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Demographical changes have stimulated a coordination reform in the Norwegian health care sector, creating new working practices and extending coordination within and between primary and hospital care, increasing the need for inter-municipal cooperation (IMC). This study aimed to identify challenges to coordination and IMC in the Norwegian health ca...
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Context 1
... kappa was used to measure agreement among the experts. Table 4 shows that value of kappa increased con- cerning Q-1 and Q-2, indicating that that the principle of a successive broader agreement between experts during the rounds was fulfilled. In round five, the value of kappa in Q-1 was higher than that in Q-2. ...
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... 41 Another aspect of intermunicipal cooperation is that it often increases the complexity of coordination between different services and actors, which can pose challenges to efficient healthcare delivery. 42 For instance, increased travel distances in intermunicipal MIPAC units may produce negative health outcomes, particularly for older adult patients, and potentially result in more upward hospital transfers. ...
Background
Norwegian Municipal Inpatient Acute Care (MIPAC) services were established as part of the 2012 Coordination Reform. The intention was to prevent unnecessary hospital admissions by redirecting and maintaining less urgent patients at the primary care level, which provides inpatient acute healthcare services closer to patients’ home. However, the role MIPAC plays in the patient trajectory and how trajectories vary across different units and settings is less clear.
Objective
Therefore, this study aimed to (1) describe the general patient transfer trajectories for MIPAC patients and (2) examine facility and regional variations in MIPAC patients’ sources of admission and discharge destinations.
Design
A cross-sectional study using aggregated register data.
Methods
The study involved 36 662 admissions across 185 MIPAC units in 2019. Descriptive statistics were used to describe patient transfer trajectories, and a random-effects multinomial logistic model was applied to assess the association between facility and regional factors and patients’ admission sources and discharge destinations.
Results
The findings revealed distinct admission and discharge patterns based on facility and regional factors. Notably, intermunicipal units with 5 and more municipalities collaborating had higher relative risk ratios (RRR) for discharging to hospital (RRR = 1.50, 95%CI: 1.30-1.72) compared with independent MIPAC units. Large MIPAC units with more than 5 beds had increased relative risk ratios of patients admitted from the hospital than from home (RRR = 4.29, 95%CI: 1.56-11.78). Additionally, regional disparities existed, with units in the Central (RRR = 2.29, 95%CI: 1.56-3.38) and Western Norway health authorities (RRR:1.58, 95%CI: 1.22-2.06) displaying higher nursing home discharge rates than units in the South-Eastern Norway health authority.
Conclusions and implications
This study confirms the Norwegian MIPAC services’ adherence to admission avoidance policies and identifies significant variations in service delivery across regions and facilities. The Norwegian MIPAC model also has potential to inspire other countries in developing admission avoidance services in the primary care setting.
... A Delphi method is an iterative process in which a group of expert stakeholders come to a structured consensus view on a particular topic [15]. Delphi processes have been successfully conducted to establish research priorities for a range of different topic areas such as identifying challenges for coordination in healthcare services [16], determining the future organisation of thrombectomy services in England [17], agreeing research priorities for patient safety in mental health [18] and for emergency medicine physicians in Australia and New Zealand [19]. ...
Background:
Clinical analytics is a rapidly developing area of informatics and knowledge mobilisation which has huge potential to improve healthcare in the future. It is widely acknowledged to be a powerful mediator of clinical decision making, patient-centred care and organisational learning. As a result, healthcare systems require a strategic foundation for clinical analytics that is sufficiently directional to support meaningful change while flexible enough to allow for iteration and responsiveness to context as change occurs.
Methods:
In New South Wales, the most populous state in Australia, the Clinical Analytics Working Group was charged with developing a five-year vision for the public health system. A modified Delphi process was undertaken to elicit expert views and to reach a consensus. The process included a combination of face-to-face workshops, traditional Delphi voting via email, and innovative, real-time iteration between text re-formulation and voting until consensus was reached. The six stage process engaged 35 experts - practising clinicians, patients and consumers, managers, policymakers, data scientists and academics.
