New and emerging trends of integrated care for frail elderly in Norway: A pilot
horizon scanning review
Student: Ashwanee A Supervisor: Eli Feiring
HMM4501 Master thesis 30 credits
Institute of Health and Society Faculty of Medicine
1.6.2021 (Spring 2021)
Abstract
This study is reported as an article-based master thesis consisting of two parts: an extended summary and an article manuscript.
Background: The rising prevalence of frailty among the elderly population has resulted in health systems worldwide, Norway included, struggling to provide quality healthcare services. An increase in longevity is often accompanied by a larger share of a frail elderly person’s life being spent with disability. The present fragmented, facility-focused, physician-based and disease-centric healthcare delivery models have been deemed unsustainable to address the complex needs of the frail elderly. Therefore, there is a need for new integrated care models and interventions to improve the coordination of services between the
specialist and municipality healthcare services for the frail elderly and provide better continuity of care.
Objectives: The overall aim of the study was to use horizon scanning to identify and evaluate emerging integrated care models and interventions for the frail elderly, as well as assess the horizon scanning approach. The sub-objectives consisted of addressing system fragmentation and lack of coordination present in current services directed at the frail elderly. Secondly, providing early information on new models and interventions of integrated care. Thirdly, recognising the need and perceived possible challenges in the introduction of these new models and interventions of integrated care in the Norwegian context and lastly establishing if horizon scanning was a fruitful tool for helping policy decision-making.
Methods: The study adopted the horizon scanning methodology. The systematic process started with the identification of frailty specific integrated care models and interventions with the use of predefined search terms, online databases and other relevant sources. These were then filtered and prioritised according to pre-set criteria. The last step of this methodology was assessment of the chosen integrated care models and interventions based on three aspects; innovativeness, impact and implementation. This was conducted through a semi-structured focus group interview with 7 experts. The experts also evaluated the horizon scanning method for its fruitfulness in aiding policy decision making.
Results: 1179 records were identified of which 605 irrelevant records were filtered based on filtration criteria. 155 duplicate, 134 disease-specific and 181 irrelevant records were removed leaving a total of 104 relevant records. These records consisted of frailty-specific models and interventions and were organised into various themes for better overview. Afterwhich prioritisation criteria were implemented and 5 system-based integrated care models and 4 community-based interventions were then chosen from the relevant records for focus group assessment. The focus group participants discussed and scored each of the nine models and interventions based on innovativeness, impact and implementation. The Walcheren
integrated care model and EuFrailSafe scored highest among the system-based integrated care models and community-based interventions respectively. The participants also stated their opinions of experienced unmet needs and trends of integrated care as well as potential barriers to consider when applying these integrated care models and interventions to the Norwegian health care system. In terms of the evaluation of horizon scanning methodology, the participants were generally positive about the fruitfulness of the method in aiding policy-decision making but had varying opinions on how it should be conducted in practice.
Conclusion: This study conducted a pilot horizon scanning for new and emerging integrated care models and interventions targeted at the frail elderly that have the potential in addressing system fragmentation and improve coordination of care. In addition, the horizon scanning’s assessment phase allowed for discussion around issues such as the need for integrated care as well as the perceived possible challenges of implementation of the discussed models and interventions in the Norwegian context. As a result, horizon scanning has the potential for fostering innovation within healthcare service delivery. Further studies should investigate more into the conduction of the horizon scanning process in a practical setting.
Preface
I would first like to thank my supervisor Eli Feiring for her valuable guidance, constructive feedback and encouragement throughout the thesis process. As this was a pilot study done in covide-times, it has been an exciting and challenging journey and I am very grateful for your positivity and support. In addition, I would also like to thank my interviewees and my co-supervisor Gloria Traina for taking their time to share their insights and experiences regarding the research topic.
Table of content Page
Abstract 1-2
Preface 3
List of tables (extended summary)
Table 1: Author’s own representation of information source types Table 2: Author’s own representation of filtration guidelines Table 3: Author’s own representation of prioritisation criteria
Table 4: Author’s own representation of strengths and limitations of focus group interviews
29 30 31 32
List of figures (extended summary)
Figure 1: The frailty cycle. Key interacting processes leading to further deterioration Figure 2: Variables of the Fried model of frailty phenotype
Figure 3: Sample items from a 70-item frailty index developed in CSHA study Figure 4: The standard comprehensive geratric assessment
Figure 5: Typology of healthcare integration Figure 6: Continuum of integration
Figure 7: Author’s own representation of integrated care models Figure 8: Intuitive logics process as part of scenario planning Figure 9: Weak signals gathered by horizon scanning process
Figure 10: Foresight Cycle in policy making including horizon scanning Figure 11: Horizon scanning process
15 16 17 18 20 20 22 24 25 26 28 Appendices
Appendix A: Interview agenda and questions
80-84 80-82
Appendix B: Information on chosen system-based integrated care models and community-based interventions
83-84
Extended summary 1. Introduction
1.1 Norwegian healthcare system and their current integrated care approaches 1.2 Prevalence of frailty in Norway
1.3 Challenges with frailty
1.4 Causes and consequences of system fragmentation 1.5 The need for an integrated care approach
2. Previous research
2.1 Frailty in a global context
2.2 Existing research on current frailty models 2.3 Existing research on frailty assessment methods 3. Theoretical framework
3.1 Integrated care
3.1.1 Dimensions of integration 3.1.2 Degrees of integration 4. Method and data
4.1 Horizon scanning
4.1.1 Theoretical concepts and background 4.1.2 Practical applications
4.1.3 A systematic process
4.2 Review of unpublished and published literature 4.2.1 Identification: Information source categories
4.2.2 Identification: Scanning Information Sources Selection
8-13 8 10 11 12 12 14-18
14 15 17 19-22
19 19 20 23-34
23 24 25 27 29 29 30
4.2.3 Filtration methods 4.2.4 Prioritisation methods
4.3 Assessment: Semi-structured focus group interview 4.3.1 The use of focus groups in horizon scanning 4.3.2 Strengths and limitations of focus group interviews
