Models of integrated care for older people with frailty: a horizon scanning review

Frailty, a multifaceted geriatric condition, is an emerging global health problem. Integrated care models designed to meet the complex needs of the older people with frailty are required. Early identification of innovative models may inform policymakers and other stakeholders of service delivery alternatives they can introduce and locally adapt so as to tackle system fragmentation and lack of coordination. This study used horizon scanning methodologies to systematically search for, prioritise and assess new integrated care models for older people with frailty and investigated experts’ views on barriers and facilitators to the adoption of horizon scanning in health services research.

Developing an interprofessional people-centred care model for home-living older people with multimorbidities in a primary care health centre: A community-based study

The ageing population with multiple conditions and complex health needs has forced healthcare systems to rethink the optimal way of delivering services. Instead of trying to manage numerous diseases in a siloed approach, the emphasis should be on people-centred practice, in which healthcare services are tailored to people's needs and provided in partnership with them. 

The aim was to develop an interprofessional people-centred care model (PCCM), including the contribution of a clinically trained pharmacist for home-living multimorbid older people in primary care.

How do nurses support chronically ill clients’ participation and self-management in primary care? A cross-country qualitative study

In the context of the advancement of person-centered care models, the promotion of the participation of patients with chronic illness and complex care needs in the management of their care (self-management) is increasingly seen as a responsibility of primary care nurses. It is emphasized that nurses should consider the psychosocial dimensions of chronic illness and the client’s lifeworld. Little is known about how nurses shape this task in practice. The aim of this analysis is to examine how primary care nurses understand and shape the participation of patients with chronic illness and complex care needs regarding the promotion of ...

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.

Integrated care systems need to be different - but how exactly?

ICSs are intended to be a fundamental departure from previous NHS structures with a different type of leadership based on partnership, in which local partner organisations hold collective responsibility for resource use and outcomes. However, as ICSs take on statutory responsibilities for the first time later this year (assuming the Heath and Care Bill gains parliamentary approval) there is a risk of recreating established ways of working within the new structures. To live up to their promise, what are the things that should be ‘different’ about ICSs?

First, the concept of equal partnership between the NHS, local government, voluntary sector ...

Evaluation of the North West London Diabetes Foot Care Transformation Project: A Mixed-Methods Evaluation

Diabetes foot ulceration presents an enormous burden to those living with diabetes and to the local health systems and economies. There is an increasing interest in implementing integrated care models to enhance the quality of care for people living with diabetes and related complications and the value of co-production approaches to achieve sustainable change.

This paper aims to describe the evaluation methodology for the North West London Diabetes Foot Care Transformation project.

Development of a Blueprint for Integrated Care for Vulnerable Pregnant Women

There has been increasing awareness of perinatal health and organisation of maternal and child health care in the Netherlands as a result of poor perinatal outcomes. Vulnerable women have a higher risk of these poor perinatal outcomes and also have a higher chance of receiving less adequate care. Therefore, within a consortium, embracing 100 organisations among professionals, educators, researchers, and policymakers, a joint aim was defined to support maternal and child health care professionals and social care professionals in providing adequate, integrated care for vulnerable pregnant women.

The Care Coordinator’s Tasks During the Implementation of an Integrated Care Pathway for Older Patients: A Qualitative Study Based on the French National “Health Pathway of Seniors for Preserved Autonomy” Pilot Program

Although integrated care and care coordination are known to be beneficial for older adults’ population, the specific tasks of a Care Coordinator (CC) for integrated care pathways for this population have not been studied in detail. In this study, the CC’s tasks in an integrated care pathway for older adults shows that the CC’s overall workload was greater than expected and appreciated by healthcare professionals.

Care for caregivers- a mission for primary care

The number of elderly people living in the community who are limited in daily activities is increasing worldwide. This generates prolonged care, which usually falls on one family member, the family caregiver. Caregivers are prone to develop psychosocial and physical symptoms. As a result, the World Health Organization (WHO) issued a clear directive to assess and support these caregivers. The main goals of this study were to assess primary care physicians’ (PCP) awareness to caregivers’ health risks and the extent that they recommended preventive measures to maintain the health of the caregivers. Although a high percentage of physicians were aware ...

Rehabilitation Workforce Challenges to Implement Person-Centered Care

There is an increasing emphasis on developing person-centered care in rehabilitation settings. However, this care practice has not been fully implemented due to several factors. This study explores rehabilitation workforce perspectives on the barriers and facilitators to implementing person-centered care (PCC). Participants described barriers such as an unsupportive organization and leadership, staff constraints, heavy workload, and resistance to change. Unique to this study, a patient’s clinical characteristics were identified as barriers to person-centered care. As facilitators, they described leadership, staff satisfaction, a positive physical environment, training and education, and shared decision-making. It is essential to understand the perceptions of ...