Exploring improvement plans of fourteen European integrated care sites for older people with complex needs

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Tilburg University

Exploring improvement plans of fourteen European integrated care sites for older

people with complex needs

Stoop, H. J. ; de Bruin, S. R.; Wistow, G.; Billings, J.; Ruppe, G.; Leichsenring, K.; Obermann,

K.; Baan, C. A.; Nijpels, G.

Published in:

Health Policy

DOI:

10.1016/j.healthpol.2019.09.009

Publication date:

2019

Document Version

Publisher's PDF, also known as Version of record

Link to publication in Tilburg University Research Portal

Citation for published version (APA):

Stoop, H. J., de Bruin, S. R., Wistow, G., Billings, J., Ruppe, G., Leichsenring, K., Obermann, K., Baan, C. A., &

Nijpels, G. (2019). Exploring improvement plans of fourteen European integrated care sites for older people with

complex needs. Health Policy, 123(12), 1135-1154. https://doi.org/10.1016/j.healthpol.2019.09.009

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HealthPolicy123(2019)1135–1154

ContentslistsavailableatScienceDirect

Health

Policy

jo u rn al h om ep a g e :w w w . e l s e v i e r . c o m / l o c a t e / h e a l t h p o l

Exploring

improvement

plans

of

fourteen

European

integrated

care

sites

for

older

people

with

complex

needs

Annerieke

Stoop

a,b,c,∗

_,

_Simone

_R.

_de

_Bruin

a

_,

_Gerald

_Wistow

d

_,

_Jenny

_Billings

e

_,

Georg

Ruppe

f

_,

_Kai

_Leichsenring

f,g

_,

_Konrad

_Obermann

h

_,

_Caroline

_A.

_Baan

a,c

_,

_Giel

_Nijpels

b

a_Centre_for_Nutrition,_Prevention_and_Health_Services,_National_Institute_for_Public_Health_and_the_Environment,_Bilthoven,_the_Netherlands

b_Department_of_General_Practice_and_Elderly_Care_Medicine,_Amsterdam_Public_Health_Research_Institute,_Amsterdam_UMC,_Vrije_Universiteit_Amsterdam, Amsterdam,theNetherlands

c_Scientiﬁc_Center_for_{Transformation}_in_Care_and_Welfare_(Tranzo),_University_of_Tilburg,_Tilburg,_the_Netherlands

d_Personal_Social_Services_Research_Unit,_Department_of_Social_Policy,_London_School_of_Economics_and_Political_Science,_London,_UK e_Centre_for_Health_Service_Studies,_University_of_Kent,_Canterbury,_UK

f_Austrian_{Interdisciplinary}_Platform_on_Ageing_(ÖPIA),_Vienna,_Austria g_European_Centre_for_Social_Welfare_Policy_and_Research,_Vienna,_Austria h_Mannheim_Institute_of_Public_Health_(MIPH),_Heidelberg_University,_Germany

a

r

t

i

c

l

e

i

n

f

o

Articlehistory:

Received8February2019 Receivedinrevisedform 16September2019 Accepted17September2019 Keywords:

Olderpeople Integratedcare

Expandedchroniccaremodel Broadly-basedprevention

a

b

s

t

r

a

c

t

Integratedcareprogrammesareincreasinglybeingputinplacetoprovidecaretoolderpeoplelivingat home.However,knowledgeaboutfurtherimprovingintegratedcareislimited.Infourteenintegratedcare sitesinEurope,planstoimproveexistingwaysofworkingweredesigned,implementedandevaluated toenlargetheunderstandingofwhatworksandwithwhatoutcomeswhenimprovingintegratedcare. Thispaperprovidesinsightintotheexistingwaysthatthesiteswereworkingwithrespecttointegrated care,theirperceiveddifficultiesandtheirplansforworkingtowardsimprovement.Theseven compo-nentsoftheExpandedChronicCareModelprovidedaconceptualframeworkfordescribingthefourteen sites.AlthoughsiteswerespreadacrossEuropeanddifferedinbasiccharacteristicsandexistingwaysof working,anumberofdifficultiesindeliveringintegratedcareweresimilar.Existingwaysofworkingand improvementplansmostlyfocusedonthreecomponentsoftheExpandedChronicCareModel:delivery systemdesign;decisionsupport;self-management.Twocomponentswererepresentedlessfrequently inexistingwaysofworkingandimprovementplans:buildinghealthypublicpolicy;buildingcommunity capacity.Thesefindingssuggestthatbroadly-basedpreventionefforts,populationhealthpromotionand communityinvolvementremainlimited.FromtheExpandedChronicCareModelperspective,therefore, opportunitiesforimprovingintegratedcareoutcomesmaycontinuetoberestrictedbythenarrowfocus ofdevelopedimprovementplans.

ThispaperwaspublishedonbehalfoftheSUSTAINconsortium:BorjaArrue,ElivaAtienoAmbugo,CarolineBaan,JennyBillings,SimonedeBruin,MicheleCalabro,Nuri CayuelasMateu,SandraDegelsegger,MireiaEspallarguesCarreras,EricaGadsby,NickGoodwin,TerjeHagen,ChristinaHäusler,ViktoriaHoel,HenrikHoffmann,Usman Khan,JulieMacInnes,FedericaMargheri,JennaMcArthur,MaggieLangins,ManonLette,LinaMasana,MirellaMinkman,GielNijpels,KonradObermann,GerliPaat-Ahi,Jillian Reynolds,MariRull,GeorgRuppe,MoniqueSpierenburg,AnneriekeStoop,LianStouthard,NhuTram,GeraldWistowandNickZonneveld.

∗ Correspondingauthorat:NationalInstituteforPublicHealthandtheEnvironment(RIVM),POBox1,3720BABilthoven,TheNetherlands.

E-mailaddresses:annerieke.stoop@rivm.nl,anneriekestoop@hotmail.com(A.Stoop),simone.de.bruin@rivm.nl(S.R.deBruin),G.Wistow@lse.ac.uk(G.Wistow),

J.R.Billings@kent.ac.uk(J.Billings),ruppe@oepia.at(G.Ruppe),leichsenring@euro.centre.org(K.Leichsenring),konrad.obermann@medma.uni-heidelberg.de(K.Obermann),

caroline.baan@rivm.nl(C.A.Baan),g.nijpels@amsterdamumc.nl(G.Nijpels).

https://doi.org/10.1016/j.healthpol.2019.09.009

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1136 A.Stoop,S.R.deBruin,G.Wistowetal./HealthPolicy123(2019)1135–1154 1. Introduction

An increasing number of older people with complex needs liveintheirhomesandcommunitiesintotheirlaterlives.Their complexneedsrequiremultidisciplinarycollaborationtooptimise theeffectivenessofassessmentandcarecoordinationprocesses. Integratedhealthandsocialcaremodelsappeartoprovide promis-ingapproachesfororganisingcontinuous,person-centredcarefor olderpeoplewithcomplexneedslivingathome[1–6].Wedeﬁne integratedcareasthoseinitiativesthatproactivelyseekto struc-tureandcoordinatecareandsupportaroundolderpeople’sneeds andintheirhomeenvironments[3–5,7–10].Numerousintegrated careinitiativestargetedatolderpeoplehavebeenimplementedina widerangeofsettingsandcontexts,inandoutsideEurope[11–14]. Integratedcaredeliveryisexpectedtohaveapositiveimpact onthequalityofcareand outcomesfor olderpeople,including improvedsatisfactionwithcare[15,16]andpsychologicalhealth orwellbeing[17].However,empiricalevidenceforthe effective-nessandcost-effectivenessofintegratedcareisstillinconclusive, partly due tothe heterogeneous nature of theintegrated care sitesand/ortheuseof differentoutcomemeasures[5,18,19]. In additiontoimplementingnewcaremodels,literatureshowsthat improvementstoexistingservicesarenecessarytoenhancetheir effectivenessandfurtherimproveintegratedcare[12,18,20–23]. Thisalsoincludestheneedforagreaterfocusonpopulationhealth promotioninintegratedcareprogramsforolderpeople[24].Yet, knowledgeofhowtoimplementsuchimprovementssuccessfully remainslimited,asisknowledgeofhowtotransfergoodpractices andexperiencestoothercontexts[25].

This paper reports from the cross-national research project ‘SUSTAIN’(SustainableTailoredIntegratedCareforOlderPeople inEurope)[26],whichaimstoaddresstheabovechallengesand toaccelerateimprovementsinintegrated careforolderpeople. Intheproject,establishedintegratedcaresitesforolderpeople agreedtoworkwithSUSTAINresearcherstodevelopand imple-mentplansdesignedtoimprovetheirexistingwaysofworking. Throughouttheproject,SUSTAINresearchersfollowedupand eval-uatedthedesignandimplementationprocessesandoutcomesof improvementplansforeachsite,ofwhichfindingswerereported elsewhere[27–33].Throughstudyingdifferenttypesofintegrated caresitesacrossdifferentEuropeancountriesandsettingstogether, theSUSTAINprojectaimedtoenhanceunderstandingofwhatdoes anddoesnotworkandwithwhatspecificoutcomesforintegrated careacrossarichandvariedfieldofpracticalexamples.Thereby, SUSTAINintendstoprovidethebasisforthetransferand applica-tionoflearningaboutimprovingintegratedcareacrossEuropeand elsewhere.

