COLOUR CODE • Theme 1. Value-based integrated care • Theme 2. Population health management • Theme 3. Engaging and Empowering People and Communities • Theme 4. Funding Integrated Care • Theme 5. Vulnerable Populations and Populations at Risk • Theme 6. Primary Care in an Integrated System • Cross-cutting Theme: Education & Training in association with the Integrated Care Academy© • Cross-cutting Theme: How to design and implement integrated care in association with the European Commission • Cross-cutting Theme: How technology is supporting integrated care • Cross-cutting Theme: Policy making, regulation and inspection • International Journal of Integrated Care (IJIC)
Recommended for Best Paper/Best Poster Award Shortlisted for Best Paper/Best Poster Award SIG = Special Interest Group as part of the IFIC Members Network 1
Wednesday, 23 May 2018
7.30 – 9.00 Registration, exhibition, posters and networking
9.00 – 9.10 Opening ceremony Welcome to conference: An international movement for change Dr Nick Goodwin, CEO, International Foundation for Integrated Care (IFIC) Dr Albert Alonso, Chair, International Foundation for Integrated Care (IFIC)
9.10 – 10.30 PLENARY 1: Changing the system’s perspective on health Chaired by: Henk Smid, Director of ZonMw, The Netherlands Organisation for Health Research and Development ZonMw, The Netherlands
The Dutch integration story Prof Dr Mirella Minkman, Director of Research and Innovation, Vilans, the Netherlands Centre of Expertise for Long-Term Care and Vice Chair and Secretary International Federation of Integrated Care (IFIC) Professor Henk Nies, Member of the Executive Board, Vilans, Utrecht and Professor of Organisation and Policy in Long-term Care, Vrije University, Amsterdam
The power of positive health Dr Machteld Huber, Institute for Positive Health (iPH)
Henk Smid in dialogue with Kees van der Burg, director-general long-term and social care, Ministry of Health, Welfare and Sport
Henk Smid in dialogue with Cathalijne van Doorne, Board Member, Euro-Ataxia and President of the Dutch Brain Council
Panel discussion with all morning presenters
Room – Event Hall 10.30 – 11.00 Refreshments, exhibition, posters and networking
11.00 – 12.30 PARALLEL SESSIONS 1 1.A Technology supporting 1.B The Implementation 1.C Using Patient 1.D Preventing Frailty 1.E How data enables 1.F Workshop: Providing integrated care Room: Financing and perspectives as guiding Organised by JA integrated care – Part 1 integrated health and contractual models principles AdvantAge social care to vulnerable Organised by the European populations in the Commission community (249) 2
Room 6&7 Room 11 Room 14 Room 30 Room 8 Room 9&10 Chaired by Leo Lewis, Chaired by Loukianos Chaired by Koldo Piñera Chaired by Prof Anne Chaired by Karine Iffour, Chaired by Mieke Rijken, International Foundation Gatzoulis, European Elorriaga, Bioef Hendry, IFIC Scotland COCIR NIVEL, Netherlands for Integrated Care (IFIC) Commission, DG SANTE institute for health services 217 Healthcare quality for 173 Improving access to 542 - Integrated care: only research, NL 365 We have a TIP for You! Contracting models in people with Down quality services for possible with the support - Serving Complex Patients integrated care (e.g. ACOs, Syndrome: the patient vulnerable older people in of technology? * 249 Providing integrated through Telemedicine alliance contracting etc.) perspective * Kyrgyzstan through Dr Henk Herman Nap and health and social care to IMPACT PLUS (TIP) Case Ben Collins, The King’s Francine van den Driessen engaging volunteers and Dirk Lukkien, Vilans, NL vulnerable populations in Conferences * Fund, UK Mareeuw, Tilburg establishing self-help the community (249) Dr Jocelyn Charles, Pauline University / Jeroen Bosch groups 205 - The Adjusted Neis Bitter, NIVEL, Pariser and Marsha Barnes, Financing and payment Hospital, NL Aidai Erikova, Red Crescent Morbidity Groups: a new Netherlands institute for Toronto Central Local models in integrated care Society of Kyrgyzstan, KG stratification tool for risk health services research, NL Health Integration (e.g. bundled payments, 204 Patient Experiences of assessment Network, CA population budgets etc.), Care from Multi-Speciality 376 Reversibility of David Monterde, Catalan 534 ‘An exploration of Apostolos Tsiachristas, Community Providers: nosocomial disability in Institute for the Health, ES models of care 279 - Assessment of HERC, Oxford University, Findings from a Realist hospitalized elderly coordination to meet the usability and viability in UK Synthesis of International patients through an 196 Social Determinants of needs of families requiring clinical practice of the Evidence individualized Health Composite Index health and social care in Nabelia mHealthCare The Implementation Rooms Dr Helen Lloyd, multicomponent exercise (oral poster) Sydney, Australia' Platform to support will draw lessons from early PenCLAHRC, UK program: a randomized Dr Reza Sharifi Sedeh, Erin Miller, Sydney Local integrated care and successful approaches controlled trial * Philips, US Health District, AU management of patients to integrated care in 470 Listening to the citizens Dr Nicolas Martínez-Velilla, with pulmonary Europe, and share these and building health care of Servicio Navarro de Salud- 453 Avoidable emergency 161 Social Prescribing: hypertension with the wider community the future Osasunbidea, ES admissions for ambulatory Primary care patient and Dr Albert Alonso, Hospital of stakeholders, who wish Emilie Nielsen, Odense care sensitive conditions in service user engagement Clinic Barcelona and to embark on the University Hospital, DK 329 Early Detection of the Republic of Ireland: + International Foundation implementation of Malnutrition in Community analysis of regional 164 - Service user for Integrated Care (IFIC) integrated care. They will 438 Improving Patient- Dwelling Older People, an determinants (oral poster) outcomes of a social focus on discussing the Provider Partnerships Evidence Based Integrated Brenda Marie Lynch, prescribing programme in 443 Management of “how-s” of across the Healthcare Care Approach (oral poster) University College Cork, IE general practice (oral personalised guideline- implementation. System Dr Roelof Ettema, poster) driven care plans Dr Jacobi Elliott, University University of Applied 289 A risk score of BMI, Julia Pescheny, University addressing the needs of of Waterloo, CA (oral Sciences Utrecht / HbA1c and triglycerides of Bedfordshire, UK multi-morbidity via clinical poster) University Utrecht, NL predicts future glycaemic decision support services control in type 2 diabetes Dr. Gokce Banu Laleci 486 Impact of a nurse-led (oral poster) Erturkmen, SRDC Software health promotion D.F.L. Hertroijs, Maastricht Research Development and intervention in an aging University, NL Consultancy Corp, TR population: Results from 3
Community Health 495 Synergy of patients and Consultation Offices for 370 Patient Value health professional in Seniors Measurement and successful implementation Anne Esther Marcus- Improvement using the of digital health tools (oral Varwijk, Steps of Systematic poster) Hogeschool Windesheim, Improvement (SOSI) in Amanda Hellström, Rijksuniversiteit Groningen, Yishun Health (oral poster) Linnaeus University, SE NL Naiying Liu, Khoo Teck Puat Hospital, SG 231 In a 'post-truth' world, 456 Role of the elderly healthcare organisations do volunteers in integrated not still provide readable care (oral poster) and comprehensible Sviatlana Anatsko, Belarus information on their Red Cross Society websites: An analysis of 167 websites in Italy (oral 382 Community elderly poster) * care enhances quality of Dr Sabina De Rosis, Scuola life for peers (oral poster) Superiore Sant'Anna, IT Amela Fočić, Swiss Red Cross, BA
1.G Workshop: Population 1.H Case management and 1.I Integrated health and 1.J Keynote Workshop: 1.K Economic evaluations Health Management: Are care coordination social care for people with Creating networks of care Existing Tools Fit for dementia and their in the Netherlands Purpose? (504) in informal caregivers, Innovation of the collaboration with SIG research results (564) governance of integrated Population Health care (557) Management Room 12 Room 18 Room 31 Room - Event Hall Room 19 Chaired by Dr Oliver Gröne, Chaired by Nuria Toro, Chaired by Marjolein Chaired by Prof Dr Mirella Chaired by Robbert Huijsman, Vilans OptiMedis AG and Dr World Health Organization Scholten, ZonMw Minkman, Vilans & Nicholas Hicks, Cobic (WHO) International Foundation 516 Critical Appraisal of the Quality of Economic MEETINGDEM provides for Integrated Care (IFIC) Evaluations in Integrated Care: Evidence from a As part of the global move 275 Social and economic community dwelling people Systematic Review towards value-based care, impact of a case with dementia a social club, 258 Caring in networks: a Mudathira Kadu, University of Toronto, CA many health systems are management approach for and carers information, future direction (oral experimenting with new people with rare and practical, social and poster) 433 ‘Evaluating an integrated care programme for frail forms of population health complex conditions in Salaj, emotional support. The Mark Tiemessen, elderly using Multi-Criteria Decision Analysis. The design management. Various tools Romania * programma was adaptively Radboudumc / of a case study in SELFIE’ have been developed that ParkinsonNet, NL Maaike Hoedemakers, Erasmus University Rotterdam, NL 4
aim to extract data from a Dr Vibeke Sparring, implemented in other EU range of sources, link them Karolinska Institutet, SE countries (Italy, Poland, UK) 273 Longitudinal multiple 517 - Medical Cost Savings After One Year of Integrated in a data warehouse, apply Prof.dr. Rose Marie Dröes, case study on effectiveness Behavioral Health Services in a Rural Pediatric Primary tools for patient 489 Impact on the use of Professor, VU University of network-based dementia Care Clinic segmentation and services and quality of life medical center Amsterdam care towards more Dr Andrew Cook, University of Michigan, US construct performance of a continuity of care unit integration, quality of care, dashboards to guide for multi-pathological Decidem aimed to improve and collaboration in 359 The Financial Alignment Initiative for Low-Income population health patients advance care planning primary care ** Older People and Younger Adults with Disabilities: A management. Ana Perez, Osakidetza, (ACP) in general practice. A Minke Nieuwboer, Major Initiative to Integrate Medical Care and Long-Term Basque Country, ES training for GPs is Radboudumc, NL Care ** In this interactive session developed in initiating ACP Galina Khatutsky, RTI International, US we will a) describe 372 Care coordination for with persons with 537 Improving the Cancer reporting requirements for vulnerable families in the dementia. The findings Journey: A Collaborative population health Sydney Local Health indicate that people with Model of Integrated Care in management, b) compare District: what works for dementia are able to a Community Setting ** the data sources, whom, in what engage in a shared Fiona Smith, Macmillan functionality and indicators circumstances, and why? decision-making process Cancer Support, UK included in existing Erin Miller, Sydney Local M.Perry, Senior researcher, population health Health District, AU Radboudumc Nijmegen 368 Evaluation of an management tools and c) Integrated Dementia Care map these on established 531 Admiral Nursing: case Three network-based Network in the Northern frameworks of population management for families projects, covering formal part of Singapore health and health system affected by dementia care and informal care Milawaty Nurjono, National performance. After an Dr Karen Harrison Dening, services, and integration of University of Singapore, SG input presentation covering Dementia UK and Admiral the variety of these these aims, we will d) Nursing, UK services available in engage a panel of three dementia care will be experts to discuss the 540 The challenge of discussed. implication of the work. multimorbidity: A Dr. M. van der Marck, qualitative study of general Assistant Professor Our initial findings suggest practitioners' management Alzheimer Centre Nijmegen that existing tools for of patients with population health multimorbidity (oral poster) 498 Opportunities and management are Lisbeth Ørtenblad, challenges to enhance the underutilized in many DEFACTUM, DK social network of home health systems. In addition, dwelling people with they map poorly on the 131 - Integrated Case dementia and their family conceptual frameworks of Management – supporting carers population health as General Practice in the proposed by OECD and 5
WHO. The presentation will Eastern Bay of Plenty, New Dr J.H. Groenewoud, outline which steps are Zealand (oral poster) Rotterdam University of required to ensure that Greig Dean, Eastern Bay Applied Sciences, NL future upgrades address Primary Health Alliance, NZ the determinants of population health in a more consistent manner.
