bluuebunny/crossref_metadata_2025 huggingface dataset:
Building a digital care and support plan: research as a starting point. A session for policymakers.
Authors: Taelman Bert
Published: January 2024

In 2018, the idea arose of building a digital care and support plan for primary care. The research on life goals and care goals during the COVID years allowed us to clarify informed choices in the ICT specifications and digital development can start in 2023.

The reform of the primary care in Flanders envisioned a digital capstone. Therefore, a business analysis for a digital care and support plan was prepared in 2018. This digital care plan should:

* facilitate goal-oriented and integrated care, 

* give individuals with care and support needs control over their care planning, and 

* allow care providers to collaborate interdisciplinary and coordinate their care within the care team. 

The scope and associated resources were largely lacking at that time, and the subsequent COVID crisis prevented the project from even starting at all. 

We used this pause to engage academia. We asked them what goal-oriented care might look like in practice: 

* How do you integrate life goals into care planning? 

* Can you create links between life goals and care goals?

* In what ways can you link care goals to existing care scales? 

The researchers' recommendations to these questions, gave us a clearer view of the possibilities and scope of our project. This information helped us to:

* Write a clearer ICT specification

* Clearly define the functional requirements

* Propose an evidence-based approach to stakeholders

* Prioritize the different digital modules to be developed

* Engaging academics in a technical debate

Do not underestimate the impact of sound research. Do not rush into an ICT project without fundamentally questioning the content and scope of the project. Consult academics who will work out the concepts in a research context with people in the field. Then build on this input.

The inputs from the research questions are currently being used as a starting point for the digital modules on life goals and care goals. These modules are now being further refined with stakeholders and will serve as a starting point for ICT development this year.
TransForm – Integrated Community Care (ICC) from aspiration to reality
Authors: Vandensande Tinne , Ehrenberg Nieves
Published: January 2024

Introduction: As we face crises after crises (climate, geopolitical, health, financial), each one increasing inequalities and impacting most on people and communities in vulnerable situations, we need to come up with better ways of living and caring for people and the planet. Most challenges we face today are complex and interrelated and to solve them requires participation from communities and citizens.

As part of this, the mere concept of care needs to be redefined towards a social capacity and activity involving the nurturing of all that is necessary for the welfare and flourishing of life. The current system of care was designed in and for the industrial era and it has reached the limits of what it can achieve. Today’s diseases are chronic and complex and require different responses. We need to reimagine and create a system designed for the problems we face today.

Integrated Community Care (ICC) is a concept that has evolved and is based on a range of important innovations and efforts in the field, such as people centred care, community primary care, integrated care, social determinants of health, goal-oriented care, amongst others. ICC acknowledges that each of these, although important, are not enough on their own and brings them together. In ICC, local organizations, community members, professionals, and policy makers come together in a continuous process of co-developing health, care and social support infrastructures to enhance the quality of life, social cohesion and resilience of a territorially defined community. It is not a prescriptive approach, but rather a set of principles that guide a range of existing practices that are changing the way health and care are organised.

Aim: to inspire and better equip policy makers and practitioners to make ICC the new norm by sharing learnings and experiences of the TransForm community, including defining what ICC is, its benefits and demonstrating how to put the theory into practice.

Audience: Citizens, policy makers, practitioners, academics that realise that the multiple crises we face are an opportunity to create something better. It is for anyone seeking for more effective ways to truly care for, about and with people and communities.

Who did we involve and what we did?

Since 2018, through a series of research activities, international conferences, site visits to ICC initiatives, workshops among experts, activities within a Changemakers Forum, TransForm has developed a learning journey (co-production of knowledge with stakeholders – academics, policymakers, decisionmakers, practitioners, people with lived experience, citizens) that has identified key values – ingredients – challenges- for ICC. An important part of this learning journey is the contribution of ICC changemakers, investing in locally anchored innovation and making the difference again and again in the daily lives of people.

What are the next steps? TransForm will create an open-source collection of knowledge on ICC.
Implementation of change management in a large scale interdisciplinary primary care practice: experiences from Menen.
Authors: Depoot Peter
Published: January 2024

Background: The ongoing process of Change Management Implementation in the Community Health Center of Menen leads to the provision of integrated care more in line with the quintuple aim model.

Abstract: This presentation describes the process of Change Management Implementation in the Community Health Center of Menen, an interdisciplinary primary care practice in a medium size city in the western part of Flanders funded by a needs based capitation model. In the first 5 years of its existence, the organization knew a vast growth, both in the number of patients (2200 to about 6000) as in the number of staff and different disciplines gathered within the center. This continually challenged the team to reorganize care in line with the Quintuple Aim Model. 

