Boundaries and e-health implementation in health and social care.
ABSTRACT: The major problem facing health and social care systems globally today is the growing challenge of an elderly population with complex health and social care needs. A longstanding challenge to the provision of high quality, effectively coordinated care for those with complex needs has been the historical separation of health and social care. Access to timely and accurate data about patients and their treatments has the potential to deliver better care at less cost.To explore the way in which structural, professional and geographical boundaries have affected e-health implementation in health and social care, through an empirical study of the implementation of an electronic version of Single Shared Assessment (SSA) in Scotland, using three retrospective, qualitative case studies in three different health board locations.Progress in effectively sharing electronic data had been slow and uneven. One cause was the presence of established structural boundaries, which lead to competing priorities, incompatible IT systems and infrastructure, and poor cooperation. A second cause was the presence of established professional boundaries, which affect staffs' understanding and acceptance of data sharing and their information requirements. Geographical boundaries featured but less prominently and contrasting perspectives were found with regard to issues such as co-location of health and social care professionals.To provide holistic care to those with complex health and social care needs, it is essential that we develop integrated approaches to care delivery. Successful integration needs practices such as good project management and governance, ensuring system interoperability, leadership, good training and support, together with clear efforts to improve working relations across professional boundaries and communication of a clear project vision. This study shows that while technological developments make integration possible, long-standing boundaries constitute substantial risks to IT implementations across the health and social care interface which those initiating major changes would do well to consider before committing to the investment.
Project description:BACKGROUND:The integration of community health and social care services has been widely promoted nationally as a vital step to improve patient centred care, reduce costs, reduce admissions to hospital and facilitate timely and effective discharge from hospital. The complexities of integration raise questions about the practical challenges of integrating health and care given embedded professional and organisational boundaries in both sectors. We describe how an English city created a single, integrated care partnership, to integrate community health and social care services. This led to the development of 12 integrated neighbourhood teams, combining and co-locating professionals across three separate localities. The aim of this research is to identify the context and the factors enabling and hindering integration from a qualitative process evaluation. METHODS:Twenty-four semi-structured interviews were conducted with equal numbers of health and social care staff at strategic and operational level. The data was subjected to thematic analysis. RESULTS:We describe three key themes: 1) shared vision and leadership; 2) organisational factors; 3) professional workforce factors. We found a clarity of vision and purpose of integration throughout the partnership, but there were challenges related to the introduction of devolved leadership. There were widespread concerns that the specified outcome measures did not capture the complexities of integration. Organisational challenges included a lack of detail around clinical and service delivery planning, tensions around variable human resource practices and barriers to data sharing. A lack of understanding and trust meant professional workforce integration remained a key challenge, although integration was also seen as a potential solution to engender relationship building. CONCLUSIONS:Given the long-term national policy focus on integration this ambitious approach to integrate community health and social care has highlighted implications for leadership, organisational design and inter-professional working. Given the ethos of valuing the local assets of individuals and networks within the new partnership we found the integrated neighbourhood teams could all learn from each other. Many of the challenges of integration could benefit from embracing the inherent capabilities across the integrated neighbourhood teams and localities of this city.
Project description:OBJECTIVE:We describe sources expected to provide for future care needs among baby-boomers in their late sixties and examine how expectations vary according to earlier health and social experiences. We hypothesised that greater integration in social relationships across adulthood is associated with greater expectation of informal care, and that greater morbidity over a longer time period is associated with greater expectation of formal care. METHOD:The MRC National Survey of Health and Development, a population-based birth cohort study set in mainland Britain, provided data on care expectations for 2135 participants aged 68-69. The outcome was who, besides the partner or spouse, is expected to provide for the future care needs, coded as adult children, other relatives, friends/neighbours, paid/professional care, or no one. Adult children were taken as the reference category and the latter two categories were combined as 'formal care' in the multiple regression analysis. RESULTS:91% had an adult child, of whom 74% expected them to provide care if needed, and 11% expected formal care. The latter rose to 33% of those with no adult children. Geographical distance to adult children (over 25 miles) was strongly correlated with expectations but, independently of this, lack of someone to help in a crisis from midlife onwards and low social contact were associated with expecting formal care. Expectations did not differ by number of chronic conditions, functional limitations or longstanding illness from age 60?+?. CONCLUSION:Those lacking social relationships in midlife onwards and those living further from adult children are more likely to expect formal help with their future care needs. As personal care needs are projected to rise with population ageing and families are increasingly expected to provide for these needs, initiatives to remove barriers to smaller distances between ageing parents and their children and to support and maintain high-quality family relationships across the life course should be considered.
