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1.  The performance of integrated health care networks in continuity of care: a qualitative multiple case study of COPD patients 
Background
Integrated health care networks (IHN) are promoted in numerous countries as a response to fragmented care delivery by providing a coordinated continuum of services to a defined population. However, evidence on their effectiveness and outcome is scarce, particularly considering continuity across levels of care; that is the patient's experience of connected and coherent care received from professionals of the different care levels over time. The objective was to analyse the chronic obstructive pulmonary disease (COPD) patients’ perceptions of continuity of clinical management and information across care levels and continuity of relation in IHN of the public health care system of Catalonia.
Methods
A qualitative multiple case study was conducted, where the cases are COPD patients. A theoretical sample was selected in two stages: (1) study contexts: IHN and (2) study cases consisting of COPD patients. Data were collected by means of individual, semi-structured interviews to the patients, their general practitioners and pulmonologists and review of records. A thematic content analysis segmented by IHN and cases with a triangulation of sources and analysists was carried out.
Results
COPD patients of all networks perceived that continuity of clinical management was existent due to clear distribution of roles for COPD care across levels, rapid access to care during exacerbations and referrals to secondary care when needed; nevertheless, patients of some networks highlighted too long waiting times to non-urgent secondary care. Physicians generally agreed with patients, however, also indicated unclear distribution of roles, some inadequate referrals and long waiting times to primary care in some networks. Concerning continuity of information, patients across networks considered that their clinical information was transferred across levels via computer and that physicians also used informal communication mechanisms (e-mail, telephone); whereas physicians highlighted numerous problems of the information system, thus the need to use informal communication channels. Finally, regarding continuity of relation, patients of some networks pointed out high turnover of personnel - being frequently seen by locum doctors or assigned to new physicians - which hindered the development of a trusting relationship.
Conclusion
Study findings suggest a generally perceived adequate performance of IHN in continuity of care but also the existence of a series of difficulties related to all continuity types. Results can provide opportunities to improving the care process of COPD patients but also of patients with other conditions who receive care across the primary and secondary care level.
PMCID: PMC4512888  PMID: 26213524
continuity of patient care; integrated delivery systems; qualitative research; chronic obstructive pulmonary disease; patient–physician relationship; clinical management continuity; clinical information continuity
3.  Developing a Patient Care Co-ordination Centre in Trafford, England: lessons from the International Foundation for Integrated Care (IFIC)/Advancing Quality Alliance integrated care fellowship experience 
The NHS and Social Care in England are facing one of the biggest financial challenges for a generation. Commissioners and providers need to work on collaborative schemes to manage the increasing demand on health and social care within a period of financial constraint. Different forms of care co-ordination have been developed at different levels across the world. In the north-west of England, the Trafford health and social care economy have been working through a competitive dialogue process with industry to develop an innovative and dynamic solution to deliver seamless co-ordination for all patients and service users. The strategy is to develop a new Patient Care Co-ordination Centre, which will be responsible for the delivery of co-ordinated, quality care. The Patient Care Co-ordination Centre will work at clinical, service, functional and community levels across multiple providers covering risk stratification, preventative, elective and unscheduled care. I am the clinical lead for the Patient Care Co-ordination Centre and during my year as an Advancing Quality Alliance Integrated Care Fellow, I have had the opportunity to study examples of care coordination from UK and international sites. The learning from these visits has been assimilated into the design process of the Patient Care Co-ordination Centre.
PMCID: PMC4447232  PMID: 26034468
patient care co-ordination; AQuA; Fellowship
4.  Better experiences with quality of care predict well-being of patients with chronic obstructive pulmonary disease in the Netherlands 
Objective
This study was conducted to (1) identify improvements in care quality and well-being of patients with chronic obstructive pulmonary disease in the Netherlands and (2) investigate the longitudinal relationship between these factors.
Methods
This longitudinal study was conducted among patients diagnosed with chronic obstructive pulmonary disease enrolled in the Kennemer Lucht care programme in the Netherlands. Biomarker data (lung capacity) were collected at patients’ health care practices in 2012. Complete case analysis was conducted, and the multiple imputation technique allowed us to report pooled results from imputed datasets.
