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Sample Research Proposal on An Integrated Care Plan For A Continued Care In Stroke Patients


Stroke patients present a complex range of problems for health care providers and that stroke patients who have experienced a stroke can often be one of the most challenging patient populations seen by a caregiver. Unlike most other patient populations, stroke patients vary greatly in care needs and require a wide range of individualized nursing interventions based on patient deficits. Stroke patients that require interventions from a variety of care providers and are discharged to a number of different care settings further complicate care coordination. Keeping the care providers on pace is critical to ensuring smooth transitions to other care settings for the patient. For example, there was a patient experiencing a stroke without surgical intervention was selected as a focus population for redesign efforts as stroke patients require complex discharge planning, generally require interventions from a large multidisciplinary team, have numerous family support issues and show a wide variation in presentation of symptoms to represent better integrated care plan within the stroke patient care unit.







Literature Review

The integration have several meanings and interpretations (Kodner and Spreeuwenberg 2002). Here, we define integrated care as a well planned and well organised set of services and care processes, targeted at the multi-dimensional needs/problems of an individual client, or a category of persons with similar needs/problems and concentrate on integration issues around older persons with complex, multiple needs, focusing on cross-organisational integration of services. Tasks and services have to be integrated within organisations, but that type of integration is a more common management task, while integration across organisations and services is a relatively new issue for the long-term care sector. Moreover, integrated care can be conceived as client- or consumer-driven care (Kodner 2003). As such, it is not very different from developments in industry, agriculture, commercial services, or other public sectors such as education, town and country planning, youth care or public transport. In all these sectors, supply-driven management systems are gradually being replaced by integrated, demand-driven systems. These systems are developed because of client demand, but also because they are cost effective and efficient, as well as offering employees more job satisfaction (van der Aa and Konijn 2001, Goodwin et al 2003).



Integrated and linked services can serve all these objectives and the various services can fit together well in a range of areas, including care for older people. What is more, service users are demanding integrated services. In a time of increasing demands and decreasing resources, it is obvious and politically compelling that health services should work closely with community and social care services to fulfil their objectives. Finally, for care workers, integration provides new perspectives in career and professional development. Integrated care is not an outcome, but a means to achieve optimum performance at service level – in this case, for older people. This shift from supply-driven to demand-driven care requires new management styles and skills as the challenge is to organise and secure care and service provision so that it:

  • supports the 'life world' of clients
  • combines tasks of professionals, informal carers and volunteers
  • connects and combines services within organisations
  • co-ordinates services delivered by different providers
  • interconnects with the specific framework or care system.






The challenges in establishing integrated care are as follows:

Supporting the 'life world' of clients – A client's 'life world' includes their personal background within their social and physical environment. Supporting this includes helping clients experience their essential personal identity and meaning of life.

Combining tasks of professionals, informal carers and volunteers – This involves adequately assigning all necessary tasks to services or professionals, in a well-balanced dialogue with clients.

Interconnecting with the specific framework or care system – It is important to work within the context of the system in which the services have to be delivered, such as the financing system, legal regulations or standards for good quality care.









Dimensions of continuity of care

In developing well-linked, co-ordinated or fully integrated services, continuity is the key priority (Haggerty et al 2003). The design of the services and the care pathways along which the services are provided needs to take into account that integration is a dynamic process. It changes over time and needs regular monitoring and adaptations. Both the content and timing must have continuity. Two dimensions of continuity are always at stake: Page 24

The simultaneous dimension – The provision of multiple services has to be coherent in its contents and its logistics. For instance, there may need a multiple package of care and services. This package must be fitted into a daily rhythm or programme. All the professionals involved should work according to consistent principles, so as not to make her even more confused and depressed. In this context, one can speak of 'simultaneous' linking, co-ordination or integration of services during the entire process.




