PurposeA realist review of the evaluative evidence was conducted on integrated care (IC) programs for older adults to identify key processes that lead to the success or failure of these programs in achieving outcomes such as reduced healthcare utilization, improved patient health, and improved patient and caregiver experience.Data sourcesInternational academic literature was searched in 12 indexed, electronic databases and gray literature through internet searches, to identify evaluative studies.Study selectionInclusion criteria included evaluative literature on integrated, long-stay health and social care programs, published between January 1980 and July 2015, in English.Data extractionData were extracted on the study purpose, period, setting, design, population, sample size, outcomes, and study results, as well as explanations of mechanisms and contextual factors influencing outcomes.Results of data synthesisA total of 65 articles, representing 28 IC programs, were included in the review. Two context-mechanism-outcome configurations (CMOcs) were identified: (i) trusting multidisciplinary team relationships and (ii) provider commitment to and understanding of the model. Contextual factors such as strong leadership that sets clear goals and establishes an organizational culture in support of the program, along with joint governance structures, supported team collaboration and subsequent successful implementation. Furthermore, time to build an infrastructure to implement and flexibility in implementation, emerged as key processes instrumental to success of these programs.ConclusionsThis review included a wide range of international evidence, and identified key processes for successful implementation of IC programs that should be considered by program planners, leaders and evaluators.

BackgroundThere is a growing interest in redesigning health‐care systems to better manage the increasing numbers of people with multimorbidity. Knowing how patients experience health‐care delivery and what they need from the health‐care system are critical pieces of evidence that can be used to guide health system reforms.ObjectiveThe purpose of this study was to understand the challenges patients with multimorbidity face in accessing care in the community, and the implications for patients and their families.MethodsA secondary analysis of qualitative data was conducted on semi‐structured interviews with 116 patients who were receiving care in an urban rehabilitation facility in 2011. Exploratory interpretive analysis was used to identify themes about access to care.ResultsChallenges occurred at two levels: at the health system level and at the individual (patient) level. Issues at the health system level fell into two broad categories: availability of services (failing to qualify, coping with wait times, struggling with scarcity and negotiating the location of care) and service delivery (unreliable care, unmet needs, incongruent care and inflexible care). Challenges at the patient level fell into the themes of logistics of accessing care and financial strain. Patients interacted and responded to these challenges by: managing the system, making personal sacrifices, substituting with informal care, and resigning to system constraints.ConclusionIdentifying the barriers patients encounter and the lengths they go to in order to access care highlights areas where policy initiatives can focus to develop appropriate and supportive services that are more person and family‐centred.

BackgroundDelayed hospital discharge (also known as Alternate Level of Care or ALC) is a global health care quality issue with negative implications for people (e.g., functional decline) and the health care system (e.g., costly interruptions in hospital flow and procedures). ALC disproportionately impacts people with cognitive impairment, and insight into the needs and experiences of this specific sub population and their carers is lacking. The purpose of this study was to understand the hospital experience of carers (e.g., family members) of patients with ALC and cognitive impairment who were waiting for long-term care from the hospital.MethodsThis is a qualitative descriptive study entailing 12 semi-structured interviews with 15 carers of patients with ALC from three hospitals in Northwestern Ontario. Interviews were conducted between October 2015 and February 2016. Two reviewers thematically analyzed the interview data.ResultsFive core themes were identified from the interview data: patient over person, uncertain and confusing process, inconsistent quality in care delivery, carers addressing gaps in the system, and personalization of long-term care.ConclusionsWaiting for long-term care from the hospital is a stressful and uncertain time for family carers. ALC is an ‘in-between’ phase when patients and carers may be at their most vulnerable yet receive the least care from the formal care system. Carers provide critical insight into the needs and behaviors of patients as well as processes that need to be improved to enhance their experience. Such insights will help health systems internationally as they grapple with the issue of ALC whilst trying to optimize engagement with patients and their families.Electronic supplementary materialThe online version of this article (doi:10.1186/s12913-017-2272-6) contains supplementary material, which is available to authorized users.

PurposeLeading health systems have invested in substantial quality improvement (QI) capacity building, but little is known about the aggregate effect of these investments at the health system level. We conducted a systematic review to identify key steps and elements that should be considered for system-level evaluations of investment in QI capacity building.MethodsWe searched for evaluations of QI capacity building and evaluations of QI training programmes. We included the most relevant indexed databases in the field and a strategic search of the grey literature. The latter included direct electronic scanning of 85 relevant government and institutional websites internationally. Data were extracted regarding evaluation design and common assessment themes and components.Results48 articles met the inclusion criteria. 46 articles described initiative-level non-economic evaluations of QI capacity building/training, while 2 studies included economic evaluations of QI capacity building/training, also at the initiative level. No system-level QI capacity building/training evaluations were found. We identified 17 evaluation components that fit within 5 overarching dimensions (characteristics of QI training; characteristics of QI activity; individual capacity; organisational capacity and impact) that should be considered in evaluations of QI capacity building. 8 key steps in return-on-investment (ROI) assessments in QI capacity building were identified: (1) planning—stakeholder perspective; (2) planning—temporal perspective; (3) identifying costs; (4) identifying benefits; (5) identifying intangible benefits that will not be included in the ROI estimation; (6) discerning attribution; (7) ROI calculations; (8) sensitivity analysis.ConclusionsThe literature on QI capacity building evaluation is limited in the number and scope of studies. Our findings, summarised in a Framework to Guide Evaluations of QI Capacity Building, can be used to start closing this knowledge gap.