Background: Reducing maternal-child health disparities in resource-constrained communities requires meaningful collaboration between different sectors to deliver integrated care. Community health workers (CHWs) are uniquely positioned within their communities, typically as volunteers, to act as an intersectoral bridge and catalyst for collaborative efforts to improve maternal and child health and care outcomes. While CHWs are widely recognized as crucial actors in the health and social care workforce, particularly in contexts with decentralized public health systems, a need exists to critically examine the strategies they employ to facilitate intersectoral collaboration and improve maternal and child health, with an eye to informing the expansion of these programs across resource-constrained contexts.

Methods: This study was anchored by a partnership with a Philippines-based, non-governmental organization (International Care Ministries) and embedded within their ‘Community Health Champions’ (CHW) program, a program that trains and supports CHWs. In April 2023, CHWs from six locations in Negros Oriental, Philippines were recruited for 11 participatory focus groups (n=75 CHWs) and 64 semi-structured interviews. Data collection focused on strategies used by CHWs to collaborate across sectors to improve maternal and child health and social care. Focus groups and interviews were audio-recorded and transcribed. Transcripts were thematically analyzed using a hybrid inductive-deductive approach. Ethics approval was provided by the University of Waterloo, Canada (#44828).

Results: CHWs (all female; ages 21-60) facilitated linkages between communities, non-governmental organizations, and the local public health system vis-à-vis working alongside public sector healthcare workers to identify individuals in need of support and to provide treatment or referral to formal care. This collaboration enabled a continuity of care, with CHWs viewing their role as addressing existing gaps within the public sector. Critically, CHWs' positionality and social networks held within communities shaped the degree and quality of intersectoral collaboration. The CHW volunteer role was one of many held by some participants (e.g., leader in a local savings group; employee within the municipality) which facilitated collaboration across sectors. Most CHWs were embedded within communities where they both lived and worked, and thus had expansive social networks to draw upon to facilitate intersectoral collaboration. All CHWs exhibited motivation to care for their communities, which shaped the overall quality of collaboration.

Conclusion: This study highlights strategies used by CHWs as they embody and embed intersectoral collaboration in their efforts to enhance maternal and child health in resource-constrained settings in the Philippines. Opportunities exist to further amplify these efforts and support CHWs to act as a bridge across sectors. In particular, focused training and material resources could extend CHWs' impact in bridging communities, local health systems, and non-governmental organizations to improve maternal and child health and care outcomes. Within these efforts, further research is needed to examine and understand the role of social networks, trust, and pre-existing relationships in shaping the capacity of CHWs with respect to intersectoral collaboration and the delivery of integrated care.

Background: Allied health professionals possess the expertise to improve primary healthcare for frail older adults but do not structurally engage in interprofessional collaboration. Game theoretical concepts may help characterize and explain collaboration and decision-making in the Dutch primary healthcare setting to offer professionals a better perspective for action than the current barriers and facilitators known.
Goal: To explore game characteristics between allied health and other primary healthcare professionals and to explain which collaboration aspects contribute to certain game-play and outcomes.
Participants: Primary healthcare professionals (general practitioners, practice- and community nurses) and allied healthcare professionals (dieticians, physiotherapists, occupational therapists).
Methods: We conducted 25 semi-structured interviews with healthcare professionals, either in-person or online. We asked about their experiences with collaboration between allied health- and other primary healthcare professionals. We used inductive thematic analysis to identify barriers and enablers of collaboration. We used an existing codebook to identify context elements, actor-strategies, game outcomes, and possible implications. We coded three types of games: The Principal-Agent game (P-A), i.e., the principal has more power and the agent more information resulting in power-information asymmetries; The Battle of the Sexes (BS), i.e. healthcare professionals share a common goal but have conflicting preferences and often show go-alone behavior; and the Volunteers Dilemma (VD), i.e., not acting is beneficial, but can lead to worst-case scenarios for both patients and professionals.
Results: In each interview, we found multiple games and identified variations of each game. These variations led to clusters of games representing generic patterns and individual collaboration situations. Examples include a P-A-game that involves a general practitioner who chooses to reject the physiotherapist’s advice, damaging their working relationship; a BS-game in which a community nurse does not reconcile with an occupational therapist on care aid use, which confuses older adults; a VD-game where community nurses are hesitant to involve a dietician, which frustrates the dietician and can lead to preventable weight loss.
Discussion: In this study, we characterize game theoretical concepts between allied health- and other healthcare professionals in a primary healthcare setting. All three games appeared in different forms, showing a variety of implications for collaboration or older adults. Furthermore, the form of a game relates to specific collaboration elements that help to explain or prevent certain game-play. These findings support designing behavioral interventions. Changing how healthcare professionals play games could benefit primary care collaboration with allied health- and other primary healthcare professionals. As a result, quality of care could be improved by better utilization of allied health expertise.
Next steps: These games can raise awareness of game-playing during collaboration in multidisciplinary training sessions. Additionally, they could provide starting points to change behavioral patterns and improve collaboration between allied health- and other primary healthcare professionals. Further research is needed to test whether interventions on behavior can support changing primary healthcare.

