Musings on Integrated Care: A Visible and Invisible Matter

If measures for clinical outcomes, health literacy, patient satisfaction, benefits and many more present a challenge then a measure for integrated care falls into the category of a very steep peak.

It's a nebulous concept, we know what we mean, we recognize the principles and we even allow for variation in what integration and integrated care means for different people.

The January 2012 integrated care report by The King's Fund and Nuffield Trust (my post on this) had me thinking about some of the ingredients that might contribute to measures of integrated care and our efforts to record it. What instruments and formats do we need - what mix of microscope (individual), telescope (population), strobe (snapshot), time lapse (series), objective - subjective? Some elements  then (in no particular order):

Breadth of the 'episode' (primary-secondary-tertiary-palliative)
The number of systems
  information - e-records
  commissioners
  datasets: total, number of gatherers, submissions
The number of people - individuals involved
The number of 'responsible' organisations
 Primary organisational efficiency - Lean Standing?
The number of teams
The number of policies (policy touches)
 The number of interviews, assessments (paper, electronic, formal), care plans, reviews
Opportunities for communications
  potential
  actual
  media forms
  delivery forms (inc. technologies)
Number of handovers
  weighted according to type
Patient experience - measure
 (that is holistic across physical, mental health, social care?)
 staff attitude
 therapeutic relationship engagement (quality)
 therapeutic modalities (quantity)
 educational content, materials provided / information gains
 number of patient (carer) choice points (potential - exercised)
Incidents of positive risk taking
Increase in health literacy
Co-ordination effectiveness
Self-care - autonomy, decision making
Patient (carer) as budget holder
Patient as record holder and direct data source (telecare - data entrant)
Carer involvement
Health : Social care (main dependency, ratio, index)
The number of disparate care philosophies encountered
Diagnoses
Diagnostic investigations complex (location, time)
Declarative success: agreed plan - success?
The geographic encounter footprint
Duration of engagement
Follow-up - care continuity care
Care Disintegration - safety
 care interrupts^# (falls, errors)
 relapse, readmission
 dependency (deferred discharge)
Influence of public engagement - involvement in local health services^*


While many of the above might qualify as candidates for a measure of integrated care, you have to wonder whether in order to measure integration you must measure everything else. It appears here at least that integration and complexity are closely related. Several of the items above might individually represent - and no doubt do - indices of various kinds that also beg definition (e.g., co-ordination, success, philosophies, episode ...).

Although I've referred to 'numbers' you could no doubt refine the list by consulting the literature and considering the quantitative : qualitative mix.

Perhaps the key indicator of integrated care isolates the primary concepts for the person concerned and then fuses those within the INTERPERSONAL and POLITICAL care domains (policy touches would be one example)?

^*How does a measure of integration incorporate those socially excluded?
^#For want of a better word.

Report - Integrated care for patients and populations: Improving outcomes by working together

I've posted on integrated care previously on W2tQ. The core recommendations of this New Year  report on integrated care are:

• government policy should be founded on a clear, ambitious and measurable goal to improve the experience of patients and service users and to be delivered by a defined date
• patients with complex needs should be guaranteed an entitlement to an agreed care plan, a named case manager responsible for co-ordinating care, and access to telehealth and telecare and a personal health budget where appropriate
• change must be implemented at scale and pace; this will require work across large populations, significant reform and flexibility to take forward different approaches.

Publication prompted Time to integrate words with action by Chris Ham and Jennifer Dixon (HSJ 5 January pp. 16-17 - and my source for this news). The report and mention of measures of integrated care that include patient experience provoked further reflection.

Integration in health and social care should be considered critically over the past 25 years and more (but that's a thesis). Evolution in policy matters, but there is a deep archaeology that illustrates the policy aspiration - practice gap the reports priorities seek to address. A comment in response on the King's Fund's site notes the need for (strategies, methods and) a framework. While no magic wand there is a framework that can at least unify disciplines, public and policy makers. And act as a bridge between words and actions.

Integration needs a shared and agreed origin.

(A point* around which disintegration turns)

Although brief (20 pages) the report is an excellent source for references (3 pages) that includes:

Kodner D, Spreeuwenberg C (2002). ‘Integrated Care: Meaning, logic, applications, and implications – a discussion paper’. International Journal of Integrated Care, vol 2,
Available at: www.ijic.org/index.php/ijic/article/view/67 (accessed 13 December 2011).

