Showing papers in "International Journal of Integrated Care in 2007"

Knowledge to action? Evidence-based health care in context

Abstract: Health care organisations often fail to implement good research findings in practice and are therefore, not able to increase efficiency and quality. The implementation gap that exists between ‘knowledge’ and ‘action’ in an evidence-based health care context is well known as such, but has in my opinion rarely been researched in depth. Dopson’s and Fitzgerald’s ‘Knowledge to action? Evidence-based health care in context’ is an interesting book that thoroughly describes this subject. For those concerned about why it takes so long before research has been totally adopted in work practices, the book provides enough insight to understand the matter. The book is very complete and still comprehensive enough to be valuable in practice.

A literature review on integrated perinatal care

Abstract: Context: The perinatal period is one during which health care services are in high demand. Like other health care sub-sectors, perinatal health care delivery has undergone significant changes in recent years, such as the integrative wave that has swept through the health care industry since the early 1990s. Purpose: The present study aims at reviewing scholarly work on integrated perinatal care to provide support for policy decision-making. Results: Researchers interested in integrated perinatal care have, by assessing the effectiveness of individual clinical practices and intervention programs, mainly addressed issues of continuity of care and clinical and professional integration. Conclusions: Improvements in perinatal health care delivery appear related not to structurally integrated health care delivery systems, but to organizing modalities that aim to support woman-centred care and cooperative clinical practice.

Bridging the gap: a virtual health record for integrated home care

Abstract: Introduction : The coexistence of different information systems that are unable to communicate is a persistent problem in healthcare and in integrated home care in particular. Theory and methods : Physically federated integration is used for design of the underlying technical architecture to implement a mobile virtual health record for integrated home care. A user centered system development approach is followed during design and development of the system. Results : A technical platform based on a service-oriented approach where database functionality and services are separated has been developed. This guarantees flexibility with regard to changed functional demands and allows third party systems to interact with the platform in a standardized way. A physically federated integration enables point-of-care documentation, integrated presentation of information from different feeder systems, and offline access to data on handheld devices. Feeder systems deliver information in XML-files that are mapped against an ideal XML schema, published as an interface for integration with the information broker, and inserted into the mediator database. Conclusions : A seamless flow of information between both different care professionals involved in integrated home care and patients and relatives is provided through mobile information access and interaction with different feeder systems using the virtual health record.

Managing networks of twenty-first century organisations

Abstract: On this topic, Bob Hudson w1x previously observed that ‘‘It is now de riguer to talk of the shift from hierarchy to network in public sector governance « but what is often lacking is an understanding of how to analyse network governance’’. In literature, many commentators indeed point out that networks are unlike markets and hierarchies. However, the current authors argue that such forms are not necessarily distinctive and might be overly inclusive, whereas when looking at inter-organisational relations, networks do not necessarily form a distinct category (superior in terms of flexibility, trust and innovation); they might still derive from market relations or hierarchical regulation. For such reasons, the book highlights that in order to understand the relationship between network structure and organisational performance, it is ‘‘necessary to examine the biases that particular types of relations might have to support certain kinds of performance’’. A balanced account of inter-organisational relations is therefore provided and tested throughout the chapters with explanatory purposes.

The challenges of joint working: lessons from the Supporting People Health Pilot evaluation

Abstract: Purpose: This paper reports the findings of the evaluation of the Supporting People Health Pilots programme which was established to demonstrate the policy links between housing support services and health and social care services by encouraging the development of integrated services. The paper highlights the challenges of working across housing, health and social care boundaries. Method: The evaluation of the 6 health pilots rested on two main sources of data collection: Quarterly Project Evaluation Reports collected process data as well as reporting progress against aims and objectives. Semi-structured interviews - conducted across all key professional stakeholder groups and agencies and with people who used services - explored their experiences of these new services. Results: The ability of pilots to work across organisational boundaries to achieve their aims and objectives was associated not only with agencies sharing an understanding of the purpose of the joint venture, a history of joint working and clear and efficient governance arrangements but on two other characteristics: the extent and nature of statutory sector participation and, whether or not the service is defined by a history of voluntary sector involvement. In particular the pilots demonstrated how voluntary sector agencies appeared to be less constrained by organisational priorities and professional agenda and more able to respond flexibly to meet the complex needs of individuals. Conclusion and discussion: The pilots demonstrate that integrating services to support people with complex needs works best when the service is determined by the characteristics of those who use the service rather than pre-existing organisational structures.

