Transforming community nursing services in the UK; lessons from a participatory evaluation of the implementation of a new community nursing model in East London based on the principles of the Dutch Buurtzorg model

The implementation of embedded researchers in policy, public services, and commercial settings: a systematic evidence and gap map

BACKGROUND

Embedding researchers into policy and other settings may enhance research capacity within organisations to enable them to become more research active. We aimed to generate an evidence map on evaluations of embedded researcher interventions to (i) identify where systematic reviews and primary research are needed and (ii) develop conceptual understandings of 'embedded researchers'. We define 'embedded researchers' through a set of principles that incorporate elements such as the aim of activities, the types of relationships and learning involved, and the affiliations and identities adopted.

METHODS

We included studies published across all sectors, searching fourteen databases, other web sources and two journals for evaluations published between 1991 and spring 2021. Data were extracted using a coding tool developed for this study. We identified new typologies of embedded researcher interventions through undertaking Latent Class Analysis.

RESULTS

The map describes 229 evaluations spanning a variety of contexts. Our set of principles allowed us to move beyond a narrow focus on embedded researchers in name alone, towards consideration of the wide range of roles, activities, identities, and affiliations related to embedded researchers. We identified 108 different allied terms describing an embedded researcher. Embedded researcher activity spanned a continuum across lines of physical, cultural, institutional, and procedural embeddedness (from weaker to more intense forms of embeddedness) and took a range of forms that bridge or blur boundaries between academia and policy/practice.

CONCLUSIONS

We developed a broad map of international embedded researcher activity in a wide range of sectors. The map suggests that embedded researcher interventions occupy a broader suite of models than previously acknowledged and our findings also offer insight on the type and nature of this literature. Given the clear policy interest in this area, a better understanding of the processes involved with becoming embedded within an organisation is needed. Further work is also necessary to address the challenges of evaluating the work of embedded researchers, including consideration for which outcome measures are most appropriate, to better understand their influence.

State of the Art on Family and Community Health Nursing International Theories, Models and Frameworks: A Scoping Review

A Family and Community Health Nursing (FCHN) model was first conceptualized by the WHO approximately 25 years ago in response to the epidemiological transition leading to major changes in the population health needs. To date, no study has comprehensively explored the adherence of current applications of FCHN to the WHO original framework. We carried out a scoping review on PubMed, Scopus and CINAHL with the aim to compare the main features of FCHN models developed at the international level with the WHO's framework. We identified 23 studies: 12 models, six service/program descriptions, four statements and one theoretical model. The FCHN models appear to focus primarily on sick individuals and their family, mainly providing direct care and relying on Interaction, Developmental and Systems Theories. While these features fit the WHO framework, others elements of the original model are poorly represented: the involvement of FCHN in prevention activities is scarce, especially in primary and secondary prevention, and little attention is paid to the health needs of the whole population. In conclusion, current applications of FCHN show a partial adherence to the WHO framework: population approaches should be strengthened in current FCHN models, with a stronger involvement of nurses in primary and secondary prevention.

Interdisciplinary frontline teams in home-based healthcare services-paradoxes between organisational work structures and the trust model: a qualitative study

BACKGROUND

Achieving access to quality healthcare services to ensure healthy lives and promote well-being for all at all ages is one of the United Nation's Sustainable Developments Goals. In view of this goal, sustainable community healthcare services in Norway need to be urgently restructured in light of demographic changes, including an increase in the percentage of older adults in the country. National healthcare policies recommend finding new ways to organise and perform services using new technology, new methods and new solutions. The goal is to ensure greater continuity in the provision of services and softer transitions that enable service users to deal with a smaller number of people. The trust model is one such suggested organisational approach. The goal of the trust model is to involve service users and their next of kin in decisions that concern them while also trusting frontline workers' professional judgement in assessing the need for services and adjusting them to address changes in the health of the users, thus making the services individually tailored and more flexible. This study aims to explore how organisational work structures influence the delivery of interdisciplinary home-based healthcare services.

METHODS

Observations, individual-, and focus groups interviews were conducted within community home-based healthcare services in a large Norwegian city with managers at different levels, nurses, occupational therapists, physiotherapists, purchaser-unit employees and other healthcare workers. Data was analysed thematically.

