An aging population, whose multi-morbidities and risk of frailty increase with age results in significant health and social care consumption. Increasing complexity amplifies fragmentation of care and results in sub optimal care outcomes. Ireland, in keeping with other jurisdictions seeks to implement integrated care for older persons as a policy response. There is growing evidence base supporting effective service responses for older persons. These typically include multidisciplinary, community based teams providing services in or near to the older person's home (the 'what'). However, examples of systemic implementation are confined to smaller regions notably in Catalonia (Spain), Scotland and Singapore. This reflects the fact that the implementation of integrated care is problematic at scale. The need to attend to methods that support high autonomy professionals tasked with local implementation (the 'who') is a neglected area. This is especially important in light of the fact managerial and clinical leaders already have operational and clinical imperatives to attend to. Whilst ideologically committed, the change management challenge presented by integrated care is daunting as they may lack the capacity (time, resources, structures) required to test a new care model. In addition, most change methodologies fail to recognise powerful social dynamics that reflect the characteristics of a complex adaptive system (the 'how'). This paper proposes a framework to implementing integrated care for older persons. In addition, it offers some initial empirical evidence that this approach has utility among managers and clinicians. In doing so seeks to bridge the implementation gap associated with systemic change.

The new Mental Health Act (2001) became a law on 1 November 2006. The new Act, reflective of international legislative norms, outlines an agenda for the mental health services in Ireland which, in part, aims to maximize patient autonomy. This paper seeks to contextualize autonomy within nurse-patient interactions in the mental health care setting. The acceptance of autonomy as an unconditional principle, as outlined within traditional bioethics, is challenged. The paper draws on the social critique of normative ethics and suggests an alternative framework within which to operationalize patient autonomy. The authors conclude that a broader, more contextualized perspective on autonomy would more suitably inform mental health nursing. Narrative ethics and a framework of 'protective responsibility' are offered as an alternative to more traditional approaches. Practice-based initiatives to maximize patient autonomy and facilitate-reasoned ethical decision making are outlined.

Background Older people receive care from multiple providers which often results in a lack of coordination. The Information and Communication Technology (ICT) enabled value-based methodology for integrated care (ValueCare) project aims to develop and implement efficient outcome-based, integrated health and social care for older people with multimorbidity, and/or frailty, and/or mild to moderate cognitive impairment in seven sites (Athens, Greece; Coimbra, Portugal; Cork/Kerry, Ireland; Rijeka, Croatia; Rotterdam, the Netherlands; Treviso, Italy; and Valencia, Spain). We will evaluate the implementation and the outcomes of the ValueCare approach. This paper presents the study protocol of the ValueCare project; a protocol for a pre-post controlled study in seven large-scale sites in Europe over the period between 2021 and 2023. Methods A pre-post controlled study design including three time points (baseline, post-intervention after 12 months, and follow-up after 18 months) and two groups (intervention and control group) will be utilised. In each site, (net) 240 older people (120 in the intervention group and 120 in the control group), 50–70 informal caregivers (e.g. relatives, friends), and 30–40 health and social care practitioners will be invited to participate and provide informed consent. Self-reported outcomes will be measured in multiple domains; for older people: health, wellbeing, quality of life, lifestyle behaviour, and health and social care use; for informal caregivers and health and social care practitioners: wellbeing, perceived burden and (job) satisfaction. In addition, implementation outcomes will be measured in terms of acceptability, appropriateness, feasibility, fidelity, and costs. To evaluate differences in outcomes between the intervention and control group (multilevel) logistic and linear regression analyses will be used. Qualitative analysis will be performed on the focus group data. Discussion This study will provide new insights into the feasibility and effectiveness of a value-based methodology for integrated care supported by ICT for older people, their informal caregivers, and health and social care practitioners in seven different European settings. Trial registration ISRCTN registry number is 25089186. Date of trial registration is 16/11/2021.

Purpose Healthcare quality improvement is a key concern for policy makers, regulators, carers and service users. Despite a contemporary consensus among policy makers that integrated care represents a means to substantially improve service outcomes, progress has been slow. Difficulties achieving sustained improvement at scale imply that methods employed are not sufficient and that healthcare improvement attributes may be different when compared to prior reference domains. The purpose of this paper is to examine and synthesise key improvement attributes relevant to a complex healthcare change process, specifically integrated care. Design/methodology/approach This study is based on an integrative literature review on systemic improvement in healthcare. Findings A central theme emerging from the literature review indicates that implementing systemic change needs to address the relationship between vision, methods and participant social dynamics. Practical implications Accommodating personal and professional network dynamics is required for systemic improvement, especially among high autonomy individuals. This reinforces the need to recognise the change process as taking place in a complex adaptive system where personal/professional purpose/meaning is central to the process. Originality/value Shared personal/professional narratives are insufficiently recognised as a powerful change force, under-represented in linear and rational empirical improvement approaches.

Implementing integrated care for older people in Ireland; inside the black box