Learning to cross boundaries: The integration of a health network to deliver seamless care

Abstract

We analysed the development of an integrated network from a learning perspective to see how care givers from different organisations were able to cross the professional and organisational boundaries that existed between them to make sure patients receive the right care, at the right moment, in the right place. We show how through a process of collective learning social contacts between health professionals increased and improved. These professionals learned to speak each other's language, learned how other professionals and organisations work and learned to look at the care process from a network perspective instead of only from a professional or organisational perspective. Through this learning process, they also experienced the limitations of standardizing knowledge in criteria, protocols and rules, and the value of direct contact for sharing information and knowledge, to ensure continuity in care.

Introduction

Better coordinated care, it is widely acknowledged, leads to more efficient and effective care [1], [2], [3], [4]. Health care, however is characterised by an enormous high level of differentiation (between professionals, units and organisations) and a low level of integration. To be able to deliver more efficient and more effective care either differentiation has to be reduced or integration increased [5]. ‘Since differentiation (specialisation) is not only the very essence of this system, but also a source of its great strength, it is the level of integration that shall have to be increased’ [5]. Integration of care can be seen as an organisational process that seeks to achieve seamless and coordinated care, tailored to the patient's needs, and based on a holistic view of the patient [6].

In the United States, large regional care organisations, called Health Maintenance Organisations (HMO), have been founded to be able to deliver integrated care. Potential benefits are reductions in cost because of economy of scale, and better coordination because all professionals and processes are part of one system. However, according to Burns and Pauly, who studied these integration processes, ‘integrated care structures rarely integrated the actual delivery of patient care’ [7]. In many Health Maintenance Organisations, only structures are integrated, the processes and professionals are not better aligned. It seems that these structures are not able to fundamentally change the practice of professionals and the way in which they collaborate [7], [8]. But in many countries, there are now successful examples of integrated care, where professionals still work in separate organisations [1]. These integrated care networks are able to coordinate care services across people, functions, activities and sites over time [9].

So, instead of taking a management perspective and looking at structures as many authors do (for example, [5], [9]), we should focus on the health professionals, to see how they are stimulated to change their practice and collaborate. For this paper, we analysed the development of such an integrated care network for stroke patients in The Netherlands in which professionals from different organisations were able to improve coordination and deliver more seamless and continuous care.

According to Anthony [10], who analysed the referral relationships in the US between the primary care provider and other providers, direct communication between health professionals improves integration of care. These professionals give each other more information and conform better to established rules and norms (structures) between them. Direct communication is stimulated by the existence of informal relationships between health professionals, says Anthony [10]. According to Cott [11], such informal relationships are based on proximity. Individuals are more likely to interact if they are situated close to each other (physical proximity), work on the same tasks (task proximity), in the same formal organisational unit (formal, organisational created proximity), already established social contacts with each other (social proximity), and have a similar professional background (professional proximity) (see also, Farris [12]). Relevant for the latter are similarity of techniques, values, mental images, status and jargon [13]. The problem in establishing integrated networks, however, is that there are many boundaries between health professionals [1]. Direct communication between professionals is often lacking [5], [11], [14], because these professionals work in different organisations, on different locations, have different professional backgrounds (jargon, techniques, values and status), perform related but different tasks, and many of them have never even met. So, how are health professionals able to look beyond the boundaries of their own profession and organisation and establish an integrated network for the delivery of a continuum of care?

To answer this question, we analysed the development in The Netherlands of an integrated network for stroke patients, called stroke service. Our case study is a stroke service in a specific region in The Netherlands. The Dutch government gave this region a grant to experiment with the development of a stroke service. The aim was to see if the same positive results that were generated in other countries by reorganizing stroke care could also be reached under the specific conditions in the Dutch Health Care organisations. We were asked to evaluate the process [15].

We focus our analysis on one specific intervention, namely the development of transfer criteria for the referral of patients from the hospital to two newly developed rehabilitation units in two nursing homes. This specific intervention is interesting because it is exemplary for integration of care. It is about crossing barriers between professionals from different organisations, so the right patient is referred at the right moment to the right care provider. What makes this intervention even more relevant for our research is that many interests are involved. In our research case, a conflict arose about the transfer criteria. The rehabilitation centre was namely afraid of losing clients to the new units. Although such an open conflict is unusual, as most conflicts remain hidden, it offered us the opportunity to study the direct social contacts between the professionals more easily, as the differences in tasks, interests and professional backgrounds were part of this conflict.