Components and Outcomes in Under- and Postgraduate Medical Education to Prepare for the Delivery of Integrated Care for the Elderly: A Scoping Review

Search Strategy

With the help of a librarian, we developed a search strategy by dividing the research question into four concepts:

1. Integrated care and its synonyms

2. Elderly and its synonyms

3. Learning and its synonyms

4. Students/trainees, and their synonyms.

For concept 2, we adapted the search string for geriatric people published by van de Glind et al.. To adapt the concept from geriatric to elderly people in general, we replaced disease-specific components, such as ‘Alzheimer’s’, with broader components, such as ‘comorbidity’ and added ages, such as ‘70 years’ [28]. Concepts 3 and 4 were combined with [AND] to avoid papers about patient learning. We combined these concepts in the following Boolean search: (Concept 1 AND Concept 2 AND ((Concept 3 AND 4)). In April 2021, we adapted the final search string to PubMed, Embase, PsycINFO, ERIC, and Web of Science databases (see Appendix 1 for PubMed search string, the remaining search strings can be found in the review protocol at OSF). We searched these databases for English publications, including papers from 2000 onwards because integrated care had been upcoming since the end of the 1990s [20, 29, 30].

Selection criteria

The included publications had to describe an educational programme for medical students or postgraduate trainees, in which they learned to provide or gained insight into integrated care for the elderly. For this scoping review, we defined the elderly as 65 years and older. We concluded that the health system-based definition of integrated care, documented in the overview of integrated care models by the WHO Regional Office for Europe, best fitted the purposes of our review (Box 1) [12]. The first screening showed that none of the full-text papers met the full WHO definition. Therefore, we divided the definition into ten components to determine essential components for this review (Box 1).

In order not to exclude too many papers based on their abstracts, we decided that at least two out of the ten WHO components should occur during the abstract screening process. During the full-text selection, the review team discussed that all papers should comply with educational programmes targeting component I. (‘people-centred’), component III. (‘multidimensional needs’), component IV. (‘multidisciplinary team’), and component V. (‘across settings and levels’). We decided that the remaining components were desirable but not essential for selection. We chose these four mandatory components because they are within the sphere of influence of (future) physicians. Components such as VIII. feedback loops are more challenging for medical students or trainees to influence as they are not responsible and sometimes not even included in the evaluation of care during their internships.

Interprofessional collaboration, as mentioned earlier, is an important component to ensure greater collaboration within the healthcare sector [16], making IV. multidisciplinary team essential. We defined ‘multidisciplinary team’ as generalists and specialists who collaborate together in health and social care, as mentioned by the WHO in their report as a key factor for implementing integrated care [12]. Currently, for multidisciplinary collaboration, the term interprofessional collaborations (IPC) and intraprofessional collaboration (IntraPC) are also used. IPC means health professionals with different backgrounds collaborating to deliver high-quality care within health and social care [31, 32]. IntraPC is defined as health professionals with the same background collaborating to provide care [32]. For this review, we included papers that involved multidisciplinary, interprofessional or intraprofessional collaboration with respect to health and social care.

Selection

The review team MW, NS, CF, and DA screened 6,936 titles and abstracts using Rayyan [33]. At least two researchers screened every abstract. The abstract screening resulted in 30 papers for full-text reading. During full-text reading, DA and MW scored every paper on the presence of the WHO components (Box 1). These WHO components had to be reflected as an intention, learning objective, outcome, or element of the described educational programme. If the researchers intended to develop an educational programme for students to become more patient-centred, for example, we scored that component I. was present.

Ten full-text articles and six conference abstracts met the inclusion criteria. The references in these articles were screened in the same way as above, resulting in one additional paper [34]. During inclusion, the review team discussed disagreements. The Prisma flow diagram shows an overview of the selection process (Figure 1).

Figure 1

Data analysis

All 17 inclusions were read and reread. DA and MW developed and piloted a charting template to collect descriptive and content data. We categorised the data into four main categories:

1. descriptive information (e.g., title, author, country),

2. information regarding integrated care (e.g., definitions, levels, components),

3. information regarding the educational programmes (e.g., relevance, content, setting, educational theories),

4. and information regarding the outcomes of the educational programmes.

