International Journal of Integrated Care Feed

Supporting Aging in Place: A Relational and Preventive Approach to Integrated Care in Naturally Occurring Retirement Communities

Fri, 23 Oct 2026 00:00:00 GMT

Introduction: Naturally Occurring Retirement Communities (NORCs) offer a unique opportunity to deliver integrated care within existing housing where older adults already live. In this context, NORCs are defined as high-rise buildings where at least 50 residents and at least 30% of residents are aged 65 and above. This paper presents an implementation case study of the NORC Innovation Centre’s (NIC) integrated care model (The UHN NORC Program). Description: The UHN NORC Program partners with housing, community, health, and social care providers to enable NORC buildings to adopt community-embedded care. An interprofessional care team collaborates with residents and local organizations to co-design building-level health and wellness programs. Across two Toronto NORCs, the program engaged 60% of residents, with 14% (n = 109) referred for individualized support. Relational care practices that emphasized trust-building, advocacy, and strength-based engagement were key enablers of success, along with the team composition and structure, system partnerships, and community leadership. Discussion: This model demonstrates how integrated care can be embedded within existing housing infrastructure using a relational, team-based approach that links health, social, and community systems.

Governing for Care Integration: Evidence from Spain’s Health and Social Care

Thu, 22 Oct 2026 00:00:00 GMT

Background: Integrating health and social care is particularly challenging when responsibility is distributed across multiple levels of government and sectors, yet the governance conditions that enable or hinder integration remain poorly understood. Spain offers a valuable comparative setting: while its Autonomous Communities share a common national framework and hold responsibility for both health and social care, they have developed distinct governance models for integration. Objective and methods: We examine the multi-level governance of integrated health and social care drawing from evidence in Spain and using the TAPIC framework (Transparency, Accountability, Participation, Integrity and Policy Capacity) to identify barriers and enablers. This two-phase qualitative study covered six Autonomous Communities with established integrated care initiatives, combining six semi-structured interviews with senior regional leaders and three in-depth case studies based on document review and multi-stakeholder focus groups. Coding was deductive against TAPIC, attending throughout to how authority, resources and responsibilities are distributed across levels of government; a second, inductive stage, reported in the Methods, derived the CARE framework from the same dataset. Findings: We found substantial variation across all TAPIC dimensions, with governance weaknesses arising primarily from relationships between levels of government rather than within individual tiers. Fragmented information systems and unclear cross-sector responsibilities undermined transparency and accountability, while participation often remained procedural and failed to meaningfully engage underserved groups. Integrity challenges stemmed from blurred organisational boundaries and ethical dilemmas surrounding resource allocation and data sharing. Policy capacity varied widely, ranging from regions with strong digital infrastructure to those reliant on voluntary resources. Building on these findings, we developed the CARE framework—Collaboration, Adaptation, Resource Use and Empowerment—which translates TAPIC’s diagnostic insights into actionable governance functions. Conclusions: Multi-level governance gaps, particularly around transparency, accountability and consequential participation, continue to constrain integrated health and social care in Spain. CARE offers a practical governance framework to support implementation by strengthening collaboration, adaptation, resource use and empowerment across sectors and levels, though it is derived from a single national context and requires validation elsewhere.

Transition to ‘Close Care’ with a Joint Roadmap for Person-Centered and Integrated Care

Thu, 01 Oct 2026 00:00:00 GMT

Introduction: Health and social services face increasing fragmentation and costs, underscoring the need to transition toward more person-centered and integrated care. The Swedish government’s ‘Close Care’ [Nära vård] initiative promotes this transition by encouraging shared regional visions and roadmaps. However, translating a vision into practice remains challenging. This study aimed to explore the experiences of healthcare and social services stakeholders regarding the transition to Close Care, focusing on using a joint roadmap. Methods: This qualitative study included three focus groups with 19 regional healthcare and municipal social service representatives, analyzed using reflexive thematic analysis. Results: Four main themes summarize the findings: 1) A rocky road toward Close Care; 2) A patchwork of Roadmap practices; 3) Navigating ambiguity: defining and positioning the roadmap; 4) Mobilizing shared meaning for Close Care and the roadmap. Discussion: A growing understanding, awareness, and engagement with Close Care is demonstrated, although challenges, including limited cross-organizational leadership and dialogue, remain. Participants reported varied familiarity and strategic document use with the roadmap, which was often considered vague or irrelevant for actionable guidance. Conclusion: Roadmap clarity, linked to measurable indicators, and strategic leadership and dialogue are required to strengthen relational coordination and transition toward more person-centered and integrated care.

Early Implementation of Collaborative Care in France: Facilitators and Barriers from the First Year of the SESAME Program

