The only constant is change exploring the evolvement of health and social care integration
Introduction: Health and social care services, in Sweden and worldwide, struggle to provide comprehensive care and support for people with complex needs. As these services are currently structured, it is difficult to provide service users with such care. This difficulty is especially acute for patients with mental illness. However, many challenges exist in the effort to achieve cross sectoral cooperation of health and social care services. This thesis addresses one of these challenges: the evolvement of long lasting integrated health and social care services in mental health care. Aim: This thesis explores the organisational dynamics of long term health and social care integration. Methods: A qualitative research approach is taken in a longitudinal case study. The research consists of three studies on integrated health and social care: two studies take an organisational (managerial) perspective; one study takes a service user perspective. Data were collected in individual and group interviews and from steering committee minutes. Findings: The findings from the three studies are summarized using four theoretically and empirically based themes related to the evolvement of long term mental health and social care integration. Shared structure and ongoing refinement: The integrated services were co located under coleadership management. A shared mission on the value of integrated health and social care was essential for establishing a culture of shared values and for sustaining the required longterm collaboration and cooperation. Continuous learning: The continuous exchange of competencies and experiences was prioritized. Forums were established in which the various stakeholders could exchange information, interact, and learn in a culture of improvement. Team members were encouraged to help find effective solutions to the problems encountered when providing equal health and social care. Cooperation as a guiding principle: The integration of health and social care services, which was based on the principle of cooperation, encouraged the participation of informal caregivers and of other parties such as stakeholder/service user associations, service user representatives, and municipal and county representatives. Service user centeredness: The central role of the service user was formalized by an agreement that specified the individual care and rehabilitations plans. Attention was paid to service users' holistic needs and to their abilities and strengths in the focus on finding bestpossible solutions to their individual circumstances. Conclusion: This thesis identified three main factors that proved to play a central role in the achievement of long term integration of health and social care services. First, partnership building between the health and social care services, as well as with service users and service user associations, enabled the sharing of responsibility for the integrated services and a long term orientation in decision making. The formulation of an overall agreement, a shared mission, and the involvement of all stakeholders in the steering committee of the integrated services were activities that exemplified this. Second, person centeredness was important in the design and provision of the integrated services, as well as during encounters with service users. Co location of services, coleadership, and interprofessional teams were some of the strategies that were used to meet service users' holistic needs. Third, organisational learning was a strategy to overcome obstacles resulting from crosssectoral cooperation, and to continually adapt and align services to the changing needs of service users. In conclusion, the findings in this thesis suggest that the emergence and long lasting integration of health and social care services were based in the capacity to manage differences and changes by relying on the concepts of partnership, person centeredness, and continuous learning. LIST OF SCIENTIFIC PAPERS I. Klinga, C. Hansson, J. Hasson, H. Sachs, M. A. (2016) Co leadership A management solution for integrated health and social care. International Journal of Integrated Care, 16(2):7. II. Klinga, C. Hasson, H. Sachs, M. A. Hansson, J. (2018) Understanding the dynamics of sustainable change: A 20 year case study of integrated health and social care. BMC Health Services Research, 18:400. III. Klinga, C. Hasson, H. Sachs, M. A. Hansson, J. &Wannheden C. Through the eye of the service user representative: What key components contribute to value in integrated mental health and social care services? Submitted (2018) to Health and Social Care in the Community. Reprints are made with permission from the publishers. CONTENTS 1 Prologue 1 2 Introduction 3 2.1 Aim 4 2.2 Overview of the thesis 4 2.3 Why study integrated care with emphasis on sustainability? 5 2.4 Integrated care as a complex adaptive system 6 2.4.1 Complexity leadership 7 2.5 Organisational Change management 9 2.6 What is integrated care? 11 2.6.1 Definitions of integrated care 11 2.6.2 Dimensions of integrated care 12 2.6.3 Concepts of integrated care 14 2.6.4 Remaining knowledge gaps in the study of integrated care 16 2.6.5 Challenges in pursuing integrated care 17 2.6.6 Challenges in studying integrated care 18 2.7 How can organisational sustainability be understood? 19 2.7.1 Current state of knowledge about sustainability 21 2.7.2 Challenges in studying organisational sustainability 21 2.7.3 Models and frameworks to study organisational sustainability 23 2.7.4 The Dynamic Sustainability Framework 24 2.8 The Swedish health and social care system 24 2.8.1 The mental health care reform in Sweden 26 2.8.2 Mental health and social care in Sweden and Europe 27 2.8.3 Remaining challenges in mental health integration 29 3 Methodology 31 3.1 Main research strategies 31 3.2 The empirical case 31 3.2.1 Case study research design 32 3.2.2 The perspectives and target groups in the thesis 34 3.2.3 Data collection. 35 3.2.4 Data sources, methods for data collection, and analysis 36 3.2.5 Ethical approval and guiding principles 39 4 Findings 41 4.1 Shared structure and ongoing refinement 41 4.2 Continuous learning 42 4.3 Cooperation as a guiding principle 43 4.4 Service user centeredness 44 5 Discussion 46 5.1 Shared structure and ongoing refinEment 46 5.2 Continuous learning 48 5.3 Cooperation as a guiding principle 50 5.4 Service user centeredness 52 5.5 Methodological considerations 54 5.6 Ethical considerations 58 6 Conclusion 60 6.1 Implications for practice 61 6.2 Implications for research 61 6.3 Future perspectives