BackgroundThe Chronic Care Model (CCM) is a framework developed to redesign care delivery for individuals living with chronic diseases in primary care. The CCM and its various components have been widely adopted and evaluated, however, little is known about different primary care experiences with its implementation, and the factors that influence its successful uptake. The purpose of this review is to synthesize findings of studies that implemented the CCM in primary care, in order to identify facilitators and barriers encountered during implementation.MethodsThis study identified English-language, peer-reviewed research articles, describing the CCM in primary care settings. Searches were performed in three data bases: Web of Knowledge, Pubmed and Scopus. Article abstracts and titles were read based on whether they met the following inclusion criteria: 1) studies published after 2003 that described or evaluated the implementation of the CCM; 2) the care setting was primary care; 3) the target population of the study was adults over the age of 18 with chronic conditions. Studies were categorized by reference, study design and methods, participants and setting, study objective, CCM components used, and description of the intervention. The next stage of data abstraction involved qualitative analysis of cited barriers and facilitators using the Consolidating Framework for Research Implementation.ResultsThis review identified barriers and facilitators of implementation across various primary care settings in 22 studies. The major emerging themes were those related to the inner setting of the organization, the process of implementation and characteristics of the individual healthcare providers. These included: organizational culture, its structural characteristics, networks and communication, implementation climate and readiness, presence of supportive leadership, and provider attitudes and beliefs.ConclusionsThese findings highlight the importance of assessing organizational capacity and needs prior to and during the implementation of the CCM, as well as gaining a better understanding of health care providers’ and organizational perspective.

Background Health and care services are becoming increasingly strained and healthcare authorities worldwide are investing in integrated care in the hope of delivering higher-quality services while containing costs. The cost-effectiveness of integrated care, however, remains unclear. This systematic review and meta-analysis aims to appraise current economic evaluations of integrated care and assesses the impact on outcomes and costs. Methods CINAHL, DARE, EMBASE, Medline/PubMed, NHS EED, OECD Library, Scopus, Web of Science, and WHOLIS databases from inception to 31 December 2019 were searched to identify studies assessing the cost-effectiveness of integrated care. Study quality was assessed using an adapted CHEERS checklist and used as weight in a random-effects meta-analysis to estimate mean cost and mean outcomes of integrated care. Results Selected studies achieved a relatively low average quality score of 65.0% (± 18.7%). Overall meta-analyses from 34 studies showed a significant decrease in costs (0.94; CI 0.90–0.99) and a statistically significant improvement in outcomes (1.06; CI 1.05–1.08) associated with integrated care compared to the control. There is substantial heterogeneity in both costs and outcomes across subgroups. Results were significant in studies lasting over 12 months (12 studies), with both a decrease in cost (0.87; CI 0.80–0.94) and improvement in outcomes (1.15; 95% CI 1.11–1.18) for integrated care interventions; whereas, these associations were not significant in studies with follow-up less than a year. Conclusion Our findings suggest that integrated care is likely to reduce cost and improve outcome. However, existing evidence varies largely and is of moderate quality. Future economic evaluation should target methodological issues to aid policy decisions with more robust evidence on the cost-effectiveness of integrated care.

Introduction:The aim of this review is to systematically assess the methodological quality of economic evaluations in integrated care and to identify challenges with conducting such studies.Theory and methods:Searches of grey-literature and scientific papers were performed, from January 2000 to December 2018. A checklist was developed to assess the quality of economic evaluations. Authors’ statements of challenges encountered during their evaluations were qualitatively coded.Results:Forty-four articles were eligible for inclusion. The review found that study design, measurement of cost and outcomes, statistical analysis and presentation of data were the areas with most quality variation. Authors identified challenges mostly related to time horizon of the evaluation, inadequate or lack of comparator group, contamination bias, and a post-hoc evaluation culture.Discussion:Our review found significant differences in quality, with some studies showing poor methodological rigor; challenging conclusions on the cost-effectiveness of integrated care.Conclusion:It is essential for evaluators to use best-practice standards when planning and conducting economic evaluations, in order to build a reliable evidence base for decision-making in integrated care.

Introduction An increasing number of individuals are living with multiple chronic conditions, often combined with psychosocial complexities. For these patients with complex conditions, an integrated primary care model that provides care coordination and a team-based approach can help manage their multiple needs. Information and communication technologies (ICTs) are recognized as a critical enabler of integrated primary care. A better understanding of the use of ICTs in an integrated care setting and how ICTs are being leveraged would be beneficial to identify knowledge gaps and could lead to successful implementation for ICT-based interventions. Objective This study will systematically scope the literature on the topic of ICT-enabled integrated healthcare delivery models for patients with complex care needs to identify which technologies have been used in integrated primary care settings. Method This study protocol outlines a scoping review of the peer-reviewed literature, using Arksey and O’Malley’s (enhanced by Levac et al.) scoping review methodology. Peer-reviewed literature will be identified using a multi-database search strategy. The results of the search will be screened, abstracted, and charted in duplicate by six research team members. Discussion The key findings of the study will be thematically analyzed to describe the implemented ICTs aimed for complex patients within the integrated primary care model. The finding will highlight what types of ICTs are being put in place to support these models, and how these ICTs are enabling care integration. This review will be the first step to formally identify how ICT is used to support integrated primary health care models. The results will be disseminated through peer-reviewed publications, conference presentations, and special interest groups.