12.30 – 2.00 Buffet Lunch, exhibition, posters and networking
Lunchtime Workshops WLW1 Poster WLW 2 Workshop: Sharing WLW 3 Workshop: WLW 4 SIG Polypharmacy WLW 5 Poster WLW 6 Workshop: Flow- presentations: Care insights: Positive health a Engaging and empowering presentations: Improving Improving System coordination across sectors different view on health citizens with long-term child health Pathways: a person- (351) conditions: How to define centred system discovery personal goals and how to programme (333) support the goal achievement with technology? (212) 12.30 – 1.30 12.30 – 1.30 12.30 – 1.30 1.00 – 2.00 1.00 – 2.00 1.00 – 2.00 Room 6&7 Room 8 Room 9&10 Room 12 Room 14 Room 18 Chaired by Leo Lewis, Chaired by Paulien Chaired by Eunji Lee, Oslo Chaired by Alpana Mair, Chaired by Frank Tracey, Chaired by Wendy Lewis, International Foundation Vermunt, Vilans University Hospital Scottish Government and Children’s Health AQuA, Salford, UK for Integrated Care (IFIC) Dr Albert Alonso, Hospital Queensland, AU In this Network discussion 212 Engaging and Clinic Barcelona and During this interactive 389 The Belarus State recent experiences and empowering citizens with International Foundation 510 Ministries guiding of workshop we will share the Social Order funding insights on the use of the long-term conditions: How for Integrated Care (IFIC) services for children and Advancing Quality mechanism for integrated concept of Positive Health to define personal goals young people in eleven Alliance's (AQuA)'4 Arrows medical and social home will be presented and and how to support the 451 eHOME for an countries – a comparative Model' for understanding care barriers and facilitators for goal achievement with integrated care approach study flows across care systems Dr Tatyana Svetlovich, the implementation of the technology? for drug-related problems Dr Katja Joronen, University in order to design Belarus Red Cross, BY concept will be discussed. Eunji Lee, Oslo University in home-living older people of Tampere, FI sustainable improvements. Participants will be asked to Hospital (oral poster) 109 Development of a fill in the self-assessment Nienke Dijkstra, HU 529 How fair is the dental The workshop will be patient-centered tool “Mijn Positieve 264 Goal Planning in University of Applied chair? Equity in oral health delivered with Wendy Bell, organizational model for Gezondheid” (My Positive Person-Centred Care Sciences Utrecht, NL access and outcomes for a patient representative multimorbidity in general Health) and discuss their Supports Older Adults to children under five, Hawkes who has worked with AQuA practice results in couples. Starting Attain Their Health-Related 127 Impact of a quality Bay, New Zealand to test a person centred from this broad self- Goals (oral poster) improvement initiative on and person focussed 6
Ramune Jacobsen, reflection on health and Klaske Wynia, UMCG, NL reducing the overuse of Wietske Cloo, Hawke's Bay improvement programme Bispebjerg and well-being, there will be a treatment in infants with District Health Board, NZ with 3 health economies in Frederiksberg Hospital, plenary discussion on 313 Health literacy: more bronchiolitis North West England. Denmark, DK issues that arise along than the understanding and Javier Benito Fernández, 449 Comparison of key implementation of patient- processing of health Basque Country University, findings relating to care During the workshop 143 Relational coordination centred care in general and information (oral poster) ES coordination in children attendees will test the in inter-organizational Positive Health specifically Dr Monique Heijmans, with three complex model on their own care settings. How does lack of for health services NIVEL, NL conditions: A MOCHA study system and share questions proximity affect (amongst others: Dr Miriam O’Shea, Trinity and experience in coordination between measuring quality of care, College, IE discussion. Wendy will hospital-based and involvement of the clients’ ensure a focus on quality community-based social network, governance 320 Integrated school improvement by sharing healthcare providers? health services in Europe: her training and experience Stine Bligaard Madsen, an overview as an AQuA team member. Aarhus University, Dr Danielle Jansen, Denmark, DK University Medical Center The workshop will explore Groningen, NL how this ensured the 530 Inter-professional person centred and collaboration and 394 Developing new appreciative approach to communication during pathways to Health and tackling the difficult acute hospitalization of Social Care for vulnerable problem of flow in our older patients with clients in targeted Primary challenged care systems. dementia Schools in Sydney, Marie-Julie Heeren, Australia ** Verenso, Utrecht, the Erin Miller, Sydney Local Netherlands Health District, AU
380 Flexibility and reablement in home care in dementia Dr. Mairead Bracken-Scally, Trinity College Dublin, IE
2.00 – 3.30 PLENARY 2: Moving towards value-based integrated care Chaired by Dr Nick Goodwin, CEO, International Foundation for Integrated Care (IFIC)
Reforms to support value-based care
7
Dr Jeroen Struijs, Senior Researcher, National Institute for Public Health and the Environment (RIVM) and International Foundation for Integrated Care (IFIC)
Population Health Management in the US Dr Gregg Meyer, Chief Clinical Officer, Partners Healthcare System, US
The case of Parkinsonnet Prof Bastiaan Bloem, Medical Director & Consultant Neurologist, Radboud University Medical Centre and Parkinson Centrum Nijmegen (ParC)
Illustrator Feedback
3.30 – 4.00 Refreshments, exhibition, posters and networking
4.00 – 6:00 PARALLEL SESSION 2 2.A Workshop: SIG 2.B The Implementation 2.C Barriers to 2.D Identifying Frailty 2.E How data enables integrated care – Part 2 Intermediate Care Room: Designing strategies implementation Organised by JA and models for integrated AdvantAge care Organised by the European Commission Room 14 Room 11 Room - Event Hall Room 30 Room 8 Chaired Prof Anne Hendry, Chaired by Guy Dargent, Chaired by Dr Albert Chaired by Dr Ana Maria Chaired by Karine Iffour, COCIR IFIC Scotland European Commission, Alonso, Hospital Clinic Carriazo, Regional Ministry CHAFEA Barcelona and International of Health, Andalucía, Spain 309 Health and social electronic records integration in 297 VEER: Volunteers Foundation for Integrated Catalonia Engaged to Enhance Securing political support, Care (IFIC) 457 Development of the Dr Oscar Solans, eSalut. Ministry of Health., ES Reintegration. A building national coalitions, GeriatrICS, an ICF-based Comparative Study on and designing care models 243 Identifying barriers to and person-centred 207 Information technology in multispecialty community Intermediate Care * based on international Implementation of New assessment tool for providers: results from a realist evidence synthesis Dr Michelle Nelson, experience Care Models, a Multi- evaluation of health- Amanda Wanner, Community and Primary Care Research Lunenfeld-Tanenbaum Anna Kozieł, World Bank Stakeholder Engagement related problems in Group, Peninsula Schools of Medicine and Dentistry, Research Institute, Sinai Office in PL and Katarzyna Study community-living older University of Plymouth, United Kingdom Health System, CA Wiktorzak, the National Prof Aine Carroll, HSE, IE adults * Health Fund, PL + 130 Big data combined with clinical insight: identification 518 The 6 A’s Global 442 Barriers and facilitators 458 Results of a cross- of patients at-risk for 30-day readmission to be included in Transitional Care Model for 330 Towards a sustainable for the implementation of sectional study on health- prevention interventions * Addressing Hospital-to- health system in the Integrated Care Pathways related problems of Natalie Flaks-Manov, Clalit Health Services, IL home Care Fragmentation Netherlands: strategies to (ICPs): a systemic community-living older improve cross-sector perspective * adults using the GeriatrICS, 8
Prof Janet Bettger, Duke collaboration and Elena Urizar, Deusto an ICF-based assessment 213 What happens to patients after their first diagnosis of University, US community engagement. Business School Health, ES tool dementia? (oral poster) Caroline Baan, RIVM and Klaske Wynia, University Timo Schulte, OptiMedis AG, DE 538 Program to improve Tranzo, NL 235 The communicative Medical Center Groningen, the discharge process: constitution of population University of Groningen, NL 181 Integrated care issues: Transfer of patient care TRANSICIONA The Implementation Rooms health systems * information (oral poster) Mónica Mesas Cervilla, Parc will draw lessons from early Anna-Sophia Bilgeri and 185 Pre- and within Dr Bianca Buijck, Rotterdam Stroke Service, NL Sanitari Pere Virgili, ES and successful approaches Matthias Mitterlechner, hospitalization risk factors to integrated care in University of St. Gallen, CH for readmission of older 200 Presenting the status of project SIFT – Research of the 561 A joint emergency Europe, and share these adults * patient flows and structures in health and social services response for those at risk of with the wider community 545 Adaptation and Orly Tonkikh, University of in three Finnish cities in 2009–2015 acute hospital admission in of stakeholders, who wish standardization of Haifa, IL Dr Reija H. Haapanen, Sosiaalitaito – Centre of Expertise Cambridgeshire. to embark on the integrated care practices to on Social Welfare in Western and Central Uusimaa, FI Joe Lynch, CPFT, UK implementation of facilitate scale-up and 281 Inter-Relationship integrated care. They will spread: Insights from Between Frailty & 569 First Use of a Population Health Management 386 Perceived quality of focus on discussing the Ontario case studies Multimorbidity in East Strategy in Dutch Primary Health Care care transitions between “how-s” of Prof G. Ross Baker, Berkshire, UK. Shelley-Ann Girwar, Leids Universitair Medisch Centrum hospital and the home - a implementation. University of Toronto, CA Dr Steve Sutch, Johns Campus Den Haag, NL cross sectional study (oral Hopkins HealthCare poster) 477 Solitary, merge or Solutions, US Sebastian Lindblom, collaborate. Determinants Karolinska Institutet, SE of collaboration of elderly 463 Home mobile system care organizations: a case to early detect functional 122 A quasi experimental survey approach decline to prevent and before and after study of a Steven van den Oord, manage frailty transitional care Antwerp Management Elena Villalba-Mora, programme for older adults School, BE Universidad Politécnica de in the area of the IJsselland Madrid, ES Hospital (oral poster) 499 Assessing Factors that Wilma van der Vlegel- Influence the Brouwer, IJsselland implementation of hospital, NL Technologies Enabling Integrated Care Delivery for 503 Transitional care: the Older Adults with Complex evolution of an ever-green Needs: A Systematic service to make integrated Review (oral poster) * care happen Mudathira Kadu, University Dr Lucia Ferrara, Cergas, of Toronto, CA SDA Bocconi - Bocconi University, IT 9
