Supporting Older People to Live Safely at Home – Findings from Thirteen Case Studies on Integrated Care Across Europe

Introduction: While many different factors can undermine older people’s ability to live safely at home, safety as an explicit aspect of integrated care for older people living at home is an underexplored topic in research. In the context of a European project on integrated care, this study aims to improve our understanding of how safety is addressed in integrated care practices across Europe. Methods: This multiple case study included thirteen integrated care sites from seven European countries. The Framework Method guided content analyses of the case study reports. Activities were clustered into activities aimed at identifying and managing risks, or activities addressing specific risks related to older people’s functioning, behaviour, social environment, physical environment and health and social care receipt. Results: Case studies included a broad range of activities addressing older people’s safety. Although care providers felt they sufficiently addressed safety issues, older people were often concerned and insecure about their safety. Attention to the practical and social aspects of safety was often insufficient. Conclusions and discussion: Integrated care services across Europe address older people’s safety in many ways. Further integration of health and social care solutions is necessary to enhance older people’s perceptions of safety.

Information collected throughout the preparation phase was stored in a secure online database. Uniform templates were used to analyse and report the baseline information for each integrated care site [2].
Development phase: Based on the local improvement priorities identified in the preparation phase, steering groups consisting of local stakeholders were set up in each participating site. Starting in spring 2016, these steering groups designed improvement activities that were tailored to local priorities and addressed SUSTAIN's core domains. Information on these improvement activities was collected in two ways: 1. Improvement and implementation plans: A template for a structured and uniform description of the improvement and implementation plans was developed and used across the sites. This template included information on the sites' improvement objectives, improvement activities, expected outcomes, stakeholders involved and necessary resources. Templates were completed by the research partners collaborating with the sites after the steering group had agreed on the improvement project. 2. Flowcharts: For each site, flowcharts were developed to depict the pre-existing and improved pathways. Flowcharts were developed by research partners collaborating with the sites and included existing, new and modified actions, stakeholders, materials and processes needed to realise the proposed improvements.
Implementation phase: Starting in autumn 2016, participating integrated care sites implemented their improvement activities during the 18-month implementation phase. Table 1 shows the set of quantitative and qualitative data collection tools that was developed in order to monitor and evaluate implementation progress and impact on SUSTAIN's core domains. Data were collected at agreed and specified times and participants included health and social care professionals, managers from the integrated care service, older people using the integrated care service and (informal) caregivers of these older people. Data collection tools developed by SUSTAIN research partners were provided in English and subsequently translated into the national languages. Regular meetings and teleconferences took place between partners in order to standardise methods of data collection in each country.
Collected data were stored in a secure online database, for which strict data entry guidelines were developed and shared across research partners. To build the individual case studies, data were analysed using a three-staged approach, described in De Bruin et al., 2018 [3]: 1.
Step 1: Each individual data source was analysed using either quantitative or qualitative methods, as appropriate for that specific data source. In order to standardise data analysis across all sites, uniform data analysis templates were developed based on discussions among research partners.

2.
Step 2: After analysing each individual data source, results for that source were reduced to a series of summaries (in case of quantitative data) and thematic statements (in case of qualitative data). These summaries and thematic statements were provided in English. 3.
Step 3: For each case study, summaries and thematic statements were amalgamated and underwent a process of pattern-matching across the data. In order to guide this process and ensure uniformity in data analyses across all case studies, an analysis framework was developed and used by all research partners. Data were analysed against two propositions and five analytical questions:  Proposition 1: Integrated care activities will maintain or enhance personcenteredness, prevention-orientation, safety, efficiency and coordination in care delivery.
 Proposition 2: Explanations for succeeding in improving existing integrated care sites will be identified.  Analytical question 4: Are there any factors that are particularly strong in your analysis that could be seen as having an impact on integrated care improvements?
 Analytical question 5: What factors can you identify in your site analysis that could apply to integrated care improvements across the EU, and be transferable?
Results of these analyses were reported in individual case study reports [4][5][6][7][8][9][10].  [11] Survey measuring older people's experience and understanding of the care and support they have received from health and social care services Recruitment and collection took place throughout implementation period Perceived Control in Health Care (PCHC) [12] Survey addressing older people's perceived own abilities to organise professional care and to take care of themselves in their own homes, and perceived support from the social network Recruitment and collection took place throughout implementation period Team Climate Inventoryshort version (TCI-14) [13] Survey measuring vision, participative safety, task orientation and experienced support for innovation of the improvement team Collection took place at the beginning and end of implementation period

INTERVIEWS
Semi-structured interviews with older people and/or their informal caregivers Interview schedule developed by SUSTAIN researchers with items regarding users' and carers' perceptions of and experiences with the integrated care services and the extent to which they work in a personcentred, prevention-oriented, safe and efficient manner Recruitment and collection took place throughout implementation period Group interview with participating health and social care professionals Interview schedule developed by SUSTAIN researchers with items regarding professionals' perception of and experiences with the improvement process, its facilitating and impeding factors and the extent to which it impacted person-centeredness, prevention-orientation, safety and efficiency of their way of working Collection took place at the end of implementation period Semi-structured interviews with managers Interview schedule developed by SUSTAIN researchers with items regarding managers' perception of and experiences with the improvement process, its facilitating and impeding factors and the extent to which it impacted personcenteredness, prevention-orientation, safety and efficiency of their way of working