4.3.3 Key considerations: focus group interview preparation and execution 5. Findings
5.1 Review of unpublished and published literature 5.2 Semi-structured focus group interview
6. Discussion
6.1 Integrated models and interventions 6.2 Horizon scanning a fruitful method?
6.2.1 Participants’ reflections
6.2.2 Horizon scanning of new healthcare delivery models in Norway 6.3 Limitations and Recommendations
7. Conclusion
30 31 31 32 32 33 35 35 35 36-38
36 37 37 37 38 39
Reference list for extended summary 40-48
Article manuscript 1. Abstract 2. Introduction 3. Methods
3.1 Identification 3.2 Filtration 3.3 Prioritisation 3.4 Assessment
49-50 51-52 53-58
53 55 55 56
4. Results
4.1 Findings from review of unpublished and published literature 4.2 Findings from focus group interview
4.2.1 Integrated models/interventions 4.2.1.1 Quantitative scores
4.2.1.2 Qualitative findings 4.2.1.3 Qualitative assessment
4.2.2 Horizon scanning: Assessment of method 4.2.2.1 Current decision making processes
4.2.2.2 Horizon scanning as a decision making tool 5. Discussion
5.1 Integrated models and interventions 5.2 Horizon scanning a fruitful method?
5.3 Limitations and Recommendations 6. Conclusion
58-70 58 61 62 62 63 66 67 67 68 70-73
70 71 72 73
Reference list for article manuscript 74-79
Total number of words for extended summary:9223 Total number of words for article:6693
Extended summary 1 Introduction
The rising prevalence of frailty resulting in increased healthcare resource utilisation and system
fragmentation issues have placed added pressure on decision makers in the health sector to think of new ways to deliver healthcare services to meet the complex needs of the frail population.The study provided an opportunity to conduct and evaluate the horizon scanning methodology so as to determine its ability in helping decision-makers in the healthcare sector to fill in knowledge gaps, address current service delivery challenges, and contribute to innovation of health services.The horizon scanning process was conducted through identifying, filtering and prioritising relevant integrated care models/intervention sources from various databases following pre-set criteria and search terms. The evaluation of the prioritised integrated care models/interventions as well as the horizon scanning methodology was conducted through a semi-structured focus group interview with a panel of experts.
The extended summary was aimed to provide comprehensive theoretical statements and more in-depth discussions on frailty, healthcare service delivery issues, integrated care and horizon scanning
methodology. In addition, horizon scanning methodology criticism, practical and ethical issues, critical reflections on results generated from the horizon scan search and semi-structured focus group interview as well as limitations and recommendations of the study has been discussed here.
To allow for these themes to be discussed with relation to the Norwegian context, the extended summary began with a description of the Norwegian healthcare system.
1.1 Norwegian healthcare system and their current integrated care approaches
The ideals of equal access, decentralization, and free provider choice underpin the Norwegian healthcare system. It is based on the Nordic model of healthcare which consists of the following features: mainly financed by taxes, a decentralized public governance system, taxable elected local councils, public ownership of the distribution structure, social and geographical equity driven and public engagement (Magnussen, 2009).
Although health-care policy is centralized, accountability for health-care delivery is decentralized.
Specialist care is the responsibility of the state, while primary health care, long-term care, and social services are the responsibility of municipalities.The delivery of specialist care by health trusts is under the jurisdiction of the four regional health authorities (RHAs) which are also owned by the state. The national
insurance system (Folketrygden, NIS), operated by the Norwegian Health Economics Government (Helseøkonomiforvaltningen, HELFO), protects all citizens. The use of private medical insurance is minimal. Every Norwegian citizen is given the option of selecting a general practitioner (GP) from a public registry. These outpatient physicians operate as gatekeepers of specialized care (Norwegian Medicines Agency, 2016).
In terms of financing, hospitals are funded by a mix of block grants and activity-based funding, with health workers receiving a set wage. Municipality provided health and social services are largely funded by the government and delivered by public actors despite the fact that private companies are becoming more prevalent. GPs are paid partly through capitation, based on the number of patients on their waiting list and partly through fee-for-service (Steihaug et al., 2016).
Between 2016 and 2070, government healthcare expenditure as a percentage of Gross Domestic Product (GDP) was reported to increase by 1.2 percentage points, outpacing the European Union’s (EU) 0.9 percentage point average rise. This was due to the rising prevalence of chronic conditions linked to aging populations which was anticipated to place additional strain on the public budget. Forecasts indicated that public expenditures on long-term care in Norway will rise by 3.4 percentage points of GDP, faster than in any other EU nation. Thus, it is a primary concern for the Norwegian government to devise ways to adapt efficiently to the rising demands for health and long-term care in the coming years while securing the system's long-term fiscal sustainability (Organisation for Economic Co-operation and Development &
European Observatory on Health Systems and Policies, 2019)
Policies to enhance care coordination in Norway include the Coordination Reform 2012 where the primary aim was to ensure that patients got adequate care at the appropriate time and place. This resulted in municipalities becoming in charge of providing 24/7 local emergency care services for those in need of pre-or post hospital care. Another example would be the development of primary care facilities through multidisciplinary care GP-led teams where the treatment and follow-up of chronically ill patients are now more patient-centered such that they would be able to live at home longer as well as minimize
hospitalization and nursing home admission. Furthermore, there has been more emphasis on municipal governments and general practitioners to be in charge of public health promotion. The Norwegian Organization of Local and Regional Authorities (KS) is in charge of establishing strategic plans and resources to help municipalities carry through local public health initiatives (Organisation for Economic Co-operation and Development & European Observatory on Health Systems and Policies, 2019). These initiatives are important to take into account when assessing integrated care measures targeted at the frail.
Despite shifting care responsibilities from inpatient to outpatient settings to reduce hospital admissions and increase access to services within the municipalities, challenges such as strengthening coordination, ensuring quality of care and consistent information flows between hospitals and municipalities persists.
Delayed hospital discharges and readmissions of newly discharged patients are occurring especially among the frail as many municipalities lack the capacity to offer adequate treatment and follow up care for them (Organisation for Economic Co-operation and Development & European Observatory on Health Systems and Policies, 2019). The lack of followup for the frail can be also related to the fact that the Norwegian healthcare services are split between two tiers of governance. The question of where accountability for one service stops and responsibility for another starts is still being debated. Hospitals (secondary) and municipalities (primary) each have incentives to move patients between each other (Tjerbo & Kjekshus, 2005).
Therefore, for the Norwegian healthcare system to ensure integrated services are provided to the frail, certain key questions have to be addressed. These include, among others, “what are the measures that help to avoid or postpone the development of frailty and/or help the elderly cope with frailty?”, “what are the key components of these measures?”, “what is needed for implementation?” as well as “what are the potential outcomes after adopting a measure?” (Hendry et al., 2018).
By doing a horizon scan for integrated care models and interventions targeted at the frail, the goal was to bridge the gap between what's already out there and what is coming via theory and shared expertise and- with that offer options and guidance to policy makers on what they could do to enhance the quality of integrated health services for the Norwegian frail elderly.
1.2 Prevalence of frailty in Norway
In less than ten years, Norway will have far more elderly people than kids and adolescents for the very first time. The number of people aged 70 and above was estimated to double from 670,000 today to 1.4 million by 2060. In line with the global trend of ageing populations, the growth in the 80-plus population would be much greater, with the 80-plus population projected to be three times bigger by 2060 (from 230,000 to 720,000), while the 90-plus population was set to increase nearly five times its current size (from 45,000 to 210,000). Life expectancy was also projected to rise by 8 years for men and 6 years for women by 2060 (Thomas & Syse, 2020).
