Organizational Capabilities for Integrating Care: A Review of Measurement Tools

Is a bio-psychosocial approach model possible at the first level of health services in the Democratic Republic of Congo? An organizational analysis of six health centers in South Kivu

BACKGROUND

The health system, in the Democratic Republic of Congo, is expected to move towards a more people-centered form of healthcare provision by implementing a biopsychosocial (BPS) approach. It's then important to examine how change is possible in providing healthcare at the first line of care. This study aims to analyze the organizational capacity of health centers to implement a BPS approach in the first line of care.

METHODS

A mixed descriptive and analytical study was conducted from November 2017 to February 2018. Six health centers from four Health Zones (South Kivu, Democratic Republic of Congo) were selected for this study. An organizational analysis of six health centers based on 15 organizational capacities using the Context and Capabilities for Integrating Care (CCIC) as a theoretical framework was conducted. Data were collected through observation, document review, and individual interviews with key stakeholders. The annual utilization rate of curative services was analyzed using trends for the six health centers. The organizational analysis presented three categories (Basic Structures, People and values, and Key Processes).

RESULT

This research describes three components in the organization of health services on a biopsychosocial model (Basic Structures, People and values, and Key processes). The current functioning of health centers in South Kivu shows strengths in the Basic Structures component. The health centers have physical characteristics and resources (financial, human) capable of operating health services. Weaknesses were noted in organizational governance through sharing of patient experience, valuing patient needs in Organizational/Network Culture, and Focus on Patient Centeredness & Engagement as well as partnering with other patient care channels.

CONCLUSION

This study highlighted the predisposition of health centers to implement a BPS approach to their organizational capacities. The study highlights how national policies could regulate the organization of health services on the front line by relying more on the culture of teamwork in the care structures and focusing on the needs of the patients. Paying particular attention to the values of the agents and specific key processes could enable the implementation of the BPS approach at the health center level.

Developing evaluation capacities in integrated care projects: Lessons from a scientific support mission implemented in Belgium

The capacity of self-assessment, to learn from experience, to make information-based decisions, and to adapt over time are essential drivers of success for any project aiming at healthcare system change. Yet, many of those projects are managed by healthcare providers' teams with little evaluation capacity. In this article, we describe the support mission delivered by an interdisciplinary scientific team to 12 integrated care pilot projects in Belgium, mobilizing a set of tools and methods: a dashboard gathering population health indicators, a significant event reporting method, an annual report, and the development of a sustainable "learning community." The article provides a reflexive return on the design and implementation of such interventions aimed at building organizational evaluation capacity. Some lessons were drawn from our experience, in comparison with the broader evaluation literature: The provided support should be adapted to the various needs and contexts of the beneficiary organizations, and it has to foster experience-based learning and requires all stakeholders to adopt a learning posture. A long-time, secure perspective should be provided for organizations, and the availability of data and other resources is an essential precondition for successful work.

Implementing Integrated Community-Based Primary Healthcare: Applying the iCoach-Approach to Case Selection to Denmark

BACKGROUND

The iCoach approach to case selection focuses on innovative models of community-based primary healthcare (CBPHC) and their contexts. The aim of this study was to assess the possibilities and limitations of the approach based on Denmark, which differs in significant ways from the jurisdictions initially included.

THEORY AND METHODS

Case study research suggests the approach is an interesting attempt to standardise case selection based on literal replication. The study reviewed the national grey literature and interviewed key informants at national and local levels.

RESULTS

Applying the approach to Denmark required redefining selection criteria related to collaboration and context to capture its specific institutional and policy context. Selecting cases at the organisational level also required assessing how the system level contexts compared to those of the initial three jurisdictions included in iCoach.

DISCUSSION

The iCoach approach allows collecting broadly comparable cases of innovative models of CBPHC across jurisdictions. However, the analysis of underlying conditions of implementing innovative models requires a more interactive approach to case selection.

CONCLUSION

Researchers need to be clearer about the specific purpose of the case selection. This is also highly relevant for practitioners to ensure that insights are applicable in specific local and national contexts.

A Scoping Review of Facilitators of Multi-Professional Collaboration in Primary Care

INTRODUCTION

Multi-professional collaboration (MPC) is essential for the delivery of effective and comprehensive care services. As in other European countries, primary care in Norway is challenged by altered patient values and the increased expectations of health administrations to participate in team-based care. This scoping review reports on the organisational, processual, relational and contextual facilitators of collaboration between general practitioners (GP) and other healthcare professionals (HCPs) in primary care.

METHODS

A systematic search in specialist and Scandinavian databases retrieved 707 citations. Following the inclusion criteria, nineteen studies were considered eligible and examined according to Arksey and O'Malley's methodological framework for scoping reviews. The retrieved literature was analysed employing a content analysis approach. A group of stakeholders commented on study findings to enhance study validity.

