European Union under grant agreement No. 634144.
INTERACT WITH US ! @SUSTAINeu #SUSTAINeu The SUSTAIN project is funded under Horizon 2020 – the Framework Programme for Research and Innovation (2014-2020) from the European Union under grant agreement No. 634144.
INTEGRATED CARE ‘ON THE GROUND’: THE SUSTAIN INTEGRATED CARE INITIATIVES AND KEY LEARNINGS Annerieke Stoop National Institute for Public Health and the Environment (RIVM)) Simone de Bruin National Institute for Public Health and the Environment (RIVM))
Integrated care ‘on the ground’ The SUSTAIN integrated care initiatives and key learnings S I M O N E D E B R U I N A N D A N N E R I E K E S T O O P O N B E H A L F O F T H E S U S T A I N C O N S O R T I U M
13 initiatives in 7 countries
Rehabilitative care Proactive primary care Pflegewerk Berlin (DE) Osona Program for Geriatrics (CAT) KV RegioMed Zentrum Templin (DE) Sabadell Social/healthcare integration (CAT) Surnadal Holistic Care at Home (NO) Geriatric Care Model (NL) Sondre Nordstrand Everyday Mastery Team (NO) Over 75 Service (UK) Dementia care Gerontopsychiatric Zentre (AT) Transitional care Home nursing In één keer goed! (NL) Alutaguse Care Centre (EST) Swale home first (UK) Medendi (EST)
Challenges Coordination and Competences, motivation collaboration and workload Communication and information Person-centred working Resources and support
Improvement projects Collaboration, Actual care delivery communication and process coordination
Examples of integrated care activities Needs assessments Location of care and care plans delivery Building multidisciplinary teams Training and advice
What seems to work? Person-centredness Prevention-orientation Safety Efficiency Coordination
Explanations for (not) succeeding Micro level Meso level Macro level
Recommendations to improve integrated care Recommendations for Policy recommendations service providers Recommendations for the research community
PANEL DISCUSSION – INSIGHTS FROM THE SUSTAIN INTEGRATED CARE SITES Carme Guinovart Santa Creu University Hospital of Vic Julia Baldwin Sandgate Road Surgery Julie MacInnes University of Kent Jillian Reynolds AQuAS Nick Zonneveld Vilans
Lunch Break Join us outside & discover the SUSTAIN sites! The SUSTAIN project is funded under Horizon 2020 – the Framework Programme for Research and Innovation (2014-2020) from the European Union under grant agreement No. 634144.
INTERACT WITH US ! @SUSTAINeu #SUSTAINeu The SUSTAIN project is funded under Horizon 2020 – the Framework Programme for Research and Innovation (2014-2020) from the European Union under grant agreement No. 634144.
FROM RESEARCH TO PRACTICE TO POLICY: ‘WALKING’ THE SUSTAIN ROADMAP Maggie Langins International Foundation for Integrated Care Seline Noteboom Vilans Nick Goodwin International Foundation for Integrated Care Gerald Wistow London School of Economics
What is the roadmap? An open-access and easy to use resource to plan, design and implement integrated care to older people living at home with complex care needs Objectives ❑ Integrate, translate and customise work done in WP3-5 ❑ Develop a step-by-step guide to support successful adoption ❑ Co-designed with the case sites and end users - iterative development from implementation science approach ❑ Enabling dissemination and exploitation of results as defined in WP7
Seline Noteboom Monique Spierenburg
How did we get to this design? Book 1 Book 2 Book 3 Book 4 Book 5 Setting up Design Improving Context of Resources of integrated integrated integrated integrated integrated care care care care care features steps phases layers resources
Sketch 1 of the story
Sketch 2 of the story
The final storylin e
Please open the roadmap on your laptop
Person-centred Coordinated Empowering an interprofessional workforce Safeguarding dignity
Person-centred Coordinated Empowering an interprofessional workforce Safeguarding dignity
Person-centred Coordinated Empowering an interprofessional workforce Safeguarding dignity
Person-centred Coordinated Empowering an interprofessional workforce Safeguarding dignity
Person-centred Coordinated Empowering an interprofessional workforce Safeguarding dignity
Person-centred Coordinated Empowering an interprofessional workforce Safeguarding dignity
PANEL DISCUSSION – BEYOND SUSTAIN: DISCUSSING INTEGRATED CARE IN EUROPE Anne-Sophie Parent AGE Platform Europe Axel Kaehne Edge Hill University and EHMA SIG Integrated Care Chair Jenny Billings University of Kent Toni Dedeu International Foundation for Integrated Care
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