iCOACH: Integrated care as boundary spanning: Organizational workarounds in the delivery of community based primary health care

摘要

Introduction : In Ontario, Canada publicly funded healthcare extends across siloed sub-systems, spanning acute, primary, home and community care (H&CC). The fractured and constantly evolving nature of healthcare can pose challenges for integrated care. Community-based primary health care (CBPHC) may serve as a strategy to work across several subsystems, specifically between primary and H&CC, to support the independence of the frail elderly. Here we explore the efforts of three organizations to provide integrated CBPHC in the absence of integrative “boundary-spanning” policy regimes (Jochim and May, 2010). Theory/Methods : As part of a wider CIHR-funded multi-jurisdiction comparative case study (iCOACH project) this research investigates three community-based organizations with distinctive approaches to coordinating a continuum of primary healthcare and support services in Ontario. We purposively sampled key informants (n=22) comprised of senior leadership from the organizations, key partners including government, leaders within various provincial agencies, and policy advisors to government with insight into the policy environment and political factors impacting on the ability of these types of models to develop, sustain and/or scale-up. Analysis involved an iterative inductive thematic approach to explore how CBPHC organizations work across subsystems. Discussion and implications of findings were informed by policy subsystems literature and international CBPHC frameworks to address integrated care. Results : In Ontario, organizations offering integrated CBPHC work in complex and rapidly changing policy environments which result in internal fissures and the need for multiple workarounds. First, they are subject to continual change and adaptation to new and emerging policy directives. Second, they must devise complex internal structures, accounting systems and service arrangements to overcome the requirements of multiple external partners and funders, each with their own service criteria, geographies, reporting specifications, regulation and oversight. Third, considerable commitment, visionary leadership and organizational strength is involved to overcome such schisms and overburden. Discussion : With no formal mechanisms to ensure or support efforts toward greater integration of care, CBPHC organizations can struggle to maintain cohesiveness (e.g., multiple locations, funding streams, and performance and accountability expectations) and wrap-around care. In spanning boundaries across the system, they also appear to be subject to internal fracturing. Conclusions : To counter issues working within and across multiple subsystems the creation of boundary-spanning policy frameworks would aid to better identify and integrate relevant elements/issues identified as areas of consistent challenge. In their absence, the need for workarounds and the effects of overburden will constrain ability to provide integrated CBPHC. Lessons Learned : With limited formal mechanisms available to support and maintain CBPHC models attempts to integrate care, the cycle of external fracturing impacting on internal fracturing will likely to continue. Limitations : A policy perspective that looks solely at health or social care may be more clearly identifiable; however, within each system there are multiple and less distinct subsystems related to broader health making the identification of relevant subsystems for CBPHC extremely complex. Suggestions for Future Research : A cross-jurisdictional comparative policy analysis with Quebec and New Zealand is planned to increase understanding of the extent to which cross-boundary issues influence the ability to offer integrated CBPHC and recommendations to address them.