Based on a diagnosis of the main health problems within the inscribed population, priorities for change management were identified. The team chose to first focus on both diabetes and shoulder/neck complaints, as they make up a big proportion of the provided care. Subsequently, the team implemented (1) a protocolled follow-up of diabetes patients by specialized nurses and (2) the implementation of a curative and preventative interprofessional approach for back problems (“rugschool”) with a central role for high end training machines . 

Concerning the first, all type 2 diabetes patients are proactively contacted twice a year to book a consultation with a specialized nurse. The necessary parameters are checked and necessary care is provided. If needed, the patients are referred to other professionals (dietician, physiotherapist, …) within the team or outside the center. Concerning the latter, the center invested in high end training devices that allow for patients to individually follow a customized training program. Individual contact with the team of physiotherapists are additional to the automatized proportion of the training program. 

At the microlevel, both change processes contributed to improvement towards more integrated and high level care and were deemed cost efficient. At the microlevel, improvements are observed in patients outcomes and experiences (compliance, motivation,…..). At the mesolevel, the projects lead to a more efficient use of the available work force. At the macro level, the investments within primary care may lead to a societal cost saving (comparing rehabilitation of patient in the center to the regional hospital).
Parkinson's care innovation through the learning glass
Authors: Stap Thieme , Van Woezik Tamara , Engbers Rik , Laan Roland , Munneke Marten , Bloem Bas , Koksma Jur
Published: January 2024

Increasingly, successful healthcare innovation is understood to rely on learning processes of all those involved. Quality depends on persons in healthcare practice and the environment they enact together. Nevertheless, how people learn in innovation, and how these learning processes contribute, is still understudied. The convictional dimensions of such a mindset change imply a crucial role for transformative learning. From this position we studied healthcare innovation, based on the following research question: What kind of transformative learning processes, if any, did people go through, when they were involved in a highly innovative healthcare context that has person-centered care as the core of its mission and vision?

We conducted a retrospective, multi-level stakeholder analysis of an innovative center focused on Parkinson’s care (2004-). We did semi-systematic observations at the workplace (2018-2022), and conducted 22 in-depth interviews on the levels of healthcare practitioners in a network organization, employees of a center of expertise, and the managers overseeing both. Through grounded analysis, six themes were constructed: 1. Reflections about learning and education; 2. Reflections about change and innovation; 3. Convictions about care; 4. Vision; 5. Practice and community; 6. Personal leadership. The six themes are presented in four sections, all with their own specific focus on forms of learning: A) Formal Learning; B) Learning in the Workplace; C) Learning across Borders; D) Transformative Learning.

We found that formal learning plays a big role, providing structure for the development of professionals. Nevertheless, it also hinders learning in the workplace. Taking on ownership is a goal presented by management, yet employees found it hard to create a learning path for themselves in that direction. Strikingly, a lot of learning across borders happen in this innovative environment. Nonetheless, not many transformative learning processes were captured. But then again, we did observe a central paradox which pivots around perspective transformation: to be able to gain a broader perspective, one needs to be in the appropriate environment. But to become that appropriate environment, that broader perspective is necessary.
Suicide prevention in Flemish pharmacies
Authors: Verboven Barbara , Deneyer Hilde
Published: January 2024

Introduction: In Flanders, the Flemish Pharmacists Network (VAN), in collaboration with the Flemish Centre of Expertise in Suicide Prevention (VLESP), wants to explore how pharmacists and pharmacist assistants in the public pharmacy can play an active role in suicide prevention in collaboration with other health care providers.

Background: Mental health is an important area of focus in health care. Numbers from the Care and Health Agency tell us that nearly 1,000 people die of suicide in Flanders every year. By 2030, the Flemish Health objective is to reduce deaths by suicide by 10% compared to 2020. Poisoning is a common method of suicide and medication is used in the majority of suicide attempts. There is strong scientific evidence that when commonly used methods are made less lethal or accessible, the number of suicides using that method as well as other methods decreases. Restricting access to substances for suicide is a very effective prevention method. Pharmacists occupy a crucial role in society regarding the distribution of medication and are among the most trusted professions. Thus, they are pre-eminent key figures who can play a role in suicide prevention.

Who is it for? The objective is to assessing and questioning actively the suicide risk of citizens in pharmacy.

Who did you involve and engage with? In 2022 VAN launched a project among Flemish pharmacists in collaboration with VLESP and with the support of the Flemish government.

What did you do? In the first phase, a literature review was conducted and a large group of experts from different healthcare professions was assembled. A survey was launched and the results are being analyzed by VLESP. These will be used for the further elaboration of the training and the launch of a pilot project in early 2023.

