Mirella Minkman

A four phase development model for integrated care services in the Netherlands

BackgroundMultidisciplinary and interorganizational arrangements for the delivery of coherent integrated care are being developed in a large number of countries. Although there are many integrated care programs worldwide, the process of developing these programs and interorganizational collaboration is described in the literature only to a limited extent. The purpose of this study is to explore how local integrated care services are developed in the Netherlands, and to conceptualize and operationalize a development model of integrated care.MethodsThe research is based on an expert panel study followed by a two-part questionnaire, designed to identify the development process of integrated care. Essential elements of integrated care, which were developed in a previous Delphi and Concept Mapping Study, were analyzed in relation to development process of integrated care.ResultsIntegrated care development can be characterized by four developmental phases: the initiative and design phase; the experimental and execution phase; the expansion and monitoring phase; and the consolidation and transformation phase. Different elements of integrated care have been identified in the various developmental phases.ConclusionThe findings provide a descriptive model of the development process that integrated care services can undergo in the Netherlands. The findings have important implications for integrated care services, which can use the model as an instrument to reflect on their current practices. The model can be used to help to identify improvement areas in practice. The model provides a framework for developing evaluation designs for integrated care arrangements. Further research is recommended to test the developed model in practice and to add international experiences.

The implementation of integrated care: the empirical validation of the Development Model for Integrated care.

BackgroundIntegrated care is considered as a strategy to improve the delivery, efficiency, client outcomes and satisfaction rates of health care. To integrate the care from multiple providers into a coherent client-focused service, a large number of activities and agreements have to be implemented like streamlining information flows and patient transfers. The Development Model for Integrated care (DMIC) describes nine clusters containing in total 89 elements that contribute to the integration of care. We have empirically validated this model in practice by assessing the relevance, implementation and plans of the elements in three integrated care service settings in The Netherlands: stroke, acute myocardial infarct (AMI), and dementia.MethodsBased on the DMIC, a survey was developed for integrated care coordinators. We invited all Dutch stroke and AMI-services, as well as the dementia care networks to participate, of which 84 did (response rate 83%). Data were collected on relevance, presence, and year of implementation of the 89 elements. The data analysis was done by means of descriptive statistics, Chi Square, ANOVA and Kruskal-Wallis H tests.ResultsThe results indicate that the integrated care practice organizations in all three care settings rated the nine clusters and 89 elements of the DMIC as highly relevant. The average number of elements implemented was 50 ± 18, 42 ± 13, and 45 ± 22 for stroke, acute myocardial infarction, and dementia care services, respectively. Although the dementia networks were significantly younger, their numbers of implemented elements were comparable to those of the other services. The analyses of the implementation timelines showed that the older integrated care services had fewer plans for further implementation than the younger ones. Integrated care coordinators stated that the DMIC helped them to assess their integrated care development in practice and supported them in obtaining ideas for expanding their integrated care activities.ConclusionsAlthough the patient composites and the characteristics of the 84 participating integrated care services differed considerably, the results confirm that the clusters and the vast majority of DMIC elements are relevant to all three groups. Therefore, the DMIC can serve as a general quality management tool for integrated care. Applying the model in practice can help in steering further implementations as well as the development of new integrated care practices.

The current state of integrated care: an overview

Purpose – Although a large amount of literature about the levels, aims, and relevance of integrated care is present, to realise change in practice knowledge about the implementation and development process of integrated care is also crucial. Instruments such as quality management models can facilitate improvement, but are not frequently used in integrated care practice. The purpose of this paper, therefore, is to present further insight into these models and into the related literature about network and organisational development.Design/methodology/approach – An overview of the recent literature is presented.Findings – The improvement of integrated care is complex and there is no consensus about a set of relevant elements for integrated care. Available quality management models vary in their underlying evidence and do not have integrated care as their central focus or are aimed at specific patient groups such as the chronically ill. The lack of a consistent set of elements and the need for a generic, evid...

