Background: Older adults with frailty are at high risk of adverse outcomes during hospitalisation. To address this, two Acute Geriatric Community Hospitals (AGCH1 and AGCH2) were established in the Netherlands. This study examined similarities and differences in setting, staffing, care pathways, patient populations, outcomes, and improvement opportunities in the first quarter of 2024.Methods: We conducted a mixed-methods evaluation using questionnaires (n = 2), documents (n = 10), case vignettes (n = 20), case vignette surveys (n = 7), and focus groups (n = 2). Quantitative data on patients admitted between January 1 and March 31, 2024, (n = 161) were collected in aggregated form via the questionnaires and analysed descriptively; qualitative data were analysed thematically.Results: Both sites implemented the core model elements but varied in setting and staffing. Patients showed high multimorbidity with respiratory conditions and infections as common diagnoses. Across ten case vignettes per AGCH, experts reported variation in referral appropriateness. Mean length of stay was shorter at AGCH2 (9.0 vs. 12.5 days), while less patients were discharged home (51.7% vs. 70.3%). Focus groups highlighted seven improvement areas: referral, expectation management, discharge planning, IT integration, funding, and evening/night/weekend care.Conclusions: The two AGCHs appeared to have largely similar care pathways, patient populations, and improvement opportunities, but differed in context, staffing, and outcomes. Sustainable implementation requires continuous learning, clear referral pathways, and skill mix review; national scale-up demands effectiveness studies, role delineation, and defining core versus adaptable model elements.
Introduction: The growing number of older adults with multiple long-term conditions increases the need for better vertical integration of providers, especially in home care. Ensuring information continuity and care coordination is essential but remains time-consuming for home care professionals (HCPs).Methodology: This study aimed to quantify HCPs’ time on health information management (HIM) and examine factors associated with this time use. We conducted an exploratory cross-sectional survey in four Finnish home care organizations. Respondents estimated weekly time use for five predefined tasks related to information retrieval, care coordination, and communication. Descriptive statistics, ANOVA, and multiple linear regression examined total HIM time variation.Results: Based on 625 responses, HCPs averaged 258 minutes weekly on HIM tasks. On average, highest time use was reported by registered nurses (518 minutes) and physicians (336 minutes). Across measured tasks, the largest share of the total time was spent on information retrieval (32.0–46.5%). Profession and direct patient care were the only factors associated with time use, regardless of the region’s integration maturity.Conclusion: HCPs spend substantial time managing care information. Our findings highlight the critical need for better-integrated systems to enhance care coordination, reduce administrative burden, and enable professionals to devote more time to direct care.
Introduction: To promote recovery of individuals with severe mental illness and reduce fragmentation of care, network partners collaborated to develop a cross-domain, multi-agency approach by integrating Flexible Assertive Community Treatment (FACT) teams with municipal District Social Services (DSS), referred to as FACT+DSS teams.Aim: To describe how team members experienced the implementation of the FACT+DSS teams by team members, including perceived effects on various themes such as service delivery, network collaboration, the target population, and facilitators and barriers to implementation.Methods: A qualitative study using semi-structured interviews (N = 15) was conducted to explore the experiences of team members in two new FACT+DSS teams in the Netherlands using thematic analysis.Results: The FACT+DSS approach was experienced to improve service access, continuity of care, case-finding and client enrolment (care-avoiders), time efficiency for team members, and strengthen network collaboration. Identified barriers and facilitators underlined the importance of strong leadership, ownership, equality, direct relationships, and professional expertise.Conclusion: Participants experienced the FACT+DSS approach as a highly positive development, improving network collaboration and recovery-oriented care for clients. Our findings may contribute to the development and implementation of FACT (and related practices) as an integrated multi-agency approach.