RESULTS

The results are presented in terms of themes- "Balancing on the margins: Negotiations between the time available, users' needs, unforeseen events and administrative tasks" and "One gathered unit, but with different work structures". The results identify organisational work structures that influence the performance of the trust model with regard to its intention of making flexible and individually tailored services available. However, these structures are different for the members of the interdisciplinary team, thus creating several paradoxes that need to be negotiated while fulfilling their daily responsibilities.

CONCLUSION

This study suggests that it is crucial to pay attention to paradoxes and structures experienced by interdisciplinary frontline workers in home-based healthcare services, since they are unavoidable factors that need to be acknowledged when designing approaches for addressing the changes expected in community healthcare services.

The mediating effect of psychosocial factors in the relationship between self-organizing teams and employee wellbeing: A cross-sectional observational study

BACKGROUND

Several benefits of working in a self-organizing team, such as higher job satisfaction and better engagement to work have been demonstrated in previous studies.

OBJECTIVE

To examine whether those employees working in a self-organizing team have higher job satisfaction and lower turnover intentions compared to those in non-self-organized teams. Further, to test whether psychosocial factors defined by the Job Demand-Control model would function as mediators.

DESIGN

A cross-sectional survey study.

SETTING(S)

Home care and assisted living facilities (with 24-h assistance).

PARTICIPANTS

Licensed practical nurses (N = 377), registered nurses, therapists and managers (N = 183), and other employees (N = 31) in services for older people.

METHODS

A survey for employees working in services for older people and who were either in the self-organized teams or in the non-self-organized teams. Data was analyzed using linear regression and mediation analyses.

RESULTS

Those employees who worked in a self-organizing team were more satisfied with their job and had lower turnover intentions compared to those in a non-self-organizing team (mean [SD] 3.9 [1.0] vs. 3.7 [1.0], p = 0.006 and 2.2 [1.2] vs. 2.5 [1.3], p = 0.006, respectively). Moreover, job demands and job strain partially mediated the effect of self-organizing teamwork on job satisfaction (Average causal mediation effect [95%CI] 0.09 [0.02-0.15] and 0.10 [0.03-0.18], respectively), as well as on turnover intentions (Average causal mediation effect [95%CI] -0.08 [-0.15 to -0.01] and -0.20 [-0.18 to -0.03], respectively).

CONCLUSIONS

In the context of older people care services, working in self-organizing teams may enhance employee wellbeing by lowering job demands and job strain, but not by improving job control. Based on the findings of this study, self-organization seems beneficial, however, it requires real autonomy for the teams and team building.

TWEETABLE ABSTRACT

Self-organizing teamwork increases job satisfaction and decreases turnover intentions via lower job demands and strain in older people care.

The Family and Community Nurses Cultural Model in the Times of the COVID Outbreak: A Focused Ethnographic Study

The ageing population, increasingly frail and chronically ill, and COVID-19 pandemic challenges have highlighted national health systems' vulnerability and, more strongly/to a greater extent, the pivotal role of the family and community nurse (FCN). However, the recent introduction of FCNs in primary care settings has yet to be explored in Italy. This study aimed to identify the FCNs' cultural model and its implementation during the COVID-19 outbreak. A focused ethnographic study was performed in a primary care community service in northern Italy. Participants were FCNs (N = 5), patients and caregivers (N = 12). Qualitative data were collected through semi-structured interviews, field notes, observation of FCNs' activities and access to documents. Qualitative analysis identified themes concerned with crucial aspects of FCNs' activities, role implementation, and their relationship with patients and families. This study illuminated how the FCN strategically takes care of and identifies patients' and community needs. Although the COVID-19 outbreak hindered effective FCN project implementation, this study highlighted that the pandemic provided a chance to better identify cultural, organisational and educational weaknesses that need to be addressed to support the full accomplishment of FCNs' scope of practice.

Implementing Buurtzorg-derived models in the home care setting: a Scoping Review

Background

Buurtzorg is a pioneering healthcare organization founded in the Netherlands. Buurtzorg has established independent, self-managing teams of nurses and promises high-quality home care at a lower cost through person-centered care, continuity of care, building trusting relationships, and networks in the neighborhood. Traditional home care services are increasingly reorganized according to the Buurtzorg-principles.

Objectives

This review aims to describe the experiences gathered during the implementation of the Buurtzorg-derived model outside the Netherlands. It further outlines their potential effects.