The prevalence of frailty among community dwelling Norwegian elderly was estimated to be ranging from 14 to 24%. As there are many varying definitions of frailty and no agreed upon approach to
measuring frailty, this figure was considered only an ambiguous estimate. Despite that, one can be certain
that this figure is expected to rise as a result of increase in longevity especially among those aged 80 and above. Due to the fact that frail elderly have increased vulnerability and generalised functional decline in multiple physiological systems, relatively small stress incidents such as an infection can significantly affect one’s ability to live independently and carry out the activities of daily living (ADL). It was also reported that 3 to 5% of deaths among the elderly could have been postponed by preventing frailty.
Therefore, it is of utmost importance that the frail elderly persons are identified in time (Husebø et al., 2017).
Frailty has also been proven to be associated with increased healthcare resource utilisation and costs (Bock et al., 2016). Hajek et al.(2017) reported that the transition from non-frailty to frailty was correlated with a rise of 54 to 101 percent in overall healthcare expenses. If frailty is identified early and appropriate treatment strategies are implemented, adverse outcomes such as falls, institutionalization and mortality as well as high healthcare expenses can be avoided (Boyd et al., 2005).
1.3 Challenges with frailty
Despite frailty being described as an emerging concern for public health globally, there are currently no standardised guidelines for identifying the frail among the Norwegian elderly population. This is partly due to the fact that frailty is difficult to define and that there is no clinical consensus on which approach should be used to test frailty. Furthermore, there is a lack of awareness of the prevalence of frailty and the need for identifying frailty in time as well as the possible societal health economic implications as a result of unmet needs of the frail elderly population (Norwegian Institute of Public Health, 2018).
The frail elderly person’s needs are complex and thus, they are often in need of services from both the specialist as well as the community (Hoeck et al., 2011). This is key to prevent disease exacerbation, acute hospital admissions and unwanted readmissions which can be experienced as very stressful for the frail and in fact worsen their health status. It was reported that 20% of the frail elderly that have been critically admitted to the hospital are at risk of readmission within 30 days. These readmissions have significant personal and economic implications for the frail patients and their families (Andreasen et al., 2015). It is therefore vital for the presence of effective collaboration where the specialist and community care service providers share information and provide holistic care to each frail patient.
In addition, it would be beneficial if the frail patients had easy access to healthcare from where they live.
This would require the specialist health service providers to support the municipal health and care
services either through outpatient or virtual services. Currently, these patients are referred by their general practitioner to nursing and home care services from the municipality and are admitted to the hospital only
when in need of specialist care services such as emergency care (Norway Ministry of Health and Care Services, 2019).
1.4 Causes and consequences of system fragmentation
In addition to the two-tiers of governance in the Norwegian healthcare system, the specialist health services tend to focus mainly on medical healing while the municipal health services focus mostly on the patient’s functional capabilities has led to little interaction between the two types of services. As a result, the Norwegian healthcare system is faced with challenges pertaining to system fragmentation, lack of coordination as well as inefficient use of resources (Norway Ministry of Health and Care Services, 2009).
Apart from a need for better collaboration between the municipal and specialist health care providers, system fragmentation causes can also be linked to other reasons. These include disease-focused models of care, increased specialised services, referrals that take long time to process, poor exchange of knowledge among health workers as a result of not having a shared electronic health record, insufficient staff numbers, lack of guidelines and accountability for care management, absence of professional expertise regarding the patient's health condition, lack of clarity with regards to health personnel's duties and responsibilities as well as a failure in offering updates to patients and their families, along with preparing them for future care transfers (Storm & Wiig, 2018).
1.5 The need for an integrated care approach
The causes of system fragmentation stated above are complex and challenging to tackle especially since the frail elderly population are highly dependent on receiving healthcare services from both the
community and specialist care services. It is essential that healthcare services are integrated as system fragmentation can often lead to elevated risk of mortality and a range of negative health effects, such as falls and injuries, many of which can lead to a lower quality of life and a rise in medical expenses and healthcare utilization, such as emergency room visits, hospital admissions, and institutionalization into nursing homes/care centers. Given the multifaceted and heterogeneous nature of frailty, as well as the diverse care needs of the frail, an integrative coordinated approach involving various stakeholders such as physicians, politicians, caregivers and the frail people themselves is a vital measure required to enhance their health and well-being as well as prevent adverse outcomes (Kojima et al., 2019).
The introduction of integrated care for the frail elderly has received considerable attention as a means to tackle system fragmentation as well as enhance cooperation between service providers. There is
widespread belief that integrated services increase satisfaction, quality of life, efficacy, patient outcomes,
as well as minimize costs (Ganz et al., 2008). This is mainly due to the fact that a sole service provider is unable to cater to the frail elderly person’s multiple needs. To address the various needs of the vulnerable elderly in an efficient and productive way, the service providers would have to align their efforts in a cohesive manner (Glendinning, 2003).
As a result, the following objectives guided this research. Firstly, to provide policy makers and
stakeholders with service delivery alternatives they can introduce and locally adapt so as to tackle system fragmentation and lack of coordination. Secondly, to provide early information on emerging integrated care models and interventions tailored to the needs of the frail elderly. Thirdly, to recognise the need and perceived possible challenges in the introduction of these measures in the Norwegian healthcare system and as well as determine whether horizon scanning can aid policy decision-making.
The horizon scanning methodology was used to achieve these objectives, which included a review of unpublished and published material as well as a semi-structured expert focus group interview.
2 Previous research
The next sections provide a more extensive overview of frailty in a global context, existing research on current frailty models, and finally existing research on frailty assessment methods in order to better understand frailty.
2.1 Frailty in a global context
The dawn of the 21st century has seen an accelerating rise in ageing populations. According to the United Nations (2019) report on World Population Prospects, 1.05 billion people which comprises about 13% of the world population are aged 60 years and older. By 2100, this figure was estimated to grow to 3.07 billion. When assessing ageing populations, it is often vital to differentiate between the old and the oldest old. The oldest old is variously defined as people aged 80 or 85 years old and above, with multiple chronic diseases that require long term care. In several countries, they made up the quickest growing portion of the total population. Globally, the oldest old population was estimated to increase 151 percent between 2005 and 2030 as compared to a 104 percent increase for those aged 65 and above (Dobriansky et al., 2007). It was estimated that 23% of the oldest old are frail (Sharma et al., 2020).
