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Health Policy 85 (2008) 45–59

The impact of integrated care on direct nursing home care

Aggie T.G. Paulus ∗ , Arno J.A. van Raak 1
University of Maastricht, Care and Public Health Research Institute (CAPHRI), Faculty of Health, Medicine and Life Sciences,
Department of Health Organization, Policy and Economics (HOPE), P.O. Box 616, 6200 MD Maastricht, The Netherlands

Abstract

Background/aim: The introduction of integrated nursing home care is an important policy goal in many countries and is expected
to affect the type, frequency and duration of activities delivered to nursing home residents. The exact impact however is unknown.
The aim of this paper is to reduce this information gap in order to provide decision supporting information to policy makers and
managers.
Design/methods/ethical issues: At three measurement points between 1999 and 2003, caregivers belonging to 18 functions
registered activities delivered to somatic and psycho-geriatric nursing home residents in The Netherlands. Residents either
received traditional care, integrated care or care that contained elements of traditional and integrated care (hybrid care). Thirty-
six thousand and seventy-one registration lists were used for data analysis. Data analysis included determining, comparing and
linking the (total) average frequency and duration of each activity per care type, measurement point and type of resident.
Results: The (total) average frequency and total duration of most activities were higher for integrated care than for traditional
and hybrid care. The average duration per activity was generally higher for traditional care. The (total) average frequency of
most direct care activities at most measurement points and the total average duration per resident per day were higher for somatic
care than for psycho-geriatric care.
Conclusions: The introduction of integrated nursing home care affects the total average duration and frequency of direct care
activities. However, there is no noticeable impact on individual activities or on differences in activities received by somatic and
psycho-geriatric residents and the degree to which the occurrence of an activity is related to the duration of that activity. This is
because a large proportion of care delivery represents patterned behaviour (routines). Because existing routines are difficult to
get rid of, we should not have too high expectations about the effect of integrated care on service delivery.
© 2007 Elsevier Ireland Ltd. All rights reserved.

Keywords: Integrated care; Traditional care; Nursing home care; Time spent on residents; Activities; Routines; Somatic care; Psycho-geriatric
care

∗ Corresponding author. Tel.: +31 43 3881706;
fax: +31 43 3670960.
E-mail addresses: a.paulus@beoz.unimaas.nl (A.T.G. Paulus),
a.vanraak@beoz.unimaas.nl (A.J.A. van Raak).
1 Tel.: +31 43 3881699; fax: +31 43 3670960.
1. Background
In many countries, health care policy is increasingly
aimed at replacing traditional nursing home care with
integrated care [1,2]. In its general use, the term inte-
grated care refers to “. . .a coherent and co-ordinated set