Project description:Background: The National Integrated Care Programme for Older People (NICPOP), formerly NCPOP aims to support older people to live well in their homes by developing primary and secondary care services for older people, especially those with complex needs. The programme develops integrated intermediate care which traverses both hospital and community settings through multidisciplinary and interagency teams. This team-based approach to the integration of health services is a novel innovation in Irish health service delivery and will require, over time, a shift in cultures of care to allow for the development of competencies for inter-professional collaboration across the care continuum. The ECLECTIC project will develop an implementation framework for achieving, maintaining and monitoring competencies for interprofessional collaboration among multi-disciplinary teams charged with delivering care for older people across the continuum from acute to community settings. Design: The ECLECTIC research design has been developed in collaboration with the NICPOP. In phase one of the project, a co-design team will collaborate to define and shape competencies for interprofessional collaboration. Phase two will involve the delivery of a collective leadership intervention over a 10-month period with multidisciplinary professionals working with older people across two geographical regions (Mullingar/Midlands and Beaumont/Dublin North). Each group will comprise of members of two multidisciplinary teams charged with coordinating and delivering care to older people across the continuum of acute to community care. Observations of collaborative inter-professional working will take place before, during, and after intervention. In phase three of the study, analysis of the interview and observation data will be presented to the co-design team in order to develop an implementation framework for future teams. Discussion: The co-design process will develop core competencies and performance indicators for collaborative interprofessional working. The resulting implementation framework will be implemented nationally as part of the NICPOP.
Project description:<h4>Background</h4>While there is a considerable corpus of theoretical and empirical literature on networks within and outside of the health sector, multiple research questions are yet to be answered.<h4>Objective</h4>To conduct a systematic review of studies of professionals' network structures, identifying factors associated with network effectiveness and sustainability, particularly in relation to quality of care and patient safety.<h4>Methods</h4>The authors searched MEDLINE, CINAHL, EMBASE, Web of Science and Business Source Premier from January 1995 to December 2009.<h4>Results</h4>A majority of the 26 unique studies identified used social network analysis to examine structural relationships in networks: structural relationships within and between networks, health professionals and their social context, health collaboratives and partnerships, and knowledge sharing networks. Key aspects of networks explored were administrative and clinical exchanges, network performance, integration, stability and influences on the quality of healthcare. More recent studies show that cohesive and collaborative health professional networks can facilitate the coordination of care and contribute to improving quality and safety of care. Structural network vulnerabilities include cliques, professional and gender homophily, and over-reliance on central agencies or individuals.<h4>Conclusions</h4>Effective professional networks employ natural structural network features (eg, bridges, brokers, density, centrality, degrees of separation, social capital, trust) in producing collaboratively oriented healthcare. This requires efficient transmission of information and social and professional interaction within and across networks. For those using networks to improve care, recurring success factors are understanding your network's characteristics, attending to its functioning and investing time in facilitating its improvement. Despite this, there is no guarantee that time spent on networks will necessarily improve patient care.
Project description:The number of social media users has increased substantially in the past decade, creating an opportunity for health-care professionals and patients to leverage social media for health communication. This study examines the recent use and predictors of social media for health communication in a nationally representative sample of US adults over time. We used 2013, 2014, and 2017 National Cancer Institute's Health Information National Trends Survey to identify respondents' use of social media for sharing health information or exchanging medical information with a health-care professional. We conducted bivariate analysis using the Pearson χ2 test to assess the association of respondents' basic demographic characteristics as well as health status and the use of social media for health communication. We performed multivariable logistic regression models to examine factors associated with the use of social media for health communication. We identified 4242 respondents (weighted sample size: 343 465 241 [2-year pooled sample]) who used social media for sharing health information and 4834 respondents (weighted sample size: 354 419 489 [2-year pooled sample]) who used social media for exchanging medical information. Multivariable analyses indicated the proportion of respondents who used social media for sharing health information has decreased (odds ratio [OR], 0.65; 95% confidence interval [CI], 0.49-0.85, P = .002), while the use of social media for exchanging medical information with a health-care professional has increased (OR, 1.88; 95% CI, 1.09-3.26, P = .025). The younger population had significantly higher odds of using social media for health communication. The study found no racial/ethnic disparities in the use of social media for health communication. Use of social media for sharing health information has declined, while exchanging medical information with health-care professionals has increased. Future research is needed to determine how to engage the population in social media-based health interventions, particularly for older adults.