Inordertounderstandoutcomesandprogressofimplementing improvementsintheintegratedcaresites,asaﬁrststep,insight intotheexistingwaysofworkingofthesitesandcontentoftheir improvementplansisessential.Theaimsofthispaperare there-fore:(i)describingandcomparingthecharacteristicsandexisting waysofworkingoftheintegratedcaresitesparticipatingin SUS-TAIN,(ii)describingandcomparingperceivedlimitationsintheir existingwaysofworking,and(iii)describingandcomparingthe contentofimprovementplansdrawnupbyeachintegratedcare siteinSUSTAIN.

2. Methods 2.1. Studydesign

Fourteenestablishedintegratedcaresiteswereselected-and agreed-toparticipateintheSUSTAINproject.Theintegratedcare siteswerelocatedinsevenEuropeancountries:Austria,Estonia,

Germany,Norway,Spain,theNetherlandsandtheUnitedKingdom. Criteriafortheirselectionincludedaprimaryfocusonolderpeople livingathomewithcomplexneedsandtheinvolvementof profes-sionalsfrommultiplehealthandsocialcaredisciplines.Inaddition, sitesshouldbewillingand committedtoimprovetheircurrent practiceby workingtowards more person-centred, prevention-oriented,safeandefﬁcientcare[26].Priortothestartoftheproject, SUSTAINresearchersinvitedintegratedcaresitesintheircountries, knowntobecommittedtoimprovingexistingwaysofworking,to participateinSUSTAIN.Mostsiteshadalongstandingpartnership withoneoftheSUSTAINresearchers.

Local SUSTAIN researchpartners collaborated with thesites in each countryto design and eventually implement improve-mentplansover an18-monthperiod.Improvement planswere co-createdby local stakeholders and SUSTAIN researchers, and shapedby localstakeholder prioritiestoimprovecurrent prac-ticeintheirownsite.Noadditionalresourcesweremadeavailable fromtheSUSTAINprojecttocontributetofundingforthecostsof implementingtheplansinthesites.

TheSUSTAINprojectteamcomprisedtwogroupsofresearch partners:1)sevencountry-specificresearchteams,whofacilitated improvementprocessesin twositespercountryeach by bring-ing local stakeholders together and supportingthe design and implementationofimprovementplans.Country-specificresearch teamswerealsoresponsibleformonitoringtheprocesses associ-atedwithdesigningandimplementinglocalimprovementplans, andevaluatinghowthesetsofimprovementsimpactedoncare forolderpeople,alsoreferredtoas‘site-specificevaluations’;and 2) a group of research partners responsible for the ‘overarch-inganalysis’throughwhichfindingsfromsite-specificevaluations undertakeninthefourteensiteswerecomparedandcontrasted toidentifyrecurringpatternsin thedesignand implementation ofintegratedcareimprovements[34].Thelatterteamalsoledthe draftingofthispaper.

2.2. Dataanalysis

Toobtaininsightintheexistingwaysofworkingand character-isticsofthesites,theirperceivedlimitationsandtheimprovement plans,allcountry-speciﬁcresearchteamswereresponsiblefordata collectionandanalysisintheirownsites.Theyperformedthisin theirownlanguage.Basedonthesesite-speciﬁcevaluations,they produced threesets ofdocumentsin English.Assuch, for each individualsite,thefollowingdocumentswereproduced:

(i)Baselinereports:providinginsightintothecharacteristicsof eachintegratedcaresite,theirperceiveddifﬁcultiesand limi-tationsregardingtheirexistingwaysofworking,andpotential areasforimprovement[35].

(ii)Project plans: providing details on thecontent and imple-mentationoftheimprovementplan.Theplansincludedthe sites’ambitionsandrationaleforimprovingcurrentpractice, togetherwiththeactionsandresourcesrequiredtoimplement it.

(iii)Flowcharts:depictingtheexistingwayofworkingandhow theimprovementplanwouldmodifyit.

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A.Stoop,S.R.deBruin,G.Wistowetal./HealthPolicy123(2019)1135–1154 1137 purposeofthethreesetsofdocumentscanbefoundinanonline

AppendixA.Becauseoflanguagebarriers,thegroupofresearch partnersresponsibleforthe‘overarchinganalysis’wasnotableto analysesite-specificdata.Theyinsteadcarriedoutcontent anal-ysisofthethreesetsofdocumentsproducedforeachsitebythe country-specificresearchteamsforthecurrentpaper.The overar-chinganalysisteamreviewedalldocumentstodescribe,compare andcontrastthecharacteristicsandexistingwaysofworkingofthe integratedcaresites,theirperceptionsofdifficultiesandlimitations regardingtheircurrentpractice,andthecontentofimprovement plansofthosesites.

In the content analysis, the Expanded Chronic Care Model (ECCM)wasusedtoprovideaconceptualframeworkforanalysing andcomparingtheexistingwaysofworkingandtheimprovement plansofthefourteenindividualsitesinaconsistentand system-aticway.TheECCMisadevelopmentoftheChronicCareModel (CCM),wherethelatterisawell-knownmodelthatdescribesthe essentialelementsofaproactivehealthsystemcapableof improv-ingthequalityofcareforpeoplewithchronicdiseases[3,36,37]. TheCCMfocusedonfourcomponentsofintegratedworking: self-managementsupport;deliverysystemdesign;decisionsupport;and clinicalinformationsystems.Barretal.arguedthat theCCMwas developedwithin atoonarrow paradigmandthat itshouldbe extendedtoincorporateabroadly-basedfocusonpreventionby includingthesocialdeterminantsofhealth,andtheprinciplesof healthpromotionaswellasclinicalpreventionservices[7].Asa result,Barretal.developedtheECCMbyaddingthreefurther com-ponents:buildhealthypublicpolicy;createsupportiveenvironments; andbuildcommunitycapacity[7].

TheECCMwasusedforanalysingexistingwaysofworkingand contentsofimprovementplans.Thissoughttoprovideinsightinto theextenttowhichexistingwaysofworkingandtheimprovement plansofthedifferentsiteswereinalignmentwiththe conceptual-isationsandambitionsoftheECCM.Forthepurposeofthisstudy, thecomponentsoftheECCMwereadoptedtoprovideacommon frameworkforidentifyingcorecharacteristicsofthefourteen inte-gratedcaresites.ThedescriptionsofthecomponentsoftheECCM fromtheoriginalresearchweresubjecttolimitedrevisionfor adop-tionwithin theSUSTAINprojectwith itsspeciﬁcfocus oncare andsupportforolderpeoplelivingathomewithcomplexneeds (Table1)[7].TheECCMwasnotusedasthebasisorcriteriafor designingtheimprovementplans.

Forthisstudy,contentanalysiswasconductedindifferentsteps, basedonbothadeductiveandinductiveapproach:

(i)Relevantdataontheexistingwaysofworkingandthe improve-mentplanswereextractedfromthethreesetsofdocuments. Informationabouttheexistingwaysofworkingandthecontent oftheimprovementplansforeachsitewerecodedaccording totheindividualECCMcomponents(i.e.deductiveapproach): self-managementsupport;deliverysystemdesign;decision sup-port; clinicalinformation systems; buildhealthy public policy; create supportive environments; and build community capac-ity.CodeddataallocatedtoeachECCMcomponentwerethen examinedinordertoidentifyanddeﬁnerecurringpatternsin theactivitiesacrossthesites.WithineachECCMcomponent, activitieswerethenclusteredintoanumber ofmain activi-ties(perECCMcomponent)tofacilitatedatainterpretation(i.e. inductiveapproach).Thesemainactivitieswillbedescribedin theResultssection(andtheTables).

(ii)Alsorelevantdataontheperceiveddifficultieswereextracted fromthethreesetsofdocuments.Datawerethenexaminedin ordertoidentifyanddefinerecurringpatternsacrossthesites (i.e.inductiveapproach).Thedifficultieswereclusteredinto fivesubcategories,whicharedescribedintheResultssection.

Theresultsobtainedfromthisanalyticalprocesswerereviewed bytwomembersoftheresearchteamresponsibleforthe overarch-inganalysis(ASandGW).Aftertheinitialanalyseswereconducted, ASconsultedmembersofthecountry-specificresearchteamsto verifytheirinterpretationofsite-specificanalysisresults.Thiswas donebysharinganddiscussingthetableswithinterpreteddata withthemembersofthesecountry-specificresearchteamsattwo timepoints.Theseconsultationstookplaceface-to-face(first iter-ation)andbye-mailandtelephonecalls(seconditeration).Based ontheseconsultations,ASandGWrestructuredandsupplemented theanalyseswherenecessary.

3. Results

3.1. Characteristicsandexistingwaysofworkingofintegrated caresites

Theintegratedcaresitesprovideddifferenttypesofcareand supportservicesincludinghomenursingandrehabilitativecare, proactiveprimarycareforfrailolderpeople,dementiacare,care forolderpeoplebeingdischargedfromhospital,andpalliative(end oflife)care(Table2).Caresettingsandthetypeandnumberof providersvariedacrosssites.Someconsistedexclusivelyofmedical professionals,whereasothersinvolvedbroadlyequalnumbersof healthandsocialcareprofessionals.Stafﬁngpatternswerebroadly similarinindividualsitesprovidingthesametypesofcareand sup-portservices.Forinstance,inallproactiveprimarycaresites,at leastoneGPandone(practice)nursewereinvolved.

