This document discusses challenges in commissioning research on integrated care and how new studies are tackling these challenges. Integrated care research is complex due to the interplay of context, mechanisms and outcomes, and difficulty tracking activity and costs across settings. New studies are using more robust methods like difference-in-difference analysis across multiple sites and person-linked data to better understand costs and impacts. They are also considering generalizability and using mixed methods to understand how micro-level integrated care can be supported at higher levels.

1. Challenges in commissioning research on
what works in integrated care
Tara Lamont, Scientific Adviser
NIHR Evaluation, Trials and Studies Coordinating Centre (NETSCC)
www.netscc.ac.uk
27/11/12

2. National Institute
for Health Health Services and
What
research do
Delivery Research
Research (NIHR) Programme managers
need to
C£16m (€19.8m) deliver good
£1bn (€1.2bn)/year Focus on quality and services?
effectiveness of
applied health healthcare systems
research system for
NHS
Impact
Ask the right Answer them
questions the right way

3. What do we mean by integration?

4. What mechanisms work?
Call for new research in 2009 (England/Wales) – Evaluating
innovations in integrating health + social care > £2m (€2.4m)

5. Problems in evaluating integrated
models of care
Systematic review of international
evidence – few high quality,
controlled evaluations of models of
integration
[Johri 2003]
• Complex interplay of context, mechanism and outcome
• Difficult to track real patient activity and costs across
settings
• Local initiatives which may be difficult to replicate
• Small-scale studies often at single sites

6. How do the new studies tackle
these challenges (i)?
New evidence on
efficacy and cost-
• Lewis and team at Nuffield Trust UK effectiveness of
integration at
• Virtual wards – started as experiment 10 years ago, spreading
micro and meso
widely Robust
levels
• Target patients at high risk of emergency admission and monitor
economic
analyses
daily by involving 2008
multidisciplinary team (matron, pharmacist, social worker,
GP) with coordination by ward clerk and integrated care record
patients over 3
sites
• Sophisticated methods on costing and activity:
- difference-in-difference analysis (comparison of admissions with
matched non-intervention groups)
- economic analysis (person-linked data on patients services across
Tracking use of
across sectors
health and social care)
Useful practical
using innovative
tools for
• person-level
Should answer question: what do virtual wards cost and what effect
managers eg
`bottom-up’
calculating
do they have on costs and use of hospital and other services?
costing
optimal
casemix for
virtual wards

7. How do the new studies
tackle these challenges (ii)?
Case study
• Parker et al at York University, UK design
informed by
• Innovations in integrated services for people with neurological
programme
disorders (as exemplar longterm condition) theory
• 4 organisational case studies selected purposively to test different
forms of structural integration (eg comparison of joint funding
agencies versus separate authorities) against micro-level initiatives
• Initiatives compare and contrast models of multidisciplinary team
management for brain injury – health led, social care led, joint led
Evidence on how
• Multi-methods tomicro-level
understand interplay of context and mechanisms
integrated care
• Working with patients to develop user-derived outcome measures
can best be
against which to assess at
supported models of care
meso- and
macro-levels.

8. 5 top tips for researchers
evaluating integrated care
• Describe intervention well (eg workforce – include
grademix, skillmix, professions) – could it be replicated
elsewhere?
• Think about generaliseability of findings (eg comparator
sites, controls, use of national reference data) – will
findings be meaningful elsewhere?
• Consider context in study design (eg sampling frame
based on variables derived from evidence)
• Consider new methods to capture costs and service
complexity (eg person-linked data to track activity across
settings) – top class health economics input essential
• Position your study against existing body of knowledge –
what is already known and what will your study add?

9. For more information on these and some other
health services research studies, visit
http://www.netscc.ac.uk/hsdr/project.php
This presentation presents independent research funded by the National
Institute for Health Research (NIHR). The views expressed are those of the
author(s) and not necessarily those of the NHS, the NIHR or the Department of
Health.
Tara Lamont
Scientific Adviser
NIHR Health Service & Delivery Research Programme
t.lamont@southampton.ac.uk
.