Results
Surveys were filled out by 548/1303 (42%) patients at T0 (2012) and 569/996 (57%) remaining participants at T1. Quality of care improved significantly (p < 0.05). Analyses adjusted for well-being at T0, age, educational level, marital status, gender, lung function and health behaviours showed that patients’ assessments of the quality of chronic care delivery at T0 (p < 0.01) and changes therein (p < 0.001) predicted patients’ well-being at T1.
Conclusion
These results clearly show that the quality of care and changes therein are important for the well-being of patients with chronic obstructive pulmonary disease in the primary care setting.
Practice implications
To improve quality of care for chronically ill patients, multicomponent interventions may be needed.
PMCID: PMC4491321  PMID: 26150766
chronic obstructive pulmonary disease; disease management; health behaviour; quality of care; well-being
5.  Building integrated care systems: a case study of Bidasoa Integrated Health Organisation 
Introduction
This paper analyses the implementation of integrated care policies in the Basque Country through the deployment of an Integrated Health Organisation in Bidasoa area during the period 2011–2014. Structural, functional and clinical integration policies have been employed with the aim to deliver integrated and person-centred care for patients, especially for those living with chronic conditions.
Methods
This organisational case study used multiple data sources and methods in a pragmatic and reflexive manner to build a picture of the organisational development over a 4-year period. In order to measure the progress of integration three concepts have been measured: (i) readiness for chronicity measured with Assessment of Readiness for Chronicity in Healthcare Organisations tool; (ii) collaboration between clinicians from different care levels measured with the D'Amour Questionnaire, and (iii) overall impact of integration through several indicators based on the Triple Aim Framework.
Results
The measurement of organisational readiness for chronicity showed improvements in five of the six areas under evaluation. Similarly the collaboration between professionals of different care levels showed a steady improvement in each of the 10 items. Furthermore, the Triple Aim-based indicators showed a better experience of care in terms of patients’ perceptions of care coordination; a reduction in hospital utilisation, particularly for patients with complex chronic conditions; and cost-containment in terms of per capita expenditure.
Conclusion
There is a significant amount of data that shows that Bidasoa Integrated Health Organisation has progressed in terms of delivering integrated care for chronic conditions with a positive impact on several Triple Aim outcomes.
PMCID: PMC4491322  PMID: 26150764
integrated care; Chronic Care Model; Basque Country; health organisation; Triple Aim
7.  Chronic and integrated care in Catalonia 
Introduction
The Chronicity Prevention and Care Programme set up by the Health Plan for Catalonia 2011–2015 has been an outstanding and excellent opportunity to create a new integrated care model in Catalonia. People with chronic conditions require major changes and transformation within the current health and social system. The new and gradual context of ageing, increase in the number of chronic diseases and the current fragmented system requires this transformation to be implemented.
Method
The Chronicity Prevention and Care Programme aims to implement actions which drive the current system towards a new scenario where organisations and professionals must work collaboratively. New tools should facilitate this new context- or work-like integrated health information systems, an integrative financing and commissioning scheme and provide a new approach to virtual care by substituting traditional face-to-face care with transfer and shared responsibilities between patients, citizens and health care professionals.
Results
It has been observed some impact reducing the rate of emergency admissions and readmission related to chronic conditions and better outcome related to better chronic disease control. Some initiative like the Catalan Expert Patient Program has obtained good results and an appropriate service utilization.
Discussion
The implementation of a Chronic Care Program show good results but it is expected that the new integrated health and social care agenda could provoke a real change and transformation. Some of the results related to better health outcomes and a decrease in avoidable hospital admissions related to chronic conditions confirm we are on the right track to make our health and social system more sustainable for the decades to come.
PMCID: PMC4491324  PMID: 26150763
chronic care; expert patient; integrated care; multimorbidity
8.  Do patients with long-term side effects of cancer treatment benefit from general practitioner support? A literature review 
Background
Alongside specialist cancer clinics, general practitioners have an important role in cancer patients’ follow-up care, yet no literature summarises the nature, extent and impact of their involvement. This paper addresses this issue through a review of the literature.
