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Introduction: East Toronto Health Partners (ETHP) is a network of organizations that serve residents of East Toronto, Ontario, Canada. ETHP is a newly formed integrated model of care in which hospital, primary care, community providers and patients/ families work together to improve population health. We describe and evaluate the evolution of this emerging integrated care system as it responded to a global health crisis. Description: This paper begins by describing ETHP’s pandemic response mapping out over two years of data. To evaluate the response, semi-structured interviews were conducted with 30 decision makers, clinicians, staff, and volunteers who were part of the response. The interviews were thematically analyzed, and emergent themes mapped onto the nine pillars of integrated care. Discussion: The ETHP pandemic response evolved rapidly. Early siloed responses gave way to collaborative efforts and equity emerged as a central priority. New alliances formed, resources were shared, leaders emerged, and community members stepped forward to contribute. Interviewees identified positives as well as many opportunities for improvement post-pandemic. Conclusion: The pandemic was a catalyst for change in East Toronto that accelerated existing initiatives to achieve integrated care. The East Toronto experience may serve as a useful guide for other emerging integrated care systems. [ABSTRACT FROM AUTHOR]

Introduction: In response to the challenges of the traditional mental health system for youth both in Canada and abroad, models of integrated youth services (IYS) that span the integration of mental health, health, substance use, eucation, employment, peer support, and navigation into ‘one-stop shops’ are being established nationally and internationally. IYS models, however, need to be better described and evaluated to inform the replicability of this approach in other jurisdictions. Description: This paper describes the implementation of an IYS in a small urban city and rural county in Ontario, Canada, including insights from key informants into barriers, facilitators, and lessons learned. Discussion: This evaluation identified a number of barriers and facilitators to the implementation of the IYS model in this specific context. Implementation facilitators included youth and family engagement, network partner collaboration, leadership, governance structure, community enthusiasm and support, and collaborative funding models. Barriers to implementation included the COVID-19 pandemic and related public health restrictions, the diverse needs of youth, change management, sustainable funding, and transportation. Lessons learned: By establishing a shared vision of delivering youth services across the integrated network, and engaging youth early in the process of model development, IYS have the potential to transform the service system for youth and their families. Meeting the diverse needs and challenges of youth who live in rural or small urban communities will enhance service delivery and experience for young people. [ABSTRACT FROM AUTHOR]

Introduction: Network platforms are interesting for integrated care governance as they seek solutions for the problem of competition and tensions between networks. In this paper, we analyse how a network platform functions for the actors involved, and how it is used in their work. Methods: We employed a case study in a Dutch urbanised hospital region, and conducted 17 interviews with hospital physicians, directors, and supporting staff who are involved in a network platform called “BeterKeten” (BK). Results: Actors assign different functions and purposes to BK: facilitating and legitimising professional (learning) communities; adapting to a changing policy context; enlarging professionals’ and the networks’ circle of influence; and extending governing possibilities. Network platform’ dynamics and frictions entail changing professional and managerial practices; embedding a BK network in a partner network; and alignment of (conflicting) network platforms. Discussion: Network platforms are a promising strategy to govern, facilitate, and nurture network-building actions to enhance integrated care, offering new ways of working to cope with its multi-level nature. Conclusion: BK is a dynamic actor with steering capacities that enables the coexistence of multiple purposes. Further research could pay attention to how network platforms are able to develop modalities of integrated care governance that suit healthcare system’s networked character. [ABSTRACT FROM AUTHOR]

Introduction: The healthcare journey to create integrated care in Ontario, Canada, was bolstered in 2019 by the creation of Ontario Health Teams(OHTs). These newly formed meso-level networks of providers are collectively responsible for providing appropriate, coordinated, effective and efficient health services for an attributable population. These "self-determined and fit for purpose" OHTs are developing governance structures to enable partnership among community-based organizations, patients/caregivers, primary care and home and hospital providers. This study describes the different governance structures and pathways adopted by three OHTs, detailing factors that enable OHTs to take steps towards their maturity and highlighting the lessons learned from the experience. Methods: This paper is aimed to assess the diverse governance models, their pathways to maturity and intended advantages and challenges across the OHTs. This study aims to understand how OHTs set up their governance structures based on their population need and context. The study follows a mixed-methods design. An initial survey was used to collect data across all 50 OHTs to describe governance structures and processes adopted (council membership, joint decisionmaking, separate legal entities). The qualitative study will use a cross-case comparative design amongst three OHTs to compare and study the different governances adopted by OHTs. The three OHTs were selected to allow variability in governance structures; for example, OHTs formed a separate legal entity or enacted a joint-decision making or a collaborative agreement. This phase will collect data from interviews (leadership/collaborative council and management team members) and document review (key documents, meeting minutes) across three OHTs and will be analyzed using thematic network analysis. Highlights: We intend to interview 7-9 decision-makers across each selected OHT, who are council members or have been involved in the governance setup. Using a three-stage network development and change cycle, we will assess initial readiness and activation, current stabilization and routinization practices and finally, efforts towards stability and sustainability across each OHT. The key governance themes that will be explored with the OHTs are partner composition and engagement, legal form, role and functioning of governing bodies, decision-making authority and dynamics funding and accountability. A thematic network analysis will enable a methodical systematization of the textual data and help depict graphical web-like nets of the themes. Enabling a richer understanding of an issue and facilitating disclosure on researchers' analysis process and a more precise understanding for the reader. [ABSTRACT FROM AUTHOR]

