The institutional logic of integrated care: an ethnography of patient transitions

Pia Kontos,Wendy Martin,Christina Victor,James A Shaw

doi:10.1108/jhom-06-2016-0123

Abstract

PurposeThe purpose of this paper is to use theories of institutional logics and institutional entrepreneurship to examine how and why macro-, meso-, and micro-level influences inter-relate in the implementation of integrated transitional care out of hospital in the English National Health Service.Design/methodology/approachThe authors conducted an ethnographic case study of a hospital and surrounding services within a large urban centre in England. Specific methods included qualitative interviews with patients/caregivers, health/social care providers, and organizational leaders; observations of hospital transition planning meetings, community “hub” meetings, and other instances of transition planning; reviews of patient records; and analysis of key policy documents. Analysis was iterative and informed by theory on institutional logics and institutional entrepreneurship.FindingsOrganizational leaders at the meso-level of health and social care promoted a partnership logic of integrated care in response to conflicting institutional ideas found within a key macro-level policy enacted in 2003 (The Community Care (Delayed Discharges) Act). Through institutional entrepreneurship at the micro-level, the partnership logic became manifest in the form of relationship work among health and social care providers; they sought to build strong interpersonal relationships to enact more integrated transitional care.Originality/valueThis study has three key implications. First, efforts to promote integrated care should strategically include institutional entrepreneurs at the organizational and clinical levels. Second, integrated care initiatives should emphasize relationship-building among health and social care providers. Finally, theoretical development on institutional logics should further examine the role of interpersonal relationships in facilitating the “spread” of logics between macro-, meso-, and micro-level influences on inter-organizational change.

Highlights

The purpose of this paper is to use theories of institutional logics and institutional entrepreneurship to examine how and why macro, meso, and micro-level influences inter-relate in the implementation of integrated transitional care out of hospital in the English National Health Service
The first discusses the actions of organizational leaders reacting to the Delayed Discharges Act, focussing on the institutional ideas they prioritized in their leadership practices at the meso-level to promote more integrated care
The third discusses one key institutional entrepreneur in particular at the clinical level (Dr Aitkin), illustrating his role in developing the collaborative model of care that was regarded as best practice for integrated care in the region, and the relationship work that was fundamental to the success of an integrated model of transitional care

Summary

Introduction

The purpose of this paper is to use theories of institutional logics and institutional entrepreneurship to examine how and why macro-, meso-, and micro-level influences inter-relate in the implementation of integrated transitional care out of hospital in the English National Health Service. Findings – Organizational leaders at the meso-level of health and social care promoted a partnership logic of integrated care in response to conflicting institutional ideas found within a key macro-level policy enacted in 2003 (The Community Care (Delayed Discharges) Act). Through institutional entrepreneurship at the microlevel, the partnership logic became manifest in the form of relationship work among health and social care providers; they sought to build strong interpersonal relationships to enact more integrated transitional care. Theoretical development on institutional logics should further examine the role of interpersonal relationships in facilitating the “spread” of logics between macro-, meso-, and micro-level influences on inter-organizational change.

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