Linking up with the community: a fertile strategy for a university hospital?

Abstract Purpose To systematically identify, describe and characterise the collaborative initiatives, which have been established between the Academic Medical Centre/University of Amsterdam and local health care providers in the adjacent community. Background The viability of university hospitals is jeopardised. Their narrowed orientation on delivering the most advanced services to the sickest patients challenges their missions in patient care, science and education. By linking up with local health care providers, university hospitals create synergistic relationships that should secure these three academic missions for the future. Methods We conducted a multiple case study in two stages. Initially, division leaders and the director of integrated care were consulted to identify all existing collaborative initiatives of the Academic Medical Centre. Successively, face-to-face interviews were held with the leaders of these initiatives. During these interviews data were primarily collected through a questionnaire. Notes of the interviewer, and documents (if available) were also collected. The analysis focused on systematically describing and characterising the initiatives using the concept of ‘community-based integrated care’. Results Twenty-seven heterogeneous initiatives were identified. Half of these initiatives are targeted to the adjacent community of the Academic Medical Centre, but only four of them are initiated on the basis of community information and involve the community and/or patients. Furthermore, the extent of integration differed per dimension. Functional integration within the initiatives has been relatively low, clinical integration mixed, and professional integration quite advanced. Conclusions The results indicate that a considerable number of collaborative initiatives have emerged. Still, these initiatives are loosely ‘community-based’ and hardly focus on the full integration of care services. This suggests that the community linkages of the Academic Medical Centre in Amsterdam could be further developed by gaining the full support of all clinical departments for the strategic approach and by adapting an overall hospital perspective to monitor the progress towards community-based integrated care.


Introduction
Wider societal pressures jeopardise the viability of university hospitals w1, 2x. The basic problem is that these hospitals have become high-tech knowledge intensive institutions providing highly-specialised and complex medical services to the sickest patients. Routine patient care is increasingly transferred out, which is facilitated by the advancements in medical technology and knowledge. Financiers, governments and patients advocate this natural transformation as they consider outpatient care to be more efficient and patient centred w3-5x.
The high-tech profile challenges the multiple missions of university hospitals. It raises issues in patient carehow to offer effective, efficient and patient-centred services that neatly fit in with the care delivered by other professionals and institutions; in medical edu-This article is published in a peer reviewed section of the International Journal of Integrated Care cation-how to educate undergraduate and graduate medical students in the full spectrum of medicine while they only see the sickest patients; and in sciencehow to create new knowledge and evaluating new technologies for medical practices that are located outside the university hospital.
In order to address these issues, academic institutions have adopted several strategies. They primarily started to collaborate and merge with other hospitals. The rationale underlying this strategy is often economic, reactive and defensive-i.e. reducing uncertainty by building monopolies and cartels. These strategies seem to have been successful w6-8x. Apart from that, university hospitals also developed more proactive approaches by building organisational and community linkages through which the multiple missions of academic institutions can be fulfilled and secured w9, 10x. This strategy can be seen as an opportunistic way to get more patients in, to minimise costs, to use community sites for training and research, and thus to maintain the status quo in health care w11x. However, if university hospitals seriously attempt to optimally serve their adjacent communities, they can contribute to maximise population health within restricted resources. It would mean that they look across all the various community needs and preferences, set priorities among them, and then build collaborative arrangements in which those needs and expressed preferences can be adequately met. Such a strategy is articulated in the vision of community-based integrated care w12x.
The topic outlined above has been particularly relevant to US academic health centres. There are fewer reports on the situation of academic institutions elsewhere. However, the natural transformation of hospitals into high-tech knowledge intensive institutions is common and visible in many industrialised countries w4, 5x. Moreover, the International Campaign to Revitalise Academic Medicine has considered the situation of academic medicine on a global level and underscores the aforementioned instabilities w13x. So, one can expect university hospitals in other countries to be pressured as well. This is certainly the case for university hospitals in The Netherlands. Generally, the Dutch hospital sector faced a similar restructuring and strategically responded as elsewhere w14, 15x. In January 2006 the Health Insurance Act will come into force, which will formalise regulated competition among care providers and among care insurers w16x. In anticipation to this Act, a new system for hospital and medical specialists' reimbursement has partially come into force. This socalled diagnosis treatment combinations approach reimburses hospitals through output prices that are based on the production process instead of the original budgeting system. This approach is broader than the Diagnosis Related Group concept, as it also covers ambulatory care and includes the remuneration of medical specialists w17x. Moreover, increased competition for research funding and for subsidisations of undergraduate and graduate medical education is also visible w18, 19x.
Consequently, Dutch university hospitals face more competition and financial pressures in all their core activities, which challenge them to develop sustainable strategies for the future. In anticipation to these changes, 7 out of the 8 university hospitals have transformed into University Medical Centres. They merged with their adjacent faculties of medicine in order to synergistically organise patient care, research and education w19x. The first university hospital to do that was the Academic Medical CentreyUniversity of Amsterdam established in 1992. This merger was followed by the introduction of a community-based integrated care strategy, called the 'academic population' w20, 21x. Since its introduction in 1996, the evolution of community-based integrated care throughout the Academic Medical Centre has not been systematically monitored or evaluated. Thus, there was a need for conducting a multiple case study as presented in this paper. We focused on all collaborative initiatives in patient care, which we systematically identified, described and characterised. Collaborative initiatives in science and in medical education were excluded. In this paper, the results of this multiple case study are reported and discussed.

