Strengthening a Dutch initiative with action research; community involvement one of the key stumbling blocks

Abstract

Introduction: There is a strong call from integrated care initiatives for practical guidance, including translating existing scientific knowledge into the local context. This covers several themes such as regional governance, adjusting payment models, and community involvement. In the presented project, we used an action research approach to support the team of HealthKIC implementing the ‘Kavelmodel’ in the Netherlands. HealthKIC supports regions that are willing to change using a population health management approach by facilitating the implementation together with stakeholders on all levels. The Kavelmodel focusses on improving the health and wellbeing of the population of the involved regions, ‘Vallei Vitaal & Gezond’ and ‘8terhoek Gezond’ for now. 
 Methods: Together with the HealthKIC-team we co-designed an action research process looking to evaluate the tools and approaches that were used by the HealthKIC-team to enable key themes and issues in the regions and with system-level stakeholders. Working with an emergent paradigm perspective in this complex and dynamic environment, we attempted to balance the flexibility in the process to adapt to emergent circumstances, while still have the ability to validate the findings. The process focussed on exchanging knowledge and lessons learned between science and practice using learning cycles. 
 Results: While all above-mentioned themes were discussed, one key stumbling block was community engagement. Using several learning cycles in different settings, we were able to continuously stress the importance of it, share knowledge and practical examples, and discuss next steps. However, both system-level stakeholders and regional stakeholders remained reluctant to adopt a form of community involvement and haven’t implemented it yet. The actual doing, listening to community members and hand over some control, was perceived the most difficult and crucial aspect for stakeholders on all levels. Reflection sessions about this theme revealed the main reason for not taking action was feeling insecure about how to progress. As was seen with other themes, this hesitation often led to people falling back into old habits and working on other day-to-day tasks. 
 Discussion: As is evidenced by the literature and practice, community involvement often remains theoretical. We tried out a new way of working using learning cycles to provide practical guidance, but it didn’t result in effective implementation of community involvement yet. Having the knowledge of the importance of and how to involve community members proved to be not enough. Therefore, we still need to search for the most effective strategy to include community members successfully in these kind of initiatives. One of the lessons learned is that it is important is to consider the attitude and commitment of the stakeholders involved. The project leaders need to feel supported by them to take action. Next to that, the community involvement needs to fit within the bigger picture of the initiative, supported by a joint vision, sustainable resources, and a learning environment. These are crucial insights into why community involvement is still lacking. Looking forward, having PHM-coaches in the region could bring the necessary assurance for people to work differently and in new and unexpected circumstances.