During analysis, we defined the micro-level of care as direct (individual) patient care, including the patient’s social system; we defined the meso-level as the organisation of care for (a group of) patients; and we defined the macro-level as the care organisation for the entire population, including government policy, legislation, and finance. The content data were deductively and inductively analysed in Excel and Atlas.ti. using template analysis [35, 36]. DA and MW read and reread the data. They analysed, coded and categorised the data independently in Excel and Atlas.ti. They discussed their findings weekly. SG joined the review team during analysis to add expertise on integrated care. The findings and discrepancies were discussed within the review team until consensus was reached. Finally, overarching and several sub-themes were identified, which we describe in the results.

The review team

The review team consisted of professionals from different fields and backgrounds: a PhD student and a geriatrician in training (MW); a programme director in geriatrics, educator and geriatrician (DA); a strategic consultant and researcher in integrated care (SG); an experienced educationalist and professor of innovative and person-centred learning and working in healthcare (CF); and a general practitioner and professor of general practice, specialising in interprofessional and primary-secondary care collaboration (NS).

Description of the educational programmes

The included papers described a wide variety of educational programmes. Table 1 presents an overview of the included papers with participants, brief description, setting, and duration of the educational programmes. Thirteen papers originated from North America [34, 37, 38, 39, 40, 41, 42, 43, 44, 45, 46, 47, 48], two from Europe [49, 50], one from South America [51], and one from Oceania [52]. The majority (n = 13) was published after 2008 [37, 38, 39, 41, 42, 43, 44, 46, 48, 50, 51, 52].

Thirteen papers contained educational programmes for undergraduate students [34, 37, 38, 39, 41, 42, 45, 46, 47, 48, 49, 51, 52] and four for postgraduate trainees [40, 43, 44, 50]. The duration of the programmes varied between 90 minutes and four years (Table 1). The duration was not specified in four papers [40, 43, 46, 52].

Content and setting of the educational programmes

We subsequently divided the programmes according to their learning settings, i.e. classroom-based, workplace-based, or a mix of both (Table 1). Six programmes had a classroom-based setting [34, 37, 39, 40, 47, 48]. These programmes varied from interactive seminars based on a clinical case [34, 40], a workshop based on a clinical case [37], an application of a web-based tool to manage care on a population level [47], a quality improvement project [39], and a scenario play [48].

The remaining 11 papers described workplace-based programmes. One described a non-traditional longitudinal interdisciplinary clerkship (LIC) incorporating ambulatory care within longitudinal education [42]. Another complemented regular resident rotations with six longitudinal interprofessional curriculum components taught over two years [51]. Other activities included home visits [43, 46], joint primary and secondary care clinics [50], ward observations [41], a student-led clinic for recently discharged elderly [52], and an interprofessional student team examining one patient’s care and discharge [49]. Lastly, these papers described students or residents paired with elderly persons to provide care [44] or observe their health needs [38, 45].

Four of these workplace-based programmes also used teaching activities in a classroom-based setting [38, 41, 43, 51]. For example, students completed a foundational curriculum, after which they continued with home visits to patients [38].

Educational theories and concepts

Five papers mentioned an educational or theoretical concept on which their programme was based. One paper described the concept of situated learning, in which learning requires interaction and collaboration [52]. The second paper described a productive struggle to ensure students’ understanding of the complexity of care experienced by patients [48]. The third paper mentioned the pedagogical guideline of problem-solving, in which the students were encouraged to reflect on their actions concerning the actions of other professionals [51]. Another paper described the Leicester Model of Interprofessional Education, which taught students to value teamwork [49]. Finally, the last paper based their programme on problem-based learning, which stimulates creative solution finding and teaches students how to cope with complex problems on a population level [47].

The relevance for developing the educational programme

Thirteen papers mentioned the relevance of developing education on providing care for the elderly. The relevance items mentioned were the ageing society, the increasing complexity of care demands, and the shortage of geriatricians [34, 37, 38, 39, 40, 41, 43, 44, 45, 47, 48, 51, 52]. Four papers, however, did not motivate why they taught (a component of) integrated care [42, 46, 49, 50].

