How has the impact of 'care pathway technologies' on service integration in stroke care been measured and what is the strength of the evidence to support their effectiveness in this respect? How has the impact of 'care pathway technologies' on service integration in stroke care been measured and what is the strength of the evidence to support their effectiveness in this respect? Making sense of change: patients' views of diabetes and GP-led integrated diabetes care. mHealth Technology and Nurse Health Coaching to Improve Health in Diabetes: Protocol for a Randomized Controlled Trial Development of mWellcare: an mHealth intervention for integrated management of hypertension and diabetes in low-resource settings Can primary care team-based transition to insulin improve outcomes in adults with type 2 diabetes: the stepping up to insulin cluster randomized controlled trial protocol Improving diabetes care: multi-component cardiovascular disease risk reduction strategies for people with diabetes in South Asia--the CARRS multi-center translation trial. Dignity Through Integrated Symptom Management: Lessons From the Breathlessness Support Service. Effectiveness and cost-effectiveness of a proactive, goal-oriented, integrated care model in general practice for older people. A cluster randomised controlled trial: Integrated Systematic Care for older People—the ISCOPE study Protocol for a process evaluation of a cluster randomised controlled trial to improve management of multimorbidity in general practice: the 3D study Integrated Management of Type 2 Diabetes Mellitus and Depression Treatment to Improve Medication Adherence: A Randomized Controlled Trial A pilot test of an integrated self-care intervention for persons with heart failure and concomitant diabetes. Realist complex intervention science: Applying realist principles across all phases of the Medical Research Council framework for developing and evaluating complex interventions Evaluating the integration of chronic disease prevention and management services into primary health care An office-based intervention to maintain parent-adolescent teamwork in diabetes management. Impact on parent involvement, family conflict, and subsequent glycemic control. Integrated primary care for patients with mental and physical multimorbidity: cluster randomised controlled trial of collaborative care for patients with depression comorbid with diabetes or cardiovascular disease Randomised controlled trial of an automated, interactive telephone intervention to improve type 2 diabetes self-management (Telephone-Linked Care Diabetes Project): study protocol Integrating medical management with diabetes self-management training: a randomized control trial of the Diabetes Outpatient Intensive Treatment program. An integrated wound-care pathway, supported by telemedicine, and competent wound management - Essential in follow-up care of adults with diabetic foot ulcers Functional outcomes of multi-condition collaborative care and successful ageing: results of randomised trial The effects of a pro-active integrated care intervention for frail community-dwelling older people: a quasi-experimental study with the GP-practice as single entry point The United Kingdom Expert Patients Programme: results and implications from a national evaluation. Randomised trial of impact of model of integrated care and case management for older people living in the community
Background Across the developed world , we are witnessing an increasing emphasis on the need for more closely coordinated forms of health and social care provision . Integrated care pathways ( ICPs ) have emerged as a response to this aspiration and are believed by many to address the factors which contribute to service integration . ICPs map out a patient 's journey , providing coordination of services for users . They aim to have : ' the right people , doing the right things , in the right order , at the right time , in the right place , with the right outcome ' . The value for ICPs in supporting the delivery of care across organisational boundaries , providing greater consistency in practice , improving service continuity and increasing collaboration has been advocated by many . However , there is little evidence to support their use , and the need for systematic evaluations in order to measure their effectiveness has been widely identified . A recent Cochrane review assessed the effects of ICPs on functional outcome , process of care , quality of life and hospitalisation costs of in patients with acute stroke , but did not specifically focus on service integration or its derivatives . To the best of our knowledge , no such systematic review of the literature exists . Objectives To systematic ally review all high‐ quality studies which have evaluated the impact of care pathway technologies on ' service integration ' and its derivatives in stroke care To examine how elements of service integration are defined in such studies To examine the type of evidence utilised to measure service integration To analyse the weight of evidence used to support cl aims about the effectiveness of ICPs on improving service integration To produce recommendations for ICP developers , users and evaluators . Inclusion criteria Types of participants The review focused on the care of adult patients who had suffered a stroke . It included the full spectrum of services ‐ acute care , rehabilitation and long‐term support ‐ in hospital and community setting s. Types of intervention(s)/phenomena of interest Integrated care pathways were the intervention of interest , defined for the purpose of this review as ' a multidisciplinary tool to improve the quality and efficiency of evidence based care and is used as a communication tool between professionals to manage and st and ardise the outcome orientated care ' . Here ' multidisciplinary ' is taken to refer to the involvement of two or more disciplines . Types of outcomes Service integration ' was the outcome of interest however , this was defined and measured in the selected studies . Types of studies This review was concerned with how ' service integration ' was defined in evaluations of ICPs ; the type of evidence utilised in measuring the impact of the intervention and the weight of evidence to support the effectiveness of care pathway technologies on ' service integration ' . Studies that made an explicit link between ICPs and service integration were included in the review . Evidence generated from r and omised controlled trials , quasi‐experimental , qualitative and health economics research was sought . The search was limited to publications after 1980 , coinciding with the emergence of ICPs in the healthcare context . Assessment for inclusion of foreign papers was based on the English‐ language abstract , where available . These were included only if an English translation was available . Exclusion criteria This review excluded studies that : focused only on a single aspect of stroke care ( e.g. dysphasia ) evaluated ICPs as part of a wider program of service development did not make an explicit link between ICPs and service integration did not meet the definition of ICP utilised for the purpose s of the review focused exclusively on the outcomes of variance analysis Search strategy In order to avoid replication , the Joanna Briggs Institute for Evidence Based Nursing and Midwifery Data base and the Cochrane Library were search ed to establish that no systematic review s existed and none were in progress . A three‐stage search strategy was then used to identify both published and unpublished studies ( see Appendix III ) . Data collection Our search strategy located 2123 papers , of which 39 were retrieved for further evaluation . We critically appraised seven papers , representing five studies . These were all evaluation studies and , as is typical in this field , comprised a range of study design s and data collection methods . Owing to the diversity of the study types included in the review , we developed a single‐ appraisal checklist and data ‐ extraction tool which could be applied to all research design s.32 The tool drew on the Joanna Briggs Institute ( JBI ) appraisal checklists for experimental studies and interpretive and critical research , and also incorporated specific information and issues which were relevant for our purpose s ( see Appendix VI ) . This extends the thinking outlined in Lyne et al.31 in which , drawing on Campbell and