0168-8510/$ – see front matter © 2007 Elsevier Ireland Ltd. All rights reserved.
doi:10.1016/j.healthpol.2007.05.014
46 A.T.G. Paulus, A.J.A. van Raak / Health Policy 85 (2008) 45–59
of services which are planned, managed and delivered
to individual service users across a range of organiza-
tions and by a range of co-operating professionals and
informal carers. It covers the full spectrum of health and
health care-related social care” [3]. Applied to nursing
home care, integrated care refers to a demand-oriented
delivery of services (i.e. the demand of residents dic-
tates what is delivered, when, how often, how long
and by whom) by caregivers with different disciplinary
backgrounds. Caregivers have to cooperate and coor-
dinate the provision of services in order to meet the
demand of residents in an environment in which spe-
cific features of the home situation (e.g. residents being
engaged in daily activities such as cooking and cleaning
or joining social group activities) are copied in nurs-
ing home care [4,5]. Traditional nursing home care, on
the contrary, is supply oriented (i.e. caregivers dictate
what is delivered, when, how often, how long, etc.),
mono-disciplinary and requires no integrated – thus
cooperative or coordinated – actions from caregivers
or adaptations of service delivery to a home-like envi-
ronment. Due to the differences between traditional
and integrated care, a transition process will generally
precede the formation of integrated care. During this
process, nursing homes offer hybrid care, i.e. nursing
home care which contains elements of both traditional
and integrated care [5,6].
The process of care delivery clearly differs between
traditional and integrated care. Compared to tradi-
tional nursing home care, the process of integrated
care delivery is tailor-made and thus directly aimed at
the individual needs and wants of residents [3,7]. The
part of the service delivery that is primarily related to
activities directly conducted for individual residents is
known as direct care. Well-known examples are morn-
ing care, toileting and medication. Direct care is often
considered a desired goal in nursing care [8]. Due to its
focus on activities desired by individual residents, it can
be expected that integrated care will affect direct care
delivery [9]. However, studies on nursing home care
activities are limited [10]. Available research shows
that the duration of many direct care activities (which
are often irregular) seems to depend on the type of
patients (e.g. patients with psycho-geriatric or somatic
needs) or resident case mix levels [11–13]. Research
also suggests that the frequency of individual nursing
activities is often related to the total amount of time
spent on (i.e. the duration of) these activities [10,14].
However, we observed that it is still largely unknown
whether this is true for various types of nursing home
care or different types of nursing home residents and
will change as a result of the introduction of integrated
care [6,15,16]. Given this lack of knowledge, we there-
fore investigated the following questions:
1. Compared to traditional and hybrid nursing home
care, what is the impact of integrated care on how
frequently (somatic and psycho-geriatric) residents
receive direct care activities?
2. Compared to traditional and hybrid nursing home
care, what is the impact of integrated care on the
duration of direct care activities?
3. Compared to traditional and hybrid nursing home
care, what is the impact of integrated care on the
relationship between the frequency and duration of
direct care activities?
From a policy point of view, providing answers
to these questions is relevant for different reasons.
First, duration and frequency are generally considered
as important cost-drivers in the delivery of services
[17,18]. If integrated care leads to changes in the
duration and/or frequency of direct care activities, our
analysis may indicate whether this type of care has a
cost-saving potential. Secondly, if integrated care leads
to a totally different pattern of direct care delivery,
policy makers and managers need to know these dif-
ferences in order to efficiently allocate nursing time
and make decisions with respect to manpower plan-
ning, resource utilization and improvements in the
quality and productivity of work and the quality of
care [16,19–21]. Finally, even if integrated care does
not lead to a different pattern of direct care deliv-
ery in comparison to traditional care, our analysis
may indicate that this is because of the perseverance
of certain ‘routines’ in the delivery of nursing home
care. These repetitive, recognizable patterns of interde-
pendent actions performed by multiple agents [22,23]
could indicate that different types of care for different
types of residents are not altogether that different. As
we will show in our discussion, if routines are present,
this has important consequences for the implementa-
tion of integrated care, which to date are underexposed.
The paper starts with a brief summary of our theoret-
ical and methodological framework. Then, the results
are shown. The result section is divided into three parts,
each dedicated to one of the research questions. Finally,
 A.T.G. Paulus, A.J.A. van Raak / Health Policy 85 (2008) 45–59
the main conclusions are shown, followed by a discus-
sion of the findings and limitations of the study.
1.1. Theory on direct care
Direct care refers to ‘nursing activities that are
patient-centred and that take place in the presence of
the patient and/or family’ [9,24]. Direct care is one of
the four groups of nursing activities, which also include
indirect care, unit-related care and personal activities
[9,24].
Direct care consists of different activities to which
caregivers (depending on their roles and responsibili-
ties) have to allocate their time during working hours
[25,26]. Since time is a scarce resource, the delivery of
each activity has opportunity costs: time spent on one
activity is time not spent on another activity. The time
spent on one activity depends on how long it takes to
deliver that particular activity and how often that spe-
cific activity has to be provided during a particular time
unit. Ceteris paribus, an activity which lasts longer and
takes place more frequently within a restricted time-
unit is more time-consuming than an activity with a
shorter duration and a lower frequency.
The duration and frequency of direct care activities
can be considered from the perspective of the provider
(i.e. the organization or caregiver) and/or the consumer
(i.e. the patient, client or resident). In the first per-
spective, task analysis in terms of how long and how
often a particular caregiver delivers a specific activity
is the main underlying goal [10]. In the second per-
spective, the delivery process is reviewed in order to
determine how much direct care a consumer receives
per time-unit and how often [27,28]. Most studies (e.g.
time and motion studies and work-sampling studies
[29,30]) focus on the first perspective and generally
neglect the second one [31]. In this study we analysed
duration from both perspectives and frequency from
the perspective of the resident.
Studies indicate that the frequency and duration of
(direct) nursing care activities are closely correlated
[10,14] and influenced by such factors as the meth-
ods of care provision [32], caregiver characteristics
[33,34], patient characteristics [11–13] and the orga-
nizational structure [35]. A study by Lundgren and
Segesten [9] with respect to a medical-surgical ward,
for instance, showed that changing the staffing pattern
through the introduction of a patient focused system
47
of nursing delivery increased the time used for direct
care. However, the same study also showed that it took
time for caregivers to change their routines with respect
to direct care delivery [9]. Authors agree that it is dif-
ficult to change routines [36] because they are bound
by rules [37]. This may imply that, for change in rou-
tines to occur, these rules are a stumbling block and
they should be changed [36]. The concept of routines
is relevant for health care and nursing in particular,
because a large part of the care providers’ work is per-
formed through routines [20,37–39]. When a nursing
home intents to introduce the concept of integrated care
(i.e. a new routine) this will require change of existing
routines.
2. Methods
2.1. Design
Since the introduction of integrated nursing home
care is unmistakably present in The Netherlands [27],
we have chosen this country for our analysis. Our
study took place between September 1999 and Febru-
ary 2003.
To be able to uncover possible differences between
various types of care and in order to obtain a spread
which is indicative for nursing home care in The
Netherlands, we selected three nursing homes. They
offered either traditional care (A), ‘hybrid’ care (B)
or integrated care (C). ‘Hybrid’ care refers to nursing
home care which contains elements of both traditional
and integrated care. The differences between traditional
and integrated nursing home care were related to the
presence of the following five dimensions in the latter
type of care:
• a demand-oriented supply structure;
• a home-like environment in the nursing home (e.g.
wards that were furnished and decorated to make
them comparable with a home-setting and engag-
ing residents in daily activities such as doing the
laundry);
• a limited number of residents per ward (to mimic the
home situation, the number of residents per ward was
limited to a maximum of 12);
• social group activities for residents (both in- and
outside the nursing home);
48 A.T.G. Paulus, A.J.A. van Raak / Health Policy 85 (2008) 45–59
• a coordinated care delivery by co-operating care-
givers with different disciplinary backgrounds.
Selection of the nursing homes took place on the
basis of criteria that included comparability of size,
a stable working environment, motivation to con-
tribute to the research and being indicative for that
specific type of nursing home care in The Nether-
lands. In addition, different types of residents had to
be present. In The Netherlands, these types gener-
ally include somatic residents (i.e. people with mainly
physical/physiological problems) and psycho-geriatric
residents [27]. We purposefully chose three nursing
homes that fulfilled all criteria.
One nursing home, with 121 beds and 2 somatic
care wards and 2 psycho-geriatric care wards, was
selected as the ‘A’-setting. This setting represents a
nursing home that delivered traditional nursing home
care during the entire research period. Another nurs-
ing home (with 141 beds and 3 somatic care wards
and 2 psycho-geriatric care wards), which delivered
comparable traditional care at the beginning of the
research, was selected as the ‘B’-setting’. This nursing
home delivered ‘hybrid’ care. Here, integrated nursing
home care (with the five dimensions indicated above)
was gradually implemented during the research period.
Finally, a nursing home (with 88 beds and 3 participat-
ing wards (with 28 beds; 2 somatic care wards and
1 psycho-geriatric care ward) was selected as the ‘C’-
setting. This nursing home delivered integrated nursing
home care since March 1998.
2.2. Data collection
During the period 1999–2003, for all types of nurs-
ing home care, data were collected once (May/June
2000) before implementation and twice afterwards (6
and 14 months after implementation, which took place
in the ‘B’-setting in March 2001). Approval to con-
duct the study was obtained from the relevant ethics
committees in the nursing homes. Data were obtained
from formal caregivers, who recorded the direct care
activities employed for individual residents. Caregivers
recorded activities on forms that listed 14 different
activities (e.g. evening care; meal activities), which
were customary for nursing home care in The Nether-
lands. The selection of these activities was based on
a literature study, interviews with caregivers in nurs-
ing homes throughout the country and observations
in nursing homes that offered traditional or integrated
care. Table 1 gives an overview of the activities and the
number of times they were registered.
During each of the 3 measurement points, each
lasting 14 consecutive days (14 × 24 h), caregivers
recorded the type of activity performed for residents
and the frequency and duration of each activity. In
total, 36071 forms were subjected to data analysis (see
Table 1 for further details).
All somatic (som) and psycho-geriatric (pg) resi-
dents had average dependency scores between 7 and
9.5 (on a scale from 1 to 12). The higher the depen-
dency score, the more help the resident needed from
carers. In the A-setting, at each measurement period,
activities were registered for 84; 89 and 98 residents,
respectively. In the B- and C-setting, these numbers
were 101; 91; 97 and 25; 23 and 26, respectively.
Caregivers in the nursing homes belonged to 18
functions. These categories ranged from various types
of nurses to household assistants and aids. Volunteers
were also included as caregivers. Table 2 specifies all
functions.
2.3. Data analysis
All data were put into a SPSS 10.0 data file. The
basic units of analysis were the frequency and dura-
tion of the direct care activities mentioned in Table 1.
Frequency was considered from the consumer’s point
of view. From this point of view, frequency refers to
the average number of times a nursing home resident
obtained a particular activity per day. This frequency
was calculated as follows. First, the total number of
times a particular activity was registered during a spe-
cific measurement point for a specific type of resident
was determined (e.g. suppose medication was reg-
istered 300 times for somatic residents at the first
measurement point). Then, the average number of
times that activity was registered per day was cal-
culated. Since each measurement took 14 days, the
average was the total number divided by 14 (thus
300/14 = 21.42). This number indicates that medica-
tion on average was delivered more than 21 times a
day. Then, per measurement point, the number of resi-
dents was determined (e.g. 10 somatic residents). With
10 residents and an activity that is delivered more than
21 times a day, this means that each somatic resident
on average received this activity more than twice a day
Table 1
Registered direct care activities
Activity Description Care type

