Obstacles and Facilitators in Developing Integrated Team Based Home Care Services in Lithuania

Abstract

Introduction. The development of innovative high quality care forms is a challenging issue in rapidly aging society of Lithuania. The new shape integrated homecare services for people with chronic conditions have been constructed and have been functioning over the year as the pilot projects in the 21 municipality around Lithuania. In almost all integrated care pilot municipalities except two regions (in Alytus and Sakiai, with primary health care units as integrated care providers) the initiative to develop team based integrated homecare services to persons with chronic conditions has been taken by departments of social services. The purpose of this study is to identify the key contextual elements and related strategic, organizational processes from pilot municipalities as facilitators and obstacles in developing mobile team based integrated homecare services as contrast to traditional institutionalised care. Theory/Methods. Pettigrew and Whipp's context, content and process model of strategic change was used as theoretical framework for the case studies of team based integrated homecare pilots. According this framework the data collection focused on three entities: what external and internal contexts instigated municipalities and service providers to take the challenge to develop the new shape integrated team based homecare services and how service providers perceive, construct and implement integrated team based homecare; and finally, what outcomes have been shaped with new form integrated care. Data were analysed from transcripts of 20 focus groups with administrators, social and health care providers and 12 in depth interviews with care receivers (informal caregivers and patients) in ten purposively sampled municipalities: pilots executed by municipality social provision departments in partnership with private and state agencies, directly by social services departments and by primary health care unit. The findings were compared with factors and dimensions of Normalisation Process Theory (May et al. 2007). Results and discussion. The study revealed the obstacles and facilitators related to individual and different organizational levels in constructing team based integrated homecare. The study 15th International Conference on Integrated Care, Edinburgh, UK, March 25-27, 2015 1 International Journal of Integrated Care – Volume 15, 27 May – URN:NBN:NL:UI:10-1-117127– http://www.ijic.org/ revealed individual level topics such as trust and collaboration building between integrated team care providers and informal caregivers, challenges in building new routines and habits for patient in homecare process, resistance and adaptation to presence of constant changing strangers’ at home. The study exposed the organizational issues related to interaction between team members and administration, tensions issues in status difference between social and health care providers, tasks distributions between team members, perception diversity of team and care, lack of teamwork experience and sense of shared responsibility, issues of staff commitment due to termed pilots. The inter-institutional and intra-institutional hindering tensions between social and health care providers unclosed the competition over the homecare field; new institution as threat to monocracy of health care; lack of skills and early transition from hierarchical to dialog based horizontal structures; inequality of resource distribution between integrated team members uncompensated travel costs for social care providers vs. car with fuel coverage for health care providers. The mentality of monolog culture with highly hierarchic structures in health care system hinders recognition of nursing as separate profession with certain competencies: avoidance by nurses to take decisions on nursing issues without consultation with physician even in areas of their professional competence supremacy as care of bedsores. The important facilitators were the support of municipality in service development and participatory involvement of the unit from the beginning of project planning. The professionally organized integrated homecare services facilitated transition to collaborative relationship between health care and social care providers. The requirement to follow literally description of project activities even the performance of planned activities contradicted the reality in practice hinders development of new service. As study limitation is the administrators gatekeepers’ role in accessing research participants: patients, informal caregivers, health and social care providers. In some municipalities the presence of head of the unit in the focus group suppressed openness of the staff. The study had insufficient data on patients’ experience of care as the integrated care pilots addressed severely ill patients with limited communication abilities. Conclusions. The study revealed micro, mezzo and macro levels obstacles and facilitators in constructing team based integrated homecare. The distinction of developed models of team based integrated homecare services participatory interaction between stakeholders of the care with the traits of patient centred approach and collaborative practices between existing social and health care structures. The move from the tradition of hierarchical model of service development ( i.e. from “above” perspective constructing orders of ministers with limited perception of reality and municipalities as executive committees with resistance performing commandments and shaping service delivery imitation) grounded the participatory practice in service development.