Dr.PimP.Valentijn,PhD,MSc

@pimvalentijnMemberoftheboardDeEssenburgh

SeniorresearcherMaastrichtUniversity&MaastrichtMedical UniversityCentre

WednesdayMarch29th 2017

Evaluatingintegratedcareacrossthecarecontinuum

Objectives

1. PresentanoverviewofthedevelopmentprocessoftheRainbowModelofIntegratedCare(RMIC);

2. PresentanoverviewofthedevelopmentandvalidationprocessoftheRainbowModelofIntegratedCareMeasurementTool(RMIC-MT);

3. DiscusstheinterestonacollaborativeresearchagendaandactionplantovalidatetheRMIC-MTinItaly;

4. Determinenextsteps.

Outline

1. TheRainbowModelofIntegratedCare(RMIC)

2. TheRainbowModelofIntegratedCareMeasurementTool(RMIC-MT);I. TaxonomyII. RMIC-MT1.0III. RMIC-MT2.0

3. Furtherresearch

4. Determinenextsteps

TheRainbowModelofIntegratedCare(RMIC)

Thefragmenteddeliverysystem

NewEnglandJournalofmedicine (2010), Institute ofmedicine RANDcorp (2003)&Kodner (2009),Hoangmai etal(2007)

Differentiation,specialisation,segmentation,silomindset (i.e.,policy,regulation,financing,organisation,servicedeliveryandprofessional/institutionalculture).

Currentchallenges

1. Integratedcareisconsideredanessentialstrategytoimprovepatientexperienceofcare,healthofthepopulation andreducethecostpercapita(TripleAim)(Berwick 2009;Alderwick 2015)

2. However,thereisalackofpublisheddatatobackupthisassertion(Valentijn 2015;Nolte; 2014)

3. Informationonintegratedcaremechanismsareneededtodeterminetheaddedvalueofanintegratedcarestrategywithindifferentsettings(Porter2006;Evans2013&2014;Valentijn2015)

Integratedcare=Conceptualconfusion

Kodner (2009)

Differentperspectivesandvalues

Easyaccessandnavigation;seamlesscare

Coordinationoftasks,servicesandcareacross

professionalandinstitutionalboundaries

Improvequality,marketshareand

efficiency

Improveaccess,qualityandcontinuity

ofservices

Diseasespecificorperson-focused?!Reductionism(Diseasespecific)

Inter-determinism(Person-focused)

Implications

ThelegacyofBarbaraStarfield

Person-focusedcare

Populationbasedcare

Comprehensive&coordinatedcare

Firstcontactofcare

TheRainbowModelofIntegratedCare(RMIC)

Clinical integration Coordination of care for a complex need at stake in a single process across time, place and discipline.

Professional integrationInter-professional partnerships based on a shared accountability to deliver care to a defined population.

Organisational integration Inter-organisational partnerships based on collaborative accountability and shared governance mechanisms, to deliver care to a defined population.

System integrationCoherent set of (informal and formal) political arrangements to facilitate professionals and organisations to deliver a comprehensive continuum of care .

Valentijn (2013, 2015 and 2016)

Thecontinuumofeachdimension

Valentijn (2013)

Thehypotheses

QualityofcareAveragecosts

Segregation

Linkage

Coordination

Integration

Openingtheblackbox

Segregation Linkage Coordination Integration

Service

Professional

Organizational

Functional

Normative

System

?

TheRainbowModelofIntegratedCareMeasurementTool(RMIC-MT)

Background

1. Thereisnouniversallyacceptedframeworkandmeasurementtoolthatmeasuresthelevelofintegratedcareacrossthecarecontinuum(Valentijn2016)

2. Thelackofavalidatedmeasurementtoolthatassessesallaspectsofintegratedcare,whichhighlyimpedesthesystematicunderstandingandposessignificantchallengesforpolicymakers,commissioners,managers,professionalsandresearcherstosupporttheeffectivedeploymentandevaluation ofintegratedcareinpractice(Valentijn 2015and2016)

3. Theoverallobjectiveistodevelopandvalidate ameasurementtoolthatisshort,simpleandgenericincontentinordertomaximise itspotentialforroutineuseacrossthecontinuumofcare.