Conceptualization and measurement of integrated human service networks for evaluation

Abstract: Introduction: Integration has been advanced as a strategy for the delivery of a number of human services that have traditionally been delivered by autonomous agencies with independent processes and funding sources. However, measurement of the dimensions of integration has been hampered by numerous factors, including a lack of definitional and conceptual clarity of integration, and the use of measurement tools with atheoretical foundations and limited psychometric testing. Theoryymethods: Based on a review of integration measurement approaches, a comprehensive approach to the measure of multiple dimensions of integrated human service networks was conceptualized. The combination of concepts was derived from existing theoretical, policy, and measurement approaches in order to establish the content validity and comprehensiveness of the proposed measure. Results: The dimensions of human service integration measures are:

Inter-organisational communication networks in healthcare: centralised versus decentralised approaches

Abstract: Background: To afford efficient and high quality care, healthcare providers increasingly need to exchange patient data. The existence of a communication network amongst care providers will help them to exchange patient data more efficiently. Information and communication technology (ICT) has much potential to facilitate the development of such a communication network. Moreover, in order to offer integrated care interoperability of healthcare organizations based upon the exchanged data is of crucial importance. However, complications around such a development are beyond technical impediments. Objectives: To determine the challenges and complexities involved in building an Inter-organisational Communication network (IOCN) in healthcare and the appropriations in the strategies. Case study: Interviews, literature review, and document analysis were conducted to analyse the developments that have taken place toward building a countrywide electronic patient record and its challenges in The Netherlands. Due to the interrelated nature of technical and non-technical problems, a socio-technical approach was used to analyse the data and define the challenges. Results: Organisational and cultural changes are necessary before technical solutions can be applied. There are organisational, financial, political, and ethicolegal challenges that have to be addressed appropriately. Two different approaches, one ‘‘centralised’’ and the other ‘‘decentralised’’ have been used by Dutch healthcare providers to adopt the necessary changes and cope with these challenges. Conclusion: The best solutions in building an IOCN have to be drawn from both the centralised and the decentralised approaches. Local communication initiatives have to be supervised and supported centrally and incentives at the organisations’ interest level have to be created to encourage the stakeholder organisations to adopt the necessary changes.

Infrastructural arrangements for integrated care: implementing an electronic nursing plan in a psychogeriatric ward

Abstract: Purpose: The paper contributes to the conceptualisation of “integrated care? in heterogeneous work practices. A dynamic perspective is developed, emphasising how integrated care is malleable, open, and achieved in practice. Furthermore, we explore the role of nursing plans in integrated care practices, underscoring the inherent difficulties of building one common infrastructural system for integrated care. Methods: Empirically, we studied the implementation of an electronic nursing plan in a psychiatric ward at the University Hospital of North Norway. We conducted 80 hours of participant observation and 15 interviews. Results: While the nursing plan was successful as a formal tool among the nurses, it was of limited use in practice where integrated care was carried out. In some instances, the use of the nursing plan even undermined integrated care. Conclusion: Integrated care is not a constant entity, but is much more situated and temporal in character. A new infrastructural system for integrated care should not be envisioned as replacing most of the existing information sources, but rather seen as an extension to the heterogeneous ensemble of existing ones.

Creating integrated health care

Abstract: It was the ambition of this thesis to contribute to the growing interest in integrated care and to the ongoing research in this area by exploring the Swedish development of integrated health care. The general purpose was to study different strategies to improve integration in the Swedish health care system in order to identify some of the key issues and conditions in the creation of integrated care.

