A theory-driven evaluation of Integrated Health and Social Care Programmes in the Apulia Region

Abstract

Introduction: Service delivery has traditionally developed in ways that have tended to fragment care. In the last decades, however, the growing numbers of people with complex needs (i.e. chronic conditions and multiple care needs) have required the development of delivery systems that bring together a range of professionals and skills from both the cure and care sectors to meet those needs. In other words, on the one hand people needs are changing and growing challenging the financial sustainability of health care systems while on the other delivery services are still linked to traditional organizational models and resources – people, time, facilities and knowledge— are scarce. In this contest Integrated care (IC) arrangements have emerged in a variety of ways and have become a priority in the policy agenda at National and Regional level throughout Europe. In response to concerns that the needs of the aging population for well-integrated care are increasing, our research aims to evaluate the impact of IC programs in terms of improvements in the quality of life, patient satisfaction, staff satisfaction and change in work processes. According to the literature evidence stating that the effectiveness of attempts to provide better integrated care is highly dependent on the context in which the intervention takes place and cannot be seen separated from this, the question guiding our research shifts from “what is the effectiveness of the particular integrated model (compared with non-integrated)?” to “what is the effectiveness of integrated model designed for a specific context?.”Theory and methods: We employed a theory-driven approach for the evaluation of IC programs in the Apulia Region (Italy). It requires surfacing the assumptions on which the program is based in considerable detail: what activities are being conducted, what effect each particular activity will have, what the program does next, what the expected response is, what happens next, what are the expected outcomes. Then the evaluation follows each step in the sequence in order to assess whether the expected mini-steps are actually experienced or not. According to this approach the evaluation aims to answer the following questions: what are the aims of IC? Why IC arrangements have emerged? What approaches work well and in what contexts? What is the role of different actors? What are the facilitating factors? What are the key components of good practical examples found? How to align objectives? What resources are required to make integration succeed and how can these be efficiently distributed and used?We adopted a multi-method approach triangulating data from different sources in order to gain an in-depth picture of the contexts, mechanisms and driving factors of IC. These include qualitative data collection, interviews and questionnaires with decision makers, staff, and patient/service users and non-participant observation of meetings. The evaluation presented is part of a broader three year PhD research project on the evaluation of IC.Results: The evaluation involved a number of activities leading to an exercise of judgement and an important part of the logic of the evaluation was to develop a set of hypotheses based on the ‘theory of change’. These evaluations aimed not only to understand the contribution made by a programme or activity to achieving outcomes, but also to interrogate evidence and communicate findings to support both learning and accountability. In the first paragraph we discuss the program theory underlying IC program based on the literature, on national and regional regulations and on interviews with decision-makers, we identify the main people and organisations involved and their roles, and we assess the financial flows. We then present some of the findings of the evaluation derived from staff questionnaires and patient questionnaires related to various domains (i.e. communication, care planning, frequency of certain critical events, job changes, satisfaction etc.). We finally discuss the results in order to derive some lessons from the experiences analysed and to process mapping the patient journey.Conclusion and discussion: The evaluation of IC arrangements is complicate and this is due to the complexity of the intervention itself, the fact that the evaluation may require detailed data collection across the health care system, the necessity (at least in some arrangements) to take into account other sectors than the health sector as well, the inclusion of a substantial percentage of patients with co-morbidity, and the situation that integrated care programmes may cover multiple patient groups.