Integrating Primary and Secondary Care to Enhance Chronic Disease Management: A Scoping Review

In Ireland, as in many healthcare systems, health policy has committed to delivering an integrated model of care to address the increasing burden of chronic disease.

Integrated care is an approach to healthcare systems delivery that aims to minimise fragmentation of patient services and improve care continuity. To this end, how best to integrate primary and secondary care is a challenge.

This paper aims to undertake a scoping review of empirical work on the integration of primary and secondary care in relation to chronic disease management.

Elements and Performance Indicators of Integrated Healthcare Programmes on Chronic Diseases in Six Countries in the Asia-Pacific Region: A Scoping Review

Globally, hospital-based healthcare models targeting acute care, are not effective in addressing chronic conditions. Integrated care programmes for chronic diseases have been widely developed and implemented in Europe and North America and to a much lesser extent in the Asia-Pacific region to meet such challenges.

This scoping review aims to examine the elements of programmes identified in the literature from select study countries in the Asia-Pacific, and discuss important facilitators and barriers for design and implementation.

Factors supporting the implementation of integrated care between physical and mental health services: an integrative review

In Australia and internationally there is a strong policy commitment to the redesign of health services toward integrated physical and mental health care. When executed well, integrated care has been demonstrated to improve the access to, clinical outcomes from, and quality of care while reducing overtreatment and duplication. Despite the demonstrated effectiveness and promise of integrated care, exactly how integrated care is best achieved remains less clear. The aim of this review study was to identify factors that support the implementation of integrated care between physical and mental health services. An integrative review was conducted following the framework developed by ...

JICA Special Issue: Integrated Palliative and End of Life Care for People with Advanced Dementia or Frailty

This special issue now seems uncannily prescient in view of the devastating impact of COVID-19 on people with advanced dementia or severe frailty, particularly in care homes.

The pandemic has heightened awareness of the possibility of a sudden and rapid transition from relative health to a palliative or end of life stage. This has opened up conversations about the potential burden from intensive treatments that are likely to be futile and the benefits of advance care planning.

The collection of papers in this special issue will be of interest to readers involved in planning, commissioning or delivering palliative and end ...

Integrating patient complexity into health policy: a conceptual framework

Clinicians across all health professions increasingly strive to add value to the care they deliver through the application of the central tenets of people-centred care (PCC), namely the ‘right care’, in the ‘right place’, at the ‘right time’ and ‘tailored to the needs of communities’.

This ideal is being hampered by a lack of a structured, evidence-based means to formulate policy and value the commissioning of services in an environment of increasing appreciation for the complex health needs of communities. This creates significant challenges for policy makers, commissioners and providers of health services. Communities face a complex intersection of challenges ...

Care Coordination for Vulnerable Families in the Sydney Local Health District: What Works for Whom, under What Circumstances, and Why?

 Healthy Homes and Neighbourhoods (HHAN), an integrated care programme in the Sydney Local Health District (SLHD), seeks to address the needs of disadvantaged families through care coordination, as one of its components. This research aims to determine for whom, when and why the care coordination component of HHAN works, and establish the reported outcomes for clients, service-providers and partner organisations.

Use of Dementia Assessment Sheet for Community-based Integrated Care System 8-items (DASC-8) for the screening of frailty and components of comprehensive geriatric assessment

Comprehensive geriatric assessment (CGA)—a key tool for geriatric medicine—is commonly used to assess older people’s health status and frailty. However, performing CGA in outpatient clinics is difficult because the assessment of cognition, activities of daily living (ADLs), depression, quality of life (QoL), nutrition, medications and social conditions is time consuming and requires the cooperation of medical staff. Frailty—an aspect of geriatric medicine that indicates the weakness of the body—is a critical measure of older adults’ physical function.

The Dementia Assessment Sheet for Community-based Integrated Care System 8-items (DASC-8) is a validated and simple ...

Patient Privacy and Integrated Care: The Multidisciplinary Health Care Team

This article explores legislative provisions in relation to patient privacy in the context of integrated health and social care and the development of multidisciplinary health care teams that include practitioners from private sector and government agencies in the health, education, child protection, family welfare, disability, aged-care, housing, local government and criminal justice sectors. 

Refining Program Theory for a Place-Based Integrated Care Initiative in Sydney, Australia

A number of families living in our community experience many barriers to accessing health and social care. The problems that these families face are highly complex, often spanning over generations, and cannot be addressed by one agency alone.  The Healthy Homes and Neighbourhoods (HHAN) Integrated Care Initiative attempts to connect services to address these barriers, and ensure families have their complex health and social needs met; keep themselves and their children safe; and keep families connected to society.

This article shows that in addition to serving families in Sydney, HHAN has also established place-based initiatives (PBI) in disadvantaged areas such ...

A critical realist evaluation of an integrated care project for vulnerable families in Sydney, Australia

Healthy Homes and Neighbourhoods (HHAN) Integrated Care Initiative was established to improve the care of families with complex health and social needs who reside in Sydney Local Health District. HHAN seeks to provide long-term multi-disciplinary care coordination as well as enhance capacity building and promote integrated care. Findings of this study supported the initial programme theory that engagement and trust building with clients, alongside enhanced collaboration and integration of services, improved outcomes for vulnerable families with complex needs.