Thu, 01 Oct 2026 00:00:00 GMT

Background: The Collaborative Care Model (CoCM), which integrates mental health services into primary care through a team-based approach involving GPs, care managers (CM), and mental health consultants, is a proven way to meet these challenges. A first CoCM adaptation in French primary care settings called SESAME has been implemented since 2021. Methods: Semi-structured interviews were conducted with all the healthcare professionals involved in SESAME to examine the facilitators and barriers experienced during the first year. Data were analyzed using a qualitative approach combining manual thematic analysis and lexicometric analysis with ALCESTE software. Results: Four discourse classes emerged from the analysis. Key facilitators included prior collaborative experience, effective digital communication tools, and clear role understanding. Barriers such as technological challenges, role ambiguity, and referral framework misunderstandings were also identified. The structured inclusion process and rapid access to care were appreciated, but challenges persisted in referral processes and role boundary definitions. Financial coverage and a less stigmatizing approach were seen as benefits. Conclusion: This study provides insights into the early implementation dynamics of CoCM in a novel context, underscoring the need for clear protocols, ongoing communication, and tailored support to ensure successful integration of mental health services into primary care. Résumé Contexte: Le modèle de soins collaboratifs (Collaborative Care Model, CoCM) intègre les soins de santé mentale en soins primaires au sein d’équipes pluridisciplinaires associant médecins généralistes, infirmiers de coordination (care managers, CM) et professionnels de santé mentale consultants. Il constitue une approche éprouvée pour répondre à ces enjeux. En France, une première adaptation de ce modèle, le projet SESAME, est déployée en soins primaires depuis 2021. Méthodes: Des entretiens semi-directifs ont été menés auprès de l’ensemble des professionnels de santé impliqués dans SESAME afin d’examiner les facilitateurs et les obstacles rencontrés au cours de la première année de mise en œuvre. Les données ont été analysées selon une démarche qualitative combinant analyse thématique manuelle et analyse lexicométrique à l’aide du logiciel ALCESTE. Résultats: Les résultats ont mis en évidence quatre classes de discours. Les principaux facteurs facilitants concernaient une expérience préalable de collaboration, l’utilisation d’outils numériques de communication efficaces et une bonne compréhension des rôles. Les obstacles relevaient de difficultés techniques, d’ambiguïtés persistantes dans la définition des rôles et d’incompréhensions concernant les modalités d’inclusion et d’orientation dans le dispositif. Le caractère structuré du parcours d’inclusion et la rapidité d’accès aux soins ont été largement appréciés, mais des tensions persistaient autour des processus d’orientation et des responsabilités professionnelles. La prise en charge financière du dispositif ainsi que son caractère moins stigmatisant ont également été identifiés comme des bénéfices. Conclusion: Cette étude apporte des éclairages sur les dynamiques précoces de mise en œuvre d’un modèle de soins collaboratifs en santé mentale en soins primaires dans le contexte français. Elle souligne la nécessité de protocoles clairs, d’échanges réguliers entre professionnels et d’un accompagnement adapté pour soutenir l’intégration des soins de santé mentale en soins primaires. Mots-clés: modèle de soins collaboratifs; recherche en implémentation; soins primaires; facilitateurs et obstacles; prise en charge de la dépression et de l’anxiété

The “Iron Triangle” of Healthcare Services: Evaluating an Integrated Healthcare Alliance’s Impact on Primary Care in Shenzhen, China

Wed, 30 Sep 2026 00:00:00 GMT

Introduction: In response to the challenges of inequitable healthcare access and underdeveloped primary care systems, integrated care reforms have emerged as a promising solution. This study examines the effectiveness of one such reform, i.e. the establishment of a cross-regional, tightly integrated healthcare alliance (specifically an urban healthcare group) in the resource-constrained Dapeng District of Shenzhen, China. We assess its impact on service delivery performance through the lens of three core health system objectives: accessibility, quality, and affordability. Methods: We utilised longitudinal data from 2012 to 2023 and defined seven indicators aligned with the three core health system goals: accessibility, quality, and affordability. Both annual and quarterly data were used, with quarterly data applied to the interrupted time-series analysis. We employed an interrupted time-series analysis (ITSA) to estimate both immediate level changes and subsequent slope changes in the trends. Serial autocorrelation was assessed using the Durbin-Watson (DW) test. Where autocorrelation existed, we used Prais–Winsten generalised least squares (GLS) to ensure robust estimation. Furthermore, we analysed bidirectional referral data to corroborate the effectiveness of the hierarchical diagnosis and treatment system. We also incorporated per-capita medical expenditure, drawn from district administrative records, to track affordability trends over time. Results: The reform was associated with significant improvements across quality, accessibility, and affordability. The capacity of local healthcare institutions to manage severe and complex conditions was substantially enhanced, reflected in significant post-reform trend increases in both Level III/IV surgeries (β3 = 14.498, p < 0.001) and Type C/D cases (β3 = 51.743, p < 0.001). Accessibility improved notably through expanded bed capacity, with a significant increase in beds per 1,000 population (β3 = 0.031, p < 0.01). Physician and nurse densities showed significant immediate-level increases at the reform point, but their post-reform trend changes were not statistically significant. Affordability also improved, including immediate increases in the proportion of medical insurance patients (β2 = 0.085, p < 0.05) and the proportion of medical income from medical insurance (β2 = 0.113, p < 0.01). Furthermore, both outpatient and inpatient unit costs in Dapeng remained consistently below the Shenzhen citywide average and exhibited slower growth rates. Finally, the hierarchical care system showed strengthened performance, exemplified by a marked increase in the share of consultations delivered by community health centres (CHCs) from 28.13% in 2019 to 55.43% in 2023. Conclusion: The integrated urban healthcare group model effectively strengthened primary care delivery in a resource-limited setting, achieving concurrent improvements in access, quality, and affordability. However, the gains in human resources were mainly immediate rather than sustained, suggesting that persistent workforce constraints can limit the translation of infrastructure expansion into long-term accessibility improvements. The experience of Dapeng, Shenzhen, China, offers valuable and transferable insights for health systems in comparable contexts seeking to implement integrated care reforms.