Knowledge improvement within the sector is crucial to take an active role in suicide prevention. Pharmacists should be aware of existing help and support possibilities and referral options to other health care providers. Agreements with other health care providers should be made for this purpose. Pharmacists must be taught the tools to recognize and question signs of suicidal behavior so that they can then raise awareness about medication management, provide appropriate advice, make appropriate delivery and referrals.

What results did you get? Around 50 pharmacies will start the pilot project in early 2023, which will be evaluated on a regular basis. Conclusions and recommendations will be written out by the end of 2023. 

What is the learning for the international audience? For the international audience, it is interesting to know how pharmacies can play an active role and what elements are necessary to promote this. The conclusions and recommendations can serve as a guide for application in other countries. This project can be an important step to a more integrated approach around this topic

What are the next steps? After the pilot project, the objective is to extend the active role within all Flemish pharmacies and then within Belgium.
From research to practice: an evidence-based and participatory approach to suicide prevention.
Authors: Dumon Eva , Portzky Gwendolyn
Published: January 2024

Introduction: Suicide is a major public health concern, and its prevention is complex, challenging multiple stakeholders from research, policy, and practice to work together in order to develop multi-level interventions. Since 2006, an extensive Suicide Prevention Strategy has been implemented in Flanders, Belgium, aiming to decrease the suicide rates and support everyone affected by it. Using evidence-based methods and involving multiple stakeholders are the key strengths of this strategy.

Method: The Suicide Prevention Strategy in Flanders is developed with the support of the Flemish government and in cooperation with various stakeholders, including researchers, policymakers, healthcare workers, and people with lived experience. Key criteria for the development and implementation processes of new interventions in the Strategy are: tailored to the target group’s needs, evidence-based, innovative, monitored and evaluated in terms of their outreach, usability and effectiveness.

Results: The Strategy includes various interventions. In this presentation, the development process of two innovative evidence-based interventions will be presented, as well as their impact on clinical practice.

1)The development and implementation of clinical guidelines and an e-learning course for health professionals on the detection and treatment of suicidal behaviour;

2)The development and implementation of online tools, such as an online self-help course and smartphone application for suicidal individuals.

Conclusion: In order to build solid suicide prevention strategies and interventions, cooperation between various stakeholders is essential. Implementing evidence-based and innovative tools in clinical practice, tailored to the needs of clinicians and people with lived experience, is a key strategy which can enhance the quality of care in suicide prevention.
Guidelines for disclosure of TM use to AMPs by patients who use both TM and AM: Perspectives of AMPs in Gauteng, South Africa
Authors: Gumede Lindiwe , Nkosi Busisiwe , Sibiya Nokuthula
Published: January 2024

Background: Concurrent use of traditional medicine (TM) and allopathic medicine (AM) is frequently not disclosed to allopathic medicine practitioners (AMPs) during a consultation in Gauteng, South Africa. To promote person-centred care and allow patients to be forthcoming about the details of their choice, AMPs could strive for longer engagements with patients who use both TM and AM during consultations. The TM clinical setting allows for longer patient engagement as well as empathic, individual-centred approaches that are characteristic of traditional medicine practitioners (TMPs), whereas the AM clinical setting is limited by shorter patient engagements, limited progressive care, and less individual-centred care by AMPs. Guidelines for disclosure could help patients who use both TM and AM to disclose their use of TM.

Objectives: To explore and describe AMPs' perceptions of patients who use both TM and AM without disclosing TM use to AMPs, to eventually develop guidelines for disclosing TM use to AMPs in Gauteng, South Africa.

Methods: An exploratory, descriptive, qualitative research design was followed. The research population comprised 14 participants representing a group of AMPs. Non-probability, purposive sampling was used. Data collection was achieved through one-on-one, semi-structured interviews and qualitative observations.

Results: Results indicate that the use of both TM and AM presents challenges that are associated with lack of scientific evidence; unspecified dosage of TM; non-adherence to the AMPs treatment plan and complications because of interaction between TM and AM. The disclosure was deemed critical to effectively ensure improved treatment outcomes from the prescribed AM treatment. Participants made recommendations to inform the development of guidelines to encourage the disclosure of TM use.

Conclusions: Given the realities of negative interactions caused by patients' concurrent use of TM and AM in Gauteng, South Africa, facilitating disclosure to AMPs is advised. The recommendations could be used to develop strategies to encourage voluntary disclosure by gently probing patients who use both TM and AM to ensure that they receive the best treatment for their condition.

