Integrated Care: The Way Forward for Advanced Nurse Practitioners by Using Strategy Initiatives

Strategy enables nurses and managers to respond to the challenging trends occurring in health service delivery. The aim of this Commentary is to explore the importance of Integrated Care by demonstrating its strategic potential for advanced nurse practitioners in delivering care. An evidence review of 35 articles accessed from Cinahl and Medline (2023) is presented. A new strategic area of nursing practice is Integrated Care although involvement by the


Integration initiative by advanced nurse practitioners
A systematic review to gain insight into shifting specialist care from the hospital to primary care/community care identified quality care within this setting, delivered by nurse practitioners at patient and professional level as being associated with better access to healthcare and fewer referrals to hospital [4].A survey of nurse practitioner perceptions of integration into acute care organisations (n = 66) across one region in Ireland found that successful integration of nurse practitioner roles is integral to the success of the health service and sustainability of the role [5].These researchers identify that nurse practitioner integration is not currently structured and that a framework to support integration is needed to ensure ongoing support for the role, as integration is not currently optimised.Little is known of Advanced Practice Registered Nurses' (APRNs) integrating primary and behavioural healthcare.An American study found implications for the Integrated Care advanced practice nurse to have roles inclusive of competencies, leadership, engagement, collaboration and advocacy [6].Halliday et al. [7] in exploring perceptions of the role of the advanced nurse practitioner in a 'hospital at day' setting found similar competencies expressed by ward staff.However, Ryder and Gallagher [5] caution that failure to successfully integrate the nurse practitioner role risks the long-term sustainability of the role and is a missed opportunity to demonstrate the success of advanced clinical leadership to health care.
Integration is about the movement of people as they transition between services and processes as healthcare transforms activities and organisations, implements and evaluates the current situation and are informed by many variables given that Integrated Care requires transformation across these areas [8].
Patients, families and communities drive the design, implementation and evaluation of digitally enabled Integrated Care; particularly in the formative development of these systems and frameworks.In the United Kingdom, Baxter et al. [9]  out a systematic review of the effects of integration between healthcare services, or between health and social care on service delivery outcomes including effectiveness, efficiency and quality of care and found a greater need for better integrated models of care.Countries with more mature integrated systems are Spain, the Netherlands, Germany and the United Kingdom [10].Innovations stemming from health care organisations, universities and industry can help drive the change process.Digitally enabled Integrated Care can support health and social care integration efforts.

Leading the way forward:
Strategically, at the International Congress of Nursing ICN [11] in Singapore, keynote speakers presented a strategic dimension to health care and nursing.Dr. Sheila Tiou and Lord Nigel Crisp presented jointly on "Nursing Now," a global movement, which aims to improve health and health care globally by raising the status and profile of nursing.One way of supporting this initiative is ensuring strategy is at the forefront of nurses' thinking and education for patient care delivery by evaluating policy and strategic approaches to health care in various settings.Integrated Care is one such initiative.Engagement in the strategic process will allow nurses to contribute to debate concerning the future strategic planning and direction of their organisation and to strategic issues concerning integrated health care at national level.Adopting strategies for networking that focus on working collaboratively and flexibly with other practitioners, clinical colleagues, health administrators and national and international experts will ensure that consensus of Integrated Care strategy is possible.Enhancing inter-professional collegial relationships and improving managerial recognition of the ANP role are key target areas [12].Further strategies could focus on creating a research climate that attracts a diverse group of researchers who value interdisciplinary work in Integrated Care is then possible.This includes the application of information technology to health care, including the generation and usage of health care data that values and focuses on interdisciplinary collaborative research [13].Ricciardi and Tarricone [14], via a survey provided by the Italian Association for the Quality of Health and Social Care (ASIQUAS), examined the assessment of management quality of the COVID-19 pandemic to evaluate the new real possibility to invest funds in new healthcare structures and projects.