The Influence of Community-Based Integrated Care on the Physical and Mental Health of Older Adults: Evidence from China

Wed, 30 Sep 2026 00:00:00 GMT

This study examined the association between community-based integrated care and older individuals’ self-rated health, physical health, and mental health. The core components of community-based integrated care services include four major components: daily care, medical services, health services and psychological support. The study used data from the 2018 Chinese Longitudinal Healthy Longevity Survey (CLHLS). The study employed a rigorous methodological framework to mitigate potential endogeneity biases, integrating ordinary least squares (OLS) regression with propensity score matching (PSM) and an instrumental variables (IV) approach. This multi-method design aimed to address both observed confounders and unobserved heterogeneity or reverse causality, thereby enhancing the robustness of causal inferences. The results of the study suggest that older persons who received community-based integrated care were associated with better self-rated health, physical health, and mental health than those who did not receive it. Overall, community-based integrated care was associated with greater health benefits among older persons aged 80 and above, women, older people living alone, and older people who reside in rural regions. Community-based integrated care is positively associated with the health status of older people, and a higher degree of community-based integrated care is associated with better physical and mental health among older people.

Understanding the Impact of Integrated Care

Mon, 21 Sep 2026 00:00:00 GMT

Seventy-eight role titles and inconsistent role scopes: Can we consolidate, streamline and create professional identities for care navigators?

Mon, 21 Sep 2026 00:00:00 GMT

Background:A growing workforce is being employed to assist patients and clients in navigating between health and social care providers. These professionals operate under various care models including care navigation, social prescribing, and care coordination. An evidence synthesis is needed to better understand role scopes, experiences, and enablers and barriers of embedding these roles in the health and social care systems. Methods: An umbrella review of reviews of five databases (MEDLINE, Embase, CINAHL, Scopus, PsycINFO) were searched to May 2024. Reviews were included if they discussed the role or function of workers who were employed to coordinate services involving health and social care to support clients with complex needs. Reviews on volunteer coordinators or link workers were excluded. A qualitative thematic data synthesis approach was used to determine the key evidence themes. Although there was no public or patient involvement, we sought advice from link workers affiliated with a not-for profit organisation that provides link worker services. Results: Twenty-six review articles were included, representing 824 unique primary peer-reviewed sources (1). Seventy-eight unique role titles were used to describe care navigators, which aggregated under seven role categories: Patient Navigator, Link Worker, Care Coordinator, Case Manager, Social Prescriber, Intermediary, Health Mediator, the most common being Patient Navigator and Link Worker. At least 20 task domains were identified, mostly related to care navigation, building service users’ capacity for self-management, and providing person-centred care, goal setting, motivational and emotional support, and education. Patient Navigators more frequently provided motivational and emotional support, client education, care planning and clinical tasks, while Link Workers most frequently provided navigation and linking services with community supports, helped with practical tasks such as accompanying clients to appointments, appointment coordination, cultural or language interpretation. Barriers of implementing navigator roles included unstable funding models; unclear role descriptions, role scope and role boundaries, often leading to burnout. There was also limited shared infrastructure e.g. medical records platforms, guidelines and training courses; limited professional networks or communities of practice, unclear referral pathways and limited understanding among other professionals about of the link worker role scope. Enablers included clear role descriptions, tailored training and support networks, lived experience or deep understanding of the population being served and local resources that could support clients. Personal attributes that enhanced experiences included high levels of health literacy, ability to explore client needs within context, communication and rapport-building skills. Conclusion: s:Interchangeable role titles and overlapping role scopes and tasks create complexity for service users, providers, and researchers. Developing professional identities, training, and strategies to seamlessly embed such roles into existing health and social care structures are needed. Reference: Wijekulasuriya S, Wahlstrom L, Lewis S, Triandafilidis Z, Rojas C, Goodwin N, Semkina A, Boaz A, Norrie C and Zurynski Y. (2025) Working between systems: an umbrella review of care navigator roles and responsibilities. Front. Health Serv. 5:1632307. doi: 10.3389/frhs.2025.1632307

Assessing general practitioners’ perceived self-competence in applying Population Health Management (PHM) as an indicator of PHM implementation.

Fri, 11 Sep 2026 00:00:00 GMT

Background: Population Health Management (PHM) is increasingly implemented in routine clinical practice as healthcare systems aim to achieve the quintuple aim outcomes. As a proactive and data-driven approach, PHM utilizes data on health and social determinants of health to identify population needs and risk profiles, facilitating earlier and more targeted interventions. This study introduces a self-efficacy questionnaire designed to evaluate general practitioners’ (GPs) perceived self-competence in performing PHM-related tasks, based on their knowledge and skills, as a proxy for the evaluation of PHM implementation. Approach: A qualitative approach was employed to develop questionnaire items assessing GPs’ perceived self-competence in performing PHM-related tasks, serving as a proxy for PHM implementation in general practice. A focus group comprising nine experts – including PHM implementation and evaluation specialists as well as GPs – collaboratively co-designed the questionnaire. Key PHM competencies were identified and translated into specific actions, supported by relevant national and local GP-specific examples of PHM. Thematic analysis was used to structure the items, with actions framed as: “To what extent do you consider yourself capable of…”. The questionnaire has been refined based on feedback from GPs actively integrating PHM into their routine clinical practice. Results: Six PHM themes, encompassing 21 competencies and 31 actions, were defined for assessing perceived self-competence in PHM implementation in primary care: 1) using electronic medical records for documentation, care planning, … (Nactions = 4); 2) population identification using health and contextual data (N=2); 3) evaluating practice performance with evidence-based indicators (N=9); 4) aligning practice policy with patient needs (N=2); 5) proactive, personalized communication (N=5); and 6) multidisciplinary collaboration, including digital documentation and referrals (N=9). Each competency was linked to actions and GP-specific examples of PHM, reflecting the diverse skill set needed for effective PHM. Implications: By specifying PHM-related competencies and corresponding actions, the results of this self-efficacy questionnaire – designed to assess GPs perceived self-competence in performing PHM-related tasks – serve as a proxy for evaluating PHM implementation in primary care. The questionnaire’s comprehensive scope reflects both the complexity and evolving nature of PHM. Completing the questionnaire enables assessment of the current state of PHM implementation and the identification of specific challenges encountered in practice. These insights can inform policymakers, implementation scientists, educators, and healthcare professionals about areas where primary care providers experience difficulties, thereby supporting the development of targeted educational and implementation strategies to address identified knowledge and skill gaps. Although the current examples of PHM initiatives are tailored to the Belgian GP context, the generically defined competencies and actions support broader applicability. The tool can be adapted to evaluate PHM implementation by other primary care professionals by linking discipline-specific examples to the existing competencies and actions. For international application, it can be customized by contextualizing these examples to align with local healthcare systems. In both cases, consultation with an expert panel is recommended to ensure content validity.