2.F Integrated Care 2.G Policy and planning 2.H Integrated approach 2.I Poster Presentations: 2.J Research and 2.K Workshop: Sharing Academy©: building for support and care for Reorganising primary care Evaluation Design (in wisdom: Integrated care in competencies for socially/psychologically collaboration with SIG partnership – A work in integrated care vulnerable people with Research and Evaluation) progress in Queensland, disturbed behaviour (225) Australia (374) Room 6&7 Room 9&10 Room 31 Room 12 Room 18 Room 19 Chaired by Maggie Langins, Chaired by Ri de Ridder, Chaired by Cule Cucic, Chaired by Dr Robin Miller, Chaired by Roelof Ettema, Chaired by Leonie International Foundation Department Medical ZonMw, NL University of Birmingham, University Utrecht, NL Sanderson, Health for Integrated Care (IFIC) healthcare, National UK Consumers Queensland, AU Institute for Health and How to evaluate an 340 Too complex to test? 324 Client-centered Disability Insurance, integrated approach in a 532 Virtual Heart Failure Using exploratory trials to Presenters: integrated services and Belgium vulnerable population by Clinic - An Integrated Care identify relevant contexts Judith Piccone, Department new competencies in combining data from police Programme Support for and mechanisms prior to of Health, Queensland health and social care 410 Value of Treatment: a systems, local health care General Practice ** larger scale evaluations Government, AU Dr Timo Sinervo, National design journey towards an organizations and mental Dr Orlaith O’Reilly, Health Dr Carolyn Steele Gray, Institute for Health and optimised person-centred health organizations over Service Executive, IE Bridgepoint Collaboratory, Katherine Moodie, Welfare, THL, FI care model for Europe time Lunenfeld-Tanenbaum Department of Health, Sanna Laulainen, University Dr Nick Guldemond, Dr Annemieke Spijkerman, 304 - Piloting an Integrated Research Institute Queensland Government, of Eastern, FI Erasmus School of Health National Institute for Public Care Model for the Elderly AU Policy & Management, NL Health and Environment Diabetic Patients 253 Primary care service 553 Coordinated Care: Our (RIVM), NL Ariana Bytyci, Accessible innovation: The importance Michelle Bond, Department Forward View (oral poster) 111 The critical importance Jitske Nijhuis, Significant, Quality Healthcare (AQH) of measuring person- of Education, Queensland Thomas Lawrence, of going beyond NL Project, XK centred coordinated care * Government Birmingham City University, administrative data for Ben Fosh, University of UK health systems planning 129 Substituting hospital Plymouth, UK Gunther DeGraeve, and integration * care with primary care: The Destravis Group, AU 266 Improving Dr Richard Lewanczuk, evaluation of a cardiology 430 Importance of Triple collaborative mental health Alberta Health Services, CA Primary Care Plus Aim outcome measures: do 352 The establishment of care across Australia: intervention patients, partners, effective collaboration development and 137 Integrated care for Tessa.C.C. Quanjel, professionals, payers and between primary care and evaluation of the Mental mentally ill offenders in Maastricht University, NL policy makers differ in welfare in the promotion of Health Professionals Belgium: an analysis of a opinion? mental health in patients Network (MHPN) initiative mandated collaboration 144 Reorganising Maureen Rutten-van with multi-problems (oral Chris Gibbs, Mental Health dermatology care: Mölken, Erasmus University poster) Professionals Network, 136 The role of the Belgian predictors to substitute Rotterdam, NL Mark van der Wel, Melbourne, Vic, AU government in enhancing secondary care with Radboud University the integration of primary care 336 Measurement of Medical Center, NL 412 Developing an healthcare for Mentally Ill Esther van den Bogaart, health organisation interprofessional training Offenders: an analysis of Maastricht University, NL performance across 10
for primary care: a co- the reform plan (oral multiple sector services: a 208 The role of peer creation with practice, poster) 223 Luohu Model: A population health analytic support in mental health education and research. Maurice François Pans, template for integrated perspective care (oral poster) * Linda Smit, University of Vrije Universiteit Brussel, urban health care systems Dr Stephen Sutch, Johns Ann Claeys, Erasmus Applied Sciences Utrecht, BE in China Hopkins, NL University College, BE NL Xin Wang, SUN Yat-Sen 556 Collaboration between University, CN 295 Setting Up A 461 Meeting for innovation 550 Building Blocks of Local Public Health Units Monitoring System to in mental healthcare Knowledge on integrated and Regional Health 379 Learning from the evaluate a Whole System organisation (oral poster) care for professionals in Authorities in Canada for development of two Change towards Integrated Prof Sophie Thunus, neighborhood teams Integrated Health System Integrated Care Pathways Care: the Belgium Catholic University of Rian van de Schoot, Vilans, Planning Using a Population for dementia Experience Louvain, BE NL Health Approach: Research Dr Mairead Bracken-Scally, Prof Geert Goderis, Dr Ruta Kristina Valaitis, Trinity College Dublin, IE KULeuven, BE McMaster University, CA 496 - Implementing a 392 Participatory 421 Building collaboration complex innovation in Approaches to Improve from scratch: exploring general practices: from a Integrated Care Programs: mandated collaboration universal to a practice- Methods, Experiences, and between healthcare centred approach Early Results Applying insurers and municipalities Gijs Brouwer, Maastricht Methods from Sarah van Duijn, Vrije University, NL Implementation Research Universiteit Amsterdam, NL Dr Helen Schonenberg, 366 Integrating Health Care Philips, NL 378 Governance and – Our Journey Continues performance measurement Dr Andrew Knight, South in integrated care. An Western Sydney Local Evidence Based Integrated Health District Care Approach Dennis Richard van 189 Integration of Primary Kerkvoorden, Health Care of a small HU University of Applied Brazilian city in the health Sciences, NL care network Prof Ed Wilson Vieira, Universidade Federal de Minas Gerais (UFMG), BR
135 Exit versus Voice: Competition and Dissatisfied Patients’ 11
Responses to General Practitioners Tigist Sommeno, UiO, NO
7.00 – 8.30 Welcome Drinks Reception Museum Speelklok, Utrecht City Centre
12
Thursday, 24 May 2018
7.30 – 9.00 Breakfast sessions TBW 1 Workshop TBW 2 Workshop EMBRACE TBW 3 IJIC Editors TBW 4 SIG Leaders TBW 5 Workshop: TBW 6 Workshop: Integrating Health and (474) breakfast meeting breakfast meeting in Transforming integrated Cognitive computing, Social Care: Special Interest association with the care in Europe through information technology Group (SIG) Kick-Off (247 + Integrated Care Academy© collaboration and and integrated care 246) knowledge transfer (395) Room 14 Room 6&7 Room 8 Room 11 Room 9&10 Room 12 Chaired by Prof John 474 Quality Standard for Chaired by Donna Chaired by Dr Hector Eastwood, Sydney Local Person-centred and Henderson and Andrea Upegui and Nicholas Health District, AU Integrated Care for Older Pavlickova, NHS National Cronshaw, IBM Watson adults Services Scotland Health 247 SIG Integrating Health Dr. Klaske Wynia, UMCG, NL and Social Care Part 1: This workshop is an IBM Watson Health is Establishing a Special opportunity to explore the investing heavily to Interest Group potential of the SCIROCCO ensure the individual is tool to facilitate supported through 246 SIG Integrating Health collaboration and 'Integrated Care' and and Social Care Part 2: The knowledge transfer that remains the absolute Healthy Homes and accelerates the adoption focus. A “win” for the Neighbourhoods Integrated of integrated care in individual needs to also Care Initiative Europe. The session be a “win” for the features experience of supporting using the SCIROCCO tool organisations. Some of from three European the obstacles in a regions, the Basque successful strategy Country, Norrbotten are: setting coordinated, Region in Sweden and integrated care plans Puglia Region in Italy. Each based on relevant, Region tested the tool in effective evidence; the process of assessing coordination and the maturity of their communication amongst healthcare systems for the the person and a multi- adoption of integrated disciplinary team; and care. establishing and maintaining person centricity. This session will provide IBM's point of view on integrated 13
care, along with existing and future capabilities of our solutions.
9.00 – 10.00 PLENARY 3: Uncovering the full potential of primary health care Chaired by Prof Caroline Baan, Head of the Department of Quality of Care and Health Economics, National Institute for Public Health and the Environment (RIVM)
Expanding the scope of primary health care: developing cross-disciplinary cooperation to improve the health and well-being of older people Prof Tine Rostgaard, VIVE Danish Centre of Applied Social Sciences, Denmark
Care transitioning: the interface between transitional care and primary care Dr Eric Coleman, Director of the Care Transitions Program and Head of Division of Health Care Policy & Research University of Colorado Anschutz Medical Campus, US
10.00 – 10.30 Refreshments, exhibition, posters and networking
10.30 – 12.00 PARALLEL SESSIONS 3
3.A Innovative approaches 3.B The Implementation 3.C Bundling payments to 3.D Managing Frailty 3.E Workshop: Regulating 3.F Workshop: Co- to keeping communities Room: Engaging and support integrated care: Organised by JA AdvantAge and inspecting integrated designing care with healthy educating the care evidence from around the care – creating an older people workforce in new roles world international platform for Organised by the European change Commission Room - Event Hall Room 11 Room 6&7 Room 30 Room 8 Room 9&10 Chaired by Dr Aine Carroll, Chaired by Dr Eszter Kovacs - Chaired by Dr Jeroen Chaired by Angel Rodriguez- Host: Ronnie van Diemen, Chaired by Des Mulligan, HSE, IE Coordinator of the joint Struijs, National Institute Laso, Foundation of the Inspector General, Dutch HSE, IE tender "Support for the for Public Health and the University Hospital of Health and Youth Care 146 Multipronged health workforce planning Environment (RIVM) and Getafe, Madrid, Spain Inspectorate 555 A strategic management strategy for and forecasting expert International Foundation partnership approach to patients with complex needs network" for Integrated Care (IFIC) 454 Geriatric Rehabilitation Chaired by Kees Reedijk, enabling co-production using an integrated healthworkforce.eu Network – Patient in the Strategic inspector, Dutch of integrated care for organizational mode * 511 Bundled payment for Lead: Aiming for Health and Youth Care older people Dr Beñat Zubeltzu, Basque mental health care: a realist personalised, efficient, and Inspectorate Des Mulligan, HSE, IE Health System, ES review 14
Strategies to engage health Dr Lucia Ferrara, Cergas, effective geriatric This workshop will serve 347 Co-designing a 179 System wide self-care in professionals in the design of SDA Bocconi - Bocconi rehabilitation to exchange experiences framework for Greater Manchester new care models University, IT Romke van Balen, Leiden and discuss the challenges integrated home care Kirsty Marshall, University of Professor Rick Iedema, University Medical Center, faced by regulators and planning with older Salford, UK Director, Centre for Team 349 Impact of Bundled Care NL inspectors to accredit, adults, family caregivers Based Practice & Learning in in Ontario monitor and assess and health care 519 Bridge: a piloting project Health Care, Health Walter Wodchis, University 405 Improving self- integrated care. providers (oral poster) of social enterprise to Faculties, King's College of Toronto, CA management of health ** enhance reablement and London, UK through an eHealth Speakers: Justine Giosa, University social inclusion for people 469 Investigating the application: an action-based Dr Nick Goodwin, of Waterloo/ Saint with physical disabilities * Practical measures to association of integrated study among older adults International Foundation Elizabeth, CA Prof Verdiana Morando, SDA educate and upskill health care on healthcare costs: living in the community for Integrated Care (IFIC) Bocconi, Bocconi University, professionals in new roles evidence from a large Margot Jager, University of 206 Putting the Patient IT for integrated care, retrospective cohort study Groningen, University Prof Dr Mirella Minkman, Voice at the Heart of Francesca Avolio, Regional in the Netherlands Medical Center Groningen, International Foundation Service Redesign: an 311 Neighbourhood Care Healthcare Agency of Puglia, Dr Milad Karimi, Erasmus NL of Integrated Care (IFIC) introduction to the use Development in Inverness, IT and EU HP project university, NL and Vilans of patient reported Highland, Scotland SCIROCCO 251 Preventing measures to improve Rhiannon Pitt, NHS 119 A comprehensive perioperative surgical site Patricia Sullivan-Taylor - person centred Highland, UK The Implementation Rooms overview of barriers and infections among hip Executive Lead for Policy coordinated (integrated) will draw lessons from early facilitators in the design fracture patients: An and Partner Engagement, care and successful approaches to and implementation of integrative care-bundle Accreditation Canada Dr Helen Lloyd, integrated care in Europe, bundled payment contracts approach Community and Primary and share these with the ** Wen Qi Mok, Khoo Teck Heleen Buijze, Care Research Group, wider community of Sander Steenhuis, Talma Puat Hospital, SG Coordinating inspector Plymouth UK stakeholders, who wish to Institute / VU University Dutch Health and Youth embark on the Amsterdam, NL 156 Shared Care Planning: A Care Inspectorate implementation of new model to integrate integrated care. They will Advance Care Planning into Janet Ortega, Head focus on discussing the community. The Basque Integrated Care, Care “how-s” of implementation. Country experience * Quality Commission Dr Inaki Saralegui, Osakidetza, ES Nick Goodwin will start this session by outlining 290 Comprehensive geriatric the scientific evidence and assessment in integrated frameworks available for care for older people living assessing integrated care. at home: a systematic Dr Mirella Minkman will review (oral poster) go into the governance Annerieke Stoop, RIVM, NL and performance 15
measurement of care 259 Cognitive Inclusion networks. Patricia will be through Digitally Supported talking about integrated Independent Living health and social services Dr Rachelle Kaye, Assuta program being developed Medical Centers, IL in Canada, consisting of an Integrated health and social services standard, maturity scale model and implementation tools.
