About anoset al.2019

Yes

Voluntary, trauma-informed services offered are the following: (1) safety planning, including assistance in getting a protective order if requested; (2)short-term supportive counselling, referrals, and accompaniment to service providers and the legal system; (3) coordination of care between law enforcement, courts, sexual, and DV pro-grams, legal aid, and other community-based resources; (4) se-cure shelter with temporary lodging for patients and their families when in Richmond for medical treatment; (5) follow-up services, as requested/needed; and (6) crisis funds for patient needs, such as for transportation Project Empower also connect IPV patients with interdisciplinary services already offered by VCU health system including insurance or financial assistance for health care, mental health services, an addiction clinic, and obstetrician-gynaecologist care. Apart from inpatient screening, intervention, and referral, the staff work to build report and foster a sustained relationship post-discharge until the patients’ needs are met, or they no longer wish to continue services.

ED and trauma units to other in-hospital units and clinics including women health and obstetrics.

Virginia Commonwealth University (VCU)Level I trauma center has developed a multitier inters for VCU’s hospital-based injury and violence prevention programs (IVPP), historically focusing on youth violence, bums, head trauma, and distracted driving. Hospital wide adopted intervention

Face-to-face.

IPV program coordinator, lived experience program peer advocate, and Master of Social Work interns from VCU Health.

There is a partnership between VCU Sexual Assault Response Team, the Richmond Fatality Review Team, the neighboring county strangulation workgroups, and is actively involved in the Virginia Sexual and Domestic Violence Action Alliance and other statewide groups

1130 clinical providers were trained for IPV screening and referral

Funded by local foundations grants and a Victim of Crime Act (VOCA) grant, Project Empower addresses the immediate need of IPV patients, but is limited in its resources for long-term follow-up and comprehensive community wrap around approaches

An integrated hospital EMR-IVPP Redcap database was created

Alexanderet al. 2018

Yes

Service integration initiative: The workshops to

Not applicable

The programme was facilitated by

Not applicable

Not applicable

The program brought

The program brought multidisciplinary teams

NR*

NR*

clinicians covered aspect of early help, communication, resources and building capacity. Early help is defined as the principle of providing at an early point, support to children, young people and families to maximise their life and prevent other acute problems. The training focused on improving literacy around social services amongst clinicians as well as improving ability and confidence when navigating services.

the Early Help Partnership, an organisation that advises schools on statutory responsibilities regarding safeguarding and providing early support to children and families. The policies supporting this program is the Collaboration for Integrated Care and Support and Making Every Contact Count

multidisciplinar) teams together when delivering the intervention

together when delivering the intervention

Aredes et al. 2021

Yes

Social Assistance Reference Centre offers a wide range of services for people of all ages, with a particular emphasis on protecting and strengthening relationships between family members and guaranteeing human rights. It offers practical support by assigning home paid carers

'Sistema Único de Saúde' (SUS) Health Centre offers comprehensive set of primary health care services to defined communities

Belo Horizontes municipal departments of health and social assistance

National coordination and local hubs for community engagement. Local hubs known as Social Assistance Reference Centres.

Family Health Teams (ESF) are responsible for referral, coordinating different SUS health services and operating as a bridge between the health system and local communities

A partnership between Belo Horizonte municipal departments of health and social assistance. Carers are hired through a contract between the municipality and governmental Civil Society Organisation (Organiza da Sociedade Civil OSC in Portuguese)

PMC management is intersectoral, with joint oversight at the central level of the Secretariats of Health and Social Assistance, and the local level through joint activities involving the CS (Centro de Salud) and CRAS teams (Centro de Referencia Social). Each CRAS has staff members with specific responsibility for PMC. At the central level, programme supervisors have overall responsibility for the management of caregivers and for care quality assurance. At the local level, PMC is supported by a close collaboration between families, health professionals, social assistance professionals and PMC carers

The finance system combines Department of Health and Social Assistance funding schemes. Social Assistance folly fonds the carers

There were gaps in the PMC data systems operated by both the departments of Health and Social Assistance, and they were mutually incompatible, thus preventing data sharing

Bussuet al.2020

Yes

Care navigatore were introduced. These are non-clinicians who support complex adults and help them navigate the health and social care system, by ensuring they receive adequate support to attend hospital appointments and have access to the benefits and care they are entitled to. At piloting stage, each community team had a dedicated social worker co-located with healthcare professionals.

Multi-professional community care team (EPCT) providing community nursing and therapies for patients aged over 18 and incorporating eight GP clusters. Community teams aimed at improving coordination between nurses, therapists and social workers and were envisaged to play a crucial role in reducing hospital admissions. EPCTs and integrated Care Teams (ICTs) comprise of district nurses (DN), occupational therapists (OT) and Physiotherapists; Locality ICTs also include community matrons. In each locality, a Rapid Response (RR) team was also established as part of the admission avoidance strategy. RR is a nurse-led service that delivers unplanned and urgent care services in the patients home to avoid non-elective hospital admissions. RR team is based within the hospital but managed by community services Trusts

With NHS foundation trusts and local authorities, three East London municipalities came together to form an integrated care programme and achieved pioneer status

Face-to-face; outreach

Care navigators (e.g. social workers in the pilot phase)

The integrated care programme brought together Clinical Commissioning Groups (CCGs), providers (NHS Trusts) and local authorities of the municipalities

Rapid Response (RR) tea, and Discharge to Assess (D2A) teams, and integrated community teams work collaboratively provide holistic care to patients in the community

Funding from NHSE (£20,000 initially, later supplemented with a further £90,000) was given.