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1138 A.Stoop,S.R.deBruin,G.Wistowetal./HealthPolicy123(2019)1135–1154

Table1

ComponentsoftheExpandedChronicCareModel[7].

ComponentsoftheECCM Description Self-management/developpersonal

skills

Supportofself-managementincopingwithproblemsolderpeoplemayexperienceindifferentdomains(spheres)of theirlives(includingphysical,cognitive,psychological,socialandenvironmentaldomains)anddevelopmentof personalskillsforhealthandwellbeing(e.g.self-helpgroups)

Decisionsupport Aligningstrategiesofallorganisationsinvolved(e.g.healthcare,socialcare,communityandvoluntaryorganisations) fordealingwithproblemsolderpeoplemayexperienceindifferentdomainsoftheirlivesandsupportingtheirhealth andwellbeing(e.g.trainingofstafftoworkwithcommontoolstosystematicallyassessolderpeople’sneeds) Deliverysystemdesign/re-orient

healthservices

Re-orientationofhealthservicestowardsadoptionofabroaderhealthpromotionrolealongsidetheprovisionof clinicalandcurative(i.e.medical)servicestoprovideacomprehensiveapproachtohealthandwellbeingofolder people(e.g.addresssocialdeterminantsofhealthandprovidetimely,interdisciplinarycareandsupportasnecessary) Informationsystems Creationofmorecomprehensivesystemsforinformationsharingtoincluderelevantdatabeyondthehealthcare

system(e.g.electronicdossieraccessibletoallinvolvedcareandsupportorganisations)

Buildhealthypublicpolicy Developmentandimplementationofpoliciesdesignedtoimprovehealthandwellbeingofolderpeople(e.g.health andwellbeingimpactonolderpeopleofallrelevantpublicpolicies)

Createsupportiveenvironments Generationoflivingconditionsthataresafe,stimulating,satisfyingandenjoyable(e.g.effortstomaintainolder peopleintheirhomesforaslongaspossible)

Buildandstrengthencommunity capacityandaction

Supportofcommunitycapacity-buildingsothatcommunitiesareabletoinitiate,shapeanddeliverinterventionsand environmentswhichdirectlycontributetotheirmembers’healthandwellbeing,andstrengtheningrelationships betweenstatutoryagenciesandcommunitygroupsandvoluntaryandcharityorganisationsbycollaboratingtoset prioritiesandachievegoalsthatcontributetocommunityhealthandwellbeing(e.g.collaborationwithvoluntaryand charityorganisations).

policies,for instance through participationin national working groupsandnetworks,orbyprovidingservicedevelopment exem-plarsthroughtheirstatusaspilotprojects.Informationsystemswere inplaceinsomesites.However,nonehadcreatedacomprehensive informationsystemincludingalltheparticipatingcareandsupport organisations.Instead,professionalsfromthesamesectorusually exchangedinformationaboutserviceusersusinge-mail,electronic messagingsystemsorelectronicpatientrecordsystems.

3.2. Perceiveddifﬁcultiesintheexistingwaysofworking

Severalcommondifficultiesassociated withexistingways of working were reported across the fourteen sites during inter-viewsandworkshopmeetingswithlocalstakeholdersfromthe sites.Theimportanceofthedifficultiesforthesiteswashighly context-dependent.Table4showshowweclusteredthemintofive categories.Thefirst,mentionedinalmostallsites,wasthe diffi-cultytheyencounteredinsecuringcoordinationandcollaboration amongtheorganisationsandprofessionalsparticipatinginthesite. Thiscategoryincludedsomeverybasicbarrierssuchastheabsence ofsustainableandclearagreementsaboutrolesandresponsibilities oforganisationsandtheirprofessionalstaff.Inaddition,alackof knowledgeaboutandtrustinareasofexpertiseofdifferenthealth andsocial careproviderswereobserved.Co-operationbetween organisationsprovidingserviceswithinthesamecaresetting(e.g. primarycare)wasconsideredeasierthanco-operationbetween organisationsfromdifferentcaresettings.Becauseofdifferences inculturesandvisionsoforganisations,stakeholdersfromsome sitesspecificallyreportedthatcollaborationwithexternal stake-holders,forinstancewiththecommunityandsocialcaresectors, wasweakornotyetinplacedespitetherecognisedimportanceof assessingandaddressingthebroadrangeofolderpeople’sneeds.

Asecondfrequentlyreporteddifficultywasthelackof infor-mationsharingwithinand betweenorganisations. Theabsence ofsharedITsystemsorincompatibilitiesbetweensystems com-plicated information flows and contributed to restricted levels ofcommunication and collaborationbetweenprofessionals and organisations.Athirddifficultyrelatedtolimitedresourcesand support,andparticularlyhavingtorelyontemporaryfundingfor integratedcaresiteswithalltheuncertaintiesabouttheirlonger termfuture whichaccompaniedsuchfunding.Itsconsequences influencedlevelsofstaffrecruitmentandretention.Furthermore, financialbarriersbetweenthehealthandsocialcaresectorswere perceivedasmajorobstaclesfor workinginan integratedway.

Stakeholdersfromdifferentsitesindicatedthatthesebarrierscould bepartlyduetoabsenceofvisiononintegratedworkingand com-mitmenttoremovingoratleastminimisingﬁnancialbarriersat national,regionalandlocallevels.

Afourthdifficultyfloweddirectlyfromthethirdintheshape oftheimpactofstaffshortagesinhealthandsocialcare. Profes-sionalsreportedheavyworkloads,andsawthisfactorasonewhich limitedtheirmotivationandcapacitytoparticipateintraining pro-grammes.Afinalareaofdifficultywasindevelopingbetterquality person-centredpractice.Particularinstancesincludedlimited com-municationwitholderpeopleandtheirinformalcaregivers,lack ofshared-decisionmaking,anddifficultiesintailoringservicesto theneedsandpreferencesoftheolderperson.Possible explana-tionsgivenbylocalstakeholderswereprofessionals’limitedtime availabilityandlackofknowledge.Thefundamentalnatureofthese limitationssuggestedperson-centredpracticeinatleastanumber ofsiteswasatafairlyearlystageofdevelopment.

3.3. Improvementplans

Inallsites,localsteeringgroupsweresetup.Steeringgroups consistedofstakeholderswhoparticipatedintheinterviewsand workshop meetingstogether withadditional localstakeholders whoseparticipationwasconsideredrelevant.Duringoneorseveral meetings,dependingonthesite,membersofthesesteeringgroups designedimprovementplanswithsupportfromcountry-specific researchteams.Sitesdifferedintheextenttowhichdiscussinglocal improvementprioritiesanddesigningtogetherimprovementplans wasastraightforwardprocess.Mostsitesbasedtheirimprovement plansonthedifficultiestheyhadidentifiedduringinterviewsand workshopswiththeirresearchpartners.However,asmallnumber ofsitesdraftedplansfocusedonissuesthatwerebasedon pre-existingissuesidentifiedbymanagersbeforetheworkshopstook place.Table5presentstwelveimprovementplansincludingtheir objectivesand plannedactionsandactivitiesforrealisingthem. TwositesdecidedtowithdrawfromtheSUSTAINprojectbefore thecompletionofthedesignoftheirimprovementplan(WICM andCPC).Theyfeltunabletodesignaplanwitharealisticprospect ofimplementationduetolimitedstaffing,restrictedtimeandalack ofsupportfromstakeholders.

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A.Stoop,S.R.deBruin,G.Wistowetal./HealthPolicy123(2019)1135–1154 1139

Table2

Characteristicsoftheintegratedcaresites.

Country Integratedcaresite Typeofcareservices Objectiveofsite Providersinvolved Austria _(GPC)GerontopsychiatricCentre Dementiacare _suspectedTosupport_ofolder_sufferingpeople_fromsuffering_mainlyor

cognitivepsychiatricdisordersand theirinformalcaregiverstoliveat homeforaslongaspossible.

• GerontopsychiatricCentreis afﬁliatedtothePsychosocial Servicesunitwhichispartofthe municipalityinViennacoordinating careandsupportservices. • Teamconsistsofpsychiatrists,

psychologists,nursesandsocial workers,andreferspeopletoawide rangeofhealthandsocialcare organisationsprovidingcareand support.

CoordinatedPalliativeCare (CPC)

Palliativecare Toprovideintegratedpalliativecare servicesinhospitalsandthe communitytoterminallyillpeopleand theirfamilymembers.

• CoordinatedPalliativeCareisa coordinatingorganisationandan organisationalunitoftheRegional HospitalHolding.Itcoordinates mobilepalliativecareteams (MPCTs),whichareafﬁliatedto homecareorganisationsand hospitals.

• MPCTsconsistofphysicians,nurses, socialworkers,therapists,dietitians, volunteers,coordinatorsand administratorsdependingonusers’ needs.

Estonia AlutaguseCareCentre(ACC) Home_{rehabilitative}nursing_careand _programmeToprovidea_fornursing₂₁_daysand_torehabilitative_support_and enableolderpeoplewithchronic conditions(e.g.CVD,diabetes)to returntotheirhomes.

• AlutaguseCareCentrestaffinclude nurses,socialworkers,PT,and professionalsprovidingpractical helpandsupport.

• Staffconsultlocalfamilydoctorsand medicalspecialistsfromthe hospitalswhenconsidered necessary.

Medendi(MED) Homenursing Toprovidenursingcareathometo improveandmaintainpeople’squality oflife.