Project description:BACKGROUND:An online health community (OHC) is a novel sharing channel through which doctors share professional health care knowledge with patients. While doctors have the authority to protect their patients' privacy in OHCs, we have limited information on how doctors' privacy protection choices affect their professional health care knowledge sharing with patients. OBJECTIVE:We examined the relationship between privacy protection and professional health care knowledge sharing in OHCs. Specifically, we examined the effects of privacy protection settings in an OHC on doctors' interactive professional health care knowledge sharing and searching professional health care knowledge sharing (two dimensions of professional health care knowledge sharing). Moreover, we explored how such effects differ across different levels of disease stigma. METHODS:We collected the monthly panel data of 19,456 doctors from Good Doctor, one of the largest OHCs in China, from January 2008 to April 2016. A natural experimental empirical study with difference-in-difference analysis was conducted to test our hypotheses. The time fixed effect and the individual fixed effect were both considered to better identify the effects of a privacy protection setting on professional health care knowledge sharing. Additionally, a cross-sectional analysis was performed for a robust check. RESULTS:The results indicate that the privacy protection setting has a significant positive effect on interactive professional health care knowledge sharing (?=.123, P<.001). However, the privacy protection setting has a significant negative effect on searching professional health care knowledge sharing (?=-.225, P=.05). Moreover, we found that high disease stigma positively impacts the effect of privacy protection on interactive professional health care knowledge sharing (coefficients are in the same valence) and negatively impacts the effects of privacy protection on searching professional health care knowledge sharing (coefficients are in the reverse valence). CONCLUSIONS:Privacy protection has a bilateral effect on professional health care knowledge sharing (ie, a positive effect on interactive professional health care knowledge sharing and a negative effect on searching professional health care knowledge sharing). Such bilateral switches of professional health care knowledge sharing call for a balanced state in conjunction with practical implications. This research also identifies a moderate effect of disease stigma on privacy protection settings and professional health care knowledge sharing.
Project description:<h4>Objectives</h4>To understand whether and how effective integration of health and social care might occur in the context of major system disruption (the COVID-19 pandemic), with a focus on how the initiative may overcome past barriers to integration.<h4>Design</h4>Rapid, descriptive case study approach with deviant case sampling to gather and analyse key informant interviews and relevant archival documents.<h4>Setting</h4>The innovation ('COVID-19 Protect') took place in Norfolk and Waveney, UK, and aimed to foster integration across highly diverse organisations, capitalising on existing digital technology to proactively identify and support individuals most at risk of severe illness from COVID-19.<h4>Participants</h4>Twenty-six key informants directly involved with project conceptualisation and early implementation. Participants included clinicians, executives, digital/information technology leads, and others. Final sample size was determined by theoretical saturation.<h4>Results</h4>Four primary recurrent themes characterised the experiences of diverse team members in the project: (1) ways of working that supported rapid collaboration, (2) leveraging diversity and clinician input for systems change, (3) allowing for both central control and local adaptation and (4) balancing risk taking and accountability.<h4>Conclusions</h4>This rapid case study underscores the role of leadership in large systems change efforts, particularly in times of major disruption. Project leadership overcame barriers to integration highlighted by prior studies, including engaging with aversion to clinical/safety risk, fostering distributed leadership and developing shared organisational practices for data sharing and service delivery. These insights offer considerations for future efforts to support strategic integration of health and social care.
Project description:<h4>Background</h4>The integration of mental health and social services for people diagnosed with severe mental illness (SMI) has been a key aspect of attempts to reform mental health services in the UK and aims to minimise user and carer distress and confusion arising from service discontinuities. Community mental health teams (CMHTs) are a key component of UK policy for integrated service delivery, but implementing this policy has raised considerable organisational challenges. The aim of this study was to identify and explore facilitators and barriers perceived to influence continuity of care by health and social care professionals working in and closely associated with CMHTs.<h4>Methods</h4>This study employed a survey design utilising in-depth, semi-structured interviews with a proportionate, random sample of 113 health and social care professionals and representatives of voluntary organisations. Participants worked in two NHS Mental Health Trusts in greater London within eight adult CMHTs and their associated acute in-patient wards, six local general practices, and two voluntary organisations.<h4>Results</h4>Team leadership, decision making, and experiences of teamwork support were facilitators for cross boundary and team continuity; face-to-face communication between teams, managers, general practitioners, and the voluntary sector were facilitators for information continuity. Relational, personal, and longitudinal continuity were facilitated in some local areas by workforce stability. Barriers for cross boundary and team continuity were specific leadership styles and models of decision making, blurred professional role boundaries, generic working, and lack of training for role development. Barriers for relational, personal, and longitudinal continuity were created by inadequate staffing levels, high caseloads, and administrative duties that could limit time spent with users. Incompatibility of information technology systems hindered information continuity. Flexible continuity was challenged by the increasingly complex needs of service users.<h4>Conclusions</h4>Substantive challenges exist in harnessing the benefits of integrated CMHT working to deliver continuity of care. Team support should be prioritised in terms of IT provision linked to a review of current models of administrative support. Investment in education and training for role development, leadership, workforce retention, and skills to meet service users' complex needs are recommended.