Aspace Digital Care: A Data-Driven Platform for Integrated and Person-Centred Support in Complex Disability Care

Fri, 11 Sep 2026 00:00:00 GMT

Introduction: Fundació Aspace Catalunya, a non-profit organisation within the Catalan SISCAT network, supports people with complex disabilities and neurodevelopmental disorders through integrated social, health and educational services. Fragmented records and disconnected communication across systems limited coordination, continuity and preventive care. To address this, Aspace Catalunya developed Aspace Digital Care—a comprehensive digital ecosystem that unifies all organisational information under a single electronic social, educational and health record (ESEHR). The project integrates internal digital processes and a mobile app designed to enhance prevention, participation and communication between professionals, users and families. This initiative aligns with the Catalan Integrated Social and Health Care Strategy and the WHO’s Integrated People-Centred Health Services framework. Methods: The project was co-designed through participatory methodologies involving professionals, families and people with lived experience. It followed four main phases: (1) Process mapping and needs assessment to identify fragmentation and inefficiencies in communication, documentation and follow-up; (2) Digital ecosystem design combining organisational management tools with a unified ESEHR, ensuring interoperability; (3) Development of a mobile application to facilitate user engagement, symptom monitoring and preventive alerts; and (4) Implementation and evaluation across residential, day care, early intervention and outpatient neurorehabilitation services. A multidisciplinary digital governance board oversaw implementation, and iterative testing cycles allowed for continuous improvement. Quantitative indicators (efficiency, coordination, time use) and qualitative data (user satisfaction, professional experience, participation) were collected to assess impact. Results: The introduction of Aspace Digital Care has led to a substantial organisational and cultural transformation. The unified record enables real-time access to person-centred information across disciplines, facilitating consistent and coordinated decision-making. Digitalised workflows have reduced administrative burden and improved traceability of actions, allowing professionals to dedicate more time to direct support. The mobile app empowers families and users to actively participate in their care journey, fostering transparency, communication and co-responsibility. Preventive alerts and dashboards support early identification of health or social risks, enabling timely, data-informed interventions. Moreover, the digital system provides management teams with aggregated insights that enhance planning, evaluation and value-based decision-making across services. Conclusion: Aspace Digital Care demonstrates how a unified electronic social, educational and health record can serve as a foundation for truly integrated, preventive and person-centred care. The initiative represents a replicable model for digital integration in complex disability contexts, advancing equity, efficiency and participation across social and health ecosystems.

Building an evidence base for the use of Advice and Guidance Referrals at the primary-secondary care interface: multistage mixed-methods study

Fri, 11 Sep 2026 00:00:00 GMT

Background: Advice and Guidance (A&G) was introduced in NHS primary care to reduce waiting times for elective care and improve access to specialist input without the need for an outpatient referral. However, its impact on care pathways and equity remains unclear, especially for underserved populations. Approach: This mixed-methods study included analysis of 16.3 million patients’ primary care electronic health records from the Clinical Practice Research Datalink (CPRD) Aurum (2015–2023) to compare trends in A&G and direct referrals stratified by demographic factors (age, gender, deprivation, ethnicity, and commissioning locality). Qualitative interviews with 20 primary care clinicians explored decision-making around A&G use, analysed using reflexive thematic analysis. Patient and public involvement (PPI) contributors were involved throughout: co-applicant roles, protocol development, topic guides, and interpretation of findings. Community conversations with seldom-heard groups informed dissemination and equity framing. Results: Recorded A&G use rose 19-fold (0.1% to 2.0% of the registered population) from 2015 to 2023, peaking during the pandemic. Direct referrals fell in 2020 but recovered to 24% of the registered population receiving a referral in 2023. Cardiology, dermatology, and ENT were the most common A&G specialties. Most patients receiving A&G (86%) also had a direct referral within ±4 months - often preceding A&G - suggesting A&G adds steps rather than replaces referrals. Disparities were evident: A&G was recorded more frequently for older, white, and less deprived patients, while minority ethnic groups experienced slower recovery in referral rates. Regional variation was substantial, but higher A&G use did not correlate with reduced referrals. Interviews revealed four key influences on A&G use: patient presentation, clinician experience of using A&G, balancing potential patient benefit with clinician workload, and the clinical need for specialist input. Clinicians valued A&G for supporting the management of patient with complex clinical needs and navigating unclear boundaries between primary and secondary care, but raised concerns about service availability, transfer of costs, and inconsistent policies. PPI contributors shaped the study’s equity lens, identified barriers such as digital exclusion and transport, and co-produced dissemination materials. Implications: A&G has not displaced direct referrals and may introduce inefficiencies. Its disproportionate use among advantaged groups risks widening health inequalities. To align with NHS goals of integrated, equitable care, A&G processes should consider efficiency across systems, routinely monitor for equity, and be supported by investment in primary care capacity. These findings offer transferable insights for international delegates exploring digital referral systems, outpatient reform, and strategies to reduce access disparities.