3.G Workshop: Integrated 3.H Supporting homeless 3.I Empowering patients 3.J Workshop and poster 3.K Establishing a Special Interest Group (SIG) on care: challenges for people with chronic conditions presentations in Children, Youth and Families (240) professions and collaboration with SIG interprofessional education Palliative Care (124) in association with the Integrated Care Academy© Room 12 Room 14 Room 18 Room 19 Room 32 Chaired by Prof Dirk Chaired by Leo Lewis, Chaired by Roberto Nuño- Chaired by Anne Mills, Chaired by Frank Tracey, Children’s Health Ruwaard, Maastricht International Foundation for Solinís, University of Hospice Isle of Man Queensland, AU University, NL Integrated Care (IFIC) Deusto, ES a) Implementing and 240 Integrating Care for Children Young People and During this workshop a 322 A cross-sectoral 293 Patients experiences of evaluating Their Families Part 1: Establishing a Special Interest member of the national integrated care approach to self-management and Compassionate Group committee will highlight the addiction services, homeless strategies for dealing with Communities – Prof John Eastwood, Sydney Local Health District, AU findings of recent national services and prison services chronic conditions in rural experience from reports. Then we will focus – the experience from Malawi Spain and UK 157 Establishing Paediatric Integrated Care for on one of the Dutch Southern Ireland ** Vibian Angwenyi, Vrije Children with Medical Complexity in a Fragmented breeding grounds, the Joe Kirby, Irish Health Universiteit Amsterdam, NL 436 Developing a Health System region of South-Limburg. We Service Executive, IE Compassionate Community Christie Breen, Sydney Children's Hospitals Network, will present and discuss how 296 Improving Chronic (oral poster) AU interprofessional education 160 Improving Hospital diseases management Alison Bunce, is being developed and Discharge Arrangements for through integration, in Compassionate Inverclyde, 377 A qualitative study into health and social needs implemented in vocational People who are Homeless: Jeddah, Saudi Arabia UK and barriers to service access for families residing in a and academic programmes, The Role of Specialist Dr Zaki Algasemi, Ministry suburb of Sydney with high rates of disadvantage embedded in primary care Integrated Care * of health, SA 261 Healthcare Erin Miller, Sydney Local Health District, AU professionals’ experiences 16
and other health care Dr Michelle Cornes, King's 166 Considering patients’ of interprofessional 426 Barriers and facilitators to integration of care for settings. College London, UK empowerment in chronic collaboration during children with complex care needs across 30 European care management: a palliative patients’ transfer countries: A MOCHA study 565 The Development of an multidisciplinary approach of care setting: a focus Dr Miriam O'Shea, The University of Dublin, Trinity Inclusion Health Integrated Caroline Tilkin, ULiège, BE group study (oral poster) College, IE Care Programme for Fien Mertens, Universiteit Homeless Adults in Dublin, 138 Implementing an Gent, BE Ireland Integrated Care System for Dr Clíona Ní Cheallaigh, St Chronic Patients in 139 Family experiences with James's Hospital, IE Belgium: a Co-creation palliative care of people Process (oral poster) with severe dementia in 338 A city's system approach Mélanie De Winter, Norwegian nursing homes to complex needs provision. University of Liège, BE (oral poster) (oral poster) May Helen Midtbust, Wendy Lewis, Advancing 268 Occupational Therapy Norwegian University of Quality Alliance/ Salford Perspective on Integrated Science and Techonology, Royal, UK Care Faculty of Medicine and Marie-Antoinette Minish, Health Sciences, NO HAN University of Applied Sciences, NL 497 Barriers to engaging in end-of-life communication in heart failure: perceptions of patients and their family caregivers Jennifer Im, University of Toronto, CA
b) Topic poster walk HA-REACT Symposium: Different ways to overcome challenges, Part 1 (by invitation)
12.00 – 13.30 Buffet lunch, exhibition, posters, networking and lunchtime workshops
Lunchtime Workshops
TLW 1 Co-designing green TLW 2 iCoach (284) TLW 3 Poster TLW 4 Network discussion: TLW 5 Multiple Roads TLW 6 Workshop SIG social care services: Farmers presentations: Population Regulating and inspecting Travelled: A Career Panel Values and Principles and citizens as new social health management in integrated care – creating on Integrated Care for the care providers for collaboration with SIG Next Generation of 17
vulnerable populations Population Health an international platform Researchers and (387) Management for change Practitioners (528) in association with Integrated Care Academy© 12.00 – 1.00 12.00 – 1.00 12.00- 1.00 12.30 – 1.30 12.30 – 1.30 12.30 – 1.30
Room 6&7 Room 8 Room 9&10 Room 12 Room 14 Room 18
Chaired by Dr. Jan Hassink, Chaired by Walter Wodchis, Chaired by Alex Pimperl, Host: Ronnie van Diemen, Chaired by Mudathira Chaired Prof Dr Mirella Wageningen University and University of Toronto Optimedis Inspector General, Dutch (Mudi) Kadu and Henriikka Minkman, Vilans and Research, NL Health and Youth Care Laurola, International International Foundation In this workshop we will 390 Unravelling the Drivers Inspectorate Foundation for Integrated for Integrated Care (IFIC) During this workshop we discuss an emerging of Regional Variation in Care (IFIC) and Nick Zonneveld, present an overview of the international network of Healthcare Spending by Chair by Dr Nick Goodwin, Vilans different types of green care patients, clinicians and Analysing Prevalent Chronic International Foundation for The audience will have the initiatives, and how managers, researchers and Diseases Integrated Care (IFIC) opportunity to hear and 236 Values underpinning vulnerable citizens and policy decision-makers Eline Frouke De Vries, learn from the integrated care: a communities are interested in understanding, Tilburg University, NL This workshop is intended experiences of panellists systematic review, empowered and engaged implementing and evaluating for regulators and who have navigated the Nick Zonneveld, Vilans, respectively within these integrated care. We will 282 = 283 A Population inspectorates around the field of integrated care. NL initiatives. We have invited a describe the approach Health Approach: world who want to continue farmer who will be undertaken in iCOACH across Addressing equity and collaborating on integrated Nuria Toro, World Health 385 Values and interviewed followed by two the 4 perspectives and the social determinants of care after the conference. Organization (WHO) challenges in a care short presentations in which advantages of involving health in Canadian The main objective is to set Jodeme Goldhar, The ecosystem design we share the lessons so far. multiple jurisdictions. healthcare ** up a Special Interest Group Change Foundation approach * We conclude with a Dr Elina Farmanova, on integrated care for Dr Robin Miller, University Ezra Dessers, Ku Leuven, discussion with all people University of Toronto, CA regulators and inspectorates of Birmingham BE present about similar within the health, youth and Dr Jacobi Elliott, University experiences in other 482 Long-term advantages social care sector. The of Waterloo countries and about the of person-centred and outcomes will be a clear Dr Helmut Hildebrandt, future of green care. integrated care: results of a focus for the Special Interest OptiMedis longitudinal study on Group, an agenda with the Dr Viktoria Stein, Embrace main issues for exchanging International Foundation Dr Klaske Wynia, UMCG, NL knowledge as well as for Integrated Care (IFIC) experiences and some practical agreements. The discussion will offer insights into the different transferable approaches, tools and skills they leveraged to: 1) overcome 18
a major research or policy gap that was challenging at the time and; 2) achieve career milestones that lead to their current role in integrated care.
1.30 – 3.00 PLENARY 4 Co-designing a system with the people for the people
Chaired by Professor Henk Nies, Member of the Executive Board, Vilans, Utrecht and Professor of Organisation and Policy in Long-term Care, Vrije University, Amsterdam
272 Recalibrating the integration agenda: the position of citizens and communities in integrated care Ludo Glimmerveen, Vrije Universiteit Amsterdam, NL and Professor Henk Nies, Member of the Executive Board, Vilans, Utrecht and Professor of Organisation and Policy in Long-term Care, Vrije University, Amsterdam
Co-designing policies and strategies Jodeme Goldhar, Executive Lead, Strategy and Innovation, The Change Foundation, Canada Carole Ann Alloway, Family caregiver
Illustrator Feedback
Theatre performance
Room – Event Hall 3.00 – 3.30 Refreshments, exhibition, posters and networking
3.30 – 5.30 PARALLEL SESSIONS 4
4.A Keynote Workshop: Co- 4.B The Implementation 4.C Workshop: Integrating 4.D Organising for Frailty 4.E Changing workforce in 4.F Supporting informal designing a system with the Room: Transferring care by payment reform – Organised by JA AdvantAge association with caregivers people for the people (341) knowledge and good A workshop on the Integrated Care practice Organised by the implementing of bundled Academy© European Commission payments for birth care in the Netherlands (465) Room - Event Hall Room 11 Room 6&7 Room 30 Room 8 Room 9&10
19
Chaired by Jodeme Goldhar, Chaired by Cristina Bescos, Chaired by Dr Jeroen Chaired by Prof Anne Chaired by Dr Viktoria Chaired by Sanna The Change Foundation, CA Project Coordinator of EU HP Struijs, National Institute Hendry, IFIC Scotland Stein, International Laulainen, University of project ACT@Scale for Public Health and the Foundation for Integrated Eastern 341 Co-designing a system Environment (RIVM) and 183 How to succeed in Care (IFIC) with the people for the Experiences from the International Foundation population health 294 Understanding the people twinning between Scotland for Integrated Care (IFIC) management by strategic 353 The policy discourse(s) outcomes of specialist Kerry Kuluski, Lunenfeld- and the Basque Country alliances of patient autonomy in nursing: the continuing Tanenbaum Research (focus on transferring 465 Integrating care by Evelien Heinrich and home care and the re- importance of Institute, Sinai Health knowledge and tools for risk payment reform – A Sandra de Loos, Robuust, NL shaping of nurses’ relationships for carers System, CA stratification and patient workshop on the professional work and of people with dementia Carole Ann Alloway, Family empowerment) – work from implementing of bundled 476 Evaluating the identities * * caregiver the EIP AHA and the EU HP payments for birth care in Implementation of Dr Gaby Jacobs,Fontys Kate Gridley, University project SCIROCCO the Netherlands Integrated Care for Older University of Applied of York, UK 448 Empowering Corine van Geffen, College Persons as a path to Sciences, NL communities: drawing on Donna Henderson, NHS24, Perinatale Zorg, NL Universal Health Care 364 Improving CARE evidence to build successful Scotland, UK and Ine Pennings, JIJWIJ Dr Sarah Barry, Trinity 227 Hospital Nurse Case Together – Building community engagement Esteban de Manuel Keenoy, Helmond College Dublin, IE Managers Drive Integrated Partnerships with Family initiatives * Kronikgune (Basque Centre Care Caregivers * Esther de Weger and Sanne for Health Services Research 239 How (not) to create 472 From a national Dr Efrat Danino. Assuta Dr Jacobi Elliott, Raap National Institute for and Chronicity), ES value based integrated program to local Medical Centers, IL University of Waterloo, Public Health and The maternity care: Lessons implementations: how to CA Environment, NL The Implementation Rooms from the Netherlands coordinate patient-centred 285 Preparing the future will draw lessons from early Prof Raymond De Vries, care for elderly taking workforce to address the 467 Exploring 151 Back to basics: Building and successful approaches to University of Michigan, US territorial specificities into health needs of small rural experiences and a health service grounded integrated care in Europe, account Australian towns through perspectives of people on what people want and share these with the A patient perspective in Alina Morgoci, National non-traditional allied living with dementia and Prof Amanda Phelan, wider community of maternity care and bundle agency to support the health student placements their informal carers and University College Dublin, IE stakeholders, who wish to payment: what do women performance of healthcare + combined entrepreneurs on embark on the want? institutions and medico- 371 Preparing the future dementia friendly leisure 242 Your Voice Matters, a implementation of Anne Mooij, social facilities, FR workforce to address the activities. pilot qualitative study of integrated care. They will Patiëntenfederatie health needs of rural Dr Mathilde Matthijsse integrated care in Ireland focus on discussing the Nederland 178 Avoidance of communities – Excellence and Iris van de Velde, Hz Clare Hudson, HSE and Anne “how-s” of implementation. unnecessary hospital in Multidisciplinary University of Applied Lawlor, 22q, IE admissions through the Education Sciences, NL implementation of a digital Frances Lee Barraclough, 342 Integrating patient health programme (oral University of Sydney, AU 356 Integrated Care for engagement in care, poster) people with dementia: organizational processes and Kirsty Marshall, University of 142 Primary Care how to improve quality policy to configure systems Salford, UK Networks and Team of life of people with around patient capabilities Effectiveness: The Case of 20
Susan Usher, École nationale 414 Should I stay or should I a Large-Scale Quality dementia and their d'administration publique, go? A retrospective Improvement Disparity informal care-givers? CA propensity score matched Reduction Program Rinske Boomstra, Vilans, analysis of hospital-at-home Dr Sivan Spitzer-Shohat, NL 301 - An Integrated services Bar-Ilan University, IL Approach to Prevent Chronic Dr Apostolos Tsiachristas, 132 - Measuring Lifestyle Diseases in Māori University of Oxford, UK 361 Examining the extent Integrated Care’s Men 30-55 and drivers of integration Reliance on Caregiver Prof John Oetzel, Ray Wihapi 418 A 305 in primary care teams Support: A Caregiver and Carey Manuel, to support integrated Anum Irfan Khan, Experience Survey University of Waikato, NZ person-centered care University of Toronto, CA Sara Shearkhani, Dr Henk Herman Nap, University of Toronto, CA Vilans, NL 419 Emotional Dynamics in Integrated Care 302 Measuring Dr Anneli Hujala, UEF, FI Caregivers Experience: design and results of IEXPAC Caregivers Juan Carlos Contel, Spain Universidad Miguel Hernandez
4.G Workshop: Academic 4.H Uncovering the full 4.I Transformational 4.J Child health in 4.K Evaluations in collaboration with SIG Realist networks for more potential of primary health change collaboration with SIG Evaluation integration and more care Children, Young People and demand-driven care and Families support for people with complex needs (547) in association with Integrated Care Academy and ZonMw Room 31 Room 12 Room 14 Room 18 Room 19 Chaired by Carlijn van Aalst, Chaired by Dr Henk Nies, Chaired by Prof Dr Mirella Chaired by Frank Tracey, Chaired by Ezra Dessers, KU leuven ZonMw Vilans Minkman, Vilans and Children’s Health International Foundation Queensland, AU 375 A realist evaluation of Healthy Homes and How to work in academic 226 Transformed Primary for Integrated Care (IFIC) Neighbourhoods’ place-based initiative in an inner city networks, together with Care in Wales: Integrated, 508 Integrated Behavioral public housing estate in Sydney practice and policy on Multi-professional and 441 East Sussex Better Health Services in Primary Salwa Barmaky, Sydney Local Health District, AU integrated care for frail Asset-based Together Alliance - Care - Improving Patient elderly, people with Dr Robin Miller, University of Governance to enable cross Access and Outcomes 254 - Health and Social Care influences on Long dementia and people with Birmingham, UK sector delivery Dr Andrew Roger Cook, Hospital Length of Stay (LOS): A Critical Realist Study in (intellectual) disabilities. University of Michigan, US a large metropolitan hospital * 21
Prof. dr. Jacobijn Gussekloo, 348 Building a Population- Dr Niamh Lennox- Bahare Moradi, Sydney Local Health District, AU Academic Network Elderly based Integrated Health Chhugani, Optimity 128 - Integrated care for Care and Elderly Board, System on a Foundation of Advisors, UK diagnostics along the 312 Implementation and effects of risk-dependent Leiden University Medical Primary Care in Toronto disease trajectory of obstetric care in the Netherlands: a clinical impact Centre, NL Dr Jocelyn Charles, Pauline 491 Comparing children with a study. Expect Study II * Prof.dr.Sophia de Rooij, Pariser and Marsha Barnes, sustainability and business neurobiological Pim van Montfort, Maastricht University, NL Hospital at home University Toronto Central Local Health models of scaling up care developmental delay or Medical Centre Groningen, Integration Network, CA programmes within EU disorder. A network 358 Navigating the healthcare neighbourhood: Academic Medical Centre regions approach Evaluation of a bottom-up, inter-agency integration Amsterdam, NL 121 The Value from Sander Holterman, UMCG, Eva Cloet, Vrije Universiteit program Dr. Kitty Jurrius, Acquired Integrating Primary and NL Brussel, BE Rhiannon Beck, Agency for Clinical Innovation, AU brain injury network, Community Care in Windesheim, Flevoland, NL Weymouth and Portland 117 - Learning from + to be combined with 176 Integrated Care for High-need High-cost Patients: Helen Persey, Dorset integrated care top The Comprehensive Care for Multimorbid Adults HealthCare, UK performers in Spain 112 How regulations of Program (CC-MAP) Roberto Nuño-Solinís, multidisciplinary diagnostic Prof Efrat Shadmi, University of Haifa, IL 479 Improving person University of Deusto, ES settings for children with a centered care in district neurobiological 452 Evaluating an integrated health and social care health systems of Sud Kivu in 250 A National Programme developmental delay or programme for vulnerable people: The case of ‘Better DRC: an innovative tool for for Improving Access and disorder impact on Together in Amsterdam North’ * primary care organizational Quality of a integration of care: the case Dr Milad Karimi, Erasmus university, NL analysis multiprofessional Primary of Flanders, Belgium Jean Macq, Ndjangulu Care system Eva Cloet, Vrije Universiteit Molima, Catholic University Prof Anya Pimentel Gomes Brussel, BE of Louvain, CD Fernandes Vieira-Meyer, Fundação Oswaldo Cruz, BR 533 Coordination of health 551 Population management and social care for children in integrated care 411 Basque health service - with complex health needs organization in Poland: Osakidetza integrates care: across in the EU/EEA: a case resource utilization for Scaling-up process of scenario approach exploring performing health risk integrated care program for care coordination for an assessment multimorbid patients adolescent with an acquired Artur Prusaczyk, National within ACT@Scale project brain injury Institute of Public Health - Danika Schepis, Rebecca McHugh, Trinity National Institute of Kronikgune, ES College Dublin, IE Hygiene, PL 270 Health care reform in 350 - Nationwide structure Belgium: contracting for co- for Integrated Children creating integrated care as Palliative care
22
change management Stephanie Vallianatos, PAL strategy Foundation, NL Dr Ri De Ridder, NIHDI- Belgium, BE
HA-REACT Symposium: Different ways to overcome challenges, Part 2 (by invitation only)
7.30 – 11.30 Gala Dinner (Conference Venue)
Friday, 25 May 2018
9.00 – 10.30 The Future of Integrated Care Innovation Session
Welcome and Session Introduction Dr Albert Alonso, Chair, International Foundation for Integrated Care (IFIC) Prof Dr Mirella Minkman, Director of Research and Innovation, Vilans, the Netherlands Centre of Expertise for Long-Term Care and Vice Chair and Secretary International Federation of Integrated Care (IFIC)
The purpose of this session is to create an environment in which delegates feel safe to share ideas, transfer knowledge and work together to visualise the future of integrated care.