Identification of the initiatives and data collection
All collaborative initiatives of Academic Medical Centre departments with partners outside the hospital such as general practitioners, home care agencies and nursing homes were the cases to be studied. In the absence of a readily available list, we had to identify them first. Therefore, division leaders were asked to sum up their collaborations with one or more external care providers and to name the person in the Academic Medical Centre most knowledgeable of the ongoing activities-often the professional in the lead of the collaboration. The resulting list was appraised and validated by the director in charge of integrated care.
Then, we used multiple data sources to collect data on the initiatives. Data were primarily collected through a questionnaire filled out during face-to-face interviews with the aforementioned leaders or an appointed rep-This article is published in a peer reviewed section of the International Journal of Integrated Care resentative. These interviews were held in the period November 2003 to February 2004. Other data were collected by making notes of additional remarks respondents made during these face-to-face interviews and by gathering documents such as project proposals, annual reports or evaluations (see Table  1). Both data sources were used to corroborate the findings ('triangulation').

Description and characterisation of the initiatives
We used the vision of 'community-based integrated care to describe and characterise the cases. It builds upon two formerly unattached concepts: communitybased care and integrated care. The former was defined as the extent to which the collaborations are based upon and driven by community health needs as well as assure a certain level of community participation. The latter concept was defined as the methods and types of organisation, which aim at reducing fragmentation in health care delivery by increasing coordination and 'continuity of care' between different care providers w3x. There is a growing awareness that both concepts need to be jointly embedded in health care in order to maximise community health within the context of limited resources w12, 22x. However, it is not obvious that university hospitals set up collaborative initiatives with external parties such on the basis of this combined vision. We analysed whether the collaborative initiatives are developed from this combined vision or not. Thereby, the quantitative anal-ysis through the questionnaire provided general comparative information while the documents and the notes were used to substantiate the specific case descriptions.
The questionnaire measured 'community-based integrated care' on the basis of 74 closed as well as open-ended questions (see Table 2). Items Q66-Q71 measured whether the cases were community-based care or not. Notwithstanding some adjustments to the Dutch situation, the concept of integrated care was conceptualised on the basis of the work of Shortell et al. w23x. In comparison to the US context, Dutch academic medicine already shows high levels of physician integration. All specialists are salaried, work in a closed hospital model, and several of them have taken up leadership roles. Moreover, Dutch general practitioners function as gate-keepers to inpatient care w24x. We therefore defined physician integration as the extent to which the organisation of professional work merits participation in collaborative initiatives w25x. Moreover, we have broadened it to include also paramedics and registered nurses. Professional integration defined as such was measured by 12 items (Q37-Q38). Clinical integration was measured using the typology of a quality system consisting of five elements (i.e. structural assets, allocation of responsibilities, protocols, information transfer and monitoringy feedback cycles). The items Q50-Q65 measured clinical integration as defined above. The questionnaires were analysed using the SPSS 12.01 software and descriptive statistics were generated.   The analyses of the documents and notes focused on labelling and grouping the cases using common types of integrated care such as intermediate care w26x, shared care w27x, disease management w27x, transitional care w28x, hospital-at-home w29x, and professionalyorganisational networks w30x. Furthermore, analyses were guided by the results of the questionnaire in order to corroborate these.

