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Introduction: In this paper, we provide a detailed and explicit description of the processes and decisions underlying and shaping the emergent multimethod research design of our study on workforce changes in integrated chronic care. Theory and methods: The study was originally planned as mixed method research consisting of a preliminary literature review and quantitative check of these findings via a Delphi panel. However, when the findings of the literature review were not appropriate for quantitative confirmation, we chose to continue our qualitative exploration of the topic via qualitative questionnaires and secondary analysis of two best practice case reports. Results: The resulting research design is schematically described as an emergent and interactive multimethod design with multiphase combination timing. In doing so, we provide other researchers with a set of theory- and experience-based options to develop their own multimethod research and provide an example for more detailed and structured reporting of emergent designs. Conclusion and discussion: We argue that the terminology developed for the description of mixed methods designs should also be used for multimethod designs such as the one presented here. [ABSTRACT FROM AUTHOR]

Background: Although community engagement is seen as key to achieving citizen-centred and collaborative healthcare systems, organisations and neighbourhood networks are still searching for effective ways to engage citizens in shaping the health and care landscape. Many Dutch regions are currently implementing and fostering community engagement initiatives; however, little is known about which engagement approaches are effective under which circumstances, and how to implement such initiatives successfully. This holds especially true for initiatives focusing on disadvantaged groups. The National Institute for Public Health and the Environment and the University of Tilburg, in co-design with stakeholders of six Dutch community engagement initiatives, are conducting a mixed-methods multiple case study evaluating six community engagement initiatives. The study is following the realist evaluation methodology to investigate which community engagement initiatives are effective in improving communities' health outcomes and the sustainability of healthcare systems. The University of Maastricht is investigating the dynamics between health and citizen participation on a neighbourhood level. As barriers and possibilities for participation are supported by material and spatial components of the environment and constructed in the lack of daily contacts between neighbours and professionals, the study conducts an in-depth ethnography of the life of inhabitants of three low-income neighbourhoods in Maastricht. Local experiences of non-participation are gathered and related to the social and material conditions of the neighbourhoods. Aims and objectives: The workshop's main objectives are to present two distinctive investigations into community engagement and to provide professionals with the analytical tools and the evidence-base to build their own successful initiatives that can help improve communities' health and wellbeing. Format: During the session, we will briefly present our investigations, focusing on our preliminary results. In an interactive group session, we will examine the common lessons learned, including the often divergent ideas and motivations that organisations and communities have regarding community engagement. Discussions about the key enablers and barriers for community engagement initiatives will inspire participants to reflect upon and implement their own initiatives. Target audience: Our target audience includes participants involved or interested in developing and implementing community engagement initiatives, in co-design with communities themselves. Participants will share their own thoughts and experiences during the session. Learnings/take away: Participants will learn that community engagement is expected to bring a wider range of services together that reflect citizens' more holistic views and needs. However, barriers including service fragmentation which hampers professionals' willingness to take on board citizens' more holistic views, will need to be addressed before this can be achieved. Participants will gain insight into the key enablers for overcoming these barriers, like addressing power imbalances between professionals and citizens and within communities. Participants will also learn of the supportive conditions for community engagement such as informal contacts and the availability of publicmeeting places. This will enable them to overcome barriers and build a vision for community engagement that is shared between professionals and citizens. [ABSTRACT FROM AUTHOR]

Introduction: Integrated care is expected to contribute to improved health outcomes, better patient experiences and increased cost effectiveness, but so far, findings have been mixed. Our objective was to develop a model for the comprehensive evaluation of integrated care interventions that provides insights into when, why and how successful outcomes can be achieved. Methods: A preliminary model was developed based on the Context-Mechanism-Outcome Model and further developed based on its application to a literature review, two case studies and an expert questionnaire. Results: The COMIC Model for studying the Context, Outcomes and Mechanisms of Integrated Care interventions assumes that an intervention is introduced using certain mechanisms (categorised according to the Chronic Care Model), which are met with particular context factors (described by barriers and facilitators and categorised according to the Implementation Model), which combined, contribute to specific outcomes (categorised by the WHO dimensions of quality of care). Discussions: Using the COMIC Model makes it possible to comprehensively study the interplay of the mechanisms, context and outcomes of integrated care interventions and thereby provides insights into when, why and how integrated care contributes to improved outcomes. As such, the COMIC Model does not in itself propose 'what works' but makes it possible for people involved in the implementation of integrated care to find the answer to what works, when and why themselves. Since the COMIC Model supports comprehensive and explicit descriptions of how specific context factors shaped the implementation of an intervention, evaluations conducted in one setting are likely to also provide lessons learned that are of added value to other organisations in other settings. Conclusions: The COMIC Model makes it possible to (1) comprehensively analyse the mechanisms, context and outcomes of a specific case, (2) to make the relationships between the mechanisms, context and outcomes within each case visible, and (3) to compare two cases to each other in a systematic way that adds value to the analysis. [ABSTRACT FROM AUTHOR]

