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Jee Wei Lim: Challenges of measuring care integration

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Integration of health and social care – predicting the quality, costs and consequences 17.4.2018

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Jee Wei Lim: Challenges of measuring care integration

  1. 1. © Copyright National University of Singapore. All Rights Reserved. CHALLENGES OF MEASURING CARE INTEGRATION Yee Wei LIM Yong Loo Lin School of Medicine National University of Singapore 17 April 2018
  2. 2. © Copyright National University of Singapore. All Rights Reserved. Outline • Challenges: – Definition – The process of integration – Measurement • Unique considerations for health-social care integration • Recent and future trends of care integration PRESENTATION TITLE
  3. 3. © Copyright National University of Singapore. All Rights Reserved. CHALLENGE 1: WHAT IS INTEGRATION AND DO WE NEED IT?
  4. 4. © Copyright National University of Singapore. All Rights Reserved. Many definitions… At least 175 overlapping definitions of integrated care (Armitage et al, 2009) WHO definition (2002): integrated care is bringing together inputs, delivery, management and organization of services related to diagnosis, treatment, care, rehabilitation and health promotion. integration is a means to improve access, quality, user satisfaction and efficiency.
  5. 5. © Copyright National University of Singapore. All Rights Reserved. Intensity of the relationship: Is integration needed? Levels Of Integration And User Need As Described By Leutz (1999).
  6. 6. © Copyright National University of Singapore. All Rights Reserved. Where Are We On This Map? Peck E. (2002) and Gladsby J (2007)
  7. 7. © Copyright National University of Singapore. All Rights Reserved. Assuming we want integration, which area(s) to integrate? • Vertical integration: e.g., primary and secondary care • Horizontal integration: e.g., hospital and rehabilitation facility • Integration centered around primary care: e.g., patient centered medical home • Integration centered around social care: e.g., home-based service models
  8. 8. © Copyright National University of Singapore. All Rights Reserved. Which dimension to integrate?
  9. 9. © Copyright National University of Singapore. All Rights Reserved. CHALLENGE 2: MEASURING EXECUTION
  10. 10. © Copyright National University of Singapore. All Rights Reserved. Measuring the planning process and execution Questions include: 1. Do organizations have the same goal? 2. Was there a situational analysis? 3. Was a value case made? Risk management plan? 4. Are staff/teams ready to integrate? 5. Is there capacity building? 6. Is the infrastructure in place to integrate? Technology use appropriate and effective? 7. What about governance?
  11. 11. © Copyright National University of Singapore. All Rights Reserved. Example: Scirocco Model to assess integration capabilities
  12. 12. © Copyright National University of Singapore. All Rights Reserved. Tracking the journey of integration Important to measure readiness and capacity to integrate so as to: •Reduce the probability of failure •Continuously improve the process of integration •Gain insights for scale up or replication
  13. 13. © Copyright National University of Singapore. All Rights Reserved. CHALLENGE 3: WHAT MEASURES TO USE?
  14. 14. © Copyright National University of Singapore. All Rights Reserved. Hundreds of measures out there! • Focus on user groups and care pathways varies • How a dimension is measured could vary. E.g., care continuity: – 32 indices identified by Jee and Cabana (2006) – Concepts included: duration of provider relationship, density of visits, dispersion of providers, sequence of providers, subjective assessment • Measurement gaps exist
  15. 15. © Copyright National University of Singapore. All Rights Reserved. Another example: Measuring patient centeredness 15 dimensions identified: characteristics of clinician, clinician-patient relationship, clinician- patient communication, patient as unique person, biopsychosocial perspective, patient information, patient involvement in care, involvement of family and friends, patient empowerment, physical support, emotional support, integration of medical and non-medical care, teamwork, access to care, coordination and continuity of care. Scholl I, Zill JM, Härter M, Dirmaier J (2014) An Integrative Model Of Patient-centeredness – A Systematic Review And Concept Analysis. PLOS ONE 9(9): E107828.
  16. 16. © Copyright National University of Singapore. All Rights Reserved. Measures are not always Tested/Validated Bautista et al (2016) systematic review found: • <50% of the validation studies to be of good or excellent quality • Minority of instruments showed strong evidence for internal consistency (15%), content validity (19%), and structural validity (7%); with moderate evidence of positive findings for internal consistency (14%) and construct validity (14%). Bautista MA, Nurjono M, Lim YW, Dessers E, Vrijhoef HJ. Instruments Measuring Integrated Care: A Systematic Review of Measurement Properties. Milbank Q. 2016 Dec;94(4):862-917.
  17. 17. © Copyright National University of Singapore. All Rights Reserved. Multiple paths taken – what worked? • Integration programs may have several simultaneous objectives • Various disparate mechanisms used to improve integration • Time lag for impact • Multiplicity of parallel initiatives – hard to attribute cause and effect
  18. 18. © Copyright National University of Singapore. All Rights Reserved. How to decide what to measure and how to measure? • Decide what dimensions will be assessed – Need to prioritize with stakeholders • Need to have a conceptual framework everyone can agree on • Select validated instruments • Consider culture and context • Mixed methods probably needed
  19. 19. © Copyright National University of Singapore. All Rights Reserved. HEALTH AND SOCIAL CARE INTEGRATION: SOME THOUGHTS
  20. 20. © Copyright National University of Singapore. All Rights Reserved. Health Social Health Social Which form of health and social care integration? Social Health
  21. 21. © Copyright National University of Singapore. All Rights Reserved. A B CD E 1 2 34 5 Measuring integration within and across systems? Healthcare Social care
  22. 22. © Copyright National University of Singapore. All Rights Reserved. Health and social goals may differ • Healthcare system may prioritize individual clinical outcome and health system goals • Social care may focus on individual wellbeing and social relationships in the community • Can joint ownership of goals and responsibilities occur?
  23. 23. © Copyright National University of Singapore. All Rights Reserved. FUTURE TRENDS
  24. 24. © Copyright National University of Singapore. All Rights Reserved. Scope of integration will broaden • Beyond health and social care integration: – Economic dimension – Broader social goals – e.g., intergenerational integration • Beyond disease-specific care integration, focus on whole person health • Not limited to service delivery for individuals but population management • Taking a life-course approach • Quadruple aim: beyond quality, access and cost, to include staff wellbeing
  25. 25. © Copyright National University of Singapore. All Rights Reserved. Tools of measurement will multiply • Participatory data collection – Living labs • Use of multi-media, e.g., video-diary • Use of social media data • Use of real time feedback • Rapid pilots
  26. 26. © Copyright National University of Singapore. All Rights Reserved. FINAL THOUGHT The work of care integration is never done - Society evolves, focus of integration shifts, priorities change
  27. 27. © Copyright National University of Singapore. All Rights Reserved. THANK YOU! yee_wei_lim@nuhs.edu.sg

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