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.

Impact of Proactive Integrated Care on Chronic Obstructive Pulmonary Disease

In the United States, chronic obstructive pulmonary disease (COPD) affects over 16 million people, costs $32 billion per year, and is the fourth leading cause of death.Exacerbations of COPD are among the most devastating complications of COPD, because they greatly increase the risk of death and account for 60% of COPD costs.Efforts have focused on standardizing recommendations for therapies that improve symptoms and limit exacerbations, identifying patients who might benefit from these treatments, and increasing compliance with recommended therapies.Surprisingly, only about 50% of COPD patients receive recommended therapies for COPD and COPD exacerbations, up to two-thirds of ...

Patient Experiences of Integrated Care in Medicare Accountable Care Organizations and Medicare Advantage Versus Traditional Fee-for-Service

Health insurance design can influence the extent to which clinical care is well-coordinated. Through alternative payment models, Medicare Advantage (MA) and Accountable Care Organizations (ACOs) have the potential to improve integration relative to traditional fee-for-service (FFS) Medicare.

Applying Elinor Ostrom’s Design Principles to Guide Co-Design in Health(care) Improvement: A Case Study with Citizens Returning to the Community from Jail in Los Angeles County

Increased interest in collaborative and inclusive approaches to healthcare improvement makes revisiting Elinor Ostrom’s ‘design principles’ for enabling collective management of common pool resources (CPR) in polycentric systems a timely endeavour.

Ostrom proposed a generalisable set of eight core design principles for the efficacy of groups. To consider the utility of Ostrom’s principles for the planning, delivery, and evaluation of future health(care) improvement, the autors retrospectively applied them to a recent co-design project.

Three distinct aspects of co-design were identified through consideration of the principles. These related to: (1) understanding and mapping the system (2) upholding democratic ...

A Conceptual Framework for Integrated Community Care

The various health and social care services provided in a given local area (i.e., place-based) must not only deliver primary care in proximity to the population, but act upstream on the social determinants of health. This type of care, when provided in a holistic and integrated manner, aims to improve the physical and mental health—but also the well-being and social capital—of individuals, families, groups and communities. This type of approach is known as Integrated Community Care (ICC).

This article was developed from a non-systematic review of scientific and grey literature followed by a qualitative analysis and researcher ...

A Community Resource Navigator Model: Utilizing Student Volunteers to Integrate Health and Social Care in a Community Health Center Setting

While unmet social needs are major drivers of health outcomes, most health systems are not fully integrated with the social care sector to address them. 

This case study describes the development and implementation of a model utilizing student volunteer community resource navigators to help patients connect with community-based organizations. The authors then detail initial implementation outcomes and practical considerations for future work.

A multilevel study of patient-centered care perceptions in mental health teams

The successful combination of interprofessional collaboration in multidisciplinary teams with patient-centered care is necessary when it comes to delivering complex mental health services. Yet collaboration is challenging and patient-centered care is intricate to manage. This study examines correlates of patient-centered care such as team adaptivity and proactivity, collaboration, belief in interprofessional collaboration and informational role self-efficacy in multidisciplinary mental health teams.