• Medendiisahomecareorganisation whosestaffincludehomenurses. Germany KVRegioMedZentrum

Templin(RMZ)

Rehabilitativecare Toprovideathree-weekrehabilitative programmetoenablepeopletolive independentlyathome.

• RMZTemplinislocatedinan outpatientdepartmentinalocal hospitalandisrunbytheregional physicianassociation.

• RMZtreatmentbyPT,OT,speech therapist

• Professionalsinvolvedinthe programmearetherapists,GPsand casemanagers.

PﬂegewerkBerlin(PB) Homenursingand rehabilitativecare

Tocombineandaligndischarge management,long-termcare, therapies,andcasemanagementto supportolderpeopletolive independentlyathome.

• PﬂegewerkBerlinislong-termcare facilityprovidinghomenursingand rehabilitativecareinvolving therapists(PT,OT,speechtherapist), long-termcarenursesand volunteers.

• Therapistsandnursescollaborate withlocalGPswhoremain responsibleforpeople’scareand support.

Norway SurnadalHolistic PatientCareatHome(SUR)

Homenursingand rehabilitativecare

ToprovideinhabitantsofSurnadalin needofmunicipalhealthservices smoothtransitionbetweenhospital, institutional,andhomecare,andto supportthemtoliveathomeforas longaspossible.

• HolisticPatientCareatHome(HPH) ispartofSurnadal’smunicipal healthservicesandtheframework onwhichSurnadal’shomecare servicesaregrounded. • HolisticPatientCareatHomeisa

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1140 A.Stoop,S.R.deBruin,G.Wistowetal./HealthPolicy123(2019)1135–1154 Table2(Continued)

Country Integratedcaresite Typeofcareservices Objectiveofsite Providersinvolved SøndreNordstrandEveryday

MasteryTraining(SØN)

Rehabilitativecareandmastery ofactivitiesofdailyliving

Topromoteasenseofmasteryand independenceinactivitiesofdaily livingofresidentstoenablethemto liveathomeforaslongaspossible throughrehabilitativecareand trainingforaboutfourtosixweeks. Senseofmasteryconcernspersonal controloverthosecircumstancesthat areimportanttothelifeoftheolder people.Independenceconcernsability toliveasindependentlyaspossiblein theirownhomesandcommunities.

• EverydayMasteryTraining(EMT)is partofSøndreNordstrand’s municipalhealthservices,involving borough’sPrevention,Voluntary ServicesandPublicHealth departmentwhichclosely collaborateswithHomeServices department.

• EMTrehabilitationmultidisciplinary teamconsistsofPT,OT,nurses,and professionaltrainers.

Spain OsonaProgrammeforSevere ChronicPatients/Advanced chronicdisease/Geriatrics (OSO)

Proactiveprimaryand intermediatecare

Toimprovetheintegrationand coordinationofdifferentservicesand careprovidersinvolvedincareand supportforpeoplewithadvancedor complexchronicconditionsthrougha shared,individualisedcareplanamong healthprofessionalstoavoidhospital admissions,crisesandrisks,and enhanceperson-centrednessofcare

• OsonaProgrammeforSevere ChronicPatients/Advancedchronic disease/Geriatricsisa

hospital-basedprogramme involving:oneintermediateandone long-termcarehospitalwitha specialistgeriatricunit,which coordinatesthesite;theconsortium ofacutecarehospitalsofthearea; primarycarecentres(includingGPs andnurseswhoarespecialisedin geriatricpatients,andsocialworkers employedbyCatalanDepartmentof Health);andlocalgovernment/city councilsprovidingsocialservices, i.e.socialworkers,familyworkers, cleaners,technicaladaptions,etc. NorthSabadellsocialand

healthcareintegration(SAB)

Proactiveprimarycare Toprovideproactive,integrated, holisticcareandsupportforpeople withcomplexneeds.

• NorthSabadellSocialandhealth careintegrationinvolvesprimary (basic)socialservices,i.e.social workers,andprimaryhealthcare, i.e.GPandnurses,workingtogether inPrimaryCareCentres.

TheNetherlands West-Friesland_Model_(GCM) GeriatricCare Proactiveprimarycare _careToprovide_and_supportproactive_to_adequatelyandcoordinated_address needsoffrailolderpeoplelivingat home.

• GeriatricCareModelisaproactive caremodelimplementedamongGP practicesinWestFriesland,under theresponsibilityoftheregional umbrellaorganisationforprimary care.

• GPandpracticenursecollaborate withdifferenthealthcare professionals,suchaspharmacist, PT,OT,dietitian,elderlycare physician,casemanagerforpeople withdementiaandcommunity nurse,basedonolderpeople’sneeds. WalcherenIntegratedCare

Model(WICM)

Proactiveprimarycare Toaddressneedsoffrailolderpeople proactivelysotheycanliveathomefor aslongaspossible.

• WalcherenIntegratedCareModelis partofIntegratedCareFoundation Zeelandwhichcarriesoutmultiple healthcareprogrammes,oneof whichisWalcherenIntegratedCare ModelinvolvingseveralGP practices.

• GPandpracticenursecollaborate withhomecareorganisationsand consultwithcasemanagersfor peoplewithdementiaandsocial workers.

UnitedKingdom SandgateRoadOver75Service (O75)

Proactiveprimarycare Tosupportolderpeoplewith long-termconditionsandcomplex needstoliveindependentlyathome foraslongaspossibleandtoimprove thecoordinationofcareandsupport aroundthoseneeds.

• SandgateRoadSurgeryis accountabletoandfundedbythe regionalClinicalCommissioning Group,whichisanorganisationthat commissionslocalhealthcare services.

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A.Stoop,S.R.deBruin,G.Wistowetal./HealthPolicy123(2019)1135–1154 1141 Table2(Continued)

Country Integratedcaresite Typeofcareservices Objectiveofsite Providersinvolved SwaleHomeFirst(Dischargeto

Assess)(HF)

Hospitaldischargeplanning Tosupportthesafeandefﬁcient transferofpatientsneedingsupport and/orrehabilitationfromhospitalto home

• Thetransferofolderpeoplefrom hospitaltohomeismanagedbythe KentCountyCouncilintegrated dischargeteambasedinMedway hospital.

• TheyworkcloselywithMedway hospital’smultidisciplinaryward teams(nurses,OT,PT,clinicians),the VirginCareRapidResponseteam, andtheKentEnablementatHome (KEAH)service(providedbyKent CountyCouncil).

• KeystakeholdersalsoincludeSwale ClinicalCommissioningGroup(who commissionhealthcareservicesin thearea),andAgeUKandSwale BoroughCouncil,bothofwhich provideadditionalsupportservices forolderpeople.

PT:physicaltherapist;OT:occupationaltherapist;GP:generalpractitioner.

(i)Generalimprovementstolocalcapabilities forcoordination, collaboration and communication withother careand sup-portorganisationsandespeciallybyenhancingknowledgeand understandingofdifferentorganisations’rolesand responsi-bilities.Plansfocusedonbothinternalandexternalpartners withwhomcollaborationwasseentobesub-optimalor non-existent.Examplesofactivitiesoractionswere:meetingsto improve understandingsof professionals’roles andworking relationships including inter-professional training based on caseexamples.Thisfocusonimprovinginter-professional rela-tionshipswasexpectedtoimprovecaredeliveryprocessesat theclinicallevel.

(ii)Thesecondmainapproachtoimprovementintheplanswas tofocusmoredirectlyonimprovingspeciﬁccaredelivery pro-cesses.Someplansconcentratedonprovidingcareinamore person-centredway,whileothersfocusedonspeciﬁcaspects ofthecareprocesssuchasimprovingcasemanagementand arrangementsforhospitaldischarge.Otherexamplesincluded: organisingeffectivemeetingsbetweenhealthandsocialcare professionals, olderpeople and theirinformal caregivers to shapeandvalidatetheircareplans;andproviding rehabilita-tionservicesathomeinsteadofinaninstitution.

Fiveplans(SUR,SØN,OSO,SABandO75)coveredﬁveoutof sevenECCMcomponents,threeplans(ACC,PBand HF)covered fourcomponents,twoplans(GPCandMED)coveredthree compo-nents,andtwoplans(RMZandGCM)coveredtwocomponents.All improvementplansincludedactionsoractivitiesrelatedto deliv-ery systemdesign. Theseactivitiesincluded thedevelopmentof co-operationandcommunicationbetweenstaffofdifferent organ-isations and professions by, for example, conducting jointcare reviewsand establishingagreementsoninformation sharingfor individualpatients.Decisionsupportimprovementsweretargeted inmostimprovementplansandincludedproposalstoadoptnew needsassessmenttemplatesandjointcareplanningframeworks tosupportcomprehensiveandperson-centredwaysofworking. Trainingprogrammesforstaffworkingwithsuchtoolswerealso includedindecisionsupportimprovements.Asmallernumberof the improvement plans addressed self-management, strengthen-ingcommunityaction,informationsystemsandcreatingsupportive environments.Self-managementimprovementsprimarilybuilton currentwaysofworkingsuchastheprovisionofinformationand adviceabouttheavailabilityoflocalservices,andtheinvolvement ofolderpeopleandtheirinformalcaregiversinthedevelopmentof

theircareplans.Actionstobuildandstrengthencommunity capac-ityandactionincludeddevelopingthecapacityandcontribution ofvoluntaryorganisationstosupportintegratedcare.Information systemactivitiesincludedthedevelopmentorexpansionofaccess topaper-based orelectronicpatientrecordsfor existing and/or neworganisationsandprofessionals.Undertheheadingofcreating supportiveenvironments,oneprojectdesignedaresourcemapto expandaccesstoadviceandinformationservicesabout neighbor-hoodresources.

