A Co-Creation Process Toward Sustainable Adoption of Integrated Care for Prevention of Unplanned Hospitalizations

Introduction Complex chronic patients (CCP) are prone to unplanned hospitalizations leading to a high burden on healthcare systems. To date, interventions to prevent unplanned admissions show inconclusive results. We report a co-creation process performed into the EU initiative JADECARE (2020-2023) to elaborate an integrated care program aiming at preventing unplanned hospitalizations. Methods A two-phase process of structured interviews and design thinking (DT) sessions was conducted. Firstly, we assessed the management of CCP in Catalonia (ES) through twenty interviews (five patients and fifteen professionals), including the results of a cluster analysis of 761 hospitalizations, followed by two DT sessions (Oct 2021 to Feb 2022). Then, we examined the 30- and 90-day post-discharge periods of 49,604 hospitalizations as input for two DT sessions with seven professionals. Discussion The co-creation process identified poor personalization of the interventions, the need for organizational changes, immature digitalization, and suboptimal services evaluation as main explanatory factors of the observed efficacy-effectiveness gap. Additionally, a program for prevention of unplanned hospitalizations, to be evaluated during 2023-2025, was generated. Conclusions A digitally enabled adaptive case management approach to foster collaborative work, as well as organizational re-engineering, are endorsed for value-based prevention of unplanned hospitalizations. ### Competing Interest Statement The authors have declared no competing interest. ### Funding Statement This study was funded by JADECARE project- HP-JA-2019 - Grant Agreement number 951442 a European Unions Health Program 2014-2020. ### Author Declarations I confirm all relevant ethical guidelines have been followed, and any necessary IRB and/or ethics committee approvals have been obtained. Yes The details of the IRB/oversight body that provided approval or exemption for the research described are given below: Ethical Committee for Human Research at the Hospital Clinic of Barcelona in 2017 (Approval numbers: 26/04/2017, 2017-0451, and 2017-0452) gave ethical aproval for this work. Ethical Committee for Human Research at Hospital Clinic de Barcelona in 2021 (Approval number: HCB/2021/0768) gave ethical approval for this work I confirm that all necessary patient/participant consent has been obtained and the appropriate institutional forms have been archived, and that any patient/participant/sample identifiers included were not known to anyone (e.g., hospital staff, patients or participants themselves) outside the research group so cannot be used to identify individuals. Yes I understand that all clinical trials and any other prospective interventional studies must be registered with an ICMJE-approved registry, such as ClinicalTrials.gov. I confirm that any such study reported in the manuscript has been registered and the trial registration ID is provided (note: if posting a prospective study registered retrospectively, please provide a statement in the trial ID field explaining why the study was not registered in advance). Yes I have followed all appropriate research reporting guidelines, such as any relevant EQUATOR Network research reporting checklist(s) and other pertinent material, if applicable. Yes All data produced in the present study are available upon reasonable request to the authors * ACM : Adaptive Case Management ACPs : Advanced Chronic Patients AMG : Adjusted Morbidity Groups ATDOM : Home Care CCP : Complex chronic patients CFIR : Consolidated Framework for Implementation Research DT : Design-thinking EAIA : Integrated Care Team for specific target groups EEG : Efficacy-effectiveness gap ESCA : Enquesta de Salut de Catalunya ETODA : Team Directly Supporting Therapy on Outpatient basis. EU : European Union DT : Design Thinking FOT : Forced Oscillation Technique FS : Forced Spirometry HaH : Hospital Care - Hospital at Home HCB : Hospital Clinic Barcelona JADECARE : The Joint Action on implementation of digitally enabled integrated person-centred care. KPI : Key performance indicators PADES : Palliative care PHCs : Primary healthcare centres PIAISS : Plan of Social and Health Interaction RCT : Randomized controlled trial UFISS : Functional Unit for Socio-health care