The sequential dimension – Care and services have to follow the needs of the user over time, but the stages of progression must appear seamless. Then the user will need a rehabilitation programme of aftercare or long-term care, so sequential linking, co-ordination or integration is required. The chain of care has to fit to achieve continuity in contents and actual delivery over time (Åhgren 2003).

Presentation of the Proposed New Practice

Some of the patient outcomes defined by the team included stabilization or improvement of neurologic deficits. In addition, patient or family verbalization of understanding of activity precautions, home safety measures, diet instructions and signs and symptoms to report to the physician were expected. With these outcomes clearly defined and the information shared by patients and their families regarding unmet patient needs, the team set out to improve care of the stroke patient.  With the ideal stroke patient care in mind, the team reviewed weaknesses in meeting discharge needs and patient outcomes. This led to the formation of various tools and the redesign of processes to reduce the likelihood of failure.



The stroke critical path includes assessments, tests, treatments, medications, nutrition, teaching, safety and discharge planning interventions. Medications on the critical path include heparin or aspirin therapy, which are ordered at the physician discretion. In order to facilitate improved communication among care providers, a multidisciplinary planning sheet was developed. This is placed in the chart with the physician orders, and is used as a communication tool between the multidisciplinary team in planning for discharge needs. It is hoped to incorporate this information into the computerized critical path to expedite future documentation and eliminate duplication within the medical record. Redesigning care for the stroke patient has had positive impact on patient satisfaction, care provider satisfaction, care provider communication, timelessness of physician orders and consistency of patient teaching.











Management focus in integrated care Page 20

Thus, having to deal with the fields involved in the figure, which may reflect contrasting or contradicting commitments, can cause ambiguities and dealing with these ambiguities is one of the most challenging tasks that need to deal with (Carrier 2002).

Source of the above data: EHMA online publications (2004) Integrating Services for Older People: A resource book for managers

Retrieved at:



In order to present good assumptions, it is important to note some key characteristics of care pathways for stroke care plan such as the following:

Ø      Validity Interventions should produce the expected results

Ø      Reliability as involved should be able to interpret and apply the interventions in the same way

Ø      A systematic approach Interventions should follow an agreed, standardised process

Ø      Clarity Interventions should be easily understood by clients and professionals

Sources: McQueen and Milloy (2001); Integrated Care Pathway Users Scotland

An integrated care pathway is not a substitute for professional judgement. When monitoring the way in which care pathways are applied, there should be some variance measured as this is needed to individualise interventions to each client, based on his specific idiosyncrasies as it may also be a consequence of organisational factors or different performance of the professionals involved.








A clear statement of the aims or objectives or outcomes


Objectives and intended outcomes Page 85

Care pathways serve multiple goals for all the stakeholders involved, such as clients, carers and managers in the health and social sector, public and private service providers, voluntary organisations and non-government organisations (McQueen and Milloy 2001; Integrated Care Pathway Users Scotland).

Care pathways serve the needs of clients through:

Ø      better approaches and practices, based on empirical evidence on outcomes, such as health, activities of daily living, quality of life, well being, cost-effectiveness, quality of life and respect for the person and their rights

Ø      continuity of care to ensure quality of life for the carers, providing added value to informal care

Ø      standards of care and expenditures becoming explicit to clients and their carers as well as increased client involvement and improved communication



Care pathways serve the needs of health professionals through:

Ø      standards of care and expenditures becoming explicit, justifying professional activities and the means that are required

Ø      care advances being incorporated into daily practice

Ø      better quality of care and quality of life for the client and her/his family, which may add to professional satisfaction

Ø      well-defined roles, responsibilities and actions to be taken that are amenable to education and training

Ø      better understanding of the needs of clients and their carers, as well as shortcomings of the systems by analysing processes in practice

Aims of integration

Objectives for the client (Kodner and Spreeuwenberg, 2002; Carrier, 2002).