AT1a (4012b ) AT2 AT3 BT1 BT2 BT3 CT1 CT2 CT3
(4898) (5591) (5988) (5798) (4535) (1769) (1623) (1857)
Morning care Residents receiving help with getting out of bed, 1299c 1265 1488 1422 1443 1396 374 389 396
bathing, dressing, shaving, getting their hair combed in
the morning
Coffee/tea-activities Residents receiving activities related to the making and 288 278 414 537 535 449 168 182 218
pouring out coffee and tea, doing the dishes, cleaning up
Medication Residents receiving activities related to medication (e.g. 907 1032 1320 2330 1849 1145 898 590 938
help with medication)

A.T.G. Paulus, A.J.A. van Raak / Health Policy 85 (2008) 45–59

Toileting Residents receiving help if they need to go to the 1594 1716 2095 1869 1959 1368 1114 946 996
bathroom, a change incontinence slips, or help with
emptying catheters
Afternoon care Residents receiving help with getting in or out of bed, 160 182 224 722 799 606 179 263 245
getting (un)dressed, getting their hair combed in the
afternoon
Extra care Getting extra attention through conversations, walking 265 559 702 457 699 407 133 323 440
or shopping, extra pedicure or hair treatment, ‘snooze
activities’ (“snoezelen”: activating and stimulating
primary senses such as hearing, smelling, taste)
Evening care Residents receiving help with getting to bed, bathing, 1337 1435 1489 1398 1384 1236 319 339 418
cleaning teeth and dentures in the evening
Meal activities Helping residents with eating, doing the dishes, setting 942 1411 1585 2841 2991 2072 912 975 1114
the table
Medical Care Taking care of wounds, catheterise, medical treatments, 628 509 953 736 462 259 191 222 163
etc.
General activities Activities such as pottering, singing, playing games and 173 279 172 88 46 103 128 56 64
cleaning up afterwards
Social group activities Preparing and doing social activities in groups (e.g. a 0 4 4 0 4 3 6 8 4
choir or bridge-club)
Transfer/transport Helping residents to or back from a particular social 846 1497 1851 1304 1332 1222 309 203 228
activities meeting ward or room for general activities or
appointments
Incidental care Taking care of residents in case of extra-ordinary events 45 65 86 125 231 134 55 124 113
(e.g. a sudden change in health, aggressive behaviour
towards other residents or staff)
Additional direct Activities Activities other than those mentioned above such as: 243 262 240 513 284 279 155 158 230
Caregivers buying extra food or clothing or doing the
Laundry for a particular resident
Source: data in table from original research by authors; presentation of data and translated terms partly based on Paulus et al. (2003; 2006).
a A: traditional care; B: hybrid care; C: integrated care; T1: first measurement point; T2: second measurement point; T3: third measurement point.
b # number of registration lists filled in by caregivers (in total 36071 lists).
c The numbers in the table refer to the absolute number of times that a particularly activity was registered by caregivers at the specific measurement point (e.g. at the first

measurement point, the activity ‘morning care’ was registered 1299 times in traditional home care).