Implication to practice: TM use among patients who consult AMPs is not uncommon therefore the developed guidelines could inform the disclosure procedures during AMP consultations with patients in South Africa.
Pediatric behavioral health care utilization in integrated primary care and hospital-based clinics during the pandemic – Implications for virtual care
Authors: Cook Andrew , Birnbaum Richard , Turnier Luke
Published: January 2024

Introduction: The COVID-19 pandemic forced health care organizations and providers to adapt innovative approaches to ensure patient care needs are met. In particular, improving patient access to behavioral health services is essential to improving population health.

Methods and Aims: Clinical visit volume and utilization data were analyzed via the Tableau platform for behavioral health visits by providers within the division of Pediatric Psychology at the University of Michigan Health (UM) during the pandemic through the present. UM is a publicly funded academic medical center that manages a total of approximately 2.5 million patient visits per year. Psychologists provide care within hospital-based specialty clinics or primary care clinics, both of which utilize integrated models of care. Unprecedented changes were made with regards to care delivery format and workforce allocation, and the present paper examines the corresponding impact on patient behavior health care.

Results: During Fiscal Year 22 (July 2021 to June 2022), 24 pediatric psychology providers completed a total of 8,252 visits within 12,802 available patient slots, a utilization rate of 64.5%. Utilization was significantly higher in primary care clinics (80.9%) than in hospital-based clinics (51.6%), Z = 34.47, p < .00001. Services were delivered virtually in 100% of the 4549 visits completed in primary care and 72.6% of the 3703 completed hospital visits. These data are currently being analyzed for the present Fiscal Year 23. Patient satisfaction data revealed barriers impacting access to care, including scheduling issues, setting up virtual care and managing, technology problems.

Conclusions: Utilization data provides strong support for delivery of behavioral health services in primary care via virtual care means. However, patients area likely to encounter significant barriers to initiating and participating in care when systems are designed to exclusively or primarily support remote users.
Shared medical appointments (SMA) for metabolic syndrome patients in the Hague, the Netherlands
Authors: Jacz-Kruithof Loïse , Vos Rimke , Breas Martin , Samlal Anil
Published: January 2024

The pilot with the  Shared Medical Appointment (SMA)started in januari 2021 in the Schilderswijk which is a deprived area of the Hague , with low health literacy and high prevelence of metabolic syndrome . This group of patients are are seen in the SMA together with a multidisciplinair Team (MDT) of professionals and scientists.

The patient journey of the participants starts at population care towards customized patient orientated care.

This proactive, integrative towards personalized care migth benefit applying a quadruple or quintuple aim.

The study desing is a quasi experimental population based controlled cohort trial

The study employs a dif -in -dif design using a regional control group on non participating GP ‘s

Good collaboration is important between the primary care , the social care , welvare , and science.

A shared shavings contract could proved financial incentives  to realize efficiency gain value based competition.

The SMA will be evaluated in 2023-2024 to measure the effects of the Sma intervention.

Thank  you In behalf of the team members

Loïse Jacz, GP, Msc PHM i.o

Rimke Vos , ass Prof

Martin Bread , sportcoach

Emma Witte : student Sportscience

Maud Verhoeven : Msc PHM i.o

Anil Samlal: experience expert

Frank Kanhai : walking coach NDC

Younes Bouadi:   NDC coordinator
Co-designing collaborative health deterioration prevention together with older people, civic society, and community health and social care
Authors: Flink Maria , Strehlenert Helena , Lindgren Christofer , Karlsson Eva , Klinga Charlotte , Meinow Bettina , Wallcook Sarah , Johansson Karin , Goliath Ida
Published: January 2024

Introduction: As the population ages, the number of older people whose health is at risk of deteriorating is expected to increase. This may imply decreased quality of life for the individual and rising costs for social and health care. This project acknowledges that health in older people is a complex matter, that includes physical, social, and psychological dimensions, and needs to be targeted at individual, societal and structural levels. Thereby, we recognize that collaborative efforts by diverse actors are necessary to prevent the deterioration of health. Development of collaboration, defined as cross-organizational integration in networks, accomplished through agreements, adjustments, and a willingness to work together, requires the substantial efforts of all stakeholders. We therefore use experience-based co-design to develop collaborative prevention. We will present findings from co-design processes aiming at developing collaborative prevention of deterioration of health.

Method: This multiple case design study is performed in Stockholm, Sweden. A case is defined as a community social care unit and its interacting partners who currently are – or potentially could be – involved in collaborative prevention. In each of the project’s three cases, a series of six co-design workshops is conducted. Participants in these workshops are older people and participants from community social care, health care, and civic society (e.g., voluntary and faith/religious organisations). In each case, the participants explore their current collaboration, define their collaborative challenges and work together to develop and test ideas and solutions for improved collaboration to prevent deterioration of health for older people. The workshops are led by researchers.