Ø      The client is the main beneficiary of integrated care. From their point of view, integrated care works best if it is run in the following way:

Ø      The services are organised around the service user in response to his or her needs, and, if possible anticipating and preventing care needs

Ø      The services cover the full range of needs responding to the client's personal preferences and responsibilities



Ø      The interest of carers is an interest in its own right – they have their own rights, and their well being and quality of life must be taken into consideration

Ø      The possible and desirable roles and contributions of the clients, and of their carers, are regarded as a vital element of care provision.

Objectives for the organisation

In line with these requirements, the objectives and intended outcomes for the organisation can be understood as:

Ø      to enhance quality of care, quality of life, user satisfaction and system efficiency cutting across multiple services, providers and settings

Ø      to improve services in relation to access, quality and financial sustainability – including efficiency, public expenditure, common good (Commission of the European Communities 2003)

Ø      to strengthen the voice of older people with complex, multiple needs to enable them to live their lives according to their personal preferences and objectives




A plan for implementation of the practice and how it will be monitored


Moreover, in order to emphasize integrated care for stroke patients, there needs to have a set of services o be linked and integrated properly as such services are delivered by professionals and providers who may work in various sectors having different policy frameworks. To mention the most relevant ervices are used for practice and monitoring:

Ø      short-term health care – general practitioners, physiotherapy, occupational therapy, rehabilitation centre, outreach inter-disciplinary team (interventions and co-ordination), palliative home care team, hospitals

Ø      long-term care – district nursing, personal care workers, home helps, day hospital or day care, sheltered housing and psychiatric hospitals

Ø      social care – social work, support groups, sitting services, education and community centres

Aside, innovative services and its monitoring is then crucial especially when full integration is required, new, innovative services are to be required as there is a need to fit tin care plan roles, pathways and responsibilities. The information can provide clients and carers with some insight into the condition. It can also give them practical information and reduce their reluctance to seek professional support (Miesen and Jones 2002). The majority of care is provided by informal carers, such as next of kin and neighbours, often at irregular hours, and volunteers can also be important in care provision.


The implementation process

The philosophy of integrated care especially favours as there are strong pressures towards hierarchical structures of accountability to support political accountability, driven by experience and evidence rather grand blueprints or the pulling of big policy levers seem to be called for (Naylor et al (2001), cited in Woods 2002).  It is therefore necessary to experiment with the design of integrated organisations, as well as with integrated networks, to find the appropriate mix that fits the local circumstances. Integrated care pathways can be developed by following a series of steps, outlined in the checklist below, adapted from McQueen and Milloy (2001), Integrated Care Pathway Users Scotland (2003), Zander (2002):

Steps to an integrated care pathway Page 89

Step 1: Raise awareness and gain commitment for your endeavour

This includes raising the idea, convincing participants, setting the boundaries, choosing the site, planning the activities, appointing the team and its roles, and clarifying the involvement of clients and carers.

Step 2: Define the population for whom the care pathway is designed to fit

The population can be defined in terms of three factors: problems that are most prominent, diagnoses, and location. This definition determines to a large degree the character of the pathway that is to be developed – whether it is clinically oriented, disease oriented, oriented on well being, oriented on carers' needs, and so on.

Step 3: Review the evidence

Assess the information to ensure that it is relevant to your specific circumstances and to the specific population. The choice of the population will also influence to what extent evidence can be found. Summarise the evidence and make it available to the team members. Make sure that standards are agreed upon. Evidence that is scientifically sound is often not available in the fields of long-term care and social care.

Step 4: Collect data

The data illustrate current practice and establish a baseline for future evaluation of the pathway's impact. Only collect data on the particular client group or population and, where possible, include economic and organisational data.

Step 5: Review current practice

This practice can be recorded in a flow chart – a graph depicting the order of steps in a particular process. Record all improvement ideas while drawing this chart. This so-called 'process mapping' should not go too much into detail. For further guidance, see NHS Modernisation Agency (2003).