OverallstudydesignAmixed-methodapproachconsistingof:1)aliteraturereview;2)thematicanalysis;and3)threeDelphistudieswereusedtodeveloptheRMIC-MT.

• Narrativeliteraturereview&expertmeetings

METHODS

RESU

LT

Conceptualisation1

• RMIC• Valentijn etal.(2013)

Operationalization2

• Literaturereview&thematicanalysis

• Preliminarytaxonomy• Valentijn etal.(2015a)

Consensus3

• ThreeDelphistudies

• Finaltaxonomy• Valentijn etal.(2015a

and1015b)

Prototyping4

• Threepilotstudiesassessingface andcontentvalidity

• PreliminaryRMIC_MT• Nurjono etal.(2016)

andAngus(2016)

Validation5

• Threepilotstudiesassessingthepsychometricproperties

• RMIC-MT• Nurjono etal.and

Angus(2016)

Step1-3:Taxonomy

Step4-5:RMIC-MT

Step1– 3:Thetaxonomyofintegratedprimarycare

Aimandresearchobjectives

Contributetothe(ongoing)debateofdefiningandspecifyingintegratedcare:

1. RefinetheRMICbydevelopingataxonomythatspecifiestheunderlyingkeyfeatures

2. Developaconsensusbasedtaxonomybasedonnationalandinternationalexpertopinions

Studydesign

Valentijn et al. (2015)

ThreeDelphistudies• Expertswithascientificand/orpracticalbackground fieldof ICPC• RANDUCLAappropriatenessmethod Fitchetal. (2001)

- Self-administratedquestionnaire(round1)- Physicalmeetingofexperts(round2)

• Appropriateness toachieveICPC:1(completely irrelevant)to9(extremelyrelevant)

Median(1-3) Median(4-6) Median(7-9)

Round1 Agreement(≤70%) Equivocal;discussionround 2 Equivocal;discussionround 2 Equivocal:discussionround 2

Agreement(≥70%) Inappropriate; excluded afterround1 Equivocal;discussionround 2 Appropriate; included afterround 1

Round2 Agreement(≤70%) Equivocal Equivocal Equivocal

Agreement(≥70%) Inappropriate Equivocal Appropriate

Valentijn et al. (2015)

ParticipantsThreeDelphistudiesDelphistudy1(national) Delphistudy2(international) Delphistudy3(international)Round1 Round2 Round1 Round2 Round1 Round2

Noofparticipantsparticipating 14 10 16 15 8 8Dominantbackground,n(%)

Practical 7(50) 6(60) 7(44) 6(40) 4(50) 4(50)

Scientific 7(50) 4(40) 9(56) 9(60) 4(50) 4(50)

Yearsofexperience,mean(SD),range 11.6(8.8),4-40 10.9(10.3),4-40 9.5(6.7),3-25 9.5(6.9),3-25 13.4(8.6),4-25 13.4(8.6),4-25

<5 1(7) 1(10) 2(12) 2(13) 2(25) 2(25)

5-10 7(50) 6(60) 10(63) 9(60) 2(25) 2(25)

>10 6(43) 3(30) 4(25) 4(27) 4(50) 4(50)

Experiencegainedincountry,n

Australia 0 0 1 0 2 2

Austria 0 0 1 1 0 0

Belgium 0 0 2 2 1 1

ElSalvador 0 0 1 1 0 0

Germany 0 0 0 0 1 1

NewZealand 0 0 0 0 2 2

Russia 0 0 1 1 0 0

Singapore 0 0 5 5 0 0

Spain 0 0 1 1 0 0

Sweden 0 0 1 1 0 0

TheNetherlands 14 10 1 1 2 2

UK 0 0 1 1 0 0

USA 0 0 1 1 0 0

Valentijn et al. (2015)

Synthesisofresults

Valentijn et al. (2015)

Mainfindings• Clinical,professionalandorganisational integrationdomainsweremostrecognised

• Lessemphasiseswasbeingplacedonthesystemintegrationdomain

• Normativedomainas‘soft’enablerwashighly recognisedbyallexperts

Valentijn et al. (2015)