NR*

Cammyet al. 2017

Yes

A palliative care- and hospice-trained clinical oncology social (POR PCP) worker utilises clinical skills and supports the team in approaching sensitive and challenging end-of-life discussions with clarity and compassion. The social work team member responds to patient and family's feelings as they relate to their past experiences with previous family losses including prior involvement with palliative and hospice care. Interventions may include connection to services to prevent caregiver breakdown, education on signs and symptoms of disease progression, and assessment of high-risk bereavement concerns

Radiation oncology physician expert palliative care, acute care nurse practitioner, registered nurse, and registered dietician

Palliative radiation oncology team was created at the University of Pennsylvania in 2013

New consults and patients under active treatment are conducted in health settings. Telephone contact with patients is available as many patients transitioned to hospice care or are homebound

Social workers

Palliative teams established bimonthly oncology team rounds, called integrative cancer care rounds. This offered a formal gathering to review current and shared palliative patient cases to enhance communication between multiple palliative specialties

The University of Pennsylvania palliative radiation oncology team includes a radiation oncology physician who completed specialized fellowship training in palliative care, nurse practitioner with advanced certification in acute care, registered nurse, licensed clinical social worker with palliative care and hospice experience, and registered dietician

NR*

Some system integration has been developed. The PRO PCP was created in the electronic medical record (EMR) program

Chnget al. 2021

Yes

The links worker programme (LWP) was expected to operate at three levels: patient, practice, and community: at the patient level, practices were to set up referral systems so that GPs and practice nurses could refer patients who they thought would benefit from engagement with community resources to the community link practitioners (CLP) for one-to-one work; at the practice level, CLPs were also expected to act as agents of change promoting the ethos of social prescribing among all staff by, for example, enabling activities to support staff wellbeing, activities to develop shared learning, and awareness about community resources, gathering intelligence about local resources and solving problems through the redeployment of staff; and at the community level, CLPs were expected to build networks and cultivate relationships with local community organisations, develop referral pathways and multiagency resolution of problems, and organise shared learning events to consolidate new and existing community linkages

GP practices and practice nurses providing health

Practices in Glasgow, funded by Scottish Government

Face-to-face

Community Link Practitioners

NR*

Each intervention practice had a full-time salaried CLP appointed, who was employed by a Scottish Government-funded third-sector organisation (the Health and Social Care Alliance Scotland). The CLPs were selected by the programme manager and clinical lead, who also made the final decision on which practice assigning each CLP

Each intervention practice had a full-time salaried CLP appointed, who was employed by a Scottish Government-funded third-sector organisation (the Health and Social Care Alliance Scotland).

Intervention practices were also provided with a practice development fund of £35000, around 80% of which was used for creating more time, particularly clinical time for GPs (and the practice nurse in one practice) to have longer consultations with patients. Practices also invested to free-up receptionist time, by, for example, hiring another receptionist or purchasing self-check-in systems

NR*

Collinset al. 2017

Yes

The initiative provides low-threshold nursing care services (e.g. health assessments, medication assistance, support, symptom management) and social support and programmes (e.g. recreational therapy outings, karaoke). Residence and day health programme provide counselling services, including art and music therapies, and mental health resources and referrals. Day health programme provides, nutrient-dense meals twice daily, seven days per week, and residence provides clients with regular meals and snacks. Staff provide referrals to supportive and subsidised housing, particularly housing intended for PLHIV (people living with HIV;

The initiative provides highly active antiretroviral therapy (HAART) and retention in HIV care. Integrating supersised injection into the Dr. Peter Centre (DPC) residence and day health programme

The DPC, a Vancouver-based HIV care sersice organization, employ's an integrated sersices model and provides sersices to approximately 425 PLHIV annually

Face to face

Nurses

Adoption of comprehensive model to minimize barriers PLHIV who inject drugs face when accessing care sersices and consults with decision-makers (eg. policymakers, police) to increase awareness of the public health benefits of this approach

NR*

NR*

NR*

Davenportetal.2021

Yes

Occupational interventions are aimed at maintaining safety in essential activities of daily living (ADL), falls prevention, moving and handling solutions such as hoist and specialist sling provision or bed mobility solutions and major adaptations such as level access shower, stairlifts, through floor lifts and ramping, specialist seating provision and liaison with local housing services. Interventions can consist of telephone advice, or one or more visits depending on complexity

Rehabilitation or intermediate care service provision (primary care) which are provided by the Trust.

Occupational therapists, plus support practitioners working for the adult social care service covering Wirral local authority were integrated into Wirral Community Health and Care NHS Foundation Trust (WCHC) in 2017

Face-to-face

Occupational therapists

NR*

NR*

The initiative is funded by NHS Foundation Trust

Patients records are recorded and taken from the adult social care recording system Liquid (https://www.liquidlogic.co.uk/) by a Trust information analyst

deVriesMcC Unlocket al. 2016

Yes

The basic interienti on involved the interventionist collaborating with physicians to provide education, guideline-based treatment recommendations, and to monitor adherence and clinical indicators. Key components of the basic intervention were: (1) an individualized program to improve adherence to oral hypoglycemies agents or anti-hyperglycemic agents; and (2) integration of depression treatment with Type 2 Diabetes Mellitus (T2DM) management. Patient prioritized planning (PPP) was introduced. The goal was to identify priorities that were likely to influence adherence to treatment. Biomedical needs as well as financial, social, and emotional needs patients with T2DM and depressive symptoms. Participants received information about local resources (e.g. emergency shelter services, the Department of Public Welfare, disability services, Medicare and Medicaid, social security income)

Physicians services provision aimed at diabetes and depression treatment

Physicians practices in Philadelphia, Pennsylvania

Face-to-face

Interventionists

NR*

NR*

NR*

NR*

Dohenyetal. 2020

Yes

The 290 municipalities provide the social care services (ie, home-help including both household and personal care senices) needed by older persons (regions and municipalities are independent, as they both collect taxes to finance most care services)

Primary healthcare (PHC) is the basis of the Swedish healthcare system, where most patients with chronic diseases are treated, and includes home-health care services

IC was initiated as a shared project between Norrlje municipality and Region Stockholm

NR*

Hospital-based care teams

The Norrtlje model was set-up to provide care to the entire population of the municipality. The intersenti on had its base at the hospital and set out to join the efforts of health and social care services, through aligning medical documentation, care planning, rehabilitation, preventative care, home-help, home-health care and PHC services. Care teams were created with specific purposes to facilitate inter-professional group meetings, for training and to improve service delivery.