Stanley 's classic paper , the case is made for developing an appraisal tool which is applicable to all types of evaluation , irrespective of study design . In assessing the quality of the papers , we were sympathetic to the method ological challenges of evaluating complex interventions such as ICPs . We were also cognisant of the very real constraints in which service evaluations are frequently undertaken in healthcare context s. In accordance with the aims of this particular review , we have included studies , which are method ologically weaker than is typical of many systematic review s because , in our view , in the absence of stronger evidence , they yield useful information . Data synthesis Given the heterogeneity of the included studies , meta‐ analysis and /or qualitative synthesis was not possible . A narrative summary of the study findings is presented . Results ICPs can be effective in ensuring that patients receive relevant clinical interventions and /or assessment s in a timely manner , although these improvements may reflect better documentation rather than actual changes in practice . ICPs can be effective in improving the documentation of rehabilitation goals , documentation of communication with patients , carers ( diagnosis , prognosis and follow‐up arrangements ) and documentation of notification of primary care physicians of discharge . However , this can create additional burdens of work for staff . Early studies of  ICP‐managed care in the acute stroke context have demonstrated reduced length of stay without any associated adverse effects on discharge destination , morbidity or mortality . These effects do not reach statistical significance , however , and may reflect wider changes in service provision and a general trend towards reduced length of hospital stay . While later studies in the acute and rehabilitation context s do not reveal any significant reduction in length of stay , they do report greater documented use of certain clinical interventions and assessment s , suggesting that ICPs can be effective in mobilising hospital re sources around the patient . ICPs implemented in the context of acute stroke care can be effective in reducing the occurrence of urinary tract infections , although we do not know whether this can be attributed to improved service integration . ICP management in stroke rehabilitation may not be flexible enough to meet diverse patient needs and can result in insufficient attention to higher‐level functioning and carer needs influencing perceptions of quality of life . ICP management may assist in clarifying role boundaries and a shared underst and ing of the work , but this can result in some members of the disciplinary team perceiving that their contribution is not appropriately reflected in the documentation . There is some evidence that ICPs may be effective in changing professional behaviours in the desired direction where there is scope for improvement , but in situations in which multidisciplinary working is effective , their positive effects may be limited . Furthermore , it is far from clear what the active ingredients of ICPs actually are . Kwan et al. suggest that it was the process of ICP development that had most impact on behaviours rather than the use of the artefact per se.20 None of the studies assessed the balance of costs and benefits of ICP use . Therefore , we do not know whether the costs of ICP development and implementation are justified by any of the reported benefits . Conclusions Implication s for practice There is some evidence that ICPs may support certain elements of service integration in the context of stroke care . This seems to be as a result of their ability to support the timely implementation of clinical interventions and the mobilisation of re sources around the patient without incurring additional increases in length of stay . ICPs appear to be most successful in improving service coordination in the acute stroke context where patient care trajectories are predictable . Their value in the context of rehabilitation setting s in which recovery pathways are more variable is less clear . There is some evidence that ICPs may be effective in bringing about behavioural changes in context s where deficiencies in service provision have been identified . Their value in context s where inter‐professional working is well established is less clear . While earlier before and after studies show a reduction in length of stay in ICP‐managed care , this may reflect wider healthcare trends , and the failure of later studies to demonstrate further reductions suggests that there may be limits as to how far this can continue to be reduced . There is some evidence to suggest that ICPs bring about improvements in documentation , but we do not know how far documented practice reflects actual practice . It is unclear how ICPs have their effects and the relative importance of the process of development and the artefact in use . As none of the studies review ed included an economic evaluation , moreover , it remains unclear whether the benefits of ICPs UNLABELLED EXECUTIVE SUMMARY : BACKGROUND Across the developed world , we are witnessing an increasing emphasis on the need for more closely coordinated forms of health and social care provision . Integrated care pathways ( ICPs ) have emerged as a response to this aspiration and are believed by many to address the factors which contribute to service integration . ICPs map out a patient 's journey , providing coordination of services for users . They aim to have : ' the right people , doing the right things , in the right order , at the right time , in the right place , with the right outcome ' . The value for ICPs in supporting the delivery of care across organisational boundaries , providing greater consistency in practice , improving service continuity and increasing collaboration has been advocated by many . However , there is little evidence to support their use , and the need for systematic evaluations in order to measure their effectiveness has been widely identified . A recent Cochrane review assessed the effects of ICPs on functional outcome , process of care , quality of life and hospitalisation costs of in patients with acute stroke , but did not specifically focus on service integration or its derivatives . To the best of our knowledge , no such systematic review of the literature exists . OBJECTIVES • To systematic ally review all high- quality studies which have evaluated the impact of care pathway technologies on ' service integration ' and its derivatives in stroke care • To examine how elements of service integration are defined in such studies • To examine the type of evidence utilised to measure service integration • To analyse the weight of evidence used to support cl aims about the effectiveness of ICPs on improving service integration • To produce recommendations for ICP developers , users and evaluators . INCLUSION CRITERIA Types of participants The review focused on the care of adult patients who had suffered a stroke . It included the full spectrum of services - acute care , rehabilitation and long-term support - in hospital and community setting s. Types of intervention(s)/phenomena of interest Integrated care pathways were the intervention of interest , defined for the purpose of this review as ' a multidisciplinary tool to improve the quality and efficiency of evidence based care and is used as a communication tool between professionals to manage and st and ardise the outcome orientated care ' Here ' multidisciplinary ' is taken to refer to the involvement of two or more disciplines . Types of outcomes ' Service integration ' was the outcome of interest however , this was defined and measured in the selected studies . Types of studies This review was concerned with how ' service integration ' was defined in evaluations of ICPs ; the type of evidence utilised in measuring the impact of the intervention and the weight of evidence to support the effectiveness of care pathway technologies on ' service integration ' . Studies that made an explicit link between ICPs and service integration were included in the review . Evidence generated from r and omised controlled trials , quasi-experimental , qualitative and health economics research was sought . The search was limited to publications after 1980 , coinciding with the emergence of ICPs in the healthcare context . Assessment for inclusion of foreign papers was based on the