Step 6: Identify key indicators

Key indicators are milestones against which one can measure a client's progress along a care pathway. These indicators should be based on evidence with respect to the stages where the clients should be in their care. Indicators:

Ø      should be seen as alerts when the activity has reached a certain target

Ø      are points of reference for evaluation

Ø      challenge organisations to provide better care

Step 7: Design an integrated care pathway Page 90

Based on the current process analysis, the pathway should be modified and supported by the team and organisation involved, as well as by the clients and carers. Where decisions are unclear, rules should be established, so that policies are put in place for every eventuality. The pathway needs to be constructed as a multi-disciplinary plan and record of care that includes all key information, so make sure all the relevant and required documentation and records are taken into consideration.

Step 8: Determine the tools

There are two types of tools available. The first is 'content tools', which add precision and depth, and enable analysis of inclusion and exclusion criteria, clinical outcome progressions, critical indicators, guidelines, algorithms, decision rules, protocols and practice support information. The second type is the 'action tools' connected to the contents of the care pathway, such as assessments, progress notes about variance, client and family educational materials, and forms (Zander 2002).

Step 9: Review and revise the draft

When the draft is developed, review the representatives of all relevant disciplines and professions, as well as clients and carers. The basis of this review should be the evidence on which the pathways are based. Pilot the care pathway, whenever possible.

Step 10: Develop a client version of the pathway

This enables you to involve clients, to be explicit about the match between your services and their expectations, and to answer some of the common questions that they undoubtedly will have. It is important to use plain language and communicate clearly.

Step 11: Implement the care pathway

Agree a timescale. Remove previous documentation, agree the dates for reviewing the care pathway and allocate enough time for training and support.

Source: SPREAD (2003)

Monitoring and evaluation Page 93

Monitoring is an essential part of working with care pathways because it provides a constant review of the pathways of the clinical choices and their impact on the use of resources. To monitor and evaluate the process and effectiveness of the pathways, it is necessary to have practical instruments that identify the total needs of the person, before and after the intervention. In other words, 'evaluation' is a comparison that enables differences and changes to be measured at the different stages of the care plan. So it is important to use validated measurement instruments that compare the changing situation over time – both within one pathway, and between one pathway and another.



There are two main methods for improving outcome evaluation: managing absolute outcomes and managing relative outcomes (Vecchiato 2002). The absolute outcome option measures the state of a person referring to different parameters over time (for example, organic, functional or cognitive parameters). It is useful to link the seriousness of the need to a specific care intensity, which can then be guaranteed in the care pathway. The relative outcome option measures the differences between the client's health and life conditions before and after the intervention. The greater the relative outcome, the more effective the impact of the care pathway.

Criteria for defining outcome indicators

  • Specific need-related outcomes These are identified by the various domains, such as body functions and structures, activities and participation, environmental factors and personal factors
  • Everyday life-oriented outcomes These are identified in terms of the benefits in the life-space which includes the home/personal environment for the client and their family or carers. Page 94





The greatest challenge is to develop a set of outcome indicators that reflects a comprehensive assessment of the person with a complex need pattern. These indicators need to give an overall picture of the relevant domains of individual functioning, and to put the objectives of the intervention into operation, so they need to be monitored, and interventions and objectives may be adapted or altered.


A strategy for evaluating the innovation

Designing integrated organisations is typically top-down. A kind of strategic alliance with an agreement on central goals and values is negotiated at the start, and the partners consolidate this into an integrated organisation 'under one roof'. The process of the design itself will follow a strategy applying the principle of optimising. Integrated care organisations can use different strategies to develop (see Pelikan 1998), including:

Ø      adapting an existing organisation

Ø      outsourcing or contracting out additional services, constituting binding partnerships

Ø      forming a managed care organisation on the basis of existing provider organisations

Ø      creating new types of integrated care centres

A managed care strategy should combine knowledge and technologies, the economies of scale of larger organisations, lower transaction cost, the pooling of budgets, common infrastructures, and research and development capacities to organise integrated care 'under one roof'. It is basically a strategy of optimising, so that different interests are balanced within the organisation through hierarchies and contracts. Reviews of managed care and care trusts provide experiences with integrating partners (Wernet 1999, James and Miles 2002, Bailyn and Miller 2001).