The model facilitated the development of a variety of care paths (eg, dementia, stroke), in addition to the national care plans for certain conditions already established in Sweden

Care teams were created with specific purposes to facilitate inter-professional group meetings, for training and to improve service delivery

A joint health and social care board with politicians from Region Stockholm and Norrtlje municipality was formed, responsible for the financial and organisation administration as well as the purchasing of care services from a jointly owned public company (tax-funded). The Norrtlje Model used a shared approach to policy and financing in order to promote a better integration of resources and care staff, and further, provided a stimulus for the development of a shared information system to facilitate IC

A stimulus for the development of a shared information system to facilitate IC. Shared information systems were reported

Eastwoodet al. 2020

Yes

Sustained Nurse Home Visiting services for vulnerable mothers and their infants until 2 years using a tiered approach. Intensive wrap around counselling models for high-risk mothers experiencing interpersonal violence, and with complex mental health and substance use problems Preschool and school-based centre and home visiting interventions to reduce conduct disorder, bullying, depression, and alcohol use

Early intervention and public health approach to interrupting cycles of family disadvantage, poor health and psychological trauma. Use of evidence-informed integrated care methods by service partners, including family case conferencing, and wrap-around care delivery. Providing a supporting structure to general practice providers to care for families that are often seen to be too difficult

Sydney Local Health District implemented an integrated care initiative for disadvantaged families in the Inner West region of Sydney, Australia. The initiative, known as Healthy Homes and Neighbourhoods (HHAN), is designed as a cross-agency care coordination network for disadvantaged families. At the level of service providers, the New South Wales. (NSW) Government, Australia

Face-to-face

HHAN consists of five service-providers: three senior clinical nurse consultants and two senior social workers. Two service-providers are based in the place-based multiagency hub in Redfern, two service-providers are based in the community centre in Riverwood, and one service-provider covers the families enrolled in HHAN who are located between the two areas. All service-providers work independently, however, come together weekly for case reviews, intake meetings, and business meetings

In 2014, collaborative interagency work commenced on an Inner-West Interagency Child Health and Well-being Plan. Following the launch in 2014 of a New South Wales (NSW) Government integrated care initiative, the Healthy Homes Neighbourhoods (HHAN) Integrated Care Initiative was designed

HHAN consists of five service-providers: three senior clinical nurse consultants and two senior social workers. Two service-providers are based in the place-based multiagency hub in Redfern, two service-providers are based in the community centre in Riverwood, and one service-provider covers the families enrolled in HHAN who are located between the two areas. All service-providers work independently, however, come together weekly for case reviews, intake meetings, and business meetings

SLHD provides independent budget for this program.

NR*

Elstonet al. 2019

Yes

The Well-being Coordination service uses 12 Co-ordinators employed by 7 key voluntary sector organisations, embedded in local communities across the area. Co-ordinators are based in a variety of settings, including NHS premises. The Co-ordinator works with the individual for up to 12 weeks to enable them to take action to achieve their goals. This includes resilience-focused coaching and practical support and advocacy to navigate and access local health, social and economic services.

GPs, community and social care staff in multidisciplinary meetings, hospital discharge staff (acute and community)

In Torbay and South Devon, the Integrated Care Organisation, a provider organisation, commissioned a SP service from the voluntary sector to be integrated into its five locality hubs, alongside primary care, community and social services

face-to-face; outreach

Co-ordinators (Social Prescribing)

South Devon service commissioned by Torbay and South Devon NHS Foundation Trust is managed by Teignbridge CVS, an umbrella voluntary sector organisation

This study focuses on the South Devon service commissioned by Torbay and South Devon NHS Foundation Trust and managed by Teignbridge CVS, an umbrella voluntary sector organisation

Social prescription service from the voluntary sector to be integrated into its five locality hubs, alongside primary care, community and social services

Data on the use of health and social care services were collated from local IT systems 12 months prior to and after the date of each referral. It included the following services: accident & emergency (A&E) and minor injury units (MIU), in-patient, outpatient, community service (ie, occupational therapy, physiotherapists and nursing) and social service contacts and length of stay (in-patients only) and GP contacts. Contacts outside the clinical commissioning group (CCG), boundary were also included

Ismailet al.2020

No

Social interventions lead by a community support worker if social problems were recorded involved advocacy in housing, debt problems, childcare, domestic violence, immigration and/or signposting to employment training. These were integrated into their routine diabetes care by ensuring 3DFD clinics were co-located with the diabetes MDT clinics via joint consultations with the key diabetes healthcare professionals or weekly feedback at the generic diabetes MDT meetings. The 3DFD liaison psychiatrist and/or community worker met the participant in weekly-to-monthly appointments, depending on their needs, for a period of up to 6 months

A multidisciplinary diabetes team MDT), which included a general practitioner (GP), diabetologist, diabetes specialist nurse and dietitian in three settings of increasing severity: primary, intermediate and secondary care for diabetes. Any professional from the diabetes MDT in Lambeth and Southwark could refer adult individuals to 3DFD via a standardized online or paper referral form. Each referral was discussed and triaged at weekly 3DFD team meetings attended by the psychiatrist and community worker and allocated to: the liaison psychiatrist (if the referral indicated pressing safety concerns or presence of multiple psychiatric morbidities) for a diagnostic assessment and initiation and monitoring of psychotropics; assessment for psychological therapy

Research Centre for Mental Health at the South London and Maudsley NHS Foundation Trust and loPPN, King's College London.

