Multiple Perspectives Analysis of the Implementation of an Integrated Care Model for Older Adults in Quebec

Introduction: Integrated care models for older adults are increasingly utilised in healthcare systems to overcome fragmentations. Several groups of stakeholders are involved in the implementation of integrated care. The aim of this study is to identify the main concerns, convergences and divergences in perspectives of stakeholders involved in the implementation of a centralised system-wide integrated care model for older adults in Quebec. Theory and methods: Qualitative multiple-case study. Semi-structured interviews of key stakeholders: policymakers (n = 11), providers (n = 29), managers (n = 34), older adult patients (n = 14) and caregivers (n = 9), including document analysis. Thematic analysis of the views of stakeholders along the lines of the six dimensions of the Rainbow Model of Integrated Care. Results: While patients/caregivers were mostly concerned by their unmet individual needs, policymakers, managers and providers were concerned by structural barriers to integrating care. Stakeholders’ diverse perspectives indicated implementation gaps in a top-down implementation context. Conclusion: Mandated system-wide integration appears to have structural, organizational, functional, and normative transformations, but its clinical changes are more uncertain in view of the observed divergent perspectives of actors. It will be interesting to explore if the systemic changes are precursors of clinical changes or, on the contrary, explains the lack of clinical changes.


CLINICAL INTEGRATION
The coordination of person-focused care in a single process across time, place and discipline.

1) Centrality of client needs
The principle of care is to address the needs of clients in terms of medical, psychological and social aspects of health.

2) Case management
Coordination of care for clients' with a high risk profile (e.g. identifying risks, developing policies and guidance).

3) Patient education
Education for clients is focused on medical, psychological and social aspects of health.

4) Client satisfaction
User satisfaction of the individual client is central to the organisation of care.

5) Continuity
The organisation of care aims to provide fluid care delivery for an individual client.

6) Interaction between professional and client
Attitude and behavioural characteristics between professional and client regarding all health needs of the client.

7) Individual multidisciplinary care plan
Implementation of a multidisciplinary care plan at the individual client level.

8) Information provision to clients
Provide unambiguous and understandable information at the individual client level.

9) Service characteristics
Provision of services is focused on medical, psychological and social aspects of health.

10) Client participation
Clients are (pro)actively involved in the design, organisation and provision of care at the operational level.

11) Population needs
The interdisciplinary approach is consistent with the dominant needs of the population.

12) Self-management
Tailor-made support of self-management at the individual client level PROFESSIONAL INTEGRATION Inter-professional partnerships based on shared competences, roles, responsibilities and accountability to deliver a comprehensive continuum of care to a defined population.

13) Inter-professional education
Inter-professional education for professionals focused on interdisciplinary collaboration.

14) Shared vision between professionals
A shared vision between professionals focused on the content of care.

15) Agreements on interdisciplinary collaboration
Agreements on the establishment of interdisciplinary cooperation at the operational level.

16) Multidisciplinary guidelines and protocols
Multidisciplinary guidelines and protocols are implemented in coherence with the operational level.

17) Inter-professional governance
Inter-professional governance is focused on openness, integrity and accountability between professionals at the operational level (e.g. joint accountability, appeal on pursued policies and responsibilities).

18) Interpersonal characteristics
Interpersonal characteristics of the professionals involved in the partnership (e.g. trust, equality, respect, values).

19) Clinical leadership
Accepted leadership with power and influence at the operational level (e.g. professional status characteristics such as reputation, specialization, position and seniority).

20) Environmental awareness
Environmental awareness of professionals with regard to economic, social and political developments.

21) Value creation for the professional
Value is added for the individual professional through interdisciplinary collaboration.

22) Performance management
Performance management at the operational level is focused on improving health outcomes for the individual client and the population.

23) Creating interdependence between professionals
Creating mutual interdependencies between professionals regarding interdisciplinary collaboration.

ORGANISATIONAL INTEGRATION
Inter-organisational relationships (e.g. contracting, strategic alliances, knowledge networks, mergers), including common governance mechanisms, to deliver comprehensive services to a defined population.

24) Value creation for organisation
Value is added through the collaboration of each involved organisation.

25) Inter-organisational governance
Inter-organisational governance is focused on openness, integrity and accountability between organisations at the strategic level (e.g. joint responsibilities, strategy and policy).

