Developing a Programme Theory of Integrated Care: udthe effectiveness of Lincolnshire’s multidisciplinary Neighbourhood Teams in supporting older people with multi-morbidity’ (ProTICare) summary report

摘要

It is a well-rehearsed conversation that an ageing population places a significant ‘burden’ on the healthcare system where this narrative has become arguably more prevalent during a time of unprecedented economic restraint. A key approach to ensuring cost-effective service delivery through the integration of health and social care services aims to ensure a ‘seamless’ care pathway from early preventative interventions, planned care for complex needs, and a reduction in unscheduled hospital admissions and inappropriate service use. Ultimately it is acknowledged that integrated care will lead to the improvement of older people’s quality of life (Curry and Ham, 2010). An innovative concept developed from this discourse is the ‘Neighbourhood Teams’, a multidisciplinary team, comprising healthcare professionals and voluntary sector services with the underlying focus of providing streamlined case managing of care for individuals with multiple long term conditions. It is evident that multimorbidity is an increasing concern for the healthcare system, recognisable amongst individuals over 65 years of age, especially those defined as the 'oldest old'. Echoing current policy, an additional but essential role of the Neighbourhood Teams is encouraging individuals to self-manage their conditions. udThis research will report on the effectiveness of four Lincolnshire Neighbourhood Teams in supporting older people with multimorbidities. Furthermore drawing upon existing literature and qualitative interviews with healthcare and voluntary sector staff, the development of a programme theory of integrated care derived from various elements of the project will reflect upon the perceived outcomes of the Neighbourhood Teams and their successes in achieving their stated aims.