3DFD was set in Lambeth and Southwark, London, UK

Face-to-face

The 3DFD team consisted of a full-time consultant liaison psychiatrist and two full-time community support workers from a third sector (or nongovernmental organization), voluntary organization, Thames Reach, that provided social welfare

NR*

The 3DFD team consisted of a full-time consultant liaison psychiatrist and two full-time community support workers from a third sector (or nongovernmental organization), voluntary organization, Thames Reach, that provided social welfare

the NHS London Regional Innovation Fund, Guy's and St Thomas's, King's, and Maudsley Charities and Lambeth and Southwark Clinical Commissioning Groups

NR*

Janseet al. 2016

Yes

Primary Care Practices (PCP) is a cooperative of a hospital, a nursing home, the three largest home-care organisations, a mental health organisation, allied health practices and elderly patient-, informal care and volunteer associations. Home-care organisations were important network partners, as they provide various services in the elderly patients homes through small community-based teams consisting of a community nurse, general

GP and case managers.

A local cooperative of PCPs initiated, developed, and implemented the Walcheren Integrated Care Model (WICM)

Face-to-face

Case workers, community nurse, general and specialized nurses and domestic helpers

Organizational administrative integration was achieved through the creation of a geriatric care network, consisting of the PCP cooperative a hospital, a nursing home, the three largest home-care organizations, a mental health organization,

Small community-based teams consisting of a community nurse, general and specialized nurses and domestic helpers

Integrated funding involved an experimental financial module provided by the regional healthcare insurer to reimburse intervention-related costs to participating PCPs

NR*

and specialised nurses and domestic helpers. Services range from around-the-clock supervision and/or specialized nursing care, home recovery/rehabilitation, home meal services, personal care and domestic assistance

allied health practices and elderly patient-, informal care and volunteer associations.

Network partners, governmental social care/welfare organizations and the municipalities formed a steering group that was responsible for the further development and planning of the WICM

Mateo-Abadet al. 2020

Yes

The CareWell integrated care model has defined a specific pathway for patients with multimorbidity (addition to the usual/primary care). It has several phases: identification of frail older patients, comprehensive baseline assessment, definition of the therapeutic plan, programmed follow-up, patient stabilisation at home, integrated care during hospitalisation and coordinated hospital discharge. The pathway focuses on two main dimensions: l)care coordination and communication between health providers and 2) patient empowerment and home-based care. A patient empowerment program, KronikOn, was defined. The KronikOn targets frail older patients and their carers.

Primary Care professionals, GPs and Primary Care (CP) nurses are responsible for most of the healthcare activities performed at the community and home levels, such as on demand consultation, home visits, drug prescription, patient education, or referral to the specialist or hospital care all recorded via electronic health records (EHR) and e-ρrescriρtion availability and eHealth call centre, staffed by trained nurses available to respond to phone calls from patients. A dedicated consultant can coordinate other specialists during the hospitalization period. A dedicated consultant can coordinate other specialists during the hospitalization period. Discharge is coordinated between the hospital liaison nurse and the PC nurse

The Department of Health of the Government of the Basque Country and the Basque health system, Osakidetza, has deployed a specific strategy to improve the structural integration and care coordination

Follow-up within 24 hours after discharge and monthly telephone calls by the PC nurse to allow early detection of possible deterioration. Messaging between patients and/or carers and healthcare practitioners via the Personal Health Folder was enabled and outreach as needed

A dedicated consultant can coordinate other specialists during the hospitalization period. Discharge is coordinated between the hospital liaison nurse and the PC nurse

Multidisciplinary primary care teams and collaboration among different disciplines in multiple planning activities related activities are central to the integrated approach.

Geriatric expertise is easily accessible by close involvement of elderly care physicians and geriatric staff

The multidisciplinary teams include the following profiles: the General Practitioner, the Social Worker, the Specialists, the Nurse Care Manager, and the eHealth Centre. The Nurse Care Manager is responsible not only for the specific case management but also supports the patients in the hospital, emergency department, and during the discharge process. The roles of the Reference Internist and the Hospital Liaison Nurse are reinforced

This was funded by Department of Health of the Government of the Basque Country and the Basque health system, Osakidetza

These are supported by ICT-based platforms, including a Personal Health Folder, which allows the patients to access their clinical information

Melvinet al. 2019

Yes

The Open Arms program involves case management, and social support services linkage (transportation, emergency food assistance, housing, and legal service) Case management. The clinical case manager assesses the patients’ medical and psychosocial needs. The manager works with patient navigators to coordinate all referrals internal to and external to Open Arms and facilitates all HΓV and behavioural health care linkage within 24 hours. Referrals to social support services are made on the same day and are based on the patients’ needs. Social support services. The model provides wrap-around sendees in the form of internal and external referral sendees (ie, support groups, transportation, and emergency food assistance; housing, employment sendees, and mental health sendees)

HIV care (primary health care), behavioural health care (mental and substance abuse screening and treatment), and adherence counselling (a pharmacist-led intervention)

The Open Arms Healthcare Centre (Open Arms) is a nonprofit health care organization established in 2013 to provide innovative, holistic, health care sendees to undersened, underinsured, underrepresented populations in Mississippi with emphasis on lesbian, gay, bisexual, transgender, and intersex populations

Face-to-face; telephone

Case managers and patient navigators

NR*

NR*

NR*

Data were collected and stored in Advanced MD, the Open Arms medical record system, and CAREWare (https://hab.hrs a.g ov/program-grants-manag ement/care ware), a free, electronic health and social support sendees information system for Ryan White HIV/AEDS

Moonet al. 2021

Yes

Emotional wellness promotores conducted an exploratory session to uncover the priority issues for the participant and identify their most pressing social needs. Thereafter, participants engaged in group sessions and one-on-one sessions with a promotor by using a curriculum based on principles of narrative therapy. Promotores provided a range of interventions, including education (navigating legal, medical, education, penal, or immigration systems), peer support (donations, goal setting, identifying strengths and barriers, moral support, system support), leadership development (advocacy and individual coaching), community building and engagement (group projects, activities, volunteering), addressing barriers to service use (application assistance, childcare, health care access, translation services, transportation arrangements), and referrals to legal, social, and health services.