Purpose: Achieving greater health and social care integration is a policy priority in many countries, but challenges remain. We focused on governance and accountability for integrated care and explored arrangements that shape more integrated delivery models or systems in Italy, the Netherlands and Scotland. We also examined how the COVID-19 pandemic affected existing governance arrangements. Design/methodology/approach: A case study approach involving document review and semi-structured interviews with 35 stakeholders in 10 study sites between February 2021 and April 2022. We used the Transparency, Accountability, Participation, Integrity and Capability (TAPIC) framework to guide our analytical enquiry. Findings: Study sites ranged from bottom-up voluntary agreements in the Netherlands to top-down mandated integration in Scotland. Interviews identified seven themes that were seen to have helped or hindered integration efforts locally. Participants described a disconnect between what national or regional governments aspire to achieve and their own efforts to implement this vision. This resulted in blurred, and sometimes contradictory, lines of accountability between the centre and local sites. Flexibility and time to allow for national policies to be adapted to local contexts, and engaged local leaders, were seen to be key to delivering the integration agenda. Health care, and in particular acute hospital care, was reported to dominate social care in terms of policies, resource allocation and national monitoring systems, thereby undermining better collaboration locally. The pandemic highlighted and exacerbated existing strengths and weaknesses but was not seen as a major disruptor to the overall vision for the health and social care system. Research limitations: We included a relatively small number of interviews per study site, limiting our ability to explore complexities within sites. Originality: This study highlights that governance is relatively neglected as a focus of attention in this context but addressing governance challenges is key for successful collaboration. [ABSTRACT FROM AUTHOR]

Introduction: Multiple sclerosis (MS) is a chronic and progressive disease characterised by central nervous system lesions and subsequent neural damage. Patients have increasingly severe disability and there are no therapies for healing. Since the onset, usually between 20 and 40 years old, MS dramatically affects the quality of life (QoL) of patients and their families. Whereas literature suggests the importance of integration in MS management, evidences show many difficulties to achieve integration and seamless integrated clinical pathways (ICPs) for this target of patients. Hitherto there are limited experiences around comprehensive interventions for the MS management, exploiting a life-course approach and broader scales and scopes towards special group commissioning strategies - with only one relevant exemption in the U.S. Veterans Integrated Service Network (VISN) supporting MS Regional Program. The paper presents the undergoing experience at the LHA of Parma, located in northern Italy, in Emilia Romagna Region, which accounts for 443.770 habitants, covering a surface of 3.448 kilometres, including a mountain area, with 46 municipalities. Of interest, in the context of a broad regional programme oriented to reorganise primary health care through the development of medical homes model, the LHA in mid-2014 started a project for setting up a MS managed care network. Moving from a systematic analysis yet of the demand of MS patients yet of the local supply chain, the project has sought for establishing a managed care network based on the newly primary health care system and for identifying special commissioning strategies for this targeted group through ICPs. Objectives and methods: The project pursues two main objectives: developing a managed care network for MS patients from the commissioners' perspective and therefore identifying a system for programme planning resources needed for MS management and procuring services within the LHA. The project is broken down into three major phases exploiting different methods and stakeholders' engagement. The first phase focused on the demand analysis. On one hand, the MS patients' population was identified and stratified using LHA administrative databases. An algorithm based on the individual fiscal code and patient exemption extrapolated the targeted population. To stratify the targeted group and analyse their current pattern of resources' utilization two further actions were performed. Firstly, neurologists' team from MS centres fulfilled a Joint Need Assessment (JNA) through clinical vignette for their patients. Health needs were assessed through the Expended Disability Status Scale (EDSS) that measures the rate of MS progression. The scale was aggregated in three clusters relying on the disease staging and use of disease modifying drugs (DMDs): little disability (EDSS 02); severe (x⩾2). Cross-tabulating the level of disability and fragility, the group of MS patients was stratified in 9 classes. Secondly, the pattern of resources utilisation for each class was analysed to create care-profiles based on the types of care (PCTC) provided. To this extent through the unique patient record different data sources were consulted: patients discharge reports, A&E reports, specialty and diagnostic outpatients services, pharmaceutical prescriptions (hospital and community databases), home care services, care home and intermediate care services, hospice, social care services and personal budget/disability allowance dataset and finally prosthetics. On the other hand, the first phase included also the analysis of the supply chain, to identify current MS centres and their resources as well as the broad range of services accessed by the MS patients. The second phase is going set up nine ICPs, one for each care-profile, to design seamless and integrated processes through different settings (MS centre, medical homes, rehab services etc.). Moreover, this phase includes the estimation of the total cost of care for each ICP based on the resources' utilisation pattern associated with each PCTC. Finally, the third phase is going to set up the managed care network for SM patients, based on the nine ICPs as standard base-line of the care packages guaranteed and integrated processes of care delivery. To fulfil this phase a consensus building process with professionals and providers will support the implementation of ICPs and the set-up of a dashboard of process and outcome indicators, directly monitored by the LHA commissioners. Timeline: The project started in June 2014 and is expected to end up in February 2015 with the outline of the MS managed care network. The demand analysis and stratification across the nine care-profiles as well as the supply chain review were completed in November 2014. Current work is focused on the ICPs' design for the nine care-profiles and their cost-assessment. Highlights and conclusions: The project holds a paradigmatic and innovative value from two perspectives. Firstly, the methods used for the MS patients group identification and segmentation is remarkable for further exploitation and transferrable yet to different contexts yet to different care groups, providing a reliable tools for strategic commissioning for complex care needs. In fact, the method applied to the LHA of Parma, was previously tested in other contexts and gradually improved through adjustments and due to the maturity of data management systems. Secondly, this methodology hinges on the set-up of ICPs, thus it allows to directly establish a routinely system relating the patient-centred perspective and the commissioners objectives, focused on the programme planning and procuring in a given local health economy. Therefore, the efforts to standardise a set of ICPs through a process-based set of PCTC paved the way for interesting practice achievements in the management of complex chronic conditions. Finally, the project delivers an innovative experience towards understanding how to implement a managed care network through the integrative function of primary care and ICPs. One of the major question the project ought to reply, in fact, is whether the MS centre, the hub of the care network, could be placed in the future in a medical home, out of hospital, if it will have to coordinate spokes centres at the community level through ICPs. [ABSTRACT FROM AUTHOR]

