A Critical Realist Evaluation of an Integrated Care Project for Vulnerable Families in Sydney, Australia

Abstract

Background Healthy Homes and Neighbourhoods (HHAN) Integrated Care Initiative was established to improve the care of families with complex health and social needs who reside in Sydney Local Health District. HHAN seeks to provide long-term multi-disciplinary care coordination as well as enhance capacity building and promotion of integrated care. We describe the qualitative component of a critical realist pilot case study aimed at exploring, explaining and refining emerging HHAN programme theories in relation to care coordination. Methods Semi-structured qualitative interviews with HHAN clients (n=12), HHAN staff and other stakeholders (n=21). Emerging themes informed the development of Context-Mechanism-Outcome configurations aimed at evaluating HHAN’s effectiveness and refining the programme theory. Results HHAN’s effectiveness was based on two process mechanisms: Engagement of vulnerable clients and integration of services. The relational mechanisms underpinning effective engagement of clients by care coordinators included: building trust, leveraging other family, social and organisational relationships, meeting clients on their own terms, demonstrating staff effectiveness as quickly as possible, and client empowerment. Operational mechanisms for enhancing care integration included knowledge transfer activities and shared learning among collaborators, structural and cultural changes, enhancing mutual respect, co-location of multidisciplinary and/or interagency staff and cultivating faith in positive change among staff. Conclusions Use of a critical realism case study approach served to elucidate the varied influences of contexts and mechanisms on programme outcomes, to highlight what works for whom and in what context. Findings supported the initial programme theory that engagement and trust building with clients, alongside enhanced collaboration and integration of services, improved outcomes for vulnerable families with complex needs. Further research is needed to explore the cost-effectiveness of integrated care initiatives, in view of the long term nature of service provision and the risk of staff burnout.

Formulating Initial Programme Theories of the Healthy Homes and Neighbourhoods Integrated Care Initiative

“…The explanatory models were developed using the CIMO heuristic tool, which facilitated our theory development. Those efforts have been published in peer-reviewed journals [1,12,[27][28][29]. This step examines these different explanatory models developed at the various stages of the HHAN initiative development.…”

“…Initially, a Theory of Change logic model [7] and a critical realist-informed approach were used to construct folks' theories -ancillary background theories [11] from programme designers' perspectives informing the design of the HHAN initiative [7]. After piloting the HHAN initiative, critical realist evaluations were conducted to test the realist-informed folks' theories [12]. Based on evidence obtained from these studies and other sources of information, we sought to formulate a refined initial programme theory.…”