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Table 3 Summary of measures identified in review articles

From: Measures for the integration of health and social care services for long-term health conditions: a systematic review of reviews

MeasuresMeasure sub-groupTopics identified
StructuralIntegration ethos: Understanding, appreciation and ‘buy-in’Goals/aims aligned [15, 22]
Professional roles and responsibilities [22]
Management support (Vision, risk management, health and safety, structure, confidence in staff) [22]
Perceived systems integration [15]
Historical/cultural/contextual issues [15, 22]
Communication and information sharingCoordination between services and linkages, Inter/intra organisation communication across providers [15, 21, 30, 33, 34], transition policies, efficiency in assessments, case prioritisation, connections with partner organisations, case and care management [15, 22, 30, 33]
IT systems and data management [15, 22, 33]
IT accessibility to patients [15]
Logistic and suitability of information sharing, Co-location [22]
StaffTeam effectiveness, productivity, competency, cohesion, communication, task completion, role performance [15, 23, 30, 34]
Teamwork between providers [21, 30]
Physician integration in provider collaboration [15, 33]
Budget compatibility and resourcesUnified/pooled budgets/integrated management [22, 31]
Transfer payments [31]
Barriers to financial integration [31]
Resource allocation [15]
Other organisationalHR arrangements (e.g. sick leave) [22]
Administrative burden [21]
Service differentiation [33]
Operational and organisational structure integration [15, 33]
Clinical integration [33]
OtherExtent of integration (Depth/level/degree of integration) [15, 32]
Implementation of integrated delivery, Plan-do integration [33]
Care integration and chronic care [20]
ProcessesPerformance measuresQuality: Perceived quality, quality standards [13, 15, 21, 28, 31], quality of care transistion [15], quality of care planning, performance management [15]
Time spent in emergency/urgent care, length of wait [13], timeliness of assessments [22], timeliness of information transfer [15]
Rates of patients leaving insurer [21]
Adherence to process measures [27]
Improved documentation [28]
Patient, family and carer perspectivesSatisfaction, experience, preferences met, involvement in decision making, incidents of complaints [13, 15, 20, 21, 23, 29,30,31,32, 34]
Level of empowerment and empathy [15, 30, 32], person centeredness, comprehensive care [20, 24]
Personal respect (dignity, confidentiality, autonomy, comfort with care provider) [15, 34], compassionate care, preferred place of death [24]
Unmet needs identified [13, 32], meeting needs of patient [22, 34]
Carer experiences and satisfaction [23, 31]
Quality of interactions [28]
Provider experienceProvider experience, staff satisfaction [21, 34]
Work experience [13]
Staff stress, role conflict, trust in other team members, frequency of contradictory demands of staff, empowerment, staff wellbeing [15, 22, 34]
Coordination and planningCooperation, coordination between providers (patient and provider, provider-patient interaction and transition planning) [15, 20, 21, 33, 34]
Coordination following discharge [21]
Continuity of care/ continuous [15, 20, 21, 24, 33, 34]
Number of patients/existence of care plans, follow ups [15, 21]
System outcomesHealthcare and social care utilisation: Admissions and length of stayAdmissions/readmissions (including unscheduled (e.g. due to fall), care home, long term care) [13, 21,22,23, 25,26,27,28,29,30], Ambulatory care sensitive hospital admissions [24], Time from event to admission [23], Inappropriate admissions [22], Hospital admissions and nursing home transfers avoided [28]
Discharge (including delayed discharge, community discharge, unintended) [22, 23, 31]
Emergency and urgent care use [13, 19, 21, 29, 30, 32]
Length of stay [13, 19, 21, 23, 26, 27, 29, 30, 32]
Entry and retention in primary medical care [26]
Healthcare and social care utilisation: Amount of services usedNumber of contacts (including clinicians, case manager, ancillary services) or appointments (GP or outpatient appointments and/or checkups/consultations) [13, 21, 26, 30], Missed appointments [34]