Design

Scoping Review.

Methods

Several electronic databases were searched for relevant articles, supplemented by hand-searching and internet searches for gray literature. Various publication types that described the implementation of the Buurtzorg model or its outcomes in countries other than the Netherlands were included. The data were analyzed using qualitative content analysis. Two authors coded the data in several cycles and created categories and subcategories.

Results

The review identified 25 publications reporting the experiences or outcomes of Buurtzorg-derived models outside the Netherlands. Upon implementing elements of Buurtzorg, the home care organizations adopted a person-centered care approach, with improved communication with patients and family caregivers, and could establish new networks with other services. The main challenges were related to the self-managed working culture, the organizational framework, or national healthcare policies, which hindered the implementation process.

Conclusions

The implementation of Buurtzorg-derived models is complex, challenging, and requires adaptations on several levels: upskilling of networking and staffing competencies in teams, leadership and IT requirements in the organization, and policy changes in the healthcare system. Individualized approaches and solid conceptual preparation are required for implementation.

Tweetable abstract

Experiences with the implementation of Buurtzorg in home care services outside the Netherlands. A scoping review @HegeduesAnna.

District nursing using neighbourhood care principles in practice: reflecting on our experience

There is much interest in the UK, and elsewhere, in the Dutch Buurtzorg model of providing district nursing, and there a number of published, external evaluations of pilot projects. We are nurses who worked in one such pilot that used an adapted Buurtzorg model called neighbourhood nursing using neighbourhood care principles. This article reflects on our experience and describes how we organised ourselves and, our experiences of working in such ways as well as the challenges. This article also offers advice for others who are considering introducing such models.

The implementation and outcomes of self-managing teams in elderly care: A scoping review

AIM

We aim to map the existing evidence and gaps in research on the implementation and outcomes of self-managing elderly care teams.

BACKGROUND

Due to increasing demand for elderly nursing care and an ageing workforce, recruiting and retaining community nurses have become challenging. Implementing self-managing teams may be a solution to address this problem.

EVALUATION

This scoping review included 27 studies, varying from narrative reviews to a quantitative cross-sectional study. The studies' primary focus on self-managing teams was essential for eligibility.

KEY ISSUES

Nurses' job satisfaction was high in self-managing teams due to improved relationships with patients and increased autonomy. Continuity of care and patient acceptability were high. Transformation of managers to coaches in a team with a flat hierarchy is needed to empower nurses with responsibility for their own work. Trust and teamwork should be assisted by suitable ICT support systems.

CONCLUSIONS

International interest in self-managing teams is large, but quantitative research is limited and guidelines for implementation are needed. Recommendations for potential successful implementation were made.

IMPLICATIONS FOR NURSING MANAGEMENT

Nurse autonomy and job satisfaction can increase by implementing self-managing teams. This requires a change in management styles, from managing to coaching nurses.

Implementation of an innovative model of community nursing for older adults based on Buurtzorg principles: a scoping review protocol

OBJECTIVE

The objective of this review is to map the international evidence on the implementation of the Buurtzorg model of community nursing practice for the care of older adults. We will describe where and how it has been used, and the challenges and facilitators of implementing this model of care.

INTRODUCTION

The challenges of aging have mobilized health systems around the world to replace the current facility- and disease-centered care model with integrated patient-centered care models. The Buurtzorg model provides autonomy to nurses, who, in turn, empower patients in need-based and self-reliant care.

INCLUSION CRITERIA

We will consider both published and unpublished studies and reports exploring the process of implementing the Buurtzorg community nursing model for the care of older adults (65 years and older) internationally, in all settings. Concepts of interest will include where the model has been used, how the model has been implemented, and what challenges and facilitators were reported.

METHODS

We will implement a three-step search strategy to locate both published and unpublished primary studies, theses, dissertations, book chapters, and text and opinion reports using the following databases: MEDLINE, LILACS, Cochrane CENTRAL, CINAHL, Web of Science, Google Scholar, Embase, Scopus, ProQuest Dissertations and Theses Global, and the official Buurtzorg website. We will present the search strategy in a PRISMA flow diagram. Data will be extracted using Excel spreadsheets and then analyzed narratively. Extracted data will be quantitatively pooled in tables using descriptive statistics to synthesize the characteristics of the reports and sample, followed by a qualitative summary of how the Buurtzorg model has been used, and the challenges and facilitators of implementing this care model.