During the workshops, data on the outcomes and process are collected using audio-recordings and field notes. Between workshops, individual and dyad semi-structured interviews are conducted with participants on their perspectives of the outcomes and process. Data are analyzed with qualitative content analysis.

Results: The co-design series are ongoing and at the conference we will present 1) participants’ reasonings about participation, 2) strengths/opportunities/solutions in collaboration identified by the participants, 3) the co-designed collaborative models and 4) factors that were imperative for the development of these new models, 5) the development of collaborative governance regarded as important for sustainability. We will also critically discuss 6) lessons learned about researcher facilitation of co-design processes.

Next step: The three cases will be longitudinally evaluated regarding the impact and structures of the collaborative process.
Patient information handover between care providers
Authors: Verheirstraeten Emma , Notebaert Melissa
Published: January 2024

The handover of patient information between care providers is a big challenge. Important information is easily missed or the interpretation may differ among care providers. Structured transfer methods are used in the hospital to avoid this.

In the hospital AZ Sint-Lucas (Ghent; Belgium), we have implemented three different methods based on literature. First, during the handover we use the SBAR-method. Whit this method, patient information about ‘Situation-Background-Assessment-Recommendation’ is given to each other. The Second, in line with the SBAR is the ‘Identification-Situation-Background-Assessment-Recommendation-Readback’ (ISBARR) method we use for the telephone communication between nurses and physicians. So there is extra focus on the ‘identification’ of the care provider and ‘readback’ of the physician orders. As a third method, ‘Bedside shift reporting’ (BSR) is used on the nurse departments in the hospital. This means that the handover is carried out in the room of the patient which improves patient participation on the nursing wards. In general, it gives patients more chance to interact with nurses, providing them more notice of the information that is handed over. During the patient intake, the BSR method is explained to the patient and his preference for BSR is noted in the patient file.

Several months we did observations on the nursing wards during the handover moments from the early to the late shifts. The focus of these observations was on the performance of BSR and the use of the SBAR method. After the observations feedback was given immediately to the nurses and  findings were documented in a report. These observations indicated which wards used the methods on a daily basis and what the points of attention were, to plan additional support or training.

For physicians, file scans are used to evaluate whether they consistently create tour notes. There is a noticeable increase of the fill-in rate since the implementation of the central patient file across the different specialties. The central patient file was enrolled in several stages over the specialties from 2017 until 2019. In 2021 the integrated patient file over the different discipline was introduced, where patient information is shared between the different care providers. In the integrated patient file, the component 'multidisciplinary communication' was positively received. In this component findings about the patient or questions addressed to the physician can be noted. Physicians can also note certain instructions aimed at the nurse in this component. The findings in this component are often further discusses verbally between the responsible nurse and the attending physician.

In sum, we can conclude that a good documentation in the integrated patient file and the use of different methods like SBAR can help us to provide a structured patient handover, reducing the risk that crucial information will be lost during handover. Nevertheless, further monitoring is needed.
Educational training in disease management for persons providing peer support to patients with type 2 diabetes and arterial hypertension at the primary healthcare level.
Authors: Virtic Tina , Mori Lukančič Majda , Mihevc Matic , Zavrnik Črt , Ketiš Zalika Klemenc , Susič Antonija  Poplas
Published: January 2024

Introduction: Good metabolic control of a patient with type 2 diabetes (T2D) and arterial hypertension (AH) requires continuous monitoring of patient's health and associated diseases, where lifelong education and support represent key factors in patient empowerment and successful self-management. This is a task beyond the capabilities of healthcare professionals in Slovenia, which could be solved with engagement and cooperation of partners outside the healthcare system. Therefore, appropriate organisation, training and functioning of lay persons, who will provide peer support, can significantly contribute to improved integrated care in patients with T2D and AH. In this way trained peer supporters will voluntarily share their knowledge, experiences and support to other patients with the same chronic disease without linguistic nor cultural barriers.

Aim: The aim of our pilot study was to determine the acceptability, effectiveness and feasibility of educational training in disease management for persons providing peer support to patients with T2D and AH at the primary healthcare level in Slovenia.

Methods: This study is a part of an ongoing international research project SCUBY (SCale Up diaBetes and hYpertension care). Our pilot study started with recruitment of 36 patients with T2D and/or AH. Participants were educated in a total of 15 hours of group and individual training by nurses with special skills. Before and after completing the training, participants filled out questionnaires including sociodemographic and clinical data, knowledge about T2D and AH, Appraisal of Diabetes Scale and Theoretical Framework of Acceptability.

