Table 1.

Project INTEGRATE People Centred Integrated Care Process Framework.

The Project INTEGRATE framework to assess people-centred integrated care processes
Strategy, Project Charter, Governance [37,41,46]: This section includes a number of criteria to assist managerial teams to define how to organise, develop and facilitate the achievement of the mission and vision of a process or project; to create values required for long-term success and implement them via appropriate actions and behaviours; to support organisational policy and strategy; and to support the effective operation of its processes. This is compiled in a Project Charter – a blueprint that contains the vision and scope set out by leaders, and the roles and responsibilities of stakeholders, and a salient role for implementation. A Project Charter is a tangible reference point for focusing teams towards a common set of goals, which goes beyond describing the vision and responsibilities of stakeholders involved.
Service name: Add the title of the PCIC process being assessed or planned.
Service description: Describe the PCIC process being assessed or planned and what is included within it. What is the intended service innovation (i.e. the intended change)? Define the intended service users/target population.
Mission: Explain the rationale for the new PCIC process.
Objectives: Provide operational objectives that correspond to the mission statement. Are they specific; measurable; attainable; relevant and time-bound?
Deliverables and milestones: List all deliverables and milestones that will be achieved during this PCIC process (tangible and intangible).
Scope: State the boundaries of the PCIC process include what is included and required for the service delivery from your organisation, and what is required externally in order to successfully achieve this care process.
Risk Management [20,41,42]: In the design/planning phase, identify any assumptions or potential risks to the PCIC process and how this might impact the service user. This includes any aspects that can facilitate or complicate the development, and deployment of the care process and which focuses on the variability and the risks within the process, taking into account the impact these can have on the service provided. Attempt to classify the risk types identified ‘PESTEL analysis’ (i.e. political, economic, social, technological and legal) and these can be classified into the following broad service quality terms [20,41,42]: Reliability (e.g. coherence; consistency). Tangibles (e.g. facilities; personnel/staff; equipment and tools; documentation). Quality assurance (e.g. technical competence; professionalism; safety; confidentiality). Responsiveness (e.g. institutional response capacity and agility). Empathy (e.g. manner of communication). Actions for mitigating these risks should then be discussed in a suitable environment in which all the relevant stakeholders can be clear on how to minimise risk.
Pre-defined ideal success criteria [41]: Pre-define the ideal success criteria for the PCIC process, considering all stakeholders; note that this may or may not be the same as the objectives.
Governance [37]: Detail: 1) how to organize, develop and facilitate the achievement of the services mission and vision, and 2) how to create values required for long-term success, and 3) how to implement them via appropriate actions and behaviours.
Degree and breadth of integration [13,14,48,49]: Describe the current connectivity between the different PCIC process steps between and across different levels of services and other care providers and teams, degree and breadth of integration. Identify the essential elements that facilitate and/or hinder this. Within each of these stages it is important to know: when, where, and what is happening; who is doing what, and how it is done, including the supportive tools used. In addition to knowing why- as this can provide understanding on what prompted a given step of the process, and quite often provides a rationale for the subsequent step in the process chain.
Leadership [37]: Define the ‘leader(s)’ of this PCIC process. In this case, a leader is defined as being a role model striving for excellence and promoting a good communication strategy. Detail the people who lead the transitions between different stages of the case process, and who supports the integration of these care services.
People [37]: This section is about how an organisation coordinates, develops and releases knowledge, skills, and full potential of its people at an individual, group, and organisational levels. People centredness’ should underpin the entire care process design and therefore an assessment of how this is operationalised at each implementation stage is required.
Professional Integration [13,14,42,47,48]: Define the level of professional integration, in terms of joint working and group practices, contracting or strategic alliances of health professionals within and between institutions and organisation; an important distinction should be between whether these are ‘formal’ or ‘informal’ alliances. Define any person that will or could impact results of PCIC process; include any additional roles that have been created to support this innovation. Detail the multidisciplinary care plans and comprehensive assessment tools used by the team members. Detail whether the shared care protocols and procedures are in place and are well disseminated to the team(s); add a description of how the team may formally work together with such procedures and protocols. Finally, detail whether (and how much) investment is demanded by understanding the needs of providers and team. Define the additional skill sets and/or education required for the service providers and multidisciplinary team members involved in the PCIC process in order to fulfil their ‘new roles’ to support PCIC (in comparison to ‘traditional care’). Define any new task delegation or advanced roles that may be required to support this process innovation (e.g. from doctors to nurse) [57].
