The central pivot of integrated care for older people is the care provided by a team of service providers through integrated processes that overcome professional and organisational barriers. Workers of various professional backgrounds, and in different organisations, have to form collaborative teams in order to provide a full array of services that are integrated to meet the needs of older people.
Much of this care may be already provided by the older people’s family members and friends, so family and other informal carers are closely involved in the work of the integrated team – both as co-providers of care and as clients with their own needs. The issues of family carers’ training and needs for support are addressed in chapters 5 and 6.
Integrated teams aim to address the gaps in care for older people with complex health and social care needs that can occur between traditional services. They achieve this by offering a comprehensive and seamless care service designed to organise the way the required services are provided around the needs of the older person and the informal family care network, rather than trying to fit the clients’ needs into an existing, set service system.
Integrated teams are groups of multi-disciplinary and inter-organisational health and social care professionals, working together as a distinct team to provide services to support the various individual needs of non-self-sufficient older people and their family carers. Service provision is based on comprehensive needs assessment (see Chapter 4), and the team is defined by its agreement on common tasks and outcomes, which are designated by management, with clear roles and duties.
The clients of integrated teams are defined as older people and their family carers with complex health and/or social care needs.
From a management perspective, the integration of the team occurs at different levels:
From the perspectives of the clients, professional care-providers (staff) and managers of the organisation, the objectives of integrated teamwork are as follows:
For clients, the main objective of integrated care teams is to provide satisfactory, consultation-based solutions to their short- and long-term health and social care needs that cannot be addressed through the regular single-service system.
The staff’s objectives
For staff, the intended outcome of working as an integrated team is to provide effective and efficient health and social care to older people, aimed at improving their quality of life through:
Here, the main objective and outcome of integrated teamwork is to provide and evaluate health and social care to improve the lives of the older people for whom they are managerially responsible. This care must be financially viable, equitable, effective and appropriate.
Managers in the regular, non-integrated care pathway often ask ‘Why should I as a manager introduce integrated teams?’. A key answer is the issue of acute hospital beds being ‘blocked’ because there is no suitable community care into which to discharge older patients. By introducing integrated community care teams, managers can reduce the length of stay for older patients, thus reducing the cost of expensive and inappropriate hospital care while improving patient well being by providing care at home. It is a major challenge to integrated teams to prove their worth in this way, through appropriate evaluation methods (see Monitoring and Evaluation).
In 1992, the Swedish government’s Adel policy reform aimed to integrate all public care for older people under the authority of the municipalities, strengthening the social service culture and de-medicalising care, while simultaneously providing the municipalities with a strong financial incentive to offer home-based care for hospital patients on discharge. Between 1992 and 1996, the number of hospital beds has been halved and the average stay in hospital has dropped from 11 to 7 days, with a more pronounced decline in geriatric hospitals and clinical wards from 52 to 22 days in 1996. Most of the patients who are now cared for at home are older people.
Source: Theobald (2003)
Many different models of integrated teams have been developed in response to specific needs and areas. They share the common characteristics identified in Definitions, being composed of multi-disciplinary and inter-organisational health and social care professionals working together as a distinct team, the composition of which depends on the designated service target group.
Examples of different integrated team approaches include:
These approaches are discussed in detail below.
These teams are based in the community, and operate at the interface between primary and secondary care, to assess and intervene and/or treat older people with complex health and social care problems.
The ‘specialist integrated programme of home care with home-support teams’ (ESAD) is based in Madrid’s primary health care sector and aims to co-ordinate home and hospital services for older people, by setting up home care teams in three of the city’s health areas, and to provide support for primary care. Each core team consists of:
Integration takes place between the team members and the family carers, and between primary (home) and secondary (hospital) health care levels, as well as with the social service sector, using a shared electronic record system (see Supports).
The positive results of evaluation of the project have included:
Source: Sanchez del Corral (2002)
In Ireland, Home First is a collaborative project for home care between a hospital and an area health board (regional body with responsibility for planning, administration and implementation of health services). The project was initiated by the primary care sector, and its aim is to enable older people to return home, and remain there, after hospitalisation.
The project involves the hospital and the health board working together to provide individualised packages of home care to older people whose care needs would otherwise have necessitated institutional care. The team uses comprehensive assessments to draw up a care plan, which is then implemented by the care organiser. Integration takes place between the primary and secondary health care sectors, and with the social service sector.