Home-based primary care in Canada is currently greatly under-powered, despite an aging population, an increasing proportion of homebound older adults,1 and 100% of Canadians hoping to age at home.2

Homebound older adults in Canada have increased comorbidities, medications and mental diagnoses compared to their non-homebound peers.3,4 They have difficulty accessing office-based care due to a combination of physical, mental and social frailty, resulting in higher emergency department (ED) visits and hospitalization rates.4 Our team, House Calls, reaches homebound adults with further identities that may impact equitable care, including racialized older adults, newcomers, those with English as a second language, adults with disabilities and the precariously housed.

House Calls is a unique not-for-profit home-based primary care team in Toronto, Canada. It was founded in 2007 through consultation with local older adults, caregivers and service providers identifying the type of services that mattered most to their care. It was further developed in collaboration with local community partners.
The team is a health worker-led multidisciplinary team, with physicians, nurse practitioners, occupational therapists, physiotherapists, social workers and administrators working together in a horizontal, trust-rooted leadership structure. Through regular intra-team consultation and annual patient/caregiver surveys, the team evolves its operational structure responsively to patient and community needs.

The goal of House Calls is to help homebound older adults age and die in place, through a three-pronged program: geriatric-focused interdisciplinary primary care, urgent care support and home-based palliative care.
We designed a retrospective cohort study to assess rates of hospitalization, ED visits and time spent in the community for House Calls patients from January 1, 2015 to January 1, 2022, when compared to similarly frail, homebound older adults in the same geographic areas. The study will also measure House Calls program implementation, through rates of interprofessional and urgent care visits.

Study results are pending. We hypothesize that this home-based primary care model results in reduced ED visits and hospitalizations, and more successful aging at home as measured by time spent in the community.

Through the description of this program and its evaluation, we hope to contribute valuable, evidence-based knowledge to inform the care of older adults, in a challenging international climate of aging populations, limited research and often stigma-based funding challenges.

We hope to use our results to improve the quality of care offered at House Calls, and inform wider implementation of similarly structured home-based primary care teams.


References

1. Lapointe-Shaw L, Jones A, Ivers NM, Rahim A, Babe G, Stall NM, Sinha SK, & Costa AP. Homebound status among older adult home care recipients in Ontario, Canada. J Am Geriatr Soc 2022; 70(2):568–578.
2. Sinha, S.,Nolan, M. Bringing long-term care home. NIA. Nov 2020.
3. Qiu, W. Q., Dean, M., Liu, T., George, L., Gann, M., Cohen, J. Bruce, M. L. Physical and mental health of homebound older adults: an overlooked population. J Am Geriatr Soc 2010; 58(12):2423–2428.
4. Musich, S., Wang, S. S., Hawkins, K., Yeh, C. S. Homebound older adults: Prevalence, characteristics, health care utilization and quality of care. Geriatr Nurs. 2015; 36(6):445–450.