49
 50
Table 2
Function categories: description and absolute number of participants
English term Regular term in The Netherlands Nature of the work AT1a AT2 AT3 BT1 BT2 BT3 CT1 CT2 CT3
Licensed practical nurse Ziekenverzorgende Niveau 3 Basic bedside care, monitoring and changing catheters, 79 73 68 93 79 72 20 21 28
treat bedsores, etc.
Geriatric nurse Bejaardenverzorgende Niveau 2 Household work, physical care, assisting with meals, 1 – 10 11 12 13 11 9 7
bathing, administering medicine, consultation with
registered nurse, etc.
Registered nurse Verpleegkundige niveau 4 Direct patient care (treatment, observing and recording – 1 – 1 1 – 3 1 1
symptoms and progress in patients); administering
medications; supervising student nurses, trainees, etc.
(Ward) assistant Afdelingsassistent niveau 1 Administrative activities other than those performed by – 3 1 16 17 20 – – –

A.T.G. Paulus, A.J.A. van Raak / Health Policy 85 (2008) 45–59

the registered nurse
Evening/night/weekend manager ANW-hoofd Supervises nursing personnel, is responsible for 8 7 10 10 10 9 3 8 5
treatments and, if necessary, also employs nursing
activities
Night duty watcher Zwerfwacht Is on duty during night-shifts and, on call, performs – – – 4 5 3 – – –
nursing and supervisory activities
Recreational activities supervisor Activiteitenbegeleider Offers and employs a variety of activities (games, art, 6 5 7 7 6 7 2 2 2
craft, music) for nursing home residents
Nutrition assistant Voedingsassistent Takes care of food and drinks, serves meals, helps 3 4 1 16 14 19 6 5 6
residents with meals and consults with dietician
Household assistant Huishoud(elijk) assistant Supports and assists in household activities – – – 14 16 15 5 5 5
Living room assistant Huiskamerassistent Provides extra care to residents (e.g. through reading – 3 7 2 5 4 – – –
with or talking to residents)
Hostess Gastvrouw Assists activities in nursing home restaurants (e.g. – – – – – 1 – – –
receiving guests, setting the table, etc.)
Student nurse Leerling To gain job experience, supports or assists registered or 11 7 7 3 3 13 2 3 1
licensed practical nurse
Trainee Stagiaire Students who during their internship support certain – 7 – 1 6 1 – 1 1
activities (e.g. those by the recreational supervisor)
Volunteer Vrijwilliger Unpaid persons who assist in meals, having coffee/tea, 24 26 27 58 49 59 11 10 11
shopping, recreational activities)
Nursing assistant Zorgassistent Supports in basic bedside care under supervision of a – – 1 – – – 3 7 6
licensed nurse
Nursing care coordinator Zorgcoördinator Coordinates, administrates and manages activities 16 12 8 – – – – – –
including planning of personnel and also performs
nursing activities
Aid Helpende Perform tasks under the supervision of nursing staff; 2 7 7 – – – – – –
serving meals, making beds, take temperatures, etc.
Kitchen assistant Keukenassistent Assists in preparing meals and transports meals to 5 7 9 – – – – – –
wards or restaurant

Total 155 154 163 236 223 236 66 72 73

Source: data in table from original research by authors; presentation of data and translated terms partly based on Paulus et al. (2003; 2006).
a A: traditional care; B: hybrid care; C: integrated care; T1: first measurement point; T2: second measurement point; T3: third measurement point.
 A.T.G. Paulus, A.J.A. van Raak / Health Policy 85 (2008) 45–59
(21.42: 10 = 2.14). The latter number indicates the aver-
age frequency, which is summarized for all types of
residents and types of nursing home care in Table 3.
The duration indicates how long, in terms of minutes,
a particular activity on average lasted. Duration was
considered first from the provider’s point of view. For
each registration, caregivers had to indicate how many
minutes the activity took place per resident. The total
number of minutes registered (e.g. 1500) was divided
by the number of times that activity was registered (e.g.
300) in order to determine the average duration per
activity (5 min for medication for somatic residents).
These averages are summarized in Table 4. The last
row of this table, however, considers duration from
the resident’s perspective and indicates the total aver-
age duration of direct care received per resident per
day (e.g. 80 min/day). This average was calculated as
the summation of the total duration of direct care per
resident per day during the registration period (e.g.
1120 min) divided by the number of registration days
(e.g. 14 days).
The analysis then proceeded in different steps. First,
per measurement point, per type of nursing home care
and per type of resident (somatic and psycho-geriatric),
the average frequency and duration were determined.
Per activity (e.g. morning care) and per set of activi-
ties per measurement point (e.g. all activities in A at
the first measurement point) also standard deviations
(S.D.) were determined (see Tables 3 and 4). Then,
the duration, frequency and activities were compared
per type of nursing home care, per measurement point
and per type of resident. A one-sample t-test (α = 5%)
was performed (see Tables 3 and 4), using SPSS 10.0.
Finally, the relationship between the frequency and
duration of activities was determined and compared for
the different types of nursing home care and residents.
On the basis of all comparisons, the most important
similarities and differences between all care types as
well as the impact of integrated care on direct care
delivery were determined.
3. Results
3.1. Frequency
Table 3 indicates the average frequency of the direct
care activities, i.e. the average number of times a nurs-
51
Fig. 1. Average frequency direct care activities. Legend—Som:
somatic residents; PG: psycho-geriatric residents; T1: first measure-
ment point; T2: second measurement point; T3: third measurement
point.
ing home resident obtained a particular activity per day.
A score of 1 for instance indicates that this particular
activity on average is received once per day. A score
of 0.50 indicates that a resident obtained that activity
once per 2 days.
3.1.1. Activities
The table shows that meal activities, toileting,
medication, morning- and evening care and trans-
fer/transport had the highest average frequency. A
resident, for instance, on average received between
0.614 and 3.531 activities related to toileting per day.
Social group activities were part of the activities with
the lowest frequency. On average, a nursing home resi-
dent obtained between 5.8 and 16.3 direct care activities
in total per day.
3.1.2. Changes over time
Over time, the average frequency showed signifi-
cant changes mainly for extra care, general activities,
medication, meal activities and additional direct activ-
ities. Most of these changes occurred between the
first and third measurement point (T1 and T3, respec-
tively). Except for general activities, afternoon care
and evening care, the average frequency of activities
significantly increased over time.
3.1.3. Differences between care types
Fig. 1 shows the average frequency of the set of
14 activities. Integrated care had higher average fre-
 52
Table 3
Average frequency of direct care activities received by nursing home residents per day
Activities AT1a AT2 AT3 BT1 BT2

