Toward Sustainable Adoption of Integrated Care for Prevention of Unplanned Hospitalizations: A Qualitative Analysis

Setting the scene

Since 1981, the Catalan Health System [1314] has been fully responsible for policy formulation, organization management, service delivery, and financial aspects of health services in Catalonia (ES), with 7.7 million citizens. This regional system ensures universal coverage and free access at the point of service [1516]. Basic principles, traits and outcomes of the regional health system are reported in [1415161718]. Regional health planning [1920] has played a backbone role in triggering the health system transformations toward digitally supported integrated health and social care services during 2011–2020. A myriad of interconnected service modalities currently available for chronic care management is outlined in Table 1.

Two distinct documents were used as background information in the development of the current integrated care case, each of them contributing to its conceptual framework. One document encompasses the fundamental characteristics of the regional integrated care model for chronic patients [1], providing operational definitions of the two profiles of candidates to the program for prevention of unplanned hospitalization: i) Complex chronic patients characterized by multimorbidity, > 65 years of age, and showing mild frailty, ii) Advanced chronic patients with a life expectancy of less than 18 months. These two groups correspond to the 5% (P_≥95) of citizens at the tip of the population-based risk stratification pyramid at regional level.

The second report outlines the ongoing digital health strategies for 2021–2025 [22], specifically focusing on implementing a knowledge-based digital platform to support cloud-based health services. Moreover, the description of specific digital developments [21] providing support to collaborative adaptive case management across healthcare providers, currently used for peri-surgical care (prehabilitation), was also considered in the qualitative analysis.

Setting the scene Co-design process: the methodological approach

The qualitative analyses were conducted following a grounded theory approach [24], using a methodology like the one [2526] described in detail in [27]. Figure 1 depicts the timeline and the focus of its two phases.

Figure 1

Phase I, entitled “Discovery”, had a twofold purpose: i) to identify actionable factors to enhance management of complex chronic patients; and ii) to generate specific recommendations to be tested during the period 2024–2025. The two design thinking sessions carried out in Phase I were done in December 2021 and February 2022, respectively.

Phase II, entitled “Confirmation”, aimed to consolidate the achievements of Phase I. The corresponding two design thinking sessions were conducted during the last quarter of 2022 [26].

Details on methodological aspects of the qualitative analysis are reported in the on-line supplementary material.

The Discovery phase – Between October to December 2021, in-depth interviews were conducted with 20 key informants. This group comprised 5 patients and 15 clinical professionals and healthcare service managers, chosen for their leadership in the Catalan Health System. The interviews, on average 45 minutes each, were carried out by the first author alongside a specialist in qualitative research and services design.

Patients – A total of 25 patients were selected from the community as potential candidates for the interviews. The inclusion criteria were: i) At least one hospital admission in the last year, ii) Two or more chronic pathologies and iii) Allocated > P₈₀ in the Catalan risk stratification pyramid. We excluded those patients presenting: i) Difficulties in conducting an interview (sensory problems, cognitive impairments, or severe mental illness), and ii) Refusing to participate. The final five patients, with whom the interviews were conducted, were selected balancing the following criteria to achieve the highest representativeness: i) Male/female, ii) With/without caregiver and iii) With transition from hospital to home/hospital to intermediate care to home.

For the patients, the interviews were structured to capture the reported experience on the following aspects: i) initiation of the acute episode, ii) emergency room admission, iii) hospitalization period; iv) follow-up after hospital discharge, v) intermediate care, if needed, vi) home-based support and services, if needed; vii) primary care services; and viii) care continuum. All of them signed an approved informed consent form to participate in the interviews (NCT04056663).

Professionals (Table 1S) – Fifteen experts were selected based on their leadership in integrated care, as well as the coverage of three areas: i) Clinical activities (physicians, nurses, and social workers), ii) Managers and policy makers (micro-, meso-, and macro levels), and iii) Technological expertise. Representativeness of different healthcare tiers (Primary care, Hospital care, Intermediate care, and Macro-management) was also considered.