Results: 31 patients (21 women and 10 men) successfully completed structured educational training in management of their T2D and AH and became trained peer supporters. Their average age was 63,9 ± 8,9 years, they were treated for T2D on average of 14,3 ± 11,7 years and for AH on average of 7,9 ± 8,1 years. Compared to the knowledge at the time of entering the research, their knowledge about T2D (p<0,001) as well as about AH (p=0,022) increased significantly. The impact on the quality of life with T2D was insignificantly better (p=0,146). The participants rated training as highly acceptable in all 7 domains of acceptability; the total mean score on a 5-point scale was 4,44 ± 0,52. 

Conclusions: Educational training in disease management for peer supporters proved to be highly acceptable, effective and feasible, which indicates a great potential for successful implementation of peer support for patients with T2D and AH at the primary healthcare level in Slovenia. Active role of trained peer supporters will lead to the development of a new form of cooperation and collaboration between patients, their family members, informal caregivers in local community and healthcare professionals.
What is successful integrated community care? A systematic literature review.
Authors: Steurs Manon , Verté Dominique , Verté Emily
Published: January 2024

Introduction: The ageing process vastly impacts the need for care and support, as it is often associated with a decrease in health and function. Governments of ageing populations are using “ageing in place” as the main policy perspective, in which people receive care and support in their personal environment. Although great value is within this perspective, recent studies accentuate that the location where people live vastly impacts their need for care and support. This highlights the need for the development of new, long-term care systems to address these challenges. Scholars argue that the issue can be resolved by implementing locally, integrated and community-based health and social care. Integrated community care (ICC) has been defined as a range of strategies to support multiple stakeholders to co-develop and health, care and social support services and infrastructures, aiming to achieve several goals. However, it is unclear of which key elements ICC consists of.

Method: The main goal of this systematic literature review was to identify the key elements which successful ICC consists of. We searched five electronic databases with several search strings which we defined as closely related to, a part of or the same as ICC based on the preliminary results of the literature review. A total of 65 articles were included in the review based on eligibility criteria, divided into two groups. The first group included twenty articles mentioning ICC or one of the search strings in the title or abstract, the second group contains forty-five articles linked to ICC but clearly focus on a different issue or topic. Thematic analysis was used to code the articles.

Results: Eight key elements of integrated community care were identified, namely: (1) asset-based, (2) person-centred, (3) co-development, (4) governance, (5) locality, (6) improvement of mental and physical health, (7) improvement of the existing health care system, (8) tackling determinants of health. Different perspectives and possible difficulties related to these elements were discussed.

Discussion: We identified eight key elements of ICC, dealing with the starting point (asset-based and person-centred), strategies and stakeholders (co-development, governance, locality) and aims or ambitions (improvement of mental and physical health, improvement of the existing health care system, and tackling health determinants). However, it is still unclear how these elements correlate with each other. Some of these key elements remain rather vague or abstract. Further research should focus on formulating specific definitions for these elements in the context of ICC as well as codifying ways to implement these key elements in practice.
Implementation and Evaluation of Innovation in Integrated Care: Strategies to Overcome the Challenge of Work as Imagined
Authors: Shearkhani Sara , Smith Kelly , Pradhan Rishma
Published: January 2024

Health system learning is an iterative process. The six phases of a learning health system (LHS) are problem identification, design, implementation, evaluation, modification, and dissemination.  In theory, evaluation is supposed to inform design and implementation and in turn implementation process and modification as the direct result of the evaluation endeavour set the direction for future evaluation. In other words, evaluation and implementation go hand-in-hand. In practice, however, when designing an integrated model of care, more often than not in the fast-paced environment of the healthcare where lives are literally at stake, both evaluation and implementation planning are sacrificed. This happens for many reasons, from lack of resources to lack of expertise. One main reason that work as imagined is perceived as work as done is that those who run the program are smart and dedicated people who are well aware of the needs of their communities and clients, and have their best interest at heart. 

East Toronto Health Partners (ETHP) has invested in evaluations since 2018 to create a learning health system by embedding rapid cycles of evaluation to support learning, knowledge transfer, and decision making for scale and spread of their new models of care. One of the main findings of our evaluation work was that implementation planning and monitoring the implementation process raised the likelihood of a successful evaluation which in turn resulted in tangible improvement in the program.  

In our poster presentation, we will focus on both implementation and evaluation. We showcase the link between the logic model/evaluation plan and the implementation plan. We will cover the following questions:

Why having an implementation plan is necessary to bring an idea for an intervention to a reality?

How an implementation plan helps you to carry out your evaluation plan more successfully?

What questions you should be thinking about when you are developing your implementation plan?

