The transformation into an integrated care organisation (ICO): applying a realist review and evaluation framework in a researcher-in-residence model

Background: Integrated health and social care appears to be the standard for patient-centred coordinated care (PCCC) in the three devolved UK regions, most recently with The Public Bodies (Joint Working) (Scotland) Act coming... [ view full abstract ]

Background: Integrated health and social care appears to be the standard for patient-centred coordinated care (PCCC) in the three devolved UK regions, most recently with The Public Bodies (Joint Working) (Scotland) Act coming into force in April 2016. In England however, few pathfinder sites pioneer this approach to whole system change of the various providers and commissioners, amongst which are those based in the South Devon and Torbay area. Developing useful theory of unpredictable systems in flux, while also learning from natural experiments within them requires a bringing together of theory, research, innovation and evaluation. We explore how the applied model of ‘researcher-in-residence’ can be combined with the rigour of realism as a way of developing robust and useful practice-based theory.
Aims & Methods: This applied evaluation project uses a realist review on the complexity of shared and intermediate care as a basis for understanding and explaining how and why multiple initiatives for integrated care within one system may improve experience and outcomes for patients with multiple long-term conditions. It will do so using a researcher-in-residence approach, working from within the providers and commissioners to understand, explain, evaluate, and improve implementation. In a mixed-methods approach and over the course of the coming two years it will map planned and on-going innovations, conduct secondary analysis of evaluation and performance data, and collect data from interviews with patients, practitioners and managers.
Findings: Research is ongoing and we will present early findings in relation to three middle-range theories derived from the previous realist review on shared care. These were related to: 1. Supposed efficiency gains (shifting care to less costly settings, better tailoring to need, enhanced use of patient and carer resources); 2. Routinising care through System change (introducing new components, reconfiguring existing ones); and 3. Sharing relationships (the development and maintenance of trusting and reciprocal relationships between practitioners and services).
We will focus the presentation on the methodological process of building on prior theory gained from a review using local real world evidence from one wide-ranging complex system. We will also reflect on how emerging theory was fed back to, interpreted by and acted on by local stakeholders.
We will share our experience of how these theories translated into an emerging realist evaluation framework and how this sits within the local context and outcomes. We also hope to present emerging findings from applying this framework that test and refine the three mid-range theories and their relationships.
Implications: This project addresses several key problems facing the NHS including how to marry evidence based practice with practice based evidence in applied and transferable health services research models, as well as how to effectively and efficiently transform service provision for increasingly complex health needs and ageing populations. Sharing methodological insights and developments early and interactively seeks to strengthen realist practice by providing feedback loops and shared learning for all stakeholders involved.