Designing an Integrated Care Initiative for Vulnerable Families: Operationalisation of Realist Causal and Programme Theory, Sydney Australia

John G. Eastwood; Miranda Shaw; Pankaj Garg; Denise E. De Souza; Ingrid Tyler; Lauren Dean; Morag MacSween; Michael Moore

doi:10.5334/ijic.3980

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Table 1

NSW Ministry of Health Integrated Care Functional Components.

Functional Component	Key Feature
Patient and carer empowerment
Engaging the patient/carer in care planning	The implementation of processes and systems that ensure the integrated care plan meets the needs and preferences of patient/carers as defined by patients or carers themselves (shared decision making).
Using patient reported measures in care delivery	The implementation of a system of patient reported measures for enrolled patients that measure both the patient’s perceptions of both their care experience and their outcomes, due to the care that they receive. This includes the timely provision of the information to clinicians/team delivering care to enable shared care planning/shared decision making.
Supporting and promoting self-management	A set of defined care interventions specific to the targeted patient cohort to support self-management. This also includes strategies to increase capacity for patients and carers to better self-manage their condition.
Building patient/carer health literacy	The implementation of processes and systems (such as training and information) that improve the patient’s understanding of their health condition(s), how to maximise their ability to manage it themselves, how/when to access health services and what role they play in managing their health condition(s). This also includes care plan access, and active participation to the extent possible in care planning.
Patient identification and selection
Defining local health needs	The set of local health system parameters which broadly identify the types of patients that require the implementation of an integrated care pathway to improve the effectiveness of healthcare delivery (such as potentially avoidable hospital admission, ED presentations, delays in receiving specialist treatment).
Identifying target cohorts	Patient level parameters (such as demographic, e.g. age; clinical, e.g. diagnosis; utilisation, e.g. number of medications; other, e.g. measure of social disadvantage) that define the group of patients that will be targeted/enrolled in the integrated care program.
Developing systematic approaches to risk identification	The standardised approach to risk identification (such as signs of health deterioration) and methodology (such as automated processes in PAS/EMR/EHR) for identification of the targeted cohort of patients who would benefit from an integrated model of care. The targeted risks and cohorts can vary locally, and can vary over time within locality as programs mature.
Innovative ways of working
Establishing new business models	The identification and implementation of business models across the continuum of care are being to promote care delivery which improves patient care and experience through improved coordination and integration. The models sit alongside service models (which operationalize service delivery). They potentially incorporate financial and/or non-financial elements. The models may include the selection of alliance partners (such as GPs, NGOs or other government organisations) and investment in new roles, as well as the use of known business models (such as Person Centred Medical Homes or a Commissioning Framework).
Ensuring appropriate and timely access to specialist care	Needs for the identified cohort. The function may be achieved in a number of different ways (for example, quarantining appointments in hospital based clinics or purchasing services from a telehealth provider).
Shared/joint care planning and management with the patient/carer	The development of shared or joint care planning and care management strategies between the initiator of the care plan, the patient, and other healthcare professionals who are to be involved in the care and service delivery to targeted patients.
Establishing roles focused on organising patient-centred care	The establishment of roles (such as case managers, care navigators, care facilitators) to support the implementation of the integrated care model of care across care settings (such as hospital, primary care, specialist care, community care).
Embedding agreed models of care	The uptake of models of care for patients with specified conditions that are based on evidence based medicine and adhered to by those clinicians seeing targeted patients. This includes the process of designing and agreeing the models with stakeholders to optimise uptake.
Primary and Community care as the hub
Connecting people to their healthcare team	The assignment of targeted patients to a clinical provider (individual/practice) whose role is to be the lead clinical provider with responsibility for the shared care plan and initiating communication with other care providers (such as specialist, GP, aged care, community care).
Systematic assessment, review of patients	The implementation of a system of standardised assessments, regular patient reviews, and uploading of relevant clinical metrics by clinical care providers based on developed integrated care pathway protocols.
Building capacity/capability in primary and community care	The enhancement of resources (such as care navigators, training programs, care pathways, share care planning tools) in the primary and community care settings to support integrated care delivery to targeted patients.
Information Sharing
Establishing a trackable cohort list	The establishment of an electronic patient list/register that identifies all patients enrolled in the integrated care initiative and enables the monitoring of the patient journey, as reflected through the patient’s use of healthcare services.
Establishing shared access to patient information	The extent of electronic patient information on enrolled patients available to clinicians across care settings who are delivering the agreed integrated model of care (such as care plans, e-referral, discharge summaries, medication profiles, test results, service events).

