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      Integrated care pilot in north-west London: a mixed methods evaluation

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          Abstract

          Introduction

          This paper provides the results of a year-long evaluation of a large-scale integrated care pilot in north-west London. The pilot aimed to integrate care across primary, acute, community, mental health and social care for people with diabetes and/or those aged 75+ through care planning, multidisciplinary case reviews, information sharing and project management support.

          Methods

          The evaluation team conducted qualitative studies of change at organisational, clinician and patient levels (using interviews, focus groups and a survey); and quantitative analysis of change in service use and patient-level clinical outcomes (using patient-level datasets and a matched control study).

          Results

          The pilot had successfully engaged provider organisations, created a shared strategic vision and established governance structures. However, the engagement of clinicians was variable and there was no evidence to date of significant reductions in emergency admissions. There was some evidence of changes in care processes.

          Conclusion

          Although the pilot has demonstrated the beginnings of large-scale change, it remains in the early stages and faces significant challenges as it seeks to become sustainable for the longer term. It is critical that National Health Service managers and clinicians have realistic expectations of what can be achieved in a relatively short period of time.

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          Most cited references42

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          The Discovery of Grounded Theory

          <p>Most writing on sociological method has been concerned with how accurate facts can be obtained and how theory can thereby be more rigorously tested. In The Discovery of Grounded Theory, Barney Glaser and Anselm Strauss address the equally Important enterprise of how the discovery of theory from data--systematically obtained and analyzed in social research--can be furthered. The discovery of theory from data--grounded theory--is a major task confronting sociology, for such a theory fits empirical situations, and is understandable to sociologists and laymen alike. Most important, it provides relevant predictions, explanations, interpretations, and applications.</p><p>In Part I of the book, Generation Theory by Comparative Analysis, the authors present a strategy whereby sociologists can facilitate the discovery of grounded theory, both substantive and formal. This strategy involves the systematic choice and study of several comparison groups. In Part II, The Flexible Use of Data, the generation of theory from qualitative, especially documentary, and quantitative data Is considered. In Part III, Implications of Grounded Theory, Glaser and Strauss examine the credibility of grounded theory.</p><p>The Discovery of Grounded Theory is directed toward improving social scientists' capacity for generating theory that will be relevant to their research. While aimed primarily at sociologists, it will be useful to anyone Interested In studying social phenomena--political, educational, economic, industrial-- especially If their studies are based on qualitative data.</p></p>
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            Large-system transformation in health care: a realist review.

            An evidence base that addresses issues of complexity and context is urgently needed for large-system transformation (LST) and health care reform. Fundamental conceptual and methodological challenges also must be addressed. The Saskatchewan Ministry of Health in Canada requested a six-month synthesis project to guide four major policy development and strategy initiatives focused on patient- and family-centered care, primary health care renewal, quality improvement, and surgical wait lists. The aims of the review were to analyze examples of successful and less successful transformation initiatives, to synthesize knowledge of the underlying mechanisms, to clarify the role of government, and to outline options for evaluation. We used realist review, whose working assumption is that a particular intervention triggers particular mechanisms of change. Mechanisms may be more or less effective in producing their intended outcomes, depending on their interaction with various contextual factors. We explain the variations in outcome as the interplay between context and mechanisms. We nested this analytic approach in a macro framing of complex adaptive systems (CAS). Our rapid realist review identified five "simple rules" of LST that were likely to enhance the success of the target initiatives: (1) blend designated leadership with distributed leadership; (2) establish feedback loops; (3) attend to history; (4) engage physicians; and (5) include patients and families. These principles play out differently in different contexts affecting human behavior (and thereby contributing to change) through a wide range of different mechanisms. Realist review methodology can be applied in combination with a complex system lens on published literature to produce a knowledge synthesis that informs a prospective change effort in large-system transformation. A collaborative process engaging both research producers and research users contributes to local applications of universal principles and mid-range theories, as well as to a more robust knowledge base for applied research. We conclude with suggestions for the future development of synthesis and evaluation methods. © 2012 Milbank Memorial Fund.
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              Impact of case management (Evercare) on frail elderly patients: controlled before and after analysis of quantitative outcome data.

              To determine the impact on outcomes in patients of the Evercare approach to case management of elderly people. Practice level before and after analysis of hospital admissions data with control group. Nine primary care trusts in England that, in 2003-5, piloted case management of elderly people selected as being at high risk of emergency admission. Rates of emergency admission, emergency bed days, and mortality from April 2001 to March 2005 in 62 Evercare practices and 6960-7695 control practices in England (depending on the analysis being carried out). The intervention had no significant effect on rates of emergency admission (increase 16.5%, (95% confidence interval -5.7% to 38.7%), emergency bed days (increase 19.0%, -5.3% to 43.2%), and mortality (increase 34.4%, -1.7% to 70.3%) for a high risk population aged >65 with a history of two or more emergency admissions in the preceding 13 months. For the general population aged > or =65 effects on the rates of emergency admission (increase 2.5%, -2.1% to 7.0%), emergency bed days (decrease -4.9%, -10.8% to 1.0%), and mortality (increase 5.5%, -3.5% to 14.5%) were also non-significant. Case management of frail elderly people introduced an additional range of services into primary care without an associated reduction in hospital admissions. This may have been because of identification of additional cases. Employment of community matrons is now a key feature of case management policy in the NHS in England. Without more radical system redesign this policy is unlikely to reduce hospital admissions.
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                Author and article information