Introduction:A Cardiology Integrated Chronic Care (ICC) clinic was established at a polyclinic through collaboration between a tertiary hospital and a polyclinic. This novel model in Singapore prompted a study exploring explore how stakeholders conceptualise and operationalise integration when implementing the clinic in primary care, aiming to understand if common cardiology conditions can be anchored in primary care. Methods:Nine semi-structured interviews were conducted with a cardiologist, intervention's director, family physician, polyclinic head, coordinators and advanced practice nurse. Twelve documents -including implementation monitoring reports, steering committee reports and meeting minutes - were analysed using Singer and colleagues' conceptual model of integration types. Results:Co-located consultation rooms, direct access investigations and remote consultations between healthcare providers promoted structural integration. Interpersonal integration was fostered through teamwork. Functional integration was accomplished via comprehensive care management protocols and training. Low patient numbers reduced polyclinic revenue but positively impacted care efficiency. Provider satisfaction remained high, with participants gaining knowledge and confidence in managing cases. Conclusion:The clinic demonstrated operational integration but may lack a broader healthcare system perspective. For sustainable larger-scale evolution, economic and policy scrutiny is needed focusing on operational feasibility and outcomes, given low patient volume constraints affecting financial viability and scalability potential.
This perspective paper draws on our experience as a clinician researcher and a patient partner involved in the implementation and evaluation of an integrated care program for people with complex needs. Although an organization actively engaged in integrated care agreed to participate in a research project evaluating implementation, no patient referrals were ultimately received from case managers. Using a real-world vignette, we examine how well-intentioned protective practices within integrated care settings can lead to de facto exclusion from research. We explore the ethical tensions this creates-particularly regarding justice, autonomy, and equity-and outline practical lessons to support more inclusive research practices embedded in integrated care programs.
A notable development in recent years has been the emphasis on structuring integrated care around 'neighbourhoods' or 'places' and engaging 'communities' in the planning, design and delivery of support. Across the world, related principles are being used to inform national and regional policies and to develop local practice innovations. Despite such interest, community and neighbourhood working can feel a radical endeavour which clashes with established structures, relationships, investments and skills. A group of international experts from policy, practice, communities and research came together at a roundtable at the International Conference on Integrated Care 2026 to debate how integrated care can authentically adopt these principles. Agreeing what is meant by such concepts and how they can be utilised in practice is an important starting point - 'neighbourhoods' were generally seen to be more geographically oriented and where people physically live, whereas 'communities' relate to the connections and relationships which matter to people. Addressing power and resource imbalances requires investing in the voluntary and community sector and framing neighbourhoods as the responsibility of the whole system, including hospitals. Building the professional skills and capacity for neighbourhood working means embedding as a core competency with qualifying and on-going education. Creating the organisational and system capacities to sustain involves developing performance metrics and processes which emphasis shared outcomes. Such developments also require researchers to support with the process of change through responsive, co-produced and accessible methodologies.
Background:The number of older adults living with dementia is increasing in China and worldwide. Three-level prevention is vital to delay the occurrence and development of dementia. However, the current state of these services remains suboptimal. This study aimed to explore the programs and challenges in providing dementia prevention services. Methods:A one-year ethnographic study, including semi-participatory observations and in-depth interviews, was conducted in nine settings in China from July 2022 to June 2023. Twenty-four service providers and 26 residents or family members were observed, and seventeen of these 50 participants were interviewed. Data collection was guided by the Rainbow Model. A combination of deductive and inductive content analysis was applied to identify the challenges. Results:Dementia-friendly communities, Dementia Screening Program, Medical Consortia, and Long-term care services were the main programs in dementia three-level prevention services. This study identified 32 challenges, including four at system level, ten at organizational level, seven each at professional and clinical levels, and four additional challenges. Conclusions:Enriching the diversity of programs and strengthening primary prevention services will be beneficial for improving the dementia three-level services. The challenges identified in this study can provide valuable insights to guide targeted interventions, inform policy, and optimize service delivery for relevant stakeholders.