Identified collaborative initiatives of the Academic Medical Centre
In total 27 collaborative initiatives were identified. Most of them concern collaborations in the primary processes of patient care (ns23). The others focus at collaboration at the local health policy andyor management level. For example, the Zizo (case 26) is an organisational network within which representatives of local care providers in Amsterdam Southeast are participating. Its core activities encompass the initiation, development, facilitation and implementation of collaborative initiatives for the elderly and chronically ill in Amsterdam Southeast wgx. This is illustrated by its involvement with the cases 1, 6, 19, 21 and 24.
The 27 cases largely differ in type of collaboration, purpose, scope and targeted patient group, which is shown in Table 3. This heterogeneity is further illustrated by the differences in ''maturity'' of the initiatives. Structural funding for 2y3 of the cases is uncertain, as they are financed on incidental basis (ns8) or without additional funding at all (ns10). This is substantiated by the reported problems of inhibiting legislation (ns15). Respondents commented that these problems mostly have to do with getting or maintaining funding. For example, the respondent, who executed the outpatient consultations for rehabilitation, said that she had difficulty to get her consults paid. Conversely, the majority of initiatives already exists for a couple of years and have no end date (ns23) suggesting that initiatives will be continued in the future. The care insurers (ns12), the regional AWBZ executive body (ns7) as well as the Academic Medical Centre itself (ns11) are the major financiers.
Departments of the division of internal medicine are involved in 1y3 of the initiatives. Still, all 9 divisions of the Academic Medical Centre are involved in at least one of the 27 collaborative initiatives. External partners who participated most often in the initiatives are the nursing home Gaasperdam (ns10), Amsterdam Home Care (ns10) and the general practitioners (ns10). Almost all initiatives (ns24) involved at least three or more collaborative partners and were developed after 1996 (ns17).

Community-based care
The extent of community-based care in the initiatives is moderate. More than half of the initiatives (ns15) are targeted to a circumscribed zip code area. However, additional information from the respondents and documents learned that the targeted zip code areas differed and not coincided with the area circumscribed in the academic population strategy, except the GPdesk (case 15). Half of the geographically targeted initiatives have also community information available (ns7). Ultimately, 4 out of these 7 initiatives also involve the community or service users (see Figure  1).
These 4 initiatives are the stroke service, the emergency psycho-geriatric care unit, the diabetes mellitus protocol, and the physical therapy for premature babies at home initiative. From the notes andyor documents, it can be notified that the former two initiatives only cover the urbanised zip code areas of the 'academic population' (i.e. Amsterdam Southeast) waxwnx, while the latter two have a citywide orientation partly overlapping with the 'academic population' area wfx. Furthermore, they seem to have been initiated primarily because of signalled problems in care delivery. Although these initiatives address major community health needs, we could not reconstruct decision-making processes within which community needs and expressed preferences are taken as the starting point. This is illustrated by the community information used. Overall, information available in the This article is published in a peer reviewed section of the International Journal of Integrated Care        initiatives is most on ageysex (ns13), the size of the target population (ns11) and morbidity (ns11). Residents and patients are involved in more than half of the initiatives (ns15), most often through patient surveys (ns10) and patient associations (ns9).

Integrated care
The levels of integration differ for each dimension. First, the extent of functional integration is relatively low. Only eight of the initiatives are formalised on the basis of a legal contract and one initiative implied a merger. The other initiatives are based on a signed letter-of-intent (ns4) or on informal agreements (ns14). In 16 of the initiatives at least one support functions is centralised; most often administrative work (ns9) and information technology (ns7). However, in 6 out of these 16 initiatives 3 or more support functions are centralised.
Second, the extent of professional integration is quite high. In the Academic Medical Centre all professionals are salaried, medical specialists work in a closed hospital model, and all departments are headed up by physicians. Moreover, professionals working for institutions in the adjacent community mostly are employed by an institution, except the general practitioners. In addition, the other facets of physician's integration show that the organisation of professional work fairly merits participation in the collaborative initiatives. In 18 of the initiatives professionals fulfil managerial responsibilities. However, only in eight initiatives professionals are exempted for management tasks. Furthermore, expertise is exchanged in 18 of the initiatives, and additional medical education is given in 12 of the initiatives. Last, the clear lines of professional authority are less in place. This is illustrated by the full mandate that professionals have in 10 of the initiatives and the existence of a formal hierarchy in 11 of the initiatives.
Third, clinical integration achieved varies on the five key facets measured. In none of the initiatives all preconditions (i.e. staffing, resources, information technology) are fully fulfilled. However, in 11 of the initiatives all preconditions are more or less achieved. Only four of the initiatives have a clear allocation of responsibilities explicated both in an organisational chart and in a job description; 10 of the initiatives have one of these. In 18 of the initiatives integrated guidelines and protocols are available. The use of integrated patient records was reported for six initiatives. Last, in 17 initiatives data are systematically collected and used to manage the collaboration. Overall, only the DIANET initiative is fully clinically integrated having all elements in place. The other initiatives scored modestly on the overall sum score of the five elements.

