A realist evaluation of local networks designed to achieve more integrated care

© 2019 The Author(s). Introduction: Not surprisingly given their multi-component nature, initiatives to improve integrated care often evolve to find the best way to bring about change. This paper provides an example of how an evaluation evolved alongside such an initiative designed to better integrate care across primary, community and hospital services in South Auckland, New Zealand. Theory and methods: Using the explanatory power of a realist evaluative approach, theories of new ways of working that might be prompted by the initiative were explored in: (i) interviews with stakeholders in 2012 and 2015, (ii) online surveys of general practices and local care organisations, and (iii) a purposive sample of ten general practices. Results: The results highlighted the institutional contexts that led to difficulties in implementing population health initiatives. They also revealed that changes in work practices focussed mostly on activities that improved the coordination of care for individuals at risk of hospital admissions. Discussion: Multi-component complex interventions can vary in their delivery and be vulnerable to one or more components not being implemented as originally intended. In the case of this intervention, the move towards strengthening local relationships arose when contractual arrangements stalled. Realist evaluative approaches offer a logic that helps unpick the complexity of the relationships and politics in play, and uncover the assumptions made by those developing, implementing and assessing health service changes. Conclusion: Given the multi-component and evolving nature of initiatives seeking to better integrate care, the realist evaluative emphasis on surfacing early the theories to explain how change is expected to occur helps overcome the challenge of evaluating “a moving targetA..

A realist evaluation of local networks designed to achieve more integrated care

© 2019 The Author(s). Introduction: Not surprisingly given their multi-component nature, initiatives to improve integrated care often evolve to find the best way to bring about change. This paper provides an example of how an evaluation evolved alongside such an initiative designed to better integrate care across primary, community and hospital services in South Auckland, New Zealand. Theory and methods: Using the explanatory power of a realist evaluative approach, theories of new ways of working that might be prompted by the initiative were explored in: (i) interviews with stakeholders in 2012 and 2015, (ii) online surveys of general practices and local care organisations, and (iii) a purposive sample of ten general practices. Results: The results highlighted the institutional contexts that led to difficulties in implementing population health initiatives. They also revealed that changes in work practices focussed mostly on activities that improved the coordination of care for individuals at risk of hospital admissions. Discussion: Multi-component complex interventions can vary in their delivery and be vulnerable to one or more components not being implemented as originally intended. In the case of this intervention, the move towards strengthening local relationships arose when contractual arrangements stalled. Realist evaluative approaches offer a logic that helps unpick the complexity of the relationships and politics in play, and uncover the assumptions made by those developing, implementing and assessing health service changes. Conclusion: Given the multi-component and evolving nature of initiatives seeking to better integrate care, the realist evaluative emphasis on surfacing early the theories to explain how change is expected to occur helps overcome the challenge of evaluating “a moving targetA..

The vulnerability of the family: reflections about human condition

ABSTRACT Objectives: to reflect about the vulnerability of the family, using the book The Human Condition by Hannah Arendt as reference, to better understand how this institution has been structured in today’s world. Results: the rupture of assistance relations among family members represents a situation of vulnerability that weakens the family institution, leading to the loss of the assertiveness in the society. Support for the development of human capabilities in families and in the territory provides the benefit of strengthening them to face of vulnerabilities. Conclusions: the vulnerability of the family presents itself as a historic milestone, condition on which the family institution was built and organized as a public and private property, putting in evidence the importance to develop a more holistic and integrate care to the people, based on health public policies and social assistance.

Integrating health and social care in Brazil

Integrating health and social care is now a high priority for public health policy in high-income countries. It has received much less attention in low and middle-income country (LMIC) settings. There is particular value in assessing the potential to integrate care services for older adults, given the speed of population ageing in LMICs. The presentation provides findings of process and impact evaluations of novel local government initiatives to integrate care for older people in Brazil (drawing on a study co-funded by the UK MRC and CONFAP Brazil). Programa Maior Cuidado (PMC) was established in the Brazilian city of Belo Horizonte in 2011. It is jointly managed by the departments of health and of social assistance and involves close community-level collaboration between health posts and neighbourhood social service centres. A key element of PMC is the provision of paid trained lay carers to support family care for dependent older people in socially vulnerable families. We will present findings on the implementation process and operation of PMC, as well as its effects on the following outcomes of interest: reduced unnecessary hospitalisations, enhanced health status for older people and reduced care burden for family carers. Quasi-experimental analysis using spatial-based Propensity Score Matching shows promising results in terms of increasing planned attentions as well as access to rehabilitation services, which confirms the ability of the Program to improve interface with health services avoiding unplanned unnecessary attentions We will examine the implementation of similar interventions in other Brazilian cities, including Fortaleza and Contagem, and will study the role of national and international processes in dissemination, knowledge sharing and agenda-setting. Key messages The presentation provides findings of process and impact evaluations of novel local government initiatives to integrate care for older people in Brazil. Programme under evaluation lead to interesting outcomes of interest: reduced unnecessary hospitalisations, enhanced health status for older people and reduced care burden for family carers.

Strange Bedfellows: Coordinating Medicare and Medicaid to Achieve Cost-Effective Care for Patients with the Greatest Health Needs

This perspective describes federal efforts in the United States (U.S.) to integrate care for an especially complex, vulnerable, and costly patient population: adults eligible for both Medicare and Medicaid insurance. The goal of the paper is to demystify for clinical policy leaders and practicing clinicians the origins and evolution of the Dual-Eligible Special Needs Plans (D-SNPs) recently permanently authorized by the U.S. Congress and to explore the potential for these policy changes to help such health plans improve care for the sickest and most vulnerable Americans.

Interventions to integrate care for people with serious mental illness and substance use disorders: a systematic scoping review protocol

IntroductionPeople with serious mental illness (SMI) and/or substance use disorders (SUDs) have an elevated risk of premature mortality compared with the general population. This has been attributed to higher rates of chronic illness among these individuals, but also to inequities in healthcare access and treatment. Integrated care has the potential to improve the health of people with SMI/SUDs. The aims of this scoping review are to: (1) identify empirical investigations of interventions designed to integrate care for people with SMI/SUDs; (2) describe the underlying theories, models and frameworks of integrated care that informed their development; and (3) determine the degree to which interventions address dimensions of a comprehensive and validated framework of integrated care.Methods and analysisGuidelines for best practice and reporting of scoping reviews will be followed using the framework of Arksey and O’Malley and the Preferred Reporting Items for Systematic Reviews and Meta-Analyses scoping review checklist. An iterative and systematic search of peer-reviewed publications reporting empirical research findings will be conducted. This literature will be identified by searching five databases: Medline (Ovid), PsycINFO, CINAHL, Embase (Ovid) and Scopus. The search will be restricted to articles published between January 2000 and April 2019. Two reviewers will independently screen publications in two successive stages of title and abstract screening, followed by full-text screening of eligible publications. A tabular summary and narrative synthesis will be completed using data extracted from each included study. A framework synthesis will also be conducted, with descriptions of interventions mapped against a theoretical framework of integrated care.Ethics and disseminationThis review will identify the extent and nature of empirical investigations evaluating interventions to integrate care for people with SMI/SUDs. Ethical approval was not required. A team of relevant stakeholders, including people with lived experience of mental health conditions, has been established. This team will be engaged throughout the review and will ensure that the findings are widely disseminated. Dissemination will include publication of the review in a peer-reviewed journal. The review protocol has been registered through Open Science Framework and can be accessed athttps://osf.io/njkph/