Background:
Over the past fifteen years, integrated care policies have expanded significantly in France. One of these initiatives is the IPEP pilot programme, aimed at enhancing coordination between outpatient services and hospitals. This presentation provides an analysis of the local implementation of this programme through a qualitative research study.
Approach:
This study draws on an evaluative sociological approach, utilising qualitative methodology. Approximately fifty semi-structured interviews were conducted, offering insights into the experiences and practices of health professionals at the local level. The IPEP programme, overseen by the Ministry of Health and the National Health Insurance, follows a co-constructive approach that actively involves health professionals in its design and implementation through regular consultations.
Results:
The IPEP programme, implemented between 2019 and 2024, encompassed 29 groups of health professionals. Its main objective was to encourage stronger coordination between outpatient services and hospitals, primarily through performance-based payment systems. At the local level, the programme reflects broader trends in the reorganisation of primary care in France, promoting the development of integrated care models led by health professionals committed to collaborating with public authorities and reshaping primary care delivery.
The programme facilitated two significant changes. First, it fostered improved coordination among primary care professionals, leading to shifts in professional boundaries. For example, IPEP provided funding for the employment of primary care nurses—traditionally limited to private practice in France—who have taken on new responsibilities such as coordination, prevention, patient education, and administrative support, all of which contribute to enhanced patient care. However, this shift has encountered resistance from general practitioners, who are keen to maintain their central role in patient care pathway management.
Second, IPEP aimed to encourage greater coordination with hospitals. In some cases, IPEP has led to the development of coordination protocols, improved communication, more effective management of hospital admissions and discharges, and enhanced urgent care services within the community. However, the degree of success in these areas varies significantly across organisations, with some primary care groups struggling to establish collaborations with hospitals. Success in hospital coordination often depends on local dynamics, such as hybrid professional trajectories (e.g., general practitioners working part-time in both hospital and primary care settings), rather than being solely driven by the IPEP programme itself.
Implications:
This research highlights the conditions that facilitate the development of integrated care between outpatient services and hospitals in France, as well as the challenges encountered. It provides valuable insights for policymakers and healthcare professionals. Furthermore, the findings have broader applicability, illustrating the importance of addressing professional boundaries and organisational hurdles in the implementation of integrated care.

Background: Since spring 2023, patients in “Alternate Level of Care” (ALC) have become a ministerial priority in Quebec. The ALC designation is used in hospitals to describe patients who occupy a bed but do not require anymore the intensity of services provided in that care setting. Case management committees have been established to identify these patients and reduce their waiting time in the hospital, favoring better orientation (such as return home, entry into a long-term care facility, etc.) and better collaboration between departments.

Approach: As part of a comparative project between France and Quebec, we have been documenting these case management committees by observing their meetings since September 2023 (n=43 meetings, totaling 16 hours of observation), as well as conducting individual interviews (n=6). Additionally, we analyze clinical-administrative databases on emergency admissions, hospitalizations, and ALC episodes in a hospital to better understand the profile of people who become ALC and to gain insights into their pathways and the disruptions within them.

Results: Our analyses reveal several types of vulnerabilities leading to ALC episodes, notably patients who were homeless before entering the hospital, individuals with no relatives or network to rely on (particularly associated with cognitive decline), population aging (especially linked to mental health issues, comorbidity), and an increase in the number of operations at later ages. We were also struck by unusual pathways: the recurrence of ALC episodes among certain individuals in significant numbers over the past few years and evidence of “institutional dropping,” where someone loses their place in a long-term care institution (their home) during hospitalization. These leads raise questions about the mechanisms underlying these ALC episodes, particularly in terms of responsibility and leadership: who (and how) benefits from these extended stays?

Implications: The occurrence of an ALC episode creates a blockage in hospitals and a “disruption” in the user’s care and life pathway, which could likely be prevented through improved primary care upstream of hospitalization. Our analyses will continue to model the pathways of affected individuals and identify critical points of disruption.

Background: Northern Health, along with health systems worldwide, is experiencing increasing demand due to population growth, aging and increasing rates of multimorbid chronic disease alongside complex social conditions. NH catchment area includes culturally and linguistically diverse residents, with lower levels of income, educational achievement, health literacy and employment than the Victorian average. As health services grow, they become increasingly difficult for patients to navigate. The need for proactive community-based care, and the use of non-clinician local supports is evident. Internationally, peer health navigators have been shown to improve patient use of health services and reduce acute hospital needs.

