Literature Collection

BACKGROUND: Integrated care interventions can improve patient outcomes and reduce the burden on acute health services, but need a strong evidence base to ensure their effectiveness. Understanding the meso and macro context in which care is delivered and determining whether patient needs are met are essential to successful implementation. Care coordination in New South Wales (NSW), Australia has evolved over time to meet the needs of an ageing population with chronic health conditions and multi-morbidity with the aim of reducing potentially preventable hospitalisations. OBJECTIVE: To examine how an integrated care coordination program was understood and implemented at state, district and clinician levels in NSW. The Integrated Care for People with Chronic Conditions (ICPCC) program was implemented statewide, however local implementation varied. Patients who were suitable for integrated care coordination were identified via a hospitalisation risk prediction algorithm and/or referrals from health professionals. METHODS: Understanding and implementation of ICPCC were assessed via interviews and a focus group with a range of health staff. Qualitative data were analysed using NVivo software and normalisation process theory. RESULTS: There was a strong sense of program coherence from management, clinicians and referrers. They viewed ICPCC as effective in coordinating care for patients at risk of hospitalisation and incorporating self-management at home. All health staff interviewed understood the program purpose and necessity, including the importance of achieving patient and systemic goals. Networking, linking services and program promotion were important, as was reporting on benefits. While the algorithm effectively identified previously hospitalised patients, it did not identify all suitable patients in the community with an increasing risk of requiring acute health care intervention. Referrals from health professionals familiar with patient needs and complexity were an important additional mechanism for patient selection. CONCLUSIONS: There was a shared sense of coherence and understanding of the ICPCC program among health staff at the three levels of implementation within NSW. The program played an important role in assisting patients with a range of chronic conditions to access and benefit from integrated care coordination, while increasing their capacity to self-manage at home. Program intake via hospitalisation risk prediction algorithm plus referrals from health professionals familiar with patient needs and complexity can effectively identify those who may benefit from integrated care coordination.

BACKGROUND: Health care for individuals experiencing homelessness is typically fragmented, passive, reactionary, and lacks patient-centeredness. These challenges are exacerbated for people who experience chronic medical conditions in addition to behavioral health conditions. The objective was to evaluate an innovative healthcare delivery model (The Mobile, Medical, and Mental Health Care [M3] Team) for individuals experiencing homelessness who have trimorbid chronic medical conditions, serious mental illness, and substance use disorders. METHODS: We assessed changes in study measures before and after M3 Team enrollment using multi-level mixed-effects generalized linear models. Data sources included primary data collected as part of the program evaluation and administrative records from a regional health information exchange. Program participants continuously enrolled in the M3 Team between August 13, 2019 and February 28, 2022 were included in the evaluation (N = 54). The M3 Team integrates primary care, behavioral health care, and services to address health-related social needs (e.g., Supplemental Nutrition Assistance Program benefits and Social Security/Disability benefits). Outcome measures included number and probability of emergency department (ED) visits and behavioral health symptom severity measured using the Behavior and Symptom Identification Scale (BASIS-24) and the Addiction Severity Index (ASI). RESULTS: M3 Team participants experienced a decrease of 2.332 visits (SE = 1.051, p < 0.05) in the predicted number of ED visits in a 12-month follow-up period, as compared to the 12-month pre-enrollment period. M3 Team participants also experienced significant reductions in multiple domains of mental health symptoms and functioning and alcohol and drug use severity. CONCLUSIONS: Individuals experiencing homelessness who received integrated, patient-centered care from the M3 Team saw reductions in ED use and improvements in aspects of self-reported psychosocial functioning and substance use symptoms after enrollment in this novel healthcare delivery model.