Implementing integrated care in a fragmented health care system

Abstract

Introduction: In 2009 the primary and secondary health care sectors in Region of Southern Denmark took part in an agreement (Sam:Bo) that should enhance integrated care between hospital departments and social care (home care) and ensure person-centered care. The agreement was developed to enhance coordinated care in a divided health care system where the regional level is in charge of hospitals and self-employed care professionals, and municipalities is in charge of health promotion including rehabilitation and disease prevention. The Sam:Bo agreement was drafted on both macro, meso and micro level. To ensure normative integration, it was stated that there should be an exchange of experiences and development of guidelines. Further, standards for communication was developed and implemented, using a specially developed IT platform. On the micro level staff was educated to use the standardized communication. The standardized communication is mandatory for staff to fill in for all patients receiving services from both the hospital and social care.The Integrated care initiative: Part of the implementation process of the standardized communication was to monitor to which degree departments and municipalities met the specified guidelines for exchanging information on the micro level. The monitoring also identified potential barriers to adaptation of the standardized information using the developed IT platform. The presented outcome is qualitative and quantitative data from an audit in 2010 and qualitative data from a monitoring in 2015. Monitoring was performed in selected hospital departments and all municipalities in the Region of Southern Denmark.Key findings: Data showed that the exchange of standardized communication to a large degree met the guidelines. Both hospitals and municipalities stated a need for a common language without the use of implicit abbreviations. Further, both described a need for information that was adapted to the recipient implying that the sender should adapt the information to the actual situation and not send all available information. This theme was described as a barrier to implementation. If the recipient perceived that the sender did not care about targeting the information they would not bother doing it the other way around.Municipalities reported that they for many hospitalized patients did not receive an estimated time of discharge. They also reported that they often needed information of the expected need for rehabilitation and social care after discharge. The standardized commination delivered a score of the patient’s level of functioning but without a description of why the patient scores as described it was difficult to assess the patient’s needs. Finally, the municipalities reported that it was time consuming that the hospital could not send a single message without having to fill out a complete nursing intervention plan. This resulted in receiving multiple almost identical nursing intervention plans having to read them carefully to find out what changed since the last plan.Hospital departments found that they often needed information regarding the habitual physical and mental condition of the patient. Thus, they are aware that based on the frequency and kind of social care that the patient receive it is not always possible to deliver this kind of information.Results from the monitoring were discussed on a meso level in local forums with appointed leaders and coordinators from hospitals and municipalities that meet regularly to discuss occurred barriers of implementing the standardized communication and how to address them. There was no systematic approach to manage the barriers towards implementation on a micro level.Discussion: There is a risk that staff in hospitals and municipalities perceive the standardized communication as to time consuming and not worth an effort. Staff should continuously receive education of how to use the standardized communication as a tool for optimizing the care for the patient.On the meso level, it is important that the appointed leaders and coordinators from hospitals and municipalities address barriers of implementing the standardized communication and how to take action on a micro level.Conclusion: The implementation of guidelines concerning the exchange of standardized information was fulfilled to a large degree. However, when implementing standardized communication to enhance integrated care in health care and social care it is important continuously to monitor to which degree the expected outcome is reached and identify possible barriers on the micro level. Standardized communication is not sufficient to ensure person-centered care. There is a need for detailed elaborations regarding the influence on the patients every day life. Further, it is important that leaders and coordinators address barriers and convey their knowledge to the micro level together with a plan of how to surmount the barriers.