In contemporary times, particularly when providing care for clients whose problems cross domains, professionals from various disciplines are increasingly collaborating to achieve their goals (Edmondson and Harvey 2018). This trend is on the rise as diverse groups, from various functions, work units, organizations, and sectors unite to address complex challenges in rapidly changing configurations (Kerrissey, Satterstrom et al. 2020). The added value of interprofessional collaboration is now widely recognized (Petrakou 2009, Schot, Tummers et al. 2020, Wei, Horns et al. 2022). Existing research primarily pertains to fixed teams with binary team membership, based on either belonging or not belonging to a team with clear boundaries (Mortensen and Haas 2018). However, the composition of teams is often variable (Kerrissey, Satterstrom et al. 2020), meaning that cross-boundary collaborative work is characterized by heterogeneity and constant change (Morgan, Pullon et al. 2015, Dow, Zhu et al. 2017, Schot, Tummers et al. 2020). Moreover, interdependence leads to work across boundaries, and novelty leads to fluidity, because it may be unclear who may be needed and at what point they may be needed to do the work (Kerrissey 2018). Given that interprofessional collaboration in psychosocial care often does not occur within fixed teams, it is relevant to focus on what interprofessional collaboration looks like in fluid teams.
Understanding team fluidity in healthcare is important, because this can aid in fostering improved interprofessional collaboration among professionals. This paper therefore discusses how team fluidity plays a role in behavior in interprofessional collaboration in care. The central research question is as follows: RQ: What does interprofessional collaboration look like in a fluid team context? To answer this question, a multimethod ethnographic and multisource research design was conducted. Participant observations and interviews were used and the respondents are frontline professionals from social welfare and general- and mental healthcare. Respondents were consulted in various stages of the research process for reasons of practical relevance.
The article contributes to the literature on interprofessional care by studying three different types of professionals working in dynamic collaborative contexts. Thereby, this article increases our understanding of how various disciplines of professionals may collaborate differently in different subsectors in healthcare (Croker, Trede et al. 2012, Schot, Tummers et al. 2020). Moreover, longitudinal observations are useful in studying fluid and hard to grasp contexts properly (Kerrissey, Satterstrom et al. 2020). Therefore, this empirical research has an iterative design using qualitative longitudinal observations and interviews. Schot and colleagues (2020) identified elements of interprofessional collaboration in fixed teams between professionals in healthcare, namely, bridging gaps, negotiating overlaps and creating spaces. In this research, these elements are used as sensitizing concepts to grasp whether and how these or other elements are present in fluid interprofessional contexts.
The results report on how the collaborative mechanisms bridging gaps, negotiating overlaps and creating spaces are visible in three different empirical contexts. The discussion comes back to how the structure and context of the team may impact the ways in which professionals are able to collaborate.