By attending this session we would like delegates to feel that they can go back to their organisations and be ‘Boat Rockers’ – “one that challenges the status quo when they see that there could be a better way; energise their organisation by working from their true self; capable of working with others to create success and NOT be destructive and trouble making; walk the fine line between difference and fit, inside and outside, rock the boat but stay in it” – Helen Bevan.
Each zone will have an appointed leader(s) who will take control of the zone. Each zone may include pitch type presentations and employ different methods of engaging the audience in discussion.
The hosts will introduce the session from the main stage, but delegates will also receive detailed instructions and an explanation of the session in advance. The delegate app will also provide more information. The session might start with an energizer to get people moving and energetic for the session. A short buzzer will sound every 15 minutes to alert delegates that they can move to another session or stay where they are if they prefer. Zone Leaders should not consider the buzzers but move on with session as normal.
Zone 1 Learn more about IFIC and contribute to future developments! Zone Leaders: Dr Albert Alonso, Chair, International Foundation for Integrated Care (IFIC) Prof Dr Mirella Minkman, Director of Research and Innovation, Vilans, the Netherlands Centre of Expertise for Long-Term Care and Vice Chair and Secretary International Federation of Integrated Care (IFIC)
23
Includes the following presentation: 334 International Integrated Solutions in Sport 2018 - From Dublin to Norway Catherine McClennan, Cheshire and Merseyside Women's and Children's Services Partnership, Dave Sweeney, Cheshire & Merseyside Health and Care Partnership and Kjersti Holte, Østfold University
Meet the IFIC Board, SIG Leads and IFIC Hub Directors
Zone 2 Education and Training (in association with the Integrated Care Academy (©) Zone Leaders: Dr Viktoria Stein, Director of Education and Training, International Foundation for Integrated Care (IFIC) and Dr Robin Miller, University of Birmingham
409 - Education for Integration. Helen Rainey and Elaine Gifford, University of the West of Scotland, UK
558 Research Master in Population Health Management: work in progress * Dr Marc Bruijnzeels, LUMC, NL, Marlou de Kuiper, UMC Utrecht and Cara English, Cummings Institute
229 Involving Volunteer Patients (VPs) in Medical Education not Only Trains the Medical Students but Also Promotes the VPs’ Health (oral poster) Yun-Chen KO, Taipei City Hospital, TW Zone 3 Research, Evaluation and Tools Zone Leader: Mudathira (Mudi) Kadu and Maggie Langins, International Foundation for Integrated Care (IFIC)
Includes the following presentations: 292 - Enhancing the SCIROCCO tool using quantitative and qualitative methods. Dr Tamara Alhambra-Borrás, Polibienestar - University of Valencia, ES
563 Using the Project INTEGRATE Framework for assessing progress towards care integration: results from a formative evaluation of a complex intervention in Central Coast Local Health District, NSW Australia. Hazel Dalton, Newcastle University, AU
512 Integrated Care Search: Mapping the Sources of Integrated Care Evidence Suzanne Lewis, Central Coast Local Health District, AU
515 Integrated Care Search: Adding Value to the Search Filter Dr Suzanne Lewis, Central Coast Local Health District, AU
522 Behavioural economics and integrated care Prof Guus Schrijvers, Guus Schrijvers Public Health, NL
24
Zone 4 Digital Health and Technology Zone Leaders: Leo Lewis, International Foundation for Integrated Care (IFIC) and Karine Iffour, COCIR
Includes the following presentations and demonstrations:
172 Enhancing the value of care to people: how innovations meet end-users’ needs in integrated care contexts José Ignacio Aznar-Baranda, Everis, ES
552 Mobile Health strategies to integrate health and social care: A system perspective Carmen Pratdepadua, Fundació TIC Salut Social
415 It takes more than two to tango: A case study of Information and Communication Technology enabling a person-centered approach to diabetic care Sabine Wildevuur, Vu University, NL and Lianne Simonse, Delft University of Technology - IDE, NL
554 Psychological outcomes of eCare technologies on informal carers of older people (oral poster) Simona Hvalič Touzery, University of Ljubljana, Faculty of Social Sciences, SI
199 IBM Watson Health: Leveraging Social Determinants in Integrated Care Solutions Luc Chamberland, IBM Watson Health, CA
Market place including product demonstration
Zone 5 Networking Zone Zone Leader: Mandy Andrews, NHS Lanarkshire and IFIC Scotland
Meet fellow delegates and solve integrated care challenges together!
Zone 6 Participation Clinic Attendees will arrive and receive a new passport with a new age of birth (in between 1918 – 1935). After a small introduction, participants will visit a carousel of four experiences, housed in small tents. Afterwards there is a presentation of some outcomes of the scientific research on the impact of experiential learning in the Participation Clinic and the methods behind this intervention.
These are the four themes of the experiences: 1. How does it feel to be old and care-dependent? 2. Design your own last home. What do you really need? 3. How does it feel to have dementia? 4. Being old and thinking positive
Please sign up for the participation clinic at the Registration Desk; spaces are limited. 25
10.30 – 11.00 Refreshments, exhibition, posters and networking
11:00 – 12:30 PARALLEL SESSIONS 5
5.A Impact of integrated 5.B The Implementation 5.C Establishing an 5.D Developing the 5.E Workshop Improving 5.F Workshop: Comparing care on quality, equity and Room: integrated healthcare workforce for frailty integrated care for older the implementation of patient experience Assessing/evaluating system in a deprived urban Organised by JA people living at home in integrated care across integrated care Organised neighbourhood: is there a AdvantAge Europe: findings and countries: Your opinion by the European recipe for success for experiences from the counts! (308) Commission vulnerable populations? SUSTAIN project (291) (566) Room 6&7 Room 11 Room 8 Room 30 Room 9&10 Room 32 Dr Viktoria Stein, Chaired by Filip Domański, Chaired by Dr Helmut Chaired by Mandy Chaired by Simone de Bruin, Chaired by Pim Valentijn, International Foundation European Commission, DG Hildebrandt, OptiMedis, Andrew, NHS Lanarkshire RIVM, NL Maastricht University for Integrated Care (IFIC) SANTE Gesundes Kinzigtal GmbH and Gesundheit für 369 Moving beyond the During this workshop, we will During this workshop the 422 Evaluation of the 434 Assessing the Billstedt/Horn UG and fragmented and share lessons learned so far results of an international Navarra Strategy for performance of integrated International Foundation reductionist model of from the implementation cross-sectional study about Integrated Care for Chronic care implementation, for Integrated Care (IFIC) aged care: Evaluation of a and evaluation of the countries’ ability to and Pluripathologic Patients Mariana Dates and Hugo process to create an aged improvement projects in the implement integrated Cristina Ibarrola Guillén, Sant Ana Pereira, Optimity Preparation of an care worker of the future SUSTAIN project. The aim of delivery models and/ or Servicio Navarro de Salud- Advisors, UK integrated healthcare * the workshop is threefold: 1. programs in practice will be Osasunbidea, ES system in a deprived urban Dr Sharyn Hunter, inform the audience about presented. We will focus on 218 Innovative approaches neighbourhood: Learnings Univeristy of Newcastle, the objectives and design of the key elements that 177 Opening the windows: to outcome measurement of four years of AU the SUSTAIN project, 2. influence the uptake of Integration as a means to in EU-funded research preparation, of talks, illustrate outcomes and integrated care across improve the quality of life projects on integrated care negotiations and proposals 384 The influence of experiences related to countries. We hope you can of people with a learning for people with complex Dr. h.c. Helmut quality of primary care on designing and implementing free up some time to disability and/ or autism needs Hildebrandt, OptiMedis, productive interactions improvements in three of the participate in this Dr Robin Miller, University Helen Schonenberg, Philips Gesundes Kinzigtal GmbH among community-living participating integrated care interactive workshop. of Birmingham, UK Research, NL and Gesundheit für frail older persons and initiatives, and 3. present Billstedt/Horn UG their general practitioners preliminary findings from the 230 Intervention study on The Implementation Rooms and practice nurses integration of outcomes and the effect of integrated will draw lessons from early Reflecting on the first Lotte Vestjens, Erasmus experiences of all care on equity in healthcare and successful approaches “health kiosk” in Germany: School of Health Policy participating initiatives. (oral poster) to integrated care in Sixteen month of work – and Management, NL Europe, and share these about 18 staff members 26
Dr Janne Agerholm, with the wider community with eight language 484 Case and Care Presenters: Karolinska Institutet, SE of stakeholders, who wish backgrounds, more than 50 Management for the Manon Lette, VU University to embark on the initiatives and social Elderly (oral poster) Medical Center, Amsterdam, 525 Building an integrated implementation of agencies being involved, Christoph Michael NL system of urological care: integrated care. They will and more than 1500 Pammer, Chance B the case of Russian regions focus on discussing the consultations Sozialbetriebs GmbH, AT Nick Zonneveld, Vilans, Dr Igor Sheiman, National “how-s” of implementation. Dr Oana Gröne, Gesundheit Utrecht, NL Research Univerity -High für Billstedt-Horn, Project 316 Capabilities of older School of Economics, RU Manager Patient Activation people in adjusting to Lina Masana, Agency for and Health Literacy frailty (oral poster) * Health Quality and Dr Emily Verté, Vrije Assessment of Catalonia Challenges and successes of Universiteit Brussel, BE (AQuAS), Barcelona, ES developing a physician network in a deprived 237 National Clinical Annerieke Stoop, RIVM, urban neighbourhood. Programme for Older Tranzo and University of Dr. Gerd Fass, Board People: National Frailty Tilburg, Tilburg, NL Member Physician Education Programme Network, practising "Fundamentals of Frailty" orthopedist and surgeon in Deirdre Lang, Health Billstedt Service Executive, IE
Learning of sickness funds / payors of health care in improving quality and reducing avoidable costs of care together with partners Christoph Rupprecht, AOK Rheinland/Hamburg
An optimistic outlook into the future of integrated healthcare in deprived urban neighbourhoods Dr. h.c. Helmut Hildebrandt, OptiMedis, Gesundes Kinzigtal GmbH and Gesundheit für Billstedt/Horn UG
27
5.G Workshop: 5.H Community 5.I Funding and 5.J Poster presentations: 5.K Workshop: Positive Health in the Northern Maas Valley Understanding integrated engagement Commissioning Vulnerable Populations (562) care: frameworks and evidence based Room 12 Room 14 Room 18 Room 19 Room 31
Chaired by Dr Niamh Chaired by Jodeme Chaired by Apostolos Chaired by Dr Albert Chaired by Hans Peter Jung, GP in Afferden, NL Lennox-Chhugani, Optmity Goldhar, The Change Tsiachristos, University of Alonso, Hospital Clinic Advisors Foundation Oxford Barcelona and Participants will be inspired by exposure to practical International Foundation examples of positive health approaches and methods. They 110 Understanding new 425 Addressing social 548 A new culturally for Integrated Care (IFIC) will be equipped with a number of tools, techniques, tips models of integrated care: determinants of NCDs informed and innovative and tricks. a systematic review through community commissioning approach to 319 Targeted social care Sil Lieband, Director of Network Positieve Health in the examining outcomes, mobilisation: comparative boost access and primary for highly vulnerable Northern Maas Valley/Advisor ar Syntein, NL pathways of change, and research for effectiveness health care performance pregnant women: design Lee Ann Weeks, Patient, psychologist, editor, NL applicability of evidence assessment for Indigenous communities of the Mothers of Dr Susan Baxter, University Tatyana Haplichnik, Swiss of rural and remote New Rotterdam cohort study of Sheffield, UK Red Cross, BY South Wales and Marije van der Hulst, Queensland Erasmus MC, NL 327 Towards Evidence 184 Experiment Ruwaard: Stuart Gordon, Western Based Integrated Care (oral Thinking, acting and Queensland Primary Health 424 HepCare Europe: poster) organizing differently! Network, AU HepCheck; Reaching Dr Roelof Ettema, Sandra de Loos, Robuust, Bob Davis, Maari Ma Health Vulnerable Populations University of Applied NL Aboriginal Corporation, AU Walter Cullen, School of Sciences Utrecht / Medicine; University University Utrecht, NL 174 Tackling the social 490 Paying for impact: College Dublin, IE determinants of health: Venture philanthropy and 507 Analysing cross- maximising community social investing as funding 468 Integrating Hepatitis sectorial cooperation in the assets to help people models for integrated care C Care for at Risk Groups: Danish health care system receive the right support, in Dr Alexander Franz Pimperl, Findings from a Multi- (oral poster) the right place, at the right OptiMedis AG, DE Centre Observational Dr Ditte Høgsgaard, time Study in Primary and Roskilde Universitet, DK Douglas Maxwell, Health 105 Introducing a fee for Community Care and Social Care Alliance hospital overstays and its John Lambert, University 420 Challenges Faced by Scotland (the ALLIANCE), links to adverse events College Dublin, IE the Leaders in Integration UK among patients hospitalized for hip 488 Development of fracture, heart failure, HepFriend; a Dublin 28