Introduction: The growing prevalence of chronic diseases and rising number of older and often multi-morbid patients have led to an increasing demand for complex, long-term care. During the past decades, integrated care has been endorsed as a means to approach these challenges. This is expected to contribute to better outcomes, increased efficiency and improved access to care. The aim of our study was the investigation of a best practice case of integrated care implementation at a geriatric care hospital in Germany. Specifically, we studied the type of integrated care intervention that was implemented, the barriers and facilitators to its implementation, as well as the outcomes achieved. Background: At the case site, geriatric patients receive care according to the criteria of the national framework of geriatric early rehabilitative complex treatments. These include the provision of care to a geriatric patient population (i.e. multimorbid, older than 60 years) by a multidisciplinary team conducting weekly team meetings and performing a comprehensive geriatric assessments. The length of stay is usually between 15 and 21 days, after which patients are discharged or transferred to a different institution. Methods: A qualitative case study was conducted at a geriatric hospital in Germany. Fifteen semi-structured interviews were conducted with medical doctors, occupational therapists, neuropsychologists, physical therapists and nurses. Relationships between mechanisms (as defined by the Chronic Care Model), context factors (as categorised by the Implementation Model) and outcomes (operationalised as aspects of quality of care) were studied. Results: Integrated care at the geriatric hospital involved components related to the health system, delivery system design and decision support. Self-management support was practiced by individual health professionals but not implemented in a structured way. The staff used a documentation system but because of its age and limitations it could not be considered an information system. Community involvement was not found. Barriers included IT problems, resistance to change by health professionals, problematic leadership, unclear division of tasks, problematic patient transfers to and from the geriatric hospital and cost pressure. Facilitators included the involvement of family members in care process and discharge management, a cooperation attitude among the team members, and flat hierarchical structures. Negative outcomes included frustration among staff members, less time available for the patients and, in some cases, a lower quality of care for the patients. Positive outcomes included successful discharges of complex patients to their homes and a high level of staff satisfaction. Discussion: The analysis of the interplay between the mechanisms, context factors and outcomes is still ongoing. However, the preliminary findings show that evaluations of complex interventions require complex methods of analysis. Instead of simply focusing on input and output, it is necessary to investigate the specific type of integrated care intervention that was implemented, the barriers and facilitators by which its execution was met, as well as the different outcomes that were achieved. During the conference we will specifically focus on these issues and discuss implications for future integrated care practice and research. [ABSTRACT FROM AUTHOR]

Introduction: In discussing the importance of the relationship between what is being studied and how this is studied, various researchers have called for an increased focus on examining the implementation process of integrated care interventions and its relationship to the outcomes achieved instead of a narrow focus on outcomes only. Therefore, this study has two objectives: First, to examine the international scientific literature for current evidence on the impact of the implementation of integrated care for type 2 diabetes mellitus on its outcomes, and second, to investigate the extent to which the CMO model (context + mechanism = outcome) can be applied to the analysis of this relationship. Methods: A systematic literature search was conducted in PubMed and Cochrane for the period 2003-2013. We operationalised the components of the CMO model as follows: mechanism was defined as intervention type, context as barriers and facilitators encountered in the implementation process, and outcomes as intentional and unintentional effects of the intervention. Wagner's Chronic Care Model (CCM) was used to identify intervention types and the implementation model by Grol and Wensing was used to categorise barriers and facilitators. Results: 44 articles met the inclusion criteria. Overall study quality was acceptable, except for four studies to be treated with caution. We found that the CMO model could be applied to all included studies. Regarding mechanisms, most studies reported interventions including all four CCM components and a variety of sub-components. Regarding context, most barriers were related to the organisational context and most facilitators to the social context. Regarding outcomes, most studies reported positive patient, process and health services utilisation outcomes. The information on costs was limited and inconsistent. We found no association between mechanism, context and outcomes. Discussion/Limitations: The CMO model proved to be applicable to the analysis of international scientific literature on integrated care for type 2 diabetes and helped to identify rich evidence on all three components of the model. However, the very low number of articles adequate for quantitative analysis as well as the low number of articles reporting useful qualitative insights made it extremely difficult to make meaningful statements about the presence or absence of associations between mechanism, context and outcomes. Conclusion/Lessons Learned: The CMO model is a useful tool for the analysis of the implementation of integrated care for chronic diseases. However, based on research conducted without specific focus on the CMO model, a retrospective analysis of the relationships between mechanism, context and outcomes is not possible. Suggestions for future research: Future research should explicitly incorporate the CMO approach in its research design so as to make it possible to study the relationships between intervention type, implementation context, and outcomes of integrated care. [ABSTRACT FROM AUTHOR]