Promoting acute thrombolysis for ischaemic stroke (PRACTISE)

Rationale Thrombolysis with intravenous rtPA is an effective treatment for patients with ischaemic stroke if given within 3 h from onset. Generally, more than 20% of stroke patients arrive in time to be treated with thrombolysis. Nevertheless, in most hospitals, only 1–8% of all stroke patients are actually treated. Interorganisational, intraorganisational, medical and psychological barriers are hampering broad implementation of thrombolysis for acute ischaemic stroke. Aims To evaluate the effect of a high-intensity implementation strategy for intravenous thrombolysis in acute ischaemic stroke, compared with regular implementation; to identify success factors and obstacles for implementation and to assess its cost-effectiveness, taking into account the costs of implementation. Design The PRACTISE study is a national cluster-randomised-controlled trial. Twelve hospitals have been assigned to the regular or high-intensity intervention by random allocation after pair-wise matching. The high-intensity implementation consists of training sessions in conformity with the Breakthrough model, and a tool kit. All patients who are admitted with acute stroke and onset of symptoms not longer than 24 h are registered. Study outcomes The primary outcome measure is treatment with thrombolysis. Secondary outcomes are admission within 4 h after onset of symptoms, death or disability at 3 months, the rate of haemorrhagic complications in patients treated with thrombolysis, and costs of implementation and stroke care in the acute setting. Tertiary outcomes are derived from detailed criteria for the organisational characteristics, such as door-to-needle time and protocol violations. These can be used to monitor the implementation process and study the effectiveness of specific interventions. Discussion This study will provide important information on the effectiveness and cost-effectiveness of actively implementing an established treatment for acute ischaemic stroke. The multifaceted aspect of the intervention will make it difficult to attribute a difference in the primary outcome measure to a specific aspect of the intervention. However, careful monitoring of intermediate parameters as well as monitoring of accomplished SMART tasks can be expected to provide useful insights into the nature and role of factors associated with implementation of thrombolysis for acute ischaemic stroke, and of effective acute interventions in general.

A survey study to validate a four phases development model for integrated care in the Netherlands

BackgroundThe development of integrated care is a complex and long term process. Previous research shows that this development process can be characterised by four phases: the initiative and design phase; the experimental and execution phase; the expansion and monitoring phase and the consolidation and transformation phase. In this article these four phases of the Development Model for Integrated Care (DMIC) are validated in practice for stroke services, acute myocardial infarct (AMI) services and dementia services in the Netherlands.MethodsBased on the pre-study about the DMIC, a survey was developed for integrated care coordinators. In total 32 stroke, 9 AMI and 43 dementia services in the Netherlands participated (response 83%). Data were collected on integrated care characteristics, planned and implemented integrated care elements, recognition of the DMIC phases and factors that influence development. Data analysis was done by descriptive statistics, Kappa tests and Pearson’s correlation tests.ResultsAll services positioned their practice in one of the four phases and confirmed the phase descriptions. Of them 93% confirmed to have completed the previous phase. The percentage of implemented elements increased for every further development phase; the percentage of planned elements decreased for every further development phase. Pearson’s correlation was .394 between implemented relevant elements and self-assessed phase, and up to .923 with the calculated phases (p < .001). Elements corresponding to the earlier phases of the model were on average older. Although the integrated care services differed on multiple characteristics, the DMIC phases were confirmed.ConclusionsIntegrated care development is characterised by a changing focus over time, often starting with a large amount of plans which decrease over time when progress on implementation has been made. More awareness of this phase-wise development of integrated care, could facilitate integrated care coordinators and others to evaluate their integrated care practices and guide further development. The four phases model has the potential to serve as a generic quality management tool for multiple integrated care practices.

Values and Principles of Integrated Care.

This is the first editorial of the International Journal of Integrated Care to be published by our new open-access publisher, Ubiquity Press. It follows a successful 15-year period supported by Igitur at the University Library Utrecht where IJIC was the first digital journal in their portfolio. However, as integrated care has grown as a service innovation, so the ever increasing numbers of articles being submitted to IJIC means that the ‘incubation’ period of our Journal within Igitur has long since passed and so we now enter into a new venture to support a larger audience of academics, professionals and decision-makers keen to absorb the latest knowledge in this growing field of scientific inquiry.

Service integration across sectors in Europe: Literature and practice

Introduction: To meet the needs of vulnerable people, the integration of services across different sectors is important. This paper presents a preliminary review of service integration across sectors in Europe. Examples of service integration between social services, health, employment and/or education were studied. A further aim of the study was to improve conceptual clarity regarding service integration across sectors, using Minkman’s Developmental Model for Integrated Care (DMIC) as an analytical framework. Methods: The study methods comprised a literature review (34 articles) and a survey of practice examples across Europe (44 practices). This paper is based on a more comprehensive study published in 2016. Results: The study demonstrates that although the focus of integration across sectors is often on social services and health care, other arrangements are also frequently in place. The review shows that integration may be either tailored to a particular target group or designed for communities in general. Although systems to monitor and evaluate social service integration are often present, they are not yet fully developed. The study also highlights the importance of good leadership and organizational support in integrated service delivery. Discussion: The study shows that the DMIC can work as a conceptual framework for the analysis of service integration across sectors. However, as this is an exploratory study, further in-depth case studies are required to deepen our understanding of the processes involved in service integration across sectors.