English- language abstract , where available . These were included only if an English translation was available . EXCLUSION CRITERIA This review excluded studies that : • focused only on a single aspect of stroke care ( e.g. dysphasia ) • evaluated ICPs as part of a wider program of service development • did not make an explicit link between ICPs and service integration • did not meet the definition of ICP utilised for the purpose s of the review • focused exclusively on the outcomes of variance analysis SEARCH STRATEGY In order to avoid replication , the Joanna Briggs Institute for Evidence Based Nursing and Midwifery Data base and the Cochrane Library were search ed to establish that no systematic review s existed and none were in progress . A three-stage search strategy was then used to identify both published and unpublished studies ( see Appendix III ) . DATA COLLECTION Our search strategy located 2123 papers , of which 39 were retrieved for further evaluation . We critically appraised seven papers , representing five studies . These were all evaluation studies and , as is typical in this field , comprised a range of study design s and data collection methods . Owing to the diversity of the study types included in the review , we developed a single- appraisal checklist and data - extraction tool which could be applied to all research design s.(32 ) The tool drew on the Joanna Briggs Institute ( JBI ) appraisal checklists for experimental studies and interpretive and critical research , and also incorporated specific information and issues which were relevant for our purpose s ( see Appendix VI ) . This extends the thinking outlined in Lyne et al.(31 ) in which , drawing on Campbell and Stanley 's classic paper , the case is made for developing an appraisal tool which is applicable to all types of evaluation , irrespective of study design . In assessing the quality of the papers , we were sympathetic to the method ological challenges of evaluating complex interventions such as ICPs . We were also cognisant of the very real constraints in which service evaluations are frequently undertaken in healthcare context s. In accordance with the aims of this particular review , we have included studies , which are method ologically weaker than is typical of many systematic review s because , in our view , in the absence of stronger evidence , they yield useful information . DATA SYNTHESIS Given the heterogeneity of the included studies , meta- analysis and /or qualitative synthesis was not possible . A narrative summary of the study findings is presented . RESULTS 1 ICPs can be effective in ensuring that patients receive relevant clinical interventions and /or assessment s in a timely manner , although these improvements may reflect better documentation rather than actual changes in practice . 2 ICPs can be effective in improving the documentation of rehabilitation goals , documentation of communication with patients , carers ( diagnosis , prognosis and follow-up arrangements ) and documentation of notification of primary care physicians of discharge . However , this can create additional burdens of work for staff . 3 Early studies of ICP-managed care in the acute stroke context have demonstrated reduced length of stay without any associated adverse effects on discharge destination , morbidity or mortality . These effects do not reach statistical significance , however , and may reflect wider changes in service provision and a general trend towards reduced length of hospital stay . While later studies in the acute and rehabilitation context s do not reveal any significant reduction in length of stay , they do report greater documented use of certain clinical interventions and assessment s , suggesting that ICPs can be effective in mobilising hospital re sources around the patient . 4 ICPs implemented in the context of acute stroke care can be effective in reducing the occurrence of urinary tract infections , although we do not know whether this can be attributed to improved service integration . 5 ICP management in stroke rehabilitation may not be flexible enough to meet diverse patient needs and can result in insufficient attention to higher-level functioning and carer needs influencing perceptions of quality of life . 6 ICP management may assist in clarifying role boundaries and a shared underst and ing of the work , but this can result in some members of the disciplinary team perceiving that their contribution is not appropriately reflected in the documentation . 7 There is some evidence that ICPs may be effective in changing professional behaviours in the desired direction where there is scope for improvement , but in situations in which multidisciplinary working is effective , their positive effects may be limited . Furthermore , it is far from clear what the active ingredients of ICPs actually are . Kwan et al. suggest that it was the process of ICP development that had most impact on behaviours rather than the use of the artefact per se.(20 ) 8 None of the studies assessed the balance of costs and benefits of ICP  use . Therefore , we do not know whether the costs of ICP development and implementation are justified by any of the reported benefits . CONCLUSIONS Implication s for practice There is some evidence that ICPs may support certain elements of service integration in the context of stroke care . This seems to be as a result of their ability to support the timely implementation of clinical interventions and the mobilisation of re sources around the patient without incurring additional increases in length of stay .  ICPs appear to be most successful in improving service coordination in the acute stroke context where patient care trajectories are predictable . Their value in the context of rehabilitation setting s in which recovery pathways are more variable is less clear . There is some evidence that ICPs may be effective in bringing about behavioural changes in context s where deficiencies in service provision have been identified . Their value in context s where inter-professional working is well established is less clear . While earlier before and after studies show a reduction in length of stay in ICP-managed care , this may reflect wider healthcare trends , and the failure of later studies to demonstrate further reductions suggests that there may be limits as to how far this can continue to be reduced . There is some evidence to suggest that ICPs bring about improvements in documentation , but we do not know how far documented practice reflects actual practice . It is unclear how ICPs have their effects and the relative importance of the process of development and the artefact in use . ( ABSTRACT TRUNCATED BACKGROUND Health system reform is directed towards better management of diabetes . However , change can be difficult , and patients ' perspectives are a key aspect of implementing change . OBJECTIVE This study investigated patients ' perceptions and experiences  of  type 2 diabetes ( T2DM )  , self-care and engagement with GP-led integrated diabetes care . DESIGN Qualitative interviews were conducted with purposively selected patients with T2DM following their initial medical appointment in the new model of care .  