Methods
Studies were sourced from six academic databases - AustHealth (n = 202), CINAHL (n = 500), the Cochrane Library (reviews and trials; n = 200), Embase (n = 368), PHCRIS (n = 132) and PubMed/Medline (n = 410). Studies that focused on interventions designed for patients receiving follow-up care and reported cancer care provided by a general practitioner delivered alongside specialist care were reviewed.
Results
A total of 19 papers were identified as relevant for this review (3 randomised control trials; 4 cross-sectional, 5 cohort and 3 qualitative studies, and 3 systematic reviews). The reviewed studies indicated that providing general practitioner-led supportive interventions for post-treatment care of cancer patients is feasible and acceptable to patients. General practitioner involvement resulted in improved physical and psychosocial well-being of patients and continuity of care, especially for patients with concomitant health conditions.
Conclusion
Involving general practitioners in post-treatment cancer care is beneficial to patients. However, proactive initiatives that encourage and facilitate patients to consult their general practitioner about their needs or symptoms of recurrence should be considered.
PMCID: PMC4491325  PMID: 26150761
cancer; primary health care; follow-up care; supportive care; integrated care
9.  Does it matter who organises your health care? 
Background
As the prevalence of long-term and multimorbid conditions is increasing, patients increasingly require consultations with multiple health care professionals and coordination of their care needs.
Methods
This study is based on a 2011 survey of older Australians which draws on sub-populations of people with diabetes aged 50 years or over, people with chronic obstructive pulmonary disease, and members of Nationals Seniors Australia. We develop a composite coordination measure and examine differences in the measure with different care coordination indicators using both descriptive and regression methods. Three categories of respondent-perceived care organisers are used: health care professionals; “no one”; and patients, their partner, relative or friend.
Results
Of the 2,540 survey respondents (an overall response rate of 24%), 1,865 provided information on who organised their health care, and composite coordination measures were calculated for 1,614. Multivariate analysis showed the composite score was highest where a health care professional coordinated care, followed by care organised by self or a carer, and then the group reporting no organiser.
Conclusion
In moving towards care coordination there are opportunities to improve the care coordination process itself, and the key enablers to improving care coordination appear to be the availability and communication of clinical information and the role of the clinical team.
PMCID: PMC4491326  PMID: 26150760
coordination; chronic disease; long-term conditions
10.  The common characteristics and outcomes of multidisciplinary collaboration in primary health care: a systematic literature review 
Introduction
Research on collaboration in primary care focuses on specific diseases or types of collaboration. We investigate the effects of such collaboration by bringing together the results of scientific studies.
Theory and methods
We conducted a systematic literature review of PubMed, CINAHL, Cochrane and EMBASE. The review was restricted to publications that test outcomes of multidisciplinary collaboration in primary care in high-income countries. A conceptual model is used to structure the analysis.
Results
Fifty-one studies comply with the selection criteria about collaboration in primary care. Approximately half of the 139 outcomes in these studies is non-significant. Studies among older patients, in particular, report non-significant outcomes (p < .05). By contrast, a higher proportion of significant results were found in studies that report on clinical outcomes.
Conclusions and discussion
This review shows a large diversity in the types of collaboration in primary care; and also thus a large proportion of outcomes do not seem to be positively affected by collaboration. Both the characteristics of the structure of the collaboration and the collaboration processes themselves affect the outcomes. More research is necessary to understand the mechanism behind the success of collaboration, especially on the exact nature of collaboration and the context in which collaboration takes place.
PMCID: PMC4491327  PMID: 26150765
primary health care; inter-professional relations; multidisciplinary collaboration; integrated care; outcomes
11.  Who would most benefit from improved integrated care? Implementing an analytical strategy in South Somerset 
Aims
The Symphony Project is designed to identify which groups of the South Somerset population in England would most benefit from greater integration across primary, community, acute and social care settings.
Methods
We analysed linked health and social care data for the entire South Somerset population for the financial year 2012/2013. The data captured acute, primary, community, mental health and social care utilisation and costs; demographic characteristics; and indicators of morbidity for each individual. We employed generalized linear models to analyse variation in annual health and social care costs for all 114,874 members of the South Somerset population and for 1458 individuals with three or more selected chronic conditions.