Objective:The Integrating Prevention into Connect Care for Health (IPiC-Health) initiative embeds a Screening, Brief Intervention, and Referral (SBIR) approach for health promotion into routine inpatient and ambulatory care, facilitated by the province-wide, EPIC™-based, electronic clinical information system in Alberta. The SBIR approach supports patients in achieving behaviour change regarding tobacco and alcohol use and physical inactivity. This methodological article describes the research plan to evaluate the implementation and effectiveness of SBIR intervention. Methods:This effectiveness-implementation hybrid study includes a quasi-experimental design for quantitative assessment of SBIR implementation (adoption/coverage) and effectiveness (behaviour change and health service use) outcomes. Each participating site recruits control patients for 6 months, followed by 15 months intervention. Patients are followed up for 12 months after recruitment to assess effectiveness outcomes. Mixed methods are used to assess implementation uptake, process, and experience. Expected results and implications:Recruitment and data collection activities are ongoing in participating sites. This effectiveness-implementation research will strengthen evidence and implementation guidance to inform spread and scale up of the approach across Alberta's hospitals and beyond. An electronic record of patient's risk factors can improve patients' care and population health by making these data readily available to support care decisions.
Introduction: People with experience of homelessness (PEH) often have multiple inter-related needs and for support rely on various services working together. To improve Out-of-Hospital Care (OOHC), it is crucial to understand their preferences. This study used a Discrete-Choice Experiment (DCE) to identify what matters most to them, ensuring services align with real-life experiences. Methods: A mixed methods approach combined interviews, group discussions, and DCE data. Service users, providers, and planners participated in workshops. Researchers with lived experience of homelessness co-designed a user-friendly questionnaire and supported data collection, fostering trust. Preferences were analysed using logistic regression, with findings presented in clear, interactive dashboards. Results: A total of 112 PEH participated from 10 sites, with 108 valid responses (35% response rate). Participants preferred care delivered at home, delivered by trusted housing workers, with minimal behavioural restrictions. Accommodation type and behavioural rules significantly influenced service uptake. DCE outputs were shared with PEH, who confirmed that the findings accurately reflected their priorities and real-life experiences. In one locality, insights were used to reshape service modelling. Discussion & conclusion: This study highlights the importance of co-designing OOHC services with PEH. Stability, trust, and fewer restrictions encourage service engagement. These insights can guide policymakers and service providers in developing more effective, person-centred care models, ultimately improving access and outcomes for PEH.
The aim of this Letter to Editor is to point out the impact of some of the article’s conclusions, while in our opinion these conclusions might not be accurate based on the detailed results. The authors report that 56% of health care providers in general practices do not feel capable of delivering integrated care. However, based on Table 2, this main conclusion appears inaccurate. Furthermore, it remains unclear which specific healthcare providers reported feeling incapable. We are concerned that the current interpretation may be misleading and we recommend correcting percentages and providing more detailed subgroup data in order to enhance the accuracy and clarity of the findings.
Background: Education and training in integrated care have been the focus of many presentations at previous events, and the subject of recent publications related to the need for globally-aligned competencies for the integrated care workforce. IFIC's Education and Training SIG was founded in 2017 with an aim to build a global network of researchers and educators focused on best practices for workforce development in integrated care. During the pandemic, that SIG became inactive; however, many of its members continued their work either independently or in collaboration with SIG colleagues. A recent study led by the IFIC Academy team focused on identifying the state of education and training in integrated care across seven countries. The findings from that study and other recent publications on this topic will be discussed in this workshop, which has been designed to re-invigorate the SIG on Education and Training by building upon findings, attracting new partners who wish to engage in this movement, and identifying next steps for this group as we respond to the global workforce crisis. When we discuss workforce training and education in this context, we will include formal education (beginning with undergraduate education curriculum) through graduate degrees and beyond into continuing education and professional development for health and social care providers in the workplace, as well as education and development for caregivers and patient/person self-management of care in communities. The importance of involving people, patients, and carers in developing, designing, delivering, and evaluating curriculum will be a theme interwoven throughout this workshop. Audience: Educators, leaders, and managers who want to be part of the movement towards a global community of practice in Integrated Care Education and Training. We also wish to raise education and development for those vital practitioners who are not ‘formal’ professionals, but who support people on a day to day basis and are central to experiences of person-centered care. Approach: We propose a 90 min. workshop (formerly called a "world café session,") structured as follows: I. Introduction (10 minutes) - Brief introduction of speaker(s) and background/context of the former SIG II. Overview of Published Research and IFIC Report (15 minutes) 1. Scope of Work to Date 2. Key Statistics and Recommendations III. Small Group Work - Interactive Case Study Analysis, Discussion, and Reflection (20 min) 1. Macro, Meso, Micro Levels - barriers and opportunities 2. Strategies to Address Opportunities 3. Develop recommendations for next steps for global workgroup VI. Large Group Reflection and Planning (20 min) 1. Share small group main takeaways and recommendations VII. Developing Next Steps as a Large Group (20 min) VIII. Closing (5 min) Outcomes: After group discussions, key takeaways from group discussions will be summarized in the large group, and notes will be captured as the large group plans the next steps to continue this work after the conference. Information and follow up opportunities will be provided in closing remarks and notes on the workshop will be shared with participants.
