Background:
For those living with type 2 diabetes (T2D), mental health issues including distress, anxiety, and depression are common. However, existing models of care require those living with these co-occurring conditions to navigate a fragmented healthcare system across providers, settings, and even sectors to receive adequate physical and mental health services. In a completed co-designed mixed methods explanatory sequential feasibility trial, titled Technology-Enabled Collaborative Care for Diabetes and Mental Health (TECC-DM), existing assets, including widely available technology, were leveraged to integrate T2D and mental health support through weekly virtual health coaching sessions, supported by an interdisciplinary virtual care team over 8 weeks. Primary outcomes included the feasibility and acceptability of the TECC-D model with exploratory outcomes including changes in mental health, substance use, and physical health behaviours collected at baseline, 4, 8, and 12 weeks. 31 adults with T2D and self-identified mental health challenges completed the trial with study findings revealing that the TECC-DM model is feasible and scalable, and that it additionally empowers individuals to take an active role in improving their physical and mental health. Findings also identified that while clinical and professional integration were acceptable and impactful, there was a need to better facilitate access to and treatment through primary care. This includes a need to identify and describe existing practice gaps contributing to barriers to uptake and engagement with personalized T2D self-management care in primary care settings.

Objective:
With the rapid shift to virtual models of care delivery, there was a need to uncover whom the TECC-DM model best supports, how to identify individuals who may benefit from the program, and how this model could be tailored, linked to, and delivered in primary care settings. Through the mobilization of the TECC-DM feasibility findings, this project served to disseminate (share findings from the co-designed program) and plan (development of an access to treatment pathway to support a future trial; future relationship and capacity building).

Methods:
To better understand TECC-DM study findings, a mixed methods survey of primary care providers (PCPs) was completed. Distributed through the Smoking Treatment for Ontario Patients (STOP) Program, PCPs included primary care physicians, nurse practitioners, and other allied health professionals from solo practices, family health teams, and community health centres.

Partnership:
In addition to the TECC-DM study team, a person with lived experience was engaged as a co-researcher in all aspects of this study. This includes development of the survey, analysis and interpretation of findings, and knowledge mobilization.

Findings and Next Steps:
In conjunction with TECC-DM feasibility findings, survey findings identify that using existing technology and health human resources is an acceptable solution to participants, providers, and partners. Understanding the ways by which individuals with T2D and mental health challenges access (or fail to access) treatment, including barriers to integrated care, is necessary to achieve optimal, whole person care. Leveraging findings from the TECC-DM feasibility trial and these survey findings, our team will further develop the TECC-DM model for full-scale testing.

In the South East Health & Social Care Trust (SEHSCT), like other healthcare regions across the UK, Domiciliary Care services are under acute pressure with high demand and limited capacity. This has an impact on both service-users and staff working within Domiciliary Care, but also has significant consequences for other healthcare pathways, which rely on Domiciliary Care capacity to help individuals in their own homes, ensure time-efficient discharge from hospital etc.
Looking to the future, the challenges facing SEHSCT’s Domiciliary Care services will continue to grow. Northern Ireland Statistics and Research Agency (NISRA) projections estimate that between mid-2018 and mid-2043, the population aged 65 and over will increase by over 50% and the population aged 85 and over will increase by over 100%.
Various reviews have made strategic recommendations that will shape future Domiciliary Care Services.
The Department of Health’s 2022 Consultation on The Reform Of Adult Social Care sets out a vision for the future of adult social care services, at the centre of this is: ‘an evidence based, whole systems approach to the design and delivery of adult social care in co-production with service users and carers’.
Against the back-drop of these pressures, the shifting policy landscape and the anticipated growing demand for Domiciliary Care, the project aimed to bring the many stakeholders involved in supporting, co-ordinating and delivering Domiciliary Care in the SEHSCT together to map the Trust’s current ecosystem of Domiciliary Care. For the purposes of this project, ecosystem mapping can be considered to be the development of a high-level visual representation of the key pathways that make up Domiciliary Care in the SEHSCT, the stages in these pathways, connections with other services and a representation of the journey of service-users through the system.
The project has developed this shared visual representation through a series of 4 online workshops involving over 75 participants from across the Domiciliary Care Service in the SEHSCT. Stakeholders represented service users and carers, community and voluntary organisations, acute and community services, primary care teams, NIAS, health service planning, finance, HR, governance and quality teams and commissioners.

