The importance of normative integration in stroke services: Case study evidence from Sweden and England

Baeza, Juan; Boaz, Annette; Fraser, Alec; Fulop, Naomi; McKevitt, Christopher; Wolfe, Charles D A

doi:10.1177/0951484812474245

Cited by 3 publications

(5 citation statements)

References 23 publications

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“…Fuller accounts of these case studies can be found in another paper by the authors. 20 These five case studies allowed us to investigate a number of important factors related to translating research evidence into healthcare practice in the area of stroke care. Through interviews with medical doctors, nurses and therapists, the original research examined what organisational aspects might help or hinder an organisation's ability to successfully transfer research evidence into practice in stroke services, 21,22 In this paper, we reflect on aspects of this work to consider what we learned about the differential interprofessional perspectives to EBP in stroke care.…”

Section: Methodsmentioning

confidence: 99%

Evidence-based practice: reflections from five European case studies

Baeza

Fraser

Boaz

2014

London Journal of Primary Care

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Key message(s). Evidence-based practice (EBP) needs to draw on a wide range of evidence that is not only based on randomized controlled trials. . The location of practice (acute, community or primary care) needs to be carefully considered when using EBP. . Inter-and intraprofessional relations need to be carefully considered in relation to EBP. Related LJPC papersToon and Thomas (both in this issue). Why this matters to meThrough our European study, we have learnt that the nature of evidence is a contested term that can both bring different professionals together, for example, within stroke units, or harm professional relationships, for example, between stroke units and primary and community care. For evidence-based practice to have a positive impact on patients, it needs to be used as an inclusive endeavour rather than an exclusive one. ABSTRACTBackground Evidence-based practice (EBP) is now the accepted orthodoxy in clinical practice and developed from evidence-based medicine. EBP is based on a specific type of evidence that is derived from studies based on randomised controlled trials (RCT). This type of evidence is suited to acute medical care and is more problematic for other clinicians such as nurses and therapists, particularly when they are situated within community or primary care settings. Setting Five stroke care services in England (2), Sweden (2) and Poland (1). Aims To reflect on the evidence gained from these case studies to shed light on various aspects of EBP. This paper focuses on three key issues: (1) the importance of context for evidence, (2) the nature of knowledge, and (3) professional hierarchies. Methods Five qualitative case studies into stroke care were carried out in England, Sweden and Poland. One hundred and twenty semi-structured interviews were carried out with a range of healthcare staff who provided specialised and non-

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Section: Methodsmentioning

confidence: 99%

Evidence-based practice: reflections from five European case studies

Baeza

Fraser

Boaz

2014

London Journal of Primary Care

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“…Cross-sectional continuity (synonyms: 'clinical', 'comprehensive', 'holistic', 'management', 'therapeutic' continuity 34,[82][83][84][85] ) denotes managing a patient's complex health conditions as a totality in the light of how they, and the corresponding interventions and care, interact, so as to produce a single, consistent care process to meet all of the patient's health-care needs. 86 This is critical when more than one provider is needed at a time. 2.…”

Section: Continuities Of Carementioning

confidence: 99%

“…This is what Øvretveit et al 33 call 'clinical integration', that is, how well services are co-ordinated between people and sites over time 3. capitation payment, creating incentives for preventative care 4. competing with other providers on quality rather than cost 5. good management and information systems, with 'functional integration' (i.e. support functions such as the management of finance, human resources, IT and planning closely co-ordinated across units) 86 6. a sufficiently large organisation and population served to ensure long-term stability of the organisation and enable the development of care pathways for common diseases 7. doctors who actively participate in management and are economically linked to their organisation.…”

Section: Vertical Integrationmentioning

confidence: 99%

“…The absence of such norms appears to have contributed to the weak clinical co-ordination of post-discharge care found in both the English and the Swedish health systems. 86…”

Section: Emergent Networkmentioning

confidence: 99%

“…286 Having different owners, objectives and internal managerial regimes, 38,287,288 these different types of organisation might be expected to differ in how they interpret and implement care integration and what priority they give to it. That is, how far are the care processes that different kinds of provider organisation select, in pursuit of their multiple and diverse objectives, compatible with the requirements for care co-ordination and continuity outlined in Chapter 2 (coherence of rules and policies at different organisational levels 86 )?…”

Section: Care Network' Dependences On Health-system Governancementioning

confidence: 99%

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Integration and continuity of primary care: polyclinics and alternatives – a patient-centred analysis of how organisation constrains care co-ordination