Kodner D (2009). ‘All together now: a conceptual exploration of integrated care’. Healthcare Quarterly, vol 13(Sp), pp 6–15.

Leutz W (2005). ‘Reflections on integrating medical and social care: five laws revisited. Journal of Integrated Care, vol 14, no 5, pp 3–12.

As we try to integrate words and actions we need to remember:

how we dice and slice influences the scope of integration.

We'll explore this more soon.
*Points?

Nick Goodwin, Judith Smith, Alisha Davies, Claire Perry, Rebecca Rosen, Anna Dixon, Jennifer Dixon, Chris Ham Integrated care for patients and populations: Improving outcomes by working together. Report to the Department of Health and NHS Future Forum from The King’s Fund and Nuffield Trust

Masquerade in health care but on which level?

There is a Drupal module called Masquerade, the project page explains:

The masquerade module is designed as a tool for site designers and site administrators. It allows a user with the right permissions to switch users. While masquerading, a field is set on the $user object, and a menu item appears allowing the user to switch back. Watchdog entries are made any time a user masquerades or stops masquerading.

Life frequently asks more of us and the same applies for employees in whichever employment sector. For teachers and nurses they know the call. As a nurse you adopt the mask of the uniform and the role. You may not actually carry the lamp, but it's there. Sometimes it helps light the way; for the public, for you. If you are a 'bad' nurse - whether your attitude put the lamp out this morning, yesterday, or several years ago -  the darkness that follows you about speaks volumes.

It prompts Prime Ministers to make announcements:

PM announces new focus on quality and nursing care

06 January 2012 12:54

A new drive to free up nurses to provide the care patients and relatives expect has been announced today by Prime Minister David Cameron and Health Secretary Andrew Lansley.

The push will see nurses spending more time on front line care in wards and other services, a senior ward nurse with whom the buck stops, patients leading on inspections and a new 'friends and family test' to show whether nurses and patients had a good overall experience, or would want loved ones needing care to be treated at each hospital.

Prime Minister David Cameron said:

“We know the vast majority of patients are very happy with the care provided by the NHS. And I’ve seen the NHS at its very best. But we have heard recently that in some hospitals patients are not provided with the level care or respect they deserve and I am absolutely appalled by this.
“If we want dignity and respect, we need to focus on nurses and the care they deliver. The whole approach to caring in this country needs to be reset. And it needs to start with this simple fact. Caring for patients is what nurses do. Everything else comes second."

<->

While we all play masquerade there are many levels. As a 'nurse' it's difficult (but never impossible) to play the caring, skilled, knowledgeable, patient, warm, efficient ... representative AND ensure all records are maintained, letters written, all communications logged, targets achieved, electronic records and data gathering requirements met. ... If you need a steer-clear from the stereotypical image of Angels, then you should see the faces nurses pull behind the mask trying to satisfy the audience.

That audience does not just include managers, patient representatives, inspection agencies but policy makers and politicians. Of course the latter are expert proponents of masquerade (they practice through a 4-5 year cycle).

Closer to home and the Drupal module? Well, I can't see a role for masquerade on a new h2cm website, but the thought crosses my mind of general nurses masquerading as mental health nurses; social workers masquerading as nurses. ... Although I'm playing games :-) it makes you think about what we mean by 'multidisciplinary'. To what extent, for example, is care of people living with dementia being missed because these disciplinary distinctions - silos really do still prevail? Surely the nursing issue isn't just a lack of light?

This announcement is not exactly news given what has gone before in the UK media through 2011.

What is strange is that this policy should emerge in 2012: The Alan Turing Year.

Yes, nurses DO need time to care, but perhaps we also need a test for empathy and rapport and not just intelligence?

Essential Nursing Resources 2012 now available online

The Interagency Council on Information Resources in Nursing (ICIRN) has released the 26^th edition of Essential Nursing Resources (ENR), an expansive resource list intended to be used by nurses and librarians. Because the list of possible resources has grown so large the ENR has become too large and expensive to publish in print and so it appears only online at www.icirn.org , on the ICIRN website.

