Key factors of change processes in shared care: viewpoints of managers, care providers and patients

The aim of this thesis was to assess the impact of key factors in the process of development and implementation of shared care projects for patients with diabetes mellitus type 2 and Chronic Obstructive Pulmonary Disease. The purpose of the research was to assess the experiences of managers, caregivers and patients in order to draw conclusions for further and successful implementation of the shared care projects.


Background
The aim of this thesis was to assess the impact of key factors in the process of development and implementation of shared care projects for patients with diabetes mellitus type 2 and Chronic Obstructive Pulmonary Disease. The purpose of the research was to assess the experiences of managers, caregivers and patients in order to draw conclusions for further and successful implementation of the shared care projects.
Five shared care projects were studied, which provided forms of care delivery in which generalists and specialists worked together on the basis of partnership agreements that stipulated levels of co-operation, responsibilities and management practices. The focus of each shared care project was patient-centreddirected at the patients' needs rather than the priorities of any care-giver group. The projects implied 'horizontal' substitution (the transfer of care delivery from hospital to the general practitioner's practice) as well as 'downward' substitution (such as the transition of care from doctor to nurse). All projects aimed at improving quality of care and forms of substitution was described in a protocol. Two of them were nurse-led and initiated in the Maastricht region, just like the project on joint consultation between internist-endocrinologists and general practitioners. Later, two further nurse-led projects were set up in the North Limburg region. The project management of all five projects chose for an evaluation programme, including qualitative research.

Methods
The qualitative research was based on case study methodology. This was implied on all five projects as cases. Data sources included in-depth interviews, written questionnaires, observations of project meetings, documents and reports next to focus groups. The general analytic strategy involved an adapted model of critical influencing factors, that focused on the influencing factors as such and their interrelationships. The model used the open-system approach, showed characteristics of the interactionist approach and the theory of the learning organisation. The influencing factors were the units of analysis and could be either external or internal and could have a promoting or inhibiting impact. External factors entailed the role of authorities, legislation and societal developments. Internal factors encompassed the local context-including structure, culture and power-, as well as commitment and change management, including project management. Additionally, specific analytic strategies of explanation building and time-series analysis were partially used. The result was a cross-case analysis, next to analysis of each case. The respondents were 15 persons with management or other organisational functions, 6 specialised nurses, 63 GPs, 10 internists-endocrinologists, 6 pulmonologists, 5 dieticians and 2 district nurses. In total 559 patients were involved, while 26 patients participated in focus groups.

Results
The results showed that from the management viewpoint the internal factors prevailed to accomplish changes successfully, especially the (project) management that demonstrated leadership, applied longterm solutions and took care that participants learned.
From the caregivers' viewpoint the specialised nurses experienced Dutch legislation as most inhibiting external factor and the local context as most inhibiting internal factor, particularly the way shared care delivery was structured. They complained about unmet preconditions and unclear agreements about authority and capability. Starting off rather anxiously, they finally became eager to take full responsibility for their job and to fight for its full recognition. The structure aspect was also judged the most troublesome by the physicians, although they emphasized task performance and task division more than the nurses.
Another important finding was that most patients preferred the nurse-led care models compared to usual doctor-led care. According to the patients view the main quality aspect was the provision of information by the specialised nurse and other caregivers, although its performance needed improvement.
The study indicated that the applied research model was founded as a basic design, both concerning the key-influencing factors discerned and the depicted linkage between them.
The evidence especially regarded the internal factors change management, i.e. project management, commitment and local context, which also seemed their most likely order. This means that the application of this model enabled to approach dynamic complexity of the studied shared care projects more closely, and looks promising for further use.

IJIC specifics
For the readers of the IJIC it is of special interest to learn that the project management appeared crucial in change processes of shared care activities. Particularly the way the project manager behaved as a leader was dominant. The leadership implied the best demonstration of qualities such as courage, inspiration, innovation, creativity, passion and vision, using personal power, sharing information, showing authority and succeeding in uniting a regional network of people working together.
Further observations related to integration of care are that the organisations and project managers involved were not familiar with the concept of the learning organisation. Results showed that learning processes were lived through but could have been improved if the change management had consciously used this concept.
A conclusion relevant to integrated care is that its implementation depends on the inclusion of the longterm perspective in strategies and tactics. Learning as a core characteristic of the project organisation, shared responsibility, open communication and problem solving by choosing solid changes have to be ensured. All parties involved should stick to this principle. This requires leaders and participants who are willing to learn.