Background: Digital Health and Data Enabling Integrated Care SIG members have been working together on the priority area of interoperability for the last 3 years through meeting at ICIC and NACIC conferences and building partnerships. In these meetings members of the SIG have joined the co-leads to share and advance knowledge regarding translational challenges of interoperability (ICIC23), how to ensure interoperable efforts remain person-centred (ICIC24), and developing a process to iteratively adopt standardized minimum data sets to enable information sharing across systems (NACIC24). These efforts are being brought together into a white paper from the SIG to provide an international perspective on how health and care system efforts towards interoperability may help to ensure, rather than upend, efforts towards delivering more person-centred and integrated health and social care services. This session will seek to wrap-up our 3 year-long discussion on interoperability, sharing with delegates the learnings from past workshops, offering an opportunity to provide feedback on content and to suggest how the white paper’s recommendations can dovetail with relevant national or regional initiatives. Participants will also discuss what is next for the SIG to continue to build the vision for the future of a digitally-enabled integrated care systems. Audience: All existing and newly interested members of the SIG are welcome. Our growing membership consists of patients and family caregivers, researchers, frontline providers, managers, system leaders and decision-makers, policy makers, informaticians, and industry partners. We will also include a virtual component to this meeting so that our larger international members can participate whether attending the conference or not. Approach: The session will begin with a short introduction from SIG leads (C. Steele Gray, L. Lewis, I. Meyer) who will provide a summary of the work from the previous conference workshops on interoperability. Three sections of content will be covered by each of the leads (translational needs, ensuring person-centredness, and data standardization through minimum data sets), which will include points at which delegates can provide feedback and point to national / regional initiatives addressing each section. The leads will use tools like MentiMeter to collect rapid feedback from delegates in and out of the room. This first section of the meeting will take 40 minutes allowing for introduction time and about 12 minutes per section. The final 20 minutes will focus on the future asking delegates to work in small groups in the room and online to discuss the “Future of Digital Health and Data Enabling Integrated Care.” Outcomes: The White Paper being generated by the team will be refined based on feedback from delegates at this conference and posted to the IFIC website and other network websites as an open-source resource and living document. SIG members who share their names and contact information will be credited in the white paper as contributors to the work. The white paper will include the “Future of Digital Health and Data Enabling Integrated Care” discussion as a call to action for international partners around “what’s next.”
Introduction:The primary focus of this paper is the application of case study design to investigate the integration of complex health services. Description:This paper presents a co-created case study research project that examined the integration of a regional palliative care service. It outlines the study's design including the mixed-methods approach to data collection and the processes used for analysis and triangulation. The paper also details the tools and strategies implemented across the macro, meso, and micro levels of the service, offering practical insights into how case study research can be applied to explore the dynamics of integrated care. Discussion:Case study methodology enables comprehensive, context-rich data collection and supports theory development through real-world observation. Its adaptability makes it particularly suited for evaluating complex systems. Co-creation added significant value by fostering interest-holders' engagement and enhancing the relevance and applicability of the findings. The iterative and flexible design also allowed the study to respond effectively to challenges such as COVID-19 restrictions and a national cyber-attack. Conclusion:Case study research is a robust and flexible approach that provides deep insights into the integration of complex healthcare systems. Its co-creation potential and adaptability make it particularly useful in real-world health service evaluations.
