Various views of the same elephant: crossing perceptions of key actors on an integrated local health network for older adults

Abstract

Context: In 2004, Quebec’s government lead an important reform of its health and social structure, aiming at improving integration of services. Accordingly, 94 Health and social services centers were created by the mergers of public establishments local community health centers, long term care facilities and acute care hospitals in most cases. Each new organisation was mandated to lead in the implementation of an integrated local health network that ensures the delivery of a comprehensive continuum of care for the population living on their territories. Several stakeholders policy makers, managers, providers, patients and caregivers were involved at different levels in the implementation of the integrated local health networks. Aims: To analyse an integrated local health network for older adults according to multiple perspectives. Methods: This research is part of an international research program “implementing integrated care for older adults with complex health needs” ICOACH where three case studies were carried out in each jurisdiction: Quebec, Ontario and New Zealand. This presentation is based on data collected in Quebec from 96 semi-structured interviews with various key stakeholders such as policy makersn=11; healthcare providers n=28, managers n=33, older adult patients n=14 and caregivers n=10, as well as the analysis of official documents. data was analysed based on the 59 items of the six dimensions of the Rainbow Model of Integrated Care framework to identify convergences and divergences in the perspectives of the major stakeholders. Results: In general, there is a strong convergence in the views of policy makers, managers and providers on several key features of functional, professional and clinical integration. Although they often adhere to the same principles, differences are sometimes observed at the level of implementation. For instance, they all view, the Continuity item as a central element where organizational structures must support service trajectories. However, several providers report that the poor harmonization of the operating rules between the organizations and the lack of knowledge of the various programs create a lack of fluidity. Another example is related to the item centrality of client needs. Policy makers and managers report that services are developed on the needs of patients while provider’s nuances by repeatedly reporting that services are offered according to their availability at the organization. Among the six dimensions, the clinical dimension is the one that is illuminated by all perspectives while the organizational and systemic dimension are more addressed by policy-makers and managers. Adding the perspectives of patients/caregivers reveals a dissonance of the apparent consensus around the clinical dimension. Conclusion: Based on the Rainbow model, we observed discrepancies between the 4 perspectives in analyzing the implementation of integrated local health networks. Policymakers and managers hold very similar perspectives. Providers often converge in the guiding principles with policy makers and managers, but often diverge at the implementation level by reporting several barriers. They are the buffer group whose perspectives sometimes converge with policy-makers and managers, and at other times with patients/caregivers. Regarding patients/caregivers, they mainly focus on t the clinical dimension and their views often diverge from those of decision makers and managers.