After COVID-19, social needs proliferated and promotores assisted with COVID-19 financial relief, nutrition assistance, and affordable housing support

Health care service provision via Latino Health Access (LHA) services

LHA, a nonprofit public health organization in Santa Ana, California, partners with Latinx communities in Orange County to advance health equity and run culturally appropriate services

Once COVID-19 struck, service delivery changed: group sessions convened via video conferencing, and one-on-one sessions were carried out over the telephone

Emotional Wellness Promotores (incorporating equity in a COVID-19 community mental health intervention in the Latino communities)

There is a strong collaboration between LHA, a non-profit public health organization in Santa Ana, California, and Latinx communities in Orange County.

Promotores are integrated and part of the LHA services, incorporated equity

LHA Emotional Wellness Program receives contributions from the Orange County Community Foundation, the Keith and Judy Swayne Family Foundation, and the Health Care Foundation for Orange County. CARES ACT has provided emergency rent relief in May 2020 (USI.6 million). Cify council approves 2S.6 million via CARES act for rental assistance, childcare, testing, community resources in 2020 and 2021.

NR*

Moretti et al. 2017

Yes

Social workers accompanied acute brain injury (ABI) people and their families for six months to conduct a support path, from hospital discharge to home care and social reintegration. The criteria for the identification of families were agreed upon by the project team, with the following requirements being considered essential: high intensity care needed by the person and the family, the need to activate a variety of resources in the Marche Region

Hospital-based care

Centre of Research and Service on Social and Health Integration (CRISS) of Polytechnic University of Marche, The Santo Stefano Rehabilitation Institute, in Porto Potenza Picena, Marche Region, and the Andrea Brain Injury Association of Marche and other voluntary* organizations

Face-to-face

The social workers are implementing the support path, as well as the operators of social and healthcare services and voluntary organizations. This activity favoured a greater understanding of both the needs of people with ABI and their families, as well as those of the organization, the working methods and problems of local services

A technical group, consisting of representatives of the subject partner, defined the objectives of the project and the methods for testing and verification, while the creation of a working group, composed of social workers actuated the support path, enabling the interventions to be monitored

Social workers assisted with the creation of a map of services and resources, collaboration with GPs, collaboration with the health and social services. These actions, while maintaining a character of continuity, take on specific features in each of the three phases. With regard to collaboration between the services, the meetings organized by the social worker during the support path, which were attended by social and healthcare services and the families, favored the use of a shared vision of the situation, the definition of actions to be implemented and mode of link

NR*

NR*

Murphyet al. 2017

Yes

The intervention was admission to a purpose-built health and social care day facility to receive services provided there by a multidisciplinary team of health and social care professionals: nurses, doctors, social workers, physiotherapists, and occupational therapists. Depending on the needs identified, the client had access to an individually tailored programme of interventions. These could include assistance with activities of daily living such as personal cleansing, hair care, mobility and elimination, occupational therapy, and physiotherapy as well as other nursing and social work interventions. The interventions provided depended on the client's individual needs, however optimum nutrition was emphasised for all. The unit offered a programme of activities such as music groups, choirs, bands, quizzes, bingo, raffles, shopping project. No specific incentives to attend were offered but in keeping with normal practice, transport was provided

If more specialist referrals were required such as to specialist nurses, dieticians, audiologists, and podiatrists then this was actioned. A general practitioner visited the unit at least once weekly.

Integrated Health and Social Care day unit (IHSCDU)

Face-to-face

Nurses, social workers, and occupational therapists

The integrated care provision was a purpose-built IHSCDU established in 2007. A multidisciplinary team of health and social care professionals who collaboratively.

Nurses, doctors, social workers, physiotherapists and occupational therapists. Referral routes were via individuals themselves, their families or health and social care professionals, such as general practitioners and social workers

NR*

NR*

Pauleyet al.2016

A new program has been developed that integrates cluster care and supportive housing models. In the supportive housing model, services and housing are combined in the same location. Integral to this approach is an interdisciplinary care team composed of shelter/alternative housing staff, and a personal support worker (PSW), and health professionals as well as a care coordinator responsible for providing intensive case management. As the supportive housing model gathers people with similar needs into one location, the cluster care model can be easily implemented

A primary care physician, a psychiatrist, a dedicated registered nurse (RN)

NR*

Face-to-face

Interdisciplinary care team composed of a primary care physician, a psychiatrist, shelter/ alternative housing staff, a dedicated registered nurse (RN), and a personal support worker (PSW), as well as a care coordinator

NR*

Both social and health care providers are part of an integral team

NR*

NR*

Permanet al. 2021

Yes

The counsellors carried out a review of the social and biological situation in the patients’ home, following a structured process, evaluating different domains: functionality, nutrition, mobility, pain, cognition, medication reconciliation and adherence evaluation, need for care and supervision, quality of care, and environmental safety.

