Enacting a model of integrated care for people with complex health needs

摘要

Introduction : Improving health care through integrated care has been a goal for governments and policymakers internationally for three decades. However, it is still unclear how integrated care can be achieved in practice. This doctoral study examined how a model of integrated care evolved as an approach to caring for people with complex health needs. The case is HealthOne, a NSW government initiative, located in primary health care. Theory / Methods : Drawing on resources from actor-network theory, practice theory and integrated care literatures, this study explored how a model of integrated care was enacted in practice. The multi-sited, mobile ethnographic fieldwork extended from 2011 to 2013. Data was collected from shadowing HealthOne liaison nurses, observing meetings, semi-structured interviews and documents. The focus was on work practices associated with care of HealthOne clients carried out by a range of health and social care professionals. Results : The enactment of integrated care emerged as a relatively unstructured form of integration, understood as linkage. While embedded practices such as working in silos and protecting client confidentiality reacted uneasily to the model of care, practices including engaging clients and working with general practitioners fostered change. This enactment of integrated care was an approach to new ways of working reliant on relational practices encouraging engagement with the model of care. HealthOne liaison nurses and case conferences held together shifting relations and emerging practices. Care was individualised and attuned to the client’s immediate needs and the realities of the local context. Discussion : Policy positioned HealthOne as a new model of care that would encompass primary care and community-based services, with integrated patient-centred care provided by multidisciplinary teams. The absence of adequate structural arrangements for shared care and lack of supportive technologies were matters of concern. Practice change evolved in uneasy tension with stability, rather than as a straightforward replacement of old with new. The policy did not work in practice entirely as envisaged, however, a form of integrated care was accomplished in practice as an ongoing, fluid process of negotiation and adaptation. Conclusions : Since there were no funding incentives, formal agreements or shared care arrangements organising practice, enacting integrated care relied on creating flexible informal partnerships across professional and organisational silos with individual clinicians and services. The HealthOne approach to integrated care became cooperative care management facilitated through liaison nurses and case conferences acting as mechanisms of integration. Lessons learned : Engagement of practitioners and clients are key dependencies. Future initiatives should establish partnership agreements with private practitioners and social care services involved in integrated care. Clinical integration should be supported by systems and structures to facilitate multidisciplinary care management and care planning. Limitations : The data and findings may not be representative of all HealthOne sites, or of a different timepoint in HealthOne’s evolution. Suggestions for future research : Future studies are recommended that foreground the clients' experiences and outcomes from integrated care initiatives. Investigation of how the HealthOne model of integrated care has been embedded in practice and further evolved would produce valuable and complementary findings to this study.