4. Discussion 4.1. Summaryofresults

Theaimofthis paperwastodescribeand compareexisting waysofworking,perceivedlimitationsandplansforimprovement among fourteen integrated care sites participatingin SUSTAIN. AlthoughthefourteensiteswerespreadacrosssevenEuropean countriesand,tovaryingdegrees,differedintheirbasic character-isticsandexistingwaysofworking,anumberofthedifficultiesand areasforimprovementwereverysimilar.Inmanysites,difficulties wereassociatedwithcoordination,collaborationand communi-cation(informationsharing)betweendifferenthealthandsocial care providers,togetherwithaspects offunding, staffing levels andperson-centredworking.Mostimprovementplanswerebased onthosedifficulties,althoughsomeplansfocusedonpre-existing issuesalreadyidentifiedbymanagersfromthesites.Similaritiesin theobjectivesofimprovementplanswerealsoobserved.Objectives ofimprovementplanscouldbegroupedaccordingtotwomajor emphases:1)improvingorexpandinginter-professional coordi-nation,collaborationandcommunicationamongcareandsupport organisationsinordertomorefullyengagetheminthesite,and2) improvingtheactualcaredeliveryprocessincludingmore atten-tiontoperson-centredworking.

4.2. Understandingtheseresultsinthecontextoftheintegrated careliterature

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com-1142 A. Stoop, S.R. de Bruin, G. Wistow et al. / Health Policy 123 (2019) 1135–1154 Table3

Existingwaysofworkingoftheintegratedcaresites.

Integratedcare site

Self-management Decisionsupport Deliverysystemdesign Informationsystems Buildhealthypublic policy

Createsupportive environments

Buildandstrengthen communitycapacityand action Gerontopsychiatric Centre(GPC) • Provisionof informationand advicetoolder people(dealing withdementia, relieving caregiver burden) • Trainingabout dementiaandadvice toexternal stakeholdersabout speciﬁcaspectsof practicewithinthesite

• Establishmentof multidisciplinaryteam • Developmentof

internalcaredelivery processes:needs assessments,case conferences,jointcare planning,referraltoa rangeofservices outsidetheteam, communicationand informationexchange betweenstaffand servicesoutsidethe team,olderpeopleand informalcaregivers N/A • Inﬂuenceon national/regional healthpolicies throughparticipation innationalworking group • Referralto organisationsthat arrangeprovisionof support,equipment andotherenablement servicestoolder peopletolive independentlyand safelyintheirown homes • Collaborationwith communitygroups includingpatient advocacyorganisation Coordinated PalliativeCare (CPC) • Engagementof olderpeopleand informal caregiversin careplanningto promoteshared decisionmaking • Provisionof information, adviceand supporttoolder peopleand informal caregiversto cover,for example,the terminalphase ofdiseasein home environments, copingwith stressandgrief

• Trainingofvolunteers aboutspeciﬁcaspects ofpracticewithinthe site

• Advicetoexternal stakeholdersabout speciﬁcaspectsof practicewithinthesite (24/7support)

• Establishmentof multidisciplinary teams

• Developmentof internalcaredelivery processes:needs assessments,support andguidancetoolder peopleandinformal caregiversinthe differentdomainsof life N/A • Inﬂuenceon national/regional healthpolicies throughparticipation innationalnetwork • Provisionofsupport, equipmentandother enablementservicesto olderpeopletolive independentlyand safelyinownhomes. • Arranginghomecare

andsupportat hospitaldischarge • Performanceofhome

safetyassessmentsto evaluatesafetyand appropriatenessof homeenvironmentat pointofhospital discharge • Collaborationwith communitygroups includingthehospice association coordinating volunteers

AlutaguseCare Centre(ACC)

N/A N/A • Establishmentof

multidisciplinaryteam • Developmentof

internalcaredelivery processes:case conferencing

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A. Stoop, S.R. de Bruin, G. Wistow et al. / Health Policy 123 (2019) 1135–1154 1143 Table3(Continued) Integratedcare site

Buildandstrengthen communitycapacityand action

Medendi(MED) N/A N/A • Developmentof internalcaredelivery processes: communicationand informationexchange betweenstaffand servicesoutsidethe team

N/A N/A N/A N/A

KVRegioMed Zentrum Templin(RMZ) • Provisionof preventionand rehabilitation serviceswhich directlyreinforce capabilitiesfor living independentlyat home N/A • Establishmentof multidisciplinaryteam • Developmentof

internalcaredelivery processes:jointcare planning,case management

N/A N/A • Provisionofsupport, equipmentandother enablementservicesto olderpeopletolive independentlyand safelyinownhomes

• Collaborationwith localauthoritiesto makeGPsinregion awareofintegrated careprojectandwhat itofferslocally

PﬂegewerkBerlin (PB)

N/A N/A • Developmentof

internal(caredelivery) processes:individual staffmembersprovide careandtreatmentto olderpeople prescribedbystaffand servicesoutsidethe team

N/A N/A • Locationof

accommodationfor olderpeoplein apartmentbuilding, closetotransport servicesandservedby rangeofsupport servicesandsocial activities

• Collaborationwith communitygroupsto enableolderpeopleto accessservicesoffered bylocalgroups includingvolunteers supportingactivitiesof dailylivingandsocial activities SurnadalHolistic PatientCareat Home(SUR) • Engagementof olderpeoplein careplanningto promoteshared decisionmaking informedby theirownviews aboutneedsand goals/desired outcomes

• Detailedchecklistsas guidesforprojectstaff aboutproviding comprehensivecare, systematically monitoringthehealth statusandcareneeds • Trainingofandadvice

toprojectstaffabout speciﬁcaspectsof practicewithinthesite

• Developmentof internal(caredelivery) processes:

communicationand informationexchange byindividualstaff membersandbetween staffandservices outsidetheteam, needsassessments, carecoordination • Electronicmessaging systemfor communication betweenprofessionals andorganisations thoughnotnecessarily includingallthose involved • Inﬂuenceon national/regional policiesthrough providingexamplesof goodpractice developingduring courseofproject operation • Performanceofhome safetyassessmentsto evaluatesafetyand appropriatenessof homeenvironment • Partsubsidyof

transportcostsfor healthcareservices andsocialactivities

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1144 A. Stoop, S.R. de Bruin, G. Wistow et al. / Health Policy 123 (2019) 1135–1154 Table3(Continued) Integratedcare site

Buildandstrengthen communitycapacityand action Søndre Nordstrand Everyday Mastery Training(SØN) • Provisionof rehabilitation serviceswhich directlyreinforce capabilitiesfor living independentlyat home • Provisionof trainingto promoteskills andconﬁdence tolive independently • Engagementof olderpeoplein careplanningto promoteshared decisionmaking informedby theirownviews aboutneedsand goals/desired outcomes

Trainingofprojectstaff aboutspeciﬁcaspectsof practicewithinthesite suchastheconductof needsassessments

internalcaredelivery processes:needs assessments,jointcare planning, communicationand informationexchange betweenbyindividual staffmembers • Rehabilitativecareat home • Electronicpatient recordsystemand electronicmessaging systemfor communication betweenprofessionals andorganisations thoughnotnecessarily allthoseinvolved

• Inﬂuenceon national/regional policiesthroughstatus aspilotproject

• Performanceofhome safetyassessmentsto evaluatesafetyand appropriatenessof homeenvironment • Provisionofsupport,

equipmentandother enablementservicesto olderpeopletolive independentlyand safelyinownhomes • Partsubsidyof

transportcoststo healthcareservices andsocialactivities

• Collaborationwith communitygroupsto enableolderpeopleto accessservicesoffered bylocalgroups includingtheRed Crossandsenior centres Osona Programmefor SevereChronic Patients/ Advanced chronic disease/ Geriatrics (OSO) Provisionofadvice toolderpeople aboutmedication adherence, maintaining independenceand safetyissues • Trainingofproject staffaboutspeciﬁc aspectsofpractice withinthesitesuchas talkingaboutendof lifeandpalliativecare, andprovidingadvice onmedication adherence

• Developmentof internalcaredelivery processes: communicationand informationexchange betweenindividual staffmembers

• SeparateITsystemsfor healthandsocialcare professionals • Electronicpatient

recordsystemfor communication betweenprofessionals andorganisations thoughnotnecessarily allthoseinvolved

• Inﬂuenceon national/regional policiesthroughstatus aspioneerproject, togetherwith examplesofgood practicedeveloped duringcourseof projectoperation • Performanceofhome safetyassessmentsto evaluatesafetyand appropriatenessof homeenvironment • Provisionofadviceto

olderpeopletolive independentlyand safelyinownhomes includingsafetyadvice andmedication adherence N/A NorthSabadell socialand healthcare integration (SAB) • Provisionof informationto olderpeople aboutthe availabilityof healthandsocial services

N/A • Individualstaff membersworkin samebuilding • Developmentof

internalcaredelivery processes: communicationand informationexchange betweenindividual membersofstaff

• SeparateITsystemsfor healthandsocialcare professionals • Electronicpatient

recordsystemfor communication betweenprofessionals andorganisations thoughnotnecessarily allthoseinvolved