Medical coordinators (family physicians, internists or geriatricians) were responsible for health care provision

Hospital Italiano de Buenos Aires

Face-to-face, outreach

Health and social care counsellor

NR*

Different professionals (health and social counsellors) were involved to achieve an interdisciplinary team with complementary* skills. Together with medical coordinators (family physicians, internists or geriatricians) who had no assistance role in the programme, discussed each case from a broad perspective, integrating both clinical and social problems

Embedded in hospital funding

NR*

Pruittet al. 2018

Yes

HealthConnections represents a new model of medical and social service coordination. Participants with unmet social needs have contacted the call centre-based program to obtain free referrals to a nationwide network of local, community-based public assistance programs. The program matches participant needs to available social services such as transportation, food programs, financial assistance for utilities, education programs, and housing services

Referrals for medical service provision is also available

HealthConnectio ns was developed by WellCare Health Plans, Inc., a managed care organization (MCO)

Phone service provision

HealthConnections employs a team of individuals responsible for identifying, collecting, maintaining, and analysing the database of community-based social service organisations. The call centre is staffed with representatives who have personal experiences with the social service system, Program representatives follow* up with the participants to confirm whether the social services met their social needs

NR*

The program connects individuals with social needs to the appropriate services.

NR*

The MCO programs database contained hundreds of organizations offering more than 60 categories of social services. The program tracks each referral in the tracking database separately

Sadaranganiet al. 2019

yes

The Community-Based Health Home (CBHH) model was designed to incorporate Health Home required services (comprehensive care management, care coordination, health promotion, comprehensive transitional care/fol low-up, patient and family support, and referral to community and social support services) using the existing infrastructure of the strength-based Adult Day Health Care (ADHC) model. The registered nurse navigators (RN-Ns) work with the ADHC EDTs (registered nurse, physical therapist, occupational therapist, speech pathologist, social worker, and dietician) in coordination with the physician. The RN-lTs priority is to promptly address emerging crises within a high-risk caseload of patients. The RN-N also supports the physician’s care plan, coordinates with caregivers and other providers, and formulates patient-centred action plans to stabilize and improve participants health. The overall goals of CBHH are to stabilize individuals social, medical, and psychological conditions and reduce unnecessary utilization of health services while improving quality of life and self-care capacity

ADHC professionals (registered nurse, physical therapist, occupational therapist, speech pathologist, social worker, and dietician) provide care for vulnerable, chronically ill adults

ADHCs

Face-to-face

A full-time RN-N manages an average case load of 19 patients, providing an average 2 hours of high-intensity care to each participant on a weekly basis

U.S. health care delivery system, Affordable Care Act in 2010, Medicaid State Plan benefit for states to establish Health Homes under the authority of the Affordable Care Act of 2010, Section 2703 (1945 of the Social Security Act), CBHH model, and the ADHC model

Services are provided through the inclusion of a RN-N within the ADHC IDT (ALE, 2016) that support integration of health and social services.

Existing infrastructure of the strength based ADHC model, which has existed in the United States since the early 1980s

RN-Ns shared clinical data with providers, participated in clinical encounters across health care settings, recognised and intervened with respect to emerging clinical issues, and advocated on patient’s behalf

Sohanpal et al. 2017

Yes

The social prescribing service: Patients were referred to a social prescribing coordinator. At the first meeting with the coordinator, the patients discussed their personal circumstances and if possible, a mutually determined well-being action plan was devised. The action plan contained goals for improving patient wellbeing, in some cases this involved referring patients to community organisations and services. If necessary, a volunteer was assigned to help the patient achieve their goals. Volunteers were trained by the social prescribing coordinators to assist in the delivery of the service and provide additional support to clients. Patients could receive up to six sessions with the social prescribing coordinator and as many contacts with the volunteer as required

GPs -community based

In January 2014 the London Borough of City and Hackney Clinical Commissioning Group (CCG) commissioned a pilot project for a social prescribing service in three areas comprising 22 primary care general practices. The aim of the social prescribing service was to improve patient well-being and increase personal self-efficacy shown by a reduction in primary health care resource

Face-to-face

Three areas in the borough were included and were assigned a social prescribing coordinator. The coordinators were trained in social work and employed by a managing third sector (not-for-profit) organisation commissioned to implement the service. Three social prescribing coordinators were appointed and worked in the 22 GP surgeries enrolled.

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GPs referred patients with specific social needs to a social prescribing coordinators

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Spoorenberget al. 2019

Frail people and those with complex care needs received individual support from a case manager. The participant and case manager jointly developed an individual care and support plan which targeted all health-related problems identified during history taking using the Geriatrics. Case managers organised the care and support as decided on in the care and support plan. They monitored changes and navigated the plans delivery. Participants were also invited to follow a self-management support and prevention program that included regular Embrace community meetings, which focused on staying healthy and independent for as long as possible

GP or elderly care physician service provision (with particular focus on multimoibidity)

Dutch Organization for Health Research and Development, University Medical Center Groningen (UMCG), The National Care for the Elderly Program and the managerial netwoik of the Regional Network Northern Netherlands

Face-to-face

Case managers, a district nurse and a social wotker for the participants with complex care needs and participants who are frail

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A multidisciplinar; Elderly Care Team consisting of a general practitioner, a nursing home physician, 31 and 2 case managers, a district nurse and a social worker for the participants with complex care needs and participants who are frail, respectively organized care and support for older adults

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During these visits, case managers took a history using the Geriatrics, which was integrated into the web-based electronic record system of Embrace. Within Embrace, the Geriatrics was used for history taking from older adults who are frail and those with complex care needs receiving individual care and support by a case manager. The clinical infoimation systems will be represented by the Electronic Elderly Record System (EERS), a web-based application built for both clinical and research purposes

Talbotet al. 2020

Yes

Adolescent Multi Agency Specialist Service (AMASS) offered three different intervention packages which are leading by a social worker embedded in the service (in collaboration with a multidisciplinary team): home stability to stabilise the family home environment to prevent the adolescent from entering care; foster placement stability to stabilise the foster placement to prevent the adolescent being moved to an alternative placement; and return home to support an adolescent to move from acare setting (e.g. residential setting, secure unit and foster care) back to the care of their family

Use of individually tailored, evidence-informed methods of practice informed by a range of evidence-based approaches (e.g. behavioural parent training, systemic family therapy, cognitive behavioural therapy, motivational intersiewing, etc.)