Results:
The process resulted in the production of 135 ideas that were subsequently synthesised into 23 agreed statements and encapsulated in a single page (456 word) narrative.
Conclusion:
The visioning process highlighted three key perspectives (clinicians, patients and managers) and the need for synchronous (during the clinical encounter) and asynchronous (outside the clinical encounter) clinical decision support and reflective practice tools; the use of new and multiple data sources and communication formats; and the role of research and education.
... Achieving cooperation is challenging and can vary among issues and over time (Axelrod and Keohane 1985). Several studies have been developed to analyse the main strategies developed for cooperation and its potential benefits (De Mello and Lago-Peñas 2013;Gillies 1998;Holen et al. 2013;Oye 1985). Also, distinguished types of cooperation have been proposed depending on the type of partner (Belderbos et al. 2004), the level of integration (Cruijssen, Dullaert, and Fleuren 2007), and conflict of interest (Gramlich 1987). ...
The Agenda 2030 for Sustainable Development was approved in September 2015 and has the 17 Sustainable Development Goals (SDGs) as a central component. The role of healthy cities in achieving the SDGs, mainly SDG 11, has been reinforced by the World Health Organization (WHO). Initiatives such as the Healthy Municipalities, Cities, and Communities (HMC) in Brazil, sponsored by WHO, could be a complementary framework to support the implementation of SDG 11 at local levels. This study draws on a qualitative methodology to examine how HMC initiatives can support the integration of health promotion into the implementation of Goal 11 at local levels in Brazil. While social participation and integration of SDGs across Master Plans seem to be enablers factors, the lack of a national strategy and the absence of an effective evaluation of the results achieved by HMC seem to have hindered the potential of HMC in Brazil and could be critical factors for the integration of health into SDG 11 at local levels. Moreover, drawing on HMC potential contributions, this research proposes a framework to integrate health promotion across SDG 11 at local levels. Findings also suggest that there are several achievements and lessons learned from the implementation of HMC that could contribute to integrating health into SDG 11 at local levels in Brazil.
... Achieving cooperation is challenging and can vary among issues and over time (Axelrod and Keohane 1985). Several studies have been developed to analyse the main strategies developed for cooperation and its potential benefits (De Mello and Lago-Peñas 2013;Gillies 1998;Holen et al. 2013;Oye 1985). Also, distinguished types of cooperation have been proposed depending on the type of partner (Belderbos et al. 2004), the level of integration (Cruijssen, Dullaert, and Fleuren 2007), and conflict of interest (Gramlich 1987). ...
... In newly established inter-municipal services, there is no established process and information flow, hence the framework is less applicable. Furthermore, it is well known that management of inter-municipal cooperation is challenging [3,7]. There is a lack of literature focusing on communication and information sharing in inter-municipal healthcare services. ...
Background
In recent years, inter-municipal cooperation in healthcare services has been an important measure implemented to meet future demographic changes in western countries. This entails an increased focus on communication and information sharing across organisational borders. Technology enables efficient and effective solutions to enhance such cooperation. However, the systems in the healthcare sector tend not to communicate with one another. There is a lack of literature focusing on communication and information sharing in inter-municipal healthcare services. The aim of this article is to investigate both the characteristics of communication and information sharing, and the factors that serve as barriers to communication and information sharing for employees in inter-municipal healthcare services.
Methods
In this study, a qualitative case study approach is used to investigate both characteristics of communication and information sharing, and factors enabling barriers to communication and information sharing for employees in newly established inter-municipal healthcare services. Data collection methods were individual interviews, focus group interviews, observation studies and a workshop. A total of 18 persons participated in the study. The interviews, observations and workshop were conducted over a period of ten months.