Taxonomyof21keyfeaturesMain categories and domains Description

Scope of integrated care Person-focused care

Centrality of client needs The principle of integrated service delivery is to address the needs of individual clients in terms of medical, psychological and social aspects of health

Population based care Centrality of population needs b The principle of integrated service delivery is to address the dominant needs of well-defined populations

Type of integration processes

Clinical integration Case management Coordination of care for clients with a high risk profile (e.g. identifying risks, developing policies and guidance)

Continuity Integrated service delivery aims to provide fluid the processes of care delivery for an individual client

Interaction between professional and client Attitude and behavioural characteristics between professional and client regarding all health needs of the client

Individual multidisciplinary care plan Implementation and application of a multidisciplinary care plan at the individual client level

Professional integration Inter-professional education Inter-professional education for professionals focused on interdisciplinary service delivery and collaboration

Agreements on interdisciplinary collaboration Agreements on the establishment of interdisciplinary service delivery and collaboration between the professionals

Value creation for the professional The value added by the integrated service delivery approach for the individual professional

Organisational integration

Inter-organisational governance b The governance of the integrated service model is focused on openness, integrity and accountability between the involved organisations and professionals (e.g. joint accountability, appeal on pursued policies and responsibilities)

Inter-organisational strategy Collective elaborated strategy between the organisations involved in the integrated service model

Trust The extent to which those involved in the integrated service model trust each other

System integration

Alignment of regulatory frameworks a Alignment of regulatory frameworks for teamwork, coordination and continuity of care

Environmental climate a Political, economic and social climate in the environment of the integrated service model (e.g. market characteristics, regulatory framework, and competition)

Enablers for integration

Functional integration

Learning organisations Collective learning power between the organisations involved in the integrated service model (e.g. joint research and development programs)

Information management Aligned information management systems within the integrated service model (e.g. monitoring and benchmarking systems)

Regular feedback of performance indicators Regular feedback of performance indicators for quality improvement and self-reflection

Normative integration Shared vision b Collectively shared long-term vision among the people who are involved in the integrated service model

Reliable behaviour The extent to which the agreements and promises within the integrated service model are fulfilled

Visionary leadership Leadership based on a vision that inspires and mobilizes people within the integrated service model

Linking cultures Linking cultures (e.g. values and norms) with different ideological values within the integrated service model

a Features were added at final taxonomy during the review and synthesis process b Features were merged due to identical or nearly identical content

Valentijn et al. (2015)

Step4– 5:Developmentandvalidationofameasurementtool(RMIC-MT)

Aimandresearchobjectives

Theoverallaimistodevelopandvalidate‘TheRainbowModelofIntegratedCareMeasurementTool(RMIC-MT)’toassessthemicrolevel,meso level,macrolevelandenablingaspectsofintegratedcare.Tothisend,theresearchobjectivesinclude:

1. TodeveloptheRMIC-MTusingthetaxonomy

2. ToexplorethefaceandcontentvalidityoftheRMIC-MT

3. ToexplorethepsychometricpropertiesoftheRMIC-MTindifferentpilotstudies

4. TomodifyandimprovetheRMIC-MTbasedtheresultsofthedifferentpilotstudies

TheRMIC-MT1.0

Studydesign

Literaturereviewofintegratedcareinstruments

Coredomainsanditemselection

Person-focusedcare

Population-basedcare

Clinicalintegration

Professionalintegration

Organisationalintegration

Systemintegration

Functionalintegration

Normativeintegration Pilotversion1.0

Pre-testing• Assessmentoffaceandcontentvalidity

Designcriteria• Evidenceforpsychometricproperties;• Genericcontent;and• Easytouse(e.g.minimaluserburden).