• Inﬂuenceon national/regional policiesthroughstatus aspioneerproject, togetherwith examplesofgood practicedeveloped duringcourseof projectoperation • Performanceofhome safetyassessmentsto evaluatesafetyand appropriatenessof homeenvironment

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A. Stoop, S.R. de Bruin, G. Wistow et al. / Health Policy 123 (2019) 1135–1154 1145 Table3(Continued) Integratedcare site

Buildandstrengthen communitycapacityand action West-Friesland GeriatricCare Model(GCM) • Engagementof olderpeoplein careplanningto promoteshared decisionmaking informedby theirownviews aboutneedsand goals/desired outcomes

• Trainingofandadvice toprojectstaffabout speciﬁcaspectsof practicewithinthesite suchasconducting needsassessments usingtheRAI assessment instrumentandcase conferencingin complexsituations

internalcaredelivery processes:needs assessments,jointcare planning,care coordination,case conferencingincases withcomplexneeds

• Needsassessments andcareplansshared electronicallybetween limitedrangeofstaff workingwithRAI

N/A • Performanceofhome safetyassessmentsto evaluatesafetyand appropriatenessof homeenvironment duringneeds assessment N/A Walcheren IntegratedCare Model(WICM) • Engagementof olderpeopleand informal caregiversin careplanningto promoteshared decisionmaking informedby theirownviews aboutneedsand goals/desired outcomes

N/A • Developmentof internalcaredelivery processes:frailty screening,needs assessment,jointcare planning,case conferences,care coordination, communicationand informationexchange betweenstaffand servicesoutsidethe team,referralstoa rangeofservices outsidetheteam

N/A N/A N/A N/A

SandgateRoad Over75Service (O75) • Provisionof informationand advicetoolder peopleabout medication adherenceand self-management N/A • Developmentof internalcaredelivery processes: communicationand informationexchange betweenstaffand servicesoutsidethe team,referralstoa rangeofservices outsidetheteam

N/A N/A N/A N/A

SwaleHomeFirst (Dischargeto Assess)(HF) • Provisionof supportto promoteskills andconﬁdence tolive independently N/A • Establishmentof multidisciplinary hospitalteamand integrateddischarge team

• Developmentof internalcaredelivery processes:referralsto integrateddischarge team,needs assessmentsonward, referralstoinvolved organisations

• SeparateITsystemsfor healthandsocialcare professionals

N/A • Provisionofsupport, equipmentandother enablementservicesto olderpeopletolive independentlyand safelyinownhomes

• Collaborationwith communitygroupsto enableolderpeopleto accessservicesoffered bylocalgroups includingvoluntary organisations providingpractical support

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1146 A.Stoop,S.R.deBruin,G.Wistowetal./HealthPolicy123(2019)1135–1154

Table4

Perceiveddifﬁcultiesintheexistingwaysofworkingoftheintegratedcaresites. Coordinationandcollaboration Communicationand

information

Resourcesandsupport Competences,motivation,and workloadprofessionals

Person-centredworking • Lackofcoordinationand

integrationofservices, fragmentationofservices, andcompetitionbetween differenthealthandsocial careproviders

• Lackofformaland sustainableagreementsof collaborationwithdifferent healthandsocialcare providers

• Lackofcontinuityofservices acrossdifferentsectors • Weakcollaborationwith

regionalhealthinsurersand localgovernments • Inabilitytohireorinvolve

specialistsfromoutsidethe integratedcaresite • Poorlyattendedperiodic

multidisciplinarymeetings • Lackofclearlydeﬁnedand

allocatedrolesand responsibilitiesofhealthand socialcareprofessionals involved

• Lackofknowledgeofand trustinoneanother’s expertise

• Unfamiliaritywithone another’scareandsupport services

• Duplicationofservicesand needsassessments • Lackofandunilateral

leadership

• Insufﬁcientalignment betweenstaffand management

• Lackofcommunication/bad informationﬂow/conﬂicts betweenprofessionals withinoneorganisationor team

• Lackofcommunicationand informationsharingacross careproviders,inpartdueto limitationsofcareplanning instrumentused

• Lackofsharedorcompatible ITsystembetweenhealth andsocialcareorganisations • Lackoffollow-up

informationonserviceuser afterdischargefromservice • Lackofinformationabout

site’sperformancedueto lackofsystematic assessmentandmonitoring

• Inadequateand/or unsustainableﬁnancial resources

• Lackoffundingfor improvementstoIT infrastructure

• Inadequatestafﬁnglevels • Highstaffturn-over • Inadequatestaffhours,

resultinginlackoftimefor training,communication withserviceusersetc. • Fragmentationofbudgets

resultinginweak collaborationwithother healthandsocialcare providers

• Unsupportiveregionallegal framework,hindering cross-sectorjointefforts betweenlocalsocial services,healthandother institutions

• Unclearnationalpolicies regardingmunicipalhealth services

• Non-supportivenational policy

• Lackoftrainingand educationopportunitiesfor staffabout,forexample, shared-decision-makingand userempowerment • Weaklearningculture

amongstaff • Weakstaffmotivation • Heavyworkloadofstaff • Lackofacknowledgmentof

staff

• Lackofcoordinated, systematicand person-centredneeds assessmentandjointcare planning

• Insufﬁcientinvolvementof usersandinformal caregiversinthecare process(e.g.lackofshared decision-making) • Difﬁcultiesintailoring

servicestotheneedsand wishesoftheolderperson • Limitedtimeto

communicatewithservice users

• Inadequateinformation provisionaboutavailable servicestowardsolder peopleandtheirinformal caregivers

• Lackofinformalcaregiver support(respitecare) • Lackofmobilityand

transportation

opportunities,resultingin pooraccesstohealthand socialcareservices • Insufﬁcientattentionto

topicsrelatedtosafetyof olderpeople

municationandperson-centredworkingwererecognisedinthe fourteensitesparticipatinginSUSTAINasfrequentshortcomings intheirexisting ways ofworkingas wellasconstituting prior-itythemesinmostoftheimprovementplans.Incontrast,limited (financial)resourcesandstaffshortages,thoughfrequently men-tionedasimportantdifficulties,werenotexplicitlyaddressedin theimprovementplans.Suchissuesaremoregenerallywithinthe remitandinfluenceof“higherlevel”policy-makersand decision-makersthanstaffoflocalprojects[41,44,45]. Theimprovement plans’focusonimprovingperson-centredcareandbetter commu-nicationandcollaborativepracticebetweenlocalstakeholderscan, therefore,beconsideredconsistentwiththeirday-to-day expe-riencesof deliveringcareand theimprovement routesopento personnelattheirlevel.Knowledgeabouttheimpactofsufficient (financial)resourcesorlackof(financial)resourcesonthe objec-tivesand contentof improvement plansisstill limited. Alsoin ourresearchproposal,financialdataorinformationabout fund-ingforintegratedworkingtogainthisinsightwasnotincluded. Wesuggestitmightbeapriorityforfutureresearchonimproving integratedcare[46–49].

Theneedforimprovedcoordination,collaborationand commu-nication,arealsoimportantthemesinearlierstudiesonintegrated care[38,39,50].Asobservedinthisand earlierstudies,working towards good inter-professional collaboration requires knowl-edge,understandingandcommunicationaboutoneanother’sroles, responsibilitiesandexpertise[38,39,50].Thejointdevelopmentof careplansandtheopportunitiesformorefrequentcommunication

providedby multidisciplinarymeetingscanbenecessary build-ingblocksforimprovingcollaboration[51].Thereisalsoevidence fromotherstudies,asfromthisone,highlightingtheimportance of sharing personal data about individuals’ health and wellbe-ing,andthedevelopmentofjointcareplansacrossorganisational andprofessionalboundaries[52,53].Inthiscontext,shareddata systemsorotherITstrategies maysupportcommunicationand patientinformationexchange[38,51].IntheSUSTAINsites, how-ever,datasharingandcommunicationwereimpeded,asinother programmes, byincompatibilities between ITsystems together withdata-protectionandprivacyconcerns.Overcomingthese chal-lengeshasbeen foundtobe difﬁcultin earlier studies [38,50]. However, increasing attention to digital solutions in care may generatemoretechnicaloptionsandsupportforshareddata sys-temsandotherinformationtechnologythatenablecommunication andknowledgetransferinintegratedcare.Policy-makersshould thereforeconcentrateontechnologicalinfrastructuresthatenable seamlessdatasharingtogetherwithrobustdataprotectionandthat canbeoperatedthroughinter-operable(national)digitalsystems tosupportwell-coordinatedintegratedcaresystems.

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A. Stoop, S.R. de Bruin, G. Wistow et al. / Health Policy 123 (2019) 1135–1154 1147 Table5

Improvementsplansoftheintegratedcaresites.

