出版社：Utrecht University, Maastricht University, Groningen University
摘要：Introduction : Integrated care models for older adults are increasingly implemented in modern healthcare systems. They usually involve complex coordination and collaborations between multiple actors operating at different levels of the healthcare system. Several groups of actors such as policymakers (at the strategic level), managers (at the tactical level), providers (at the operational level), patients and caregivers, are simultaneously involved in the implementation of integrated care. Exploring their convergent and divergent perspectives may deepen our understanding of the values prioritised by these respective groups of actors in the successful implementation of integrated care. Aim : To explore the implementation of a province-wide community-based integrated healthcare model for older adults in Quebec by comparing the perspectives of policymakers, managers, providers, patients and caregivers. Theory and methods : A qualitative multiple-case study, consisting of 97 semi-structured interviews with different actors - policymakers (n=11); managers (n=34), health and social care providers (n=29), older adult patients (n=14) and caregivers (n=9) - as well as document analysis. Thematic analysis of the views of these five groups of actors were compared along the lines of the six dimensions of the Rainbow Model of Integrated Care (Valentijn, 2015). Results/discussion : In this centralised province-wide integrated care model, there are strong convergent perspectives of policymakers, managers and providers regarding the professional, organisational, systemic, functional and normative dimensions of integration. Our results showed the limited participation of patients and caregivers in the implementation process, since they had little information on those dimensions. Although policymakers, managers and providers often adhere to the same principles, differences are sometimes observed at the level of implementation. For instance, they all viewed the "continuity" item as a central element where organizational structures must support service trajectories. However, several providers report that the poor harmonization of the operating rules between the organizations and the lack of knowledge of the various programs create a lack of fluidity. Among the six dimensions, the clinical dimension was illuminated by all perspectives, with the most divergence between actors. Providers appeared to mediate between policymakers/managers, and patients/caregivers. For example, patients and caregivers offered insights into the perceived difficulties of meeting their needs. Policymakers and managers viewed the centrality of patient needs as empowering patients/caregivers to receive the services they felt most strongly about. Meanwhile, providers were mostly concerned with the capacity of the healthcare system to balance patient needs with the limited resources available. Conclusion : Centralised province-wide integration appears to have systemic, organizational, functional, and normative effects, but clinical effects are more uncertain as evidenced by the observed divergences in perspectives of actors. Lessons learned : Additional implementation efforts are needed to improve clinical integration in centralised healthcare systems. Limitations : Coordinating data analysis and interpretation was complicated by the high volume of interviews across the different perspectives. Suggestions for future research : Are systemic effects precursors of clinical changes or, on the contrary, does their importance explain the lack of clinical effects?.