Som PG Som PG Som PG Som PG Som PG

Morning care 1.017 1.139 0.944 1.126 1.126 1.047 1.087 0.974 1.143* 1.074
Coffee/tea-activity 0.133 0.050 0.104 0.071 0.130 0.127 0.113 0.115 0.101 0.136
Medication 1.189 0.411 1.291 0.425 1.223 0.747* 2.581* 0.913* 2.244* 0.635*
Toileting 2.240 0.614 2.011 0.787 2.082* 1.135 1.675 1.071* 1.766 1.281*
Afternoon care 0.209 0.097 0.203 0.097 0.281 0.084 0.671* 0.378* 0.857* 0.394*
Extra care 0.279 0.242 0.528 0.289 0.412 0.563* 0.529* 0.182 0.796 0.295
Evening care 1.073 1.281† 1.058 1.266 1.032* 1.068 0.889 1.111** 1.027 1.132
Meal activities 0.581 0.575 0.505 1.080 0.702 0.866 2.361* 0.972* 2.667* 1.086
Medical care 0.715 0.402 0.339 0.453 0.641* 0.734* 0.648 0.493 0.452 0.259

A.T.G. Paulus, A.J.A. van Raak / Health Policy 85 (2008) 45–59

General activities 0.109 0.196* 0.256* 0.215* 0.086 0.144 0.099 0.036 0.052 0.019
Social group activities 0.000 0.000 0.001 0.005 0.005 0.001 0.000 0.000 0.006 0.001
Transfer/transport 0.961 0.569 1.070 1.341† 0.902* 1.584* 0.843 1.017* 0.703 1.333**
Incidental care 0.046 0.031 0.017 0.077 0.686 0.055 0.147 0.055 0.280* 0.075
Additional direct activities 0.150 0.274 0.209 0.204 0.122 0.201* 0.567* 0.225 0.243 0.218
Average frequency of an activity (standard 0.621 (0.62) 0.420 (0.39) 0.591 (0.60) 0.531 (0.48) 0.673 (0.57) 0.596 (0.50) 0.872 (0.81) 0.538 (0.44) 0.881 (0.83) 0.567 (0.50)
deviation)

Total average frequency direct care activities 8.702 5.881 8.535 7.436 9.430 8.356 12.210 7.542 12.337 7.938

Activities BT3 CT1 CT2 CT3 Average per activity (S.D.)

Som PG Som PG Som PG Som PG

Morning care 0.982 1.176 1.076 1.048 1.188 1.276 1.183** 0.967 1.1 (0.1)
Coffee/tea-activity 0.085 0.094 0.385 0.556 0.172 0.643 0.267 0.421 0.2 (0.2)
Medication 1.564 0.488 2.728† 2.270** , † 2.058† 1.296** , † 3.005** , † 1.636** , † 1.5 (0.8)
Toileting 1.293 0.918 3.308** 2.968** , † 2.705 3.531** , † 2.962** 2.124** 1.9 (0.9)
Afternoon care 0.615 0.402* 0.469 0.587** 0.755† 0.959 0.831 0.271 0.5 (0.3)
Extra care 0.430 0.283 0.424 0.278 1.071† 0.867** , † 1.579** , † 0.495 0.5 (0.4)
Evening care 0.822 1.046 0.973 0.794 1.054 1.071 1.277** 0.917 1.0 (0.1)
Meal activities 1.177 1.109 2.134† 3.159† 2.187† 3.736** 2.859** , † 2.624 1.7 (1.0)
Medical care 0.321 0.147 0.661 0.341 0.638† 0.827 0.537 0.276 0.5 (0.2)
General activities 0.082 0.082 0.286** , † 0.508** , † 0.138** 0.265 0.080 0.510 0.2 (0.2)
Social group activities 0.006 0.000 0.023 0.008 0.004 0.082 0.008 0.029 0.009 (0.2)
Transfer/transport 0.534 1.198 0.888 0.865 0.661 0.561** 0.564 0.933 0.9 (0.3)
Incidental care 0.129 0.104 0.116 0.230 0.313† 0.561† 0.285 0.548 0.2 (0.2)
Additional direct activities 0.444 0.100 0.518† 0.302 0.433** , † 0.633** , † 0.621† 0.750** , † 0.3 (0.2)
Average frequency of an activity (standard 0.606 (0.49) 0.510 (0.47) 0.962 (1.03) 0.993 (1.03) 0.955 (0.83) 1.16 (1.10) 1.14 (1.07) 0.892 (0.74) 0.7 (0.2) (0.51)
deviation)

Total average frequency direct care activities 8.484 7.147 13.989 13.914 13.377 16.308 16.058 12.501 10.578
Values in italic: value not significant at alpha = 5% (two-sided test). Values underlined: significant change in comparison to first measurement point of same nursing home care type.
a A: traditional care; B: hybrid care; C: integrated care; T1: first measurement point; T2: second measurement point; T3: third measurement point; Som: somatic residents; PG: psycho-geriatric residents.
* Significant difference between A and B (* indicates that the average frequency of that specific activity in that specific care type is significantly higher for that specific measurement point).
** Significant difference between B and C (** indicates that the average frequency of that specific activity in that specific care type is significantly higher for that specific measurement point).
† Significant difference between A and C († indicates that the average frequency of that specific activity in that specific care type is significantly higher for that specific measurement point).
Table 4
Average duration per direct care activity (in min)
Activities AT1a AT2 AT3 BT1 BT2