The interviews addressed the following items relative to complex chronic patients: i) problems associated to the identification of such patients, ii) roles and interactions among healthcare professionals in the care of those patients, iii) satisfactoriness of the current management of complex chronic patients, iv) challenges, unmet actionable needs and proposals for management, v) proposals to reduce unplanned hospitalizations in complex chronic patients, and vi) challenges, unmet actionable needs and proposals to enhanced transitional care after hospital discharge.

All fifteen professionals participating in the interviews were invited to be active in the two design thinking sessions, but only nine of them accepted. The absences of the remaining six were due to scheduling conflict. Two additional leaders could attend only the design thinking sessions. Such that the final number of attendees to the two design thinking sessions was eleven, nine of them also participating in the interviews, as indicated in Table 1S.

Three blocks of additional information fed the debates: i) Statements of the regional government on deployment of integrated care [1] and on digital health strategy [28], ii) Results of the studies conducted in 2006 and 2015 [612] showing the efficacy-effectiveness gap alluded to above, and iii) A recent study conducted at Hospital Clinic Barcelona (HCB) [25], combining predictive modelling for mortality and early re-admissions after hospital discharge and a cluster analysis in 761 patients.

As mentioned, the first design thinking session was devoted to the analysis of the current regional management of complex chronic patients. The input information and the results of the interviews were processed to generate a Context Analysis (Figure 1S) and an Empathy Map. This map, divided into four quadrants, captured the perspectives of patients/professionals, detailing what they: said, did, thought and felt [2930] (Figure 2S). Discussion and consensus-building took place regarding the ideas presented, and proposals were collected. The results of the first design thinking session contributed to generate a SWOT analysis (identifying: strengths, weaknesses, opportunities, and threats) and to prepare a summary of the results of the session (Figure 3S), that were used to feed the second session focused on exploring actions to improve complex chronic patients’ outcomes within a care continuum scenario. The Impact-Feasibility Matrix (Figure 4S), generated from the debate, helped to assess the potential impact and effort required for each planned action. This analysis played a pivotal role to define recommendations for next steps.

The Confirmation Phase – The assessment of value generation and transferability of Hospital at Home in Catalonia (ES) during the period 2015–2019 [2531], carried out in the context of JADECARE, offered the opportunity to analyse a large dataset of post-discharge episodes.

A total of 49,604 episodes from 27 different hospitals were examined. The analysis included patients’ characteristics, multimorbidity-complexity, use of healthcare resources and expenditure during four well-defined periods: i) one year before the acute episode, ii) during the acute episode requiring hospital admission, iii) 30-days, and iv) 90-days after hospital discharge. A large portion of the patients fell into the spectrum of complex chronic patients, as reported in [24], with no differences in health outcomes between modalities of hospitalization, either Hospital at Home or in-hospital admissions.

The report [24] combines a quantitative analysis of the results with a qualitative assessment of Home Hospitalization, and post-discharge episodes, carried out by a panel of seven experts. The panel included 1-to-2 representatives of the most relevant organizations in implementing or assessing Hospital at Home services in Catalonia: two members from the Catalan-Balearic Society of Hospital at Home, two staff members from the Catalan Health Service, one staff member from the Health Quality and Assessment Agency of Catalonia (AQuAS), and two experts from the local JADECARE team. Four out of the seven experts were clinical leaders of different Hospital at Home programs. A qualitative research and service design specialist was recruited to facilitate and lead the discussions of the expert panel.

The quantitative analysis of the hospital admission episodes, and the results of a survey previously administered to the panel of seven experts, fed the debates in the two subsequent design thinking sessions, held in November and December 2022, saw participation from by the same group of seven experts (Figure 1, Table 2S). It is of note that the analysis of heterogeneities among the 27 hospitals [24] in terms of traits and services outcomes was very useful to generate conclusions in the Consolidation phase.