The problem of health technology: policy implications for modern health care systems

Abstract: This book by Pascale Lahoux at times appears lengthy and somewhat obscurely written. However, it presents many examples and a broad vision and understanding of health technology and health technology assessment as it is applied today. The fact that modern medicine is both producer and consumer of technology and in reality cannot be seen as a separate entity is stressed throughout this interesting book.

The myth of patient centrality in integrated care: the case of back pain services.

Abstract: Purpose: The purpose of this paper is to critically examine the extent of patient centrality within integrated chronic back pain management services and compare policy rhetoric with practice reality. Context: Integrated chronic back pain management services. Data sources: We have drawn on theories of integration and context specific journals related to integration and pain management between 1966 and 2006 to identify evidence of patient centrality within integrated chronic pain management services. Discussions: Despite policy rhetoric and guidelines which promote ‘patient centrality’ within multidisciplinary services, we argue that evaluations of these services are scant. Many papers have focussed on the assessment of pain in multidisciplinary services as opposed to the patients' experience of these services. Conclusions: A latent measure of the reality of its magnitude needs to be captured through analysis of the patient's perspectives. Capturing patients' thoughts about integrated services will promote patient centrality and support the reality rather than endorse the rhetoric.

The Domiciliary Support Service in Portugal and the change of paradigm in care provision.

Abstract: Context of case: In Portugal, the integration of care services is still in its infancy. Nevertheless, a home support service called SAD (Servico de Apoio Domiciliario—Domiciliary Support Service), provided by non-profit institutions to the elderly population is believed to be a first approach to integrated care. Purpose: The aim of this work is to describe and discuss the services provided by the institutions that participate in SAD and understand if this service is the first step in a change towards integrated care. Data sources: The main data sources were documents provided by institutions like INE (Instituto Nacional de Estatistica—National Institute of Statistics) and a questionnaire that was submitted to 75 institutions in order to capture: (a) demographic and structural data; (b) the type of information that the professionals need to fulfil their jobs and (c) the kind of relationship and constraints, if they exist, to better integration, between the institutions that provide SAD and the patients, the social and health systems, and other entities. Conclusion and discussion: SAD seems to have been promoting a formal collaboration between several entities in the social and health systems. The information shared between these institutions has increased, but where cooperation in care service provision is concerned this seldom surpasses the social bounds because health care is still difficult to integrate.

Taking care of integrated care: integration and fragmentation in the development of integrated care arrangements

Abstract: The aim of this thesis was to study the development of integrated delivery systems (IDSs). An IDS is a form of institutionalised partnership between organisations and health care professionals, aimed at facilitating cooperation at the levels of management, support services and the primary processes. The purpose of developing an IDS is to achieve control, quality and efficiency in health care delivery. To examine the extent to which IDSs enable integration, this study centred on the question ‘‘how do IDSs develop at the level of management, support services and integrated pathways for elderly and stroke?’’.

Treating substance abuse in primary care: a demonstration project

Abstract: Purpose : The purpose of this project was to implement the delivery of a full range of substance abuse services in a primary care setting. Implementation and logistical issues including confidentiality and communication are discussed. The delivery of services, types of patients, and contextual and policy factors that influenced project implementation are described. Context : Substance use disorders are associated with significant morbidity and mortality worldwide. Patients with alcohol/drug problems frequently present in primary care. Effective and brief treatments are available and recommended for primary care but infrequently implemented. Institutional and provider barriers to implementation have been identified. Data source : Project documentation, data from the patient tracking system, and clinical case notes were used for description and analyses. Conclusion : Addressing substance abuse problems in primary care is important. Behavioral health professionals with training in substance abuse can provide a range of services that are likely to enhance the quality and quantity of care available to patients. Although contextual factors needed to be addressed, integration of services was manageable and seemed acceptable to both providers and patients in this project.