Som PG Som PG Som PG Som PG Som PG

Morning care 19.20* 17.10 20.67* 17.05 15.09 17.19 16.36 17.03 16.99 16.61
Coffee/tea-activity 20.89† 28.99† 24.33* 31.62† 21.21† 35.21* , † 17.91 26.49** 18.83 23.58**
Medication 3.86* 3.37* , † 5.28* , † 4.29* , † 4.64* , † 3.49 2.86 2.47 3.71** 3.21**
Toileting 5.45 5.22 6.68† 4.71 6.15† 5.12 5.20 6.15* 6.47** 6.05* , **
Afternoon care 11.41 11.41* 13.49* , † 11.29* 10.12† 11.31 9.98 7.88 11.20 9.23
Extra care 6.25 7.53 7.25 5.10 7.41† 6.00 6.61 6.56 7.76 6.25*
Evening care 12.27 11.67 14.20 11.84 11.06 13.04 12.06 12.49* 13.38 12.69*
Meal activities 4.59 7.54* 5.15 9.04* , † 7.60* 7.41* 5.19 5.28 6.02* 5.96
Medical care 4.86 6.39* , † 6.96 5.36* 7.65* , † 4.62 4.57 5.09 6.41 3.90

A.T.G. Paulus, A.J.A. van Raak / Health Policy 85 (2008) 45–59

General activities 56.01* , † 87.29* , † 69.46* , † 69.93* , † 27.27† 56.58† 26.01 49.30** 14.47 43.54**
Social group activities – – 10.00 50.00 6.25 30.00 – – 8.75 50.00
Transfer/transport 4.44* 3.24* 5.52* , † 3.11 4.71† 3.39 3.03 2.33 0.82 3.13
Incidental care 8.63 15.00* 9.08 12.94† 9.32 9.78 7.19 5.21 2.37 7.45
Additional direct activities 6.47 3.07 7.40 8.35† 9.25 6.67 6.34 6.79* 1.85 8.72**
Average duration of an activity (standard 11.73 (14.02) 14.84 (22.13) 14.67 (16.82) 17.47 (19.80) 10.05 (4.92) 14.98 (15.42) 8.80 (7.08) 10.93 (12.96) 8.50 (5.71) 14.30 (14.89)
deviation)

Total average duration per resident per day 74.21 70.83 90.92 81.39* 75.05 72.61 83.77 61.93 100.08 65.45

Activities BT3 CT1 CT2 CT3 Average per activity (S.D.)

Som PG Som PG Som PG Som PG
Morning care 16.07 16.53 23.65** , † 19.25** , † 22.00** 19.48** , † 20.95** , † 21.06** , † 18.4 (2.4)
Coffee/tea-activity 24.32** 25.63 14.32 10.32 19.85 11.05 14.81 17.74 21.5 (6.8)
Medication 3.69** 3.63 3.86** 2.62 3.30 2.42 2.76 3.54 3.5 (0.7)
Toileting 6.07** 5.72* 5.82** 5.56 5.51 5.13 5.28 6.88** , † 5.7 (0.6)
Afternoon care 9.88** 10.27 10.77 9.53** 10.29 10.91 8.64 11.96 10.5 (1.3)
Extra care 8.66** 10.80* 8.80† 10.07 6.63 5.31 5.89 8.55 7.3 (1.6)
Evening care 13.34* 12.83 14.51** , † 12.78 14.11 13.56 13.67† 13.92 13.0 (1.0)
Meal activities 4.06 6.16 8.23** , † 6.70** 6.89** , † 6.70 6.00** 7.69** 6.4 (1.3)
Medical care 5.73 6.74* 7.03** , † 4.21 5.83 6.13** 4.83 5.00 5.5 (1.0)
General activities 47.36** 58.30** 27.04 17.07 25.27 13.98 8.59 13.36 40.2 (23.9)
Social group activities 37.33 – 54.00 20.00 5.00 41.57 25.00 8.50 19.2 (19.7)
Transfer/transport 5.17 3.18 4.17** 7.81** , † 3.80 4.22** , † 3.35 3.87 3.8 (1.5)
Incidental care 7.07 10.45 6.81 6.34 5.90 5.60 6.04 7.70 7.9 (2.9)
Additional direct activities 7.99 17.49* 13.87** , † 9.78† 6.87 4.90 6.80 11.06† 8.0 (3.6)
Average duration of an activity (standard 14.05 (13.33) 13.40 (14.55) 14.49 (13.29) 10.14 (5.40) 10.08 (7.25) 10.78 (10.06) 9.47 (6.71) 10.05 (5.13) 12.2 (2.6) (9.79)
deviation)

Total average duration per resident per day 71.05 73.77 126.75** , † 105.71** 120.73† 123.50 117.81** , † 111.66** , † 90.40
Values in italic: non significant value (p-value > 0.05). Values underlined: significant change in comparison to first measurement point of same nursing home care type.
a A: traditional care; B: hybrid care; C: integrated care; T1: first measurement point; T2: second measurement point; T3: third measurement point; Som: somatic residents; PG: psycho-geriatric residents.
* Significant difference between A and B (* indicates that the average duration of that specific activity in that specific care type is significantly longer for that specific measurement point).
** Significant difference between B and C (** indicates that the average duration of that specific activity in that care type is significantly longer for that specific measurement point).
† Significant difference between A and C († indicates that the average duration of that specific activity in that specific care type is significantly longer for that specific measurement point).