The rapid increase in life expectancy can be accredited to various reasons such as lower infant mortality, access to vaccinations at an early age, better nutrition and lifestyle choices, safer and cleaner living accommodations as well as advancements in medical technology, care and research. As a result, some might argue that as life expectancy increases, the prevalence of disability reduces, also termed as
“compression of morbidity”. On the other hand, others have pointed out that medical advancements have only delayed the onset of disability, meaning the additional life years are spent in poor health leading to a
“expansion of morbidity” (Suzman & Beard, 2011). The rise of non-communicable diseases coupled with multi-morbidity and frailty has therefore posed challenges to various single illness-focused healthcare systems worldwide to rethink their policy making decisions and reevaluate their healthcare expenditures so that the holistic needs of the old and the oldest old are met.
According to the World Health Organisation, successful ageing is not merely the absence of disease.
Intrinsic capacity is a measure of the body’s physiological reserve and maintaining this functional
capability is of the utmost importance. The biggest costs to societies would be if healthcare systems fail to make the necessary adaptations and investments to encourage the maintenance of functional capability among the aged (Beard et al., 2016). Frailty and preserving functional capability are seen as two sides of the same coin one must consider when it comes to successful ageing (Woo et al., 2016).
Frailty has multiple definitions and as a result it may be challenging to identify early and to know it’s prevalence in a population. Generally, it is defined as a geriatric syndrome where there is heightened susceptibility to inadequate return of homeostasis following a stress-induced incident. The common clinical aspects of frailty include severe exhaustion, unusual loss of weight, recurrent infection, impairment of posture and gait as well as fluctuating awareness and disability. Frailty is a result of cumulative functional loss in multiple physiological systems over a lifetime. This accumulated deterioration in the body weakens the homeostatic reserve such that fairly minor stressors trigger significant changes in health status. Therefore, failure to recognise and diagnose frailty early can
ultimately lead patients to treatments that do not help them and thus may harm them (Cesari et al., 2017).
Figure 1: The frailty cycle. Key interacting processes leading to further deterioration (Clegg & Young, 2011)
2.2 Existing research on current frailty models
There are primarily two principal frailty models; the phenotype model and the cumulative deficit model.
The phenotype model (PF) obtained from a prospective cohort study (the Cardiovascular Health Study) has five variables: unintended weight loss, self-reported fatigue, reduced energy expenditure; slowness in gait speed and poor grip strength. People were considered frail with three of the five variables, one or two variables were considered pre-frail, and no variables were considered to be healthy elderly. The elderly
had to be over 65 years old (Fried et al., 2001). Despite being a validated model to define frailty, an important limitation was the absence of other vital variables such as cognitive impairment, a fairly prevalent problem correlated with diminished function and disability among the frail elderly (Rothman et al., 2008).
Figure 2: Variables of the Fried model of frailty phenotype (Lally & Crome, 2007)
The cumulative deficit model using the frailty index (FI) adopted from the Canadian Study of Health and Aging (CSHA) involves a health assessment where the frailty index is obtained after counting the number of health deficits present in the individual and dividing it by the total number of health deficit variables in relation to frailty. The higher the frailty index score came to 1, the greater the frailty. More specifically, the index was used to decide if an individual was robust (ratio of 0-0.12), prefrail (ratio of 0.13-0.43), or frail (ratio of 0.44). The assessment also included irregular laboratory results, pathological conditions (Mitnitski et al., 2001). Thus, while each single deficit does not pose an apparent or immediate mortality danger (e.g. hearing dysfunction), the combined deficits lead to an increased risk of death. This is in line with the increased susceptibility and danger of potential homeostatic breakdown that is vital to the principle of frailty. Nonetheless, even with statistical convergence and overlap, the cumulative FI model of deficit accumulation presented greater discrimination for individuals with frailty than to the categorical PF model. Some data suggested the FI method could substantially classify the mortality risk for the elderly people, despite being more time-consuming, whereas the PF measure obtained non-significant results (Rockwood, 2005).
Figure 3: Sample items from a 70-item frailty index developed in CSHA study (Rockwood et al., 2001) 2.3 Existing research on frailty assessment methods
Globally, the most preferred method used to identify and assess frailty is the comprehensive geriatric assessment (CGA). It is an interdisciplinary diagnostic tool to assess the medical, psychological and functional capacity of an elderly person to establish a medical and follow-up plan (Rubenstein et al., 1991). Other instruments that have been used to identify frailty involve questionnaires such as the Frail elderly functional questionnaire, the Groningen frailty indicator and the Tilburg frailty indicator. The timed-up-and-go test (TUGT) has been used for calculating gait speed. The Edmonton frail scale is a multi-dimensional evaluation tool which includes measurement of cognitive disability (Cesari et al., 2017).
Interventions based on these diagnostic tools have increased the likelihood for the frail elderly patients to live in the community independently. Despite the fact that recognising frailty by using these current frailty assessment tools is challenging as they do require further investigation in terms of diagnostic accuracy, validation and practical implementation in clinical settings (Cesari et al., 2017), when implemented, the frail have been reported to be less prone to having further cognitive or physical deterioration, falls as well as hospital admissions (Beswick et al., 2008).
Figure 4: The standard comprehensive geratric assessment (Rockwood et al., 1998)
Despite information on frailty principal models and assessment methods as well as frailty emerging as a public health issue, most healthcare systems throughout the world, Norway included, are built on the disease-based critical care model for handling acute and defined disease events, and thus are insufficient to face the demands brought by the new era of multiple interrelated chronic conditions and the associated complexities of the frailty syndrome (Cesari et al., 2016).
To focus only on the illness, deviates from encouraging elderly people to really get the care they need to boost their functionality regardless of the broad range of health problems they might have.This serves as a catalyst for the recent discussion around the usefulness of the frailty principle in guiding the
implementation of healthcare plans targeted at the frail. Health services should be reshaped and revamped to be integrated as well as patient-centered so as to be sustainable in the long term and effectively address the unmet needs of vulnerable older people (Woo, 2017).
3 Theoretical framework
Aspects of integrated care are discussed here because it is critical to understand how integrated care measures can be classified and implemented in the Norwegian context so that they meet the needs of the frail elderly in Norway.
3.1 Integrated care
Integrated care has multiple definitions depending on the perspective one takes. It can be overall defined as a ‘well-planned and well-organized collection of treatments and care plans, aimed at multidimensional needs/problems of an individual or group of individuals with similar needs/problems' (Vestjens et al., 2018). According to the World Health Organization (2015) integrated care would make health systems more responsive to the needs of frail elderly. Patient-centeredness and continuity are the two primary aspects of integrated care. First, integrated care is demand-driven, with clinicians from various sectors meeting the needs of the patient. Second, integrated care seeks to ensure continuity: a range of services are offered in a consistent, systematic manner, and in response to clients' evolving needs over time (van der Heide et al., 2018).
3.1.1 Dimensions of integration
Evidence indicates that moving toward integrated care necessitates a detailed knowledge of the different facets of integration. Integrated care can be organised according to type, level, process, breadth and degree. In terms of type, there are generally four types;organizational, functional, service and clinical.