Bridges of Health: Culturally Relevant Hospital Care Program for Indigenous Communities in the Chirripó District, Turrialba

Fri, 11 Sep 2026 00:00:00 GMT

Background: In Costa Rica, the Cabécar Indigenous communities of the Chirripó district face significant geographic, linguistic, and cultural barriers to accessing specialized health services. In response, the William Allen Taylor Hospital developed the Bridges of Health program—an institutional strategy designed to ensure comprehensive, humanized, and culturally relevant care for this population. Approach: The program combines intramural and extramural actions, linking hospital services with Indigenous communities, local leaders, development associations, and both governmental and non-governmental organizations. Key components include: monthly extramural specialized consultations in Chirripó (pediatrics, gynecology, dermatology, social work, psychology, nutrition, and obstetric nursing); community health fairs open to all insured persons; hiring of Cabécar interpreters; educational materials and hospital signage in the Cabécar language; dietary adaptations for hospitalized patients according to their customs; and staff training in Cabécar culture and language. Coordination with local associations, the Turrialba Health Area, and the Ministry of Public Education ensures access to venues, transportation, lodging, and accompaniment. Planning involves participatory diagnosis, co-design with community leaders, impact evaluation, and continuous feedback with the beneficiary communities. Results: Between the first semester of 2023 and the first semester of 2025, there was a steady increase inthe number of Indigenous patients served by the hospital. In emergency services, attendances rose from 909 users (2.77%) in 2023 to 1,531 (3.44%) in 2025; in outpatient consultations, from 1,836 (2.18%) to 3,207 (3.11%); and in hospitalizations, from 338 to 453 cases—reflecting greater trust in hospital services. Absenteeism slightly increased from 5.33% to 6.5%, linked to the overall rise in appointments granted. Regarding childbirths, Indigenous users increased from 25.58% (2023) to 30.87% (2025); cesarean rates dropped from 10.81% to 7.44%, while out-of-hospital deliveries rose from 18.91% to 22.31%, indicating closer ties with the hospital even after delivery. For extramural care, between August 2024 and the first half of 2025, the following increases were recorded: Gynecology and Obstetrics: from 80 users (2024) to 108 (2025). Social Work: from 27 (2024) to 48 (2025). Adolescent Care Program: from 100 (2024) to 103 (2025). In 2025, consultations were also provided in the Lactation Clinic (6 users), Pediatrics (33), and Audiology (100 users aged 0–4 years). Community health fairs expanded their coverage from 252 users (April 2024) and 283 (October 2024) to 315 (May 2025) and 435 (August 2025), with a third fair scheduled for November 2025. This trend confirms the effectiveness of the Bridges of Health intramural–extramural model, which has brought specialized medical services closer to indigenous communities, reduced geographic and cultural gaps, and strengthened users' trust in hospital care. Implications: Bridges of Health is a replicable experience in culturally diverse settings, demonstrating how hospital care can evolve into an inclusive and collaborative model. Its culturally relevant approach promotes health equity, strengthens institutional management, and fosters community participation—improving the quality of life of historically vulnerable populations. It offers lessons on integrating Western medicine with Indigenous worldviews within a single care system, building a human bridge between cultures, and consolidating comprehensive and respectful healthcare.

Advancing Integrated Health and Social Care in Wales: Evidence for Change and Sustainability

Fri, 11 Sep 2026 00:00:00 GMT

Background: The Welsh Government’s Regional Integration Fund (RIF) is a five-year, £146 million programme (2022–2027) aimed at embedding inclusive, innovative models of integrated health and social care within a national Integrated Community Care System (ICCS). Central to this transformation is a robust data and reporting framework that ensures transparency and accountability across Wales’ seven Regional Partnership Boards (RPBs). Approach: Welsh Government RIF Outcomes Framework, co-developed with RPBs, comprises 20 core measures designed to evaluate progress in delivering integrated care and its impact on individuals and communities; understanding the difference made to people. These measures reflect the principles and values of A Healthier Wales (2018), including person-centred care, prevention, seamless service delivery, a strong commitment to diversity and inclusion and having a shared vision across sectors. The framework captures both quantitative and qualitative data, focusing on individual wellbeing, system performance, cost-effectiveness, and workforce development. It applies across priority population groups: older people, children and young people with complex needs, individuals with learning disabilities and neurodevelopmental conditions, unpaid carers, those with emotional and mental health needs, and care-experienced children and families. To support consistent evaluation, a technical handbook was developed, guiding data collection using a modified Results Based Accountability™ (RBA) approach. Delivery partners also use tools such as “distance travelled” metrics and case studies to demonstrate impact, particularly in diverse community settings and how people are enabled to remain at home at long as possible and when in a hospital setting are discharged in a timely manner with support. Results: Structured reporting aligned with RBA has enabled consistent, meaningful evaluation across RPBs while allowing flexibility to reflect local contexts. This balance has strengthened monitoring and supported the development of sustainable, evidence-informed models of care. Emphasis on data quality has been central—not as a bureaucratic exercise, but as a foundation for learning, adaptation, and continuous improvement. The 20 core measures are dynamic tools for change. Informed by stakeholder feedback, they evolve with the programme, ensuring integrated care is not only delivered but continuously refined. These measures are shaping policy, guiding investment, and driving better outcomes through co-designed services that reflect the needs and voices of diverse communities. Implications: RIF has played a pivotal role in reshaping service delivery and improving population health outcomes across Wales. Its long-term success depends on how deeply integrated approaches become embedded in everyday practice. The structured use of core measures offers a robust, outcomes-focused evaluation framework with international relevance. By fostering cross-sector collaboration, enhancing transparency, and promoting evidence-informed decision-making, the RIF provides a scalable blueprint for other nations seeking to transform health and social care. Its emphasis on shared accountability, inclusive service design, and improved data quality and use strengthens the foundation for sustainable integration across health and social care. Ultimately, RIF’s approach supports the vision of integrated community care as a standard in public service delivery—responsive to the needs of all individuals and communities.