53
54 A.T.G. Paulus, A.J.A. van Raak / Health Policy 85 (2008) 45–59
quencies at all measurement points in comparison with
traditional and hybrid care. Compared to T2, the aver-
age frequency increased at T3 for both traditional and
integrated care (somatic residents only).
A comparison of separate traditional and hybrid care
activities showed that at T1 and at the second mea-
surement point (T2), only the average frequency of
one activity (general activities for somatic residents)
was significantly higher in the traditional care type
(see Table 3). For medication and afternoon care, this
frequency was significantly higher in the hybrid care
setting at T1 and T2. At T3, only the average fre-
quency of afternoon care was significantly higher in
the hybrid care setting. A comparison of hybrid care
with integrated care showed that except for evening
care (in B at T1) and transfer/transport (in B at T2), the
average frequency of activities such as medication, toi-
leting, extra care, meal activities, general activities and
additional direct activities, at all measurement points,
was significantly higher in the integrated care type.
Similar patterns were noticed for the latter activities
in the comparison of traditional care and integrated
care. The average frequency of most activities was
higher for integrated care than for other types of
care.
3.1.4. Somatic versus psycho-geriatric care
With respect to the set of activities, Fig. 1 makes
clear that compared to traditional and hybrid care;
the average frequency of integrated care activities was
higher for both somatic and psycho-geriatric residents.
The average frequency of separate activities such as
medication, toileting, afternoon care and extra care
was generally higher for somatic care than for psycho-
geriatric care. For coffee/tea-activities, evening care,
general activities and transfer/transport, this frequency
was higher for psycho-geriatric care (see Table 3). With
the exception of C (at T2), the total average frequency
of direct care activities was higher for somatic care in
all care types and at all measurement points in com-
parison to psycho-geriatric care. In traditional nursing
home care, the total average frequency of direct care
activities varied between 5.8 and 9.4 activities per day.
In hybrid and integrated nursing home care, these aver-
ages were 7.14–12.33 and 12.05–16.30, respectively.
At T1 and T2, the total average frequency for both
somatic and psycho-geriatric care was the lowest for
traditional care and the highest for integrated care. At
T3, the total average frequency for both somatic and
psycho-geriatric care was the lowest for hybrid care.
3.2. Duration
Table 4 indicates the average duration of care activi-
ties. Except for the last row, the duration indicates how
long, in terms of minutes, a particular activity on aver-
age lasted. The last row indicates how long residents,
on average, received direct activities per day.
3.2.1. Activities
The table shows that morning care, coffee/tea-
activities, social group activities, evening care,
afternoon care and general activities on average had
the highest duration. Morning care on average took
between 15.09 and 23.65 min. By and large, general
activities seemed the most time-consuming. Medica-
tion, medical care and transfer/transport were among
the activities with the lowest duration. On average, a
resident obtained between 70.83 and 126.75 min of
direct care activities in total per day. The total aver-
age duration per resident per day was the highest for
integrated care.
3.2.2. Changes over time
Over time, the average duration of activities sig-
nificantly changed for medication, toileting, medical
care, transfer/transport and additional direct activities.
Mostly, duration increased for activities in A (T2)
and B (T2; T3) and decreased for activities in C (T2;
T3som).
3.2.3. Differences between care types
Fig. 2 shows the average duration of the set of 14
activities. Except for hybrid care for somatic residents,
the average duration at T3 decreased in all care types
compared to T2.
When traditional care and hybrid care are compared,
the average duration of most activities (e.g. morning
care, medication, afternoon care, general activities)
was significantly longer in traditional care. A com-
parison of hybrid care with integrated care showed
that among others morning care, afternoon care, social
group activities, meal activities and transfer/transport
were more time-consuming in the latter care type.
Coffee/tea-activities and general activities, on the other
hand, in general took substantially longer in hybrid
 A.T.G. Paulus, A.J.A. van Raak / Health Policy 85 (2008) 45–59 55

3.2.4. Somatic versus psycho-geriatric care

Fig. 2. Average duration direct care activities. Legend—Som:
somatic residents; PG: psycho-geriatric residents; T1: first measure-
ment point; T2: second measurement point; T3: third measurement
point.
Fig. 2 shows that traditional care for psycho-
geriatric residents had a higher average duration at all
measurement points in comparison with hybrid and
integrated care. With the exception of C (T1 and T2),
the average duration of coffee/tea-activities and gen-
eral activities was higher for psycho-geriatric residents
than for somatic residents. This was also true for social
group activities (except for C at T1 and CT3). For
medication (except C at T3) and toileting (except B
at T1 and C and T3) the opposite was true. With the
exception of B (T3) and C (T2), the total average dura-
tion per day was higher for somatic residents than for
psycho-geriatric residents.
3.3. Relationship between frequency and duration

care. Our comparison of traditional care with integrated
care demonstrated that, in several instances, activi-
ties in the former were more time-consuming. This
was especially the case for coffee/tea-activities, med-
ication, afternoon care and general activities. Social
activities on the other hand lasted longer in integrated
care.
Earlier we indicated that available studies suggest
that there is a link between the occurrence of an activity
and the duration of that activity [10,14]. Table 5 shows
the links between the frequency and duration for the
activities we investigated.
Activities were categorized on the basis of a high or
low frequency combined with a high or low duration.

Table 5
Relationship between average frequency and duration of activities
Activity Low frequency Low frequency High frequency High frequency
Low duration High duration Low duration High duration
Morning care X (A; B; C)
Coffee/tea-activities X (A; B; C)
Medication X (A: pg* ) X (A: som* ; B* ;
C)
Toileting X (A; B; C)
Afternoon care X (A; B: pg; C: X (B: som* ; C:
som* ) pg* )
Extra care X (A; B; C: pg) X (C: som* )
Evening care X (C: pg* ) X (A: pg; B: pg* ) X (A: som* ; B:
som* ; C: som)
Meal activities X (A: som* ) X (A: pg* ; B; C)
Medical Care X (A* ; B; C)
General activities X (A; B; C* )
Social group activities X (A:* ;B: pg* ) X (B: som* ; C* )
Transfer/transport X (B: som; C* ) X (A; B: pg)
Incidental care X (A* ; B; C)
Additional direct Activities X (A; B; C* )
A = traditional care; B = hybrid care; C = integrated care; Som = somatic residents; PG = Psycho-geriatric residents. X indicates the relationship
between the average frequency and duration of this activity.
* Relationship was present at the majority of measurement points (figures without a * indicate that the relationship was found at all measurement