Project description:<h4>Background</h4>Older people living in care homes in England have complex health needs due to a range of medical conditions, mental health needs and frailty. Despite an increasing policy expectation that professionals should operate in an integrated way across organisational boundaries, there is a lack of understanding between care homes and the National Health Service (NHS) about how the two sectors should work together, meaning that residents can experience a poor "fit" between their needs, and services they can access. This paper describes a survey to establish the current extent of integrated working that exists between care homes and primary and community health and social services.<h4>Methods</h4>A self-completion, online questionnaire was designed by the research team. Items on the different dimensions of integration (funding, administrative, organisational, service delivery, clinical care) were included. The survey was sent to a random sample of residential care homes with more than 25 beds (n?=?621) in England in 2009. Responses were analysed using quantitative and qualitative methods.<h4>Results</h4>The survey achieved an overall response rate of 15.8%. Most care homes (78.7%) worked with more than one general practice. Respondents indicated that a mean of 14.1 professionals/ services (other than GPs) had visited the care homes in the last six months (SD 5.11, median 14); a mean of .39 (SD.163) professionals/services per bed. The most frequent services visiting were district nursing, chiropody and community psychiatric nurses. Many (60%) managers considered that they worked with the NHS in an integrated way, including sharing documents, engaging in integrated care planning and joint learning and training. However, some care home managers cited working practices dictated by NHS methods of service delivery and priorities for care, rather than those of the care home or residents, a lack of willingness by NHS professionals to share information, and low levels of respect for the experience and knowledge of care home staff.<h4>Conclusions</h4>Care homes are a hub for a wide range of NHS activity, but this is ad hoc with no recognised way to support working together. Integration between care homes and local health services is only really evident at the level of individual working relationships and reflects patterns of collaborative working rather than integration. More integrated working between care homes and primary health services has the potential to improve quality of care in a cost-effective manner, but strategic decisions to create more formal arrangements are required to bring this about. Commissioners of services for older people need to capitalise on good working relationships and address idiosyncratic patterns of provision to care homes.The low response rate is indicative of the difficulty of undertaking research in care homes.
Project description:BACKGROUND:People with multimorbidity, especially older people, have complex health and social needs, and require an integrated care approach. In this respect, eHealth could be of support. This paper aims to describe the implementation of eHealth technologies in integrated care programs for people with multimorbidity in Europe, and to analyse related benefits and barriers according to outcomes from ICARE4EU study and within the more general conceptual framework of the "10 e's" in eHealth by Gunther Eysenbach. METHODS:In 2014, ICARE4EU project identified 101 integrated care programs in 24 European countries. Expert organizations and managers of the programs completed an on-line questionnaire addressing several aspects including the adoption of eHealth. Findings from this questionnaire were analyzed, by linking in particular benefits and barriers of eHealth with the "10 e's" by Eysenbach (Efficiency, Enhancing, Evidence-based, Empowerment, Encouragement, Education, Enabling, Extending, Ethics, and Equity). RESULTS:Out of 101 programs, 85 adopted eHealth tools, of which 42 focused explicitly on older people. eHealth could improve care integration/management, quality of care/life and cost-efficiency, whereas inadequate funding represents a major barrier. The "10 e's" by Eysenbach seem to show contact points with ICARE4EU findings, in particular when referring to positive aspects of eHealth such as Efficiency and Enhancing quality of care/life, although Empowerment/Education of patients, care Equity and Ethics issues seem crucial in this respect. Encouragement of a new relationship patient-health professional, and Enabling standardized exchange of electronic information, represent further aspects impacting integration/management of care. CONCLUSIONS:Aspects of eHealth, which emerged as benefits and barriers impacting integration/management of care, as well as cost-efficiency and quality of care/life, can be identified on the basis of both ICARE4EU findings and the "10 e's" in eHealth by Eysenbach. They could represent objectives of new policies for supporting the deployment of eHealth technologies within integrated care across Europe.