Improving integrated care for older people with frailty and their carers: An ethnographic study of medicines-related care within an integrated care pa

背景综合护理路径(ICP)是“本地开发的多学科基础设施技术，它映射了临床轨迹中的核心干预措施，同时也是一个工作流系统和护理记录”(Allen 2014：808)。ICPS已被广泛用于提高各种健康状况患者的护理质量和公平性。它们已被提议作为临床治理的工具(Degling等人，2005年)，将循证指南嵌入临床实践(Allen，2014)，以及卫生保健政策。然而，有限的社会科学研究侧重于从不同利益相关者的角度批判性地理解ICP的作用、价值和影响，以及影响其产生、发展和实践的社会、组织、政治-经济和历史背景。这项博士研究将在伦敦南部兰贝斯和南沃克为虚弱老年人提供ICP的背景下探索这些问题。虚弱的老年人是健康和社会护理服务的高使用者，但报告难以有效和协调地接受护理，并且由于服务提供分散，接受护理质量差的风险很高(Ament等人，2014年)。尽管英国当地正在为虚弱老年人制定、评估和委托实施若干ICP，但对不同利益攸关方对ICP的好处、局限性和意想不到的后果的看法，以及在实践中影响其制定和实施的背景，人们知之甚少。目的1)研究社会、组织、政治、经济和历史背景对体弱老年人ICP的产生、发展和实施的影响；2)探讨目前在伦敦南部兰贝斯和南沃克地区如何为体弱老年人提供和实施ICP；3)探讨体弱老年人及其家庭照顾者以及不同的提供者和组织利益相关者如何看待ICP，包括其作用、价值、限制和影响。4)综合来自1-3的知识，共同设计更明确的路径，并提供一个框架，以促进实施ICP，满足对虚弱老年人至关重要的需求，并改善伦敦南部兰贝斯和南沃克虚弱老年人的护理质量和结果。方法：本研究将采用混合方法设计：1)对医疗保健政策的系谱分析，包括历史和政治经济话语、实践和背景对虚弱老年人ICP的形成形成的影响。2)一项人种学研究，探索目前如何在伦敦南部的兰贝斯和南沃克为虚弱的老年人提供ICP。这将涉及对虚弱老年人及其家庭成员在卫生和护理系统中导航时的护理做法的抽样观察，对护理记录的分析，对参与者和参与护理的专业人员的访谈，以及路径图。3)随后将通过与一系列利益攸关方的一系列小组研讨会应用共同设计方法，以制定更明确的途径和框架，以促进实施方案方案，以改善体弱老年人的护理质量和结果。参考文献艾伦·D.(2014)在翻译中丢失了吗？综合护理路径中的“证据”与制度逻辑的表达：从积极到消极的边界对象？健康与疾病社会学，36，6：807-822。Ament B，de Vugt M，Vereh F，Kempen G.(2014)如果身体虚弱的老年人也患有认知、社会和心理上的脆弱，他们是否更有可能出现不良后果？《欧洲老龄杂志》，11：213-219。戴格灵，S，利迪，R.(2004年)重组临床治理以最大限度地发挥发展潜力。《灰色A》，哈里森·S主编《治医：理论与实践》。牛津：牛津大学出版社。

BackgroundIntegrated care pathways (ICPs) are 'locally developed, multidisciplinary infrastructural technologies that map core interventions in a clinical trajectory and are simultaneously a workflow system and a record of care' (Allen 2014: 808). ICPs have been widely used to improve quality and equity of care for patients with a range of health conditions. They have been proposed as a vehicle for clinical governance (Degeling et al 2005), embedding evidence based guidelines into clinical practice (Allen 2014), and health care policy. However, there has been limited social science research focusing on a critical understanding of the role, value and implications of ICPs from different stakeholder perspectives, and the social, organisational, politico-economic and historical contexts shaping their emergence, development and implementation in practice.This PhD study will explore these issues in the context of ICPs for frail older people in Lambeth and Southwark, South London. Frail older are high users of health and social care services, but report difficulties receiving care efficiently and in a coordinated manner, and are at high risk of receiving poor quality of care due to fragmented service provision (Ament et al 2014). Although a number of ICPs for frail older people are being developed, evaluated and commissioned locally in the UK, little is known about different stakeholders' perspectives of the benefits, limitations and unintended consequences of ICPs, and the contexts shaping their development and implementation in practice. Aims 1) To examine the social, organisational, politico-economic and historical contexts shaping the emergence, development and implementation of ICPs for frail older people; 2) To explore how ICPs for frail older people in Lambeth and Southwark, South London are currently being delivered and implemented on the ground; 3) To explore how frail older people and their family carers, and different provider and organisational stakeholders perceive ICPs, including their role, value, limitations and implications. 4) To synthesise knowledge from 1-3 to co-design clearer pathways and inform a framework to facilitate the implementation of ICPs, that meet the needs of what is important to frail older people, and improve quality of care and outcomes for frail older people in Lambeth and Southwark, South London. Methods The study will use a mixed-methods design: 1) A genealogical analysis of health care policy of the historical and politico-economic discourses, practices and contexts shaping the emergence of ICPs for frail older people. 2) An ethnographic study to explore how ICPs for frail older people in Lambeth and Southwark, South London are currently delivered locally. This will involve observations of care practices with a sample of frail older people and their family members as they navigate the health and care system, analysis of care records, interviews with participants and professionals involved in their care and pathway mapping. 3) Co-design methodology will subsequently be applied through a series of group workshops with a range of stakeholders to develop clearer pathways and a framework to facilitate the implementation of ICPs to improve quality of care and outcomes for frail older people. References Allen D. (2014) Lost in translation? 'Evidence' and the articulation of institutional logics in integrated care pathways: from positive to negative boundary object? Sociology of Health & Illness, 36, 6: 807- 822. Ament B, de Vugt M, Verhey F, Kempen G. (2014) Are physically frail older persons more at risk of adverse outcomes if they also suffer from cognitive, social and psychological frailty? European Journal of Ageing, 11: 213-219. Degeling P, Maxwell S, Ledema, R. (2004) Restructuring clinical governance to maximise developmental potential. In Gray A, Harrison S (eds) Governing Medicine: Theory and Practice. Oxford: Oxford University Press.