Nursing Care Coordination for Patients with Complex Needs in Primary Healthcare: A Scoping Review

Millions of people worldwide have complex health and social care needs. Care coordination for these patients is a core dimension of integrated care and a key responsibility for primary healthcare. Registered nurses play a substantial role in care coordination.

This review draws on previous theoretical work and provides a synthesis of care coordination interventions as operationalized by nurses for complex patient populations in primary healthcare.

Implementing Integrated Care in Practice – Learning from MDTs Driving the Integrated Care Programme for Older Persons in Ireland

The importance of multidisciplinary teams (MDTs) as critical implementation drivers emerged from this case study conducted with three pioneer sites implementing integrated care for older persons in Ireland as part of the Integrated Care Programme for Older Persons (ICPOP).

The study describes the practices of MDTs learning to deliver integrated care in service delivery settings, including the framework, resourcing, strategies, challenges and barriers they encounter.

Bridging the Gap: A Mixed Methods Study Investigating Caregiver Integration for People with Geriatric Syndrome

Transitions of care between acute hospital and community settings are points of vulnerability for people with geriatric syndrome. Routinely including informal caregivers into the transition processes may mitigate risk. Guidance for operational aspects of caregiver inclusion is currently lacking in healthcare policy and fails to address the barriers faced by caregivers and healthcare professionals.

This pilot mixed method study adopts an implementation science lens to “bridge the gap” between top-down policy recommendations and the realities experienced by healthcare professionals who provide transitional care. It explores how informal caregiver integration can be better achieved. In the past, caregiver integration literature has ...

Elderly people, dependency and vulnerability in the coronavirus pandemic: an emergency for a social and health integration

The current SARS-CoV-2 pandemic (COVID-19) is affecting elderly people worldwide with greater incidence and severity. In Spain, 68% of all coronavirus hospitalizations correspond to those over 60 years of age. This work aims to highlight the evidence about the measures to be implemented through current and future guidelines. The need to prepare for action by implementing international protocols stand out. There is a trend towards biopsychosocial care of elderly people in all settings where they are, adapting care and personalizing decisions on hospital admissions, palliative care, among other criteria, to years adjusted to quality of life, as well as alternatives ...

Conditions for successful interprofessional collaboration in integrated care - Lessons from a primary care setting in Denmark

Increasing demand for interprofessional collaboration in health care settings has led to a greater focus on how conditions influence the success of interprofessional collaboration, but little is known about the magnitude of the interactions between different conditions. This paper aims to examine the relationships of intervention conditions and context conditions at the professional and organisational level and examine how they influence the staff's perceived success of the interprofessional collaboration.

The Seniors' Community Hub: An Integrated Model of Care for the Identification and Management of Frailty in Primary Care

Integrated models of primary care deliver the comprehensive and preventative approach needed to identify and manage frailty in older people. Seniors' Community Hub (SCH) was developed to deliver person-centered, evidence-informed, coordinated, and integrated care services to older community dwelling adults living with frailty. This paper aims to describe the SCH model, and to present patient-oriented results of the pilot.

The association of vertically integrated care with health care use and outcomes

The objective of this article is to determine whether vertically integrated hospital and skilled nursing facility (SNF) care is associated with more efficient use of postdischarge care and better outcomes.

Addressing Common Challenges in the Implementation of Collaborative Care for Mental Health: The Penn Integrated Care Program

The purpose of this article was to develop and implement a new model of collaborative care that includes a triage and referral management system. The authors present initial implementation metrics using the Reach, Effectiveness, Adoption, Implementation, Maintenance (RE-AIM) framework.  

The Affordable Care Act: policy predictors of integrated care between Hispanic-serving and mainstream mental health organizations

The Patient Protection and Affordable Care Act increased funding for integrated care to improve access to quality health care among underserved populations. There is evidence that integrated care decreases inequities in access and quality of mental health care among Hispanic clients. Increasing integrated care at Hispanic-Serving Organizations may help to eliminate mental health service disparities among Hispanic clients.

Dynamics of Health Technology Diffusion in the Integrated Care System (DHTDICS): A Development and Validation Study in China

Limited diffusion of health technology has greatly halted the improvement of resource integration and healthcare outcomes. The importance of understanding the dynamics of health technology diffusion is increasingly highlighted. However, the dynamic mechanism of health technology diffusion in the context of the integrated care system (ICS) remained largely unknown.