Results
We found that multi-morbidity, not age, was the key driver of health and social care costs. Moreover, the number of chronic conditions is as useful as information about specific conditions at predicting costs. We are able to explain 7% of the variation in total annual costs for population as a whole, and 14% of the variation for those with three or more conditions. We are best able to explain primary care costs, but explanatory power is poor for mental health and social care costs.
Conclusions
The linked dataset makes it possible to understand existing patterns of health and social care utilisation and to analyse variation in annual costs, for the whole population and for sub-groups, in total and by setting. This has made it possible to identify who would most benefit from improved integrated care and to calculate capitated budgets to support financial integration.
PMCID: PMC4314133  PMID: 25674043
integrated care; health and social care costs; morbidity profiles; capitated budgets
12.  Integrating service user participation in mental health care: what will it take? 
Participation in mental health care poses many challenges for mental health service users and service providers. Consideration of these issues for improving the integration of service user participation in mental health care can help to inform integrated care within health care systems, broadly. This paper argues for practicing greater empathy and teaching it, stigma reduction, changing what we measure, valuing the intrinsic aspects of care more, employing more people with lived experience within mental health services, raising the visibility of service users as leaders and our teachers within services and redefining integrated care from the service user perspective.
PMCID: PMC4353213  PMID: 25759608
service user participation; mental health care; definition of integrated care
13.  Towards a taxonomy for integrated care: a mixed-methods study 
Introduction
Building integrated services in a primary care setting is considered an essential important strategy for establishing a high-quality and affordable health care system. The theoretical foundations of such integrated service models are described by the Rainbow Model of Integrated Care, which distinguishes six integration dimensions (clinical, professional, organisational, system, functional and normative integration). The aim of the present study is to refine the Rainbow Model of Integrated Care by developing a taxonomy that specifies the underlying key features of the six dimensions.
Methods
First, a literature review was conducted to identify features for achieving integrated service delivery. Second, a thematic analysis method was used to develop a taxonomy of key features organised into the dimensions of the Rainbow Model of Integrated Care. Finally, the appropriateness of the key features was tested in a Delphi study among Dutch experts.
Results
The taxonomy consists of 59 key features distributed across the six integration dimensions of the Rainbow Model of Integrated Care. Key features associated with the clinical, professional, organisational and normative dimensions were considered appropriate by the experts. Key features linked to the functional and system dimensions were considered less appropriate.
Discussion
This study contributes to the ongoing debate of defining the concept and typology of integrated care. This taxonomy provides a development agenda for establishing an accepted scientific framework of integrated care from an end-user, professional, managerial and policy perspective.
PMCID: PMC4353214  PMID: 25759607
integrated care; primary care; Delphi study; classification; literature review; taxonomy; coordinated care
14.  An instrument for broadened risk assessment in antenatal health care including non-medical issues 
Introduction
Growing evidence on the risk contributing role of non-medical factors on pregnancy outcomes urged for a new approach in early antenatal risk selection. The evidence invites to more integration, in particular between the clinical working area and the public health domain. We developed a non-invasive, standardized instrument for comprehensive antenatal risk assessment. The current study presents the application-oriented development of a risk screening instrument for early antenatal detection of risk factors and tailored prevention in an integrated care setting.
Methods
A review of published instruments complemented with evidence from cohort studies. Selection and standardization of risk factors associated with small for gestational age, preterm birth, congenital anomalies and perinatal mortality. Risk factors were weighted to obtain a cumulative risk score. Responses were then connected to corresponding care pathways. A cumulative risk threshold was defined, which can be adapted to the population and the availability of preventive facilities. A score above the threshold implies multidisciplinary consultation between caregivers.
Results
The resulting digital score card consisted of 70 items, subdivided into four non-medical and two medical domains. Weighing of risk factors was based on existing evidence. Pilot-evidence from a cohort of 218 pregnancies in a multi-practice urban setting showed a cut-off of 16 points would imply 20% of all pregnant women to be assessed in a multidisciplinary setting. A total of 28 care pathways were defined.
Conclusion
The resulting score card is a universal risk screening instrument which incorporates recent evidence on non-medical risk factors for adverse pregnancy outcomes and enables systematic risk management in an integrated antenatal health care setting.