Community Health Nursing in der Stadt (CoSta)

Zusammenfassung. Hintergrund: Die Erweiterung um die Pflegeprofession in der Primärversorgung wird im deutschsprachigen Raum gegenwärtig in Bezug auf Community Health Nursing (CHN) diskutiert. Dabei handelt es sich um einen bedarfsorientierten, evidenzbasierten und lebensweltbezogenen Ansatz. Akademisch qualifizierte Pflegefachpersonen versorgen eigenverantwortlich. In anderen Ländern ist CHN langjährig verankert. In Deutschland fehlt es an Modellversuchen und Belegen, um die spezifische Wirkweise in der Anwendung zu bewerten und Vergütungsoptionen durch potentielle Kostenträger abzubilden. Fragestellung/Ziel: Das CoSta-Projekt entwickelt modellhaft ein professionelles CHN-Konzept für chronisch kranke Menschen in einem marginalisierten Stadtquartier. Methode: Die Praxisentwicklung des CHN-Konzeptes erfolgt auf Grundlage einer Literaturübersicht, einer Bedarfserhebung im Quartier und eines theoretischen Rahmens unter Beteiligung des multiprofessionellen Teams in einem Stadtteil-Gesundheitszentrum. Ergebnisse: Die Konzeptentwicklung ist abgeschlossen. Das Modellkonzept basiert auf den Komponenten Public Health, Pflegetheorie, Leitbild, rechtlicher Rahmen und Evidenzbasierung. Als Interventionen sind pflegegeleitete Hausbesuche, Sprechstunden und Schulungen vorgesehen. Ihre Wirksamkeit wird derzeit in einer laufenden Interventionsstudie überprüft. Die Ergebnisse zur Machbarkeit stehen aus. Schlussfolgerungen: Das entwickelte Konzept wird als bedarfsorientiertes Angebot eingeschätzt. Für die Intervention erscheinen kultur- und peersensible Aspekte noch bedeutsamer als erwartet.

An integrated care systems model approach for speech and language therapy head and neck cancer services in England: service development and re-design in Cheshire and Merseyside

PURPOSE OF REVIEW

The incidence of head and neck cancer (HNC) is increasing globally and changes in treatment mean that patients are living longer with the condition. It is recognised that while there have been improvements at the diagnostic phase of the pathway, follow-up and on-going care can be fragmented and inequitable. Integrated care models (ICMs) are acknowledged as beneficial. The National Health Service in England is moving to a model whereby services are being re-organised to integrated care systems. This paper reviews the literature and discusses potential models of care to enhance speech and language therapy (SLT) provision for patients with HNC in line with the emerging ICS.

RECENT FINDINGS

The COVID-19 pandemic has provided an opportunity to review service provision and SLT teams quickly adapted to offering remote support. Discussions are currently on-going to explore the potential for patient initiated follow-up via the PETNECK 2 trial and the Buurtzorg 'neighbourhood model' holds promise.

SUMMARY

ICMs put the patient at the centre of care and have reported benefits for experience of care and clinical outcomes. Navigating organisational structures is complex. The Buurtzorg model provides a practical and theoretical framework to support organisational change.

Benefits of and barriers to telehealth for the informal caregivers of elderly individuals in rural areas: A scoping review

INTRODUCTION

Maintaining care for elderly individuals in rural areas is heavily dependent on support from informal caregivers. Many informal caregivers of the elderly in rural areas feel burdened and urgently require professional support. Interests in telehealth that can provide support irrespective of geographical location have been increasing.

OBJECTIVE

To identify the benefits of and barriers in telehealth engagement for rural caregivers to provide evidence for service improvement.

DESIGN

A scoping review method was used following PRISMA-ScR guidelines and Arksey and O'Malley's five-stage framework. Five databases were searched. The search terms were chosen based on the target intervention (i.e. telehealth), target population (caregivers of elderly individuals) and target context (rural areas). Two authors independently assessed the eligibility of studies and extracted data from eligible studies.

FINDINGS

Of 4220 retrieved studies, 19 articles met the inclusion criteria. This study identified four benefits of and two barriers to telehealth for rural caregivers. Four subthemes were identified as the key benefits in using telehealth for caregivers: decrease in psychological distress, increase in care efficiency, increase in social support and increase in access to resources, while inadequate telehealth infrastructures and caregivers' own reasons were the primary barriers in using telehealth for those populations.