Field-testing• Testingforclarityandfeasibilityamongtargetgroups

Validationstudies• Psychometrictesting

PreliminarypilotversionRMIC-MT1.0(44items)

Domain Variable Example Items Responseoptions

Scope Person-focusedcare Interventionsareusedtopromoteclients'self-careability 5 Never(1)– Allthetime(4)Population basedcare Populationneedsareincludedintheobjectivesofthepartnership 4 Never(1)– Allthetime(4)

Type

Clinicalintegration Professionalshaveagreementsonthereferraland transfers(follow-up)ofclients 5 Never(1)– Allthetime(4)Professional integration Professionalsusemultidisciplinaryguidelinesandprotocols 6 Never(1)– Allthetime(4)Organisationalintegration Interestoftheorganizationsinvolvedareconsidered 6 Never(1)– Allthetime(4)

SystemintegrationThepartnershipishamperedbytherulesand/orpoliciessetbytheministries(e.g.Ministryofhealth) 5 Never(1)– Allthetime(4)

Enablers Functional integrationIncentivesareusedtoimproveteamwork, coordinationandcontinuityofcareamongprofessionals 7 Never(1)– Allthetime(4)

Normativeintegration Activitiesareundertakentobetterunderstandotherorganizationalcultures 6 Never(1)– Allthetime(4)

• Operationalizationofthe21keyfeatures• Focusoninter-sectorial,inter-organisational,andinter-professionalintegrationand/orcollaboration• Developedforhealthcareprofessionals,policymakers,commissioners,managers,professionals

Preliminaryfieldtestinginthreepilots

Objectives:1. Explore theusabilityofthepilot version

Conclusion• Further workneededtoimprovethe

measurementtool

TheNetherlands Australia1 2 Singapore3

Method:• Multiplecasestudydesign(23birth centre's)

Datacollection:• Self-administrated questionnaire

Results• 77%responserate(56outof73)• Easytouse

Objectives:1. Assesstheusabilityofthepilotversion2. Explore faceandcontent validity

Conclusion• Acceptablefaceandcontent validity• Needforadditional itemdevelopmentandediting

Method:• Purposivesampleof38integratedprimary

careinitiatives

Datacollection:• Self-administrated questionnaire

Results• 114respondents• Relevantandeasytouse(65%)

Objectives:1. Explore faceandcontent validity2. Explore psychometric properties

Conclusion• Acceptablepsychometric properties• Further workneededtocoverallconceptual

dimensions oftheRMIC

Method:• Purposivesampleof2RegionalHealth

Systems(theNational Healthcare GroupandtheNational UniversityHealthSystem)

Datacollection:• Self-administrated questionnaire

Results• 40%responserate(103out260)• Goodcontent andfacevalidity• Fivedistinguishable factors(43items)• Proper scalereliability (α 0.81-0.94)

Mainfindingspreliminarypilots

• Relevantandeasytouseinstrument;

• Goodcontentandfacevaliditywithindifferentsettings;

• Needforcontextualeditinganditemdevelopment;

• Goodpsychometricpropertiesforscales:clinicalintegration,normativeintegration,andperson-focusedcare;

• Furtherworkneededtoimprovepsychometricpropertiesforscales:professionalintegration,organisationalintegration,systemintegration,functionalintegration,andpopulation-basedcare;

• Patientversionishighlyneeded/recommended;

• Furthervalidationstudiesusinglargersamplesareneeded.

TheRMIC-MT2.0

TowardsandimprovedversionoftheRMIC-MT

Literaturereviewofintegratedcareinstruments*

Coredomainsanditemselection

Person-focusedcare

Population-basedcare

Clinicalintegration

Professionalintegration

Organisationalintegration

Systemintegration

Functionalintegration

Normativeintegration Pilotversion2.0

Pre-testing• Assessmentoffaceandcontentvalidity

Designcriteria• Evidenceforpsychometricproperties**;• Genericcontent;and• Easytouse(e.g.minimaluserburden).

Field-testing• Testingforclarityandfeasibilityamongtargetgroups

Validationstudies• Psychometrictesting*BasedonBautistaetal.(2016)andUijen etal(2012)andhandsearchofreferencelists.