PMCID: PMC4359383  PMID: 25780351
non-invasive risk screening; risk assessment; integrated care; care pathway; perinatal health; pregnancy
16.  Family members of older persons with multi-morbidity and their experiences of case managers in Sweden: an interpretive phenomenological approach 
Background
Family members of older persons (75+) with multi-morbidity are likely to benefit from utilising case management services performed by case managers. However, research has not yet explored their experiences of case managers.
Objectives
The aim of the study was to deepen the understanding of the importance of case managers to family members of older persons (75+) with multi-morbidity.
Design
The study design was based on an interpretive phenomenological approach.
Method
Data were collected through individual interviews with 16 family members in Sweden. The interviews were analysed by means of an interpretive phenomenological approach.
Results
The findings revealed one overarching theme: “Helps to fulfil my unmet needs”, based on three sub-themes: (1) “Helps me feel secure – Experiencing a trusting relationship”, (2) “Confirms and strengthens me – Challenging my sense of being alone” and (3) “Being my personal guide – Increasing my competence”.
Conclusion and discussion
The findings indicate that case managers were able to fulfil unmet needs of family members. The latter recognised the importance of case managers providing them with professional services tailored to their individual needs. The findings can contribute to the improvement of case management models not only for older persons but also for their family members.
PMCID: PMC4410135  PMID: 25918497
case management; integrated care; family members; interpretive phenomenology; multi-morbidity; older persons
17.  Developing IntegRATE: a fast and frugal patient-reported measure of integration in health care delivery 
Background
Efforts have been made to measure integration in health care delivery, but few existing instruments have adopted a patient perspective, and none is sufficiently generic and brief for administration at scale. We sought to develop a brief and generic patient-reported measure of integration in health care delivery.
Methods
Drawing on both existing conceptualisations of integrated care and research on patients’ perspectives, we chose to focus on four distinct domains of integration: information sharing, consistent advice, mutual respect and role clarity. We formulated candidate items and conducted cognitive interviews with end users to further develop and refine the items. We then pilot-tested the measure.
Results
Four rounds of cognitive interviews were conducted (n = 14) and resulted in a four-item measure that was both relevant and understandable to end users. The pilot administration of the measure (n = 15) further confirmed the relevance and interpretability of items and demonstrated that the measure could be completed in less than one minute.
Conclusions
This new measure, IntegRATE, represents a patient-reported measure of integration in health care delivery that is conducive to use in both routine performance monitoring and research. The psychometric properties of the measure will be assessed in the next stage of development.
PMCID: PMC4447215  PMID: 26034467
integration of care; care coordination; continuity of care; measurement; patient-reported measures; cognitive interviews
18.  Provider accountability as a driving force towards physician–hospital integration: a systematic review 
Background
Hospitals and physicians lie at the heart of our health care delivery system. In general, physicians provide medical care and hospitals the resources to deliver health care. In the past two decades many countries have adopted reforms in which provider financial risk bearing is increased. By making providers financially accountable for the delivered care integrated care delivery is stimulated.
Purpose
To assess the evidence base supporting the relationship between provider financial risk bearing and physician–hospital integration and to identify the different types of methods used to measure physician–hospital integration to evaluate the functional value of these integrative models.
Results
Nine studies met the inclusion criteria. The evidence base is mixed and inconclusive. Our methodological analysis of previous research shows that previous studies have largely focused on the formal structures of physician–hospital arrangements as an indicator of physician–hospital integration.
Conclusion
The link between provider financial risk bearing and physician–hospital integration can at this time be supported merely on the basis of theoretical insights of agency theory rather than empirical research. Physician–hospital integration measurement has concentrated on the prevalence of contracting vehicles that enables joint bargaining in a managed care environment but without realizing integration and cooperation between hospital and physicians. Therefore, we argue that these studies fail to shed light on the impact of risk shifting on the hospital–physician relationship accurately.
PMCID: PMC4447218  PMID: 26034469
physician–hospital integration; provider financial risk bearing; methods; literature review
19.  Integrated care services: lessons learned from the deployment of the NEXES project 
Objectives
To identify barriers to deployment of four articulated Integrated Care Services supported by Information Technologies in three European sites. The four services covered the entire spectrum of severity of illness. The project targeted chronic patients with obstructive pulmonary disease, cardiac failure and/or type II diabetes mellitus.