Site Objective

improvementproject

Self-management Decisionsupport Deliverysystem design

Informationsystems Buildhealthypublic policy

Strengthen communityaction GerontopsychiatricCentre(GPC)Toimprovedetection

ofdementiacasesand improvecase-and discharge managementof hospitalisedpeople identifiedwitha cognitivedisorder • Provisionof informationabout suspicionof dementiaand availabilityoflocal servicestosupport earlydiagnosis, earlyintervention andprevention • Information/ training programmesfor external stakeholders includinghospital staff • Developmentof cooperationand communication betweenstaffof different organisationsand professionsby extending collaborationwith hospitals, collaboratively identifiedand providedsupport forpeopleidentified withacognitive disorder, collaboration agreementson sharinginformation

N/A N/A N/A N/A

AlutaguseCare Centre(ACC)

Todevelopa person-centredwayof workingbyengaging olderpeople,informal caregiversand multidisciplinary teaminprocessof deﬁninggoal-directed nursingplan • Developmentof needsassessment template incorporating user-deﬁnedneeds, preferencesand goalstoempower userdecision makingincare planningprocesses • Involvementof

usersandinformal caregiversin development, implementation andevaluationof careplans, including developmentof prioritiesandgoals injointplan

• Adoptionofnew needsassessment templateandjoint careplanning frameworkto supportharmonised andperson-centred waysofworking • Comprehensive, multidisciplinary stafftraining programmein person-centred workingusingnew assessmentandcare planningprocesses, andworkingwith newtemplatefor assessmentand careplanning • Developmentof cooperationand communication betweenstaffof different organisationsand professionsbyjoint needsassessments, jointcareplanning, jointcarereviews

• Developmentof localinformation systemforﬁle storinganddata exchangetowhich allprofessionals haveaccess

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1148 A. Stoop, S.R. de Bruin, G. Wistow et al. / Health Policy 123 (2019) 1135–1154 Table5(Continued) Site Objective improvementproject

Informationsystems Buildhealthypublic policy

Strengthen communityaction Medendi(MED) Toincreasethe

engagementofolder people,informal caregiversand differentprofessionals indevelopmentof jointcareplan;andto supportinformation exchangeonolder people’ssituation, needsandobjectives betweenolderpeople, informalcaregivers andprofessionals • Involvementof usersin developmentofcare plans,including developmentof prioritiesandgoals injointplan • Provisionof informationabout availabilityoflocal services • Adoptionofnew needsassessment templateandjoint careplanning frameworkto support comprehensiveand personcentred waysofworking • Comprehensive, multidisciplinary, stafftraining programmein person-centred workingusingnew assessmentandcare planningprocesses • Developmentof cooperationand communication betweenstaffof different organisationsand professionsbyjoint careplanning, collaboration agreementson sharinginformation fromassessments, collaboratively providedcare

N/A N/A N/A N/A

KVRegioMed Zentrum Templin(RMZ)

Toenablepeoplewith careneeds,including thosewhocompleted thecomplextherapy programme,toreceive therightservicesby providinginformation andadviceon availablecareand supportservices

N/A N/A • Co-locationofstaff frommany disciplinesina coordinationand consultingservice centreproviding casemanagement, expertconsultancy and discharge-management • Developmentof cooperationand communication betweenstaffof different organisationsand professionsby: regularmeetings; collaboratively providedcare;and jointcarereviews

N/A N/A N/A • Servicecentreas

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A. Stoop, S.R. de Bruin, G. Wistow et al. / Health Policy 123 (2019) 1135–1154 1149 Table5(Continued) Site Objective improvementproject

Informationsystems Buildhealthypublic policy Createsupportive environments Strengthen communityaction PﬂegewerkBerlin (PB) Toimprove inter-professionalcase managementand multidisciplinary collaborationbetween GPsandhealthcare therapists/nursesby transferring prescription-competencefromGPs tohealthcare therapistsandnurses; andtoestablish formalised interactionsand communicationspace amongformaland informalcaregivers

N/A • Goodpractice reﬂectionand informationsharing workshopsacross different professionalgroups • Developmentof cooperationand communication betweenstaffof different organisationsand professionsby collaboration agreementson prescribingmedical devices,therapeutic appliances,speciﬁc therapyand frequencyof treatmentunits N/A • Communication aboutroleof therapistsinlong termcareto nationaland regionallongterm care/policy communities

N/A • Buildingofcapacity andcontributionof voluntary organisa-tions/volunteersby promoting structuredcontacts betweenvolunteers andprofessional staff SurnadalHolistic PatientCareat Home(SUR) Toexpandand improvehealthcare servicesdeliveredat home • Developmentof needsassessment template incorporating user-deﬁnedneeds, preferencesand goalstoempower userdecision makingincare planningprocesses • Rehabilitationat homeinsteadof institutionsto enablemore independentliving inownhome environment • Comprehensive, ultidisciplinarystaff trainingprogramme inperson-centred workingtodevelop staffcapabilitiesin empoweringolder peopleto participatein shareddecision making • Developmentof cooperationand communication betweenstaffof different organisationsand professionsby providing rehabilitationin user’shomes, expansionofday centrecapacity, collaboration agreementson sharinginformation fromobservations, collaboratively providedcare: accompanying userstoGPfor medicationreview andGPconsultation twoweekspost discharge,proactive needsassessments

• Accesstoelectronic patientrecord systemforday centrestaff

N/A • Provisionofcare andsupportinown homesinsteadof institutions

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Informationsystems Buildhealthypublic policy Createsupportive environments Strengthen communityaction SøndreNordstrand EverydayMastery Training(SØN) Toincreasesenseof mastery,reduce relianceontraditional careservices,and maintainand encouragegood functionalabilityand socialparticipation amonguserspost EverydayMastery Training(EMT)service provision

• Provisionof information,advice aboutandsupport tomakeuseof availabilityoflocal servicestosupport earlydiagnosis, earlyintervention andprevention through,for example,low thresholdand voluntaryservices • Utilisationof differentmediato extendreachof information provided(Senior Infoservice,screens incentralplaces)

• Informationfor external stakeholders,such asmunicipalhealth staff,aboutthe rangeoflocal servicesavailable • Developmentof cooperationand communication betweenstaffof different organisationsand professionsby structured collaboration betweenhealth staffandlow thresholdservices, provisionof informationabout andpromotionto peopletomakeuse ofavailabilityof localservices (low-thresholdand voluntaryservices)

N/A N/A • Promotionofsocial interactioninlocal communities throughexpansion ofservicesexternal tothesitesuchas voluntaryand low-threshold provision • Buildingofcapacity andcontributionof voluntary organisa-tions/volunteersby expanding voluntarysector activities OsonaProgramme forSevereChronic Patients/Advanced chronicdisease/ Geriatrics(OSO) Toimprove person-centrednessof carebyconductinga standard, multidimensional jointassessmentand elaboratingashared individualisedcare plan(PIICplus)among involvedhealthcare andsocialcare professionalsandthe userandinformal caregivers • Involvementof usersin developmentofcare plans,including developmentof prioritiesandgoals injointplan • Comprehensive multidisciplinary stafftraining programmein person-centred workingandjoint careplanningusing newassessment andcareplanning processesto developstaff capabilitiesin empoweringolder peopleto participatein shareddecision making • Developmentof cooperationand communication betweenstaffof different organisationsand professionsbyjoint uservisits,joint needsassessments, jointcareplanning, collaboration agreementson sharing information;the existingcareplanto beenhancedby person-centred informationfrom jointcareplan

• Introductionofuser consentfor information exchangeand documentsharing betweendifferent professionals • Sharingprinted

copiesofcareplans withsocialworkers

N/A • Expansionofadvice one.g.safetyand otheraspectsof maintaining independence

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A. Stoop, S.R. de Bruin, G. Wistow et al. / Health Policy 123 (2019) 1135–1154 1151 Table5(Continued) Site Objective improvementproject

Informationsystems Buildhealthypublic policy Createsupportive environments Strengthen communityaction NorthSabadell

socialandhealth careintegration (SAB)

Toestablisha systematic, multidimensional assessmentandcare plantailoredto complexneedsofeach userandtoestablish careplansthatpeople feelknowledgeable andactiveabout, targetedatthose unknowntosocial services

• Provisionofsupport forolderpeople throughworkshops andtrainingabout e.g.empowerment, healthyageing, safety,social relationshipsand acceptingpersonal limitations Involvementof usersin development,of careplans, including developmentof prioritiesandgoals injointplan • Provisionof informationand adviceabout availabilityoflocal servicestosupport earlydiagnosis, earlyintervention andprevention • Utilisationof differentmediato extendreachof information providedthrough theresourcemap

• Comprehensive, multidisciplinary stafftraining programmingin person-centred workingandjoint careplanningusing newassessment andcareplanning processesto developstaff capabilitiesin empoweringolder peopleto participatein shareddecision making • Developmentof cooperationand communication betweenstaffof different organisationsand professionsbyjoint nominationof eligiblepeople,joint needsassessment, jointcareplanning, jointvisits, collaboratively providedcare • Introductionofuser consentfor information exchangeand documentsharing betweendifferent professionals • Sharingprinted

copiesofcareplans withsocialworkers

N/A • Expansionofadvice andinformation servicesabout neighbourhood resourcesthrough resourcemap • Performanceof preventativehome safetyassessments toevaluatesafety andappropriateof homeenvironment amongpeoplenot knownyettosocial services N/A West-Friesland GeriatricCare Model(GCM) Toimprove collaborationbetween professionalsinvolved inGCM(GPand practicenurse)and casemanagerand communitysocialcare teamtoadequately addressolderpeople’s complexneeds;to improveprofessionals’ person-centredwayof working;andtomake furthercollaboration agreementsbetween staff N/A • Implementationof goodpractice reﬂectionand informationsharing workshopsabout person-centred waysofworking acrossdifferent professionals groups • Implementationof exercisesto improve understandingof rolesand responsibilities,and buildworking relationshipsacross different professionals groups • Developmentof cooperationand communication betweenstaffof different organisationsand professionsbyjoint carereviews,which weretobeextended tomembersof communitysocial careteam; collaboration agreementson sharinginformation fromassessments