Furthermore, strategies and structures that are designed to set incentives for professionals to co-operate and support integrated care are crucial to the success of care integration. The strategies include:

Ø      emphasising the value of care quality and integrated care

Ø      independent assessment of needs

Ø      case management and disease management

Ø      client education, empowerment and choicePage 50

A care pathway is an integrated strategy of care for a specific user group based on guidelines and evidence, where available. It determines locally agreed, multi-disciplinary practice (National Pathways Association and Integrated Care Pathway Users Scotland) and outlines the optimal sequencing and timing of interventions (McQueen and Milloy 2001). A prerequisite for care pathways is chain management. The idea reflects a strategy of:

Ø      managing care pathways

Ø      guaranteeing continuity of care

Ø      safeguarding best quality of care

Ø      ensuring the appropriate use of resources

Ø      managing the provision of care

Care pathways are about continuity of care. It is useful to distinguish between three types of continuity: (Haggerty et al 2003)

Ø      information continuity using information about past events and personal circumstances to ensure that current care is appropriate for each individual

Ø      management continuity a consistent and coherent approach to managing a health condition that is responsive to a patient's changing needs

Ø      relational continuity an ongoing therapeutic relationship between a patient and one or more providers

Management continuity requires those involved in integrated care to have special competencies, as well as a coherent view on care and the care pathway that is relevant to the particular client. Relational continuity also requires continuity of staff, and this needs to be deliberately planned, taking into account work and salary conditions and in-service training. Moreover, by assessing, planning and evaluating, they provide a continuous process of matching care with the changing needs of the client. They also provide problem-solving and decision-making support to their professional colleagues (Zander 2002).




In conclusion, the integrated care plan for stroke patients is not an outcome but a means to achieve optimum performance at service level. It is about effective and efficient targeting of services to the needs or problems of individual or categories of older people with similar needs. Integrated care has the ambition to meet the needs of older people with long-standing multiple problems. However, it is not the one solution for all problems. Effective types of structures and strategies of integration depend on the type of integration problem involved and the phase of the process of developing integrated care. Management interventions can be directed to different levels of care provision: the individual client, care organisations and networks, and the interaction with the care system. Integration may focus on two main dimensions: sequential and simultaneous. These have to be connected to relevant processes of control or administration. Therefore, care pathways are integrated strategies of care for a specific user group based on guidelines and evidence. They determine locally agreed, multi-disciplinary practice and the ideal sequence and timing of interventions in terms of chain management, which reflects a strategy of managing care pathways, guaranteeing continuity of care, safeguarding best quality of care, appropriate use of resources and managing the provision of care.




Search Strategy

Thus, because the Web is not indexed in a normal approach, finding information can seem difficult. Search engines are popular tools for locating web pages, but they often return thousands of results. Search engines crawl the Web and log the words from the web pages they find in their databases as some search engines have logged the words from several documents, results can be overwhelming. Without a clear search strategy, using a search engine is like wandering aimlessly in the stacks of a library trying to find a particular book. Successful searching for this paper involves two key steps, one this implies a clear understanding of how the content information search was being prepared. This incorporates various search tools available in forms of websites, journal, peer-reviewed articles as well as books like for example, search engines such as high beam, questia and proquest respectively as the application for the search strategies supporting this proposal pointing towards integrated care plan and management for stroke patients could be reflected in terms of its reliability, spontaneity and accuracy of information features for the quality stance of its research evidences and its useful implications to the society.