Number of checks (clinical measures, e.g. Hb1Ac, BMI, blood pressure, foot exam, kidney function, cholesterol, eye test) [21]
Number of home-care hours received per week [22]
Numbers of and reasons for referrals [28]
Amount of home and health services used (detail not specified) [22, 23, 29, 31]
Receipt of regular services [26]
Treatment rates [23]
Medical services utilisation [26, 34]
Follow up and uptake of screening [34]
Prescribing (including appropriateness of prescribing and medication administered) [13, 26, 28]
Use of volunteer services [32]
Community care activity [13]
Secondary care activity [13]
AccessibilityAccess to other resources [13]
Access to services [13]
Access to care (for example, to culturally appropriate care, specialty or sub-specialty care) [21, 24, 26, 34]
CostsCosts [13, 19, 21,22,23,24, 26, 29, 30]
OtherDesire to be institutionalized [32], Prevention of premature institutionalisation [34]
Financial, employment, and health claims addressed (for example, employment and financial stresses, numbers of mental health patients who applied for disability benefits, behavioural health claims, proportion of patients suffering from mental illness who become insured) [34]. Costs of living at home, justice contacts [24], Vocational status [23]
Health outcomesClinical measuresMortality [21, 23,24,25, 27,28,29, 31, 32], Blood pressure [21], BMI [21], Medication [29], Complications [23], Symptoms (e.g. Head injury [23], pain and other [24]), symptom control [28], Cognition [23], co-morbidities [34].
Adverse events [23]
Treatment adherence [26], Adherence rates [23]
Condition specific clinical measures (Bowel related problems [28], Percentage healed, mean time to wound healing [28], HbA1c [21], Transmission (mother to child HIV) [26], Problems associated with substance dependence [26], biomarkers for chronic disease [34].
Levels of function and disability (clinician rated)Function: Health and function [22], function (including physical performance test) [23], physical functioning [24], Functional decline [32], Self-sufficiency [24]
Level of disability [23], Activities of daily living/dependency (Barthel Index) [27, 28], Degree of disability or dependence in the daily activities of people who have suffered stroke (Rankin scale) [27]
Glasgow Outcome Scale (brain injuries, grouping by degree of recovery) [23]
Mental health and behavioural measures (clinician/caregiver rated)Mental state (Mini Mental State Examination) [22, 32]
Frequency and severity of disruptive behaviours [28]
Patient behaviour (Neuropsychiatric Inventory (NPI)) [25]
Assessment of change by nursing home staff [28]
Neurobehavioral Functioning Inventory [23]
OtherUndefined [31]
Patient and carer reported outcomesPatient: Health and wellbeingQuality of life [22, 25, 27, 29, 30, 34], health-related quality of life [23, 27, 31]
Perceived health [29], subjective health [23]
Patient outcomes (not specified) [26]
Well-being [22]
Coping with everyday living [22]
QALYs [27]
Patient: Physical healthaPhysical function [25, 27, 29,30,31], Activities of daily living [23, 28, 29, 34]
Patient: Psychological and social factorsMood [23, 29]
Emotional state [23], worries, concerns and stress [34]
Psychological well-being [24]
Mental illness symptoms [26], Mental health [34]
Depression and anxiety [25, 29, 31], Patient Health Questionnaire (PHQ) [23], Geriatric depression scale [28]
Social participation/relationships [24]
Social support [25]
Resilience [24]
Enjoyment of life [24]
Patient: OtherActivation and engagement [24]
Autonomy [24], self-efficacy, self-management or empowerment [34], knowledge and understanding of condition [23, 34]
Total pain relief (brief pain inventory) [28]
Burden of medication [24]
Patient cognition/ cognitive function [25, 29, 30]
Disease specific measurements (undefined) [29]
Carers and familyCarers’ quality of life [23, 25]
Carer outcome (undefined) [23]
Caregiver burden [23,24,25, 29,30,31,32]
Caregiver mood [25], caregiver strain, depressive symptoms or distress [30, 34]
Family relationships [26]
Family involvement in care [15]
Time spent caring [23]
  1. a Considered patient reported unless specifically reported as clinician reported