RESULTS

Primary care research into MPC is immature and emerging in Norway. Our analysis showed that introducing common procedures for documentation and handling of patient data, knowledge sharing, and establishing local specialised multi-professional teams, facilitates MPC. The results indicate that advancements in work practices benefit from an initial system-level foundation with focus on local management and MPC leadership. Further, our results show that it is preferable to enhance collaborative skills before introducing new professional teams, roles and responsibilities. Investing in professional relations could build trust, respect and continuity. In this respect, sufficient time must be allocated during the working day for professionals to share reflections and engage in mutual learning.

CONCLUSION

There is a paucity of research concerning the application and management of MPC in Norwegian primary care. The work practices and relations between professionals, primary care institutions and stakeholders on a macro level is inadequate. Health care is a complex system in which HCPs need managerial support to harvest the untapped benefits of MPC in primary care. As international research demonstrates, local managers must be supported with infrastructure on a macro level to understand the embedding of practice and look at what professionals actually do and how they work.

Values, interests and power: the politics of integrating services

Purpose

Differences in professional values, organisational interests and access to resources are key issues to be addressed when integrating services. They are widely seen by service planners and commissioners to be matters of governance. However, they also inform critical debates in political science. In essence they revolve around the question of distribution, or (how to decide) who gets what. The purpose of this paper is to re-frame the subject of inter-organisational governance in integration by conceptualising it through the lens of three prominent politico-theoretical approaches: the liberal, the authoritarian and the radical-utopian.

Design/methodology/approach

A discussion paper that proceeds by utilising political science terms of reference and applying it to a public management problem.

Findings

All three theories provide particular insights into the way in which service planners and commissioners may think about the inescapable plurality of values and interests in integration programmes. Where the liberal perspective places particular emphasis on the purpose and utility of organisational autonomy and self-direction, the authoritarian model highlights the need to produce results within tight timescales. It also accords with the manner in which integration policy is normally implemented, top down. The radical-utopian model is built on the least realistic assumptions but offers researchers a useful framework to assess the rationale and effectiveness of value-based policy in integration programmes wherever robust inter-organisational structures fail to materialise.

Originality/value

Whilst there has been significant research on how to conceptualise integration programmes, scholars have usually championed a public management approach. The potential insights of political thought have not been explored until now. The paper demonstrates that the wider conceptual framework of political theory has significant purchase in the field of integration studies and can help us understand the benefits and limitations of an interdisciplinary approach.

Protocol for development and validation of a context-appropriate tool for assessing organisational readiness for change in primary health clinics in South Africa

INTRODUCTION

A large treatment gap for common mental disorders (such as depression) exists in South Africa. Comorbidity with other chronic diseases, including HIV and diseases of lifestyle, is an increasing public health concern globally. Currently, primary health facilities as points of care for those with chronic disease provide limited services for common mental disorders. Assessing organisational readiness for change (ORC) towards adopting health innovations (such as mental health services) using contextually appropriate measures is needed to facilitate implementation of these services. This study aims to investigate the validity of the Texas Christian University Organisational Readiness for Change (TCU-ORC) scale in the South African context. Subsequently, we will develop a shortened version of this scale. This study is nested within Project MIND, a multiyear randomised controlled trial that is testing two different approaches for integrating counselling for common mental disorders into chronic disease care. Although the modified, contextually appropriate ORC measure resulting from the proposed study will be developed in the context of integrating mental health into primary healthcare services, the potential for the tool to be generalised to further understanding barriers to any change being implemented in primary care settings is high.

METHODS AND ANALYSIS

We will establish internal consistency (Cronbach's alpha coefficients), test-retest reliability (intraclass correlation coefficient) and construct validity of the long-form TCU-ORC questionnaire. Survey data will be collected from 288 clinical, management and operational staff from 24 primary health facilities where the Project MIND trial is implemented. A modified Delphi approach will assess the content validity of the TCU-ORC items and identify areas for potential adaptation and item reduction.

ETHICS AND DISSEMINATION

Ethical approval has been granted by the South African Medical Research Council (Protocol ID EC004-2-2015, amendment of 20 August 2017). Results will be submitted to peer-reviewed journals relevant to implementation and health systems strengthening.

Creating and facilitating change for Person-Centred Coordinated Care (P3C): The development of the Organisational Change Tool (P3C-OCT)

BACKGROUND

Person Centred Coordinated Care (P3C) is a UK priority for patients, carers, professionals, commissioners and policy makers. Services are developing a range of approaches to deliver this care with a lack of tools to guide implementation.

