Integrated Health and Social Home Care Services in Catalonia: Professionals’ Perception of its Implementation, Barriers, and Facilitators

Introduction

Most countries in the world are experiencing an improvement of survival beyond the age of 65, along with an increase in the number of adults aged 65 years or older, a trend that is expected to continue [1]. Consequently, in OECD countries, the population aged 65 and older is expected to account for 26.7% of the whole population by 2050 [23]. In the case of Catalonia (North-east of Spain), which has one of the most intensively aging populations globally, this age group is projected to increase to 30.5% by 2050 [4]. This demographic shift is expected to increase the demand for long-term care in the next decades, including services to support home-based care for older adults [5], so home care services (HCS) policies could become a priority in the next years. Moreover, HCS are an important resource to promote the autonomy of individuals of all ages [6].

The main outcomes of home care include promoting the care recipients’ quality of life and functional independence in the domains of social, personal care, and mobility, but also minimizing the utilization of other services, such as hospital care, admission in other settings (e.g., nursing homes), and acute emergency admissions [78]. For this purpose, current home care models include health and social services in the home environment [8] delivered by a wide range of professionals (home care assistants, nurses, social workers, physical therapists, occupational therapists, physicians, etc.) along with informal caregivers (e.g., relatives or volunteers) [89]. In most European countries, formal home care is provided by the social and health care systems. Usually, the social system provides home help services such as household duties, personal care, and other activities (e.g., socializing or going for walks), whereas the health care system mainly provides nursing care, occupational therapy, and physiotherapy [8].

The delivery of both social and healthcare services from different sectors must be coordinated and complementary to improve accessibility for care recipients, achieve better outcomes in terms of user experience, and avoid a waste of human and financial resources, such as that resulting from duplication of services provided by different organizations [1011]. Integration, which is defined as “a coherent set of methods and models on the funding, administrative, organizational, service delivery, and clinical levels designed to create connectivity, alignment, and collaboration within and between the cure and care sectors” [12], is an important aspect to consider in Home Care Services (HCS), given that it enhances the quality of care, quality of life, and satisfaction of users, and improves the efficiency of the system [12].

In Catalonia, the Department of Social Rights [13] and the Department of Health [14] provide social and healthcare services to cover the needs of its population (about 7.7 million inhabitants [15]). Both Departments have been working together since 2014 to create a single strategy of integrated social and health HCS with the aim to benefit care recipients –improving their health, quality of life, and care experience, and preventing or postponing dependency– and guarantee proper use of social and healthcare services. Catalan social services in the home setting mainly provide help in personal care, but also deliver support in household tasks and teleassistance [16]. They are funded both by the Department of Social Rights and the local governments [17], and are mostly delivered by outsourced companies. In addition, health services in the home setting include disease prevention and health promotion activities involving primary health professionals such as physicians, nurses, and social workers [18]; hospital at home, in which hospital health care professionals deliver an active treatment to a patient who would otherwise need acute care in a hospital [19]; and end-of-life care through multidisciplinary and specialized teams [20]. In Catalonia, primary and community care is delivered through primary health centers (PHCs), whereas social care is provided by social care services (SCS). PHCs and SCS are managed by different metropolitan or county councils [2122]; counties are administrative geographic areas comprising one SCS and, usually, several PHC centers. A comprehensive model for integrating social and health care and a joint evaluation framework were developed with over 70 representatives of all stakeholders [2324].

In the last years, numerous integrated care initiatives have been developed inside and outside Europe, adding important knowledge to the field. However, evidence for the effectiveness of integrated health and social care programs for people living at home remains rather inconsistent [925]. Therefore, this study aims to contribute to bridging this gap by assessing the perception of social care professionals about the degree of implementation of integrated social and health HCS offered by the Government of Catalonia through SCS and PHCs and to identify the main barriers and facilitators of integrated social and health HCS in Catalonia.