Normalization process theory was used to orientate the thematic analysis , to explain the work of implementing change . SETTING Two specialist GP-based complex diabetes services in primary care in Brisbane , Australia . PARTICIPANTS Intervention group patients ( n = 30 ) in a r and omized controlled trial to evaluate a model of GP-led integrated care for complex T2DM . MAIN OUTCOME MEASURES Participants ' experiences and perceptions of diabetes management and a GP-led model  of care . RESULTS Three themes were identified : sensibility of change , ' diabetic life ' and diabetes care alliance . The imperative of change made sense , but some participants experienced dissonance between this rational view and their lived reality . Diabetes invaded life , revealing incongruities between participants ' values and living with diabetes . They appreciated a flexible and personalized approach to care . DISCUSSION Participants responded to advice in ways that seemed rational within the complexities of their life context . Their diabetes partnerships with health professionals coupled providers ' biomedical expertise with patients ' context ual expertise . CONCLUSIONS Learning to manage relationships with various health professionals adds to patients ' diabetes-related work . Providers need to adopt a flexible , interactive approach and foster trust , to enable better diabetes care Background Chronic diseases , including diabetes mellitus , are the leading cause of mortality and disability in the United States . Current solutions focus primarily on diagnosis and pharmacological treatment , yet there is increasing evidence that patient-centered models of care are more successful in improving and addressing chronic disease outcomes . Objective The objective of this clinical trial is to evaluate the impact of a mobile health ( mHealth ) enabled nurse health coaching intervention on self-efficacy among adults with type-2 diabetes mellitus . Methods A r and omized controlled trial was conducted at an academic health system in Northern California . A total of 300 participants with type-2 diabetes were scheduled to be enrolled through three primary care clinics . Participants were r and omized to either usual care or intervention . All participants received training on use of the health system patient portal . Participants in the intervention arm received six scheduled health-coaching telephone calls with a registered nurse and were provided with an activity tracker and mobile application that integrated data into the electronic health record ( EHR ) to track their daily activity and health behavior decisions . All participants completed a baseline survey and follow-up surveys at 3 and 9 months . Primary and secondary outcomes include diabetes self-efficacy , hemoglobin A1c ( HbA1c ) , and quality of life measures . Results Data collection for this trial , funded by the Patient-Centered Outcomes Research Institute , will be completed by December 2017 . Results from the trial will be available mid-2018 . Conclusions This protocol details a patient-centered intervention using nurse health coaching , mHealth technologies , and integration of patient-generated data into the EHR . The aim of the intervention is to enhance self-efficacy and health outcomes by providing participants with a mechanism to track daily activity by offering coaching support to set reasonable and attainable health goals , and by creating a complete feedback loop by bringing patient-generated data into the EHR . Trial Registration Clinical Trials.gov NCT02672176 ; https:// clinical trials.gov/ct2/show/NCT02672176 ( Archived by WebCite at http://www.webcitation.org/6xEQXe1M5 ABSTRACT Background : Cardiovascular diseases and diabetes are among the leading causes of premature adult deaths in India . Innovative approaches such as clinical decision support ( CDS ) software could play a major role in improving the quality of hypertension/diabetes care in primary care setting s. Objective : To describe the steps and processes in the development of mWellcare , a complex intervention based on mobile health ( mHealth ) technology . Methods : The Medical Research Council framework was used to develop mWellcare in four steps : ( 1 ) identify gaps in usual care through literature review and health facility assessment s ; ( 2 ) identify the components of the intervention through discussion s and consultations with experts ; ( 3 ) develop intervention ( clinical algorithms and mHealth system ) ; and ( 4 ) evaluate acceptability and feasibility through pilot testing in five community health centers . Results : Lack of evidence -based , integrated , and systematic management of chronic conditions were major gaps identified . Experts in information technology , clinical fields , and public health professionals identified intervention components to address these gaps . Thereafter , clinical algorithm context ualized to primary care setting s were prepared and the mWellcare intervention was developed . During the 2-month pilot , 631 patients diagnosed with hypertension and /or diabetes were registered , with a follow-up rate of 36.2 % . The major barrier was resistance to follow mWellcare recommended patient workflow , and to overcome it , we emphasized onsite training and orientation program to cover all health care team member in each CHC . Conclusion : A pilot-tested mWellcare intervention is an mHealth system with important components , i.e. integrated management of chronic conditions , evidence -based CDS , longitudinal health data and automated short-messaging service to reinforce compliance to drug intake and follow-up visit , which will be used by nurses at primary health care setting s in India . The effectiveness and cost-effectiveness of the intervention will be tested through a cluster r and omized trial ( trial registration number NCT02480062 ) Background Type 2 diabetes ( T2D ) brings significant human and healthcare costs . Its progressive nature means achieving normoglycaemia is increasingly difficult , yet critical to avoiding long term vascular complications . Nearly one-half of people with T2D have glycaemic levels out of target . Insulin is effective in achieving glycaemic targets , yet initiation of insulin is often delayed , particularly in primary care . Given limited access to specialist re sources and the size of the diabetes epidemic , primary care is where insulin initiation must become part of routine practice . This would also support integrated holistic care for people with diabetes . Our Stepping Up Program is based on a general practitioner ( GP ) and practice nurse ( PN ) model of care supported appropriately by endocrinologists and credentialed diabetes educator-registered nurses . Pilot work suggests the model facilitates integration of the technical work of insulin initiation within ongoing generalist care . Methods This protocol is for a cluster r and omized controlled trial to examine the effectiveness of the Stepping Up Program to enhance the role of the GP-PN team in initiating insulin and improving glycaemic outcomes for people with T2D . 224 patients between the ages of 18 and 80 years with T2D , on two or more oral hypoglycaemic agents and with an HbA1c ≥7.5 % in the last six months will be recruited from 74 general practice s. The unit of r and omization is the practice . Primary outcome is change in glycated haemoglobin HbA1c ( measured as a continuous variable ) . We hypothesize that the intervention arm will achieve an absolute HbA1c mean difference of 0.5 % lower than control group at 12 months follow up . Secondary outcomes include the number of participants who successfully transfer to insulin and the proportion who achieve HbA1c measurement of < 7.0 % . We will also collect data on patient psychosocial outcomes and healthcare utilization and costs . Discussion The study is a pragmatic translational study with important potential implication s for people with T2D , healthcare professionals and funders of healthcare though making better use of scarce healthcare re sources , improving timely access to therapy that can improve disease outcomes .Trial registration Australian and New Zeal and Clinical Trials Registry AIMS Cardiovascular disease ( CVD ) is the leading cause of morbidity and mortality in people with diabetes in South Asia . The CARRS Translation Trial tests the effectiveness , cost-effectiveness , and sustainability of a clinic-based multi-component CVD risk reduction intervention among people with diabetes in India and Pakistan . METHODS We r and omly assigned 1146 adults with diabetes recruited from 10 urban clinic sites , to receive usual care by physicians or to receive an integrated multi-component CVD risk reduction intervention . The intervention involves electronic health record management , decision-support prompts to the healthcare team , and the support of a care coordinator to actively facilitate patient and provider adherence to evidence -based guidelines . The primary outcome is a composite of multiple CVD risk factor control ( blood glucose and either blood pressure or cholesterol , or all three ) . Other outcomes include control of the individual CVD risk factors , process and patient-centered measures , cost-effectiveness , and acceptability/feasibility . CONCLUSION The CARRS Translation Trial tests a low-cost diabetes care delivery model in urban South Asia to achieve comprehensive cardio-metabolic disease case-management of high-risk patients ( clinical trials.gov number : NCT01212328 ) CONTEXT Dignity is poorly conceptualized and little empirically explored in end-of-life care . A qualitative evaluation of a service offering integrated palliative and respiratory care for patients with advanced disease and refractory breathlessness uncovered an unexpected outcome , it enhanced patients ' dignity . OBJECTIVES To analyze what constitutes dignity for people suffering from refractory breathlessness with advanced disease , and its implication s for the concept of dignity . METHODS Qualitative study of cross-sectional interviews with 20 patients as part of a Phase III evaluation of a r and omized controlled fast-track trial . The interviews were transcribed verbatim , imported into NVivo , and analyzed through constant comparison . The findings were compared with Chochinov et al. 