Reconciling practice, research and reality of integrated care. Critical reflections on the state of a discipline

Making integrated care happen: Middle managers' views on leadership for promoting multidisciplinary collaboration at the early stage of the Finnish social and healthcare reform

Different forms of health and social care integration are promoted in many countries to address the complex needs of the population. This qualitative study explores integrative leadership from the perspective of middle managers. The study examines how national and regional integration aspirations are converted into micro-level multidisciplinary collaborations through leadership actions in primary health and social services. The study was conducted at the early stages of major social and health services reform in Finland. The data forms a cross-section of 11 interviews with middle-level managers from different sectors in a new wellbeing services county. Thematic analysis revealed that managers view integrated care positively, considering it efficient and useful. Their main goal is to create public value, including cost-efficiency. The managers believe that their task is to promote multidisciplinary collaboration by developing visions, structures and processes that support professionals in implementing changes in daily work. Many aspects of integrative leadership, such as shared goals and collaborative processes, were identified. More contradictory issues, such as tensions and conflicts between stakeholders, complex accountabilities, legitimacy and power imbalances, were almost absent in the data. These issues should be addressed in organisations, and their role should be studied further as a potential barrier to the successful implementation of integrated care.

Does competition support integrated care to improve quality?

Introduction

This work investigates the compatibility of integrated care and competition in China and analyses the impact of integrated care on regional care quality (DeptQ) within a competitive framework.

Method

The study was built on multivariate correspondence analysis and a two-way fixed-effects model. The data were collected from Xiamen's Big Data Application Open Platform and represent nine specialised departments that regularly performed inter-institutional referrals between 2016 and 2019.

Results

First, care quality for referred patients (ReferQ) and the relative scale of referred patients (ReferScale) and competition have an antagonistic but not completely mutually exclusive relationship. Second, ReferQ and competition both have a significant effect on DeptQ, but only when competition is weak can ReferQ and competition act synergistically on DeptQ. When competition is fierce, competition will weaken the impact of ReferQ on DeptQ.

Conclusion

Changes in the intensity of integrated care and competition ultimately affect care quality.

Bumpy road: implementing integrated psychiatric and somatic care in joint-specialty emergency departments: a mixed-method study using Normalization Process Theory

Purpose

Life expectancy is 15–20 years shorter for individuals with than for people without mental illness. Assuming that undiagnosed and undertreated somatic conditions are significant causes, the Central Denmark Region set out to implement joint psychiatric and somatic emergency departments (EDs) to support integrated psychiatric/somatic care as an effort to prolong the lifetime of individuals with mental illness. Through the lens of Normalization Process Theory, the authors examine healthcare frontline staff’s perceptions of and work with the implementation of integrated psychiatric/somatic care in the first joint-specialty ED in Denmark.

Design/methodology/approach

A single-case mixed-methods study using Normalization Process Theory (NPT) as an analytic framework to evaluate implementation of psychiatric/somatic integrated care (IC) in a joint-specialty emergency department. Data were generated from observations, qualitative interviews and questionnaires distributed to the frontline staff.

Findings

Implementation was characterized by a diffuse normalization leading to an adaption of the IC in a fuzzy alignment with existing practice. Especially, confusion among the staff regarding how somatic examination in the ED would ensure prolonged lifetime for people with mental illness was a barrier to sense-making and development of coherence among the staff. The staff questioned the accuracy of IC in the ED even though they recognized the need for better somatic care for individuals with mental illness.

Practical implications

This study highlights that a focus on outcomes (prolonging lifetime for people with mental illness and reducing stigmatization) can be counterproductive. Replacing the outcome focus with an output focus, in terms of how to develop and implement psychiatric/somatic IC with the patient perspective at the center, would probably be more productive.

Originality/value

In 2020, the Danish Health Authorities published new whole-system recommendations for emergency medicine (EM) highlighting the need for intensifying integrated intra and interorganizational care including psychiatric/somatic IC (ref). Even though this study is not conclusive, it points to subjects that can help to identify resources needed to implement psychiatric/somatic IC and to pitfalls. The authors argue that the outcome focus, prolonging the lifetime for individuals with mental illness by identifying somatic illness, was counterproductive. In accordance with the recommendations of contemporary implementation studies, the authors recommend a shift in focus from outcome to output focus; how to develop and implement psychiatric/somatic IC.

Health workforce planning under conditions of uncertainty: identifying supportive integrated care policies using scenario analysis

Purpose

Integrated care presents health workforce planners with significant uncertainty. This results from: (1) these workforces are likely in the future to be different from the present, (2) integrated care's variable definitions and (3) workforce policy and planning is not familiar with addressing such challenges. One means to deal with uncertainty is scenario analysis. In this study we reveal some integration-supportive workforce governance and planning policies that were derived from the application of scenario analysis.

Design/methodology/approach

Through a mixed methods design that applies content analysis, scenario construction and the policy Delphi method, we analysed a set of New Zealand's older persons health sector workforce scenarios. Developed from data gathered from workforce documents and studies, the scenarios were evaluated by a suitably qualified panel, and derived policy statements were assessed for desirability and feasibility.

Findings

One scenario was found to be most favourable, based on its broad focus, inclusion of prevention and references to patient dignity, although funding changes were indicated as necessary for its realisation. The integration-supportive policies are based on promoting network-based care models, patient-centric funding that promotes collaboration and the enhancement of interprofessional education and educator involvement.

Originality/value

Scenario analysis for policy production is rare in health workforce planning. We show how it is possible to identify policies to address an integrated care workforce's development using this method. The article provides value for planners and decision-makers by identifying the pros and cons of future situations and offers guidance on how to reduce uncertainty through policy rehearsal and reflection.