Pitfalls of integrated care pathways for high needs patients

摘要

Introduction : In the forthcoming extensive reform of social and health care in Finland these services will be fully integrated at all levels of care. One of the most challenging target groups of the reform are patients making much use of both social and health care services, i.e. ‘high needs patients’. This paper introduces a study addressing the problems identified by care professionals working in the field in implementing integrated care pathways for this patient group. The study is part of a research project entitled ‘Successful Integration in Health and Social Care’, coordinated by the University of Eastern Finland and funded by the Foundation for Municipal Development (KAKS). The research question of the sub-study presented here is: What are the pitfalls in implementing integration in the care pathways for high needs patients? Theory/Methods : The study draws on the theoretical approaches to care pathways (Campbell et al. 1998; R?sstad et al. 2013), integration of health and social care (Nolte & McKee 2008; Valentijn 2015); integration models (Sampalli et al. 2012; Grembowski 2015); development of care services for people with multimorbidity (Rijken et al. 2016); and collaboration among health and social care professionals (e.g. D’Amour 2005; Schepman et al. 2015). The data was gathered in Finland in spring 2016 from participants on the Better Everyday Life project. Twenty-two teams of composed of various care professionals (altogether 130 people) representing primary, specialized and social care conducted a problem analysis of the development challenges in pathways for high needs patients. The professionals used the LEAN-based ‘fishbone tool’ for analyzing the pathways. The data were analyzed by two researchers using content analysis and the ATLAS.ti qualitative data analysis software. Results : Four main categories of problems in the care pathways were identified: helpless professionals, tired patients, insufficient coordination of care between the ‘silos’ of health and social care and lack of support from management. Professionals often find patients with multiple needs burdensome and that they lack the capacity to solve their problems. The only way to deal with them is to pass them on to another professional or care provider. Patients suffer from fragmentation of services: they get lost in the jungle of separate services and wear themselves out. Nobody in the care system is responsible overall for a patient needing services from several separate actors. Management is unaware of the problems at the operative level and does not give enough support for the care professionals to improve the pathways through collaboration. Discussions and Conclusions : (comprising key findings) Successful implementation of care pathways for high needs patients requires multi-professional and inter-organizational collaboration beyond professional, organizational and sectoral silos. Lessons learned : Thorough consideration of state-of-the-art of care pathways by grassroots professionals is a fruitful starting point for development work. Limitations : The findings are based on a small-scale study in the health and social care context of a single country. However, the challenges of integrated care pathways may be quite similar in other European countries. Suggestions for future research : In addition to listening to grassroots professionals, high needs patients themselves as well as managers should be involved in the study.