Introduction: Previous research has shown that integrated care can lead to improved processes and patient outcomes. However, this is not always the case and there is a lack of evidence regarding the reasons why and in which cases integrated care works. This study contributes to filling this knowledge gap by examining the implementation of integrated care for type 2 diabetes by two Dutch care groups. Methods: An embedded single case study with two units of analysis was conducted, including 26 interviews with care group staff and health care providers. The CMO model (context + mechanism = outcome) was used to study the relationship between context factors (as categorised by the Implementation Model), mechanisms (as defined by the Chronic Care Model) and outcomes (operationalised as aspects of quality of care). Results: Dutch integrated care reflects five of the six chronic care model components, namely health system, self-management support, delivery system design, decision support, and clinical information system. Barriers were found at all levels of the IM and included decreases earnings, too many innovations, the negative role of some health insurers, yearly changes in insurance policies, the funding system incentivising the provision of care exactly as described in the care protocols, patients' insufficient medical and policy-making expertise, disease-specific care management, resistance by GPs and GP assistants, too much care provided by PNs, and insufficient integration between the various patient databases. Facilitators were also found at all levels of the IM and included increased earnings, care group management and support, financial incentives for care innovations, health insurer cooperation, financial pressure in the health sector, increased focus on self-management, GP support, innovators, tradition of transmural cooperation, integrators, performance monitoring via the care chain information system, and financial incentives for guideline adherence. Discussion/Limitations: The implementation of integrated care led to perceived improvements in certain aspects of quality of care such as improved communication and cooperation but also to perceived deteriorations in others such as insufficient and unnecessary care provision and the preconditions for person-centred care. With so many diverse factors impacting on the outcomes achieved, respondents' opinions varied on whether, overall, integrated care had led to improved or deteriorated quality of care. Moreover, having been conducted in a single country and for a single chronic condition only, the results are still too context-specific to claim generalizability to other settings and conditions. Conclusion/Lessons Learned: Evaluation research benefits from an increased focus on 'how' and 'why' questions in combination with 'what has been achieved' questions using the CMO model, which will be necessary if scientific research is to provide valuable recommendations to integrated chronic care practice. Suggestions for future research: To achieve generalizability, future research should focus on the development of an integrated framework for analysing the implementation of integrated care interventions for people suffering from chronic conditions, focusing on the different mechanisms by which and context in which these are implemented and linking those factors to the outcomes achieved. [ABSTRACT FROM AUTHOR]

Purpose: In all Western countries, ageing populations cause the demand for elderly care services to increase dramatically. In addition, elderly clients are getting more demanding about the services they require to fulfil their widely varying and multiple needs. Besides, cost reductions have been the focus of governmental policies and organisational practices for many years. Health care providers increasingly see operations management as a promising approach to align both client-orientation and cost-efficiency in their day-today practices. Theory: The paper starts from operations management literature on front office--back office design and modular production. Organisations have several options for deciding which activities need to be performed by FO, BO, or the client himself, and in deciding which employees need to perform these activities. By applying modular production, organisations can differentiate care and related services to a high degree without major cost increases. Method: A literature review will be presented leading to a theoretical framework. This formed the basis for explorative case studies in the elderly care sector. Results and conclusions: It will be argued how insights provided with the framework may enhance a client-orientation in integrated care delivery without major cost increases. Although case studies need to be interpreted with caution, interesting implications for organisational structures and inter-organisational cooperation can be seen. We will discuss how combined supply of care services can be made transparent to enhance choice options in service products, and what is required at the level of professionals for providing care and service packages based on client demand. [ABSTRACT FROM AUTHOR]