Connecting practices: ICT infrastructures to support integrated care

Abstract: Good communication across organizational and professional boundaries is arguably the most crucial aspect to successful integrated care programs. Effective integration of care requires (as a minimum) that health care professionals share information about – and with – patients at appropriate points in the care or treatment process. This, however, will only be possible if the necessary infrastructural arrangements – such as shared patient records, regional collaboration, and a clear, transparent incentive structure are in place. Consequently, the integration of care calls for investments in supporting infrastructures, and it is increasingly hard to imagine integrative initiatives without a strong ICT (information and communication technology) component.

The individualized service plan as a clinical integration tool: qualitative analysis in the Quebec PRISMA experiment

Abstract: Introduction: One aspect of clinical integration involves case managers' tools and particularly the individualized service plan. Methods: We examined individualized service plan content and use in the PRISMA experiment. We analyzed 50 charts, and conducted and recorded interviews regarding individualized service plan use with all the case managers concerned (n=13). Results: Delays between starting case management and writing the individualized service plan were long and varied (0–596 days, mean: 117 days). During the interviews, the individualized service plan was described as the ‘last step’ once the active planning phase was over. The reasons for formulating plans were mainly administrative. From a clinical viewpoint, individualized service plans were used as memoranda and not to describe services (842 interventions not mentioned in the plans) or needs (694 active problems not mentioned). Case managers felt uncomfortable with the individualized planning task and expected a tool more adapted to their needs. Conclusion: Although a majority of the case managers' charts contained an individualized service plan, implementation of this tool seems tenuous. Because of the discrepancy between the potential usefulness expected by case managers and their actual use, a working committee was created to develop proposals for modifying the instrument.

‘Trying to do a jigsaw without the picture on the box’: understanding the challenges of care integration in the context of single assessment for older people in England

Abstract: Introduction: Demographic ageing is one of the major challenges for governments in developed countries because older people are the main users of health and social care services More joined-up, partnership approaches supported by information and communications technologies (ICTs) have become key to managing these demands This article discusses recent developments towards integrated care in the context of one of the arenas in which integration is being attempted, the Single Assessment Process (SAP) to support the care for older people in England It draws upon accounts of local SAP implementations in order to assess and reflect upon some of the successes and limitations of service integration enabled by ICTs Description of care practice: At the Department of Health in England, policy and strategy are directed at the integration of services through a ‘whole systems’ approach, with services that are interdependent upon one another and organised around the person that uses them The Single Assessment Processes (SAP) is an instance of inter-organisational and cross-sectoral sharing of information intended to improve communication and coordination amongst professions and agencies and so support more integrated care The aim of SAP is to ensure that older people receive appropriate, effective and timely responses to their health and social care needs and that professionals do not duplicate each others efforts This article examines examples from two programmes of work within the context of SAP in England: one with the direction coming from local government social services, the other where the momentum is coming from the National Health Service (NHS) Conclusion and discussion: Both examples show that the policy and practice of ICT-supported integration continues to represent a significant challenge Although the notion of integrated care underpinned by ICT-enabled information sharing is persuasive, it has limitations in practice The notion of an ‘open systems’ approach is proposed as an alternative way of improving communication and coordination across the domains of health and social care

Handling the transition of adolescents with diabetes: participant observations and interviews with care providers in paediatric and adult diabetes outpatient clinics.

Abstract: Purpose: The purpose of this study was to explore how care providers handle the transition process from paediatric to adult diabetes outpatient clinic and to describe their perception of adolescents' needs during this process. Methods: Participant observations of patient visits to nurses and physicians and 10 semi-structured interviews with care providers in two paediatric and two adult clinics in Sweden were carried out. Data were analysed using the constant comparative method developed in the grounded theory tradition. Results: The integrated framework developed in the analysis consists of subcategories, process categories and a core phenomenon. The preparation phase showed in this study that preparing transition requires modified strategies. The transition phase implied transferring responsibility and changing care relations while the evaluation phase revealed that care providers are creating mutual understanding through appraisal. All categories are related to the generated core phenomenon: enabling integration through professional meetings. The way care providers construct meeting arenas has a crucial impact on the possibility to bridge uncertainty, insufficient knowledge, routines and strategies. Conclusions: The way participating clinics handle transition greatly influences the process. Professional meetings appeared to be of vital importance to enable the building of bridges between paediatric and adult diabetes care in this study.