Table 2

Design elements of previous planning.

Design Component	Business Case	Child and Family Health Planning Priorities
Sustained Health Home Visiting (SHHV)	Antenatal screening and risk stratification Perinatal pathways and coordination Sustained home visiting commencing before birth Second tier allied health and medical services, pathways and coordination Universal maternal, child and family services with proportionate support according to need	Review and strengthen perinatal coordination Strengthen Aboriginal program (Yana Muru) New SHHV in Canterbury LGA focusing on CALD families Enhance SHHV in Sydney LGA focusing on Redfern and Waterloo suburbs Strengthen Tier 2 support services including access pathways
Family and Community Integrated Service Development (FCISD)	Integrated service models including wrap-around and family group conference model Targeted parenting programmes Domestic violence intervention High risk infant tracking models “Hub” and “place-based” community building and service coordination Universal family and community capacity building (health and wellbeing promotion)	Interagency collaborative planning Development of interagency models of care for “high need” schools and early childhood centres Commence neighbourhood “hub” development in Redfern social housing estate Enhanced collaborative interagency parenting communication strategy (phone app and web development)
Infrastructure Support (IS)	Child and family public health (epidemiology, programming, research and evaluation) System change strategies Service capacity building Project Management and leadership	Child and family epidemiology Evidence-informed programming Evaluation of perinatal referral pathways Study of universal well child care system Web-based health pathway development Development of well child care and psychological trauma workforce training packages Leadership and technical support to interagency planning groups

Table 3

Integrated Care Programme Design Elements.

	Design Component	Inner West Sydney Collaborative Design	Ministry of Health Integrated Care Policy	Design Elements
1	Shared identification and intake	Strengthen existing perinatal screening and coordination system through review, training and monitoring High risk infant tracking models	Identifying target cohorts Developing systematic approaches to risk identification Establishing a trackable cohort list Establishing shared access to patient information	Shared identification Shared risk stratification Pathways to care Shared intake systems
2	Care Coordination	Strengthen existing perinatal screening and coordination system through review, training and monitoring Strengthen Tier 2 support services Integrated service models including wrap-around and family group conference model High-risk infant tracking models	Engaging the patient/carer in care planning Supporting and promoting self-management Using patient reported measures in care delivery Ensuring appropriate and timely access to specialist care Shared/joint care planning and management with the patient/carer Systematic assessment, review of patients Connecting people to their healthcare team	Patient centered care Strength-based care coordination Facilitated access to specialist care Shared care planning Shared assessment and review of patients Wrap around connecting people to health and social care team
3	Evidence informed practice	Strengthen current SHHV by training, resourcing, management support Integrated service models including wrap-around and family group conference model Targeted parenting programmes		Sustained Health Home Visiting Wrap-around service model Family Group Conferencing Targeted Parenting Programmes
4	General Practice engagement and support		Connecting people to their healthcare team Systematic assessment, review of patients Building capacity/capability in primary and community care	Connecting families to general practice “health home” Supporting general practice to engage and support families Capacity building of general practice
5	Family Health Improvement	Review and strengthen universal services Targeted parenting programmes Universal family and community capacity building	Building patient/carer health literacy	Universal family health literacy Parent education and support programmes Sector-wide capacity building
6	Place-based initiatives	Implement new tiered model of SHHV in Canterbury, Redfern and Waterloo Integrated service models including wrap-around and family group conference model “Hub” and “place-based” community building and service coordination	Engaging the patient/carer in care planning Defining local health needs Connecting people to their healthcare team Building capacity/capability in primary and community care Establishing shared access to patient information	Place-based initiatives in City of Sydney and City of Canterbury/Bankstown Integrated care pilot projects to include: local needs analysis, consumer consultation, “service hub”, wrap-around service provision, family group conferencing, community building and service coordination
7	System Change	Strengthen existing perinatal screening and coordination system through review, training and monitoring Review and strengthen existing perinatal screening and coordination system project management and leadership Sector capacity building projects System change projects	Establishing new business models Establishing roles focused on organising patient-centred care Embedding agreed models of care Defining local health needs	New business models Strengthen existing perinatal screening and coordination system Shared outcomes, assessment tools, models of care, and evaluation Sector capacity building projects System change projects
8	Child and family Outcomes	Child and Family public health (research, programme, evaluation)	Using patient reported measures in care delivery	Patient reported measures
9	Evaluation	Child and Family public health (research, programme, evaluation)	Defining local health needs	Critical realist evaluation Population outcome evaluation

