The communicative constitution of population health systems

Abstract

Introduction: Population health systems integrate services across multiple sectors. They are widely regarded as an effective approach for addressing challenges posed by an ageing population and the associated spread of chronic diseases. However, we still know little about how we can successfully implement such systems that typically span multiple levels and organizations. Thus, this study explores practices facilitating the implementation of population health systems. Theory and methods: We conducted a qualitative longitudinal single case study in collaboration with the Healthcare Center Lower Engadin, which is considered the hub of a pioneering population health system in Switzerland. Data collection included 35 semi-structured interviews, 96 participant observations, and 46 archival records and data analysis followed an abductive approach. After a first round of inductive coding, we realized how important communication was for the emergence and change of the system. In a second round, we consulted additional literature to develop richer theoretical explanations. Recent work suggesting that complex organizations are constituted primarily in and through communication turned out to be a particularly helpful analytical device. Inspired by this lens, we went back to our empirical data, this time coding for communicative practices facilitating and impeding the implementation of the system, understanding communicative practices as structuring patterns of interaction. Results: Drawing on the work of McPhee and Zaug, we found that the population health system in the Lower Engadin was implemented in and through four interrelated communicative practices. A first practice was membership negotiation, through which actors recruited and maintained a relationship with member organizations. A second practice was organizational self-structuring, through which actors created adequate decision and control (governance) structures. A third practice was activity coordination, through which actors coordinated health, social care, and administrative activities within and across the boundaries of member organizations. A final practice was institutional positioning, through which actors legitimized the formation and maintenance of the system among political decision-makers and the regional population. We describe how regional actors mobilized these four practices to re-organize the provision of health and social care in the Lower Engadin. Discussion and conclusions: Population health systems are widely regarded as a promising approach for addressing an increasingly fragmented value creation in health and social care. Previous research has already emphasized the pivotal role of communication for implementing such systems. Goodwin underlines the need of effective communication strategies to deliver clear communication messages to relevant stakeholders. With this study, we confirm this need and draw attention to four communicative practices actors may want to consider when planning their communication activities. These practices are important not only for delivering ready-made information, but also for the social construction of new meaning regarding innovative ways of coordinating health and social care across sectoral and organizational boundaries. Limitations and future research: This study is limited to one population health system in Switzerland. Further research is required to explore the four identified practices in more detail to understand their specifics and interrelationships and to explore to what extent other systems are constituted by similar or different communicative practices.