We will share examples of best practices. The poster will also provide practical implementation templates that can be used in different setting.
Developing and Setting Up a Lung Cancer Triage Phoneline For Rural West Wales
Authors: Rees Pat , Davies Richard , Gemine Rachel , Shanbhag Savita
Published: January 2024

The incidence of people diagnosed with and living with cancer in the UK is increasing and by 2030, 1 in 2 people will develop cancer (The Cancer Delivery Plan 2016-2020 WAG). Health care providers must explore innovative ways to provide quality care both in terms of outcomes and patient experience set against the challenge of finite resources. Within Wales there are over 2,300 patients diagnosed with lung cancer each year, however less than 20% of these are diagnosed at early stage when they are eligible for curative treatment. It has been shown that early diagnoses leads to improved survival.

More than 90% of patients with lung cancer are symptomatic at diagnosis. 

Rates of lung cancer diagnosis have been drastically impacted by COVID, with referral rates and presentation to GPs at an all-time low in 2020-21.  Screening of patients by triage nurse will help reduce GP workload by allowing patients to be referred, for Chest X-ray, and then to Secondary Care for onward management.

To improve early diagnosis of lung cancer, LUMEN (Lung Cancer Symptom Assessment Line) Nurse Led Service was developed with the following aims:

To deliver a triage service that is safe, effective, equitable and accessible.

Develop and launch this service and integrate into current lung cancer pathways.

Promote and deliver the service and determine acceptability, feasibility, safety, and cost-effectiveness of the pathway.

By increasing patient access to diagnostic testing, we hope to increase early diagnosis and subsequent patient outcomes.

Patient benefits

The Nurse will make onward referrals to lung cancer team, support the person throughout this journey and offer smoking cessation advice, if needed.

Staff Benefits

Role is varied and includes raising awareness of lung cancer symptoms, promoting the service, and liaising with various teams to improve patient journey.
Goals of older hospitalized patients with multimorbidity
Authors: Tent Sanne , Verhoeff Marlies , Festen Suzanne , Van Munster Barbara
Published: January 2024

Background: The increased prevalence of older patients, often presenting with multimorbidity, challenges the traditional disease-focused approach in hospital care. To improve healthcare for older hospitalized patients with multimorbidity, patient-centered healthcare is recognized by experts as essential. An important aspect of patient-centered care is aligning healthcare to personal goals. From literature, we know that older adults rate life enjoyment, social relations, quality of life, mobility and maintenance of autonomy as most important in daily life. In the hospital setting, however, little is known about goals of older patients. Besides, patients with multimorbidity experience more burden of their disease, functional disabilities, and a reduced quality of life which can lead to prioritizing different goals. These potential differences in goals between patients with and without multimorbidity have not been established so far. Therefore, we aimed to explore goals of older hospitalized patients with multimorbidity and compare their goals to those of older hospitalized patients without multimorbidity.

Method: Older hospitalized patients (aged ≥ 70 years) were included between February 2017 and March 2020 in a prospective mixed-methods cohort study at the University Medical Centre Groningen, the Netherlands. Multimorbidity was defined as presenting with polypharmacy and two or more diseases scored with the Charlson Comorbidity index. Goals were assessed by a standardized interview, whereafter they were categorized into one of the ten predefined categories and analyzed descriptively. Goal categories were ‘wanting to know what the matter is’, ‘controlling disease’, ‘staying alive’, ‘alleviating complaints’, ‘improving condition’ (fitness), ‘improving daily functioning’, ‘improving/maintaining social functioning’, ‘resuming work/hobbies’, ‘regain/maintain autonomy’ and ‘undefinable’

Results: Four-hundred-ninety-three older hospitalized patients (mean age 76.7 ± 5.5, 64% male) were included, of which 223 patients with multimorbidity (45%). Patients were hospitalized for 7.9 ± 8.5 days on average. Patients with multimorbidity experienced more mobility problems (67% vs 52%), physical impairments (66% vs 50%) and rated their health lower (a score of 60.2 vs 67.5 on the EuroQol - Visual Analogue Scale) compared to patients without multimorbidity. The most often mentioned goals were ‘controlling disease’ (27%)  and ‘alleviating complaints’ (22%). No differences were found in goals mentioned by patients with and without multimorbidity. Forty-one percent of both patients with and without multimorbidity mentioned goals that were disease-unrelated.