The evolving ecosystem map has then be used as a catalyst for reviewing the current Domiciliary Care provision in SEHSCT from a number of perspectives, co-producing suggestions for improvement with stakeholders. This report provides summaries of these discussions. These have been mapped onto the Domiciliary Care Ecosystem visualisation and describe:
• What should SEHSCT’s definition and aims be for Domiciliary Care?
• What the are current Domiciliary Care challenges?
• What Domiciliary Care data might be useful?
• What are the opportunities for Domiciliary Care improvement?
• What might a 2030 Domiciliary Care ecosystem look like for SEHSCT.

This work has provided shared understanding of Domiciliary Care in SEHSCT that has informed and prioritised the strategic improvements work ongoing across the Trust with a vision for a modernised service for 2030.

Executive Summary
Northern Ireland Diabetes Network sets the strategic direction for diabetes treatment and care in Northern Ireland (NI) to deliver against A Diabetes Strategic Framework.
This Regional Pathway will standardise access and provide equity through integration of diabetes services, supporting treatment and care now, and within an Integrated Care System (ICS) in NI from April 2024 and beyond.
This paper outlines work, methodology and findings to support system considerations through to key principles, proposed model and recommendations for implementation.

Background
Diabetes affects nearly 112,000 people in NI. An integrated response is required for an increasing population presenting with multi-morbidities, utilising all existing assets across workforce, infrastructure, technology, finance and Community Voluntary Sector.

Methodology
The Network undertook qualitative and quantitative research with key stakeholders, using a three-strand approach of Primary Care, Hospital Services and citizen strand involving people living with diabetes (PLWD) facilitated by Diabetes UK. A Citizen Poll, (365 responses), provided a pulse check on current and proposed service provision. Together this informed a Regional Integrated Pathway for Diabetes, approved for implementation.

Regional Integrated Pathway for Diabetes and Community Care Model
The pathway outlines a high-level integrated approach across Primary and Secondary care creating a Community Care model. This model will support people living with diabetes (PLWD) who are not T1/2 complex or on Super 6 pathways, who are unable to manage or control their condition. Through support appropriate to current environment and pressures, outcomes can be optimised with the right care, at the right time, in the right place under the right HCP within Community Care Model.
Risk stratification is the overarching process supporting treatment and management of conditions, facilitating self-management and effective use of all available resources.
This model will improve equity and access to treatment and care for all PLWD across NI, upskill Primary Care and support new ways of working.

Benchmarking
Existing community models, locally, nationally and internationally, were reviewed for key evidence and learning. Current and developing workforce, technology, digital systems and available data have been considered.

Quality Assurance
Key principles (4C’s) for the delivery of care were identified through insights across service development exercises - Capacity, Capability, Culture and Configuration. These key principles underpin service design, quality assuring the final model.

ICS
This work adds considerable value to ICS progression and will enable Network to share, subject to ability to deliver, a regional approach to diabetes treatment and care for localisation by AIPB’s, to consider appropriate use and application of existing assets to support -the ICS vision. This pathway will support and demonstrate enhanced patient outcomes within an integrated health ecosystem.

Forward Plan
This work is a key enabler to ICS model implantation in NI. The pathway sets an integrated direction for a long-term condition; a template for other conditions. Our 3-year journey demonstrates the value of effective partnership with service users and HCP’s in response to challenges faced in diabetes; concluding an integrated, stratified approach which provides a person-centred solution can support all PLWD appropriately. A lesson for other conditions and services.

Introduction:

Somatic symptom and related disorders (SSRDs) pose persistent challenges in pediatric hospital settings, as children and youth manifest physical symptoms indicative of emotional distress. These complex cases result in high health system utilization, costs, and risks of iatrogenic harm. Due to diagnostic and psychosocial complexity, patients often exhibit varied readiness for mental health assessment and treatment. As part of a broader initiative to integrate physical and mental health care, our tertiary/quaternary pediatric care hospital developed and piloted a shared care model to address the needs of this resource-intensive population.