Setting the scene Main outcomes of the co-design process

The Discovery phase identified the following four actionable factors as main explanatory determinants of the efficacy-effectiveness gap:

1. Change management was found as the most relevant determinant requiring attention for action. However, several different factors/needs were considered under change management, namely: i) a better definition of the boundaries and interplay among different modalities of services depicted in Table 1, with emphasis on integration between health and social care services, ii) a definition of professionals’ profiles and roles required for enhanced management of selected chronic patients to be included in a program to prevent unplanned hospitalizations, iii) unmet specific needs in terms of education and training of those professionals, iv) request for a deeper debate defining patients’ profiles, taking into account their unique requirements for treatment and/or care, and v) the need to improved support for shared care agreements across different levels of healthcare and for collaborative work.

2. Personalization of the interventions – The results of the cluster analysis are depicted in Figure 2, reproduced from [23]. The Figure displays the main traits of the four clusters of patients identified in the analysis of 761 hospital discharges at HCB, as well as their mortality rate and use of healthcare resources after discharge. Clusters #1 and #2 include patients with a mean age in the early seventies. It is of note that patients in cluster #2, with potentially reversible risk factors related to unhealthy lifestyles, clearly showed worse health status and poorer prognosis than those in cluster #1. Whereas individuals in clusters #3 and #4 showed a similar mean age in the mid-eighties, with high medical or social complexity, respectively. These results fostered a lively debate on service selection depending on the patient profile, for example, home care or intermediate care programs (Clusters #3 and #4) versus community-based prevention of unplanned hospitalizations (Clusters #1 and #2).

   The results of the cluster analysis [2526] reinforced the need for exploring the boundaries and interplay among different modalities of clinical and social care services indicated in Table 1, as well as the debate on cure and/or care needs in specific groups of complex chronic patients. Moreover, the personalization in terms of the type of concurrent diseases, and disease severity, focuses on the complementarities between disease-focused vs patient-oriented management. Also, case management strategies to monitor the progress of the patient’s status should be considered. These aspects highlight the importance of carefully selecting services and dynamically personalizing interventions over time. Moreover, such requirements have also a significant impact on the roles of the professionals involved in the preventive program.

   The debate suggested the need for exploring the potential of predictive modelling to feed clinical decision support tools that could contribute to personalization of transitional care action plans at hospital discharge. The ultimate goal is to improve the efficiency of care integration between hospital and community services, ensuring a seamless transition for patients.

3. Mature Digitalization – Current digital support was considered not to meet the requirements for the management of complex chronic patients. The group identified the following requirements to provide scalable digitalization: i) support collaborative work with an adaptive case management approach. By implementing such management modality, integrated care processes can be designed, developed, and implemented in a way that empowers patients, clinicians, and other stakeholders, leading to improved health outcomes and better patient experiences., ii) supporting cloud-based digital health tools with an adaptive case management approach, interoperable (ad-hoc) with existing electronic health records from different suppliers across healthcare tiers.

4. Adoption and assessment – The transition from evidence-based efficacy of any intervention to the demonstration of effectiveness and healthcare value generation assessed using a Triple or Quadruple Aim approach [32] was considered a must. Also, evaluation of equity in terms of service accessibility, Quintuple Aim [33], was considered necessary. Nevertheless, the applicability of the current assessment tools in real-world scenarios shows major limitations. As reported in [34] there is an urgent need to develop and validate applicable tools to evaluate Patient Reported Outcomes/Patient Reported Experiences (PROMs/PREMs), or their surrogates, for mainstream interventions in real-world scenarios. Also, identifying relevant key performance indicators (KPI) and elaborating appropriate dashboards for quality assurance after service adoption were proposed as core requirements. To this end, refinement of the comprehensive evaluation approach described in [35], aiming at enhancing its applicability, was strongly recommended.

Figure 2

The Discovery phase supported the hypothesis that an efficient program [26] to prevent unplanned hospitalizations in selected complex chronic patients could be designed [26] by properly articulating the four areas described above. Moreover, the analysis of the heterogeneities among the 27 healthcare providers [26], including the assessment of the post-discharge period, carried out the Consolidation phase was confirmatory of the considerations raised in the Discovery phase. The two design thinking sessions of the Confirmation phase indicated a high potential of the Hospital at Home teams to foster productive interactions, between hospital-based professionals and community-based teams, for reengineering transitional care after hospital discharge.