Approach: The Northern Patient Watch (NPW) programme is based on a model where local community peer health navigators (“telenavigators”) provide weekly support and proactive monitoring over months to years, developing rapport and trust. Patients are selected using algorithms designed to identify patients at high risk for a future hospital admission within 12 months. Signs of health decline or concerns raised by patients or navigators are escalated as required to “health coaches” with a range of clinical backgrounds. Person-centred goals and actions facilitate self-management and access to the right care at the right time. Resources, ideas and strategies are shared between telenavigators and health coaches with different experience, skills and health disciplines within the team, alongside regular input from a medical lead via case conferences and consultation as required. This study aimed to assess the impact of NPW on hospital admissions, bed days, emergency department presentations, and outpatient non-attendance.

A propensity score matching design was used to compare NPW participants with controls over 3-, 6-, and 12-month follow-up periods. Acute hospital needs and bed days were the primary outcomes, with secondary outcomes including outpatient appointment non-attendance rates. Data were analysed using statistical methods appropriate for normally and non-normally distributed variables, with adjustments made for potential confounders.

Results: NPW participants had reductions in hospital bed days across all time points compared to matched controls. By 12 months the median total bed days was 2.00 (IQR 0.00, 8.00) for NPW participants and 4.00 (IQR 1.00, 14.00) for matched controls, p 0.008. There were trends towards lower admission and emergency presentations rates, however these differences were not statistically significant. Outpatient appointment non-attendance rates were significantly lower in the NPW group at 12 months (44.8%) compared with matched controls (55.6%), p 0.01, indicating improved engagement with healthcare services.

Implications: The NPW programme was associated with reduced hospital bed days and improved outpatient appointment attendance, but no significant difference in hospital presentation or admission rates. These findings suggest that local community lay health navigator programmes supported by clinicians, may be an effective strategy to engage with and support patients in a person-centred manner while reducing overall acute hospital needs. The program may be improving self-management and early detection of deterioration, resulting in proactive care-seeking and management, reducing hospital-based length of stay. Expanding the scope of future studies to include patient lived experiences, and longer term follow up would provide more comprehensive understanding of the programme’s impact and sustainability.

This abstract explores the critical partnership between Health Hawke’s Bay, Primary Health Organisation, Hawke’s Bay largest Indigenous Māori Health and Social Services Provider-Te Taiwhenua o Heretaunga, Ngati Kahungunu Iwi Incorporation (Largest Indigenous Tribe in Hawkes Bay, 3rd largest in New Zealand) and the Iwi Māori Partnership Board-Tihei Takitimu (Government mandated monitoring board for indigenous health) addressing the unique health needs of its priority population more specifically Māori and Pasifika community.

This alliance emphasises the significance of a culturally informed healthcare approach that is responsive to the shifting environmental, social, and health landscapes. By integrating indigenous Māori values and perspectives, this partnership fosters a culturally attuned climate essential to advancing community health outcomes.

Guided by Health Hawkes Bay strategic direction, 'Ka Hikitia' -developed with the principles centered on Whānau voice, encompassing both Māori and non-Māori community input. This partnership aligns with the commitments of Te Tiriti o Waitangi. With input from Maori and non-Maori providers as well as the then former HB District Health Board, (HBDHB) and Health Hawkes Bay PHO the strategy advances are culturally informed healthcare approach responsive to evolving environmental, social and health challenges.

Moving forward, it is essential to prioritise and strengthen these collaborative relationships to ensure equitable and effective healthcare for Hawke’s Bay’s priority population in Hawke’s Bay, reinforcing the commitment to culturally responsive health services that honor Indigenous identities and adapt to changing conditions.

Health Hawkes Bay will show collective data and aggregated measure and outcomes to show that Indigenous methodology and cultural targeted responsive resourcing, allocation dedication and a committed collaborative approach will ensure positive change.