CONCLUSIONS

Telehealth was shown to significantly benefit rural caregivers. Future research can be designed and conducted for overcoming the barriers to telehealth. Additionally, the benefits identified by this review need to be translated from research into practice for rural caregivers' care.

The State of the Evidence about the Family and Community Nurse: A Systematic Review

Introduction. The increase in chronic degenerative diseases poses many challenges to the efficacy and sustainability of healthcare systems, establishing the family and community nurse (FCN) who delivers primary care as a strategic role. FCNs, indeed, can embrace the complexity of the current healthcare demand, sustain the ageing of the population, and focus on illness prevention and health promotion, ensuring a continuous and coordinated integration between hospitals and primary care ser. The literature on FCNs is rich but diverse. This study aimed to critically summarise the literature about the FCN, providing an overall view of the recent evidence. Methods. A state-of-art systematic review was performed on PubMed, CINAHL, and Scopus, employing the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) statement and checklist to guide the search and reporting. Results. Five interpretative themes emerged from the 90 included articles: clinical practice, core competencies, outcomes, Organisational and educational models, and advanced training program. Conclusions. FCNs can make a major contribution to a population’s health, playing a key role in understanding and responding to patients’ needs. Even if the investment in prevention does not guarantee immediate required strategies and foresight on the part of decisionmakers, it is imperative to invest more political, institutional, and economic resources to support and ensure the FCNs’ competencies and their professional autonomy.

Co-location, an enabler for service integration? Lessons from an evaluation of integrated community care teams in East London

In an attempt to support care integration that promotes joined up service provision and patient-centred care across care boundaries, local health and social care organisations have embarked on several initiatives and approaches. A key component of service integration is the co-location of different professional groups. In this study, we consider the extent to which co-location is an enabler for service integration by examining multi-professional community care teams. The study presents findings from a qualitative evaluation of integrated care initiatives in a borough of East London, England, undertaken between 2017 and 2018. The evaluation employed a participatory approach, the Researcher-in-Residence model. Participant observation (n = 80 hr) and both semi-structured individual (n = 16) and group interviews (six groups, n = 17 participants) were carried out. Thematic analysis of the data was undertaken. The findings show that co-location can be an effective enabler for service integration providing a basis for joint working, fostering improved communication and information sharing if conditions such as shared information systems and professional cultures (shared beliefs and values) are met. Organisations must consider the potential barriers to service integration such as differing professional identity, limited understanding of roles and responsibilities and a lack of continuity in personnel. Co-location remains an important facet in the development of multi-professional teams and local service integration arrangements, but as yet, has not been widely acknowledged as a priority in care practice. Organisations that are committed to greying care boundaries and providing joined up patient care must ensure that sufficient focus is provided at the service delivery level and not assume that decades of silo working in health and social care and strong professional cultures will be resolved by co-location.

Why Resilience in Health Care Systems is More than Coping with Disasters: Implications for Health Care Policy

Health care systems need to be resilient to deal with disasters like the global spread of the Severe Acute Respiratory Syndrome Coronavirus (SARS-CoV-2) on top of serving the changing needs of a multi-morbid, ageing and often dispersed population. This paper identifies, discusses and augments critical dimensions of resilience retrieved from the academic literature. It pulls together an integrated concept of resilience characterised by organisational capabilities. Our concept does not focus on the micro-level like most resilience literature in health care but addresses the system level with many stakeholders involved. Distinguishing exogenous shocks to the health care system into adverse events and planned innovations provides the basis for our conclusions and insights. It becomes apparent only when dealing with planned interventions that transformative capabilities are indispensable to cope with sudden increases in health care pressures. Due to the current focus on absorptive and adaptive resilience, organisations over-rely on management capabilities that cannot generate a lasting increase in functionality. Therefore, reducing the resilience discussion to bouncing back from adverse events could deceive organisations into cultivating a suboptimal mix of organisational capabilities lacking transformative capabilities, which pave the way for a structural change that aims at a sustainably higher functionality.