The last five years in Ireland has seen drives towards effective service delivery through integrated care arrangements for the purpose of improved care quality. The CHO report popularly referred to as the Healy report, published in 2014 emphasizes the importance of the reorganisation of community-based service and it recommends the establishment of nine CHOs as well as the governance and management arrangements. Implementation literature in Ireland highlights that there is insufficient empirical evidence to capture the gains of integrated care in Ireland. There are calls for more research focused on organisation wide research programmes, increase in the number of researchers engaged in systems research (2, 3) and further assessment of governance arrangements (2-5). While there are investments in reforms, evidence highlights that the process of implementation diverges in practice (6) and reforms do not seem to curb challenges in the health system (4, 6, 7). Engagement in research is able to provide a loop of learning, which could inform future policy process of integrated care. In this paper, the researcher explores the interpretation of frontline professionals situated in Community Healthcare Organisations (CHOs) as they implement integrated care in Ireland. This study utilises a strategic management approach (Strategy As Practice) and draws on institutional theory as well as social theories of practice and sense making. To explore implementation, a qualitative interpretive research approach was utilised in two phases and data was thematically analysed. Using a qualitative exploratory research design, the researcher has been able to identify themes related to various aspect of implementation of integrated care. Awareness, understanding and actioning (processes and practices of professionals who are situated at different levels of implementation). Overall, there is a positive embrace and support of the change agenda. Findings highlighted lack of adequate information, communication and clear rationale before the implementation of recommendations of Healy report. Insufficient local level support to govern and make considerable changes. Implementation of the report still seems slow, lacking in the engagement of frontline/middle level managers and their involvement in decision-making. Awareness of clinical governance is still relatively low and interest in governance is dependent on its relevance to the role of professionals as well as lack of relationship between the document and their day-to-day activities. Professionals expected to implement at local level are unaware of the actioning plan at the CHO level and there is insufficient update or communication on the progression of the implementation process. There is the need for improvement on the culture around issues of governance, involvement of professionals at all levels in the health system on matters relating to governance regardless of their level of engagement with decision-making. More open decision-making as well as adequate risk assessments because current arrangements are perceived to be vague. Frontline professionals cannot overemphasize the importance of local level engagement and co-creation or involvement in the entire policy process. A larger project will give a clearer exploration of governance arrangement in the Irish healthcare. [ABSTRACT FROM AUTHOR]

Background: We analyze here major changes over the last decade in the French healthcare system for older people, in terms of the integrated care concept. Policies: During this period, the major theme of public policies was "care coordination." Despite some improvements, the multiplication of experimental programs and the multiplicity of stakeholders distanced the French healthcare system from an integrated care model. Professionals and organizations generally welcomed these numerous programs. However, most often, the programs were insufficiently implemented or articulated, notably at a clinical level, because of the persistence of a high level of fragmentation of governance, despite the creation of regional health agencies 10 years ago. The COVID-19 crisis has highlighted this fragmentation. Moreover, we still lack data on the impact of these programs on people's health trajectories and personal experiences. Conclusion: The French healthcare system seems more fragmented in 2020 than in 2010, despite improvements in the culture of professional collaboration. The future health reform is an opportunity to capitalize upon this progress and to implement "integrated care." This implies a strong and continuous national leadership in governance and change management. [ABSTRACT FROM AUTHOR]