Components of integrated care

Based on the inclusion criteria, all programmes contained the following components (Box 1):

1. people-centred

2. multidimensional needs

3. multidisciplinary team

4. across settings and levels.

Although we searched for elements of the concept of integrated care, only two papers mentioned integrated care as a learning objective, but they did not define the concept of integrated care [48, 50]. Table 2 provides an overview of the components of integrated care in the WHO definition that the educational programmes taught. Sixteen programmes included additional components to the required four [34, 37, 38, 39, 40, 41, 42, 44, 45, 46, 47, 48, 49, 50, 51, 52]. Component VI. (‘effectively managed’) was taught in 13 programmes, making it the most widely taught additional component [34, 37, 38, 39, 40, 41, 44, 46, 47, 48, 49, 50, 51]. This was followed by component II. (‘across the life-course’) [34, 42, 45, 47, 51, 52] and IX. (‘tackle upstream causes’) [34, 40, 45, 47, 51, 52], which were both taught in six programmes. Two programmes taught Component VII. (‘feedback loops’), which was, therefore, the least taught component [39, 47].

Outcomes

The authors evaluated their programmes to a greater or lesser extent. Some papers did not specify their evaluation methods [42, 45, 47], while others provided a preliminary evaluation [40], and evaluations varied from detailed to short descriptions in the remaining papers [34, 37, 38, 39, 41, 43, 44, 46, 48, 49, 50, 51, 52]. For clarity, we divided the heterogenous evaluation outcomes into the following categories: feedback on the programme, learning outcomes, key factors for learning, and challenges.

Strengths & Limitations

We would like to mention two strengths. Firstly, our diverse research team, consisting of educators, physicians, and a policy and management expert, allowed us to analyse the included papers from different perspectives. Secondly, we operationalised the WHO definitions of integrated care into ten components (Box 1), which made it possible to perform a broad search and identify the components of integrated care that the educational programmes addressed. Nevertheless, only 17 papers were electable, a limited number of papers that contrasts rather sharply with the global trend towards more integrated care. A lack of research publications does not necessarily mean that there is no education on integrated care. Nevertheless, this scoping review has exposed the limited extent of scientific knowledge and highlights the need for research regarding educational programmes on integrated care for the elderly.

A limitation is perhaps that we did not include grey literature. Because of the broadness of the concept of integrated care, searching with the same broad scope as in white literature would have led to an unworkable amount of information. A pilot search in grey literature only revealed programmes on integrated care in general, which did not address the elderly. Therefore, grey literature remained outside the scope of this review.

Another limitation could be the quality of the included papers. Some papers were very brief in describing their programmes and evaluations. Some evaluations were limited to stating that ‘students enjoyed the programme’ without clarifying what it was they enjoyed. Not all papers described the relevance of their educational programme, which made it challenging to understand the setting of the programme. The generalisability of the data, therefore, is limited. However, we believe that this review can be used as a source of inspiration and an incentive for developing education and research.

Implications for medical education

The described educational programmes did not have integrated care as a primary learning objective but taught components of the WHO definition of integrated care. Therefore, this review does not provide evidence on the effectiveness of educational interventions on the full spectrum of integrated care. Nevertheless, this research shines a light on interventions for components of integrated care and can be used as an inspiration for developing education on this subject. In addition, we suggest promoting a broad scope in medical education on integrated care, by addressing, firstly, the broader meso-level and macro-level of integrated care and, secondly, by enabling students to experience the complexity of care. Furthermore, we suggest considering the challenges described: sufficient financial resources, location, the difference in students’ levels of experience, teacher qualifications, enough time, and support from hospitals and educational institutions.

Implication for future research

Future research should focus on descriptions of educational programmes that pay specific attention to a definition of integrated care to justify the choices made. It may be valuable to include information from educational programmes on integrated care that were outside the scope of this review, such as paediatrics or psychiatry. In addition, future research could examine what components of integrated care the educational programmes should address and why. Furthermore, most programmes focused on the micro-level of integrated care, and it remains unclear how the meso- and macro-levels of integrated care could be included. It would be a valuable addition, therefore, to investigate how these levels could be included in medical education.