Dr Merja Sinkkonen, 455 Prototyping Innovation stroke, and chronic Community Hepatitis C Tampere University of in Place-Based Integrated obstructive pulmonary Peer Support Model Applied Sciences, FI Care Teams in Eastern disease or asthma Prof John Shearer Cheshire Eliva Ambugo, University of Lambert, Mater Stephanie Hambleton, Oslo, NO Misericordiae University Eastern Cheshire Clinical Hospital/ University Commissioning Group, UK College Dublin, IE Diane Cuffe, Cheshire East Council, UK 464 Integrating Primary Dr Patrick Kearns, and Secondary Care to Manchester Road Medical Optimise Hepatitis C Centre, UK Treatment: Development and Evaluation of a Multidisciplinary Educational ‘Masterclass’ Series Dr Geoff McCombe, University College Dublin, IE
12:30 – 2:00 Buffet lunch, exhibition, posters, networking and lunchtime workshops
Lunchtime Workshops
FLW 1 Poster FLW 2 How to get FLW 3 Network Discussion: FLW 4 Designing FLW 5 Workshop: Realist FLW 6 Workshop: Role presentations: published: IJIC, JIC, IJCC Stroke culturally sensitive and Quantitative Methods for playing game: the Empowering and engaging appropriate services Integrated Care Design and challenges of citizen people Evaluation (245) in engagement (403) collaboration with SIG Realist Evaluation
12.30 – 1.30 12.30 – 1.30 12.30 – 1.30 1.00 – 2.00 1.00 – 2.00 1.00 – 2.00
Room 6&7 Room 8 Room 9 &10 Room 12 Room 14 Room 18 Chaired by Koldo Piñera With Dr Nick Goodwin, co- Chaired by Dr Valerie Chaired by Fiona Lyne, Chaired by John Eastwood, Chaired by Ludo Elorriaga, Bioef editor-in-chief International Twomey, National International Foundation Sydney Local Health District, Glimmerveen, Vrije Journal of Integrated Care Rehabilitation Hospital, IE for Integrated Care (IFIC) Australia Universiteit Amsterdam, NL
29
310 Patients’ preferences Robin Miller, co-editor-in- 180 Lean in Healthcare: 187 Transitional Care Realist research To what extent can citizens for diabetes care: a discrete chief IJIC and former editor reduce wastes to increase among Minority Patients: methodology is increasingly be in charge of local choice experiment Journal of Integrated Care efficiency for stroke the role of Health Literacy, being used for the design and services? What do we see D.F.L. Hertroijs, Maastricht patients Caregiver Presence and evaluation of integrated care as the boundaries of University, NL Bert Vrijhoef, editor-in- Dr Bianca Buijck, Rotterdam Language-concordant initiatives. Much of current ‘appropriate’ citizen chief, International Journal Stroke Service, NL Care realist research and involvement? And what are 255 Patient empowerment of Care Coordination Nosaiba Rayan-Gharra, evaluation is qualitative in the consequences for in connecare 106 How integrated care University of Haifa, IL nature and yet many realist professional organizations Dr Eloisa Vargiu, Eurecat, ES Find out more about how to can alleviate treatment methodologists, including and their employees when get published and meet the burden in stroke survivors 560 Cultural Safety in Pawson, Tilley, Sayer and citizens emerge as key 506 Determinants of editors of the leading Dr Valerie Twomey, health services Olsen, have argued for the actors—can they still be in ambulatory care sensitive integrated care journals National Rehabilitation Andrew Harvey, Western use of mixed methods. control of their work? conditions hospitalizations Hospital, IE Health Alliance Limited, Questions like these – the patients’ perspective AU There remains much debate become increasingly Rodrigo Santos, ENSP, PT regarding the role of pertinent—and quantitative methods, contested—as professional 224 How to strengthen including statistics, within a care organizations engage institutional collaboration critical realist philosophical with local citizens in in a medical consortium framework. Yet quantitative organizing care services. based on patients’ methods can contribute to preference? A study in realist theory building, design In this role-playing game, China’s rural county. and theory testing through based on an actual case Xin Wang, SUN Yat-Sen their ability to use from the Netherlands, University, CN observable events to infer participants interactively the existence of underlying experience the practical 423 Multimorbidity and mechanisms and to detect implications of a patient involvement changes in both context and professional organization’s Jannike Dyb Oksavik, outcomes. ambition to strengthen a Norwegian University of rural community’s Science and Technology, This workshop will examine participation within a local Norway debates about the use of elderly care home. Facing quantitative methods in financial difficulties and the realist research and risk of facilities being evaluation, either as part of a closed, employees and local mixed-method design or on citizens started exploring their own. Examples of their and negotiating the use for both theory possibilities for a ‘joint development and theory venture’ in which part of testing will be provided. the local services would be
30
taken over by local volunteers.
FLW 7 Patient engagement in integrated care - new way of working in hospital Bernhoven together with primary care Synchroon - blending care to optimize patients treatment
12.30 – 1.30
Room 11 Chaired by Remy van den Bogaert, Integrated Care Services, Health Systems Philips Benelux
Presenter: Jeroen Tas, Chief Innovation & Strategy Officer, Philips
2:00 – 4.00 PLENARY 5 Promoting and investing in population health Chaired by Dr Jeroen Struijs, National Institute for Public Health and the Environment (RIVM) and International Foundation for Integrated Care (IFIC)
The route to people-centred and person-centred care in the OECD countries Dr. Niek Klazinga, Head of the Health Care Quality Indicators (HCQI) Project, OECD Health Division and Professor of Social Medicine, Academic Medical Center of the University of Amsterdam
Social Impact Investing in Integrated Care Speaker to be confirmed Social Value International
A citizen’s perspective Jan Smelik, Secretary, Care Cooperation ‘Austerlitz cares’ Room - Event Hall
Closing Ceremony
Conference overview 31
Dr Jeroen Struijs, National Institute for Public Health and the Environment (RIVM) and International Foundation for Integrated Care (IFIC)
Introduction to ICIC19 San Sebastian – Basque Country 1-3 April 2019 Nekane Murga, Director for Health Planning, Organisation and Assessment in the Ministry for Health, Basque Government
Illustrator Feedback
Closing Comments Dr Nick Goodwin, CEO, International Foundation for Integrated Care (IFIC)
Room – Event Hall
Poster Display Only (no oral presentation time allowed)
Theme 1. Value-based integrated care 1. 100 Difficulties in providing Palliative Care in rural India (West Bengal) – Experience of an NGO, Aditya Manna, Narikeldaha Prayas, IN 2. 141 Optimal Nurse Staffing and Scheduling for Emergency Departments, Dr Reza Sharifi Sedeh, Philips Research North America, US 3. 175 Dynamics of sustainable integration of health and social care: A 20-year case study, Charlotte Klinga, Karolinska Institutet, SE 4. 192 Early detection of metastatic colorectal cancer patients who could benefit from specialist palliative care: a prediction model, Miraja Jovi, Spaarne Gasthuis, NL 5. 193 Translating and Adapting the Patient Perception of Integrated Care Survey to Evaluate Integrated Care in Brazil: Preliminary Results, Prof Ed Wilson Vieira, Universidade Federal de Minas Gerais (UFMG), BR 6. 194 Interprofessional collaboration among care professionals in obstetrical care: are perceptions aligned? Anita Romijn, VUmc, NL 7. 195 An ehealth application for the management of obstetric care, Dr Karlijn van Stralen, Spaarne Gasthuis, NL 8. 120 Modular approach in managing and organising integrated care in the system-wide reform of social and health care in Finland, Dr Juha Koivisto, National Institute for Health and Welfare, FI 9. 210 How can patient empowerment be integrated into change management while scaling-up an integrated care program? Violeta Gaveikaite, Aristotle University of Thessaloniki, GR and Philips research, NL 10. 214 Integrated Care for High Risk Surgical Patients – Before, During and After, Dr Rachelle Kaye, Assuta Medical Centers, IL 11. 228 Reduction in Specialist Outpatient Clinic Visits with an Integrated Care Programme for Frequent Admitters in Singapore, Dr Ian Yi Han Ang, NUHS, SG 12. 234 Scaling-up strategies of integrated care initiatives: a systematic literature review, Liset Grooten, Vrije Universiteit Brussel, BE 13. 244 Realist Research Design and Evaluation for Integrated Care (RIC) SIG - Part 1: Establishing a Special Interest Group, Prof John Eastwood, Sydney Local Health District, AU
32
14. 258 Caring in networks: a future direction (oral poster), Mark Tiemessen, Radboudumc / ParkinsonNet, NL 15. 277 Embedding the patient during a service improvement programme in a healthcare system. Making beds in the NHS. Thomas Edward Thompson, University of Chichester, UK 16. 287 Social decision making in integrated care: Applying the Motivated Information Processing in Groups (MIP-G) model to integrative decision making in the context of care, Prof Bianca Beersma, Vrije Universiteit, NL 17. 300 How to evaluate a Nationwide Whole System Change in Health Care towards Integrated Care for people with Chronic Conditions? Part I: the co-construction of an evaluation framework, Prof Jean Macq, Universite Catholique de Louvain, BE 18. 318 An environmental approach to frailty management: needs of older people to age in place, Dr Emily Verté, Vrije Universiteit Brussel, BE 19. 328 Prevent Skin Cancer in the Society, an Evidence Based Integrated Care Approach, Dr Roelof Ettema, University of Applied Sciences Utrecht / University Utrecht, NL 20. 332 Social network analysis for modelling integrated social care services for older people with complex needs: a feasibility study, Dr Alison Orrell, Bangor University, UK 21. 335 Computer simulation as a methodology for theoretical learning of clinical skills in nursing, Emilio Luque, Computer Architecture and Operating Systems Department, School of Engineering, University Autonoma of Barcelona (UAB), SPAIN 22. 381 Strengthening the evidence-base of integrated care for people with multi-morbidity in Europe using Multi-Criteria Decision Analyses (MCDA), Prof Maureen Rutten- van Molken, Erasmus University Rotterdam, NL 23. 427 From the perspectives of senior managers, an exploration of the context and extent of enablers and barriers to interagency collaboration, Prof John Eastwood, Sydney Local Health District, AU 24. 406 Social Prescribing and Integrated Care: An Evaluability Assessment, Sabrena Kaur Jaswal, University of Kent, UK 25. 428 Diabolution Project Madrid: Diabetic patient management focused on the person, Ana Miquel Gomez, Universidad Rey Juan Carlos, ES 26. 432 Technology for older adults: insights from tertiary users, Dirk Lukkien, Vilans, NL 27. 435 Integrated care in practise - across regions (Scotland and Denmark), Joanne Boyle, Digital Health & Care Institute, UK 28. 445 A Gap Analysis Between the Outline Document for the Integrated Care Programme and Draft Models of Care for Four Chronic Diseases in Ireland, Dr Claire Mary Buckley, HSE, IE 29. 483 Value-Based Procurement of Added-Value Services for Home Care, Angelo Rossi Mori, Federsanita ANCI, IT 30. 527 End-users’ voice in procurement process of an integrated health and social care information system, Antti Aarni Tapani Iivanainen, Oy Apotti Ab, FI 31. 541 Integrated day- and night care by the integration of technology, Dr Henk Herman Nap, Vilans, NL 32. Simona Hvalič Touzery, University of Ljubljana, Faculty of Social Sciences, SI 33. 389 The Belarus State Social Order funding mechanism for integrated medical and social home care, Dr Tatyana Svetlovich, Belarus Red Cross, BY 34. 143 Relational coordination in inter-organizational settings. How does lack of proximity affect coordination between hospital-based and community-based healthcare providers? Stine Bligaard Madsen, Aarhus University, Denmark, DK 35. 109 Development of a patient-centered organizational model for multimorbidity in general practice, Ramune Jacobsen, Bispebjerg and Frederiksberg Hospital, Denmark, DK 36. 380 Flexibility and reablement in home care in dementia, Dr. Mairead Bracken-Scally, Trinity College Dublin, IE 37. 530 Inter-professional collaboration and communication during acute hospitalization of older patients with dementia, Marie-Julie Heeren, Verenso, Utrecht, the Netherlands 38.