People with diabetes and peripheral vascular diseases are at an increased risk for lower limb amputations. These amputations can have a significant impact on quality of life and overall health. In primary health care, diabetes management is comprehensive but there remains a care gap in publicly-funded foot care that can provide an upstream and preventative approach to lower limb preservation. This care gap is particularly pronounced for vulnerable populations in the community, particularly Indigenous and under/precariously-housed people. The Barrie and Area Ontario Health Team (BAOHT) prioritized this population health need by developing and implementing a change initiative that was people-centered and collaborative across sectors. In Ontario, Canada, Ontario Health Teams (OHTs) are a newer model of intersectoral health care designed to provide integrated care.  Through the OHT model, community organizations coordinate with OHTs as a unified team to provide integrated and cohesive care with a focus on population health. As such, the BAOHT was an ideal change agent to propose and implement a lower limb change initiative.
The Barrie and Area OHT engaged with policymakers to establish the need for this change initiative. An environmental scan revealed a high rate of amputations along with the care gap of publicly-funded foot care for at-risk individuals who have diabetes and peripheral vascular disease, particularly those who do not have a primary care provider, are under or precariously-housed, and Indigenous populations. There was also an identified lack of health human resources in the service area, particularly for chiropodists with different organizations in the region across sectors having difficulty with recruitment and retention. The BAOHT developed a collaborative capacity among organizational partners across health care sectors (i.e. acute, primary health care, and community partners) with co-creation of the program including patients, the Indigenous community and those with lived experience. The goal was to improve the population’s health through improved access to care and reducing health inequities.
As a result of this innovative work, a foot care program that is coordinated around the needs of the people in the community, particularly vulnerable and at-risk populations was developed and implemented. This program includes two foot care nurses, a consulting vascular specialist, primary health care consultation and education, and community partner support. The foot care nurses hold clinics in rotating locations across sectors and population needs, including in Indigenous clinics, homeless shelters, and primary health care settings. Significant learning has included the importance of rigorous indicators and evaluation methodology, sustainable funding models, advocating for dynamic timelines that look towards long-term upstream change, and innovative collaborative governance across sectors that is adaptive to organizational and community needs. Evaluation of the program is currently being done with the goal of expanding the program to other OHT populations that are marginalized and/or at high risk for amputations. Programs like this are an example of innovative people-centered collaboration and can be a model for integrated care that focuses on population health at a national and international scale.

Background:
Singapore faces challenges arising from a rapidly ageing population and an increasing prevalence of chronic diseases. The imperative is to strengthen connections between acute hospitals and primary, intermediate, long-term, and home care sectors, ensuring the provision of appropriate and accessible care in the community. Currently, services across the social-health continuum are provided by multiple providers. Limited visibility of patient information shared across the patient’s multidisciplinary team leads to challenges in tracking patient journeys and gathering of information. This results in duplicate or redundant services and overall poor coordination of care across providers.

We hope to address this issue by taking a design thinking approach to create the One Care Plan (OCP) application. OCP aims to facilitate the sharing and aggregation of patient information among care providers, streamlining collaboration and delivering patient-centred care to the elderly with complex health and social needs in the community. We envision that this will enhance information sharing, care coordination, and overall patient experience.

Methods:
Design and co-creation sessions involving representatives from Singapore General Hospital (SGH) and three community service providers were conducted to map current processes, identify pain points, and explore opportunities for improvement. Features were prioritised based on impact and technical complexity to develop a minimum viable product in collaboration with Synapxe, the public healthtech agency of Singapore. The selected features were also mapped to the activities and impact we hope to enable and achieve. The application was launched in October 2023, initially piloted in the SGH Empowered Communities of Care program.

Results:
Surveys conducted at launch revealed a disparity in the flow of patient health information among public healthcare institutions (PHI) and community service providers (CSP). 92% of PHI users were able to view hospital discharge summaries (“always”/”very often”) while only 36% of CSP users reported being able to. 40% of PHI users were able to access assessments from other service providers, compared to just 12% of CSP users. Overall, at least 55% of both PHI and CSP users reported lack of awareness of their patient’s care plans and issues from other providers (“rarely”/”never”).
Feedback gathered through ongoing user engagement and application monitoring will inform continuous improvement, while user experience and product effectiveness will be evaluated through continued surveys, providing insights into the crucial features required for effective integration of care in the community.

Conclusion:
The OCP application underscores the significance of a technological enabler for care integration in communities with diverse professional groups and institutions. The continued curation of features post-launch aims to uncover the key functionalities essential for users delivering clinical and social services in the community. This initiative contributes to the ongoing dialogue on technology's role in enhancing collaborative care, particularly in the context of Singapore's ageing population and evolving healthcare landscape.
Through our pilot, we have also found that beyond a technological enabler, ground processes are also key to enabling shared care. Hence, for successful implementation of care integration, the implementation team needs to partner programme teams to streamline and establish effective processes on the ground.