Clustering and inertia: structural integration of home care in Swedish elderly care

Abstract: Purpose: To study the design and distribution of different organizational solutions regarding the responsibility for and provision of home care for elderly in Swedish municipalities. Method: Directors of the social welfare services in all Swedish municipalities received a questionnaire about old-age care organization, especially home care services and related activities. Rate of response was 73% (211y289). Results: Three different organizational models of home care were identified. The models represented different degrees of integration of home care, i.e. health and social aspects of home care were to varying degrees integrated in the same organization. The county councils (i.e. large sub-national political-administrative units) tended to contain clusters of municipalities (smaller sub-national units) with the same organizational characteristics. Thus, municipalities’ home care organization followed a county council pattern. In spite of a general tendency for Swedish municipalities to reorganize their activities, only 1% of them had changed their home care services organization in relation to the county council since the reform. Conclusion: The decentralist intention of the reform—to give actors at the sub-national levels freedom to integrate home care according to varying local circumstances—has resulted in a sub-national inter-organizational network structure at the county council, rather than municipal, level, which is highly inert and difficult to change.

The effects of integrated home care and discharge practice on functional ability and health-related quality of life: a cluster-randomised trial among home care patients

Abstract: Objectives : The aim was to evaluate the effects of integrated home care and discharge practice on the functional ability (FA) and health-related quality of life (HRQoL) of home care patients. Methods : A cluster randomised trial (CRT) with Finnish municipalities (n=22) as the units of randomisation. At baseline the sample included 669 patients aged 65 years or over. Data consisted of interviews (at discharge, and at 3-week and 6-month follow-up), medical records and care registers. The intervention was a generic prototype of care/case management-practice (IHCaD-practice) that was tailored to municipalities needs. The aim of the intervention was to standardize practices and make written agreements between hospitals and home care administrations, and also within home care and to name a care/case manager pair for each home care patient. The main outcomes were HRQoL—as measured by a combination of the Nottingham Health Profile (NHP) and the EQ-5D instrument for measuring health status—and also Activities of Daily Living (ADL). All analyses were based on intention-to-treat. Results : At baseline over half of the patient population perceived their FA and HRQoL as poor. At the 6-month follow-up there were no improvements in FA or in EQ-5D scores, and no differences between groups. In energy, sleep, and pain the NHP improved significantly in both groups at the 3-week and at 6-month follow-up with no differences between groups. In the 3-week follow-up, physical mobility was higher in the trial group. Conclusions : Although the effects of the new practice did not improve the patients' FA and HRQoL, except for physical mobility at the 3-week follow-up, the workers thought that the intervention worked in practice. The intervention standardised practices and helped to integrate services. The intervention was focused on staff activities and through the changed activities also had an effect on patients. It takes many years to achieve permanent changes in every worker's individual practice and it is also likely that changes in working practices would be visible before effects on patients. The use of other outcome measures, such as the use of services, may be clearer in showing a positive impact of the intervention rather than FA or HRQoL.

Integrating health and social services for older persons: evidence from nine European countries

Abstract: This book contains a series of chapters by various authors, which describe the challenges associated with integrating community care services across professional boundaries and potential methods of addressing those challenges. The book also addresses to a limited degree integration across the health and long-term care sectors. The evidence the authors tap for their observations comes from a large qualitative study that examined 18 innovative integrated care models in nine European countries—Austria, Denmark, Finland, France, Germany, Greece, Italy, the Netherlands, and the United Kingdom. The book broadly describes this research, as it has been covered more extensively in other publications.