Methods

Study Design

The analysis of the degree of implementation of integrated social and health HCS offered by the Government of Catalonia was performed between December 2020 and June 2021. It was conducted in the context of the Integrated Care Program of Catalonia, which was developed according to a conceptual framework based on a snowball literature review of over 300 documents [26], an integrated care model, and an evaluation framework with the corresponding indicators and measurement elements [2324].

The work was performed in two phases. First, the overall perception of social workers within SCS and PHCs regarding the degree of implementation of integrated HCS was evaluated. In the second phase, those SCS with the highest scores in the first phase were selected for a more detailed assessment of the perception of the degree of implementation of integrated HCS through an in-depth questionnaire. In this second phase, SCS teams were asked to answer the questionnaire together with PHC teams of their council to the extent possible (Figure 1).

Figure 1

The study was conducted in accordance with the Ethical Principles for Medical Research Involving Human Subjects of the Helsinki Declaration and the local Personal Data Protection Law (LOPD 15/1999) and approved by the Research Ethics Committee of the University of Vic/Central University of Catalonia (UVIC-UCC) (reference number 176/2021).

Results

Identification of Indicators and Measurement Elements of the Core Components of Integrated Social and Health HCS

A total of 48 (45.7%) SCS showed scores ≥3 in at least one core component of the screening questionnaire and, therefore, received a customized questionnaire to assess the degree of compliance of the indicators and measurement elements for those core components. Specifically, the number of SCS that rated the core components ≥3 were: 21 (20.0%), for the core component “individual assessment of integrated social and health care”; 18 (17.1%), for “single individual plan for integrated social and health care”; 17 (16.2%), for “shared protocols across health and social services”; 19 (18.1%), for “coordination between social and health multidisciplinary teams”; and 11 (10.5 %), for “integrated portfolio of services with joint social and health HCS projects”. These SCS gave a mean (SD) score of 3.0 (1.8), 2.7 (1.6), 2.2 (1.9), 1.4 (1.7), and 2.1 (1.9) for the component “individual assessment of integrated social and health care”, “single individual plan for integrated social and health care”, “shared protocols across health and social services”, “coordination between social and health multidisciplinary teams”, and “integrated portfolio of services with joint social and health HCS projects”, respectively. The mean scores for the indicators of each core component are shown in Figure 2.

Figure 2

The highest rated indicators for each core component were: “conditions of the home”, for the component “individual assessment of integrated social and health care” (Figure 2A); “list of needs or problems that require intervention”, for the component “single individual plan for integrated social and health care” (Figure 2B); “assignment of lead and co-lead caregivers for the person”, for the component “shared protocols across health and social services” (Figure 2C); “information provided in the person’s transitions between different services”, for the component “coordination between social and health multidisciplinary teams” (Figure 2D); and “existence of a portfolio of social and health HCS”, for the component “integrated portfolio of services with joint social and health HCS projects” (Figure 2E). Conversely, the lowest-scored indicators for each of the components above were: “existence of an advanced care plan”, for the component “individual assessment of integrated social and health care” (Figure 2A); “the plan is accompanied by a home information file specifying the key agreements and aspects to be taken into account in relation to the care recipient and their family”, for the component “single individual plan for integrated social and health care” (Figure 2B); “shared care routes for the integrated care service”, for the component “shared protocols across health and social services” (Figure 2C); “management of differences of opinion among the teams in accordance with established procedures”, for the component “coordination between social and health multidisciplinary teams” (Figure 2D); and “existence of a personal platform or folder where the person and caregiver can interact with the key professionals”, for the component “integrated portfolio of services with joint social and health HCS projects” (Figure 2E). The detailed results including all measurement elements are shown in Tables S1–S5 (Supplementary file 1). No differences in geographic areas or size of the counties were found for these 48 SCS showing scores ≥3 in at least one core component of the screening questionnaire.

Discussion

This is the first study on the degree of integration of social and health HCS in Catalonia based on the social care workers’ perception. The questionnaires used in this analysis helped identify the perceived best and worst implemented components of social and health HCS integration, as well as its main barriers and facilitators.