Realist evaluation of a pilot intervention implementing interprofessional and interinstitutional processes for transitional care

In 2016, in Switzerland, we implemented transitional interprofessional and interinstitutional shared decision-making processes (IIPs) between a short-stay inpatient care unit (SSU) and primary care professionals. Between 2018 and 2019, we evaluated this intervention using a realist design to answer the following questions: for whom, with whom, in which context and how have IIPs been implemented? Our initial theory was tested via interviews with patients, primary care professionals and staff from the SSU. Results showed that a patient's stay at the SSU, with actors committed to facilitating IIPs, reinforced the perceived appropriateness and implementation of those IIPs. However, this appropriateness varied according to different contextual elements, such as the complexity of needs, preexisting collaborative practices and the purpose of the inpatient stay. Since IIPs occurred in a context of fragmented practices, proactive and sustained efforts are required of the actors implementing them and the organizations supporting them.

Buurtzorg Nederland, a proposal for nurse-led home care

Buurtzorg Nederland is a Dutch healthcare organization in which nursing teams provide home care in all the skills that affect their profession. This article raises some questions regarding more internal aspects of the organization based on three dimensions. The first, the organizational dimension, in which the teams are structured based on 8 roles, without hierarchies and supported by the coaching system. The second, the nursing dimension, in which it is highlighted that nurses deal with all the competences that affect their profession, from basic care to more complex care, with the aim of defragmenting care. And the third, the economic dimension, in which it stands out that the sustainability of the organization is in being a system without managers, of small teams that work in small geographic areas, with a computer system that supports all organizational matters, healthcare and financial. The main characteristics of Buurtzorg Nederland are the self-management of the teams and the defragmented care that both the nurse and the patient satisfy. However, this defragmentation has been achieved in terms of patient care, with the same team attending to all basic and complex care needs at home, but at other levels of care it has not been achieved, and the patient must visit other providers, therefore, health care at other levels continues to be fragmented.

Organisational development to support integrated care in East London: the perspective of clinicians and social workers on the ground

PURPOSE

Organisational Development (OD), with its focus on partnership working and distributed leadership, is increasingly advocated as an effective approach to driving change. Our evaluation of the impact of OD on delivery of integrated care in three London boroughs sheds light on how OD is being understood and implemented within health services, and what impact it is having on delivery of care.

DESIGN/METHODOLOGY/APPROACH

The findings presented here are based on a qualitative and participatory evaluation. The authors looked at how health and social care professionals communicated and coordinated delivery of care and evaluated the impact of current OD activities on the ground to evidence whether and to which degree they are enabling frontline staff to change their working routines towards greater coordination.

FINDINGS

Our findings highlight the limited reach and scope of a top-down approach to OD based on ad hoc coaching and staff engagement events, often delivered by external consultancies, and mostly focused at the senior management level. This approach fell short of enabling the creation of sustainable, integrated and collaborative organisations. Instead, some of the professionals that participated in our study tried to develop spaces that facilitated ongoing dialogue and mutual support among professionals on the ground.

PRACTICAL IMPLICATIONS

Initiatives of bottom-up OD such as those described in this paper have greater potential to change working routines as they enable staff to move towards more collaborative and coordinated work.

ORIGINALITY/VALUE

These findings contribute to the literature on OD in public services and highlight the benefits of a context-sensitive, pragmatic, and long-term approach to OD to help create sustainable collaborative organisations.

Buurtzorg Nederland, a proposal for nurse-led home care

Buurtzorg Nederland is a Dutch healthcare organization in which nursing teams provide home care in all the skills that affect their profession. This article raises some questions regarding more internal aspects of the organization based on 3dimensions. The first, the organizational dimension, in which the teams are structured based on 8 roles, without hierarchies and supported by the coaching system. The second, the nursing dimension, in which it is highlighted that nurses deal with all the competences that affect their profession, from basic care to more complex care, with the aim of defragmenting care. And the third, the economic dimension, in which it stands out that the sustainability of the organization is in being a system without managers, of small teams that work in small geographic areas, with a computer system that supports all organizational matters, healthcare and financial. The main characteristics of Buurtzorg Nederland are the self-management of the teams and the defragmented care that both the nurse and the patient satisfy. However, this defragmentation has been achieved in terms of patient care, with the same team attending to all basic and complex care needs at home, but at other levels of care it has not been achieved, and the patient must visit other providers, therefore, health care at other levels continues to be fragmented.