Are joint health plans effective for coordination of health services? An analysis based on theory and Danish pre-reform results

Abstract: Background: Since 1994 formal health plans have been used for coordination of health care services between the regional and local level in Denmark. From 2007 a substantial reform has changed the administrative boundaries of the system and a new tool for coordination has been introduced. Purpose: To assess the use of the pre-reform health plans as a tool for strengthening coordination, quality and preventive efforts between the regional and local level of health care. Methods: A survey addressed to: all counties (n=15), all municipalities (n=271) and a randomised selected sample of general practitioners (n=700). Results: The stakeholders at the administrative level agree that health plans have not been effective as a tool for coordination. The development of health plans are dominated by the regional level. At the functional level 27 percent of the general practitioners are not familiar with health plans. Among those familiar with health plans 61 percent report that health plans influence their work to only a lesser degree or not at all. Conclusion: Joint health planning is needed to achieve coordination of care. Efforts must be made to overcome barriers hampering efficient whole system planning. Active policies emphasising the necessity of health planning, despite involved cost, are warranted to insure delivery of care that benefits the health of the population.

Development and implementation of the Ontario Stroke System: the use of evidence

Abstract: Introduction The Ontario Stroke System was developed to enhance the quality and continuity of stroke care provided across the care continuum. Research Objective To identify the role evidence played in the development and implementation of the Ontario Stroke System. Methods This study employed a qualitative case study design. In-depth interviews were conducted with six members of the Ontario Stroke System provincial steering committee. Nine focus groups were conducted with: Regional Program Managers, Regional Education Coordinators, and seven acute care teams. To supplement these findings interviews were conducted with eight individuals knowledgeable about national and international models of integrated service delivery. Results Our analyses identified six themes. The first four themes highlight the use of evidence to support the process of system development and implementation including: 1) informing system development; 2) mobilizing governmental support; 3) getting the system up and running; and 4) integrating services across the continuum of care. The final two themes describe the foundation required to support this process: 1) human capacity and 2) mechanisms to share evidence. Conclusion This study provides guidance to support the development and implementation of evidence-based models of integrated service delivery.

The rise and fall of HMOs: an American health care revolution

Abstract: Avedis Donabedian, who created the conceptual framework for quality assessments of health services, was interviewed shortly before his death in November 1999. He described the health care problems that he had encountered during his battle with cancer that lasted nearly three decades. Jan Gregoire Coombs quotes Donabedian in his last interview on page 277 of her book as follows: I have tried to choose doctors who worked together reasonably well but there are areas where no one takes responsibility, where planning is weak, when I am left on my own (...) HMOs today are good at measuring costs but pay little attention to measuring effects. The failure to look at outcomes undercuts all the reasons that so many of us were interested in the prepaid group practice... These few words of Donabedian summarize the message in the book The Rise and Fall of HMOs: an American Health Care Revolution.

Towards managed primary care: the role and experience of primary care organisations

Abstract: Today’s choices influence the future. Smith and Goodwin have written an evidence-based book, entitled ‘Towards Managed Primary Care’, on the transformation in the organisation and the management of primary care. In line with the work by Edward Wagner and the World Health Organisation, this book embraces a new way of managing the most prevalent health problems: integrated care for patients with chronic diseases. For this, organised systems of care, not just individual health care workers, are essential in producing positive outcomes.

Attending unintended transformations of health care infrastructure

Abstract: Introduction: Western health care is under pressure from growing demands on quality and efficiency. The development and implementation of information technology, IT is a key mean of health care authorities to improve on health care infrastructure. Theory and methods: Against a background of theories on human-computer interaction and IT-mediated communication, different empirical studies of IT implementation in health care are analyzed. The outcome is an analytical discernment between different relations of communication and levels of interaction with IT in health care infrastructure. These relations and levels are synthesized into a framework for identifying tensions and potential problems in the mediation of health care with the IT system. These problems are also known as unexpected adverse consequences, UACs, from IT implementation into clinical health care practices. Results: This paper develops a conceptual framework for addressing transformations of communication and workflow in health care as a result of implementing IT. Conclusion and discussion: The purpose of the conceptual framework is to support the attention to and continuous screening for errors and unintended consequences of IT implementation into health care practices and outcomes.

