Table 2 Three main assessment dimensions: effects of the intervention, determinants of success of implementation and maturity of integration
Study Protocol | Maturity level [4] | |||
|---|---|---|---|---|
(1) Population-based | Mortality, general practitioner visits, community-nurse visits, cumulative days per year admitted in hospital, emergency department visits, all hospital admissions, potentially avoidable hospitalizations, multiple drug prescription, needs for social support, costs per patient per year (Additional file 1: Table S1) | A. What are the possible factors and agents responsible for good implementation of a health intervention? B. What are the possible factors for enhancing or expanding a given health intervention? C. What describes the context in which implementation occurs? D. What describes the main factors influencing implementation in a given context? To be assessed using a mixed methods approach: combining qualitative and quantitative methods | Assessment of the twelve dimensions of the Maturity Model for Integrated Care, both at health system and health services levels, promoted by the European Innovation Partnership for Active and Healthy Ageing, following the instructions reported in reference (4). These twelve dimensions are: 1. Readiness to Change 2. Structure & Governance 3. Information & eHealth Services 4.Standardization& Simplification 5. Finance & Funding 6. Removal of Inhibitors 7. Population Approach 8. Citizen Empowerment 9. Evaluation Methods 10. Breadth of Ambition 11. Innovation Management 12. Capacity Building | |
(2) Home hospitalization | Health and well-being | Mortality rate 30/90 days after discharge, place of death, avoidable hospital admissions, total bed days, 12 months before admission (hospital and community resources); 30-day after discharge (hospital and community resources), transitional care strategies (palliative care, primary care or hospital care) | ||
Patient experience | Person centeredness, continuity of care (Additional file 2: Table S2) | |||
Costs | Operational costs | |||
(3) Prehabilitation | Health and well-being | Cumulative hospital days of stay, intensive care unit length of stay, number of complications per patient, costs from the perspective of the hospital including inpatient services, diagnostic procedures, pharmaceutical consumption and blood products consumption, aerobic capacity, physical activity, psychological status, health status (Additional file 3: Table S3) | ||
Costs | Operational costs | |||
(4) Frail elderly | Health and well-being | Mortality rate, avoidable hospital admissions, total bed days, 30-day readmissions, number of ER visits in the month, physical functioning, psychological well-being, social relationships & participation, enjoyment of life, resilience, autonomy | ||
Patient experience | Person centeredness, continuity of care, burden of medication, burden of informal caregiving (Additional file 4: Table S4) | |||
Costs | Operational costs | |||