Results
Communication and information sharing practices were found to be complex and characterised by multiple actors, information types and a combination of multiple actions. Findings indicate that 1. IT capability and usability 2. Differences 3. Privacy, confidentiality and security and 4. Awareness are all factors enabling barriers to communication and information sharing in inter-municipal healthcare services. Specifically, these barriers were related to lack of EHR usability, inadequate workflow processes, digital systems incompatibility, the understanding of needs in different systems and knowledge and practices regarding privacy and confidentiality.
Conclusion
By focusing on the context of inter-municipal cooperation when assessing communication and information sharing in healthcare services, this article contributes to close a gap in existing knowledge. The perspective of the employees provides useful insight, and findings can be relevant for future theory development and for managers and policymakers in inter-municipal services.
... Previous research suggests that direct management, which is based on continuous information flow between practitioners and their governing body, as in a traditional, hierarchical organisational structure, is lacking in horizontal cooperation like IMC [40]. The complex leadership in inter-municipal cooperation in health care services are found to be challenging [41]. According to the theory of perceived organisational support (POS), supervisor support is an important antecedent to POS [25], and hence impacts employee commitment, loyalty and performance [23]. ...
... In previous studies, autonomy in teamwork has been highlighted as important [44,45] Employees in individual services have reduced possibility to be flexible or adapt the services provided because they lack others with whom to collaborate. Challenging governance and democratic control can be found in inter-municipal cooperation [15,41]. However, how this affects employees, and hence service delivery, has not been determined. ...
Background
Traditional, hierarchical government structures have recently been challenged by increased complexity, fragmented services and heavy public demand. When healthcare services become fragmented and decentralised, they require redesign. Inter-municipal cooperation is a strategy to deal with current challenges and future demographic changes. Few studies exist that can help us conceptualize challenges regarding employment in this context and inform managers in the involved municipalities. This study aims to identify critical issues for employees in inter-municipal health care services and to elaborate on how and why these issues are experienced.
Methods
A multiple qualitative case study was conducted with data from interviews, observation studies, a participant workshop and inter-municipal healthcare service project documents and reports. The study involved two districts in Norway and six cases including 17 informants. First, a within-case analysis was conducted for all cases; second, a cross-case analysis was conducted in each district to examine replication, contrasts and extension to emergent findings; and, eventually, replicated findings in Districts 1 and 2 were analysed across districts.
Results
Three critical issues were identified: support, differences, and geographical distances. Employees working in teams experienced fewer challenges than did those working as isolated individuals.
Conclusions
Critical issues for employees represent an important aspect of inter-municipal cooperation, and additional research should be undertaken to inform future policy and practice.
... Inadequate communication and cooperation in planning of hospital discharges, have also been described by Holen-Rabbersvik et al. [43]. Such problems may result in hospital readmissions if the municipalities are not prepared to receive the discharged patients due to facilities, lack of competence or staffing, equipment or lack of institutional space [44]. ...
Background:
Hospital readmissions is an increasingly serious international problem, associated with higher risks of adverse events, especially in elderly patients. There can be many causes and influential factors leading to hospital readmissions, but they are often closely related, making hospital readmissions an overall complex area. In addition, a comprehensive coordination reform was introduced into the Norwegian healthcare system in 2012. The reform changed the premises for readmissions with economic incentives enhancing early transfer from secondary to primary care, making research on readmissions in the municipalities more urgent than ever. General practitioners (GPs) and nursing home physicians, have traditionally held a gatekeepers function in hospital readmissions from the municipal healthcare service, as they are the main decision-makers in questions of hospital readmissions. Still, the GPs' gatekeeper function is an under-investigated area in hospital readmission research. The aim of the study was to increase knowledge about factors that lead to hospital readmissions among elderly in municipal healthcare, with special attention to GPs' and nursing home physicians' decision making.