Introduction: Professional and organisational collaboration of integrated services, like Flexible Assertive Community Treatment (FACT), plays a pivotal role in ensuring continuous and coordinated care for persons with complex mental health needs. While some research reflect team members’ view of FACT or program fidelity, no research has explored the social practice of FACT and how collaboration evolve and sustain. Aim: The aim is to explore the process of collaboration for the making of the integrated service of FACT. Methods: A constructivist grounded theory design helped to collect and analyse empirical evidence of 28 interviews with multiprofessional FACT team members and managers, in 2021 (n = 14) and 2022/2023 (n = 14) in Sweden. Results: Building care in the heart of the moment was constructed as the core category reflecting the timely process of FACT, while the sub-categories of 1) Embracing empathy and holistic view with users’ best interest at heart, 2) Openness, curiosity and genuine interest for each other, 3) Borders across disciplines and services get erased yet sharpened, and 4) Orchestration of the team and leadership underpins sustainable collaboration reflected critical ingredients and passages of collaboration. Discussion: Sustainable collaboration required organisations to support team members’ transition from individual or entrapped social niches into an enabling niche, supportive team environment. Cultivating a social learning space may reduce uncertainty and enables timely, skillful action through which relationships, expertise, and performance develop.
Introduction:When older adults living with multimorbidity are hospitalised, they often require the involvement of multiple stakeholders to ensure continuity of care when transitioning from hospital to home. More interventions have been examined. This study aimed to explore how older adults and their relatives, spouses, or adult children experienced a nurse-led, cross-sectoral home-based follow-up visit after hospital discharge. Methods:This study is grounded in critical psychological practice research. We conducted qualitative individual and family semi-structured interviews with 10 older adults, six relatives, three spouses, and three adult children. The interviews were conducted by telephone or face-to-face. The analysis was inspired by Braun and Clarke. Results:We identified three themes: 1) Cross-sectoral home-based follow-up visit - an experience of caring and competent nurses, 2) Navigating dependency and disruption - balancing a new situation, and 3) Relatives - caught between support and caregiver burden. Conclusion:The cross-sectoral, home-based follow-up visit was considered important by some older adults and all relatives during the transition from hospital to home, as it enhanced their sense of safety. The integration of care across healthcare settings improved cross-sectoral communication, facilitated collaboration across care settings, and ensured the secure transfer of information and mutual knowledge translation.
Background: Tuberculosis (TB) and diabetes mellitus (DM) represent a growing syndemic in low- and middle-income countries (LMICs), particularly across South Asia. The bidirectional relationship between these diseases exacerbates health outcomes and increases system burdens. Although the World Health Organization has advocated for integrated management of TB and DM, implementation remains inconsistent across the SAARC region. This systematic review aims to identify and analyse implementation determinants of integrated TB and DM care in SAARC countries. Methods: We conducted a systematic review following PRISMA 2020 guidelines. searching MEDLINE (via Ovid), EMBASE, Web of Science, Cochrane CENTRAL, and CINAHL for peer-reviewed studies. Grey literature was sourced from Google Scholar and citation search. Four reviewers independently screened title, abstract and full text using Rayyan. Using a structured Excel form, two reviewers extracted data. Quality assessment was conducted by using Mixed Methods Appraisal Tool (MMAT). A narrative synthesis was conducted in line with SWiM guidelines to categorize implementation determinants as barriers or facilitators. Results: Ten studies met the inclusion criteria and were conducted across five SAARC countries: India (n = 7), Pakistan (n = 1), Bangladesh (n = 1), and Sri Lanka (n = 1). Identified facilitators included political commitment, use of digital tools, and training of healthcare workers. Barriers encompassed inadequate infrastructure and finances, workforce shortages, lack of standardized guidelines and fragmented vertical health systems. Conclusion: Integrated TB-DM care in the SAARC region remains at an early developmental stage, with most efforts limited to pilot projects or small-scale screenings. Despite political and institutional recognition of the dual burden, scale-up is constrained by systemic barriers, resource gaps, and lack of evidence-informed implementation strategies. Future efforts should prioritize system-wide integration guided by implementation frameworks, standardized protocols, and investment in workforce and infrastructure to achieve sustainable impact. Systematic review registration PROSPERO registration number: CRD42025644263.