People centredness [58,26]: At what stages of the integrated care process are service users involved in their decision-making? How are they involved (i.e. what type of self-management support and/or support for informal carers offered)? How are service user needs and their feedback incorporated into the evaluation and design of the service in order to co-design solutions? If this is not done, discuss how this might be done. Identify the skill sets and education required for service users to be able to be involved in the PCIC process (e.g. health literacy)?
Resources [37]: This section relates to the enablers or barriers to PCIC and therefore the necessary internal resources required in order to support effective operation. E.g. information management, financial incentives and reimbursement structures, facilities and infrastructure and human resources. In addition, how an organisation plans and manages its external partnerships and internal resources in order to support its policy and strategy and the effective operation of its processes.
Information management: Detail the current information system(s) used to facilitate the PCIC process and their level of interoperability (e.g. shared electronic medical records, risk stratifications). What services do they connect? What services do they still need to connect?
Finance: Detail the financial incentives and reimbursement structure that are used and/or that can be used to facilitate the PCIC process. Include how these are different from standard care.
Facilities and infrastructure: Detail the necessary facilities (space, equipment, materials and technological support) to enhance the PCIC process. What additional infrastructure is required compared to standard care?
Care process [37]: This section assists to outline and clearly define the building blocks of the PCIC process, and the transition from one block to another, which typically involves a mix of situations (e.g. responsibility handover, completion-start of tasks, information transfer), and the identification of the value propositions and how to generate increased value for all stakeholders [46].
Building blocks of integrated care process [20]: Define each step of the care process, adding details about which of these steps (and which parts of these steps) are ‘visible to’ or ‘actively experienced by’ the patient and what is not but is necessary to support the care process, in terms of: access; check-in; diagnostics; delivery; check out/follow up: Access: Define how the ‘case identification’ process and ‘service user admissions’ are organised and performed. Check-in: Detail how the ‘case evaluation’, ‘service user assessment and enrolment’ of the service user into the PCIC service are conducted. Diagnostics: Explain the ‘work plan definition’ and ‘care plan development’ processes. Delivery: Detail how the ‘work plan execution and ‘treatment’ are performed and defined. Check out/follow up: Describe the ‘service user’s transition/discharge’ process and the organisation of subsequent services and visits. How are service users being supported to self-manage their care?
Identification of value proposition and waste [22,41,42,20,44]: Define the essential promoter(s) and potential inhibitors of the ‘integratedness’ of the care process. Analyse the stages of the care process and the components, while considering what value they bring to the different stakeholders. These stages can be optimised – in light of a needs analysis – or alternatively removed. High-value added and urgent changes should be prioritised to leave a larger positive impact. Short-term gains provide direction; motivate health and social care workers and aid in scaling and transferring practices. Furthermore, compare the PCIC with standard care, in terms of the value proposition and the value added to stakeholders. Assess whether an activity or criteria within a process is adding value or not using the following categories; if it does not contribute to either value potential or realization, it should be removed [44]: Value-Added Activities – an activity that is transformative if the service user needs and prefers it. Needed or Enabling Activity – if no value is created with this activity, but the activity cannot be eliminated as it is a necessary part of the current process. Non Value-Added Activity – if the activity consumes resources but does not create value to the service user and can be removed without hindering the process then it is considered as ‘waste’ and should be removed.
Results/monitoring and evaluation of impact [37]: This section assists to assess impact of the care process innovation on stakeholders. In addition to a-posteriori assessment of the entire integrated care process [37,47,48,49,42].
Service user results: What impact has the PCIC process/had on the service user(s) (i.e. how successful was the innovation)? What was the perceived impact and value added by the service users? [42] How this is measured? How often this is measured? How is the feedback incorporated?
Health professional results: What impact has the PCIC process had on the health professionals within the service provider(s)? What was the perceived impact and value added for the professionals involved? [42] How often is this measured and how? How is this feedback incorporated and used?
Service provider results: What impact has the PCIC process/service innovation had on the service provider? Has there been a change in the utilization of services and in expenditure since the PCIC process/service innovation? What was the perceived impact and value added by the service provider? [42] How often is this measured? How is this measured? How is this feedback incorporated/used?
Care process design review: Finally, review the assessment of the current PCIC process, compare it with the pre-defined ideal success criteria and then try to summarize the main changes, value-added and/or ‘waste’ identified. From this comparison, the care process can then be optimised to ensure service quality and effectiveness that will support potential scale-up and transferability to other settings [20].