AMASS service

Face-to-face; outreach

Lead Social Worker

The service was commissioned by the Local Authority. AMASS was jointly managed by a local authority employed Social Care Manager and a National Health Service (NHS) employed Child and Adolescent Mental Health Service Clinical Psychologist, alongside two Senior Social Workers, a specialist Teacher, a Youth Worker and an Assistant Psychologist.

A multi-agency team was co-located within Children Social Care, to which social workers could refer cases with which they wanted support to jointly deliver a social care, mental health and education intervention designed at reducing edge of care risk

The service was commissioned by the Local Authority to reduce the number of young people coming into care compared with previous years

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Terracdanoet al. 2021

Yes

There is a network of volunteers (neighbours) and professionals (GPs, the pharmacist) around frail older adults. The evaluation is followed by the intersentions that are identified in collaboration with social workers. Within the program, social workers draft individualised care plan, coordinate the intervention to implement it at the older population, and taking care of their specific social needs. Interventions reflect the specific needs of the elderly both in the social and health fields. The most frequent intersenti on is changing the environment to prevent home falls; socialisation; medication review; education to have a correct diet; support to search for a paid assistant; social support to the household; home care; and emotional and psychological support

GPs and pharmacy service provision

Lazio Regional Health and Social System, and the University of Tor

Telephone calls, home visits for organisation of dedicated activities

Community nurses (ON)

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The interventions performed by community nurses in the Long Live the Elderly (LLE-CN) group were carried in collaboration professional integration among nurses, social workers, psychologist, and GP

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Tonget al. 2020

Yes

Coordinated care Social care providers of the older people’s centres were invited to observe the assessment and caring planning sessions, after which the nurse or the health worker liaised with the social care providers on the status/conditions of the participant so that they could follow the participant throughout to ensure that they receive continued support or care. The report for each participant and the resource kit were provided to social care providers for reference

An integrated intervention consisting of in-depth assessment, personalised care plans and coordinated care: individual interviews were conducted to identify problems or needs, using an electronic questionnaire. Common geriatric syndromes have been considered, which included yes/no questions to the following domains (chewing difficulties, vision impairment, hearing impairment, sarcopenia, memory complaints, self-rated health, psychological well-being, incontinence, instrumental activities of daily living impairment and polypharmacy), followed by in-depth assessment and checking of prescribed medications.

This initiative is part of the Jockey Club Community eHealth Care Project commenced since 2016 for Chinese people aged 60 years or older who are members of older people’s community centres across 18 districts of Hong

Face-to-face

The nurse and the health worker

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The nurse and the health worker

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VanDijket al. 2016

Yes

As part of integrated neighbourhood approach (INA) community workers had health and social care backgrounds. Community workers visited older people at home and mapped their social and physical needs and capabilities with respect to factors such as housing, mobility issues, and social activities, through phased interviews. Together with older people, they sought appropriate solutions to identified problems or needs and composed individualised support plans. Community workers thus served as liaisons at the personal (supporting and monitoring older people), professional (seeking a multidisciplinary approach to support), and community (establishing a well-functioning network and engaging informal support givers) levels

Not part of the INA program

Rotterdam municipality, local health and social care organizations, Erasmus University Rotterdam, the University of Applied Sciences, and Geriatric Network Rotterdam initiated an INA for community-dwelling older people

Face-to-face; outreach

Community workers had health and social care backgrounds

INA combines components found to be effective for integrated care and support provision, the use of multidisciplinary and outreach teams, and preventive home visits

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the National Care for the Elderly Programme, was launched in 2008 and funded by the Netherlands Organization for Health Research and Development

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Vestjenset al. 2019

Yes

Community-dwelling older patients registered at the GP practices are screened for frailty using the Tilburg Frailty Indicator (TFI) during a home visit by the practice nurse, homecare nurse or geriatric nurse. The assessment comprised of physical, psychological, and social domains. Problems and needs are reported in multiple domains according to the SFSPC-model, i.e., somatic (e.g., pain, fall risk), functional (e.g., limitations in activities of daily living like problems with eating or household activities), social (e.g., social network), psychological (e.g., fear, coping, depression), and communication (e.g., visual or hearing impairments). Outcomes of this are reported and discussed with the GPs and elderly care physicians. The care plan is then tailored to the personal needs and wishes. Follow-up of older patients is arranged by a multidisciplinary team of (healthcare) professionals and an appointed case manager, who coordinates and evaluates the process, and provides support in goal setting and self-management

Primary health provision by GP practices and led by GPs

Finding and Follow-up of Frail older persons (FFF) approach, which aims to maintain or improve older people’s well-being and is implemented by part of the Dutch general practitioners (GPs) Located in the western part of North Brabant Province, the Netherlands

Face-to-face; outreach

Practice nurse, homecare nurse or geriatric nurse

Multidisciplinary primary care teams and collaboration among different disciplines in multiple FFF-related activities are central to the FFF approach. Geriatric expertise is easily accessible by close involvement of elderly care physicians and geriatric nurses. Older persons (healthcare) needs are discussed in multidisciplinary consultation at least once a year. Individualized care plans include reported problems and (healthcare) needs, tailored (self-management) interventions, plans for multidisciplinary follow-up and evaluation

Multidisciplinary teams are integrated

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Whiteet al. 2021

Yes

Includes liaison with or referral to inpatient and community mental health services, family sessions, allied health including dietician and exercise physiology, other specialist medical services, private psychiatry, psychology and GP services; sexual health, forensic, domestic violence services and social support agencies including financial, vocational, educational, and housing.