Co-designing the health and care workforce future: testing the European Skills Strategy for digital and green upskilling and reskilling

Fri, 11 Sep 2026 00:00:00 GMT

Context: Europe’s health and care systems are under increasing pressure to adapt to digital transformation, the green transition, and the shift towards integrated, person-centred models of care. These transitions require not only technological and organisational change, but also a workforce equipped with the right mix of technical, transversal and system-level skills. The BeWell project (Erasmus+ Blueprint Alliance, 2022–2026) addresses this challenge by developing a European Skills Strategy for the health and care workforce. The strategy aims to support workforce sustainability, quality of care and system resilience by embedding digital and green skills across education, training and lifelong learning pathways. Methods: BeWell applies a system-wide, participatory, and evidence-informed approach to skills development. The project combines desk research, policy analysis, and skills intelligence with extensive stakeholder engagement across Europe. Methods include pan-European surveys, interviews and workshops involving health and care professionals, managers, educators, policymakers, social partners, and patient and community representatives. These inputs informed the co-creation of a Skills Strategy structured around priority competence areas, implementation enablers, and governance mechanisms. Particular attention was given to ensuring relevance across different care settings, including integrated and community-based care, and across national and regional contexts. Iterative validation cycles were used to refine the strategy, ensuring alignment with EU policy priorities, labour market needs and existing education and training frameworks. Results:The BeWell project has produced a draft European Skills Strategy for the health and care workforce, identifying priority digital and green competences alongside transversal skills such as interprofessional collaboration, leadership, and change management. Results highlight significant skills gaps related to digital health adoption, data use, sustainability practices, and integrated care delivery. The consultations revealed strong demand for clearer skills frameworks, better alignment between education and practice, and improved access to continuous professional development. The strategy proposes concrete implementation pathways, including curriculum updates, modular training, micro-credentials and stronger links between health, social care, and education sectors. By June 2026, the final version of the strategy will be ready for testing and adoption across multiple European contexts. Discussion: The BeWell Skills Strategy demonstrates how skills development can act as a lever for health system transformation, supporting digitalisation, sustainability, and integrated care simultaneously. By grounding the strategy in stakeholder experience and policy realities, BeWell bridges the gap between European ambitions and local implementation. The findings underline the importance of coordinated action across sectors and governance levels, as well as sustained investment in lifelong learning and workforce well-being. While the diversity of European health systems poses implementation challenges, the flexible and modular nature of the strategy allows adaptation to different contexts. The BeWell approach offers a transferable model for aligning workforce skills with system reform, contributing to more resilient, inclusive, and future-ready health and care systems in Europe and beyond.

Beyond Coordination: Exploring Articulation Work Across People and Technologies in Chronic Condition and Mental Health Care

Fri, 11 Sep 2026 00:00:00 GMT

Background: Integrated care depends not only on coordination across systems but on the articulation work that makes coordination possible. This includes the ongoing, often invisible effort required to align people, information, and processes across settings and systems. For those living with chronic conditions and co-occurring mental health challenges, this articulation work is continuous, complex, and emotionally demanding. The Technology-Enabled Collaborative Care (TECC) program was designed to make this work visible and supported through technology-enabled, team-based, compassion approaches to care. Approach: This presentation synthesizes learning from multiple TECC research streams, including two completed feasibility trials (TECC-DM for adults living with type-2 diabetes; and TECC-T1D3 for young adults living with type-1 diabetes), a province-wide cross-sectional survey, an ongoing hybrid implementation effectiveness trial, and two evidence syntheses. Across this program of work, mixed methods approaches explored how human and digital actors share and sustain the relational, cognitive, and organizational work of integration. The focus of this combined analysis is on the potential of human and artificial intelligence partnerships to support and redistribute the articulation work required to deliver coordinated, compassionate care for people living with chronic conditions and mental health challenges. People with lived experience of chronic conditions and mental health challenges, peer supporters, care providers, and researchers worked collaboratively to co-design intervention components, digital approaches, and evaluation metrics. Individuals with lived experience contributed throughout the design, implementation, and interpretation phases of research, with this inclusive and iterative approach supporting adaptation of the TECC model to diverse contexts and populations. Results: Across TECC iterations, technology emerged as relational infrastructure – a mechanism that amplifies, rather than replaces human coordination. Findings reveal that while some individuals benefit from high-touch, relationship-driven support, others may benefit from low-touch, technology-facilitated options that offer autonomy, flexibility, and ease of access. Asynchronous communication and chatbot availability was viewed positively for sustaining engagement between sessions, extending the reach of care teams, and offering responsive support that complemented, rather than competed with, human-facilitated integration . Across studies, participants described connectedness to care and community as both an outcome and essential contributor to wellbeing. Findings reinforce that digital and AI tools hold promise in redistributing articulation work by reducing administrative burden, enhancing communication pathways, and supporting proactive, coordinated care, when implemented ethically and equitably. Across all sources of evidence, and regardless of delivery mode or context, care integration was ultimately sustained through relational trust and shared understanding. Implications: Findings from this program of work contribute to an emerging understanding of technology-enabled care as a partnership between human and AI that collectively performs the articulation work of integration. These insights advance theoretical and practical understanding of how coordination is enacted in everyday care and highlights transferable lessons for health systems internationally.