We found that 100% of SCS and 25% of PHCs answered the screening questionnaire on the perception of the degree of implementation of integrated social and health HCS. This considerable difference in the response rates may be due to the burden of the COVID-19 pandemic for the health care system in 2020 and 2021, which has probably conditioned the chances of answering the questionnaire by PHC professionals. Nevertheless, a total of 96 (25%) PHCs representing different Catalan counties completed the questionnaire, even though participation in the study was voluntary, which suggests that they were interested in the integration of social and health HCS. The excellent response rate by SCS professionals (100%) probably relies on the thorough follow-up of the assessment team and the availability of the e-mail addresses of all their participants, which allowed them to send individualized reminders. Conversely, in PHCs, the reminder e-mail was sent to the social work reference professionals who were responsible for forwarding it to each participant. Besides, the SCS response rate can also be attributed to a great interest in the integration of social and health HCS. In this regard, most of the work of social services is related to HCS, whereas, in primary care, HCS only represent a small workload.

The scores of the screening questionnaire given by PHCs were higher than those given by SCS. Although the scores of SCS and PHCs are not statistically comparable due to the disparity in the response rates, these differences may be explained by the professional profile of the persons who answered the questionnaire in PHCs –PHC social workers, who have greater access to the information shared by social and health care systems– instead of the PHC team as a whole and a potential bias induced by a higher motivation of those PHC social workers that answered the questionnaire, resulting in higher scores. Nevertheless, either SCS or PHC scores showed clear opportunities for improvement in the integration of social and health HCS. In this regard, previous studies analyzing the degree of implementation of integrated social and health programs in European countries also observed a lack of integrated care implementation [2728]. However, those programs were addressed to different users and settings and used different measures, precluding their direct comparison with this study’s results.

With respect to the scores obtained for each of the five core components of integrated care, both SCS and PHC teams agreed on assigning the highest integration scores to “coordination between social and health multidisciplinary teams”. Conversely, the lowest-rated components by SCS and PHCs were different: “individual assessment of integrated social and health care” and “single individual plan for integrated social and health care” for SCS, and “shared protocols across health and social services” and “integrated portfolio of services with joint social and health HCS projects” for PHCs. However, the lack of standardized tools, common language, and shared information procedures between social and health care teams make interpreting these differences difficult. In relation to the lowest-rated components by SCS, having a joint assessment and an integrated care plan (one person, one plan) is critical, but translating this plan to a unique Information and Communication Technology platform where both health and social care services could work is a challenging task.

Regarding the perceived barriers and facilitators of integrated care between social and health care services, the lack of 1) shared protocols and culture of coordination, 2) staff and leadership, 3) shared information procedures between social and health care systems, and 4) agreement between social and health care professionals were the barriers most frequently identified, whereas recognizing the importance and need of integrated HCS, having previous collaboration experiences between social and health care areas, and a small territory of action were the most common facilitators. Other studies reported similar perceived facilitators and barriers as those found in ours. For instance, Lewis et al. recently reported poor professional engagement and data sharing problems as frequent barriers to integrated care implementation, whereas effective senior leadership, shared values and vision, and a good level of funding were identified as common facilitators [29]. Cameron et al. found that difficulty in recruiting staff; lack of strong and appropriate management; differences in professionals’ philosophies, values, and cultures; difficulty in information sharing; and financial uncertainty were factors hindering integrated care. They also reported that understanding the aims of joint work and the roles and responsibilities of the professionals involved, previous joint working, and effective mechanisms to share information were facilitators of integrated care [30]. Urizar et al. described that non-integrated information systems, an individualist professional culture, working in silos, lack of training, and lack of systemic and integrative vision were barriers to implementing integrated care pathways. Conversely, better information systems, data collection improvement, and training health care professionals on communication and availability of professionals and teamwork skills were identified as facilitators of integrated care implementation [31]. All these barriers and facilitators are consistent with those found in our study. However, despite Auschra describing some of the inter-organizational barriers to collaboration in healthcare settings [32], we believe there is a lack of studies describing the barriers and facilitators of integrated services specifically in the home environment. Genet et al. mentioned some of them, but it was an initial, narrative study [9].