Source: O’Cleirrigh (2002)
Organisations such as Community Care, in Cumbria, UK, are implementing ‘rapid response teams’ – integrated teams designed to prevent admission to hospital or residential homes. The team provides a ‘fast-track’ needs assessment and implementation process in the patient’s own home, working collaboratively and integratively with existing services. The teams are made up of nurses and social workers, but they may be housed in different locations, so integration is ‘virtual’, which can lead to communication problems.
Source: Alaszewski et al (2003)
These teams provide home help and personal care on a regular basis to dependent older people in their local community.
A programme of 400 ‘help at home’ home care service teams has been developed throughout Greece. Each team consists of a social worker, a nurse and a home help, and the programme aims to provide care at home for dependent older people. Priority is given to those living alone and without the means to pay for private help, although in some areas the programme has recently been extended to relieve family carers (predominantly women) from the burden of full-time care, enabling them to enter the labour market.
These teams work in close association with the local primary health care services and local ‘KAPI’ community centres (see Practice example: The KAPI network). This means that the integration of care services takes place both within the team and at the local authority level at the interface between primary health and social home care. It also exists within the broader context of national policy, which aims to maintain older people’s autonomy by supporting them in their home environment.
Source: Amira et al (2002)
These teams are set up to address the multiple problems of care for patients (mainly, but not exclusively, older people) with a specific disease diagnosis (such as Alzheimer’s, diabetes, stroke, or hip fracture). In the two practice examples that follow, nurses have taken on new roles in promoting integrated care services for older people between hospital and home.
A nurse specialist-led diabetes care project in the Netherlands was set up to improve diabetes care. The specialist nurses were appointed to act as liaison co-ordinators between the hospital and primary care services, as well as central care providers to the (mainly older) patients and their families. Key stakeholders include the hospital, the home care agency and GPs. A project director and project co-ordinator were also appointed. The co-ordinator carries out daily managerial activities, such as organising meetings, writing the minutes, and answering questions from caregivers. A working group of caregivers and patient representatives from the regional diabetes union developed a multi-disciplinary protocol for the project.
The summary report states: ‘The development of the project, from experimental phase and performance until the establishment of the integrated care model as a form of regular care, took six years. This demonstrates that success in integrated care developmentâää requires patience, understanding and negotiating competencies, but also a strong vision, clear goals and constant guidance of the participants in the desired direction; in short, much depends on the change management in charge.’
Sources: Mur-Veeman et al (2001), Eijkelberg et al (2001)
In a nursing case management project in Belgium for geriatric patients and their families, each patient, as well as the family caregiver involved, was given an individualised package of care, designed and implemented in a multi-disciplinary context. The project aims to prevent premature institutionalisation of older patients with mental health problems. The total care process is co-ordinated and organised by a nurse case manager who also carries out clinical interventions towards the patients and their families. This type of case management is another way of enhancing nurses’ professionalism by encouraging them to acquire specialised knowledge and autonomy within the integrated team.
Source: Tombeur (2002)
Local community centres for older people are well situated to act as co-ordinating and implementing bodies for integrated care service provision. The range of services provided includes preventive physical and mental health programmes and primary health and social care, together with recreational programmes, aimed at promoting social participation and well being among older people in the area.
The Greek Open Care Community Centres for Older People (KAPI) constitute a pan-Hellenic network of more than 370 centres taking an innovative approach to integrating health and social care for older people in the community. The centres are run by local authorities and represent the main axis of service provision in Greece specifically for older people. They aim to promote and maintain autonomy and well being in the elderly population in general by providing primary health services, including health promotion and disease prevention programmes, together with social care services and recreational facilities. Participation in the KAPI activities is by membership, and the members elect representatives to serve on the management committee, which also has a staff representative.
The integrated team of the KAPI usually consists of a core staff of social worker, health visitor or registered nurse, home care worker, doctor, physiotherapist, occupational therapist or ergotherapist and other associated specialists and volunteers as required. Many of the KAPI centres now also provide ‘help at home’ services to older people with greater needs, thus extending their collaboration and integration with other local services and bodies (see above).
Source: Triantafillou (2002)
A manager faced with the task of implementing an integrated team of professionals to provide care to dependent older people and their family carers needs to ask:
These questions are examined in detail below.
