出版社：Utrecht University, Maastricht University, Groningen University
摘要：Introduction : Faced with rising healthcare costs and systemic inefficiencies, the Ministry of Health and Long-Term Care (MOHLTC) selected six programs, each a collection of acute/ post-acute care organizations, to implement bundled care across the province of Ontario, Canada in 2015. A single team provided patient care from hospital to home over 60 days while program partners shared funds, hoping that shorter hospital stays would lead to better patient outcomes and cost savings. Focusing on three Chronic Obstructive Pulmonary Disease and Congestive Heart Failure programs, we examine a) how unique challenges encountered within programs changed over time, and generated ideas and practices and that may help when spreading and scaling similar models and b) how stakeholder visions of sustainability spatially and temporally reimagine integrated care. Methods/ Theory : We conducted 36 interviews, 12 with each program; with the first 18 completed in 2016, and the rest in 2018. Interviews were conducted with program leaders and practitioners across the hospital-community spectrum. Anonymized transcripts were coded and a cultural constructivist framework informed analysis. We were interested in how stakeholders’ location within specific contexts shaped their experience of integration, as well as how these contexts were in turn shaped by stakeholders over time. Results : Stakeholder experiences were informed by program contexts, from program scale to existing cultures of collaboration. Program A experienced the challenges of being the largest in scale differently as the program matured, eventually advocating a local approach to clinician engagement and funding. Program B, facing early financial planning challenges due to uncertain patient volumes, developed a new financial reconciliation process. Program C, faced with the need to overcome early misgivings and work with a specific community partner, suggested developing standardized pathways for community services that mirrored those in acute care. Stakeholders across programs suggested that sustainability could be encouraged by moving the model upstream to preventative primary care, addressing comorbidities and social complexity, eliminating disincentives to integration by rethinking volume-based hospital funding, linking programs to existing health and social resources, and increasing program length to foster continuity. Discussion : Stakeholders’ reconceptualization of integrated models of care emphasized the local and familiar, from relationships to funding models. Stakeholders advocated systemic transformation that wrapped care around the patient both spatially and temporally– by expanding the hospital-community partnership to include primary care and other community-based health and social services, while providing longer-term, ongoing care. It was a reconceptualization of the original focus on seamless transitions from hospital to home in holistic, far-reaching ways. Conclusion/ Lessons Learnt : Spreading and scaling bundled care may be best accomplished by reclaiming the local, allowing individual jurisdictions some autonomy over integrated care implementation. Nevertheless, system-wide transformation is needed to support these myriad forms of integration; from transforming funding structures, enabling comorbidity tracking, and facilitating links to existing health and social resources. Limitations : Sample size is a practical limitation, given that the scale of some bundled care initiatives challenged the incorporation of all partner perspectives. Suggestions for future research : Future research might examine whether perspectives on sustainability differ among stakeholders in non-chronic programs.
关键词：implementation ; spread and scale ; sustainability ; locality ; system change