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Informationsystems Buildhealthypublic policy Createsupportive environments Strengthen communityaction SandgateRoad Over75Service (O75)

Tokeepolderpeople withlong-term conditionsand complexneedsat homeindependently foraslongaspossible andtoimprovecare coordinationacross existingservices aroundthesepeople

• Emphasison preventionby includingboth peoplemanaging wellandseverely frailpeoplein service • Provisionof informationand adviceabout availabilityoflocal servicestosupport early,diagnosis, earlyintervention andprevention • Supportforolder

peopleandinformal caregiversine.g. healthylifestyle preventing,falls, self-management, medication adherence, conﬁdencebuilding • Comprehensive, multidisciplinary stafftraining programmein frailtyandtheuse ofDalhousiefrailty screeningtool • Developmentof cooperationand communication betweenstaffof different organisationsand professionsby extending collaborationwith healthandsocial careand community organisations,joint frailtyscreening, trustedassessor model,coordinated needsassessment andreferralto involvedservices, collaboratively providedcare,joint carereviews, regularreviewof people’ssituation andneeds

N/A N/A • Creationof

supportive environments throughimproved identiﬁcationand coordination, including collaborationwith voluntary organisations providingcareand support,equipment andwithother enablement services • Buildingofcapacity andcontributionof voluntary organisa-tions/volunteersby theirinclusionas keystakeholdersin thesite,developing formalstructures forcollaboration andcoordination betweenpublicand voluntary organisation providingsupport forusersand informalcaregivers

SwaleHomeFirst (Dischargeto Assess)(HF)

Toensuremedically optimisedhospitalised peopleareabletobe dischargedstraight homewiththeright support;andtomake theperson’sdischarge smoother,quickerand saferbymovingtoa singleassessment

N/A • Delegationof overarchingcare planincludinggoals betweendifferent professionalgroups • Developmentof cooperationand communication betweenstaffof different organisationsand professionsby singleassessment form(triageat ward,complete needsassessmentat home), collaboratively providedcare • Reinforcingof communication betweendifferent multidisciplinary teamscomprising wardteams, integrated dischargeteam, communityservice providers

N/A N/A • Provisionofcare andsupportand needsassessmentin ownhomesinstead ofinstitutionsto enablelivinginown homeenvironment andprovidethe mostappropriate equipment,advice andsupporttohelp ensureuser’ssafety andwellbeing • Buildingofcapacity andcontributionof voluntary organisa-tions/volunteersby expandingreferrals tovoluntary organisations providingsupport forusersand informalcaregivers

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A.Stoop,S.R.deBruin,G.Wistowetal./HealthPolicy123(2019)1135–1154 1153 activitiesrelatedtodeliverysystemdesignand/orself-management

[5,6,54,55].Theincorporationofactionsandactivitiesrelatedto thesecomponents suggest a collectiverecognitionamong local projectsoftheneedtoworktowardsbetterinter-professionaland inter-organisational collaborationand communication, and also towardstheempowermentofolderpeopleandinformalcaregivers. However,actionsandactivitiesrelatedtothethreeadditional componentsoftheECCM(buildhealthypublicpolicy,create support-iveenvironments,andbuildandstrengthencommunitycapacityand action),andmostespeciallyactionsrelatedtobuildinghealthy pub-licpolicy,werefoundinonlyasmallernumberofexistingwaysof workingandimprovementplans.Asmentioned,theECCM,rather thantheCCM,wasusedtoprovideaframeworkfordescribingand comparingtheintegratedcaresitesinSUSTAIN.TheECCM incorpo-ratedabroadly-basedfocusonpreventionbyincludingthesocial determinantsofhealth,andtheprinciplesofhealthpromotionas wellasclinicalpreventionservices[7].TheadditionalECCM com-ponentsreﬂectedtheneedforcloserassociationsbetweenhealth servicesystemsandthecommunity,includingsocialcareandthe voluntarysector.Assuch,theECCMwasconsistentwiththecriteria wedevelopedforinvitingintegratedcaresitestoparticipateinthe SUSTAINproject,beingbroadly-basedpreventionandinvolvement ofcommunityservices[26],andthereforethoughttobesuited bet-tertothisstudy.However,ouranalysisshowedthatintegratedcare sitesweremoreoftenunderpinnedbycomponentsfromtheCCM thanbytheadditionalECCMcomponents.Thusweconcludedthat mostofthesitesinourstudydidnotappeartohaveadoptedthe approachesbasedonaddressingsocialdeterminantsofhealth, pop-ulationhealthpromotionandcommunitycapacitybuildingthatthe ECCManditsevidencebasesuggestarenecessaryforoptimising integratedcare.Similarlimitationshavealsobeenrecognisedin earlierstudies[24].Apossiblereasonmaybethecompositionof groupsofstakeholdersinvolvedindevelopingtheimprovement plan,whichwereparticularlymedicallyfocusedandlacked repre-sentationfromhealthpromotionpractitioners.Mergingpopulation healthpromotionwithclinicalhealthcareservicesmayyet con-tributetoimprovedoutcomesforolderpeopleandtheirinformal caregivers[7].Assuch,theunder-representationofECCM compo-nentshighlightstheneedforgreaterattentiontothepopulation andcommunity-orientedelementswithinintegratedcareforolder peoplewithcomplexneeds[24,56].Furtherknowledgeabouthow toincorporatepopulationhealthpromotionandenhanced com-munityparticipationinto integratedcare modelsappearstobe required.

4.3. Strengthsandlimitationsofdatacollectionandanalysis Comparisonofintegratedcaresitesacrossdifferentcountries and care settings, necessarily poses methodological challenges. Accordingly,thecountry-specificresearchteamswereexpected to employ commontemplates for data collection and analysis. Althoughsmallvariations inthe waydatawerecollectedwere observed,nosignificantdifferenceswerefound,which provides a reasonabledegreeofconfidence abouttheconsistencyof our approach.Tounderstandthecoherencebetweenindividualdata sourcesforeachsiteand toovercomeissueswithdifferent lan-guagesinwhichdatahavebeencollected,theoverarchinganalysis teamconductedcontentanalysisof documentsprovidedbythe country-specific research team. The reliability and validity of ourfindings were also tested, asdescribed above,by checking theresults fromthe overarching analysiswith country-specific researchteamsandtheirlocalsites.Inalltheseways,therefore, theSUSTAINprojectsoughttomitigatethechallengesposedby itsmultiplesourcesofdata,andmultiplecontextsaswellasthe different(methodological)backgroundsofitsresearchpartners.

In addition to collecting and analysing site-specific data, country-specificresearchteamsalsocollaboratedwithlocal stake-holders to facilitate thedesign of the improvement plans.The potentialriskstomethodologicalrigourofthisdualrole should beacknowledged[26].SUSTAIN’sapproachhadanticipated this bydistinguishingtwotypesofresearchpartners.Theoverarching analysisteamconsultedmembersofthecountry-specificresearch teamsaboutthesitesintheircountries,whichwasintendedto mit-igatethesepotentialrisksbyreinforcingtheirscientificdistance fromtheirdataaswellascreatingspaceforcriticalreflectionon theirownroleintheresearchprocess.

4.4. Conclusion

IntegratedcaresitesacrossEuropethatsoughttoimplement improvements were found to experience similar challenges in their existing ways of working.Improvement plans toaddress thechallengestendedtohaveoneoftwodifferentemphases:1) improvementoflocalstakeholdercommunicationsand collabora-tiveprocesses,leadingindirectlytoimprovementsincaredelivery, and 2) direct improvement in care deliverysystems and tools. AdoptionoftheECCMmodelasatoolforcross-sitecomparison sug-gestedthat,inthemain,thesitesdidnotdrawontheperspectives and approaches associatedwithbroaderapproaches to preven-tion,populationhealthpromotionandcommunityinvolvement. Greaterattentiontothepopulationandcommunity-oriented ele-mentswithinintegratedcareforolderpeoplewithcomplexneeds maybringthedevelopmentofintegratedcareastepfurther. Authorstatement

AllauthorswereinvolvedinthedevelopmentoftheSUSTAIN methodologyandcontributedtothestudyconceptanddesign.AS wasresponsiblefor requestingsite-specific dataandconsulting country-specificresearchteams.ASandGWanalysedand inter-pretedthedataanddevelopedthestructureofthepaper.ASdrafted themanuscriptandGW,SdB,JB,GR,KL,KO,CBandGNcritically revisedthemanuscript.Allauthorsreadandapprovedthefinal manuscript.

DeclarationofCompetingInterest None.

Acknowledgements

ThisstudyispartoftheSUSTAINprojectwhichisfundedunder Horizon2020–theFrameworkProgrammeforResearchand Inno-vation(2014–2020)fromtheEuropeanCommissionundergrant agreementNo.634144.Thecontentofthispaperreﬂectsonlythe authors’views.TheEuropeanUnionisnotliableforanyusethat maybemadeoftheinformationcontainedherein.

AppendixA. Supplementarydata

Supplementarymaterialrelatedtothisarticlecanbefound,in theonlineversion,atdoi:https://doi.org/10.1016/j.healthpol.2019. 09.009.

References