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. 2023 Feb 13;182(4):1517–1532. doi: 10.1007/s00431-023-04851-2

Table 2.

Overview of included studies

Authors Country Study design Patient population Description of programme Type of integration Terminology
1. Altman et al. [3] Australia Quality improvement project Children with medical complexity (no sample given, as results will be published in greater detail elsewhere) The Kids Guided Personalised Services (GPS): linking tertiary and local hospitals for children with medical complexity. The main foundation of the programme was care coordination, 24–7 telephone support provided to families along with a smartphone app [The My Health Memory (MHM)] that directly uploaded child’s electronic medical records and shared the care plan. Families of children frequently attending the emergency department (ED) were encouraged to ring the hotline first for guidance on what service their child should attend Vertical Integrated complex care model
2. Black et al. [27] USA Quality improvement project

Children with sickle cell disease (SCD) and suspected pulmonary comorbidities (asthma)

(2–18 yrs, n = 24)

Integrated paediatric SCD and pulmonary care clinic: paediatric haematologist and pulmonologist delivered care in parallel with standard SCD treatments. Interdisciplinary team (paediatric haematologist, paediatric pulmonologist, asthma educator, SCD nurse/clinic coordinator) delivered care. Patients received standard SCD treatment but were also screened for pulmonary symptoms using asthma control questionnaires, along with asthma education and written action plans provided to patients and families Horizontal Integrated clinic model
3. Casher et al. [15] USA Evaluation study

Patients in paediatric EDs and urgent care

(3–19 yrs, n = 213)