Supporting factors are:
A multi-professional, integrated health and social care team may include a broad mix of staff, working on a full- or part-time basis, depending on the team’s objectives and the allocated resources. However, the core team will usually include:
This core team may be supplemented or expanded, according to need, with:
The actual composition of the team depends largely on the type and objective of the integrated care programme and the allocated funding (For examples, see Models and approaches). When planning organisational structures, the manager needs to identify:
When organising project management structures and running an integrated team, the managers may also find the following strategies and steps useful:
Whatever the objectives and composition of the integrated care team, the client and the team members will take certain common steps in the assessment and care process:
The team is approached either directly, by the older person and/or their carers, or indirectly, via the health or social service currently responsible for them.
The professional who is contacted makes an initial evaluation of the case and decides whether the team can accept it, depending on whether the circumstances fit the criteria for acceptance into the programme, and on the capacity of the programme.
The team makes an integrated assessment of the older person’s needs, with the participation of any family carers and other responsible health and social care service providers.
A care or case manager is allocated, and they draw up a care plan that meets the main needs identified during the assessment process. They identify specific objectives, which are agreed on by all concerned.
The team provides the required health and/or social care interventions, together with a system of monitoring, evaluation and feedback on progress.
If the evaluation and monitoring process indicates that no progress is being achieved, or that the situation is deteriorating, then there will need to be a re-assessment and new care plan drawn up.
Either the team continues to provide care for as long as required or, in the case of specialist integrated teams when the objectives have been achieved, withdraws, and the regular service sector and the family carers continue the client’s care.
The manager will need the following systems to support the working process of the team:
In Madrid, the ESAD Home Care teams use a shared information system based on information technology, with three copies of the patient’s electronic record held by the hospital, the integrated care team and the patient and family carer, to facilitate communication and collaboration between all participants in the care process (see Models and approaches).
Source: Sanchez del Corral (2002)
In western Finland, the Satakunta Macro pilot project is an extensive national project involved in developing seamless care and service chains with the optimal use of information and communications technology (ICT). In the city of Pori, which has a population of 76,000, a specific sub-project on elderly care concluded: ‘General lessons from the project are that national [governmental] co-ordination, special legislation and funding are enablers [of integrated care], and that ICT is indispensable.’
Source: Hanninen, cited in Huijbers (2002)
The main staffing issues that relate to integrated ways of working are concerned with staff competencies and qualifications, support and training, and leadership.
These factors vary according to the different professional requirements that are set at local and national levels. At the international level, one major issue is the recognition of equivalent professional qualifications between European Union member states. Although this issue has been well addressed for the standard health care professions, there is less agreement on training and recognition of ‘new’ caring professionals such as personal care and home care workers.
Specific training for the staff of integrated care teams involves:
For more information on support and training, see WHO Europe (2001) – a comprehensive programme of training and continuing education for community-based health care providers working with older people.
In multi-disciplinary teamwork, one major difficulty is deciding who should lead the team. This issue is best approached with a management policy of equity between all team members, based on respect for the unique contribution to the team’s work of all the professionals involved. In this way, traditional professional hierarchies and rivalries may be abandoned in favour of a more egalitarian system based on the practical realities of the team’s working conditions and terms of employment.
In the Greek KAPI centres, for example, often the only member of staff employed on a full-time basis will be the social worker or health visitor. In this case, these professionals would have a natural priority as team leaders, while in situations where there are a number of full-time professionals, the manager might prefer a rotation of each team member in turn as the leader. As discussed in Chapter 10, the team leader needs to have the ability to communicate with and co-ordinate a variety of disciplines, and to work between different agencies.
To enable the manager to evaluate the effectiveness and efficiency of the work of the integrated team, information needs to be collected regularly and routinely. The figures must relate to clearly identified criteria, and will be used to assess for performance management and for evaluation by the client. This means that the staff need to continuously monitor their own work, and there needs to be a clear system for the older person and the main family carer to participate in, and give their opinions on, the care process.
A main problem is that, despite generally positive feedback from clients of integrated care teams, there is a lack of objective measures of success. These need to be addressed in terms of:
These factors are discussed in detail below.