's dignity model . The model was adapted with the themes and subthemes specific to patients suffering from breathlessness . RESULTS The findings of this study underscore the applicability of the conceptual model of dignity for patients with breathlessness . There were many similarities in themes and subthemes . Differences specifically relevant for patients suffering from severe breathlessness were as follows : 1 ) physical distress and psychological mechanisms are interlinked with the disability and dependence breathlessness causes , in the illness-related concerns , 2 ) stigma is an important component of the social dignity inventory , 3 ) conditions and perspectives need to be present to practice self-care in the dignity-conserving repertoire . CONCLUSION Dignity is an integrated concept and can be affected by influences from other areas such as illness-related concerns . The intervention shows that targeting the symptom holistically and equipping patients with the means for self-care realized the outcome of dignity Background : older people often experience complex problems . Because of multiple problems , care for older people in general practice needs to shift from a ‘ problem-based , disease-oriented ’ care aim ing at improvement of outcomes per disease to a ‘ goal -oriented care ’ , aim ing at improvement of functioning and personal quality of life , integrating all healthcare providers . Feasibility and cost-effectiveness of this proactive and integrated way of working are not yet established . Design : cluster r and omised trial . Participants : all persons aged ≥75 in 59 general practice s ( 30 intervention , 29 control ) , with a combination of problems , as identified with a structured postal question naire with 21 questions on four health domains . Intervention : for participants with problems on ≥3 domains , general practitioners ( GPs ) made an integrated care plan using a functional geriatric approach . Control practice s : care as usual . Outcome measures : ( i ) quality of life ( QoL ) , ( ii ) activities of daily living , ( iii ) satisfaction with delivered health care and ( iv ) cost-effectiveness of the intervention at 1-year follow-up . Trial registration : Netherl and s trial register , NTR1946 . Results : of the 11,476 registered eligible older persons , 7,285 ( 63 % ) participated in the screening . One thous and nine hundred and twenty-one ( 26 % ) had problems on ≥3 health domains . For 225 r and omly chosen persons , a care plan was made . No beneficial effects were found on QoL , patients ' functioning or healthcare use/costs . GPs experienced better overview of the care and stability , e.g. less unexpected dem and s , in the care . Conclusions : GPs prefer proactive integrated care . ‘ Horizontal ’ care using care plans for older people with complex problems can be a valuable tool in general practice . However , no direct beneficial effect was found for older persons Introduction As an increasing number of people are living with more than 1 long-term condition , identifying effective interventions for the management of multimorbidity in primary care has become a matter of urgency . Interventions are challenging to evaluate due to intervention complexity and the need for adaptability to different context s. A process evaluation can provide extra information necessary for interpreting trial results and making decisions about whether the intervention is likely to be successful in a wider context . The 3D ( dimensions of health , drugs and depression ) study will recruit 32 UK general practice s to a cluster r and omised controlled trial to evaluate effectiveness of a patient-centred intervention . Practice s will be r and omised to intervention or usual care . Methods and analysis The aim of the process evaluation is to underst and how and why the intervention was effective or ineffective and the effect of context . As part of the intervention , quantitative data will be collected to provide implementation feedback to all intervention practice s and will contribute to evaluation of implementation fidelity , alongside case study data . Data will be collected at the beginning and end of the trial to characterise each practice and how it provides care to patients with multimorbidity . Mixed methods will be used to collect qualitative data from 4 case study practice s , purposively sample d from among intervention practice s. Qualitative data will be analysed using techniques of constant comparison to develop codes integrated within a flexible framework of themes . Quantitative and qualitative data will be integrated to describe case study sites and develop possible explanations for implementation variation . Analysis will take place prior to knowing trial outcomes . Ethics and dissemination Study approved by South West ( Frenchay ) National Health Service ( NHS ) Research Ethics Committee ( 14/SW/0011 ) . Findings will be disseminated via a final report , peer- review ed publications and practical guidance to healthcare professionals , commissioners and policymakers . Trial registration number IS RCT N06180958 PURPOSE Depression commonly accompanies diabetes , result ing in reduced adherence to medications and increased risk for morbidity and mortality . The objective of this study was to examine whether a simple , brief integrated approach to depression and type 2 diabetes mellitus ( type 2 diabetes ) treatment improved adherence to oral hypoglycemic agents and antidepressant medications , glycemic control , and depression among primary care patients . METHODS We undertook a r and omized controlled trial conducted from April 2010 through April 2011 of 180 patients prescribed pharmacotherapy for type 2 diabetes and depression in primary care . Patients were r and omly assigned to an integrated care intervention or usual care . Integrated care managers collaborated with physicians to offer education and guideline -based treatment recommendations and to monitor adherence and clinical status . Adherence was assessed using the Medication Event Monitoring System ( MEMS ) . We used  glycated hemoglobin ( HbA1c ) assays  to measure glycemic control and the 9-item Patient Health Question naire ( PHQ-9 ) to assess depression . RESULTS Intervention and usual care groups did not differ statistically on baseline measures . Patients who received the intervention were more likely to achieve HbA1c levels of less than 7 % ( intervention 60.9 % vs usual care 35.7 % ; P < .001 ) and remission of depression ( PHQ-9 score of less than 5 : intervention 58.7 % vs usual care 30.7 % ; P < .001 ) in comparison with patients in the usual care group at 12 weeks . CONCLUSIONS A r and omized controlled trial of a simple , brief intervention integrating treatment of type 2 diabetes and depression was successful in improving outcomes in primary care . An integrated approach to depression and type 2 diabetes treatment may facilitate its deployment in real-world practice s with competing dem and s for limited re sources Studies show 30 % to 47 % of people with heart failure ( HF ) have concomitant diabetes mellitus ( DM ) . Self-care for persons with both of these chronic conditions is conflicting , complex , and often inadequate . This pilot study tested an integrated self-care program for its effects on HF and DM knowledge , self-care efficacy , self-care behaviors , and quality of life ( QOL ) .  