Enhanced integrated behavioural health service: doctoral-level psychology resident was integrated into the primary team to be the first point of contact for psychiatric consult questions. They reviewed patient medical records and were available for brief consultations. Integrated care consultant reviewed patients’ medical course, conducted brief clinical assessments, and delivered brief psychotherapy or psychoeducation, and co-ordinated with follow-up providers Horizontal Integrated service
4. Cohen et al. [23] Canada Evaluation study Children with complex chronic condition that is associated with medical fragility (up to 16 yrs old, children and their primary caregivers, n = 81) Community-based complex care clinic integrated with a tertiary care centre: clinics were staffed by local community paediatricians together with a tertiary care affiliated nurse practitioner. They were run as a co-management model with existing primary care providers. Patients were referred by their primary care providers. Clinics were run weekly at each site (2 sites: two community general hospitals- Hospital for Sick Children, Brampton Civic Hospital). The nurse practitioner participated via telemedicine during periods of bad weather. Visits were focused on care coordination, complex symptom management, and goal setting. A care plan was developed by the nurse in partnership with the family for all patients, using an electronic template with info on goals of care, patient-specific emergency management guidelines, updated medication lists, and contact details for the medical team. Care plan was given to families and uploaded to an e-portal so it was available to providers across the continuum. Health support was also available from a social worker and dietician when needed, and other community providers. Communication by the family through email and telephone with the nurse was encouraged Vertical Integrated practice model
5. Corrigan et al. [25] USA Parallel group randomized trial Mother-infant dyads (preterm infants in NICU scheduled for post-retinopathy of prematurity (ROP) examination, n = 100) Family-integrated care in the neonatal intensive care unit (NICU): Mothers participated in two separate music therapy interventions (recorded maternal singing and heartbeat for her infant post ROP examination and recorded infant heartbeat with mother-preferred music for the mother’s personal use). Music therapists met with mothers separately, and sessions began with assessing the mother’s overall coping with hospitalisation. The infant’s heartbeat was recorded, and mothers picked a song meaningful to them to be paired with the heartbeat. Music was provided to each mother in the MT group digitally or on a CD. They were advised to use the recordings when they wanted Horizontal Family integrated care
6. Dahhan et al. [31] Netherlands Feasibility study Ethnic minority children with chronic diseases (n = 189) The Mosaic Outpatient Clinic (MOC): involved support offered by a trained team of professionals: 2 supervising consultant paediatricians, 4 student healthcare workers as cultural mediators. Trained student healthcare workers performed consults (45 min) with patients to explore culturally sensitive issues, and parents were asked to specify what healthcare problems they experienced with their children and how the care could be optimised. Patients were seen 3–4 times in the MOC before they were referred back with a report to their own paediatrician at the general POPD. An individually tailored plan was proposed by the healthcare worker and finalised with input from paediatricians and discussed with patients and parents together Vertical Integrated clinic
7.Graham et al. [5] America Feasibility study Children with respiratory technology dependence (30 days–22 yrs, n = 320) The Critical Care, Anaesthesia, and Perioperative Extension (CAPE) Program: aimed to provide comprehensive service through individually tailored care with home visits, liaising with inpatient services, rehabilitation programs and outpatient clinics, school programs, and community services. A key feature was the 24–7 family driven access to critical physicians and other professionals. A key objective was to partner with community providers for routine health maintenance while addressing gaps in care related to the child’s underlying complex condition and needs. The CAPE program was provided in lieu of a traditional, hospital-based pulmonary/respiratory clinic program. Patients received scheduled home and clinic visits at regular intervals with unrestricted family program utilisation. Included MDT including nurse practitioner and social worker Vertical Integrated care programme
8. Grimes et al. [29] America Pilot study Children referred by paediatricians for outpatient child psychiatry evaluation (4–19 yrs, n = 32) Integrated care for children via a collaborative-practice model (CPM): CPM aimed to foster interdisciplinary collaboration between mental health and primary care. To facilitate integration child mental health specialists joined paediatrics team meetings and psychiatry notes were shared with paediatricians via the electronic health record (EHR). Child psychiatry and family support specialist (FSS) staff were available weekly in the paediatric clinics. FSS staff were non- clinician parents with lived experience of caring for a child with mental or substance use disorder needs. FSS staff brought a family perspective to interactions with clinicians and translated families concerns to the clinical teams. Used parent interviews, follow-up and home visits. The intervention was individualised for each child on the basis of team-identified needs and level of treatment intensity, and youth and family preferences Vertical Integrated care
9. Guarnaccia et al. [35] Italy Implementation study Children with asthma (6–15 yrs, n = 260) Integrated clinical and educational pathway for asthmatic children and adolescents (IOEASMA): included three visits with an 8-week interval. Following the first visit, an individual asthma education course was offered to all enrolled patients. The three clinical visits were followed by two visits 6 months apart. The first assessment included family history, past medical history (PMH) and history of present illness (HPI). During the pathway, prick-test and spirometry were performed. Once the control of the disease was evaluated, daily therapy was introduced or modified. At the second, third and two follow-up visits, symptoms were monitored, disease control was evaluated and daily therapy was adjusted as directed by guidelines Horizontal Integrated pathway
10. Hall et al. [28] America Pilot study Infants in PICU (aged 3–72 months, n = 33) Paediatric Critical Care Neurotrauma Recovery Program (PCCNRP): consisted of paired visits with physicians and neuropsychologists from evaluation to referral for targeted intervention. Participants were cared for in the PICU with a neurologic illness or injury and then attended the initial post-discharge follow-up appointment. All children received a physical and neurological examination from the paediatric critical care physician. All children had a brief neurodevelopmental assessment with the neuropsychologist, with parent/caregiver interview and the completion of parent-reported outcome measures. Evaluations were completed in real-time and feedback provided to families with both providers present. The length of the appointment was 2 h Horizontal Integrated care
11. Harden et al. [16] UK Quality improvement project Paediatric kidney transplant recipients (15–18 yrs n = 12) Integrated paediatric-adult clinical service for patients with kidney failure: joint medical clinics at paediatric centres with a team of a paediatric nephrologist and paediatric renal transplant nurse specialist working jointly with an adult nephrologist and adult renal transplant nurse. The joint clinics occurred every 4 months and saw patients jointly by the two teams with transfer to the adult clinic occurring by the age of 18. At each of the 3-h joint medical clinics held at the paediatric centre, 4–5 patients were seen, with individual MDT consultations up to 45 min long. Patients were seen alone to promote autonomy but also with family members to discuss progress and future management. Before transfer to the adult clinic, the patient meets with a youth worker, with at least one community visit, to look around the adult clinic informally Horizontal Integrated service
12. Husted et al. [19] Denmark RCT Adolescents with type 1 diabetes (13–18 yrs old, n = 71)