Setting
One health care sector in Spain (Barcelona) (n = 11.382); six municipalities in Norway (Trondheim) (n = 450); and one hospital in Greece (Athens) (n = 388).
Method
The four services were: (i) Home-based long-term maintenance of rehabilitation effects (n = 337); (ii) Enhanced Care for frail patients, n = 1340); (iii) Home Hospitalization and Early Discharge (n = 2404); and Support for remote diagnosis (forced spirometry testing) in primary care (Support) (n = 8139). Both randomized controlled trials and pragmatic study designs were combined. Two technological approaches were compared. The Model for Assessment of Telemedicine applications was adopted.
Results
The project demonstrated: (i) Sustainability of training effects over time in chronic patients with obstructive pulmonary disease (p < 0.01); (ii) Enhanced care and fewer hospitalizations in chronic respiratory patients (p < 0.05); (iii) Reduced in-hospital days for all types of patients (p < 0.001) in Home Hospitalization/Early Discharge; and (iv) Increased quality of testing (p < 0.01) for patients with respiratory symptoms in Support, with marked differences among sites.
Conclusions
The four integrated care services showed high potential to enhance health outcomes with cost-containment. Change management, technological approach and legal issues were major factors modulating the success of the deployment. The project generated a business plan to foster service sustainability and health innovation. Deployment strategies require site-specific adaptations.
PMCID: PMC4447233  PMID: 26034465
case management; integrated health care systems; chronic disease; long-term care; telemedicine
20.  How to build and evaluate an integrated health care system for chronic patients: study design of a clustered randomised controlled trial in rural China 
Background
While integrated health care system has been proved an effective way to help improving patient health and system efficiency, the exact behaviour model and motivation approach are not so clear in poor rural areas where health human resources and continuous service provision are urgently needed. To gather solid evidence, we initiated a comprehensive intervention project in Qianjiang District, southwest part of rural China in 2012. And after one-year's pilot, we developed an intervention package of team service, comprehensive pathway and prospective- and performance-based payment system.
Methods
To testify the potential influence of payment interventions, we use clustered randomised controlled trial, 60 clusters are grouped into two treatment groups and one control group to compare the time and group differences. Difference-in-differences model and structural equation modelling will be used to analyse the intervention effects and pathway. The outcomes are: quality of care, disease burden, supplier cooperative behaviour and patient utilisation behaviour and system efficiency. Repeated multivariate variance analysis will be used to statistically examine the outcome differences.
Discussion
This is the first trial of its kind to prove the effects and efficiency of integrated care. Though we adopted randomised controlled trial to gather the highest rank of evidence, still the fully randomisation was hard to realise in health policy reform experiment. To compensate, the designer should take efforts on control for the potential confounders as much as possible. With this trial, we assume the effects will come from: (1) improvement on the quality of life through risk factors control and lifestyles change on patient's behaviours; (2) improvement on quality of care through continuous care and coordinated supplier behaviours; (3) improvement on the system efficiency through active interaction between suppliers and patients.
Conclusion
The integrated care system needs collaborative work from different levels of caregivers. So it is extremely important to consider the supplier cooperative behaviour. In this trial, we introduced payment system to help the delivery system integration through providing financial incentives to motivate people to play their roles. Also, the multidisciplinary team, the multi-institutional pathway and system global budget and pay-for-performance payment system could afford as a solution.
PMCID: PMC4447234  PMID: 26034466
integrated health care system; prospective payment system; multidisciplinary team; multi-institutional pathway; rural health; China
22.  Patient centredness in integrated care: results of a qualitative study based on a systems theoretical framework 
Introduction
Health care providers seek to improve patient-centred care. Due to fragmentation of services, this can only be achieved by establishing integrated care partnerships. The challenge is both to control costs while enhancing the quality of care and to coordinate this process in a setting with many organisations involved. The problem is to establish control mechanisms, which ensure sufficiently consideration of patient centredness.
Theory and methods
Seventeen qualitative interviews have been conducted in hospitals of metropolitan areas in northern Germany. The documentary method, embedded into a systems theoretical framework, was used to describe and analyse the data and to provide an insight into the specific perception of organisational behaviour in integrated care.