Methods:

An interdisciplinary working group orchestrated the design and implementation of the pathway. Utilizing a logic model and engaging key stakeholders iteratively, the design phase embraced an interdisciplinary team approach. Care pathways were customized based on a patient's readiness for mental health treatment, diagnostic progress, and intensity of required resources. A patient and family engagement advisor played a critical role throughout the pathway development cycle. Further, the pathway design was reviewed by the hospital's Family Advisory Network, and their feedback was thoughtfully incorporated.
The pilot pathway aligns a patient's care journey with their mental health treatment readiness. Non-receptive patients access a care manager with dual physical and mental health expertise, supporting and guiding a shift in patient and caregiver focus towards the mind-body connection. Receptive patients and their caregivers join a group treatment program emphasizing psychoeducation on the mind-body connection led by psychiatry and psychology. The care pathway integrates Occupational Therapy and Physiotherapy resources for functional restoration, as well as regular follow-up by the pediatrician.

Pilot Evaluation Discussions:

Evaluation outcomes highlighted a significant decrease in outpatient psychiatry waiting times from 156 to 69 days. Post-launch, patients experienced fewer emergency department visits and imaging exams. The occupational therapist conducted 71 direct patient visits, and the physiotherapist had 50, reflecting active patient engagement. Caregivers praised the organized and tailored care for SSRDs, although highlighted the continued absence of awareness of necessary resources. Providers recognized the benefits of the pathway, including integration of care, care coordination by the care manager, and integral pathway roles (e.g., OT, PT).

Identified Challenges and Opportunities:

Challenges noted were the imperative need for staff training in mental health, safety, and risk management. Addressing cognitive biases related to patient care ownership, streamlining data entry, and rectifying under-resourcing of mental health and rehabilitation services were highlighted as ongoing critical gaps. A need for brief therapeutic interventions to bridge the gap between SSRD identification and ongoing treatment supports were identified.

Opportunities include development of a more robust approach to staff education and training, as well as securing access to and funding for rehabilitation services (e.g., occupational and physiotherapy services). Additionally, opportunities exist to improve the use of interdisciplinary rounds as an educational forum.

Conclusions:

The implementation of an integrated care pathway for somatic symptoms and related disorders in a pediatric tertiary/quaternary hospital was well received by patients, caregivers and providers. Further evaluative work on how best to address the needs of this high-resource population of patients is critical.

Rationale.
The great challenge for health systems is to scale up care processes that have been locally successful. These deployments are subject to a large number of conditioning factors that often mean that the achievements are not reached as they were originally planned. In the Basque Country and within the framework of the health transformation carried out since the 2010s, we have made progress in adapting the system to the enormous challenge of chronicity, emphasizing the framework of integrated care as a response to it. Within this framework, the deployment of major care routes such as the complex chronic patient takes on special relevance. This patient consumes up to 50% of healthcare resources, but as we have said, there are many imponderables to which these deployments are subject. In order to address this we have proposed a new collaborative management methodology working out the details that will help in changing the organizational model for complex patients

Objectives:
• Review of the corporate multimorbid care pathway.
• Selection of 3 process and result indicators
• Monitoring and evaluation of achievements

Methodology.
• Two working groups have been sorted to review the care pathway in its transit through primary care and hospital care.
• A scorecard has been designed with only 3 indicators, collaborative clinical record review CCRR, Shared care plan (SCP) and readmissions < 30days.
• These objectives have been communicated to all the organizations through virtual sessions and visits to the 13 Integrated care organizations (ICO).

Results
These dynamics have ensured that the implementation effort has been shared by all the organizations and clinical professionals.
the care pathway has been revisited and adjusted to the current situation.
The central governance and the ICO leadership have boosted the process possitevely.
Professionals have felt that they are key participants in the process
As can be seen in the results (three cuts carried out up to September 30), the three indicators have been evolving positively.