Guided self-determination- Youth (GSD-Y) intervention:

Intervention group: used guided self-determination (GSD), a life skills approach to facilitate empowerment in the patient-provider relationship. Two paediatric physicians, five paediatric diabetes nurses, and two dieticians provided the GDS-Y intervention as part of their conventional outpatient clinical care. Intervention consisted of 8 sessions over an 8–12-month period with each session lasting 1 h. Involved 18 semi-structured reflection sheets for adolescents, 5 for parents, and 6 if the adolescent was visiting a dietician. Adolescents were also invited to attend one session without their parents to facilitate conversation about personal affairs

Treatment-as-usual group: Adolescents in the control group were also offered 8 sessions, which were scheduled equal to the intervention group across an 8 to 12-month period. They also received typical outpatient care

Horizontal Integrated method
13. Leahy et al. [21] USA Implementation study Patients undergoing congenital cleft repair (n = 235) The Perioperative Surgical Home (PSH) model- a patient-centred integrative model of delivering healthcare during the entire patient surgical/procedural experience, from the decision of surgery through the recovery phase. A paediatric PSH was developed for patients with a diagnosis of laryngeal cleft undergoing endoscopic surgical repair. An interdisciplinary team (anaesthesiologists, surgeons, nurses, quality improvement specialists, IT personnel, finance professionals) met regularly during the design, development, and monitoring phase. Duplication of care and areas of high resource use were identified and redesigned through the integrative approach. Key caregivers were brought together for clinical decision making, input, and evaluation Horizontal Integrated care coordination pathway
14. Lee et al. [37] Hong Kong Retrospective study Paediatric patients who underwent sclerotherapy (n = 49) Joint Vascular Anomalies Clinic: MDT delivers one-stop integrated care to patients with low-flow vascular malformations via a comprehensive team of specialists and nurses. Patients are assessed at the clinic which is held every 2 weeks. Patients are concurrently assessed by the paediatric surgeon and interventional radiologist, with a detailed clinical history, physical examination, and physical measurements taken Horizontal Integrated care
15. McLean et al. [24] Canada Cluster RCT Infants born at < 33 weeks of gestation and receiving minimal or no respiratory support and their parents (n = 126)

Family Integrated Care (FICare):

Intervention group: parents at FICare sites committed to spending > 6 h/day at the infant’s bedside. Parents received enhanced training in the day-to-day care of their infant including bathing, feeding, providing skin-to-skin care, dressing, administering oral medications, taking temperature, and interacting with their infant to support development. Parents were encouraged to participate with the medical team on medical rounds, clinical decisions about their infant’s care, and chart their infant’s growth. Informal peer-to-peer support was also provided and parent and social work involvement in the education sessions, parents were provided with psychosocial support