Organisationalrefers to bringing together organisations systematically by service networks and mergers.
Non-clinical and back-office tasks, such as integrated electronic medical records, are examples of functionalintegration.Serviceintegration is the process of combining multiple health services at an institutional level, such as by creating multidisciplinary teams.Clinicalintegration is the method of integrating treatment into a standardized, cohesive process within/or across professions through the use of common standards and protocols (World Health Organisation, 2016).
In addition there isnormativeandsystemicintegration.Normativeintegration, which promotes trust and cooperation in the delivery of health care by cultivating a common culture of shared values and a focus towards improving coordination.Systemicintegration refers to the consistency of rules and regulations across all levels of an organization. This is sometimes referred to as an "integrated delivery system" (ISD) (Fulop, 2002).
Figure 5: Typology of healthcare integration (The NHS Confederation, 2005)
In terms of integrated care forms, they are generally categorised byhorizontalorvertical.Horizontal integrationhappens when services from different organisations that are at the same stage of the service delivery are brought together, for example mergers of acute hospitals. Whilevertical integrationputs organizations at various hierarchy levels into one management umbrella, for example by combining specialised and community care. Any of the aforementioned integration processes may take place in a physical or virtual environment. The first is characterized by organizational mergers such as sharing of infrastructure, while contractual agreements is an example of the latter (Staňková et al., 2020).
In terms of level/breadth,micro-levelintegration focuses on the individual so that a consistent treatment experience is achieved, for example, by customized care plans.Meso-levelintegration strives to provide comprehensive treatment for a specific care community or groups with related diseases or conditions. At themacro-level, integration can be regarded as providing comprehensive treatment to an overall
population by stratifying needs and customizing services accordingly (Curry & Ham, 2010).
3.1.2 Degree of integration
The degree of integration is described in terms of a continuum; full segregation, linkage, coordination in networks, cooperation, full integration (Ahgren & Axelsson, 2005).
Figure 6: Continuum of integration (Ahgren & Axelsson, 2005)
Full segregationis the complete opposite of full integration, and it is included in the continuum to serve as a zero-point (Ahgren & Axelsson, 2005).
Linkageis a method of contact between units with the goal of properly referring patients to the
appropriate unit at the appropriate time and maintaining good communication among the professionals involved in vulnerable elderly care. Clinical guidelines and procedures that specify who is responsible for what are types of processes that benefit the frail in this type of integration. Continuity of treatment is encouraged and communication around the vulnerable elderly is improved by establishing a connection between services and clarifying responsibilities (Ahgren & Axelsson, 2005).
Coordination in networkshas a higher level of structure than linkage. This type of integration aims to improve quality of care between different units by coordinating processes and exchanging clinical details.
Care pathways are an illustration of this level of integration, as they connect services in "chains of care"
between organizational units that are still distinctly independent. On this level of integration, a greater flow of services and collaboration around the consumer is present than the linkage level (Ahgren &
Axelsson, 2005).
With a network manager in place,cooperationis a higher degree of collaboration. A case manager is an example of a network manager who oversees the vulnerable elderly person's health and social needs (as well as the needs of the family), and what health and support services are available. This is a type of integration that aims to strengthen the relationships and contacts between the organizational units involved, as the case manager represents the processes for cooperation and coordination between
practitioners and other support resources. As a result, the frail elderly will be followed up on more closely by a holistic approach (Ahgren & Axelsson, 2005).
Full integrationis the most advanced type of integration, in which resources are unified and incorporated into a single physical location. Multiple organizational divisions now work in a single new company with just one entry. Standardizing the entry point to the services, will assist the frail and their caregivers in seeking the right support effectively. Defining the target group and integrating the relevant and required services with a balanced resource distribution is a challenge with this type of integration (Ahgren &
Axelsson, 2005). A centralized point of entry, geriatric evaluations, case management, multidisciplinary teams, multidisciplinary guidelines and meetings, digitalised patient files, and a network framework are all core traits of integrated care models known to be beneficial for the frail elderly (Looman et al., 2016).
Integrated care has multiple definitions and perspectives, and therefore can be complex to comprehend.
The figure below provides an overview of examples of integrated care models in connection with the target group, level and degree of integration.
Figure 7: Author’s own representation of integrated care models with relation to target group, level and degree of integration. Adapted from (Ahgren & Axelsson, 2005; Curry & Ham, 2010; World Health
Organisation, 2016).
It is important to note that the different degrees of integration as stated above can include both vertical and horizontal integration. Furthermore, it is not easy to find out where a model belongs on the integration continuum as it may contain several elements from the different parts of the continuum such as a case manager (cooperation) as well as referrals (linkage). It is also vital to recognize that this continuum of integration says nothing about the best way to integrate various types of healthcare providers. For some providers, the highest level of integration, full integration, may well be worth pursuing, while some are happier with lower levels of integration. High levels of differentiation necessitate high levels of integration. As a result, the various forms of health-care integration should be linked to the demands of the frail elderly, goals, and conditions of integrated care service delivery (Hall et al., 1968).
4 Method and data
With the current healthcare service delivery towards the Norwegian frail elderly population in need for better coordination, it is essential to address critical knowledge gaps regarding the frailty syndrome, frailty models and assessment methods as well as evolving demands of the frail elderly by looking into emerging integrated care models and evaluating their implications for clinical practice such as barriers for implementation and resource allocation.
Therefore, horizon scanning methodology which is a foresight method that focuses on informing policy-and decision-makers by using an exploratory approach to find new interventions as well as persistent problems and trends in health care services for the frail elderly was used in this study.
4.1 Horizon scanning
Horizon scanning (HS) is defined as a method of identifying early signs of potentially significant changes by systematically analyzing possible risks and opportunities, with a focus on emerging technology and its consequences for the situation at hand. (Organisation for Economic Co-operation and Development, 2014). The approach investigates both new and unforeseen issues, long-standing challenges and trends, as well as questions previous assumptions by often conducting an extensive data search on the issue of concern. Informational sources from government departments, scientific communities, databases and journals, among others are often used. Horizon scanning may also be done by a small team of
professionals who are at the forefront of a particular field. They share their insights and expertise in order to scan how emerging innovations can impact the future (United Kingdom government office for science, 2014).
Ultimately, the purpose of using HS is to strengthen policy resilience, resolve policymakers' needs and concerns about emerging problems, recognize market opportunities by predicting customer and societal needs, and prepare society for less anticipated or fast changes (European Commission, 2015). Efforts integrating HS into policy-making processes have been conducted in various countries such as the United Kingdom (United Kingdom government, 2017), Singapore (Tan et al., 2007), the Netherlands (European Environmental Agency, 2011), and Switzerland (Habegger, 2009).