Sheaff

Halliday

Øvretveit

et al. 2015

Health Serv Deliv Res

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BackgroundAn ageing population, the increasing specialisation of clinical services and diverse health-care provider ownership make the co-ordination and continuity of complex care increasingly problematic. The way in which the provision of complex health care is co-ordinated produces – or fails to produce – six forms of continuity of care (cross-sectional, longitudinal, flexible, access, informational and relational). Care co-ordination is accomplished by a combination of activities by patients themselves; provider organisations; care networks co-ordinating the separate provider organisations; and overall health-system governance. This research examines how far organisational integration might promote care co-ordination at the clinical level.ObjectivesTo examine (1) what differences the organisational integration of primary care makes, compared with network governance, to horizontal and vertical co-ordination of care; (2) what difference provider ownership (corporate, partnership, public) makes; (3) how much scope either structure allows for managerial discretion and ‘performance’; (4) differences between networked and hierarchical governance regarding the continuity and integration of primary care; and (5) the implications of the above for managerial practice in primary care.MethodsMultiple-methods design combining (1) the assembly of an analytic framework by non-systematic review; (2) a framework analysis of patients’ experiences of the continuities of care; (3) a systematic comparison of organisational case studies made in the same study sites; (4) a cross-country comparison of care co-ordination mechanisms found in our NHS study sites with those in publicly owned and managed Swedish polyclinics; and (5) the analysis and synthesis of data using an ‘inside-out’ analytic strategy. Study sites included professional partnership, corporate and publicly owned and managed primary care providers, and different configurations of organisational integration or separation of community health services, mental health services, social services and acute inpatient care.ResultsStarting from data about patients’ experiences of the co-ordination or under-co-ordination of care, we identified five care co-ordination mechanisms present in both the integrated organisations and the care networks; four main obstacles to care co-ordination within the integrated organisations, of which two were also present in the care networks; seven main obstacles to care co-ordination that were specific to the care networks; and nine care co-ordination mechanisms present in the integrated organisations. Taking everything into consideration, integrated organisations appeared more favourable to producing continuities of care than did care networks. Network structures demonstrated more flexibility in adding services for small care groups temporarily, but the expansion of integrated organisations had advantages when adding new services on a longer term and a larger scale. Ownership differences affected the range of services to which patients had direct access; primary care doctors’ managerial responsibilities (relevant to care co-ordination because of their impact on general practitioner workload); and the scope for doctors to develop special interests. We found little difference between integrated organisations and care networks in terms of managerial discretion and performance.ConclusionsOn balance, an integrated organisation seems more likely to favour the development of care co-ordination and, therefore, continuities of care than a system of care networks. At least four different variants of ownership and management of organisationally integrated primary care providers are practicable in NHS-like settings. Future research is therefore required, above all to evaluate comparatively the different techniques for coordinating patient discharge across the triple interface between hospitals, general practices and community health services; and to discover what effects increasing the scale and scope of general practice activities will have on continuity of care.FundingThe National Institute for Health Research Health Services and Delivery Research programme.

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Centralising acute stroke care and moving care to the community in a Danish health region: Challenges in implementing a stroke care reform

2015

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In May 2012, one of Denmark's five health care regions mandated a reform of stroke care. The purpose of the reform was to save costs, while at the same time improving quality of care. It included (1) centralisation of acute stroke treatment at specialised hospitals, (2) a reduced length of hospital stay, and (3) a shift from inpatient rehabilitation programmes to community-based rehabilitation programmes. Patients would benefit from a more integrated care pathway between hospital and municipality, being supported by early discharge teams at hospitals. A formal policy tool, consisting of a health care agreement between the region and municipalities, was used to implement the changes. The implementation was carried out in a top-down manner by a committee, in which the hospital sector--organised by regions--was better represented than the primary care sector-organised by municipalities. The idea of centralisation of acute care was supported by all stakeholders, but municipalities opposed the hospital-based early discharge teams as they perceived this to be interfering with their core tasks. Municipalities would have liked more influence on the design of the reform. Preliminary data suggest good quality of acute care. Cost savings have been achieved in the region by means of closure of beds and a reduction of hospital length of stay. The realisation of the objective of achieving integrated rehabilitation care between hospitals and municipalities has been less successful. It is likely that greater involvement of municipalities in the design phase and better representation of health care professionals in all phases would have led to more successful implementation of the reform.

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The importance of normative integration in stroke services: Case study evidence from Sweden and England

Cited by 3 publications

References 23 publications

Evidence-based practice: reflections from five European case studies

Evidence-based practice: reflections from five European case studies

Integration and continuity of primary care: polyclinics and alternatives – a patient-centred analysis of how organisation constrains care co-ordination

Centralising acute stroke care and moving care to the community in a Danish health region: Challenges in implementing a stroke care reform

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