points)
56 A.T.G. Paulus, A.J.A. van Raak / Health Policy 85 (2008) 45–59
Activities with an above or below average score were
considered as activities with a high or low frequency or
duration. The average frequencies and durations of an
activity (calculated as the average of the 14 activities)
are indicated in Tables 3 and 4.
3.3.1. Activities
The table shows that morning care and evening care
were the most time-consuming activities, both in terms
of duration as in terms of frequency. This relationship
was present in all care types and for all types of res-
idents for morning care, and for somatic residents (in
A, B and C) for evening care. Most activities such as
extra care, medical care, afternoon care, incidental care
and additional direct activities had a low frequency and
a low duration. While a high duration was combined
with a low frequency for coffee/tea-activities, general
activities and social group activities, a reverse relation-
ship was present for medication, toileting and meal
activities.
3.3.2. Type of care
Most of the relationships mentioned in Table 5 were
independent of the type of nursing home care. The most
important exceptions included afternoon care (with a
higher duration in C in comparison to A and B); social
group activities and evening care (with a higher dura-
tion in B and C in comparison to A); transfer/transport
(with a lower frequency in C in comparison to A and
B).
3.3.3. Type of resident
Many relationships between duration and fre-
quency were also independent of the type of resident.
Exceptions included medication (less frequent for pg-
residents), meal activities (less frequent for somatic
residents) and evening care (higher duration for
pg-residents) in traditional care. In hybrid care,
exceptions included afternoon care and social group
activities (a higher duration for somatic residents)
and evening care (more frequent for pg-residents).
Integrated nursing home care showed different
relationships for extra care (lower frequency for pg-
residents) and afternoon care (higher duration for pg-
residents).
4. Conclusions and discussion
4.1. Conclusions
In the introduction of our paper we formulated three
research questions in order to assess the impact of inte-
grated care on the (relationship between) frequency and
duration of direct care activities. From our analysis, the
following conclusions in relation to these questions can
be drawn.
First, integrated care had an impact on the total aver-
age frequency of most direct care activities but not on
individual activities. At most measurement points, the
total average frequency was higher for integrated care
than for traditional and hybrid nursing home care. The
average frequency of individual activities such as extra
care, general activities and medication, however, sig-
nificantly changed over time (mainly increased) for all
nursing home care types. When viewed per activity,
the average frequency of medication, toileting, after-
noon care and extra care was generally higher for
somatic care. For coffee/tea-activities, evening care,
general activities and transfer/transport, this frequency
was generally higher for psycho-geriatric care.
Second, integrated care also had an impact on the
total duration of most direct care activities (per resi-
dent per day, irrespective of the type of patient). At
most measurement points the total duration was higher
for integrated care than for traditional and hybrid nurs-
ing home care. The duration per individual activity for
most activities, however, was the most time-consuming
for traditional nursing home care. The average dura-
tion of medication, toileting, extra care, meal activities,
medical care, transfer/transport and additional direct
activities significantly changed over time. In traditional
and hybrid care, the average duration increased. In inte-
grated care the opposite was true. Differences between
somatic and psycho-geriatric residents did not depend
on the introduction of integrated care.
Third, most relationships between the average fre-
quency and duration of activities (in terms of high
(low) frequencies combined with high (low) durations)
were unrelated to the type of resident and/or the type
of nursing home care. In other words, integrated care
hardly had an impact on the relationship between the
frequency and duration of direct care activities. Our
analysis also showed that on the whole and irrespec-
tive of the type of nursing home care, the (total) average
 A.T.G. Paulus, A.J.A. van Raak / Health Policy 85 (2008) 45–59
frequency of many direct care activities at most mea-
surement points was higher for somatic care than for
psycho-geriatric care. The same was true with respect
to the total average duration per resident per day.
4.2. Discussion
The implementation of integrated care mainly leads
to increases in the duration and frequency of the total
package of direct care activities but not of separate
activities. Policymakers and managers should be care-
ful. The introduction of integrated nursing home care
could imply a pressure on the resources available for
direct care. This is not to say that the introduction of
integrated care will turn the whole package of nursing
home care topsy-turvy.
Our conclusions seem to indicate that the frequency
and duration of individual direct care activities are less
sensitive for the underlying type of nursing home care
and type of resident. A study by Keith and Cowell [40]
found a comparable result with respect to the type of
care for treatment activities for stroke patients in three
different organizational hospital settings. Although not
always related to nursing home care, studies point to
the likely influence of the characteristics of caregivers
[41–44]; the age of patients [41,44,45]; gender [46]
and the (in)ability of (older) patients to express what
they want [12,47] on the duration and frequency of
activities. We did not investigate such factors. In this
sense our research was limited.
Instead, we consider the routine nature of many
direct care activities as providing an explanation. Direct
care is a significant proportion of nursing home care.
Some authors have found that approximately between
35% [10] and 70% [8] of (nursing) time spent on nurs-
ing home care concerns direct patient care activities.
Activities such as morning care or evening care occur
daily in every nursing home, irrespective of the type
of care. They are typical examples of routines. The
durability of routines explains why the introduction of
integrated care did not result in a set of care activi-
ties that was completely different from traditional care.
A number of workers, who were supposed to provide
integrated care, were in the habit of providing these
daily care activities. Such habits are difficult to shake
off, especially when they are bound by rules that exist
on all kind of levels, including the mind of the worker.
Nevertheless, the fact that the introduction of integrated
57
care did affect the duration and frequency of the total
set of direct care activities emphasises the possibility
for routines to change. This change was accompanied
by change of rules on two levels. The organization
introduced new rules in order to bind the concept
of integrated dare. In addition, the involved workers
were trained in performing new sorts of care activities.
Assumingly this resulted in a change of their mind-
sets. Currently, many health care policies are aimed at
introducing integrated care [1,2]. If this assumption is
valid, it indicates the direction which must be taken in
order to change existing routines to make room for inte-
grated care: a simultaneous change of rules at different
levels.
Even then, however, chances are that change is not
as all-encompassing as the concept of integrated care
might have us believe. Because of the very nature of
routines (changeable but also durable), high expecta-
tions on the effect of integrated care on service delivery
(and the subsequent effect on the quality of care for
residents) may be (partly) offset. In any case, further
research on dissecting which activities are routines or
not and how these routines can be changed is there-
fore recommendable. After all, routines may be a major
barrier to achieving the policy goal of actually imple-
menting integrated nursing home care [48], but as soon
as integrated nursing home care has become a rou-
tine, this routine will probably remain in place for a
comforting while.
Acknowledgements
The research was financed by the Dutch Ministry of
Health; The Province of Limburg; VGZ Insurers; the
Boncura Foundation/Care Group ‘Noord-Limburg’;
the Foundation Stimulating Scientific Research on
Nursing Home Care (SWBV).
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