Hospitalized HF-DM participants ( N = 71 ) were r and omized to usual care or intervention using a 1:2 allocation and followed at 30 and 90 days after intervention . Intervention was an integrated education and counseling program focused on HF-DM self-care . Variables included demographic and clinical data , knowledge about HF and DM , HF- and DM-specific self-efficacy , st and ard HF and DM QOL scales , and HF and DM self-care behaviors . Analysis included descriptive statistics , multilevel longitudinal models for group and time effects , post hoc testing , and effect size calculations . Sidak adjustments were used to control for type 1 error inflation . The integrated HF-DM self-care intervention conferred effects on improved HF knowledge ( 30 days , p = .05 ) , HF self-care maintenance ( 30 and 90 days , p < .001 ) , HF self-care management ( 90 days , p = .05 ) , DM self-efficacy ( 30 days , p = .03 ; 90 days , p = .004 ) , general diet ( 30 days , p = .05 ) , HF physical QOL ( p = .04 ) , and emotional QOL scores ( p = .05 ) at 90 days within the intervention group . The participants in the usual care group also reported increased total and physical QOL . Greater percentages of participants in the intervention group improved self reported exercise between 0 and 30 days ( p = .005 and moderate effect size ES = .47 ) and foot care between 0 and 90 days ( p = .03 , small ES = .36 ) . No group differences or improvements in DM-specific QOL were observed . An integrated HF-DM self-care intervention was effective in improving essential components of self-care and had sustained ( 90 day ) effects on selected self-care behaviors . Future studies testing HF-DM integrated self-care interventions in larger sample s with longer follow-up and on other outcomes such as hospitalization and clinical markers are warranted The integration of realist evaluation principles within r and omised controlled trials ( ‘ realist RCTs ’ ) enables evaluations of complex interventions to answer questions about what works , for whom and under what circumstances . This allows evaluators to better develop and refine mid-level programme theories . However , this is only one phase in the process of developing and evaluating complex interventions . We describe and exemplify how social scientists can integrate realist principles across all phases of the Medical Research Council framework . Intervention development , modelling , and feasibility and pilot studies need to theorise the context ual conditions necessary for intervention mechanisms to be activated . Where interventions are scaled up and translated into routine practice , realist principles also have much to offer in facilitating knowledge about longer-term sustainability , benefits and harms . Integrating a realist approach across all phases of complex intervention science is vital for considering the feasibility and likely effects of interventions for different localities and population subgroups Background The increasing number of patients with chronic diseases represents a challenge for health care systems . The Chronic Care Model suggests a multi-component remodelling of chronic disease services to improve patient outcomes . To meet the complex and ongoing needs of patients , chronic disease prevention  and management ( CDPM ) has been advocated as a key feature of primary care producing better outcomes , greater effectiveness and improved access to services compared to other sectors . The objective of this study is to evaluate the adaptation and implementation of an  intervention  involving the integration of chronic disease prevention and management ( CDPM ) services into primary health care . Methods / Design The implementation of the intervention will be evaluated using descriptive qualitative methods to collect data from various stakeholders ( decision-makers , primary care professionals , CDPM professionals and patients ) before , during and after the implementation . The evaluation of the effects will be based on a combination of experimental design s : a r and omized trial using a delayed intervention arm ( n = 326 ) , a before- and -after design with repeated measures ( n = 163 ) , and a quasi-experimental design using a comparative cohort ( n = 326 ) . This evaluation will utilize self-report question naires measuring self-efficacy , empowerment , comorbidity , health behaviour , functional health status , quality of life , psychological well-being , patient characteristics and co- interventions . The study will take place in eight primary care practice s of the Saguenay region of Quebec ( Canada ) . To be included , patients will have to be referred by their primary care provider and present at least one of the following conditions ( or their risk factors ) : diabetes , cardiovascular diseases , chronic obstructive pulmonary disease , asthma . Patients presenting serious cognitive problems will be excluded . Discussion In the short-term , improved patient self-efficacy and empowerment are expected . In the mid-term , we expect to observe an improvement in health behaviour , functional health status , quality of life and psychological well-being . At the organizational level , the project should lead to coordinated service delivery , improved patient follow-up mechanisms and enhanced interprofessional collaboration . Integration of CDPM services at the point of care in primary care practice s is a promising innovation in care delivery that needs to be thoroughly evaluated . Trial registration Clinical Trials.gov Identifier : OBJECTIVE To design and evaluate an office-based intervention aim ed at maintaining parent-adolescent teamwork in diabetes management tasks without increasing diabetes-related family conflict . RESEARCH DESIGN AND METHODS There were 85 patients ( aged 10 - 15 years , mean 12.6 years ) with type 1 diabetes ( mean duration 5.5 years ; mean HbA1c 8.5 % ) who were r and omly assigned to one of three study groups -- teamwork , attention control , and st and ard care-- and followed for 24 months . At each visit , parent involvement in insulin administration and blood glucose monitoring  was assessed . The teamwork and attention control interventions were integrated into routine ambulatory visits over the first 12 months ( four medical visits ) . Measures of diabetes-related family conflict were collected at baseline and after 12 months . All patients were followed for an additional 12 months with respect to glycemic control . RESULTS In the teamwork group , there was no major deterioration ( 0 % ) in parent involvement in insulin administration , in contrast to 16 % major deterioration in the combined comparison ( attention control and st and ard care ) group ( P < 0.03 ) . Similarly , no teamwork families showed major deterioration in parent involvement with blood glucose monitoring versus 11 % in the comparison group ( P < 0.07 ) . On both the Diabetes Family Conflict Scale and the Diabetes Family Behavior Checklist , teamwork families reported significantly less conflict at 12 months . An analysis of HbA1c over the 12- to 24-month follow-up period indicated that more adolescents in the teamwork group ( 68 % ) than in the comparison group ( 47 % ) improved their HbA1c ( P < 0.07 ) . CONCLUSIONS The data demonstrate that parent involvement in diabetes management tasks can be strengthened through a low-intensity intervention integrated into routine follow-up diabetes care . Moreover , despite increased engagement between teen and parent centered around diabetes tasks , the teamwork families showed decreased diabetes-related family conflict . Within the context of a broader cultural recognition of the protective function of parent involvement in the lives of adolescents , the findings of this study reinforce the potential value of a parent-adolescent partnership in managing chronic disease Objective To test the effectiveness of an integrated collaborative care model for people with depression and long term physical conditions . Design Cluster r and omised controlled trial . Setting 36 general practice s in the north west of Engl and . Participants 387 patients with a record of diabetes or heart disease , or both , who had depressive symptoms ( ≥10 on patient health question aire-9 ( PHQ-9 ) ) for at least two weeks . Mean age was 58.5 ( SD 11.7 ) . Participants reported a mean of 6.2 ( SD 3.0 ) long term conditions other than diabetes or heart disease ; 240 ( 62 % ) were men ; 360 ( 90 % ) completed the trial .  