The routine use of these instruments, during the initial comprehensive assessment and subsequently at intervals during the monitoring and evaluation process, can provide invaluable information on the client’s progress. However, relating improvements or relapses to specific interventions in practice is more difficult, since this usually requires specific research protocols to eliminate confounding variables. Nevertheless, the routine monitoring of relevant outcome indicators is increasingly an obligation of all integrated teams aiming to justify their existence. Additionally, the use of a standardised measure of carer well being, such as the COPE index (McKee et al 2003), could further improve the assessment and monitoring process.
Unlike the standardised ways of measuring the effectiveness of clinical interventions, it is more difficult to evaluate improvements in well being and quality of life that result from the social interventions of the integrated team. This is because the multi-focused approach of many social interventions makes scientific evaluation of their effects more complex, but also because even measured improvements or decreases in older people’s well being may be due to factors in their lives other than the efforts of the team.
A crucial factor in promoting the work of integrated teams is the overall costs of running the service. While these may be higher – at least initially – than traditional methods of service provision, if the integrated team can be demonstrated to be more effective in terms of outcomes for the client and family, this may justify the extra costs. Ideally, integrated teams should be more economical to run while also resulting in better client outcomes than traditional services.
The opinions of the older people and their carers using the services of an integrated team must be routinely monitored as a part of the feedback process for staff, managers and administrators of the service. It may also be possible to compare this data with that of traditional care service users.
There is documented evidence that the promotion of ‘team working’ leads to improved professional well being and increased performance of staff working in primary care teams (Borrill 2000). However, so far, similar evidence from the staff of integrated teams is lacking.
Having to arrange for the large amounts of data needed to measure all these parameters to be routinely and systematically collected can be a major burden for care providers. Some may argue that the time this takes could be better spent on patient or client care, or simply in strengthening the relationship between client and caregiver. However, it is vital for the manager to negotiate with staff and agree on a feasible plan for monitoring and evaluating outcomes from the care provided by the integrated team, as this is an essential contribution to an evidence-based evaluation of their work.
A study in Wiltshire, UK, found that the integrated teams examined did not score better on any of the measures of clinical effectiveness and user satisfaction than traditional care services, and indeed appeared more expensive to run. However, service users were more likely to refer themselves than they did before, and were assessed more quickly than in the regular service sector. Most of the older people were not interested in the way in which services were organised and delivered, but in the quality of the service they received, and the quality of the relationship with service providers was of utmost importance.
The negative findings could be attributed to the fact that:
Source: Brown (2002)
The main barriers to integrated teamwork are:
These are explained in detail below.
The main factors that support a move towards integrated teamwork fall into the categories of policy and practice.
A supportive local or national policy on integrated care for older people is an important pre-requisite for success in implementing a service for older people, based on integrated teams.
The UK’s National Service Framework for Older People (Department of Health 2001) gives priority to integrated provision of services in community health and social care. Its Standard Two, person-centred care, states:
National Health Service and social care services treat older people as individuals and enable them to make choices about their own care. This is achieved through the single assessment process, integrated commissioning arrangements and integrated provision of services, including community equipment and continence services.
The current implementation of this policy line is assessed in the PROCARE report (Leichsenring and Alaszewski 2004), which documents the practical problems of carrying out and acting on integrated needs assessments at the local level, using the experience of a number of UK primary care trusts.
Many other countries, including Finland, Germany and Sweden, have also developed policies for the care of older people that are supportive of integrated teams, and these are examined further in the CARMEN policy framework document (Banks 2004).
Crossing organisational barriers is a pre-requisite for the function of such multi-disciplinary teams. In practice, this necessitates a major change of perspective on the parts of care providers and managers alike. If the regular care sector has a positive and supportive attitude to the integrated team, this can be a major factor in the successful functioning of such a project. To achieve this, the integrated team must demonstrate its ability to solve complex care problems, showing that it is an asset to the regular health and social care sector, rather than a threat.
Separate or independent funding for the integrated team may reduce the perceived threat of financial or staff cutbacks in the regular care system, but may also make it more vulnerable to cutbacks because the work of the team is not seen as an ‘essential service’.
The management body needs to positively promote the existence and role of the integrated team among all the related organisations and agencies. This is of major importance in establishing the team’s credibility and usefulness locally. The following supportive factors can also contribute to the effective work of an integrated team:
These factors are explained below.
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