Addressing the impact of chronic conditions on work participation requires an integrated care model that embeds work-related goals from diagnosis onward. The Work-oriented Care Model (WoCM) adopts a biopsychosocial, patient-centered approach and incorporates key elements of the Capability Approach (CA) and the International Classification of Functioning (ICF), aligning functional performance with individual goals and contextual factors. A case study illustrates the need for continuous work-oriented assessment involving healthcare and occupational professionals. Implementation challenges underscore the importance of structural integration and improved coordination across healthcare and occupational systems.
Introduction: The Interprofessional Learning and Innovation Network (IP-LIN), comprising nursing and social care professionals, students, and teachers, was established to enhance integrated care competences, specifically attention to health and wellbeing for older adults living in the community. Description: This case study with ten interprofessional case discussions and two focus groups was completed with nursing and social work professionals, students and teachers. Thematic analysis regarding five interprofessional competences of the Zuyd Interprofessional Building Blocks model was conducted. Key recurring themes included responsibility, available time, mutual understanding of professional language, reflection on attitudes, and optimising client autonomy. Identified barriers were the absence of a joint care plan, incomplete application of the methodical circle, and insufficient consultation among professionals involved with the client. Discussion: Participants recognised that interprofessional learning fosters improved collaboration between nursing and social work domains; however, the absence of a joint care plan remains a significant obstacle to fully integrated care. Conclusion: The IP-LIN facilitated opportunities for professionals, students, and teachers to understand each other’s roles, responsibilities, and perspectives, thereby increasing confidence in interprofessional and team competencies. Successful IP-LIN implementation requires sustained commitment from both care and social work sectors to overcome existing barriers and promote integrated care.
Introduction: NHS policy promotes Frailty Same Day Emergency Care (F-SDEC) units to alleviate pressure on emergency departments (ED) and improve care for frail people through comprehensive geriatric assessment and same-day discharge. However, evidence remains limited on how such services are implemented in practice, particularly in resource-constrained and geographically peripheral settings. This study aimed to examine how implementation barriers are experienced and negotiated during the day-to-day delivery of an F-SDEC pilot. Methods: Using a Researcher-in-Residence approach, a researcher embedded in a coastal hospital in Torbay, South-West England, collected field notes from prior observations to inform the interview guide, conducted semi-structured interviews with staff delivering F-SDEC, and held a feedback session. A framework-informed, reflexive thematic approach guided the identification of key implementation challenges and enablers. Results: Staff viewed F-SDEC as beneficial for improving care for older adults, but interacting barriers constrained implementation. ED-based triage was time-intensive and difficult to routinise due to fragmented, non-interoperable IT systems, inconsistent understanding of frailty across hospital teams, and shifting eligibility criteria. Operational pressures, workforce and skill-mix shortages, and an inconsistent understanding of F-SDEC’s needs and purpose also limited CGA delivery and contributed to day-to-day variability in throughput. While staff expressed a desire to reorient towards community-based referrals, the same digital and workforce constraints also limited the feasibility of alternative routes, further raising sustainability concerns. Conclusions: F-SDEC implementation was shaped by interdependent system constraints rather than isolated barriers. In peripheral and resource-constrained settings, successful implementation may depend on whole-system alignment across digital infrastructure, workforce capacity, and cross-team collaboration, with national policy better accounting for local delivery conditions.