Interventions Collaborative care included patient preference for behavioural activation , cognitive restructuring , grade d exposure , and /or lifestyle advice , management of drug treatment , and prevention of relapse . Up to eight sessions of psychological treatment were delivered by specially trained psychological wellbeing practitioners employed by Improving Access to Psychological Therapy services in the English National Health Service ; integration of care was enhanced by two treatment sessions delivered jointly with the practice nurse . Usual care was st and ard clinical practice provided by general practitioners and practice nurses . Main outcome measures The primary outcome was reduction in symptoms of depression on the self reported symptom checklist-13 depression scale ( SCL-D13 ) at four months after baseline assessment . Secondary outcomes included anxiety symptoms ( generalised anxiety disorder 7 ) , self management ( health education impact question naire ) , disability ( Sheehan disability scale ) , and global quality of life ( WHOQOL-BREF ) . Results 19 general practice s were r and omised to collaborative care and 20 to usual care ; three practice s withdrew from the trial before patients were recruited . 191 patients were recruited from practice s allocated to collaborative care , and 196 from practice s allocated to usual care . After adjustment for baseline depression score , mean depressive scores were 0.23 SCL-D13 points lower ( 95 % confidence interval −0.41 to −0.05 ) in the collaborative care arm , equal to an adjusted st and ardised effect size of 0.30 . Patients in the intervention arm also reported being better self managers , rated their care as more patient centred , and were more satisfied with their care . There were no significant differences between groups in quality of life , disease specific quality of life , self efficacy , disability , and social support . Conclusions Collaborative care that incorporates brief low intensity psychological therapy delivered in partnership with practice nurses in primary care can reduce depression and improve self management of chronic disease in people with mental and physical multimorbidity . The size of the treatment effects were modest and were less than the prespecified effect but were achieved in a trial run in routine setting s with a deprived population with high levels of mental and physical multimorbidity . Trial registration IS RCT N80309252 Background An estimated 285 million people worldwide have diabetes and its prevalence is predicted to increase to 439 million by 2030 . For the year 2010 , it is estimated that 3.96 million excess deaths in the age group 20 - 79 years are attributable to diabetes around the world . Self-management is recognised as an integral part of diabetes care . This paper describes the protocol of a r and omised controlled trial of an automated interactive telephone system aim ing to improve the uptake and maintenance of essential diabetes self-management behaviours . Methods / Design A total of 340 individuals with type 2 diabetes will be r and omised , either to the routine care arm , or to the intervention arm in which participants receive the  Telephone-Linked Care ( TLC ) Diabetes program in addition to their routine care . The intervention requires the participants to telephone the TLC Diabetes phone system weekly for 6 months . They receive the study h and book and a glucose meter linked to a data uploading device . The TLC system consists of a computer with software design ed to provide monitoring , tailored feedback and education on key aspects of diabetes self-management , based on answers voiced or entered during the current or previous conversations . Data collection is conducted at baseline ( Time 1 ) , 6-month follow-up ( Time 2 ) , and 12-month follow-up ( Time 3 ) . The primary outcomes are glycaemic control ( HbA1c ) and quality of life ( Short Form-36 Health Survey version 2 ) . Secondary outcomes include anthropometric measures , blood pressure , blood lipid profile , psychosocial measures as well as measures of diet , physical activity , blood glucose monitoring , foot care and medication taking . Information on utilisation of healthcare services including hospital admissions , medication use and costs is collected . An economic evaluation is also planned . Discussion Outcomes will provide evidence concerning the efficacy of a telephone-linked care intervention for self-management of diabetes . Furthermore , the study will provide insight into the potential for more widespread uptake of automated telehealth interventions , globally . Trial Registration OBJECTIVE This study evaluated the Diabetes Outpatient Intensive Treatment ( DOIT ) program , a multiday group education and skills training experience combined with daily medical management , followed by case management over 6 months . Using a r and omized control design , the study explored how DOIT affected glycemic control and self-care behaviors over a short term . The impact of two additional factors on clinical outcomes were also examined ( frequency of case management contacts and whether or not insulin was started during the program ) . RESEARCH DESIGN AND METHODS Patients with type 1 and type 2 diabetes in poor glycemic control ( A1c > 8.5 % ) were r and omly assigned to DOIT or a second condition , entitled EDUPOST , which was st and ard diabetes care with the addition of quarterly educational mailings . A total of 167 patients ( 78 EDUPOST , 89 DOIT ) completed all baseline measures , including A1c and a question naire assessing diabetes-related self-care behaviors . At 6 months , 117 patients ( 52 EDUPOST , 65 DOIT ) returned to complete a follow-up A1c and the identical self-care question naire . RESULTS At follow-up , DOIT evidence d a significantly greater drop in A1c than EDUPOST . DOIT patients also reported significantly more frequent blood glucose monitoring and greater attention to carbohydrate and fat contents ( ACFC ) of food compared with EDUPOST patients . An increase in ACFC over the 6-month period was associated with improved glycemic control among DOIT patients . Also , the frequency of nurse case manager follow-up contacts was positively linked to better A1c outcomes . The addition of insulin did not appear to be a significant contributor to glycemic change . CONCLUSIONS DOIT appears to be effective in promoting better diabetes care and positively influencing glycemia and diabetes-related self-care behaviors . However , it dem and s significant time , commitment , and careful coordination with many health care professionals . The role of the nurse case manager in providing ongoing follow-up contact seems important INTRODUCTION Diabetic foot ulcers are a feared complication of diabetes . Care delivered via telemedicine is suggested to be a more integrated care pathway to manage diabetic foot ulcers than traditionally delivered healthcare . Our aim was to explore patients ' experiences with telemedicine follow-up care as compared to traditional care . METHODS Interpretive description was used as an analysis strategy . Data were collected using individual semi-structured interviews in the context of a larger ongoing clustered r and omized controlled trial . Twenty-four patients ( 13 in the intervention group ; 11 in the control group ) , aged 38 - 88 years were purposively recruited from the RCT in order to obtain a diverse sample in terms of group composition ( intervention vs. control ) , age , gender , marital status , setting , and comorbidities present . The control group received traditional care . RESULTS Three themes emerged from the interpretive analysis : competence of healthcare professionals , continuity of care , and easy access . This was independed of types of follow-up that had limited impact on the patients ' follow-up experiences . Competence of healthcare professionals and continuity of care were crucial , because they can either enhance or jeopardize wound care . If these two latter factors were absent , patients would lose confidence in the wound care process . If this happened , patients pointed out that the expert knowledge of a specialist clinic was essential to receive good care . When telemedicine functioned optimally , telemedicine was an advantage in the treatment , because the images quickly captured changes in the wound healing that immediately could be corrected . Easy access is important for patients , but the importance of accessibility appears to be primary when the other two factors were present . CONCLUSION The best wound care pathway for patients with diabetes foot ulcers is depended on a combination of competence and professional skills in wound management , and continuity of care . If telemedicine is functioning as intended , it can be an important additional tool Objective To evaluate the effectiveness of integrated care for chronic physical diseases and