Project INTEGRATE: Lessons for Policy, Management and Implementation of Integrated Care in Europe

Project INTEGRATE aims to gain valuable insights into the leadership, management and delivery of integrated care to support European care systems to respond to the challenges of ageing populations and the rise of people living with long-term chronic conditions.

This project has already examined four case studies of best practices of integrated care in Europe, in the areas of COPD, Mental Health, Geriatric Conditions and Diabetes, that have had a proven impact in terms of improving patient experiences, generating better care outcomes and providing cost-effectiveness. The key aim of this part of the research was to define what constitutes good quality integrated care provision, and how integrated care systems can most effectively be built. In Phase 2 of the research, the project considered the cross-cutting themes process design, service delivery, skill mix, patient involvement, financial flows, regulatory conditions, and enabling information technologies in order to create connectivity, alignment and collaboration ...

The clinical effectiveness of the COPDnet integrated care model

COPD is a disease with a high prevalence in the world. Despite the great personal and family involvement, it has been seen that integrated care between hospitals and primary care translates into better clinical results for patients. Integrated care models have the potential to improve outcomes for patients with COPD. The research team design the COPDnet integrated care model and implemented it in two hospitals and affiliated primary care regions in the Netherlands. The COPDnet model consists of a comprehensive diagnostic trajectory ran in secondary care followed by a non-pharmacological intervention program of both monodisciplinary and multidisciplinary components.

How to Ensure Referral and Uptake for COPD Rehabilitation – Part 2: A Case of Integrated Care on How to Translate Findings of Cross- Sectorial Workflow to Improve Cross-Sectorial Rehabilitation

Patients with chronic obstructive pulmonary disease (COPD) can greatly benefit from rehabilitation initiatives, but referral to rehabilitation is sparse. Before we initiated activities to ensure hospital referrals for prevention initiatives at the municipality, we investigated referral patterns and relevant factors in the cross-sectorial workflow.

This study aims to ensure referral to municipality COPD rehabilitation, by simplifying the referral procedures, and by facilitating relational coordination across the two health care settings.

Meaningful use of a digital platform and structured telephone support to facilitate remote person-centred care - a mixed-method study on patient perspectives

Process evaluations are useful in clarifying results obtained from randomised controlled trials (RCTs). Traditionally, the degree of intervention usage in process evaluations is monitored by measuring dose or evaluating implementation fidelity. From a person-centred perspective, such evaluations should be supplemented with patients’ experiences of meaningful use, given that intervention use should be agreed upon between interested parties and tailored to each patient. This study aimed to elucidate patients’ experiences of a remote person-centred care (PCC) intervention by deepening the understanding of, if, how and for whom the intervention contributed to meaningful use.