4.1.1 Horizon scanning: Theoretical concepts and background
Horizon scanning originates fromscenario planning (SP), environmental scanning (ES), strategic foresight (SF)andAnsoff’s (1975) theory of weak signals(Holopainen & Toivonen, 2012).
Scenario planning (SP)is a collaborative intuitive logics method as shown below that uses realistic and coherent future narratives to imagine potential future scenarios, explain their consequences, evaluate the logic of long-term plans, strategies, and policies, and, eventually, prepare for imminent change. However, SP may restrict an organization's ability to respond because it allows managers to watch and wait for predetermined events to occur and as a result, they will be unable to recognize and respond to unforeseen changes that have never been anticipated. Furthermore, recent experiences can affect scenario planning, resulting in "recency bias” thus restricting the ability to plan for the future (Holopainen & Toivonen, 2012).
Figure 8: Intuitive logics process as part of scenario planning (Rowe et al., 2017)
Environmental scanning (ES)is sometimes used interchangeably with horizon scanning. It is concerned with tracking and analyzing developments, patterns, opportunities, and risks in an organization's current macro-level climate - i.e., the political, economic, social, technological, natural and legal, and competitive landscape. Since its main purpose is to collect industry-specific and competitive information, ES typically supports short-term decision-making as compared to the long term perspective conducted in horizon scanning (Holopainen & Toivonen, 2012).
Strategic foresight (SF)andAnsoff’s (1975) concept of weak signalsaim to predict future states and recognize emerging patterns early in their development, as well as consider the impact of current
decisions and actions on events in the future. Ansoff stressed the importance of weak signals, arguing that studying strong signals, such as trends and megatrends, was insufficient for developing strategic plans
because they could not cope with potential surprises. As illustrated in the figure below, a 'weak signal' is an undefined, apparently irrelevant signal that has the potential to dramatically impact an organization's goals and objectives, but needs proper interpretation; once correctly interpreted, it becomes an early warning signal. The information seen in a weak signal when it first occurs is quite ambiguous and gradually becomes more detailed, identifying the source of the threat/opportunity, its features, the necessary responses required, and finally the expected outcomes.These various states of information necessitate different responses, ranging from expert opinion in the most ambiguous information state to quantitative predictive models in the most detailed state. Traditional impact analysis methods can be used to analyze the effects of each threat/opportunity. Enhancing the organisation’s awareness of the
threat/opportunity by accurate early interpretation of weak signals through adoption of horizon scanning methodology, increases the firm’s preparedness and flexibility to adapt to sudden changes (Qi & Tapio, 2018).
Figure 9: Weak signals gathered by horizon scanning process (Washida & Yahata, 2020) 4.1.2 Horizon scanning: Practical applications
Since the 1970s, horizon scanning has been increasingly used to help financial, policy, procedure, and research planning in a variety of industries. Within the healthcare sector, horizon scanning has been mainly part of early awareness and alert systems (EAASs) where the aim is to identify, filter, and prioritize current and innovative health technologies, as well as to evaluate or forecast their effect on health states, expenses, society, healthcare sector, and to provide information to decision-makers (Amanatidou et al., 2012). Despite the fact that horizon scanning has been mainly used within the
pharmaceuticals arena, it is becoming more prevalent among policymakers as a systematic approach to promote the early detection and collaborative exploration of emerging problems. This can be viewed as a first step toward the implementation of effective policy measures on a timely basis as there are often long lead times for achieving desired policy outcomes (Konnola et al., 2012).
On a broad level, horizon scanning can be seen as an essential step of the foresight cycle model required for making policy-making decisions developed by the European Forum for Forward-Looking Activities (EFFLA). As shown in the figure below, horizon scanning is an important part ofStrategic Intelligence (phase 1).Strategic Intelligencegathering entails scouring for "future information" from a range of sources. Information about the current situation’s issues to be solved is often required as a point of reference. Horizon scanning is also closely related toSense making(phase 2) where the focus is on evaluation of whether the information retrieved from the search process fulfills a set of criteria determined by the researcher (Cuhls, 2020)
Figure 10: Foresight Cycle in policy making including horizon scanning (Cuhls, 2020) 4.1.3 Horizon scanning: A systematic process
Horizon scanning has varying definitions and thus the steps in the process may differ depending on various reasons such as aims, type of innovation and timespan required. In this study, only the first four steps of the horizon scanning process were involved.
Horizon scanning process generally involvessignal detection/identification, filtration, prioritisation, assessment and disseminationas shown in the figure below (Simpson et. al, 2009).
Figure 11: Horizon scanning process (Simpson et. al, 2009)
Prior tosignal detection/identification, it is important to determine who will use the horizon scanning services (e.g., policymakers, providers, patients) and establish a timeline for the horizon scanning initiative. Perform a horizon scan toidentifynew innovations that could have an impact on clinical and patient outcomes, the national health system and expenditures.Filterthe innovations that have been identified by using criteria to determine their relevance.Prioritiseby applying criteria based on shareholders' preferences and needs to the innovations that have gone through the filtration process.
Assessthe prioritised technologies for shareholders and forecast their possible consequences on medical care and patient outcomes. Use peer review to ensure that the horizon scanning process and results are of high quality. One way this may be done is through a process known as member checking, where the results should be shared with the study's participants. The credibility of the study may be strengthened by allowing participants to check for accuracy and relevance with their own experiences (Birt et al., 2016).
The last step is todisseminatethe information gathered by horizon scanning to the appropriate audiences as soon as possible and update the information on a continuous basis (Sun & Schoelles, 2013).
In this study, the horizon scanning has been done by reviewing a wide range of unpublished and published literature and a semi-structured focus group interview.
Theoretical explanations supporting the horizon scanning process conducted in the study is presented in the section below. More details regarding each subsection have been presented in the article manus.
4.2 Review of unpublished and published literature
The first three steps; identification, filtration and prioritisation of the horizon scanning process in this study involved review of unpublished and published literature. The aim was to capture and map out current as well as emerging integrated care models and interventions targeted at the frail, both nationally and globally.
4.2.1 Identification: Information source categories
In the study, secondary sources with predefined search terms were primarily used but other types of information sources can also be employed when conducting a horizon scan.
Table 1: Author’s own representation of information source types. Adapted from (Sun & Schoelles, 2013) Primary information sourcesare likely to provide earlier warnings about an emerging integrated care measure(s). This type of information is described as on the "margins of current thinking," and is aimed at challenging the status quo (Habegger, 2009). However, it is difficult to obtain without actively contacting the policymakers and often incomplete as there is lack of evidence of a measure’s effectiveness due to it being still under development (Robert et al., 1999).