A Practical Evaluation of Real-Time Compression Feedback in Routine Venous Leg Ulcer Management

Fri, 11 Sep 2026 00:00:00 GMT

Background: Maintaining effective compression remains a major practical challenge in venous leg ulcer (VLU) management. Digital health innovations now enable real-time monitoring, creating opportunities to move toward tailored support and patient-centred solutions that sustain therapeutic pressure and adherence, improving outcomes. Approach: A service evaluation was conducted during a ten-month period. A CE-marked, multi-point wireless pressure monitoring system (Tight Alright, FeelTect Ltd.) was integrated into routine compression therapy. Seventeen patients (23 limbs) with chronic VLUs received digitally guided care targeting 40–60 mmHg, if tolerated, with live pressure feedback through a connected app and remote data transmission to the clinical team. Patients and carers were trained to use the app to check daily pressure readings, receive automated feedback on compression levels, and apply ‘top-up’ bandages when pressure dropped below target thresholds. This process equipped participants with actionable skills and personalized care plans to sustain optimal compression between clinic visits. Results: Engagement and adherence were high, with an average of 1.7 pressure transmissions per day. Therapeutic pressure targets were successfully maintained (mean 40.3 ± 6.1 mmHg), and 83% of limbs achieved ≥50% wound area reduction within four weeks. Complete healing was achieved in 82.6% of limbs within 12 weeks (mean 58 days). The technology was well accepted, and more than half of participants (56%) self-adjusted their compression, independently or with the help of carers, using the digital guidance provided. Implications: This evaluation showed that real-time compression feedback can fit smoothly into routine care. Involving patients and carers directly, giving them clear feedback, and allowing them to top-up compression when needed helped maintain effective therapy in practice. The approach was practical, acceptable, and gave participants a more active role in their treatment. Conflict of interest statement: This work was supported by Feeltect, which provided funding and the devices used. The co-author Dr Manuel Villegas-Martinez is an employee of Feeltect.

Building Critical Thinking in Unregulated Care Providers to Support Sustainable Community Placements

Fri, 11 Sep 2026 00:00:00 GMT

Background: Community service providers are often tasked with transitioning individuals out of hospital and maintaining their safety and quality of life in the community. Many community-based organizations rely on an unregulated care provider (UCP) model, with limited access to regulated health care providers (RHCPs). Clients are living longer with chronic conditions, requiring a higher demand for more sophisticated community-based care, but without regular access to RHCPs. Approach: This presentation outlines a case study from Head Injury Rehabilitation Ontario (HIRO), which piloted two models to address this challenge. HIRO’s Clinical Roadmap was co-designed in 2019 with professionals, family members, and persons with lived experience of acquired brain injury; recommendations included inserting clinical guidance for the primarily UCP care model. Over the last several years HIRO has been implementing the model; initially, HIRO trialed a consultative model where an Occupational Therapist (OT) completed goal assessments for individuals with acquired brain injury (ABI), and delegated implementation to UCPs. Outcomes were limited due to gaps in critical thinking and confidence among UCPs, and a lack of ongoing clinical oversight resulting in little sustainability. In response, HIRO launched a second pilot embedding weekly access to OT to both support client assessment, and deliver structured critical thinking training to 19 UCPs across 8 sites. This training emphasized goal-oriented reasoning, adaptive implementation, and collaborative care planning - all skills within the public domain and not requiring regulatory authority. Qualitative analysis of outcomes for clients and staff, and quantitative review on staffing ratios and levels of supports, are underway and intended to be completed for January 2026. Results: Preliminary findings indicate higher measures of client satisfaction, and improved goal attainment by clients. This has resulted in increased client independence, consequentially requiring less staff support particularly during morning routines. Secondary findings indicate increased staff job satisfaction, potentially contributing to stay intentions in a difficult human resources market. While final quantitative and qualitative analyses are forthcoming, early evidence supports the feasibility and impact of investing in critical thinking development among UCPs. Implications: This case study at HIRO challenges the assumption that high-quality care must rely solely on RHCPs, and highlights a scalable model for optimizing unregulated workforce capacity in community settings. Clear role distinction between regulated tasks and skills versus public domain skills (e.g. critical thinking, escalation chains, and risk management) allows for enhanced workforce development to support sustainable community placement. Other community settings that have a primarily unregulated workforce would benefit from this work, and/or RHCPs may be inspired to better utilize their unregulated colleagues.

Climate Resilience for Better Health: A Co-Designed Community Initiative

Fri, 11 Sep 2026 00:00:00 GMT

Background: In Summer 2023, Canada experienced one of the worst wildfire seasons in the nation's recorded history resulting in dangerous air quality. Each summer since 2023, communities have faced the challenge of worsened air quality and extreme heat; a reality that is especially challenging for individuals exposed to the elements, living with respiratory illness, or in homes without air conditioning (> 500,000 Toronto residents). Approach: The West Toronto Ontario Health Team (WTOHT) facilitated a community co-design event in partnership with Humber College to improve population health through climate resilience. Over one weekend, community members contributed more than 1,000 hours while working in teams to develop and pitch their ideas. One of the community interventions implemented by the WTOHT was distributing Climate Resilience Kits, which consist of an air purifier, a snake plant, and window treatment to reduce in-home temperatures. The WTOHT worked across the health and social care sector to connect high-risk community members to this intervention. Results: Climate Resilience Kits were distributed to over 300 households reaching over 1,000 individuals in West Toronto. Recipients reported reductions in in-home temperature as high as 10⁰C and a near 100% recommendation rate for the kit. Primary care providers reported the Climate Resilience Kit being most relevant for older adults at risk of heat stroke, individuals living without air conditioning, and individuals managing a respiratory illness. Implications: Strengthening community resilience in the face of the climate crisis is essential for any health system looking to prioritise prevention and community-based care. Equitable health outcomes, in particular, are threatened by the climate crisis as evidenced by the disproportionate health burden carried locally by low-income and unhoused residents. As a next step, West Toronto residents expect to see interventions co-created with community members to address food insecurity, the connected mental health effects of the climate crisis, and to curb the health system's carbon emissions and waste creation.