Table 4

CIMO Propositions.

Theorised Contextual Conditions (Figure 2) [C]	Present contextual mechanisms activated [C_M]	Proposed Intervention Design Elements (Table 1) [I]	Postulated Intervention Programme Mechanisms (Table 1) [M_P]	Postulated psychological, motivational and behavioural Outcomes [O]
Self – Self-identity and individual’s experience
Lack of partner and family support, Distrust of services, Limited treatment access	Stress mechanism activated causing anxiety and depression	Friendship and family support, Professional support, Medication, Treatment	Activate mediating mechanisms of family, peer and professional support to strengthen and build trusting relationships with peers, family and clinicians through SHHV and FCISD Design Components.	Decreased depression and anxiety
Lifetime trauma, Loss, Being alone, Isolation	Stress mechanism activated arising from mismatched expectations, and loneliness	Family and peer support, Home visiting, Telephone support		Increased perceived support
Situated Activity – Face to Face activity
Services unavailable or poor access, Services not trusted, Services not skilled	Absence of trusted professional support mechanism	“wrap-around” services, Family Conferences, Workforce training	Activate services mechanisms that are client, peer and neighbourhood focused, and trauma and evidence informed through FCISD and IS Design Components.	Improved perceived access to skilled and trusted services
Community distrust, Low social capital and cohesion, crime, unemployment	Absence of trusted neighbourhood and community support mechanism	“wrap-around” services, Family Conferences, Public health, Social work services		Improved perceived support from neighbours and community
Intermediate Level social and service organisation
Unhelpful intake and referral practices, Lack of service, knowledge and trust	Absence of specialist service support mechanism for front-line professionals	Strengthened pathways and design Collocation of services	Activate mechanisms related to trust and confidence with service network, increased local social capital, community trust and community safety Activate mechanisms relating to improved coordination and access to services and information through FCISD and IS Design Components.	Improved perceived access to services that are “wrapped” around front-line workers
Weak social networks, community trust, community safety, available social services, access to information	Social level stress mechanisms relating to class, position, racism, segregation, crime and neighbourhood decay are activated tending to increase psychological stress	Population and community level interventions in neighbourhoods and communities	Decrease in psychological stress of individuals and families
Macro Level social and service organisation
Migration, Mega-malls pull service activity away from neighbourhoods, Urban development	Activation of social level stress mechanisms tend to hinder the activation of social level buffer mechanisms	Population and community level interventions in neighbourhoods and communities	Activate mechanisms related to increased social level activities in deprived neighbourhoods. Activate mechanisms related to increased migrant related social activities among ethnic populations through FCISD and IS Design Components.	Increase in perceived social level buffers
Immigration policy, Racism, Media policy, Global market, Settlement patterns, Ethnic bonding networks, Access to services	Migrant related social level mechanisms including acculturation, cultural practices and integration tend to decrease social level stress	Ethnic and cultural specific community and population level interventions	Increase in perceived migrant social level buffers

[i] Note: SHHV-Sustained Health Home Visiting; FCISD – Family and Community Integrated Service Development; IS-Infrastructure Support.

Theory of Change – Early Intervention and Clinical Elements.

Designing an Integrated Care Initiative for Vulnerable Families: Operationalisation of Realist Causal and Programme Theory, Sydney Australia

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