title: Implementation of integrated geriatric care at a German hospital: a case study to understand when and why beneficial outcomes can be achieved.
abstract: Many health systems have implemented integrated care as an alternative approach to health care delivery that is more appropriate for patients with complex, long-term needs. The objective of this article was to analyse the implementation of integrated care at a German geriatric hospital and explore whether the use of a "context-mechanisms-outcomes"-based model provides insights into when and why beneficial outcomes can be achieved.
  
  
  
  We conducted 15 semi-structured interviews with health professionals employed at the hospital. The data were qualitatively analysed using a "context-mechanisms-outcomes"-based model. Specifically, mechanisms were defined as the different components of the integrated care intervention and categorised according to Wagner's Chronic Care Model (CCM). Context was understood as the setting in which the mechanisms are brought into practice and described by the barriers and facilitators encountered in the implementation process. These were categorised according to the six levels of Grol and Wensing's Implementation Model (IM): innovation, individual professional, patient, social context, organisational context and economic and political context. Outcomes were defined as the effects triggered by mechanisms and context, and categorised according to the six dimensions of quality of care as defined by the World Health Organization, namely effectiveness, efficiency, accessibility, patient-centeredness, equity and safety.
  
  
  
  The integrated care intervention consisted of three main components: a specific reimbursement system ("early complex geriatric rehabilitation"), multidisciplinary cooperation, and comprehensive geriatric assessments. The inflexibility of the reimbursement system regarding the obligatory number of treatment sessions contributed to over-, under- and misuse of services. Multidisciplinary cooperation was impeded by a high workload, which contributed to waste in workflows. The comprehensive geriatric assessments were complemented with information provided by family members, which contributed to decreased likelihood of adverse events.
  
  
  
  We recommend an increased focus on trying to understand how intervention components interact with context factors and, combined, lead to positive and/or negative outcomes.
authors.affiliation: Tranzo Scientific Center for Care and Welfare, Tilburg University, Warandelaan 2, 5037 AB, Tilburg, The Netherlands. l.busetto@tilburguniversity.edu.
authors.forename: Loraine
authors.identifier: 0000-0002-9228-7875
authors.initials: L
authors.lastname: Busetto
authors.affiliation: Geriatrics Research Group, Charité Universitätsmedizin Berlin, Berlin, Germany.
authors.forename: Jörn
authors.initials: J
authors.lastname: Kiselev
authors.affiliation: Tranzo Scientific Center for Care and Welfare, Tilburg University, Warandelaan 2, 5037 AB, Tilburg, The Netherlands.
authors.forename: Katrien Ger
authors.initials: KG
authors.lastname: Luijkx
authors.affiliation: Geriatrics Research Group, Charité Universitätsmedizin Berlin, Berlin, Germany.
authors.forename: Elisabeth
authors.initials: E
authors.lastname: Steinhagen-Thiessen
authors.affiliation: Tranzo Scientific Center for Care and Welfare, Tilburg University, Warandelaan 2, 5037 AB, Tilburg, The Netherlands.|Panaxea B.V., Amsterdam, The Netherlands.|Department of Patient & Care, Maastricht University Medical Center, Maastricht, The Netherlands.|Department of Family Medicine and Chronic Care, Vrije Universiteit Brussel, Brussels, Belgium.
authors.forename: Hubertus Johannes Maria
authors.initials: HJ
authors.lastname: Vrijhoef
mesh_terms: D000368:Aged; D001291:Attitude of Health Personnel; D002908:Chronic Disease / Q000191:economics / Q000628:therapy*; D019033:Delivery of Health Care, Integrated / Q000191:economics / Q000592:standards*; D015577:Geriatric Assessment / Q000706:statistics & numerical data; D006282:Health Personnel / Q000706:statistics & numerical data; D006299:Health Services for the Aged / Q000191:economics / Q000458:organization & administration*; D006760:Hospitalization / Q000191:economics / Q000706:statistics & numerical data; D006761:Hospitals / Q000706:statistics & numerical data; D006801:Humans; D017063:Outcome Assessment, Health Care; D012051:Reimbursement Mechanisms
keywords: CMO model; Chronic care model; Evaluation; Geriatric care; Implementation model; Integrated care