Gothenburg: The Nordic School of Public Health, 2007, pp 174,
ISBN 978 91 85721 09 2
It was the ambition of this thesis to contribute to the growing interest in integrated care and to the ongoing research in this area by exploring the Swedish development of integrated health care. The general purpose was to study different strategies to improve integration in the Swedish health care system in order to identify some of the key issues and conditions in the creation of integrated care.
For the purpose of exploring the status of chains of care, the determinants of integrated health care development, and the evaluation of integrated health care, a combination of different quantitative and qualitative methods was used, and the research was guided by a philosophy of triangulation, that is, an application and combination of several research methodologies in the study of the same phenomenon.
The results showed that chain of care development has a high priority in Swedish health care. However, regardless of the high official priority and several years of experience, chain of care development is making slow progress. Seven out of ten county councils regard themselves as unsuccessful in developing and implementing chains of care. Even so, it seems that chains of care are here to stay. All the county councils declare that they will continue to develop chains of care. This faith in chains of care can to some extent be explained by the crucial role they have as links in the ongoing development of local health care. This is an upgraded family- and community-oriented primary care, supported by flexible hospital services. Many politicians and policy makers are convinced that such an integrated system will assure both high quality and a cost-effective health care.
The study indicated that top-down approaches are obstructing the chain of care development. Negative response emanates mostly from professional values of the body of physicians. Conversely, if a chain of care project is initiated locally by dedicated professionals, there is a good chance of a successful outcome. The legitimacy of the development work among colleagues and stakeholders is of vital importance to the success of the work. It also applies to confidence among participating organisations and authorities. This attitude includes giving space for prime movers and also trust between the participants.
A chain of quality data of input/structure, process and outcome, where the latter is dependent on the previous links in the chain, made it possible to evaluate integration from three perspectives: the patient, the professional and the management. Furthermore, a model measuring clinical functional integration, the foundation for developing integration synergy and effectiveness, was successfully validated in a local health care organisation.
Thus, chains of care are increasingly regarded as building stones of local health care. In this sense, chains of care may have a renaissance, after being high on the policy agendas for several years but with modest development results. As development of local health care has predominantly had a top-down approach, it seems that new ways have to be found to create change bottom-up by engaging health care professionals and facilitating professional dedication, legitimacy and confidence in the development work. Furthermore, clinical integration is the foundation of integrated health care and should therefore get prime attention. The validated measurement model can provide managers with crucial evaluation data. Especially for extensive evaluations, with the objective to increase understanding of the integration logic, the quality chain matrix has proven to be a helpful framework as it regards the creation of integrated care as a chain of acts. Such activities include managerial tasks, which makes it possible to evaluate the sometimes neglected role of management.
The results presented in this review are based on the author's thesis presented at the Nordic School of Public Health on 5 June 2007.
Further information on this research has been published by this author in the International Journal of Integrated Care:
Ahgren B. Chain of care development in Sweden: results of a national study. International Journal of Integrated Care [serial online] 2003 Oct 7;3. Available from: http://www.ijic.org/.
Ahgren B, Axelsson R. Evaluating integrated health care: a model for measurement. International Journal of Integrated Care [serial online] 2005 Aug 31;5. Available from: http://www.ijic.org/.