Integrated care in practice: collaborative practice in integrated care Chaired by Hernan Montenegro, Health Systems Advisor, WHO, Geneva Switzerland
This session offered participants a chance to reorient themselves on a core issue in integrated care: collaboration. Many people working to implement integrated care can easily get caught up in the technical issues of developing or changing an existing system, while forgetting that one of the main barriers to a functionally integrated and co-ordinated system is collaboration and communication between front-line staff and the end-users. The presentations ranged from summarizing current evidence to describing on-going initiatives.
Dr Petra Bywood and her colleagues from Flinders University, Australia undertook a comprehensive literature review to identify key strategies that enable integration. Ten strategies were identified:
- Understand the local context;
- Develop strong governance;
- Maintain appropriate infrastructure – physical, electronic and human capacity;
- Use effective financing and funding models;
- Engage stakeholders early and foster trusting relationships;
- Establish partnerships with a common set of goals and well-defined roles;
- Encourage regular knowledge exchange between relevant stakeholders;
- Promote open and frequent communication;
- Leverage eHealth to manage workflow; and
- Collect and analyse data and evidence for continuous improvement.
While all of these strategies are important to supporting integration, Dr Bywood noted that understanding the local context is a good place to begin designing integrated care efforts.
Dr Bywood and colleagues concluded that implementing a combination of these strategies will depend on available resources and the local context. Time and patience are required when establishing integrated care systems. Finally, a key mechanism that supports integrated care is a focus on breaking down the silos and working together.
Catherine Mangan from the University of Birmingham, UK & Jeremy Cooper, from iMPower, UK presented on the concept of breaking down silos and building trust between GPs and social care workers, two professional groups that have the largest influence on older people’s care. iMPower developed the Home Truths programme, which was evaluated by University of Birmingham staff.
The Home Truths programme investigated the perceptions and relationships General Practitioners (GPs) have of social workers. The main findings are that GPs perceive social care as inaccessible and remote. Most GPs are not aware of the range of available social services and do not trust social care to appropriately support individuals in need. This leads to the elderly entering nursing home, residential or full-time care services earlier than necessary.
The presenters found that increasing a GP’s trust and knowledge of available social care services can increase referrals to community care. The best way to ensure that GPs will refer clients to social care services is not through financial incentives, but to explain how social services will make their own work easier. GPs ultimately want to feel confident that community care services can take care of their client. Referring patients to appropriate services could lead to national savings of 600,000 GBP to social care and 1 billion GBP to health care.
Findings from the Home Truths programme suggests that explicitly addressing barriers and behavior change at the front lines will boost community care integration, which can ultimately serve as a reliable alternative to hospital admission.
Another initiative that is focused on issues on the front lines is HelsaMi, led by SINTEF technology and society, Norway. HelsaMi’s goal is to design an integrated care service via a mobile app and electronic data platform for individuals with Chronic Obstructive Pulmonary Disease (COPD). In its first stage, this effort engaged local leaders from both health and social service providers to concurrently monitor COPD patients’ health status in real-time. If an exacerbation or abnormality was reported, service providers would call the patients with further inquiries.
HelsaMi employs an iterative user centered design approach and is now poised to be piloted among a larger group of COPD patients. Thus far, findings show that patients do not feel like they are in control of their disease(s) despite the fact that they spend a lot of energy collecting and sharing information on their condition(s) with providers. Patients often do not know what to ask about their disease so health and social service providers should be trained to assist patients navigate stages of disease progression. Future work on the platform will likely include additional chronic diseases and an app for service providers.
The final presentation highlighted legal implications of health care practice. Dr Eron Manusov and two attorneys, Beau Nokes and Shari Nokes, pointed out that service providers may unwittingly encounter legal issues that can be avoided with some awareness and planning.
Some issues that are potentially litigious are elder abuse and neglect, brain death and end of life care, treatment of individuals with unstable mental capacity and patient confidentiality. Service providers can regularly assess the potential of a lawsuit by using standardized forms and checklists, holding weekly meetings, and being aware of potentially troublesome areas such as divorce, death, illness and longitudinal care and follow up. The presenters noted that the biggest barrier to doctors and lawyers working together is the lack of literacy of each other’s profession, different behavior due to each profession’s income generation model, cultural and philosophical differences as well as training that teaches each profession to have a ‘take charge’ attitude.
This presentation triggered a lively conversation among session attendees about the challenges of fostering communication and trust between professions. All acknowledged that integrated care is a multi-sector effort that may require individuals who use different lexicons and paradigms to work together. Some pointed out that from a young age, the education system not only segregates future social care workers from doctors and lawyers, but it also fosters a competitive culture that reduces the possibility of informal communication between sectors. Trust cannot develop if people are wary of each other or cannot understand what the other is saying.
This session emphasized the importance of communication in collaborating to establish integrated care systems. While structural and process changes are necessary, understanding the local context in terms of relationships in a target area or population is vital. Changes may not be implemented as envisioned if frontline staff do not know how to work with other professionals or their clients.