Secondary and tertiary sourcesprovide later warnings but the information obtained is often more and includes precise estimates of the possible effects of the emerging integrated care measure(s). In addition, involving existing specialized horizon scanning databases may help to save time and costs in the search
process. To increase the amount of useful knowledge about an emerging integrated care measure(s), the recommended approach is to combine all types of sources (Robert et al., 1999).
4.2.2 Identification: Scanning Information Sources Selection
The types of databases used in this study to identify the emerging integrated care measures were inspired from other horizon scanning articles.
However, in a practical setting, a horizon scanning team prior to the identification step, may adopt a criteria to determine the databases that are appropriate for scanning. The criteria may include material that is up to date and of high quality (impartiality, transparency, and reliability), target group and topic -related content, accessibility, convenience (easy to search and don't take long), costs and scope of coverage (national and international) (Smith et al., 2010).
4.2.3 Filtration methods
For this study, the filtration criteria, both the inclusion and exclusion criteria, were adapted from EuroScan (Simpson et. al, 2009) and the National Horizon Scanning Centre (NHSC) guidelines for horizon scanning (Packer, 2005) as well as from other horizon scanning articles.
Table 2: Author’s own representation of filtration guidelines. Adapted from (Packer, 2005; Simpson et. al, 2009)
The main aim of the filtration step was to ensure that the records included, do contain
models/interventions that meet the stakeholders’ needs. As the stakeholders are the frail elderly in this
study and their complex needs are met with integrated care, the inclusion criteria was primarily based on patient-centered integration (Kodner & Spreeuwenberg, 2002).
4.2.4 Prioritisation methods
In general, the aim of the prioritisation step is to identify the most important emerging
models/interventions in which to invest limited resources in. To improve transparency and reduce
subjectivity in the selection process, EuroScan (Simpson et. al, 2009) suggests using a checklist of clearly specified prioritization criteria based on the requirements for the stakeholders. In this study, the
requirements for integrated care towards the frail elderly on a system level and on a local level, stated by Looman et al. (2016) and Beswick et al.(2010) respectively, were used.
Table 3: Author’s own representation of prioritisation criteria. Adapted from (Beswick et al., 2010;
Looman et al., 2016)
In this study, the prioritisation phase also involved reflection around each model/intervention’s possible impact on various aspects such as patient and caregiver healthcare outcomes, resource utilisation, cost-effectiveness and healthcare delivery methods. Reflection around these aspects was done as it was a part of EuroScan’s prioritisation phase guidelines.
In a practical setting, both filtration and prioritisation phases would include input from national decision making bodies through priority-setting meetings.This is done with an aim to guide the horizon scanning process by ensuring accurate criteria that are in line with the goals of the health system are set (Simpson et. al, 2009).
4.3 Assessment: Semi-structured focus group interview
The last step in the horizon scanning process for this study was assessment. The aim of the
semi-structured focus group interview was to assess the prioritised models/interventions based on three
aspects; innovativeness, impact and implementation as well as assess if horizon scanning was a useful method in aiding policy decision making.
4.3.1 The use of focus groups in horizon scanning
A focus group interview is a qualitative data collection method comprising typically six to nine people with certain backgrounds, who are gathered together by a professional moderator to discuss attitudes, beliefs, emotions, and thoughts about a given subject matter. When there is a lack of evidence and/or the explanations for a particular pattern of thought need to be investigated, where these two issues are often present when assessing and predicting the potential impacts of emerging models/interventions as well as defining trends/needs in healthcare service delivery, focus group interviews may provide useful insight from different viewpoints (Dilshad & Latif, 2013; Smith et al., 2010). Therefore, conducting a focus group interview was chosen as a method for the assessment of the models, interventions and the horizon scanning methodology.
4.3.2 Strengths and limitations of focus group interviews
The strengths and limitations of focus group interviews were taken into account when planning and implementing the semi-structured focus group interview for this study. I have summarised the relevant points in the table below.
Table 4: Author’s own representation of strengths and limitations of focus group interviews (Halcomb et al., 2007; Leung & Savithiri, 2009; Smithson, 2000)
4.3.3 Key considerations: focus group interview preparation and execution
With the information stated in the table above in mind, the semi-structured focus group interview in this study was designed and conducted with the following key considerations:
Sampling strategy
The criterion for selection of participants was that there would be a wide set of roles and backgrounds involved in integrated care services towards the frail elderly. This was critical in the horizon scanning process because involving stakeholders that were similar in terms of their experience on the topic of concern but still having diverse backgrounds ensures homogeneity and a varied set of data (Könnölä et al., 2007). The participants involved in the pilot project "patients in need of more integrated health services - multi sickness in Vestfold" as well as participants working in Norwegian National Advisory Unit on Ageing and Health (Ageing and Health) was a natural starting point as they had roles that fitted the selection criteria.
Sample size
The number of respondents participating in the focus group session was aimed to be between six to nine people. This was because large groups are generally more difficult to manage. In addition, it was to prevent a shift in the group dynamics when each individual's ability to express their thoughts and observations were to become restricted (Oates & Alevizou, 2018).
Interview guide
Prior to the focus group interview, the participants received an interview guide (see appendix A and B).
The interview guide contained a timetable, information for the topics (models, interventions and horizon scanning process) and evaluation questions (evaluation categories: innovativeness, impact and
implementation with explanations on issues to consider within each category). The sources for all the information provided were also cited. The goal was to structure the focus group interview, ensure that the participants were familiar with the research goals, minimize the moderator's facilitation of conversation, and encourage the respondents to shape their own opinions so that they could question one another, minimise groupthink, prevent one another from presenting false information, and not be easily manipulated by a dominant voice during the focus group interview.
Data collection
To avoid respondents being fatigued, the focus group interview was scheduled to last two hours (Gibson, 2012). The interview was conducted via Zoom because aspects such as ensuring participants' comfort, safety, accessibility to the interview and adequate seating such that all participants can see each other and the facilitator clearly were considered to be important for effective discussions (J. M. Smith, 1972).
Obtaining consent prior to the focus group interview was intended to protect participants' autonomy.
Additionally, coding the participants’ responses was done to maintain privacy as well as encourage them to be less hesitant in expressing their opinions (Sim & Waterfield, 2019).
Organisation and analysis of data
This part of the study followed the continuum of data analysis framework from Krueger and Casey (2014). This meant that the focus group interview was planned and implemented in accordance with the interview guide to facilitate effective discussions. Furthermore, data generated was translated and
transcribed after listening to the recordings multiple times, reviewing the observational notes made during the interview and summary notes written immediately afterwards. By doing so, an overview of the whole interview was achieved. Afterwhich, memos were written in the form of short sentences that served as the foundation for developing categories for both the quantitative and qualitative findings. Lastly, the
descriptive statements regarding the models, interventions and the horizon scanning methodology were indexed, sorted, compared with one another, rearranged into new themes and interpreted as a whole to draw out connections and conclusions.