 

Nurses can use ENR as a tool to assist them with building a personal professional collection of resources to support and advance their area of practice. Librarians can utilize this tool as an evaluation point in determining collection development, and as a reference tool. ENR is neither a comprehensive presentation nor product endorsement, but represents the opinions of the contributors. This tool is meant to assist nurses and librarians to evaluate on their own what resources best apply to their particular situation. Only the most recent editions and website addresses have been included. The ENR was compiled to point to pathways for exploration, rather than be an end point, and to expand to other formats beyond traditional references.

 

New to this edition is a very handy key to let users know if: 

$ =fee required; M=mobile; O=online; P=print 

- for each resource listed.

New and redesigned sections  in this edition include Blogs; Forums and Discussion list; Evidence-based Nursing; Management; Patient Safety/Quality Assurance; and Toxicology, Environmental, Occupational Health.

 

Carol J. Bickford, PhD, RN-BC, CPHIMS

Senior Policy Fellow, Department of Nursing Practice and Policy

American Nurses Association

8515 Georgia Avenue, Suite 400

Silver Spring, MD  20910

www.nursingworld.org

My source:
Carol J. Bickford via nrsing-l maillist 
http://mailman.amia.org/mailman/listinfo/nrsing-l
This list serve is hosted by the AMERICAN MEDICAL INFORMATICS ASSOCIATION

Drupal ScienceCamp Cambridge 20-21st January & Thoughtworks 13th Feb.

Next month I'm looking f/w to *ThoughtWorks' Quarterly Technology Briefing:

Is programming language
choice a good thing?

Before that I've booked for Drupal ScienceCamp in two weeks. It's a drive as the trains are not straight forward.

While there I'll post and tweet through proceedings. Being a DrupalCamp the program is still to be finalised. Leeds last May was excellent, as was Manchester. There are a few names for Cambridge that I recognise which is great.


I've cleared 1GB of old stuff off the laptop, three years worth that includes Drupal modules.

Time to update, focus, make use of the whiteboard, find and maintain some impetus...

I gather the title for the Camp derives from the venue - Cambridge Science Park. If there was a scientific theme now that would be a bonus. *Trademarks acknowledged also.

ERCIM News No. 88 Special Theme: "Evolving Software"

Dear ERCIM News Reader,

ERCIM News No. 88 has just been published at http://ercim-news.ercim.eu/

Guest editors: Tom Mens (University of Mons, Belgium) and Jacques Klein (University of Luxembourg)

http://ercim-news.ercim.eu/en88/special

Keynote "Change is the Constant" by Joost Visser, Head of Research at Software Improvement Group
http://ercim-news.ercim.eu/en88/keynote/change-is-the-constant

Next issue: No. 89, April 2012 - Special Theme: "Big Data"
(see call at http://ercim-news.ercim.eu/call)

Thank you for your interest in ERCIM News.
Feel free to forward this message to others who might be interested.
Happy New Year!
Peter Kunz
ERCIM News central editor

[Includes: An introduction to this theme; Holistic Software Evolution; Wireless Sensor Networks and the Tower that Breathes; and Innovation in Disaster Management: Report from Exercise EU POSEIDON 2011. ] PJ

---

ERCIM News
is published quarterly by ERCIM, the European Research Consortium for Informatics and Mathematics.
The printed edition will reach about 10,000 readers.
This email alert reaches some 6000 subscribers.

Threshold Concepts: Undergraduate Teaching, Postgraduate Training and Professional Development A short introduction and bibliography

From:
Threshold Concepts: Undergraduate Teaching, Postgraduate Training and Professional Development
A short introduction and bibliography

The Meyer and Land Threshold Concept

	“The idea of threshold concepts emerged from a UK national research project into the possible characteristics of strong teaching and learning environments in the disciplines for undergraduate education (Enhancing Teaching-Learning Environments in Undergraduate Courses). In pursuing this research in the field of economics, it became clear to Erik Meyer and Ray Land [1-8, 9-16], that certain concepts were held by economists to be central to the mastery of their subject. These concepts, Meyer and Land argued, could be described as ‘threshold’ ones because they have certain features in common.”
	Glynis Cousin, An introduction to threshold concepts

As the calendar slipped across from 2011 to 2012 the discovery of threshold concepts is very timely and quite central to my own studies. Wish I'd been in time for the call for papers!

Threshold Concepts Conference

As one year ends it helps to have a gateway to new vistas and to make sure that my review of the literature is systematic.