Care and well-being via a screen: Can tablets really make a difference for frail older people living at home?

Fri, 11 Sep 2026 00:00:00 GMT

Background: In the Netherlands, the current policy states ‘self if possible, at home if possible, digital if possible’. This policy aims to provide older people with good and affordable care and support in the future, if needed. Care and social support are under pressure due to the increasing number of older people, while the number of care providers is not growing with them. Approach: In response to this policy, a project in the Amsterdam region sought to explore the feasibility and effectiveness of integrated digital care through the Compaan table. Two nursing care facilities and one social care facility decided to join forces and deliver nursing and social care via a tablet, the Compaan. The Compaan is a safe, user-friendly tablet for remote care, designed for people without digital experience. It offers easy access, security, and enjoyment. In 2019, the three organisations established the Interprofessional Learning and Innovation Network (IP-LIN) with a University of Applied Sciences. This learning community brought together nursing and social work students, professionals, and teachers to co-learn, conduct research, and develop digital care interventions, via the Compaan. Between 2023 and 2025, we devised, tested, and evaluated two digital integrated care interventions in the IP-LIN using an action research approach with quantitative and qualitative data. Participants included students, professionals, project leaders, trainers, managers, and older adults living at home. Two interventions were suitable for implementation: the digital half-hour exercise session and the digital welfare button. Results: The first research cycle initiated the digital project in the IP-LIN. In subsequent cycles, integrated care innovations with the Compaan began. The developed digital half-hour exercise session proved particularly successful and is still being offered on a weekly basis. Clients rated it with an average score of eight out of ten and reported improved mobility, relaxation, and a sense of trust and connection with one another. The welfare button initially met the needs of the participating older adults; however, after six months, usage declined due to outdated content and limited engagement. This highlights the importance of regular updates and ongoing user involvement in maintaining the effectiveness of digital tools. Implications: •Although developing and implementing integrated digital care and support require creativity and willingness on the part of all partners, this project shows that cross-domain learning and working is possible and has positive outcomes for all parties involved. Image-based care and well-being are particularly suitable for older people who do not yet require intensive care but need extra attention. There is still much to be gained in this field. Learning communities such as IP-LINs are an important breeding ground where professionals, students, and teachers can learn and innovate together. It is crucial to work together on a theme that is of interest to all the parties.

Barriers, Facilitators, and Unmet Needs for Achieving a Good Death in Catalonia: A Joint Perspective of Users, Relatives and Professionals

Fri, 11 Sep 2026 00:00:00 GMT

Background: & Objective: Awareness of end-of-life care and patients’ rights has grown substantially, leading to increased attention on the quality of care provided during the final stage of life. However, most existing studies have focused primarily on the views of family members and healthcare professionals. In the region of Catalonia, no previous research had explored what constitutes a “good death” from the perspective of patients, families, and professionals. This gap limits the ability to shape person-centred, integrated end-of-life services, identify unmet needs, and align care provision with citizens' values and preferences. This study aimed to identify barriers, facilitators, and unmet needs throughout the end-of-life pathway and specifically in the process of dying, from a multidisciplinary and multi-stakeholder perspective, within the framework of the Catalan Observatory of Death. Methods: A qualitative study grounded in phenomenological, hermeneutic and socio-constructivist perspectives was conducted in two phases. We undertook 25 semi-structured, in-depth interviews with adults living with advanced or complex chronic conditions and their relatives, at home and in long-term care settings. Additionally, three online focus group discussions were held with health and social care professionals — including clinical staff, community practitioners, managers, and strategic planners — alongside patient and family representatives. All interviews and focus groups were audio-recorded, transcribed verbatim and analysed using qualitative content and discourse analysis techniques. Results: Two key determinants emerged as pivotal to achieving a good death. First, the understanding of what a “red line” is for each person — a deeply personal threshold beyond which life is perceived as no longer bearable due to loss of quality of life, autonomy or dignity. Second, attitudinal profiles influenced the extent to which individual’s exercised agency over end-of-life decisions, particularly regarding symptom management, place of care, and advanced decision-making. There were facilitators and barriers that can be used as improvement areas within the system. As one participant expressed: “It is very good that you care about how we die, but it is pointless if you do not first care about how we live before dying.” This quote encapsulates the importance of a life-course, compassionate and community-based approach to end-of-life care. Unmet needs related to adequate and dignified physical settings for dying, clear communication on patient rights and advance care Planning, holistic and multidisciplinary training for professionals, structured support for informal caregivers, and enhanced psychological and emotional support for patients and families. Conclusions: A more person-centred, integrated and socially-engaged model of end-of-life care is required to honour individuals’ values, preferences and dignity. Recommendations derived from the study include: systematically eliciting and respecting end-of-life preferences normalising conversations about death through public engagement strengthening professional training in communication and compassionate care increasing resources and simplifying administrative processes This study is part of the Observatory of Death of Catalonia. Please find more available information: https://observatorisalut.gencat.cat/ca/observatori_mort/estudi-de-la-bona-mort/