Taking care of integrated care: integration and fragmentation in the development of integrated care arrangements

The aim of this thesis was to study the development of integrated delivery systems (IDSs). An IDS is a form of institutionalised partnership between organisations and health care professionals, aimed at facilitating cooperation at the levels of management, support services and the primary processes. The purpose of developing an IDS is to achieve control, quality and efficiency in health care delivery. To examine the extent to which IDSs enable integration, this study centred on the question ‘‘how do IDSs develop at the level of management, support services and integrated pathways for elderly and stroke?’’.


Thesis summary
Taking care of integrated care: integration and fragmentation in the development of integrated care arrangements Isabelle Natalina Fabbricotti, wS.l.: s.n.x, 2007, (Optima Grafische Communicatie, Rotterdam), pp 389, Thesis Erasmus University of Rotterdam, win Dutchx,  The aim of this thesis was to study the development of integrated delivery systems (IDSs). An IDS is a form of institutionalised partnership between organisations and health care professionals, aimed at facilitating cooperation at the levels of management, support services and the primary processes. The purpose of developing an IDS is to achieve control, quality and efficiency in health care delivery. To examine the extent to which IDSs enable integration, this study centred on the question ''how do IDSs develop at the level of management, support services and integrated pathways for elderly and stroke?''.
Data were obtained in three case studies using document analysis, participatory observations and 120 interviews with health care professionals, managers and support staff-members. The results show that interaction between structures, interests, social relationships and cultures causes IDS formation to display four processes of integration and fragmentation: 1. Structural integration and fragmentation. Structures are developed to align tasks, activities and functions. Structural integration strategies, however, were observed in the case studies to lead to processes of new fragmentationfor example, actors' activities became only partially aligned. No structure was found to provide the conditions needed to achieve all the goals of the IDSs. For instance, multidisciplinary teams and case management strategies enhanced the alignment of activities of professionals in different organisations (hence promoting integrated care, effectiveness and operational readiness) but the opportunity professionals have to coordinate and discuss their work with their mono-disciplinary colleges decreased. Structural integration led to differentiation in working methods and loss of expertise, consequently inhibiting specialisation, efficiency and controllability. The reverse was true for standardised and monodisciplinary mechanisms.

Integration and fragmentation of interests.
There is a strong belief that integrated care developments will succeed if the interests of actors converge. However, the thesis found that actors continually played off their own objectives, sources of power, and resources against those of other actors and, indeed, the IDS itself. Personal and professional self-interest meant that actors always had reasons to contribute to andy or inhibit developments. The priorities assigned by actors to their interests determined their contribution to the formation of IDSs and whether they subsequently cooperated, or come into conflict, with one another. The development of IDS is therefore associated with processes of integration and fragmentation of interests (processes whereby the objectives, power and resources of actors both converge and diverge).

Processes of social integration and fragmentation.
These are defined as processes whereby the social relationships between actors intensify positively or negatively. Whether actors contributed to the development of IDSs depended on their knowledge, appreciation and assessment of the value of the work done in other organisations. To ensure that actors establish positive relationships exchanges are organised and information is disseminated. But, these strategies foster social fragmentation, because actors meet, see what others do, deem it inferior or just personally dislike each other.

Cultural integration and fragmentation.
Cultural integration and fragmentation processes reflect the convergence and divergence of the values, norms, working methods, approaches and symbols of the actors involved. In the case studies, cultures were seen to both converge and diverge as actors brought existing cultures from their organisations into IDSs. Cultural differences often put a strain on actors' willingness to work together and to develop new structures since most sought to retain their own culture whilst rejecting those of others. But, despite cultural differences, IDS formation was also seen to be a tool for cultural integration where actors agreed on new working methods and so changed their actions in concurrence with requirements in IDSs.
Processes of integration and fragmentation take place simultaneously, leading to continually changing and different IDS structures and alliances between actors. The study indicates that this interplay results in four typical configurations for an IDS: a control-oriented, a system-oriented, an institution-oriented and a marketoriented. The configurations vary in the extent to which they are directed to achieving control and responsiveness, and the extent to which interests, positions and cultural traditions are preserved or abandoned. Each configuration has its own advantages and disadvantages.
The study is relevant for readers of IJIC and for integrated care because it provides a framework to analyse and develop integrated care arrangements. Secondly, the study is of importance because it breaks with the traditional rationale that the development of integrated care arrangements should be and is associated with integration. The study shows how integration leads to new fragmentation, and how cultural differences, social segmentation, structural differentiation and divergence in interest are needed to achieve the goals of IDS.
The results presented in this review are based on the author's thesis presented at the Erasmus University of Rotterdam on 8 February 2007.