Longing for Integrated Care: The Importance of Effective Governance

Last March I had the honour to do my inaugural lecture at the University of Tilburg/TIAS Business School, where I have held since 2016 my chair called ‘Innovation of the organization and governance of integrated care’ [1]. For me it was a day to remember. In the Netherlands it is also a very formal and traditional ceremony where family, friends, colleagues and other relations are invited to share this moment. The inaugural lecture and the related book were a perfect reason for me to take some time for reflection on how to bring integrated care further and what challenges there are for a research agenda. This editorial is a pleasant invitation to share some of my ideas with the readers of our Journal. My lecture was called ‘Longing for Integrated Care’ or in Dutch ‘Verlangen naar Integraliteit’. Of course this title was chosen for a reason. When I reflect on where we are in our way towards integrated care worldwide, I see that more and more clients, professionals and policy makers are looking in the direction of integrated care as a perspective; a perspective to reduce fragmentation because the real needs of people are often not really being seen and served. What really matters for a person like Mrs Van der Munt and her family, an 84 year old lady, living alone at home, becoming more and more fragile and heavily relying on her daughter to keep the promise that she can stay and die in her own home? What is the real issue in diabetes care? (Self) managing blood sugar levels? Or is it managing having diabetes in your social life, your cooking habits and daily living? Integrated care starts with a holistic perspective on what matters to people; otherwise the real essence of integrated care can be missed [1]. Integrated care is not about creating a multidisciplinary offer/supply, but it is about creating an integrative answer to the most important issues of people in need. A holistic approach seems logical, but it means a lot for how we organise our (health)care and welfare systems, and the needed connections with other domains in life [2]. Also, it asks for effective collaboration between professionals, clients and organizations. That also means a mis-fit with traditional governance which is mostly focusing on expanding or maintaining organizations or is professionally driven. Accountability is mostly targeted at ‘those who pay and those who can punish’ like health care insurers, policy makers and health care inspectorates. I expect that the era in which being mostly accountable towards clients, the community and the society will be on the rise.

The Development Model for Integrated Care: a validated tool for evaluation and development

Purpose – Integrating health, social and informal care and seeking for new effective collaborations is a major topic in many countries, and requires innovation and improvement in current practices. Conceptual quality management models can facilitate practice improvement. However, a generic quality management model for integrated care was lacking. The purpose of this paper is to describe the results of multiple studies that resulted in a validated generic quality management model for integrated care. The Development Model for Integrated Care (DMIC) is the basis for a digital tool for self-evaluation and is being used in multiple ways in a large number of integrated care settings. Design/methodology/approach – A literature review, a Delphi study and concept mapping study were executed to identify the essential ingredients of integrated care. A next step was an expert study on the development process of integrated care over time. Lastly, a survey study in 84 integrated care networks was performed to empirica...

The Development of Integrated Stroke Care in the Netherlands a Benchmark Study

Introduction: Integrated stroke care in the Netherlands is constantly changing to strive to better care for stroke patients. The aim of this study was to explore if and on what topics integrated stroke care has been improved in the past three years and if stroke services were further developed. Methods: A web based self-assessment instrument, based on the validated Development Model for Integrated Care, was used to collect data. In total 53 coordinators of stroke services completed the questionnaire with 98 elements and four phases of development concerning the organisation of the stroke service. Data were collected in 2012 and 2015. Descriptive-comparative statistics were used to analyse the data. Results: In 2012, stroke services on average had implemented 56 of the 89 elements of integrated care (range 15–88). In 2015 this was increased up to 70 elements on average (range 37–89). In total, stroke services showed development on all clusters of integrated care. In 2015, more stroke services were in further phases of development like in the consolidation and transformation phase and less were in the initiative and design phase. The results show large differences between individual stroke services. Priorities to further develop stroke services changed over the three years of data collection. Conclusions: Based on the assessment instrument, it was shown that stroke services in the Netherlands were further developed in terms of implemented elements of integrated care and their phase of development. This three year comparison showed unique first analyses over time of integrated stroke care in the Netherlands on a large scale. Interesting further questions are to research the outcomes of stroke care in relation to this development, and if benefits on patient level can be assessed.