Our work has some limitations. First, the low response rate and representativeness in answering the screening questionnaire by PHC professionals limited the gathering of data on the implementation of integrated social and health HCS in PHCs. Besides, the second questionnaire required more time to be answered than the first one; hence, it was not sent to the PHCs because they were considerably burdened with the COVID-19 pandemic. Instead, SCS teams were asked to answer it together with PHC teams of their council to the extent possible. Therefore, our results mainly reflect the SCS social workers’ perception of the degree of implementation of social and health HCS, which does not include all social care teams responsible for social and health HCS in Catalonia. In addition, the low representativeness may have introduced a bias in the PHC scores of the screening questionnaire, resulting from a higher motivation of those PHC professionals who answered it. Another limitation may arise from the choice of the core components of an integrated model, as there are no previous studies that validate or support this choice. However, given the comprehensive review of previous documents on integrated care services and the stakeholders’ high participation in the model’s development, we may assume that our results could have face validity. In this regard, there is not a single method to evaluate integrated care between social and health care services, and a large number of measures have been reported across different studies [33]. Thus, the lack of standardization in the evaluation of integrated care services makes it difficult to contextualize our results. Moreover, in our study, the assessments were not validated externally. Therefore, in PHCs they were limited to the perception of social workers and lacked that of other health care professionals that also participate in HCS and must coordinate with SCS (e.g., nurses or general practitioners). However, despite these limitations, to our knowledge, this is the first study specifically assessing the degree of implementation along with the barriers and facilitators of integrated social and health HCS. Although our results may not apply to other systems supplying integrated social and health care, they provide some valuable insights for other countries regarding the implementation of integrated care in the home setting, especially in terms of the components that need to be strengthened in order to improve the integrated care model.

In conclusion, our study shows that, according to the selected five core components of an integrated model (individual assessment of integrated social and health care, single individual plan for integrated social and health care, shared protocols across health and social services, coordination between social and health multidisciplinary teams, and integrated portfolio of services with joint social and health HCS projects), the perceived degree of implementation of integrated health and social HCS offered by the Government of Catalonia is low and has a clear opportunity for improvement. In addition, the main barriers and facilitators of HCS are similar to those reported in other analyses. Future studies should include the assessment of different professionals of PHCs involved in HCS besides social workers, external audits, and further information on counties with low-level screening responses in order to increase the accuracy of the results. Despite the limitations of the study, our results have allowed us to launch a project to assess the impact of integrated social and health HCS in the areas with high integration scores compared with those with low integration scores, which we expect to publish in the near future.

Data Accessibility Statement

The datasets used and/or analyzed during the current study are available from the corresponding author upon reasonable request.

Additional Files

The additional files for this article can be found as follows:

Ethics and Consent

The study was conducted according to the guidelines of the Declaration of Helsinki, the General Data Protection Regulation 2016/679 on data protection and privacy for all individuals within the European Union, and the local Personal Data Protection Law (LOPD 15/1999). The study protocol was approved by the Research Ethics Committee of the Universitat de Vic – University of Vic-Central University of Catalonia (UVic-UCC) (reference number 176/2021). [removed for blinded manuscript]

Based on sample size and absence of personal information in the dataset used for analysis, the Ethics Committee determined that a written informed consent from each patient was not necessary.

Reviewers

Two anonymous reviewers.

Funding information

This research was part of the PROAVA project, funded by the Economy Department of the Catalan Government.

Competing Interests

The authors have no competing interests to declare.

Author Contributions

PH, AV, JCC, SJS, JA-N, RS, AP, and EV contributed to study design and conception. PH, AV, JCC, and EV collected the data. PH, AV, JCC, SJS, JA-N, RS, AP, and EV analyzed the data. PH, AV, JCC, SJS, JA-N, RS, CB, AP, and EV interpreted the data. All authors contributed to the manuscript draft and reviewed, edited, and approved the final manuscript.