A decade of integration and collaboration: the development of integrated health care in Sweden 2000–2010

<p><strong>Introduction: </strong>The recent history of integrated health care in Sweden is explored in this article, focusing on the first decade of the 2000s. In addition, there are some reflections about successes and setbacks in this development and challenges for the next decade.    </p><p><strong>Description of policy and practice</strong>: The first efforts to integrate health care in Sweden appeared in the beginning of the 1990s. The focus was on integration of intra-organisational processes, aiming at a more cost-effective health care provision. Partly as a reaction to the increasing economism at that time, there was also a growing interest in quality improvement. Out of this work emerged the "chains of care", integrating all health care providers involved in the care of specific patient groups. During the 2000s, many county councils have also introduced inter-organisational systems of "local health care". There has also been increasing collaboration between health professionals and other professional groups in different health and welfare services. </p><p><strong>Discussion and conclusion</strong>: Local health care meant that the chains of care and other forms of integration and collaboration became embedded in a more integrative context. At the same time, however, policy makers have promoted free patient choice in primary health care and also mergers of hospitals and clinical departments. These policies tend to fragment the provision of health care and have an adverse effect on the development of integrated care. As a counterbalance, more efforts should be put into evaluation of integrated health care, in order to replace political convictions with evidence concerning the benefits of such health care provision.</p

Evaluating intersectoral collaboration: a model for assessment by service users

Introduction: DELTA was launched as a project in 1997 to improve intersectoral collaboration in the rehabilitation field. In 2005 DELTA was transformed into a local association for financial co-ordination between the institutions involved. Based on a study of the DELTA service users, the purpose of this article is to develop and to validate a model that can be used to assess the integration of welfare services from the perspective of the service users. <br><br> Theory: The foundation of integration is a well functioning structure of integration. Without such structural conditions, it is difficult to develop a process of integration that combines the resources and competences of the collaborating organisations to create services advantageous for the service users. In this way, both the structure and the process will contribute to the outcome of integration. <br><br> Method: The study was carried out as a retrospective cross-sectional survey during two weeks, including all the current service users of DELTA. The questionnaire contained 32 questions, which were derived from the theoretical framework and research on service users, capturing perceptions of integration structure, process and outcome. Ordinal scales and open questions where used for the assessment. <br><br> Results: The survey had a response rate of 82% and no serious biases of the results were detected. The study shows that the users of the rehabilitation services perceived the services as well integrated, relevant and adapted to their needs. The assessment model was tested for reliability and validity and a few modifications were suggested. Some key measurement themes were derived from the study. <br><br> Conclusion: The model developed in this study is an important step towards an assessment of service integration from the perspective of the service users. It needs to be further refined, however, before it can be used in other evaluations of collaboration in the provision of integrated welfare services

Evaluating integrated health care: a model for measurement

PURPOSE: In the development of integrated care, there is an increasing need for knowledge about the actual degree of integration between different providers of health services. The purpose of this article is to describe the conceptualisation and validation of a practical model for measurement, which can be used by managers to implement and sustain integrated care. THEORY: The model is based on a continuum of integration, extending from full segregation through intermediate forms of linkage, coordination and cooperation to full integration. METHODS: The continuum was operationalised into a ratio scale of functional clinical integration. This scale was used in an explorative study of a local health authority in Sweden. Data on integration were collected in self-assessment forms together with estimated ranks of optimum integration between the different units of the health authority. The data were processed with statistical methods and the results were discussed with the managers concerned. RESULTS: Judging from this explorative study, it seems that the model of measurement collects reliable and valid data of functional clinical integration in local health care. The model was also regarded as a useful instrument for managers of integrated care. DISCUSSION: One of the main advantages with the model is that it includes optimum ranks of integration beside actual ranks. The optimum integration rank between two units is depending on the needs of both differentiation and integration

Inter-organisational integration for rehabilitation in Sweden – variation in views on long-term goals