                Contributors
                Role: Senior Fellow,
                Health Policy, Nuffield Trust, 59 New Cavendish Street, London, UK
                Role: Academic Clinical Lecturer,
                Public Health, Department of Primary Care and Public Health, Imperial College London, UK
                Role: Associate Director,
                Global eHealth Unit & Biostatistician, School of Public Health, Imperial College London, UK
                Role: Director of Postgraduate Programmes,
                Health Services Research, School of Health Sciences, City University, London, UK
                Role: Senior Research Analyst,
                Nuffield Trust, 59 New Cavendish Street, London, UK
                Role: Clinical Research Fellow,
                Department of Public Health & Primary Care, Imperial College London, UK
                Role: Research Associate,
                Department of Primary Care & Public Health, School of Public Health, Imperial College London, UK
                Role: Fellow,
                Health Policy, Nuffield Trust, 59 New Cavendish Street, London, UK
                Role: Director of Policy,
                Nuffield Trust, 59 New Cavendish Street, London, UK
                Role: Professor of Primary Care,
                Department of Primary Care & Public Health, Imperial College London, UK
                Role: Research Associate,
                Department of Primary Care & Public Health, School of Public Health, Imperial College London, UK
                Role: Clinical Research Fellow,
                Department of Primary Care and Public Health, Imperial College London, UK
                Role: Course Leader for Clinical Communication,
                Department of Surgery and Cancer, 2nd Floor, Paterson Centre, St Marys Hospital, Imperial College London, UK
                Role: Clinical Transformation Manager-Medicine Clinical Programme Group and General Manager,
                Imperial Clinical Research Unit, Imperial College London, UK
                Role: Lecturer,
                Department of Psychology, City University, London, UK
                Role: Research Associate,
                Department of Primary Care & Public Health, Imperial College London, London, UK
                Role: Research Assistant,
                Department of Primary Care & Public Health, Imperial College London, UK
                Role: Principal Research Fellow,
                Metro North Mental Health, Royal Brisbane and Women's Hospital, Herston, Qld 4029, Australia
                Role: Senior Clinical Lecturer,
                Primary Care, Department of Primary Care & Public Health, Imperial College London, UK
                Role: Director,
                Research, Nuffield Trust, London, UK
                Journal
                Int J Integr Care
                Int J Integr Care
                IJIC
                International Journal of Integrated Care
                Igitur publishing (Utrecht, The Netherlands )
                1568-4156
                Jul-Sep 2013
                25 July 2013
                : 13
                : e027
                Affiliations
                Health Policy, Nuffield Trust, 59 New Cavendish Street, London, UK
                Public Health, Department of Primary Care and Public Health, Imperial College London, UK
                Global eHealth Unit & Biostatistician, School of Public Health, Imperial College London, UK
                Health Services Research, School of Health Sciences, City University, London, UK
                Nuffield Trust, 59 New Cavendish Street, London, UK
                Department of Public Health & Primary Care, Imperial College London, UK
                Department of Primary Care & Public Health, School of Public Health, Imperial College London, UK
                Health Policy, Nuffield Trust, 59 New Cavendish Street, London, UK
                Nuffield Trust, 59 New Cavendish Street, London, UK
                Department of Primary Care & Public Health, Imperial College London, UK
                Department of Primary Care & Public Health, School of Public Health, Imperial College London, UK
                Department of Primary Care and Public Health, Imperial College London, UK
                Department of Surgery and Cancer, 2nd Floor, Paterson Centre, St Marys Hospital, Imperial College London, UK
                Imperial Clinical Research Unit, Imperial College London, UK
                Department of Psychology, City University, London, UK
                Department of Primary Care & Public Health, Imperial College London, London, UK
                Department of Primary Care & Public Health, Imperial College London, UK
                Metro North Mental Health, Royal Brisbane and Women's Hospital, Herston, Qld 4029, Australia
                Primary Care, Department of Primary Care & Public Health, Imperial College London, UK
                Research, Nuffield Trust, London, UK
                Author notes
                Correspondence to: Holly Holder, The Nuffield Trust, 59 New Cavendish Street, London, W1G 7LP, UK. Phone: 020 7462 0516. E-mail: holly.holder@ 123456nuffieldtrust.org.uk
                Article
                IJIC-13-2013027
                10.5334/ijic.1149
                3807631
                24167455
                a3a3f11d-5147-4eea-85cf-4cbfec13c9aa
                Copyright 2013, Authors retain the copyright of their article

                This work is licensed under a ( http://creativecommons.org/licenses/by/3.0) Creative Commons Attribution 3.0 Unported License

                History
                : 5 April 2013
                : 5 June 2013
                : 6 June 2013
                Categories
                Research and Theory
                Custom metadata
                Int J Integr Care 2013; Jul–Sep, URN:NBN:NL:UI:10-1-114735

                Health & Social care
                integrated health care systems,health services research,health care,reform,patient-centred care,evaluation studies

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