As those overseeing hospital discharges, we identified significant obstacles in orthopedic trauma rehabilitation, often essential for patients to regain autonomy. High demand, limited resources, and extensive waiting lists delay discharge and increase post-surgical complications. Public rehabilitation options for safe in-home recovery are scarce, which further delays optimal patient outcomes.Using Lean and Lean Health methodologies, our project sought to enhance discharge and recovery. We meticulously traced patient journeys from admission to discharge, identifying delays, assessing solutions, and gathering insights from 100+ patient surveys. By focusing on patient experience, we pinpointed high-value care aspects and highlighted improvement areas to boost safety and satisfaction.Our phased improvement plan began with internal standardization, establishing clinical and non-clinical manuals, checklists, and post-discharge guidance. We developed cross-departmental protocols for better integration, then initiated partnerships with health and social entities like Santa Casa da Misericórdia, local municipalities, and SPMS (Serviços Partilhados do Ministério da Saúde) to streamline external referrals. Automated alerts were set up to notify primary care centers of patients needing post-hospitalization home or outpatient care. Additionally, we explored telemonitoring solutions to support in-home recovery for eligible patients.Keywords: Discharge Planning, Integrated Care, Out-of-hospital Rehabilitation, Autonomy, Safety and Trust, Continuity of Care, Interdisciplinary Collaboration, Telemonitoring, Caregiver Support, Patient and Staff Satisfaction.Conclusion This project, which is now in its implementation phase, has already achieved some successes, such as raising awareness among boards of directors and establishing partnerships with several organisations. Santa Casa da Misericórdia de Lisboa has already shown interest in collaborating. A 'Carers' Exchange' will be set up and the SCML school in Alcoitão will be available for internships as part of the project, with recent graduated Physioterapists. However, there are still no measurable results in relation to the ultimate goal of the project: to provide community solutions and home care after discharge with a guarantee of rehabilitation. Indicators to be achieved include early discharge planning, reduction in length of stay, readmissions, complications and nosocomial infections, and increased patient satisfaction. The pilot project focuses on trauma patients, but can be replicated in other departments/hospitals. The focus on these patients is due to the social impact of lost working days and family support, ensuring timely recovery and avoiding complications. The wellbeing and satisfaction of these patients has a positive effect on access to new patients, a reduction in waiting lists and a more effective network.

Background
Multimorbidity poses a significant challenge for healthcare systems. There is an urgent need for targeted interventions for individuals with high complexity to better coordinate care across hospital specialists and to support general practice. However, there is limited evidence on how best to organise this care. We propose a differentiated care approach through our Clinic for Multimorbidity to provide specialised care at the required level.

Approach
We have redesigned our existing 'Clinic for Multimorbidity', which has existed since 2012. The clinic aims to integrate care from various healthcare professionals and medical specialties, promoting shared and coordinated care for adults with complex multimorbidity. The patients are referred from general practice. Healthcare professionals and researchers involved in the clinic, re-designed the clinic with differentiated care options according to the required level of support:

I. A telephone line for general practitioners with specialist advice about the management of multimorbidity and/or polypharmacy.
II. A medication review with the patient present, conducted by a specialist in clinical pharmacology. Medication changes are agreed upon with the patient and followed up with control consultations.
III. A patient consultation with a physician, including review of previous medical records and current medications, as well as assessments from occupational and physical therapists. After the patient consultation, a multidisciplinary team meeting is held with selected medical specialists, to develop a treatment plan. The patient's general practitioner can participate via video. In agreement with the patient, a nurse coordinator facilitates follow-up based on the recommendations.

Using a stepped-wedge randomized controlled design, general practices are enrolled based on their geographical locations as hospital clusters. The project includes two studies within the fields of clinical and health services research: an implementation study to assess the feasibility of the differentiated pathways and an effect study.

Results
The data collection began in September 2024. The implementation study results will be based on Proctor et al.'s implementation outcomes: acceptability, adoption, appropriateness, feasibility, fidelity, and penetration. Data will be gathered through interviews with patients and general practitioners, as well as measurements related to referral practices, costs, and feasibility.
Effectiveness outcomes will involve perceived health-related quality of life, treatment burden, depression, and anxiety. Additionally, inappropriate medication, symptoms, mortality, care continuity, healthcare utilization, and the initiation of health-promoting initiatives.

Implications
Complex multimorbidity and polypharmacy necessitate multidisciplinary approaches and stepped care to fit the appropriate level of care. We propose a differentiated model aimed at improving patient well-being and care, reduce inappropriate medication use, and support general practitioners and hospitals in their management of these patients, allowing for more efficient resource allocation. From phone consultations to multidisciplinary assessments, other healthcare settings can adjust the level of care according to their capacities and patient needs, making this a scalable model.