Validity
The study has its limitations. The face-to-face interviews were conducted by one researcher only. Furthermore, we developed a questionnaire ourselves instead of using a validated one. From the field notes made, however, we learned that the internal validity might be hampered by three factors: (1) Some of the respondents were insufficiently knowledgeable to appropriately answer all questions. Especially the respondents replacing their heads expressed their uncertainty andyor could not always respond to the questions. (2) Due to the heterogeneity of the initiatives, the applicability of the broadly operationalised questionnaire was not always that good. (3) The questionnaire has been filled out by respondents working in the Academic Medical Centre only. Thus, the data were not enriched by representatives of the external partners, who might have responded differently.
The external validity of the study is optimal for the Academic Medical Centre, as all initiatives could be included in the study that were systematically identified and verified by the Academic Medical Centre experts most knowledgeable of them. Yet, the transportability of the results to other settings is unknown, as we did not collect data on similar initiatives elsewhere.

Discussion
Due to the narrowed strategic focus of university hospitals, the three academic core functions (i.e. patient care, medical education, scientific research) are challenged w1, 2x. In response, university hospitals adapted successful, but quite defensive, strategies such as merging with teaching hospitals and downsizing the organisation w6-8x. However, some have responded more proactively by linking up with their adjacent communities. Such a 'community-based integrated care' approach is proactive for several reasons w12x. The resulting relationships with local care providers enable university hospitals to safeguard and control patient flows and to build academic workplaces for research and education outside the hospital. Overall, it intrinsically makes university hospitals more responsive and accountable to the (local) community.
The Academic Medical Centre has adapted such a proactive approach in 1996, called the academic population policy w20, 21x. In this study we identified 27 heterogeneous initiatives, which have mostly been developed since 1996. The descriptive data learn that half of these initiatives are targeted to the adjacent community of the Academic Medical Centre, but only four of them are initiated on the basis of community information and involve the community andyor patients. Furthermore, the extent of integration differed per dimension. Functional integration within the initiatives has been relatively low, clinical integration mixed, and professional integration quite advanced. Several notions can be made.
First, the academic population policy stimulates Academic Medical Centre departments to link up with external care providers. Although we do not have comparative data, the impression is that 27 initiatives is quite a lot. In The Netherlands only the academic institutions in Groningen and Maastricht have formally adapted a community orientation w19x. Moreover, Dutch general hospitals are involved in six integrated care arrangements on average with a maximum of 20 initiatives w31x. Unfortunately, the international picture is unclear, as evaluations on university hospitals elsewhere often take another angle; they generally evaluate the whole strategy or one specific collaborative initiative only. Such a picture, however, would be enlightening which brings us to the second notion.
There seems to be a link between the described Academic Medical Centre initiatives and the health needs of the South-eastern Amsterdam community.
This article is published in a peer reviewed section of the International Journal of Integrated Care Arrangements are in place for the major chronically ill patient groups (e.g. stroke, diabetes mellitus type 2, COPD, heart failure) and the frail elderly in the area w32x. Still, there is no support that the AMC is initiating collaborative initiatives from a 'community-based integrated care' vision. The initiatives are not communitybased in the sense that they do not target the same communities (i.e. zip code areas), are not initiated on the basis of community health considerations, and are not systematically involving the community andyor service users. This contradiction might be explained by the 'redistribution dilemma' w33x. The academic population policy requires an increase in routine care delivered by clinical departments, which is at the expense of their academic activities and interests, and thus encounters opposition. By loosely applying the academic population policy, clinical departments control the proportion of routine care delivered as part of their overall activities employed. This brings us to the question whether integrated care is reflected in the initiatives. The collaborative initiatives of the AMC are 'integrated' even though their levels of integration achieved are mixed. There are rival interpretations of this result. One is that the initiatives need to be further developed, thereby focusing on the facets of integration that lag currently behind-i.e. formalising the agreements, enhancing the level of clinical integration by focusing on all five facets. However, it can be questioned whether this should be the policy advice to the Academic Medical Centre managers. Most initiatives have no end date suggesting that the desired level of integration may have been achieved. Foremost, the majority of the initiatives has a limited scope and do not aim at full integration on all levels. So, expecting full integration for most of the initiatives is probably an unrealistic objective that will never be achieved, nor strived for. This notion has also been made in the literature w34, 35x.
Elaborating more on this notion suggest that the academic population strategy of the Academic Medical Centre and a community-based integrated care approach of (university) hospitals more generally, can better be described on the overall hospital level. All 27 Academic Medical Centre initiatives together form a web of integrated care services that are congruent to each other as they cover specific care trajectories (e.g. stroke service, diabetes mellitus type 2) or centralises specific functions (e.g. coordination, R&D, discharge planning). Describing this web from a community-based integrated care perspective might be more informative as it theoretically provides insights in the overall weaknesses and strengths in meeting community health needs and demands. A 'communitybased integrated care' approach can only be fertile when the whole Academic Medical Centre is committed in vision and in practice.