BackgroundOlder adults living with heart failure (HF) in long-term care (LTC) experience frequent hospitalization. Using routinely available clinical information, we examined resident-level factors that precipitate hospitalization within 90 days of admission to LTC.MethodsThis was a retrospective cohort study of older adults diagnosed with HF, who were admitted to LTC in Ontario, Canada, between 2011 and 2013. Multivariate logistic regression models using generalized estimating equations were developed to determine predictors of hospitalization in residents with HF.ResultsEntry to LTC from a hospital was the strongest predictor of future hospitalization (OR: 8.1, 95% CI: 7.1–9.3), followed by a score of three or greater on the Changes in Health, End-stage Signs and Symptoms scale, a measure of moderate to severe medical instability (O.R 4.2, 95% CI: 3.1–5.9). Other variables that increased the likelihood of hospitalization included being flagged as a high risk for falls, two or more physician visits, and increased monitoring for acute medical illness within 14 days of admission.ConclusionOur findings highlight that health instability and transitions from acute to LTC will increase the likelihood of transitioning back into the hospital setting. The identified predisposing factors suggest the need for targeted prevention strategies for those in high-risk groups.

Background Information and communications technologies (ICTs) are recognized as critical enablers of integrated primary care to support patients with multiple chronic conditions. Although ICT-enabled integrated primary care holds promise in supporting patients with complex care needs through team-based and continued care, critical implementation factors regarding what ICTs are available and how they enable this model are yet to be mapped in the literature. Objective This scoping review addressed the current knowledge gap by answering the following research question: What ICTs are used in delivering integrated primary care to patients with complex care needs? Methods The Arksey and O’Malley method enhanced by the work by Levac et al was used to guide this scoping review. In total, 4 electronic medical databases were accessed—MEDLINE, Embase, CINAHL, and PsycINFO—collecting studies published between January 2000 and December 2021. Identified peer-reviewed articles were screened. Relevant studies were charted, collated, and analyzed using the Rainbow Model of Integrated Care and the eHealth Enhanced Chronic Care Model. Results A total of 52,216 articles were identified, of which 31 (0.06%) met the review’s eligibility criteria. In the current literature, ICTs are used to serve the following functions in the integrated primary care setting: information sharing, self-management support, clinical decision-making, and remote service delivery. Integration efforts are supported by ICTs by promoting teamwork and coordinating clinical services across teams and organizations. Patient, provider, organizational, and technological implementation factors are considered important for ICT-based interventions in the integrated primary care setting. Conclusions ICTs play a critical role in enabling clinical and professional integration in the primary care setting to meet the health system–related needs of patients with complex care needs. Future research is needed to explore how to integrate technologies at an organizational and system level to create a health system that is well prepared to optimize technologies to support patients with complex care needs.

Introduction: Evidence of the impact of inpatient palliative care on receiving home-based palliative care remains limited. Objectives: The objective of this study was to examine, at a population level, the association between receiving inpatient palliative care and home-based palliative care postdischarge. Design: We conducted a retrospective cohort study to examine the association between receiving inpatient palliative care and home-based palliative care within 21 days of hospital discharge among decedents in the last six months of life. Setting/Subjects: We captured all decedents who were discharged alive from an acute care hospital in their last 180 days of life between April 1, 2014, and March 31, 2017, in Ontario, Canada. The index event was the first hospital discharge furthest away from death (i.e., closest to 180 days before death). Results: Decedents who had inpatient palliative care were significantly more likely to receive home-based palliative care after discharge (80.0% vs. 20.1%; p < 0.001). After adjusting for sociodemographic and clinical covariates, the odds of receiving home-based palliative care were 11.3 times higher for those with inpatient palliative care (95% confidence interval [CI]: 9.4-13.5; p < 0.001). The strength of the association incrementally decreased as death approached. The odds of receiving home-based palliative care after a hospital discharge 60 days before death were 7.7 times greater for those who received inpatient palliative care (95% CI: 6.0-9.8). Conclusion: Inpatient palliative care offers a distinct opportunity to improve transitional care between hospital and home, through enhancing access to home-based palliative care.

No abstract