5 Findings
A summary of the findings is discussed here. Further details are discussed in the article manus.
5.1 Review of unpublished and published literature
There were 1179 records found, with 605 of them being filtered out according to filtration criteria. A total of 104 relevant records were left after removing 155 duplicates, 134 disease-specific records, and 181 irrelevant records. These records contained frailty-specific models and interventions that were organized into various themes to provide a clearer picture. Following that, prioritization criteria were established, and 5 system-based integrated care models and 4 community-based interventions were selected for focus group assessment from the relevant records.
5.2 Semi-structured focus group interview
Participants in the focus group debated and graded each of the nine models and interventions on innovativeness, impact, and implementation. Among the system-based integrated care models and community-based interventions, the Walcheren integrated care model and EuFrailSafe received the highest scores. Participants also expressed their thoughts on unmet needs, integrated care trends, and possible challenges to consider when implementing these integrated care models and interventions in the Norwegian health care system. In terms of horizon scanning methodology, participants were generally optimistic about the method's utility in assisting policy decision-making, but they had differing opinions about how it should be carried out in practice.
6 Discussion
6.1 Integrated care models and interventions
A summary of this section is discussed here. Further details are discussed in the article manus.
The pilot horizon scan carried out in this study discovered new and emerging integrated care models and interventions directed at the frail elderly. Both the system-based integrated care models and
community-based interventions provided the participants with insight into integrated care needs and trends, as well as alternative ways to address knowledge gaps, system fragmentation, and promote service innovation. The system-based integrated care models were primarily fully integrated models on the integration continuum (see theoretical framework) and as a result, they were complex to comprehend for the participants and challenging to evaluate the probability of implementation of these large-scale models in the Norwegian context as they were perceived to require government support and permission.
On the other hand, the community-based interventions were perceived by the participants as solutions that could be implemented without requiring large policy or legislative changes. These interventions were less complicated because they only included a few integration aspects (see theoretical framework) and thus, were possibly simpler to understand, reflect and evaluate for the participants. In addition, due to the fact that the participants’ backgrounds were mostly municipality-based, it may have been easier for them to envision and comprehend each intervention’s probability of implementation in their municipality.
Participants were also comfortable in commenting on each intervention's innovativeness since they were aware of other community-based initiatives that were currently taking place in their municipality to which they could compare to.
As the overall purpose of using a horizon scanning methodology was to identify new and emerging integrated service delivery measures, the extent to which the participants understood the results of the scan (both the system-based integrated care models and the community-based interventions) can be seen to have had an impact on how they viewed and evaluated the horizon scanning methodology itself.
6.2 Horizon scanning a fruitful method?
6.2.1 Participants’ reflections
The participants were generally optimistic about the horizon scanning methodology’s ability to aid policy decision making but had varying opinions on how it should be conducted in practice, in terms of who should conduct it, the type of filtration/prioritisation criteria to be used, when the stakeholders’ should be involved. This is further discussed in the article manus.
6.2.2 Horizon scanning of new healthcare delivery models in Norway
This section will cover how the horizon scanning methodology for the use of discovering new and emerging methods of healthcare service delivery could be implemented in Norway.
As mentioned in the methods and data section, horizon scanning has been mainly used in identifying innovative medicines or health technologies (Amanatidou et al., 2012). Within Norway, horizon scanning for pharmaceuticals is currently conducted by two national organisations, The Norwegian Medicines Agency, in partnership with the Norwegian Institute of Public Health (The Norwegian Medicines Agency:
HTA and Reimbursement, n.d.). In the United Kingdom, horizon scanning for the use of discovering new and emerging methods of healthcare service delivery to aid in policy decision making is led by a horizon scanning team. This team comprises members from the Cabinet Office’s Horizon Scanning Secretariat and the Government Office of Science’s Horizon Scanning Centre (United Kingdom government, 2017).
Similarly, if horizon scanning for service innovation were to be developed in Norway, it would need to be at a national level. As mentioned by the participants in the study, governmental support and permission was an important aspect required for implementation of models/interventions. Thus, involving national decision bodies such as the Norwegian Institute of Public Health (Division of Health Services) that possibly have competency in conducting a horizon scan, have access to emerging models and
interventions that are not yet published, have awareness of the information gaps that need to be filled that can help with setting filtration/prioritisation criteria that is in line with the national health system goals could be a way for horizon scanning for service innovation to be implemented in Norway.
On a broader scale, Norway has collaborated with other European countries through the International Horizon Scanning Initiative (IHSI) to form a joint responsibility for notice of new pharmaceuticals and health technologies (National Institute of Public Health, 2020). It may be beneficial if IHSI could expand to include health service delivery. In addition, as it is recommended that individuals with expertise in the creation and execution of horizon scanning programs make up the expert panel for a horizon scan study
(Sun & Schoelles, 2013), if IHSI were to include health service delivery, their expert panel could be employed to assess new and emerging models and interventions in Norway. Furthermore, if IHSI were to develop a specialised database for horizon scanning in service delivery, this may help increase horizon search efficiency, thus making the horizon scanning process less time-consuming.
6.3 Limitations and Recommendations
It was difficult to decide how to conduct this study because it was a pilot study. The study was guided by horizon scanning guidelines and frameworks but these were mostly directed towards innovations within the pharmaceutical industry and as a result there was some level of subjectivity in the way the study was carried out, particularly in terms of the search terms and databases used, filtration/prioritization criteria, interviewee selections, and data translation and interpretation by a single individual.
As there is no defined definition or treatment approach for frailty, as described in the previous research section, evaluating frailty-specific models and interventions may be challenging even for participants’
having relevant knowledge and experience. The robustness of the participants’ evaluations could be hampered by increased moderator participation as a consequence of the participants’ limited background knowledge of frailty, and possibly insufficient time to establish a comprehensive understanding of the horizon scanning methodology and the nine models/interventions.
There were challenges recruiting participants for the focus group interview as they had other work commitments related to the covid situation. Despite each participant having multiple backgrounds in varied work settings, the transferability of the results may be limited by the small sample size and that the participants’ mostly represented municipality services. Further studies should consider conducting
multiple focus group sessions with input from various experts including national decision makers to reach theoretical saturation when evaluating models, interventions and the horizon scanning methodology (Krueger, 1994).
7 Conclusion
We discovered new and emerging integrated care models/interventions for the frail elderly in this study by using a horizon scanning methodology. These models/interventions were shown to have the capacity to resolve system fragmentation and improve coordination of care. Furthermore, horizon scanning allowed for debate on subjects such as the need for integrated care and the anticipated challenges of implementing the suggested models and interventions in the Norwegian setting. As a result, we may infer that horizon scanning is a good strategy for fostering service innovation as well as addressing knowledge gaps. Further studies should see how the horizon scanning process can be applied in practice.
