Building a Tower of Babel in health care? Theory & practice of community-based integrated care

Many hold that performance in health care can be improved. However, the state-of-the-art on health care improvement indicates that improvement activities and strategies have too limited success so far. From a ‘systems perspective’, this limited success stems from a lack of coherence among the various strategies and instruments employed. For example, practice guidelines, client councils, regulated competition, and disease management differ in purpose and approach. Therefore, it can be argued that all improvement activities should be embedded more synergistically in health care. ‘Community-based integrated care’ is a strategic vision on how this synergy could be realized. It promotes more joined and consistent action (‘‘integrated’’) towards a better performing health care system that maximises population health (‘‘community-based’’).

Many hold that performance in health care can be improved. However, the state-of-the-art on health care improvement indicates that improvement activities and strategies have too limited success so far. From a 'systems perspective', this limited success stems from a lack of coherence among the various strategies and instruments employed. For example, practice guidelines, client councils, regulated competition, and disease management differ in purpose and approach. Therefore, it can be argued that all improvement activities should be embedded more synergistically in health care. 'Community-based integrated care' is a strategic vision on how this synergy could be realized. It promotes more joined and consistent action (''integrated'') towards a better performing health care system that maximises population health (''community-based'').
In the thesis the following questions were addressed: (1) What is 'community-based integrated care'; (2) How does it work? Based on both questions, the thesis is split up into a theoretical and an empirical part. The former deals with the meaning, content and conceptualisation of 'community-based integrated care' and draws on two theoretical-interpretative studies. The latter deals with issues related to the practicability and actual use of the strategic vision in daily practice. Empirical data were gathered from four purposeful studies in the South-eastern Amsterdam district. Each study represented a different stakeholder perspective: (1) the governance practices of the municipality of Amsterdam and Agis, the care insurer with the largest market share in Amsterdam; (2) the shared governance practices of care providers through a 30-yearold community health partnership, called the Zizo; (3) collaborative initiatives of the Academic Medical CentreyUniversity of Amsterdam in 2003y2004; (4) the intermediate care model between the Academic Medical Centre and the Henritte Roland Holsthuis, a residential home.
'Community-based integrated care' can be defined as a strategic vision that features two components: (1) a shared goal orientation-clear endpoints must be defined and prioritised within restricted resources and on the basis of community health needs, beliefs and values; (2) collaboration-continuums of care must be built within which the defined endpoints can best be met without imposing one stakeholders' perspective over the other (i.e. they must have the freedom to follow their own dynamics and patterns in meeting those endpoints).
In practice, the strategic vision of 'community-based integrated care' seems useful to unify and bring people together. However, the vision cannot undo the fundamental differences between the actors involved and change their vested interests. Therefore, health system redesign is warranted to facilitate the embodiment of 'community-based integrated care' as a strategic vision in health care.
The IJIC-readership could learn from the thesis that collaboration (i.e. integrated care) is not an end in itself. It can only contribute to a better performance in health care when it is considered in relation to the system's purposes-i.e. maximizing population health. Therefore, a continuous dialogue among collaborating partners to get and maintain a shared goal orientation, fed by local public health data on health needs and demands, is crucial for an integrated care arrangement to be successful. Subsequently, partners must recognise, value and trust each others rationales to meet those shared endpoints. This is the central thrust of the thesis. 'Community-based integrated care' can function as an Esperanto that prevents the deemed failure of improving the performance in health care towards the goal of population health, the building of a Tower of Babel alike.