The service is to provide intensive, integrated, wrap around care across mental health, medical, social, educational and occupational domains, for up to 12 months

Psychologists, general practitioners, social supports, group programmes, specialist, hospital services and after-hours acute care

Headspace, established in 2006 and funded by the Australian Government to provide accessible, youth-friendly, integrated primary care services for early intervention to young people aged 12 years

Face-to-face

The service is to provide intensive, integrated, wrap around care across mental health, medical, social, educational and occupational domains, for up to 12 months, headspace Early Intervention Teams (hEIT) has access to services of headspace and Sydney Local Health District (SLHD) such as psychologists, general practitioners, social supports, group programmes, specialist, hospital services and after-hours acute care. Further details of the model of care of hEIT, staffing and clinician experience, has been published (Nash et al., 2021)

To address these service gaps, new models of sendee were funded by the Australian government through the Primary Health Networks (PHNs) across Australia. Two (hEITs) in Sydney were supported by this funding commencing in 2017. hEIT is a product of interagency collaboration, sitting physically within the youth friendly headspace offices, yet their clinical governance and employment rests with SLHD, while funding is from the Australian Government via the local PHN, and development support comes from Orygen, National Centre of Excellence in Youth Mental Health

hEIT is co-located within the youth friendly clinical spaces of headspace, while clinical governance and staff employment rests with SLHD, an organization that serves a population of 640000 in metropolitan Sydney

To address these sendee gaps, new models of service were funded by the Australian government through the PHNs across Australia. Two hEITs in Sydney were supported by this funding commencing in 2017

EMRs and systems are in place (SLHD) sendee

Wong 2020et al.

Yes

Tins is a three-month health-social partnership program. Nurse Case Manager (NCM), functioning as the leader of health-social care team, conducted the initial assessment in the first home visit to identify the clients’ health and social problems within one week of discharge. Community workers, supervised by both the nurse case manager and social worker, provided telephone follow-up and subsequent home visits to monitor the clients progress and provide support when necessary. According to the problems identified, the NCM provided intersentions in accordance with the Omaha System scheme, which included health teaching, guidance and counselling, treatment and procedures, case management and surveillance. The NCM also coordinated care across a range of settings, from the home to the community centre or hospital when necessary

After each client was admitted to the emergency medical ward EMW, an advanced practice nurse (APN) from a hospital discharge team visited them to familiarize him/herself with their condition and prepare a discharge plan. A face-to-face or telephone call handover between the APN and the project nurse case manager (NCM) was performed before the client was discharged. The past and current medical conditions, medical and nursing management, and follow-up appointments were discussed

The community-based health-social partnership (CHSP) program linked to EMW from Queen Elizabeth Hospital, and Hong Kong Hospital Authority, Hong

Face-to-face; outreach and calls for follow-up

A case manager ensures that the support for individual clients in enhancing self-care was comprehensive and property coordinated. The nurse, backed up by a multidisciplinary team, assumed the role of case manager in the program, and home visits and telephone calls were the two approaches to care delivery performed by community workers

Efforts were directed at building a community-based intervention with a health-social partnership to ensure that system resources and collaboration among stakeholders could be activated to provide support to individuals when needed

There was a case manager to ensure that the support for individual clients in enhancing self-care was comprehensive and property coordinated. The nurse, backed up by a multidisciplinary team, assumed the role of case manager in the program, and home visits and telephone calls were the two approaches to care delivery's.

Interdisciplinary case conferences were held regularly between the NCM and social workers, with the involvement of the APN if appropriate. During the conference, the health-social team members communicated each other’s role in managing the case, which increased understanding and collaboration in the process. In addition, events such as the progress and concerns of clients, and suggestions for further actions, modifications, or adjustment of interventions were reviewed

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Zarnegaret al. 2017

Yes

Nonmedical interventions consist of artistic, musical and horticultural activities, visits and outings. The group activities have a strong social element. Breakthroughs arise from imaginative listening, sharing and exploring new ideas particularly when they come from patients: their suggestions for social and work activities, for example the choir, have helped shape the service. Homework, for example practising movement exercises or dressing differently, hands over some shared responsibility to the patient as well as enhancing the effect of the therapy. Some participants are supported in their applications for disability benefits for example help with filling out statutory forms and offered personal representation at Department of Work and Pensions (DWP) or equivalent medical examinations and appeal tribunals. They are encouraged to design realistic return-to-work schedules in keeping with their individual aspirations

All treatments and interventions have a self-management focus and are delivered by a team of a doctor, GP with special interest (GPwSI) in pain management and two therapists. Medical and nonmedical aspects of treatment run as parallel, complementary interventions. Two anthroposophie therapies (9), rhythmical massage and eurythmy (gentle movement) are delivered individually in blocks of 7 -8 weekly sessions. They aim to reduce the burden of symptoms (mainly pain, sleep disturbance, fatigue, anxiety and depression) and to restore energy. The confidence and motivation required for self-management is thereby facilitated. The intensity of the interventions is graded according to patients physical and psychological condition as well as capacity and their needs. As symptoms improve the rationalisation of repeat medication, particularly analgesics and psychotropics, becomes possible

The intervention has been developed and delivered by a charity, Kairos Rehabilitation Trust (KRT), alongside a community pain management clinic, the V anbrugh Community Pain Clinic (VCPMC) in Southeast London

Face-to-face; outreach

Delivered by a team of a doctor, GP with special interest (GPwSI) in pain management and two therapists. Medical and nonmedical aspects of treatment run as parallel, complementary intersentions. Two anthroposophie therapies (9), rhythmical massage and eurythmy (gentle movement) are delivered individually in blocks of 7-8 weekly sessions. They aim to reduce the burden of symptoms (mainly pain, sleep disturbance, fatigue, anxiety and depression) and to restore energy

Community based rehabilitation and social intervention programme which employs the components of the Kings Fund House of Care model. The intervention has been developed and delivered by a charity, Kairos Rehabilitation Trust (KRT), alongside a community pain management clinic, the V anbrugh Community Pain Clinic (VCPMC) in Southeast London

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