26) Informal managerial network
Informal network of managers within the collaboration.

27) Interest management
A climate that attempts to bridge the various interests (e.g. social, organisational and personal) at the operational, tactical and strategic level.

28) Performance management
Collective elaborated performance management between organisations within the collaboration.

29) Population needs as binding agent
The needs of the population are central in the collective policy of the various organisations in the collaboration.

30) Organisational features
Organisational features of inter-organisational collaboration (e.g. legal structure, number of organisations, profit vs. non-profit).

31) Inter-organisational strategy
A collective elaborated strategy exists between the organisations within the collaboration.

32) Managerial leadership
Leadership with power and influence at a strategic level (e.g. reputation, seniority and formal position).

33) Learning organisations
Collective learning power between the organisations within the collaboration (e.g. joint research and development programs).

34) Location policy
A collective location policy between the organisations within the collaboration (e.g. coordinated housing and facilities).

35) Competency management
Collectively utilize and select competencies of professionals and staff to the greatest possible extent for the objectives of the collaboration.

36) Creating interdependence between organisations
The organisation of the collaboration aims to create mutual interdependencies between organisations (e.g. multiyear rental agreement).

SYSTEM INTEGRATION A horizontal and vertical integrated system, based on a coherent set of (informal and formal) rules and policies between care providers and external stakeholders for the benefit of people and populations. 37) Social value creation
Value is added through the collaboration of social objectives and interests.

38) Available resources
Available resources in the environment of the collaboration (e.g. usable buildings, (over)capacity, professionals and funding streams).

39) Population features
Health determinants of the population in the environment of the partnership (e.g. population composition and use of care).

40) Stakeholder management
Engagement of various stakeholders (e.g. municipality, patient organisations and health insurance companies).

41) Good governance
Creating trust towards external stakeholders (e.g. municipality and health insurance companies) based on working method, reputation, management, control and/or supervision.

42) Environmental climate
Political, economic and social climate within the environment of the collaboration (e.g. market characteristics, regulatory framework, competition). FUNCTIONAL INTEGRATION Key support functions and activities (i.e. financial, management and information systems) structured around the primary process of service delivery to coordinate and support accountability and decision-making between organisations and professionals in order to add overall value to the system.

43) Human resource management
Aligned Human Resource Management within the collaboration (e.g. joint staffing and personnel).

44) Information management
Aligned information management systems accessible at an operational, tactical and strategic level (e.g. monitoring and benchmarking systems).

45) Resource management
Coherent use of resources (e.g. collective real estate and funding).

46) Support systems and services
Aligned support systems and services at the operational level (e.g. facility management and secretarial support).

47) Service management
Aligned service management for the client (e.g. collective telephone numbers, counter assistance and 24-hour access)

48) Regular feedback of performance indicators
Regular feedback of performance indicators for professionals at the operational level to enable them to improve their performance.

NORMATIVE INTEGRATION The development and maintenance of a common frame of reference (i.e. shared mission, vision, values and culture) between organisations, professional groups and individuals. 49) Collective attitude
Collective attitude within the collaboration towards open communication, sincerity and respect at operational, tactical and strategic levels.

50) Sense of urgency
Awareness regarding the need and purpose to collaborate at the operational, tactical and strategic levels.

51) Reliable behaviour
The extent to which the agreements and promises within the collaboration are fulfilled at operational, tactical and strategic levels.

52) Conflict management
The ability to effectively manage interpersonal conflicts within the collaboration.

53) Visionary leadership
Leadership based on a personal vision that inspires and mobilizes people.

54) Shared vision
A collectively shared long-term vision within the collaboration at the operational, tactical and strategic levels.

55) Quality features of the informal collaboration
Effectiveness and efficiency of the informal collaboration at the operational, tactical and strategic levels (e.g. group dynamics and attention to the undercurrent).

56) Linking cultures
Linking cultures (e.g. values and norms) with different ideological values within the collaboration at the operational, tactical and strategic levels.

57) Reputation
Individual reputation of those people involved in the collaboration.

58) Transcending domain perceptions
The ability to transcend one's own professional domain within the collaboration at the operational, tactical and strategic levels.

59) Trust
The extent to which those involved in the collaboration at operational, tactical and strategic levels trust each other.