Theme 2. Population health management
39. 182 From data to meaningful information, Sandra de Loos, Robuust, NL 40. 190 Exploring the health system for sustainable and integrated acute malnutrition services applying a systems lens: the case of Afghanistan, Dr Hedwig Deconinck, Université catholique de Louvain, BE 33
41. 209 Identifying experiences, enablers and barriers of healthcare providers for delivering culturally competent care, Ann Claeys, Erasmus University College, BE 42. 232 Exploring the potential of a risk stratification tool to move forward in integrated, person-centered primary care, Rowan Smeets, Maastricht University, NL 43. 269 Scorecard of Integrated Care: A Relevant and Timely Photo To Help Professionalas Clinical Management, Elena Bartolome Benito, Servicio Madrileno Salud Es 44. 271 Data-driven change towards integrated care, Tom Verhaege and Patricia Mejia Chavez, Federal Public Service Health, BE 45. 288 Measuring Population Health from a Broader Perspective: Assessing the My Quality of Life Questionnaire, Hanneke Drewe, Tilburg University, NL 46. 337 Problem identification in highly vulnerable pregnant women with multiple social and medical problems, Marije van der Hulst, Erasmus MC, NL 47. 339 Understanding system flows to improve outcomes and services for respiratory patients, Wendy Lewis, Advancing Quality Alliance/ Salford Royal, UK and Jay Mangan, Strategic Lead for the Healthier Wigan Partnership, UK 48. 390 Unravelling the Drivers of Regional Variation in Healthcare Spending by Analysing Prevalent Chronic Diseases, Eline Frouke De Vries, Tilburg University, NL 49. 397 Housing and Health as partners in a place-based hub, Erin Miller, Sydney Local Health District, AU 50. 401 The feasibilities and practicalities of the integrated working journey: exploring the development and implementation of a whole population approach to delivering patient- centred care within the United Kingdom, Anna Thomson, University of Lincoln, UK 51. 408 “Joining up the dots”: Integrated care as an element of the Andalusian public health strategy, Dr Arturo Alvarez Rosete, NewHealth Foundation, ES 52. 437 The effect of perceived discrimination on the health status of immigrant population in Spain (Valencia), Alejandro Gil-Salmerón, Polibienestar Research Institute, ES 53. 478 Risk stratification using register data from specialist, primary and social care, Prof Aslak Steinsbekk, NTNU, NO 54. 524 Can Integrated Practice Units work without the set-up of Accountable Care Organisations? Lessons learnt from the Breast Units’ experiences in Italian NHS, Prof Verdiana Morando, SDA Bocconi, Bocconi University, IT 55. 559 Risk stratification and characterisation of subpopulations of frail elderly in the primary care practice using routine healthcare data, Dr Nina Daha, Leiden University Medical Center, NL 56. 482 Long-term advantages of person-centred and integrated care: results of a longitudinal study on Embrace, Dr Klaske Wynia, UMCG, NL 57. 282 & 283 A Population Health Approach: Addressing equity and social determinants of health in Canadian healthcare, Dr Elina Farmanova, University of Toronto, CA
Theme 3. Engaging and Empowering People and Communities 58. 103 Healthy Living: when engaging people makes a difference. Evidences from an experiment with teenagers in Tuscany, Sabina De Rosis, Scuola Superiore Sant'Anna, IT 59. 138 Implementing an Integrated Care System for Chronic Patients in Belgium: a Co-creation Process (oral poster), Mélanie De Winter, University of Liège, BE 60. 145 Exploring working relationships between primary care and directly employed home care workers, Joanna Mary Moriarty, King's College London, UK 61. 167 Integrated Community Case Management of Childhood Illness: A Contextual Examination of Community Healthcare Delivery in Benue State Nigeria, Dr Abdulmumuni Samuel Aliyu, Gombe State Ministry of Health, NG 62. 224 How to strengthen institutional collaboration in a medical consortium based on patients’ preference? A study in China’s rural county, Xin Wang, SUN Yat-Sen University, CN 63. 310 Patients’ preferences for diabetes care: a discrete choice experiment, D.F.L. Hertroijs, Maastricht University, NL 64. 313 Health literacy: more than the understanding and processing of health information, Dr Monique Heijmans, NIVEL, NL (oral poster) 65. 314 Creating Age-Friendly Communities using a participatory approach, Natalia Postolachi, "CASMED" NGO, MD 66. 347 Co-designing a framework for integrated home care planning with older adults, family caregivers and health care providers (oral poster), Justine Giosa, University of Waterloo/ Saint Elizabeth, CA 67. 431 IEXPAC, a tool to assess patient experience, Koldo Pinera Elorriaga, BIOEF, ES
34
68. 513 Promoting the women’s health literacy and their access to maternal-care-pathway in Italy through an integrated mHealth intervention, Sabina de Rosis, Sant'Anna School of Advanced Studies, Pisa, IT 69. 459 Co-designing an Integrated Care Pathway for Children and Families with a Neuromuscular Disorder in Ireland, Grace Turner, HSE, IE 70. 165 ‘The integration and training of the concept of Positive Health among health and social care professionals in an integrated community approach’ – defining the facilitators and barriers, Sanneke Grootjans, Maastricht University, NL 71. 211 Person-centred approaches: emerging theories of terms of engagement, Debra Westlake, Plymouth University, UK 72. 255 Patient empowerment in connecare, Dr Eloisa Vargiu, Eurecat, ES 73. 315 Facilitators and Barriers to Self-Management of Tuberculosis Patients: A Qualitative Study, Ritzmond Fainsan Loa (University of Santo Tomas, PH 74. 323 Towards a new care paradigm: the development of the INClusive CAre framework, Dr Emily Verté, Vrije Universiteit Brussel, BE 75. 326 Can Nursing Students Gain Person-Centred Skills while Supporting Citizen Contacts to use the Internet for Health? Toni Page, University of Plymouth, UK 76. 391 Building a narrative for compassionate communities: the case of Getxo Zurekin, Maider Urtaran, University of Deusto, ES 77. 438 Improving Patient-Provider Partnerships across the Healthcare System, Dr Jacobi Elliott, University of Waterloo, CA (oral poster) 78. 460 A new infrastructure for patient empowerment through Family Integrated Obstetric and Neonatal Healthcare in Single Family Rooms. A case stud, Mireille Stelwagen, OLVG, NL 79. 461 Meeting for innovation in mental healthcare organisation (oral poster), Prof Sophie Thunus, Catholic University of Louvain, BE 80. 208 The role of peer support in mental health care (oral poster), Ann Claeys, Erasmus University College, BE 81. 506 Determinants of ambulatory care sensitive conditions hospitalizations – the patients’ perspective, Rodrigo Santos, ENSP, PT 82. 423 Multimorbidity and patient involvement, Jannike Dyb Oksavik, Norwegian University of Science and Technology, Norway 83. 352 The establishment of effective collaboration between primary care and welfare in the promotion of mental health in patients with multi-problems (oral poster), Mark van der Wel, Radboud university medical center, NL 84. 264 Goal Planning in Person-Centred Care Supports Older Adults to Attain Their Health-Related Goals (oral poster), Klaske Wynia, UMCG, NL
Theme 4. Funding Integrated Care 85. 101 Difficulties to Provide Palliative Care in West Bengal, India, Aditya Manna, Narikeldaha Prayas, IN
Theme 5. Vulnerable Populations and Populations at Risk 86. 102 The importance of broader self-management abilities in addition to health behaviours for physical health, depressive symptoms, and overall well-being among older Turkish immigrants, Dr Jane Murray Cramm, Erasmus University Rotterdam, NL 87. 139 Family experiences with palliative care of people with severe dementia in Norwegian nursing homes (oral poster), May Helen Midtbust, Norwegian University of Science and Techonology, Faculty of Medicine and Health Sciences, NO 88. 197 Value based health care for the frail elderly patient with a hip fracture, Dr Karlijn van Stralen, Spaarne Gasthuis, NL 89. 203 A coordinated and integrated approach to tackling childhood overweight and obesity, Dr Kyra Sim, Sydney Local Health District, AU
35
90. 202 Child and Adolescent Health Pathways study: a pragmatic implementation study, Dr Kyra Sim, Sydney Local Health District, AU 91. 233 The relevance of professional-patient interactions in progress notes. A focus group study with mental health staff in inpatient psychiatry, Kjellaug Klock Myklebust, Molde University College, NO 92. 238 A national model of care for children: Integrated implementation- the opportunities and the challenges, Grace Turner, Health Service Executive, IE 93. 241 Integrating Care for Children Young People and Their Families SIG - Part 2: Service Policy and System Approaches, Prof John Eastwood, Sydney Local Health District, AU 94. 263 Preventing wound reoccurance using compression garments in vulneralbe populations: What does the literature say about modified compression and its application? Yvonne Dyan Pennisi, University College Cork, IE 95. 286 Experiences of health services among patients with chronic conditions, Anna-Mari Aalto, National Institution for Health and Welfare, FI 96. 290 Comprehensive geriatric assessment in integrated care for older people living at home: a systematic review (oral poster), Annerieke Stoop, RIVM, NL 97. 320 Integrated school health services in Europe: an overview, Dr Danielle Jansen, University Medical Center Groningen, NL 98. 338 A city's system approach to complex needs provision. (oral poster), Wendy Lewis, Advancing Quality Alliance/ Salford Royal, UK 99. 344 Re-designing the integrated care program for Asylum Seekers in the Netherlands, Ferdy Pluck, GGz Centraal/Hogeschool Utrecht, NL 100. 345 There is no health without integrated oral health, Sonja Kuipers, NHL/Stenden Univercity of applied sciences, NL 101. 360 Living in Rural and Remote Australia: Health care impacts for children with medical complexity and their families, Christie Breen, Sydney Children's Hospital Network, AU 102. 363 Reconciling Incommensurate World Health Views and Explanatory Models of Mental Illness: A New Model of Integrated Mental Health Care for Culturally Diverse Populations, Prof Christopher Kewley, University of Newcastle, Australia, AU
103. 394 Developing new pathways to Health and Social Care for vulnerable clients in targeted Primary Schools in Sydney, Australia, Erin Miller, Sydney Local Health District, AU 104. 396 The Healthy Homes and Neighbourhoods Integrated Care Initiative, Erin Miller, Sydney Local Health District, AU 105. 400 Designing a population-based approach to integrated end of life care on a small island, Dr Giovanna Cruz, Hospice Isle of Man, UK 106. 424 HepCare Europe: HepCheck; Reaching Vulnerable Populations, Walter Cullen, School of Medicine; University College Dublin, IE 107. 450 Are people with mental disorders excluded from work and from active labour market programs? Magne Bråthen, Oslo and Akershus University College of Applied Sciences (HiOA), NO 108. 451 eHOME for an integrated care approach for drug-related problems in home-living older people (oral poster), Nienke Dijkstra, HU University of Applied Sciences Utrecht, NL 109. 462 Managing the Elephant in the Room: What Home Health Care Nurses Do (and Don’t Do) to Support Productive Interaction, Dr Dianne Veronica Liebel, University Of ROchester, US 110. 468 Integrating Hepatitis C Care for at Risk Groups: Findings from a Multi-Centre Observational Study in Primary and Community Care, Dr Davina Marie Swan, University College Dublin, IE 111. 484 Case and Care Management for the Elderly (oral poster), Christoph Michael Pammer, Chance B Sozialbetriebs GmbH, AT 112. 493 Tackling the care crisis in PD in East-Saxony, Germany – #Improve diagnosis and therapy in Parkinson's disease #Telemedicine-based care management #Intersectoral and interdisciplinary collaboration #Cost containment and quality improvement, Dunia Krüger, MArS Market Access & Pricing Strategy GmbH, DE 113. 497 Barriers to engaging in end-of-life communication in heart failure: perceptions of patients and their family caregivers, Jennifer Im, University of Toronto, CA 114. 501 Stratification and characterisation of complex medico-psychosocial conditions at primary health care level in Eastern DR Congo: methodological approaches, Jean Macq, UC Louvain 115. 510 Ministries guiding of services for children and young people in eleven countries – a comparative study, Dr Katja Joronen, University of Tampere, FI 116. 514 The importance of the working alliance between parent and professional, Dr Paula Sterkenburg, Bartimeus, NL 117. 544 An Integrated Approach to Chronic Pain & Opiate Use Disorder, Dr Jared DuPree, Southwest Healing & Wellness/Dixie State University, US 118. 456 Role of the elderly volunteers in integrated care (oral poster), Sviatlana Anatsko, Belarus Red Cross Society 119. 436 Developing a Compassionate Community (oral poster), Alison Bunce, Compassionate Inverclyde, UK 120. 319 Targeted social care for highly vulnerable pregnant women: design of the Mothers of Rotterdam cohort study, Marije van der Hulst, Erasmus MC, NL 36