Results
The findings suggest that integrated care partnerships rely on networks based on professional autonomy in the context of reliability. The relationships of network partners are heavily based on informality. This correlates with a systems theoretical conception of organisations, which are assumed autonomous in their decision-making.
Conclusion and discussion
Networks based on formal contracts may restrict professional autonomy and competition. Contractual bindings that suppress the competitive environment have negative consequences for patient-centred care. Drawbacks remain due to missing self-regulation of the network. To conclude, less regimentation of integrated care partnerships is recommended.
PMCID: PMC4236305  PMID: 25411573
patient centredness; integrated care; DRG; systems theory
23.  Patient participation in discharge planning conference 
Introduction
There is a need for individualized discharge planning to support frail older persons at hospital discharge. In this context, active participation on their behalf cannot be taken for granted. The aim of this study was to elucidate patient participation in discharge planning conferences, with a focus on frail older persons, supported by the theory of positioning described by Harré & van Langenhove.
Methods
The study was designed as a case study based on audio-recordings of multidisciplinary discharge planning conferences and interviews with health professionals elucidating their opinions on preconditions for patient participation in discharge planning. The analysis has been performed using qualitative content analysis and discourse analysis. Data collection took place during 2008–2009 and included 40 health professionals and 13 frail older persons in hospital or municipal settings.
Results
Findings revealed four different positions of participation, characterized by the older person's level of activity during the conference and his/her appearance as being reduced (patient) or whole (person). The positions varied dynamically from being an active person, passive person, active patient, or passive patient and the health professionals, next-of-kin, and the older persons themselves contributed to the positioning.
Conclusions
The findings showed how the institutional setting served as a purposeful structure or a confinement to patient participation.
PMCID: PMC4236306  PMID: 25411572
patient participation; hospital discharge; frail older persons
24.  Relational continuity of care in integrated maternity and child health clinics improve parents’ service experiences 
Introduction
In the Finnish primary health care, relational continuity of care is implemented in integrated maternity and child health clinics where the same nurse takes care of the family from the pregnancy until the child reaches school age. The aim of this study was to clarify the association between this relational continuity of care and the availability, utilisation and selected features of the maternity and child health clinic services, as evaluated by the parents.
Methods
A comparative, cross-sectional service evaluation survey was used. Eighteen months after their baby's delivery, mothers (N = 987) and fathers (N = 835) from Southwest Finland evaluated specific maternity and child health clinic services. Comparisons were made between the parents who had relational continuity of care in the integrated maternity and child health clinics and those who did not.
Results
Home visits were more frequently provided when relational continuity of care in integrated maternity and child health clinics existed. Parents who had this relational continuity of care, evaluated several features of the service, especially provided support, more positively than parents who did not.
Conclusions
Relational continuity of care in integrated maternity and child health clinics seems to increase parents’ satisfaction with the services and might increase the provision of home visits.
PMCID: PMC4236307  PMID: 25411571
comparative study; child health services; maternal health services; continuity of patient care; STEPS study
25.  Collaborative interaction points in post-discharge stroke care 
Introduction
Lack of appropriate electronic tools for supporting patient involvement and collaboration with care professionals is a problem in health care.
Methods
Care and rehabilitation processes of post-discharge stroke patients were analysed using the concept of interaction points where patients, next-of-kin and care professionals interact and exchange information. Thirteen interviews with care professionals and five non-participatory observations were performed. Data were analysed using content analysis and modelling of interaction points in the patient journey.
Results
Patient participation and interaction patterns vary; patients requiring home care have a passive role and next-of-kin or nurses become advocates by coordinating care on behalf of the patient, whereas patients who are able to visit primary care coordinate their own care by initiating interactions. Important categories of participation include the following: participation in care planning, in monitoring risk factors and in rehabilitation planning.
Conclusions
Designing a supportive electronic tool requires understanding the interactions and patients’ activity levels at each interaction point. A tool for patients with higher activity level should support them to coordinate their own care, whereas for a less-active patient group, the tool could focus on supporting next-of-kin and care professionals in motivating, guiding and including passive patients in their care and rehabilitation processes.
PMCID: PMC4238053  PMID: 25414623
stroke; electronic tool; rehabilitation; care planning; patient participation; integrated care

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