**COSMIN(COnsensus-basedStandardsfortheselectionofhealthMeasurementInstruments)qualityscore

TheRMIC-MT2.0

• Reviewed>300integratedcareinstrumentsforhealthcarestaff(e.g.managementandhealthcareprofessionals)andpatients

• Itemdatabasestaff:170potentiallyrelevantitems

• Itemdatabasepatients:164potentially relevantitems

• Selectioncriteria:• GenericcontentperRMICdomain• Evidenceforpsychometricproperties (e.g.COSMINqualityscore)• Easetouse

TheRMIC-MT2.0StaffversionDomain Variable Example Items Responseoptions

Person-focusedcare Thinkingaboutthepatientasapersonisimportantingettingtreatmentright. 5 Stronglydisagree(1)-Stronglyagree(5)Populationbasedcare Weworkwithnonclinicianstodelivermoreeffectivehealthcare 5 Stronglydisagree(1)-Stronglyagree(5)Clinicalintegration Writtenplansandschedulesareusedforpatientreferrals,transfersandfollow-up 7 Never(1)–Always(5)Professionalintegration Multidisciplinaryguidelinesand/orprotocolsarebeingused 7 Never(1)–Always(5)Organisationalintegration Ourcliniccoordinateswithotherorganizationsintheregiontoeliminateunnecessaryduplicationofadministrativeservices4 Stronglydisagree(1)-Stronglyagree(5)Systemintegration Localhealthcarepoliciesincentivisepartnershipswithotherorganisations 5 Stronglydisagree(1)-Stronglyagree(5)Functionalintegration Outcomesaresystematicallymonitored/followed-up 11 Never(1)–Allthetime(4)Normativeintegration Peopletreateachotherwithrespect 8 Never(1)–Allthetime(4)

Scope

Type

Enablers

1.RMIC-MT2.0staffversion(52items)

PatientversionDomain Variable Example Items Responseoptions

Person-focusedcare Careproviderslistentothethingsthatmattermosttome 6 Stronglydisagree(1)-Stronglyagree(5)Clinicalintegration Mydoctoralwaysrememberswhathe/shedidduringmylastvisit(s) 8 Stronglydisagree(1)-Stronglyagree(5)Professionalintegration Careprovidersworktogetherverywell 4 Stronglydisagree(1)-Stronglyagree(5)Organisationintegration Icangetappointmentswithmyspecialistquicklyenough 6 Stronglydisagree(1)-Stronglyagree(5)

Patientpercievedcarecoordination

2.RevisedRMIC-MTpatientversion(24items)

ValidationstepsoftheRMIC-MT2.0

Phase Description Method CriteriaPhase1:Improvementofmeasurementtool

Generationofitemsbasedonsystematicreviewofmeasurementtoolsandgreyliterature

Reviewofexistingquestionnaires 1.GenericcontentperRMICdomain;2.COSMIN quality score(>1.50);and3.Easetouse(1to3score).

Phase2:Pre-testing Assessmentoffaceandcontentvalidity Multidisciplinaryexpertpanelofapp.10professionalsandapp.5-10patients(perpilot).

1.Wordingisclear;

2.Questionisredundant;and3.Relevance(4-pointLikertscale).

Phase3:Field-testing Testingforclarityandfeasibilityamongpatients.

Pilot-testingtheRMIC-MT 2.0 amongasampleofapp.50to60patients.

1.Length;2.Clarity;and3.Upsetting.

Phase4:Validation study Testingpsychometricproperties Multinationalsurveystudyamong321dialysisclinicsin20countries

1. Reliability;2. Constructvalidity;3. Concurrentvalidity

Further research

Amultinationalsurveystudy1. ToidentifytheprevalenceofperceivedunmetcarecoordinationneedsamongChronicKidneyDisease(CKD)

patients;and

2. Toassesstherelationshipbetweenadialysisclinicscarecoordinationcharacteristicsandthepatient

perceivedcarecoordinationneeds.

Practicecharacteristics Patientperceivedoutcomes

Enablingcharacteristics

• Person-focusedcare• Populationbasedcare• Clinicalintegration• Professionalintegration• Organisationalintegration

• Normativeintegration• Functionalintegration• Systemintegration

• Person-focusedcare• Clinicalintegration• Professionalintegration• Organisationalintegration

Theglobalunmetcarecoordinationneeds?!

Sampleandsetting:

• 321clinicsin20countries

• Staff(n=3000)

• Patients(n=10.000)

Discussionandnextsteps

Discussionandnextsteps

1. AreyouinterestedtovalidatetheRMIC-MT2.0intheItaliancontext?

2. Whatkindoffundingisneededtoset-upa(validation)studyinItaly?

3. Whatcouldbeourcollaborativenextsteps?

Readmore

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