Models and Methods

As mentioned, care pathways have primarily been developed in acute health care and address sequential linking, co-ordination or integration. However, in some countries, public and private bodies have to take research and implementation into account when putting together appropriate solutions based on a good balance between cost and effect because the specific care plan is drawn up according to the requirements of each situational need.

Practice example: Stroke care pathways Page 86

The Dutch Heart Foundation has developed a model for a stroke service, as well as a workbook for those who want to develop such a service. The process is described in three phases:

Ø      Acute phase Acute diagnostics are required and the treatment has to be initiated

Ø      Rehabilitation phase The main objective of this phase is to prevent and reduce the chance of impairments and disabilities

Ø      Chronic phase The onset of this phase is identified when it becomes clear what will be the remaining impairments and disabilities

Sources: Carlier et al (1999), Verschoor et al (2004)


Also, one model of using care pathways is to consider the responsibilities at local or regional levels. A single entry point, as well as distinct roles of general practitioners, social workers, and other professionals who may have a role as gatekeeper to the system, are prerequisites to guide people through the system. There is a model for the sequence of multiple decisions that are to be made along three lines throughout the decision-making process. The left-hand column relates to the healthcare decision process. The right-hand column represents the social care decision process. The middle column represents the integrated care line. This can start as an integrated process from the beginning, or it can be suggested or promoted by the client's general practitioner or social worker, as soon as they understand that the complex needs requires integrated care.









Common access as a premise for different care pathways

Page 87


Source of the above data: EHMA online publications (2004) Integrating Services for Older People: A resource book for managers

Retrieved at:




The above figure starts from the point that the client enters the system, moves on to the integrated needs assessment, which is used to find out what can and should be done, and finally shows actual service delivery. The client's needs must be fully considered, and the care that is provided should be comprehensive. Care providers and authorities have to be explicit about which steps they will follow. Each older person will follow a different pathway and move among different providers, according to the nature and the development of their needs. However, the preferred situation is for the care providers to move towards the client. Whether this is possible depends on the system: how far professional care in the community is developed, and how far institutional services go in providing outreach activities. It is important to think in terms of location and interfaces. 'Location' refers to the place and setting in which the care plan is implemented (such as the home or hospital) and 'interface' refers to the collaboration and links between the places and settings in which the care plan is delivered.







Integrated care pathways map

Page 88


Source of the above data: EHMA online publications (2004) Integrating Services for Older People: A resource book for managers

Retrieved at:



The map identifies at least six critical areas for better defining need-related pathways. Each one is different because of the location in which the care is offered and because of the nature of its interfaces. The way in which these locations and interfaces are connected – by means of a care pathway – depends on the characteristics of the particular need group or user group, as well as the welfare system in which the system is operating


General pathways for stroke care





Note: numbers relate to corresponding points in Practice example: Guidelines for stroke prevention and treatment, pp 90–91

Source of the above data: EHMA online publications (2004) Integrating Services for Older People: A resource book for managers

Retrieved at:



Ethical issues

The ethical issues relating to integrated care of older people relate to the tension between empowerment and the client's individual rights on the one hand, and the rules and regulations of the 'system' on the other (Defever 2002).

Empowerment – If the older person makes a choice about a service that appears to be 'unsuitable', from a professional's viewpoint, this can cause a great moral and ethical dilemma, which needs to be managed sensitively and appropriately.

Freedom of choice – As opposed to consensus-based care pathways, freedom of choice can be idealistic and often not cost-effective. If a patient chooses a care pathway that results in an increase in public expenditure, the chances are that freedom of choice is actually not part of the equation at all, and may lead to shortages of care provision to other clients.

Patient privacy – The limitations of privacy are challenged by the issue of client information flows. It is important to note that client consent at an early stage may not be valid for the entire process of care provision.

Risk management – This becomes an issue when considering who is responsible for the risks involved in care provision: the client or the care providers with joint responsibilities.

Prioritisation of the target group – The notion of risk can be taken a step further when we look at the prioritisation of the target group for integrated care services.


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