Conclusion: Our study shows no major differences in goals of older hospitalized patients with and without multimorbidity. However, the large proportion of patients mentioning disease-unrelated goals emphasizes the importance of goal elicitation by healthcare professionals within hospital care to provide optimally integrated care.
Team Around the Patient: multi-professional opportunities to support care delivery in hospitals.
Authors: Walsby Alex , Williams Sharon , Best Stephanie
Published: January 2024

Background: Demands on healthcare are outstripping the resources available. Many organisations are struggling to recruit sufficient registered nursing staff to maintain service delivery and are re-evaluating how safe, high quality, sustainable care could be provided. The concept “Team Around the Patient” being piloted in Hywel Dda University Health Board seeks to understand who can provide what care outside of traditional workforce models. The objective of this study is to examine perceptions of key health board stakeholders of the Team Around the Patient model of care and establish research priorities, and to design and test a workforce analysis model to test the implementation of Team Around the Patient. The model will be designed for use in adult, acute inpatient hospital wards.

Methods: Before implementing the Team Around the Patient on select adult surgical and medical wards semi structured interviews were undertaken with key health board stakeholders to gather their understandings and perspectives on the concept, and create a working definition. A purposive approach was taken to engage a range of professional opinions including corporate and operational nursing, patient experience, allied health professionals, workforce and operational development. Interview topics included opportunities, quality indicators, barriers and enablers and organisational impacts. Ethical approval was provided by Swansea University and through The Integrated Research Application System (IRAS). Interviews were recorded, transcribed and thematically analysed. 

Results: In total 15 participants were interviewed. High level findings show support for the concept, with many participants identifying the potential new roles to be included.  Key quality indicators such as inpatient falls, medication errors, pressure damage, length of stay, complaints and staff experience were identified as being important measures for this concept.  Challenges associated with introducing new roles were mainly associated with workforce culture, delegation and finance. 

Conclusion: The results indicate overall support for “Team around the Patient” as a model of care which will help to alleviate issues surrounding skill shortages, while introducing more collaborative, inter-professional working. Further research is underway to gain wider perspectives of the concept from national and international experts in the fields of health care, academia and policy makers. The next stage of the research will include observational studies of health care delivery in practice to test the model of workforce analysis. The aim will be to identify opportunities for non-nursing staff groups to support care delivery where a gap in practice, or inefficiencies in the timely delivery of care, has been identified.
Realist Evaluation of Home-Based Palliative Care Programme for Non-Cancer Patients
Authors: Nurjono Milawaty , Lee Jing Yi , Ho Ezra , Tan Chao Min , Liaw Karen , Lee2 Angel , Vrijhoef Hubertus Johannes Maria , Koh Lip Hoe , Ng Foong Ling , Oh Hong Choon
Published: January 2024

Introduction: Disproportionately higher deaths attributed to non-cancer causes in Singapore highlight the need for palliative beyond those with cancers. The Violet Program (ViP) was developed to provide home-based palliative to non-cancer patients residing in the Eastern region of Singapore. VIP aims to (i) reduce unnecessary acute hospital utilization (ii) improve symptoms management (iii) reduce caregiver burden through caregiver support (iv) honour patient preferences better through integrated care while (v) keeping healthcare cost affordable. It is acknowledge that successful implementation and the long-term sustainability of ViP is contingent on its ability to effectively attract, grow and develop its manpower resources. However, identifying, attracting, developing, and retaining competent and engaged community-based palliative care workforce staff remains a major challenge. The aim of this study is to understand attributes of staff and contextual factors well suited for ViP and factors leading to sustainability of such a workforce

Methods: This study was conducted in 2 phases according to realist evaluation principles. First, initial programme theories (IPT) related to sustainability of palliative care manpower were developed through a scoping review and semi-structured interviews with those who were involved in the conceptualization of ViP. IPTs were expressed in Context (C) Mechanism (M) and Outcome (O) configurations. Then, IPTs were tested using interviews with healthcare care workers (HCW) who were involved in ViP. Only CMO configurations supported by substantial evidence were elicited and refined.

Results: 36 HCW of varied roles were interviewed. At the HCW level, (i) familiarity with palliative care framework (ii) comfort in dealing with death (iii) passion for palliative care field (iv) exposure to palliative care during medical/nursing training and (iv) ability to self-care were found to be important attributes for ViP care team. At the institutional level, (continuous) training and provision of socio-emotional support to staff were found to contribute to retention of staff. Self-efficacy for the required tasks, empathy for affected patients/family, passion-driven motivation and dedication to go the extra mile and strong emotional resilience were found to be the key driving forces behind the sustainability of workforce for ViP for the longer term.

Implications: This study illustrated the applicability of using realist evaluation for assessment of context specific insights for the identification of suitable workforce and how to sustain them in the longer term. These insights can potentially be used as selection criteria for recruitment of staff for ViP and points to area for training of staff.