S6.6 Enacting integrated care. Experiences, approaches and novel practices
Chair: Rose Mari Olsen & Aud Obstfelder
Discussant: Gudmund Ågotnes & Ragnhild Hellesø
The ageing population and increasing number of individuals suffering from multiple long-term conditions put pressure on healthcare budgets. To this set of challenges, the authorities expect that new models of care integrating services across sectors, will deliver better outcomes in terms of health gain, patient satisfaction and cost-effectiveness. However, evidence suggest that integrated care still is a blurred and immature concept that in its current form does not deliver the outcomes expected. There is need for more knowledge relating to how integrated care should be defined, enacted and enabled, and whether it can ever contribute significantly to tackling healthcare system challenges. The aim of this symposium is to contribute to a critical debate on the expectations of integrated care and point to further development in policy, practice and research. To achieve this, the symposium will include five individual speakers and two discussants. The individual speakers will present papers that use different methodological approaches to the analysis of novel practices for integrated care and the discussants will provide commentaries to the papers and explore how they help advance the topic.
S6.6.1 Development of care coordination models and workforce roles
Susan A. Chapman
School of Nursing, University of California, USA
Background: Implementation of care coordination is far from standardized with organizations adopting very different approaches to structure and staffing. Research on the care coordination workforce has been limited by the absence of a clear taxonomy and overlap of jobs and roles. This study examines the configuration of care coordination systems, requirements of workforce roles, training, and reimbursement. Methods: A qualitative comparative case study design including a convenience sample of four health systems across USA at different stages of adoption of risk-based contracts. Semi-structured interviews of various stakeholders across the four systems were conducted. Results: Despite differences among the study sites we found commonality in care coordination staff processes for high and low complexity patients. All used a risk stratification algorithm to identify risk level when then translated into care coordination services and staffing. Sites used unlicensed personnel for low complexity care coordination activities. They used RNs, NPs, and social workers for more complex patients. Most care coordination was conducted telephonically. Conclusion: Health reform has led to a greater investment in care coordination function and workforce development. However, there is little consistency in roles, professional base, or preparation.
S6.6.2 Nurses’ information exchange during older patient transfer between hospital and home health care
Rose Mari Olsen
Faculty of Nursing and Health Sciences, Nord University, Norway
Background: The successful transfer of an older patients between health care organizations requires information exchange about the health status and individual needs of the patients. This study explore how information exchange in this context is performed in practice.
Methods: Mixed methods including focus group interviews with 14 registered nurses in home health care and hospital, a case study of nine episodes of hospitalizations of older patients, and review of nursing documents from a total of 102 records of older inpatients admitted from home health care to hospital. Results: Hospital nurses and home health care nurses experience several barriers that negatively influence their information exchange. Admission notes were present in 1% of the patient transfers, while discharge notes were present in 69%. Incompleteness in the content of both written and verbal information was found. Both presence and content of a discharge note were associated with patient and transfer characteristics. Conclusions: The gap in the information flow, as well as incompleteness in the content of written and verbal information exchanged, constitutes a challenge to the continuity of care for hospitalized home-living patients. Recognition of the barriers that affect nurses’ exchange of information is important to ensure patient safety and successful transitions.
S6.6.3 Inter-Municipal Cooperation in out-of-hours services in Norway: the role and interplay of structures and processes
Centre for Care Research, south, University of Agder, Norway
Background: There are consensus on the beneficial outcomes of inter-municipal cooperation (IMC) in service delivery. Considering the additional transaction costs associated with this type of cooperation, this study aimed to investigate how these benefits and costs are conditioned by the quality of network processes and structures. Method: Structural Equation Modeling (SEM) was used to analyze survey- and registry data derived from 266 Norwegian municipalities participating in 93 unique IMC’s in Out-Of-Hours (OOH) services. Results: Trust and consensus among the participants are important conditions to increase the benefits and reduce transaction costs. In turn, the level of trust appears to be fostered by network stability and less formalized forms of organizing, and the level of consensus by a decreasing network-size. Conclusion: IMC’s are not uniform entities, and the outcomes are not necessarily given without considering the trust and consensus among the participants and how these are influenced by the size, stability and organizational forms of the network. Policy-makers and practitioners should use these insights as yardsticks when arranging IMC.
S6.6.4 Formalising emergent organisation in health and social care: the translation and application of insights from ethnographic research on the work of hospital nurses
School of Healthcare Sciences, Cardiff University, UK
Background: Recent decades have witnessed an explosion of technologies that draw on systems engineering and management science in order improve service integration. Yet a significant proportion of healthcare is emergent and uncertain and successful service integration depends not on rational planning processes but on iterative negotiations and adjustments to treatment and care in response to contingencies. Methods: Ethnographic research examined in-depth the nursing contribution to managing emergent organsiation in a tertiary hospital in Wales. Translation Mobilisation Theory builds on this work to offer a generic theory of emergent organisation wherever this is found. Result: In the original study, sociological theories were deployed to ‘see’ emergent organisation in action and render visible the work of nurses in mediating these processes. While social theories enable the researcher to look at familiar routines from a new perspective, these do not easily translate into practice. In this presentation, I rework the findings from the original study and draw on Translation Mobilisation Theory to develop a Care Trajectory Management Framework. Conclusion: This paper makes the case for a more explicit acknowledgement of the work involved in emergent organisation in health and social care systems and offers a framework for its formalisation.
S6.6.5 Equity and quality in public dementia care services by integrating the perspectives of families and service providers
Jill-Marit Moholt, Bodil H. Blix avina Allen
Centre for Care Research, north, UiT The Arctic University of Norway
Background: Family care for home-dwelling persons with dementia is an important issue in health policies. Knowledge regarding caregivers’ support needs and use of services is essential for the planning and design of service provisions and the integration of formal and informal care. Methods: Mixed methods explored collaborations between family caregivers and public healthcare services for persons with dementia by including a survey involving 430 family caregivers in 32 municipalities in Northern Norway, focus group interviews with healthcare professionals and senior volunteers, and individual interviews with family caregivers. Municipalities within the Sami language administrative district were included. Results: The different part studied complement and nuance each other regarding understanding of access, use and non-use, quality and content of healthcare services available to the family caregivers and the collaborations between family caregivers and public healthcare services. Conclusion: Knowledge about family caregivers’ needs and use of services is essential to form authentic partnerships between services and family caregivers, and thereby an optimal integration of formal and informal care for persons with dementia. An adequate integration of healthcare services could postpone the institutionalization of persons with dementia.