METHODOLOGY

A scoping review and critical examination of current policy, key literature and NHS guidelines, together with stakeholder involvement led to the identification of domains, subdomains and component activities (processes and behaviours) required to deliver P3C. These were validated through codesign with stakeholders via a series of workshops and cognitive interviews.

RESULTS

Six core domains of P3C were identified as follows: (i) my goals, (ii) care planning, (iii) transitions, (iv) decision making (v), information and communication and (vi) organizational support activities. These were populated by 29 core subdomains (question items). A number of response codes (components) to each question provide examples of the processes and activities that can be actioned to achieve each core subdomain of P3C.

CONCLUSION

The P3C-OCT provides a coherent approach to monitoring progress and supporting practice development towards P3C. It can be used to generate a shared understanding of the core domains of P3C at a service delivery level, and support reorganization of care for those with complex needs. The tool can reliably detect change over time, as demonstrated in a sample of 40 UK general practices. It is currently being used in four UK evaluations of new models of care and being further developed as a training tool for the delivery of P3C.

Integration as a scientific paradigm

Purpose

Integration is policy, practice as well as object of systematic investigation. What we do not know is whether or not integration can be understood as a science. In his book The Structure of Scientific Revolutions, Thomas Kuhn formulated a notion of (natural) sciences based on the emergence of commitments amongst a community of scientists to a set of logics, model and exemplars. He called this a paradigm. The purpose of this paper is to assess the scientific nature of integration by perceiving it as a paradigm in Kuhn’s sense.

Design/methodology/approach

The paper proceeds by conceptual reflection through matching existing components, theories and exemplifications of integration to Kuhn’s model of a scientific paradigm. Integration is understood broadly, either vertical or horizontal, and located within the practical domains of policy formulation, policy implementation and evaluation research. The nature, scope and depth of group commitments amongst students and practitioners of integration receive particular attention in line with Kuhn’s social interactionist approach.

Findings

Employing Kuhn’s notion of paradigm in the context of integration highlights the fundamental tension between integration efforts and integration outcomes. Whilst integration defines itself in contradistinction to professional boundaries and fragmentation, the paper argues that it fails to develop a strong theoretical and empirical foundation for a robust and stable group commitment. The reason is that the key motivational force that may create a stable group commitment amongst those engaged in integration, the patient perspective, remains outside the integration paradigm. This leaves integration as a practice and policy model underdeveloped, mainly paradigmatically illustrated by singular exemplars and rooted in aspirational policy vocabulary, while clustered around a near dogmatic belief that working together between services must lead to improved quality of care. To become a scientific paradigm the group commitment in integration would have to coalesce around a clear ontology (symbolic generalisations), epistemology (models of knowledge) and manifestations in practice (exemplars).

Research limitations/implications

At present both the ontology and epistemological foundations of integration practice and research are insufficiently clear. This hampers the development of integration practice as well as a better understanding of how to evaluate integration outcomes. Future studies should focus on the depth, nature and subject of group commitments to assess whether integration is a viable candidate for scientific paradigm or an assorted construct of policy aspirations.

Originality/value

The paper questions the rigour and trajectory of integration practice, policy and research. It identifies a tension at the centre of the field between group commitments to scientific exemplars (case studies) and symbolic generalisations, encapsulated in the desire to improve patient care. The notion of a scientific paradigm thus helps to re-frame the discussion about research and practice in integration.

Organizational Context Matters: A Research Toolkit for Conducting Standardized Case Studies of Integrated Care Initiatives

Introduction:

The variable success of integrated care initiatives has led experts to recommend tailoring design and implementation to the organizational context. Yet, organizational contexts are rarely described, understood, or measured with sufficient depth and breadth in empirical studies or in practice. We thus lack knowledge of when and specifically how organizational contexts matter. To facilitate the accumulation of evidence, we developed a research toolkit for conducting case studies using standardized measures of the (inter-)organizational context for integrating care.

Theory and Methods:

We used a multi-method approach to develop the research toolkit: (1) development and validation of the Context and Capabilities for Integrating Care (CCIC) Framework, (2) identification, assessment, and selection of survey instruments, (3) development of document review methods, (4) development of interview guide resources, and (5) pilot testing of the document review guidelines, consolidated survey, and interview guide.

Results:

The toolkit provides a framework and measurement tools that examine 18 organizational and inter-organizational factors that affect the implementation and success of integrated care initiatives.

Discussion and Conclusion:

The toolkit can be used to characterize and compare organizational contexts across cases and enable comparison of results across studies. This information can enhance our understanding of the influence of organizational contexts, support the transfer of best practices, and help explain why some integrated care initiatives succeed and some fail.