Digital health:
Digital health is playing a growing place in integrated health care.Digital health enabling Integrated Care is using digital health technologies to enable and support the functional activities and processes and the normative values put in place to achieve the aims of an integrated model of care [15][16][17].Digital care should result in better health outcomes and patients' experience at lower cost and be equitably beneficial for all members of the society.However, wide variations exist in how to build a tool through a framework of diversity, inclusion and responsible innovation [18].These researchers promote three crucial areas as being necessary for the delivery of more integrated health and social care delivery.These areas are design and development of technologies and models of care, implementation opportunities and challenges and the evaluation of the impact of digitally enabled models.
The interest in digital health in the context of integrated care has grown in recent years and accelerated when digital health became essential to how health systems responded to the COVID-19 crisis [19][20][21][22].As countries build more sustainable health systems opportunities exists to advance the transformation toward digitally enabled integrated health and social care systems [23].
Baltaxe et al. [10] in their analysis of 17 European Integrated Care programmes explores digital health transformation of Integrated Care and Buis [24] posits that implementation is the next hurdle to clinical transformation with digital health.Several studies explore virtual care including virtual care use before and during the COVID-19 pandemic [20] and virtual care expansion in the Veterans Health Administration during the pandemic [19].Similarly, Pérez Sust et al. [21] identify how the crisis was turned into an opportunity through digital health strategies.Piera Jiménez et al. [19] takes Integrated Care one step further by introducing a telehealth-enhanced Integrated Care model in the domiciliary setting for older patients for effectiveness and costeffectiveness assessments and Steele Gray [15], explores how Integrated Care's new protagonist is the expanding role of digital health systems in Integrated Care.Valentijn et al. [8] provide a comprehensive conceptual framework based on the integrative functions of primary care.Webster [22] explores virtual health care in the era of COVID-19 and Wilson et al. [25] presents a proposal for a mHealth research lifecycle.Tiirinki et al. [26] apply service engineering to establish principles and standard for a technological ecosystem to underpin Integrated Care in regional approaches and governance models, in Finland.Prior to this Sittig and Singh [27] developed a new sociotechnical model for studying health information technology in complex adaptive healthcare systems.All studies presented here highlight the complex nature of integrating health care.

Integrated health care:
Integrated health care requires getting closer to those delivering care and several researchers are exploring Integrated Care in different situations.Villa-García [28] developed an Integrated Care plan for people with complex care needs living at home, through consultation with users and identifies how to bring together research and user ideas.Chi-Ling Joanna Sinn et al. [29] presents a maturity model framework for integrated virtual care by developing a partnership with patients, families, providers and other system stakeholders.Implementing Integrated Care programmes requires significant investment with economic impact on coordination of activities and other key issues like equity requiring consideration [30].Focusing on how Integrated Care addresses chronic disease management provides guidance on how digital solutions can be used as a foundation for system transformation.Herranz et al. [31] reports that an evaluation of a new technology enabled model of post-stroke care in Catalonia, Spain which has had a strong digital infrastructure, as being in place for decades.This paper illustrates what digitally enabled Integrated Care models can look like when leveraging existing interoperability capabilities thus allowing for evaluation that can uncover system level challenges, such as, in this example, the challenge of access to timely home care (domiciliary) services.

Person centred integrated care:
Dalgarno and Donoghue [32] developed a collaborative response to person centred care in a Scottish HSCP Care home as a result of COVID outbreaks, by setting up a local enhanced service delivered by ANP's.This initiative was in response to the difficulties care home staff were experiencing in accessing weekend professional support from NHS 24 and aimed to reduce patient wait times for clinical review and subsequent management of acute presentations and symptoms at end of life.The service was well received by care home nursing staff and relatives and recognised as an example of collaborative working between the care sector and the health and social care partnership.The oversight group brought together health and social care with commissioning to take a holistic multidisciplinary approach to supporting care homes during the pandemic.

Challenges to implementation of integrated care:
Health care systems around the World are responding to the need for better Integrated Care models and for greater clarity in implementation and integration [9].Implementation is one of the greatest challenges in getting digital health into routine practice [24].Cronin et al. [30] focus on technical and information security related barriers and explore if chronic disease can be managed through Integrated Care cost-effectively through technological solutions, thus enabling health service transformation across different settings.Ling-Sinn et al. [29] focus on the technology, performance and quality by demonstrating how the model is enabling integration of service delivery around coordination of activities.Zhao et al. [33] offered foundational principles and processes that can be transferred to other settings.White et al. [34] offer a qualitative assessment of patient experiences of receiving virtual care in Australia during the COVID-19 pandemic and found that collaborative relationships between patients/residents and providers were a key factor in models of Integrated Care delivery.
In the United States, Ferguson et al. [19] present virtual care expansion in the Veterans Health Administration during the COVID-19 pandemic by exploring clinical services and patient characteristics associated with utilisation.Barber et al. [35] explored the use of a new system of information exchange between one hospital and one long-term care home in Canada and demonstrated that information exchange can support patient transitions from hospital to home.
Advancing Integrated Care with digital health innovation was also explored by Steele-Gray [16].However, many procedural challenges around technology infrastructure and workflow and the perceived value of a new care model exist.The European VIGOUR project questions if Integrated Care assists in meeting the challenges placed on health care systems by COVID-19?[23].

Conclusion
Nurse practitioners are engaged in health care transformation and need support from research experts to make strategic changes.If nurse managers, educators and clinicians focus more on strategic objectives, their contributions to integrated health care delivery will be further enhanced.Patients, family and communities drive the design, implementation, and evaluation of digitally enabled Integrated Care.Innovations stemming from health care organisations, universities and industry can help drive the change process.Digitally enabled Integrated Care can support health and social care integration efforts, however, as demonstrated here the introduction of Integrated Care in diverse settings is complex and requires technical, systems, processes, frameworks and collaborative professional supports to achieve strategic health integration objectives.