depression  in reducing disability and improving quality of life . Design A r and omised controlled trial of multi-condition collaborative care for depression and poorly controlled diabetes and /or risk factors for coronary heart disease compared with usual care among middle aged and elderly people Setting Fourteen primary care clinics in Seattle , Washington . Participants Patients with diabetes or coronary heart disease , or both , and blood pressure above 140/90 mm Hg , low density lipoprotein concentration > 3.37 mmol/L , or glycated haemoglobin 8.5 % or higher , and PHQ-9 depression scores of ≥10 . Intervention A 12 month intervention to improve depression , glycaemic control , blood pressure , and lipid control  by integrating a “ treat to target ” programme for diabetes and risk factors for coronary heart disease with collaborative care for depression . The intervention combined self management support , monitoring of disease control , and pharmacotherapy to control depression , hyperglycaemia , hypertension , and hyperlipidaemia . Main outcome measures Social role disability ( Sheehan disability scale ) , global quality of life rating , and World Health Organization disability assessment schedule ( WHODAS-2 ) scales to measure disabilities in activities of daily living ( mobility , self care , household maintenance ) . Results Of 214 patients enrolled ( 106 intervention and 108 usual care ) , disability and quality of life measures were obtained for 97 intervention patients at six months ( 92 % ) and 92 at 12 months ( 87 % ) , and for 96 usual care patients at six months ( 89 % ) and 92 at 12 months ( 85 % ) . Improvements from baseline on the Sheehan disability scale ( −0.9 , 95 % confidence interval −1.5 to −0.2 ; P=0.006 ) and global quality of life rating ( 0.7 , 0.2 to 1.2 ; P=0.005 ) were significantly greater at six and 12 months in patients in the intervention group . There was a trend toward greater improvement in disabilities in activities of daily living ( −1.5 , −3.3 to 0.4 ; P=0.10 ) . Conclusions Integrated care that covers chronic physical disease and comorbid depression can reduce social role disability and enhance global quality of life . Trial registration Clinical Trials NCT00468676 Background This study explored the effectiveness of a pro-active , integrated care model for community-dwelling frail older people compared to care as usual by evaluating the effects on a comprehensive set of outcomes : health outcomes ( experienced health , mental health and social functioning ) ; functional abilities ; and quality of life ( general , health-related and well-being ) . Methods The design of this study was quasi-experimental . In this study , 184 frail older patients of three GP practice s that implemented the Walcheren Integrated Care Model were compared with 193 frail older patients of five GP practice s that provided care as usual .  In the Walcheren Integrated Care Model , community-dwelling elderly were pro-actively screened for frailty from the GP practice using the Groningen Frailty Indicator , and care needs were assessed with the EASYcare instrument . The GP practice functioned as single entry point from which case management was provided , and the GP was the coordinator of care . The entire process was supported by multidisciplinary meetings , multidisciplinary protocol s and web-based patient files . The outcomes of this study were obtained at baseline , after 3 months and after 12 months and analyzed with linear mixed models of repeated measures . Results The Walcheren Integrated Care Model had a positive effect on love and friendship and a moderately positive effect on general quality of life . The ability to receive love and friendship and general quality of life decreased in the control group but was preserved in the experimental group . No significant differences were found on health outcomes such as experienced health , mental health , social functioning and functional abilities . Conclusions The results indicated that pro-active , integrated care can be beneficial for frail older people in terms of quality of life and love and friendship but not in terms of health outcomes and functional abilities . Recommendations for future research are to gain greater insight into what specific outcomes can be achieved with proactive and integrated care , considering the specific content of this care , and to allow for the heterogeneity of frail older people in evaluation research .Trial registration Current Controlled Trials IS RCT N05748494 . Registration date : 14/03/2013 The Expert Patients Programme ( EPP ) is a central element of chronic disease management policy in the United Kingdom . It aims to deliver self-care support by developing peoples ' self-care skills , confidence and motivation to take more effective control over their long-term conditions . A large , national r and omised controlled trial found that the EPP 's lay-led skills training was effective in improving self-efficacy and energy levels among patients with long-term conditions , and was likely to be cost-effective . Key questions remain as to whether existing outcome measures capture the core outcomes that are important to patients with long-term conditions . The development and evaluation of self-care support initiatives should take into account the extent to which self-care support initiatives can be integrated into peoples ' everyday lives , and the degree of fit with patients ' existing adaptations and strategies . Rather than being concentrated on a single course , central re sources for self-management support should be directed at a variety of systems and interventions that are able to meet the wide range of needs of patients with chronic conditions Abstract Objective : To evaluate the impact of a programme of integrated social and medical care among frail elderly people living in the community . Design : R and omised study with 1 year follow up . Setting : Town in northern Italy ( Rovereto ) . Subjects : 200 older people already receiving conventional community care services . Intervention : R and om allocation to an intervention group receiving integrated social and medical care and case management or to a control group receiving conventional care . Main outcome measures : Admission to an institution , use and costs of health services , variations in functional status . Results : Survival analysis showed that admission to hospital or nursing home in the intervention group occurred later and was less common than in controls ( hazard ratio 0.69 ; 95 % confidence interval 0.53 to 0.91 ) . Health services were used to the same extent , but control subjects received more frequent home visits by general practitioners . In the intervention group the estimated financial savings were in the order of £ 1125 ( $ 1800 ) per year of follow up . The intervention group had improved physical function ( activities of daily living score improved by 5.1 % v 13.0 % loss in controls ; P<0.001 ) . Decline of cognitive status ( measured by the short portable mental status question naire ) was also reduced ( 3.8 % v 9.4 % ; P<0.05 ) . Conclusion : Integrated social and medical care with case management programmes may provide a cost effective approach to reduce admission to institutions and functional decline in older people living in the community . Key messages Responsibility for management of care of elderly people living in the community is poorly defined Integration of medical and social services together with care management programmes would improve such care in the community In a comparison of this option with a traditional and fragmented model of community care the integrated care approach reduced admission to institutions and functional decline in frail elderly people living in the community and also reduced
It is likely that investments at the social context level will also help to decrease the development of barriers at the organisational context level , especially by increasing staff involvement and satisfaction .
Background Integrated care interventions for chronic conditions can lead to improved outcomes , but it is not clear when and why this is the case .
This study aims to answer the following two research questions : First , what are the context , mechanisms and outcomes of integrated care for people with type 2 diabetes ?
Second , what are the relationships between context , mechanisms and outcomes of integrated care for people with type 2 diabetes ?