PURPOSE: The aim was to study variation in views on long-term goals expressed by members in a project concerning rehabilitation of individuals in an area in mid Sweden. The organisations participating were the municipal social services, the county council's health care organisation, the governmental social insurance office, the national employment service and the national labour market institute. THEORY: A number of different meanings of the concept of integration are accounted for and the background of inter-organisational rehabilitation in Sweden is described. METHODS: Qualitative interviews using a semi-structured interview guide with altogether 20 leading representatives of the various organisations, all members of the Steering Committee of the project. The analysis consisted of two parts: an in-depth analysis using a phenomenographically inspired approach and qualitative content analysis. RESULTS: Two main views regarding the goal of inter-organisational integration were identified in the in-depth analysis: Category A, which regards integration as a new approach to rehabilitation, and Category B, which regards integration as a way of rendering the existing organisations more efficient. The content analysis showed a wide variation in spontaneously mentioned topics e.g. on the task of the group. CONCLUSIONS AND DISCUSSION: There exists a risk that divergent views in the Steering Committee concerning the future direction of the collaboration may send mixed messages providing uneven support for the professionals within the different organisations. The study points to the importance of having a common vision and common, well-defined goals at the outset of a collaborative project in order to support micro-level cooperation

Integration and collaboration in public health-a conceptual framework

SUMMARY With the increasing differentiation of organisations involved in the pursuit of public health, there is also a growing need for inter-organisational integration. Starting from the concepts of differentiation and integration, this article is attempting a theoretical reconstruction based on published research on inter-organisational integration in public health and related welfare services. Different forms of integration are defined and related to each other in a conceptual framework, which is in itself an integration of different theoretical perspectives. According to this framework, integration in the field of public health requires inter-organisational collaboration across different sectors of the society. Such intersectoral collaboration can be organised mainly in the form of multidisciplinary teams across the boundaries of different organisations and sectors. Such an organisation is fragile and volatile, however, which means that it needs a lot of management support in order to survive

Organizational approaches to collaboration in vocational rehabilitation—an international literature review

<p><strong>Introduction: </strong>Collaboration between welfare organizations is an important strategy for integrating different health and welfare services. This article reports a review of the international literature on vocational rehabilitation, focusing on different organizational models of collaboration as well as different barriers and facilitating factors.</p><p> <strong>Methods: </strong>The review was based on an extensive search in scientific journals from 1995 to 2010, which generated more than 13 000 articles. The number of articles was reduced in different steps through a group procedure based on the abstracts. Finally, 205 articles were read in full text and 62 were included for content analysis. <strong></strong></p><p><strong>Results: </strong>Seven basic models of collaboration were identified in the literature. They had different degrees of complexity, intensity and formalization. They could also be combined in different ways.  Several barriers and facilitators of collaboration were also identified. Most of these were related to factors as communication, trust and commitment.</p><p><strong>Conclusion: </strong>There is<strong> </strong>no optimal model of collaboration to be applied everywhere, but one model could be more appropriate than others in a certain context. More research is needed to compare different models and to see whether they are applicable also in other fields of collaboration inside or outside the welfare system.</p

Barriers of inter-organisational integration in vocational rehabilitation

Introduction: A project of vocational rehabilitation was studied in Sweden between 1999 and 2002. The project included four public organisations: the social insurance office, the local health services, the municipal social service and the office of the state employment service. The aim of this paper was to analyse perceived barriers in the development of inter-organisational integration. <br><br> Theory: Theories of inter-professional and inter-organisational integration, and theories on organisational change. <br><br> Methods: In total, 51 semi-structured interviews and 14 focus group discussions were performed with actors within the project between 1999 and 2002. A thematic approach was used for the analysis of the data. <br><br> Results: Three different main themes of barriers emerged from the data: A Uncertainty, B Prioritising own organisation and C Lack of communication. The themes are interconnected in an intricate web and hence not mutually exclusive. <br><br> Conclusions and discussion: The barriers found are all related partly to organisational change in general and partly to the specific development of organisational integration. Prioritising of own organisation led to flaws in communication, which in turn led to a high degree of uncertainty within the project. This can be seen as a circular relationship, since uncertainty might increase focus on own organisation and lack of communication. <br><br> A way to overcome these barriers would be to take the needs of the clients as a point of departure in the development of joint services and to also involve them in the development of inter-organisational integration