Method:
The study was conducted as a comparative case study. Two municipalities affiliated with the same hospital, but with different readmission rates were recruited. Twenty GPs and nursing home physicians from each municipality were recruited and interviewed. Forty hours of observation were conducted during the huddles in one long-term and one short-term nursing home in each municipality.
Results:
Seven themes describing how different factors influence physicians' decision-making in the hospital readmission process in two municipalities were identified. Poor communication, continuity and information flow account for hospital readmissions in both municipalities. Several factors, including nurse staffing and competence, patients and their families, time constraints and experience affected physicians' decision-making.
Conclusion:
Communication, continuity and information flow contributed to hospital readmissions in both municipalities. The cross-case analysis revealed slight differences between municipalities. More research focusing on GPs' and nursing home physicians' decision-making, nursing home nurses and home care nurses' experience of hospital readmissions and discharges is needed.
... In order to support commissioning decisions, we aimed to use an electronic Delphi survey to establish consensus on the options for the future organisation of thrombectomy services in England amongst physicians with clinical experience in managing large artery occlusive stroke; in the process helping demonstrate the feasibility of the methods for informing service delivery policy in other areas. We designed a Delphi and ranking exercise to to focus on questions of "what could/should be" relating to the organisation of health care services [18][19][20][21][22]. The purpose of the study was to derive consensus on thrombectomy service organisation. ...
Background:
Intra-arterial thrombectomy is the gold standard treatment for large artery occlusive stroke. However, the evidence of its benefits is almost entirely based on trials delivered by experienced neurointerventionists working in established teams in neuroscience centres. Those responsible for the design and prospective reconfiguration of services need access to a comprehensive and complementary array of information on which to base their decisions. This will help to ensure the demonstrated effects from trials may be realised in practice and account for regional/local variations in resources and skill-sets. One approach to elucidate the implementation preferences and considerations of key experts is a Delphi survey. In order to support commissioning decisions, we aimed using an electronic Delphi survey to establish consensus on the options for future organisation of thrombectomy services among physicians with clinical experience in managing large artery occlusive stroke.
Methods:
A Delphi survey was developed with 12 options for future organisation of thrombectomy services in England. A purposive sampling strategy established an expert panel of stroke physicians from the British Association of Stroke Physicians (BASP) Clinical Standards and/or Executive Membership that deliver 24/7 intravenous thrombolysis. Options with aggregate scores falling within the lowest quartile were removed from the subsequent Delphi round. Options reaching consensus following the two Delphi rounds were then ranked in a final exercise by both the wider BASP membership and the British Society of Neuroradiologists (BSNR).
Results:
Eleven stroke physicians from BASP completed the initial two Delphi rounds. Three options achieved consensus, with subsequently wider BASP (97%, n = 43) and BSNR members (86%, n = 21) assigning the highest approval rankings in the final exercise for transferring large artery occlusive stroke patients to nearest neuroscience centre for thrombectomy based on local CT/CT Angiography.
Conclusions:
The initial Delphi rounds ensured optimal reduction of options by an expert panel of stroke physicians, while subsequent ranking exercises allowed remaining options to be ranked by a wider group of experts within stroke to reach consensus. The preferred implementation option for thrombectomy is investigating suspected acute stroke patients by CT/CT Angiography and secondary transfer of large artery occlusive stroke patients to the nearest neuroscience (thrombectomy) centre.
... Norwegian studies of IMC have identified several challenges to IMC, including disagreement about financial issues (Deloitte 2013;Zeiner and Tjerbo 2015), the presence of time-consuming processes (Leknes et al. 2013;Deloitte 2013), and an uneven balance of power (Andersen 2010;Holen-Rabbersvik et al. 2013). We expect these types of challenges to be fostered by large differences in population size, economic situation, and political preferences relative to neighbouring municipalities, thus undermining IMC. ...