Indicator/date March May September October
CCRR 22,41% 28,45% 29,93% 35,20%
SCP 27,85% 30,70% 43,22% 51,26%
Readmissions
< 30 days 15,79% 15,01% 14,70% 14,61%

Considerations and limitations

Beyond the great achievements that often omit the details in the implementation processes on a corporate scale, in this case we have focused on three basic indicators, 2 of processes and 1 of results, and we have begun to build from there, making clinical professionals see that by carrying out some basic dynamics we can achieve important impacts on results. One of the strengths of this dynamic of the details is that if we manage to advance uniformly throughout the health system, this will have a driving force on the rest of the routes for chronic patients, especially.
The engagement os professioanls and managers has been key for these results.

The limitation of this dynamic is that it is still a top-down process on the one hand and that patient participation has been scarce on the other hand

Cardiff & Vale University Health Board in Wales provides health care for over one million people both locally within, Cardiff and regionally across South and Mid Wales. The purpose of our service change was to address a growing concern associated with increasing number of people attending Cardiff & Vale’s emergency department with over 88,000 people self-presenting per annuum and another 20,000 people being conveyed by the Welsh ambulance service. It was clear that people attending EU would have prolonged waits of greater than 12 hours and sometimes 24 hours, inappropriate admission with lengthy stays in hospital and a loss of independence. A forensic review showed that in many cases this could be avoided with earlier intervention at the time of crisis. The aim was to provide an immediate and safe alternative to ambulance conveyance, EU attendance and admission to hospital when it was safe and appropriate to do so. It will support patients to remain at home with the right treatment and care, enabling them to recover from the medical crisis and avoid harm associated with an inappropriate admission and long length of stay. The new service has been developed for Cardiff and Vale by drawing on learning from established services in Wales and England.
In collaboration with third sector partners, local authority, health partners we set about designing a service drawing from a considerable amount of patient experience, patient stories, risks identified across every sector and learning from other centres.
By linking data from the Health Board, Welsh Ambulance Service Trust, WAST and Cardiff Council, we identified two groups of people who are the most vulnerable, frail and having complex needs. These individuals often live with multiple co-morbidities and can have many episodes in hospital with significant lengths of stay. We classify these individuals as ‘high risk’ and there is clear data indicating that this group has a disproportionate poor experience and outcome in a secondary care setting. Most importantly, there is clear evidence that a prolonged length of stay in emergency departments and hospital causes harm through deconditioning and a poor experience for people. By turning our attention to safely preventing avoidable admissions, we will reduce unnecessary ambulance conveyances, inappropriate attendances to the emergency unit and long lengths of stay.
This indicates that if we introduce a more appropriate care model, the outcomes and experience of the individual will be better and demand on secondary care will reduce. The second cohort relates to individuals currently residing in a residential or nursing home.
“Safe@home” aimed to address these issues by introducing a fully integrated team bringing together the right range of skills from across our council and NHS services, dovetailing with existing health and social care provision and addressing a gap in current provision. The service was set up to run seven days a week initially for 8 hours per day. The aim would ultimately to run this service on a 24/7 basis acting as a “hub” for timely access for patients in crisis that could be cared for on a more individualist, patient centric footing considering what matters for that person.
The principles included:
• To care for people at home, when safe to do so
• To build the service up from existing services and resources
• Only bring in new resource if we haven’t already got it (do not layer!)
• Create a clinically-led, fully integrated true team
• Cross-organisation working between the Health Board, WAST and social care
• To have a consistent approach across the Cardiff and Vale region, with local delivery
• Initial focus on high-risk adult cohort (HRAC) as well as patients conveyed from nursing and residential care homes
• Evidence-based with clear monitoring of simple aims associated with this cohort:
• Reduced conveyances
• Reduced EU attendances
• Reduced emergency admissions
• Reduced length of stay
This service has only been running for three months and is in its infancy. Early evidence from monitoring clearly indicates that the modelling undertaken in terms of reduced conveyances, EU attendances and admissions is accurate, however the data set is not large enough presently to explore the impact on length of stay. Given the starting point for Wales as a nation we accept there may not be considerable learning for the international community although early collaboration and equal empowerment for all parties is critical for success.
Next steps will be to further integrate and streamline our overly complex system using the safe@home hub as a central tenant, building on agile, timely and flexible communication and care helping people solve their health needs on an individual basis.