121. 529 How fair is the dental chair? Equity in oral health access and outcomes for children under five, Hawkes Bay, New Zealand, Wietske Cloo, Hawke's Bay District Health Board, NZ 122. 488 Development of HepFriend; a Dublin Community Hepatitis C Peer Support Model, Prof John Shearer Lambert, Mater Misericordiae University Hospital/ University College Dublin, IE 123. 449 Comparison of key findings relating to care coordination in children with three complex conditions: A MOCHA study , Dr Miriam O’Shea, Trinity College, IE 124. 382 Community elderly care enhances quality of life for peers (oral poster), Amela Fočić, Swiss Red Cross, BA 125. 261 Healthcare professionals’ experiences of interprofessional collaboration during palliative patients’ transfer of care setting: a focus group study (oral poster), Fien Mertens, Universiteit Gent, BE 126. 464 Integrating Primary and Secondary Care to Optimise Hepatitis C Treatment: Development and Evaluation of a Multidisciplinary Educational ‘Masterclass’ Series, Dr Geoff McCombe, University College Dublin, IE 127. 329 Early Detection of Malnutrition in Community Dwelling Older People, an Evidence Based Integrated Care Approach (oral poster), Dr Roelof Ettema, University of Applied Sciences Utrecht / University Utrecht, NL 128. 178 Avoidance of unnecessary hospital admissions through the implementation of a digital health programme (oral poster), Kirsty Marshall, University of Salford, UK 129. 316 Capabilities of older people in adjusting to frailty (oral poster), Dr Emily Verté, Vrije Universiteit Brussel, BE 130. 259 Cognitive Inclusion through Digitally Supported Independent Living, Dr Rachelle Kaye, Assuta Medical Centers, IL
Theme 6. Primary Care in an Integrated System
131. 122 A quasi experimental before and after study of a transitional care programme for older adults in the area of the IJsselland Hospital(oral poster), Wilma van der Vlegel- Brouwer, IJsselland hospital, NL 132. 131 - Integrated Case Management – supporting General Practice in the Eastern Bay of Plenty, New Zealand (oral poster), Greig Dean, Eastern Bay Primary Health Allince, NZ 133. 134 Exit versus Voice: Competition and Dissatisfied Patients’ Responses to General Practitioners, Tigist Woldetsadik Sommeno, Uio, NO 134. 148 Integrating Health Care in Cancer. Our experience in OSI Donostialdea, Sara Arévalo Lobera, OSI Donostialdea, ES 135. 149 Implementation of innovative integrated models of Community-based Primary Healthcare (CBPHC) in Denmark (iCoachDK) – a study protocol, Stine Bligaard Madsen, Aarhus University, DK 136. 152 Developing citizen advocacy for adults with intellectual disability, Prof Amanda Phelan, University College Dublin, IE
137. 153 Challenges in care co-ordination: missed care in community nursing, Prof. Amanda Phelan, University College Dublin, IE 138. 154 Fit after stroke, Ernst Evenhuis, VUmc, NL 139. 155 Collaboration in CVA aftercare: CVA-network RRC/ primary care, Marinka de Ronde-Kempenaar, University of Applied Sciences Leiden, NL 140. 163 Social Prescribing: Implementation and delivery, Julia Pescheny, University of Bedfordshire, UK 141. 186 Meaningful post-discharge primary care visits and readmissions: Are primary care post discharge explanations associated with reduced risk for readmission? Nosaiba Rayan- Gharra, University of Haifa, IL 142. 189 Integration of Primary Health Care of a small Brazilian city in the health care Network, Prof Ed Wilson Vieira, Universidade Federal de Minas Gerais (UFMG), BR 143. 201 Professional Experience in an Integrated Care Model, Dr Ana Miquel Gómez, Servicio Madrileño de Salud, ES 144. 216 Multi-professional collaboration in primary care: A scoping review of Norwegian experiences, Monica Sørensen, OsloMet University, Faculty of Health Sciences, NO 37
145. 219 Various views of the same elephant: crossing perceptions of key actors on an integrated local health network for older adults, Prof. Mylaine BretonUniversité de sherbrooke, CA 146. 248 Population-based approach and integration of services: their relationship to the territory in the context of Québec's integrative reforms, Dr Yves Couturier, University of Sherbrooke, CA 147. 276 Redesign of the Services of attention to the Chronic Patients According to their Stratification, Elena Bartolome Beniito, Servicio Madrileno De Salud, ES 148. 299 Partnership to Health Pathways, Dr Andrew Knight, South Western Sydney Local Health District, AU 149. 304 - Piloting an Integrated Care Model for the Elderly Diabetic Patients, Ariana Bytyci, Accessible Quality Healthcare (AQH) Project, XK 150. 305 Clinic for Multimorbidity, Dr Charlotte Weiling Appel, Silkeborg Regional Hospital, DK 151. 306 Patients' perceptions of Continuity of care between Primary Care Physicians and Emergency departments in Belgium: a cross-sectional survey, Marlène Karam, Catholic University of Louvain, BE 152. 325 Norwegian municipal rehabilitation services in transition, Grete Dagsvik, Kristiansand Municipality, NO 153. 346 Bridging the gap from theoretical framework to practical implementation: the integrated primary care house, Dr. Jean-Pierre Hoengenaert, VZW HET EERSTELIJNSHUIS, BE 154. 357 Navigating the healthcare neighbourhood: Reframing care around the patient and their primary care ‘home’, Rhiannon Beck, Agency for Clinical Innovation, AU 155. 367 Transforming telehealth through enhanced General Practices partnerships, Andrew Knight, South Western Sydney Local Health District, AU 156. 388 Experiences of community-based Clinical Nurse Specialists in supporting the delivery of integrated diabetes care: A qualitative study, Brenda Lynch, University College Cork, IE 157. 393 Development and Implementation of Core Competencies for Integrated Care Community Health Teams: a UK experience, Dr. Sarah Eales, Bournemouth University, UK 158. 386 Perceived quality of care transitions between hospital and the home - a cross sectional study (oral poster), Sebastian Lindblom, Karolinska Institutet, SE 159. 399 Evaluation of the referral system “Ehalati” from physicians’ perspective in Primary Health Care centres in Saudi Arabia, Mohammed Senitan, University of Sydney, AU
160. 402 Investing in integrated care education in health and social care. Development of a framework to facilitate education and reflection on integrated care in primary and community care, Leen Van Landschoot, University College Ghent, BE 161. 404 The public telecare service in the Basque Country, Koldo Pinera Elorriaga, BIOEF, ES 162. 407 Crossing borders towards Integrated Care – title is changed and will be: What’s integration got to do with it? Observations and lessons from the Franciscus Gasthuis & Vlietland Study Trip to North-West London, Maria Bos and Melissa Lockhorst, Franciscus Gasthuis & Vlietland, NL 163. 413 Using a new matrix to describe real-life integrated care innovation for older persons in primary care, Antonius Poot, Leiden University Medical Center, NL 164. 417 Organizational and Care Model Analysis for C3-Cloud Deployment Preparation, Dr. Dolores Verdoy, Kronikgune, DE 165. 429 Advanced Nurse Practitioners impact across Primary Care, Joanne Jenkins, NHS Lanarkshire, UK 166. 446 Development of a checklist for ensuring the successful implementation of integrated care pathways, Elena Urizar, Deusto Business School Health, University of Deusto, ES 167. 485 Planning integrated care at primary care centres: lessons learnt through research in stratification tools in the Valencian Healthcare System, Ascensión Doñate-Martínez, Polibienestar Research Institute - University of Valencia, ES 168. 487 Integrated care for elderly receiving hospital-at-home care: Designing an innovative home-based programme, Alejandro Gil-Salmerón (Polibienestar Research Institute, ES 169. 492 Reducing the risk of readmission and death after hospital discharge using a predictive model, Maria Alkiza, OSAKIDETZA, ES 170. 496 - Implementing a complex innovation in general practices: from a universal to a practice-centred approach, Gijs Brouwer, Maastricht University, NL 171. 509 Acceptance of and intent to adopt video consultations for addressing mental health disorders in primary care: A cross-sectional mixed methods study in general practitioners, Dr Markus W. Haun, Heidelberg University, DE 172. 526 Developing shared values for strategies and policies on Primary Care Centres in Tuscany Region, Italy, Sabina de Rosis, Sant'Anna School of Advanced Studies, Pisa, IT 173. 540 The challenge of multimorbidity: A qualitative study of general practitioners' management of patients with multimorbidity (oral poster), Lisbeth Ørtenblad, DEFACTUM, DK 174. 567 Population-based management of diabetes care - approach and solutions used in the North East Locality (Oxfordshire, UK) Pilot, Dr Olga Kozlowska, Brookes, UK 175. 129 Substituting hospital care with primary care: The evaluation of a cardiology Primary Care Plus intervention, Tessa.C.C. Quanjel, Maastricht University, NL 38
176. 532 Virtual Heart Failure Clinic - An Integrated Care Programme Support for General Practice, Dr Orlaith O’Reilly, Health Service Executive, IE 177. 144 Reorganising dermatology care: predictors to substitute secondary care with primary care, Esther van den Bogaart, Maastricht University, NL 178. 223 Luohu Model: A template for integrated urban health care systems in China, Xin Wang, SUN Yat-Sen University, CN 179. 366 Integrating Health Care – Our Journey Continues, Dr Andrew Knight, Western Sydney Local Health District, AU 180. 379 Learning from the development of two Integrated Care Pathways for dementia, Dr Mairead Bracken-Scally, Trinity College Dublin, IE 181. 135 Exit versus Voice: Competition and Dissatisfied Patients’ Responses to General Practitioners, Tigist Sommeno, UiO, NO 182. 164 - Service user outcomes of a social prescribing programme in general practice (oral poster), Julia Pescheny, University of Bedfordshire, UK
Cross-cutting Theme: How technology is supporting integrated care
183. 370 Patient Value Measurement and Improvement using the Steps of Systematic Improvement (SOSI) in Yishun Health (oral poster), Naiying Liu, Khoo Teck Puat Hospital, SG 184. 495 Synergy of patients and health professional in successful implementation of digital health tools (oral poster), Amanda Hellström, Linnaeus University, SE 185. 289 A risk score of BMI, HbA1c and triglycerides predicts future glycaemic control in type 2 diabetes (oral poster), D.F.L. Hertroijs, Maastricht University, NL 186. 213 What happens to patients after their first diagnosis of dementia? (oral poster), Timo Schulte, OptiMedis AG, DE 187. 196 Social Determinants of Health Composite Index (oral poster), Dr Reza Sharifi Sedeh, Philips, US 188. 181 Integrated care issues: Transfer of patient care information (oral poster), Dr Bianca Buijck, Rotterdam Stroke Service, NL 189. 231 In a 'post-truth' world, healthcare organisations do not still provide readable and comprehensible information on their websites: An analysis of 167 websites in Italy(oral poster), Sabina De Rosis, Scuola Superiore Sant'Anna, IT 190. 453 Avoidable emergency admissions for ambulatory care sensitive conditions in the Republic of Ireland: analysis of regional determinants (oral poster), Brenda Marie Lynch, University College Cork, IE 191. 554 Psychological outcomes of eCare technologies on informal carers of older people (oral poster) 192. 199 Leveraging Social Determinants in Integrated Care Solutions, Luc Chamberland, IBM Canada
Cross-cutting Theme: Education & Training in association with the Integrated Care Academy©
193. 553 Coordinated Care: Our Forward View (oral poster), Thomas Lawrence, Birmingham City University, UK
Cross-cutting Theme: Policy making, regulation and inspection 39
194. 499 Assessing Factors that Influence the implementation of Technologies Enabling Integrated Care Delivery for Older Adults with Complex Needs: A Systematic Review (oral poster) * Mudathira Kadu, University of Toronto, CA 195. 230 Intervention study on the effect of integrated care on equity in healthcare (oral poster), Dr Janne Agerholm, Karolinska Institutet, SE 196. 106 How integrated care can alleviate treatment burden in stroke survivors (Oral poster) Dr Valerie Twomey, National Rehabilitation Hospital, IE 197. 507 Analysing cross-sectorial cooperation in the Danish health care system (oral poster), Dr Ditte Høgsgaard, Roskilde Universitet, DK 198. 327 Towards Evidence Based Integrated Care (oral poster),Dr Roelof Ettema, University of Applied Sciences Utrecht / University Utrecht, NL 199. 136 The role of the Belgian government in enhancing the integration of healthcare for Mentally Ill Offenders: an analysis of the reform plan (oral poster), Maurice François Pans, Vrije Universiteit Brussel, BE
40