... This is also in line with Norwegian studies of IMC which report that municipalities see an unequal bargaining power (e.g. Andersen 2010;Holen-Rabbersvik et al. 2013) and the presence of time consuming processes (Leknes et al. 2013;Deloitte 2013) as a challenge to cooperation. Larger municipalities surrounded by smaller ones, on the other hand, may not experience these types of problems as they are the stronger part, and may also be attractive cooperation partners as they may function as a regional 'hub' that is well equipped to fulfil the function as a host of the IMC since it has bigger and more professional staff compared to the smaller ones (Andersen and Pierre 2010). ...
Inter-municipal cooperation in service delivery is widespread, as is the notion that this type of cooperation is primarily driven by economies of scale. However, the empirical results appear to be inconclusive, suggesting that additional explanatory factors are needed to explain why municipalities cooperate. This study aimed to identify the factors and conditions that influence the level of inter-municipal cooperation in health services by exploring a broad set of explanatory factors that go beyond simple economic concerns. In addition to confirming that a small population-size and fiscal stress constitute important drivers of inter-municipal cooperation, the results from this study also demonstrates the need to consider geographical location and heterogeneity relative to neighbouring municipalities as potential barriers to such cooperation.
... Ulike IKT-systemer som ikke kommuniserer med hverandre, fører til at pasientinformasjon som dokumenteres på ett helsetjenestenivå, ikke er tilgjengelig på et annet nivå. Dette vanskeliggjør den tverrfaglige samhandlingen og informasjonskontinuitet i overføringer av eldre med kronisk sykdom (Aalbu, Carlsen & Knutsen, 2013;Heimly & Hygen, 2011;Holen-Rabbersvik, Eikebrokk, Fensli, Thygesen & Slettebø, 2013;Rønhovde, 2012;Schibevaag, 2014;Tjøstolvsen, 2016). ...
This review includes 121 publications from research and development projects
concerning patient pathways for elderly people with chronical illnesses in the
community health care and between different levels in the health care services.
The Norwegian health care service is described as a complex and fragmented system
which is constantly dealing with a severe pressure. This is a challenge for holistic care
pathways for elderly patients with chronical illnesses, since these pathways often
contain several critical transitions. Clinical guidelines developed for single diseases, in
addition to fragmented and poor coordinated services, is pointed out as challenging for
patients with several multichronical illnesses – also known as multimorbidity.
Furthermore, there is a focus on poor information flow during transitions between
hospital and community, and on distinct differences in approaches and perspectives
between specialist- and primary health care services. The specialist health care service
mainly focuses on the patient’s needs in a short time perspective. In addition, it is
having a medically, diagnosis oriented approach. On the other hand, the primary health
care service mainly focuses on the patient’s needs in a long-term perspective, emphasizing
their level of function, coping ability, quality of life, and home situation. Different
perspectives related to patient’s need of care is further reflected in different understandings
of the term “ready to be discharged”. Several publications point at the fact that
the coordination reform has resulted in a larger number of patients with more medical
needs in the communities, and to a higher rate of readmissions in hospital. In addition,
these publications show that hospitals discharge patients too soon, and many patients
are not treated to a complete healing before discharged. Furthermore, it is reported in
several publications that the community does not have sufficient knowledge to receive
these patients from hospital. Challenges related to poor economic resources in the
communities are also pointed out as important in these matters.
Standardized care pathways and the use of check-lists are described as good tools in
improving transitions from hospitals to communities and to strengthen the monitoring
of patients, while the use of IT and care messages (PLO-messages) are described as
tools that can contribute to better flow of information. Different models of cooperation
between hospital and community are measures considered to improve transition of
knowledge and increase understanding of the patient’s situation. Further, this can result
in better transitions and continuity in patient pathways. The implementation of intermediate
units and municipal emergency bed units (KAD) are described as important
and successful initiatives to improve transitions between hospital and community.
However, challenges in organization of the services are also discussed. Elderly people
discharged from hospital to the community, will according to literature benefit from
interconnected and targeted initiatives to improve transitions between different levels in
the health care system.