Challenges for IT-supported shared care: a qualitative analyses of two shared care initiatives for diabetes treatment in Denmark

Abstract: Purpose: To investigate the circumstances as to why it is so difficult in the primary care sector to implement IT based infrastructures supporting shared care. Case study: The qualitative analysis includes two separate case studies of IT-supported shared care implemented in two different regions of Denmark throughout 2005. The study comprises 21 interviews and 35 hours of observations. The data were analysed through a coding process that led to the emergence of three main challenges impeding the organisational implementation of IT-supported shared care. Discussion and conclusion: The two cases faced the same challenges that led to the same problem: The secondary care sector quickly adopted the system while the primary sector was far more sceptical towards using it. In both cases, we observe a discrepancy of needs satisfied, especially with regard to the primary care sector and its general practitioners which hinder bridging the primary sector (general practitioners) and the secondary sector (hospitals and outpatient clinics). Especially the needs associated with the primary sector were not being satisfied. We discovered three main challenges related to bridging the gap between the two sectors: (1) Poor integration with the general practitioners' existing IT systems; (2) low compatibility with general practitioners' work ethic; (3) and discrepancy between the number of diabetes patients and the related need for shared care. We conclude that development of IT-supported shared care must recognise the underlying and significant differences between the primary and secondary care sectors: If IT-supported shared care does not meet the needs of the general practitioners as well as the needs of the secondary care sector the initiative will fail.

Implementation of the concept of home hospitalisation for heart patients by means of telehomecare technology: integration of clinical tasks

Abstract: Purpose : To explore how the implementation of the concept ‘Home hospitalisation of heart patients’ by means of telehomecare technology influences the integration of clinical tasks across healthcare sectors. Theory : Inter-organisational theory. Methods : The case study approach was applied. Triangulations of data collection techniques were used: documentary materials, participant observation, qualitative and focus group interviews. Results : The clinical decision-making and task solving became multidisciplinary and integrated with the implementation of telehomecare and, therefore, complex in terms of the prescription and adjustment of patient medicine. Workflows between healthcare professionals across sectors changed from sequential to collective client flows. Pre-existing procedures for patient care, treatment, and responsibility were challenged. In addition, the number of tasks for the district nurses increased. Integration in the clinical task-solving area increases fragmentation in the knowledge technologies in a network perspective. Conclusions: Implementing the concept of ‘Home hospitalisation of heart patients’ by means of telehomecare technology will result in a more integrated clinical task-solving process that involves healthcare professionals from various sectors. Overall, the integration of clinical tasks between hospital and district nursing will result in a direct benefit for the heart patients.

IT-supported skill-mix change and standardisation in integrated eyecare: lessons from two screening projects in The Netherlands

Abstract: Introduction: Information Technology (IT) has the potential to significantly support skill-mix change and, thereby, to improve the efficiency and effectiveness of integrated care. Theory and methods: IT and skill-mix change share an important precondition: the standardisation of work processes. Standardisation plays a crucial role in IT-supported skill-mix change. It is not a matter of more or less standardisation than in the ‘old’ situation, but about creating an optimal fit. We used qualitative data from our evaluation of two integrated-care projects in Dutch eyecare to identify domains where this fit is important. Results: While standardisation was needed to delegate screening tasks from physicians to non-physicians, and to assure the quality of the integrated-care process as a whole, tensions arose in three domains: the performance of clinical tasks, the documentation, and the communication between professionals. Unfunctional standardisation led to dissatisfaction and distrust between the professionals involved in screening. Discussion and conclusion: Although the integration seems promising, much work is needed to ensure a synergistic relationship between skill-mix change and IT. Developing IT-supported skill-mix change by means of standardisation is a matter of tailoring standardisation to fit the situation at hand, while dealing with the local constraints of available technology and organisational context.