Control group: received standard care

Horizontal Family integrated care approach
16. Menon et al. [20] USA Pilot study Patients admitted with or developed acute kidney injury (AKI) in all non-ICU inpatient units (6 months–18 yrs, n = 225) Clinical decision support (CDS) system (combining electronic alert and standardised care pathway (SCP)) for children with AKI): integrated new SCP within the existing paging system used in hospitals to improve detection and management of AKI through clinical decision support (CDS) systems. AKI e-alerts were sent to the primary in-house provider (intern, senior resident, nurse) who acted as the clinical contact for the patient. A secure paging system was used to send a short system-based text-page with details of patient and stage of AKI Vertical Integrated clinical support system
17. Pereira et al. [17] USA Evaluation study Patients referred for psychiatric consultations (n = 363) Integrated care continuity clinic: embedded three predoctoral paediatric psychology residents (PSY) into paediatric medical resident continuity care clinics in an urban academic medical centre. Each PSY resident was embedded within three half-day resident primary care continuity clinics (4-h clinics held in the morning and afternoon). Paediatric resident continuity clinic teams were made up of two to four paediatric or medicine/paediatric residents, one PSY resident and one onsite licenced psychologist. PSY residents were involved in patient care during clinics in a number of ways: targeted diagnostic assessment, brief interventions, and collaborative treatment planning. A key component of the learning environment was follow-up discussion with the collaborating paediatrician provider. Discussions typically occurred on the same day as the intervention to allow for team collaboration on a joint treatment plan for the patient. If additional psychotherapy was needed, PSY residents could continue to work with families in their psychology outpatient clinics or could refer them to community resources Horizontal Integrated service
18.Pratt et al., [22] USA Longitudinal design Youths attending a weight-treatment clinic and their caregivers (8–18 yrs, n = 267) The Paediatric Healthy Weight Research and Treatment Center (PHWRTC): provides a comprehensive multidisciplinary intervention to youth referred by their primary providers due to a concern about the youth’s weight and risk of weight-related comorbidities. The care team uses an integrated care model, and care is co-ordinated between medical and mental health providers, with shared care treatment plans. Providers include two physicians that rotate clinic time, a dietician, one family therapist, and a family therapy intern. At each visit, the patients and their caregivers met with the physician and mental health provider together and a dietician. Height, weight, BMI, and blood pressure are tracked by the medical provider at each visit, and depression is tracked by the family therapist. Regular follow-up appointments are made typically every three months Horizontal Integrated care model
19. Stelwagen et al. [26] Netherlands Qualitative study Mothers (n = 27) and fathers (n = 9) of newborns who were hospitalised for at least 7 days FICare: integrated maternity and neonatal care to keep parents close together in an integrated maternity and level 2 neonatal ward. Provided a combination of different care models known to promote parent empowerment. Conducted in a mother and child centre to stimulate parent empowerment by integrating the concepts of single-family rooms, couplet care and FICare (family integrated care). Integrated nursing team consisted of specialised maternity nurses, specialised neonatal nurses, and specialised mother and newborn nurses. Care was able to be provided by one single nurse. Keeping parents and new-borns together was supported by offering room service and facilities for parents Horizontal Family integrated care
20. Tom et al. [32] USA Evaluation study Parents of children with chronic diseases (n = 256) Integrated personal health record (PHR): electronic personal health records (PHR) linked to the patient’s electronic medical record. Allowed patients to view immunisations, lab results, health plan visits, to manage their condition. The aim of providing this to parents of children with chronic conditions was to improve overall care experience by increasing their understanding of their child’s illness Horizontal Integrated personal health record
21. Waters et al. [36] Australia Implementation study Children with anxiety symptoms (4–18 yrs, n = 243) The Take Action Program: utilised a cognitive behavioural intervention (CBI) with anxious children and youth. It was delivered in a classroom-based format and consisted of eight weekly 1-h sessions. Intervention included: psychoeducation about anxiety, training in relaxation techniques, identifying anxious self-talk, development of strength and problem-solving skills and social skills. Children were given psychoeducational handouts after each session to give to their parents, to keep parents informed or what their children were learning and provide practical parenting strategies. Delivered by psychologists during school and class time Vertical

Partnership that integrates school-based, evidence-informed treatment

delivery with clinical education

22. Ye et al. [18] Canada RCT

Children with special healthcare needs (CSHCN)

(0–19 yrs, n = 445)

Children’s Treatment Network (CTN):

CTN group: each child was assigned a service navigator who assessed the child’s health conditions, then a trained service coordinator followed up with the family and working with the family an individual team of service providers was formed to suit the child’s specific health and social needs. This integrative team worked with the family to form a single plan of care for the child, and the service coordinator organised the delivery of services in accordance with the plan. The team met regularly with parents for ongoing revisions and assessment of the plan. All assessments and notes concerning the child were shared in an electronic system by all team members

Control group: families continued to manage services for their child in a self-directed manner

Vertical Integrated service