Abstract :
[en] Through our experience of general practice we noticed a lack of coordination between
the general practitioner and the hospital that could lead to poor quality patient
care. We decided, therefore, to focus upon the integration between levels of care as
our main research topic.
Problem setting
Clarifying concepts such as ‘levels of care’ (Chapter 1) and integration of care’
(Chapter 2) was the first step of our work.
The concept of ‘levels of care’ is entwined with ‘integration of care’. The historic differentiation
between concept of ‘levels of care’ is not only a consequence of the medical
specialization process, but also a result of the drive for greater efficiency in the
delivery of patient care. In general the differentiation process is a response to complex
situation and consecutive integration is necessary to maintain coherent and global
action.
An in-depth analysis of these two concepts gave us a theoretical framework for our
analysis.
We explained the distinction between ‘primary health care’ and ‘primary care’ to avoid
confusion that might occur when these terms are used.
We chose a definition of levels of care based on the work of Barbara Starfield: the
first level of care, or ‘primary care’, represents the first access to health care, and is
responsible for coordination, comprehensiveness and continuity of care; the second
level of care, or ‘secondary care’, performs a support function, of the scientific, technological
and logistical aspects.
Throughout this work we considered integration of care as a continuous process of
variable intensity depending upon the complexity of the care situation. We therefore
established a series of supporting tools to integration of care according to this continuum.
Additionally, in order to address the different ways to approach integrated care, we
chose the Rainbow Model of Integrated Care (RMIC) as a conceptual framework.
The RMIC proposes a logical hierarchy of the key dimensions of integrated care, suitable
for our research and analysis.
Within these theoretical frameworks, we formulated several research questions that
address the integration between levels of care:
How are the professional and organizational dimensions of integrated care practically
developed in the Belgian health care system, at the national and local level?
What are the conditions for implementation of a model of integrated care of the two
levels of care in a local context? What is the impact of such a model in terms of integration
of care?
Professional dimension of integration between the levels of care
The analysis of the professional dimension of integration of care consisted of two
complementary activities. First, we identified the main tools and mechanisms that
support integration of care between the general practitioner and medical specialist
within the hospital (Chapter 3). We completed our analysis with the findings of several
studies on the integration process between those professionals in different care
situations, such as treatment management between hospitalisation and discharge of
chronic care for HIV patients, cancer patients or obese patients after bariatric surgery
(Chapter 4).
From this analysis, we confirmed the state of fragmentation between levels of care
within the healthcare system.
On the professional side, we faced weaknesses on the normative and functional dimension
of integration of care. There is a tendency of the secondary care to appropriate
the primary care functions, without real consultation and with the risk of gaps in
the patient’s care (e.g. preventive care and psycho-social care).
Task clarification between professionals of both levels of care occurs too often in the
restricted scope of one disease. In this context of unclear role assignment, each professional
only relies on his own informal professional network built on interpersonal
relationships.
Some recent evolutions that may improve integration between professionals have
been noticed, such as computerized medical information transfer that may facilitate
communication between levels of care. However, the poor structure of primary care,
still characterized by solo practice and weak structural links with care coordination
function, could represent a barrier to improved professional integration.
These findings allow us to acknowledge the added value of Barbara Starfield’s functional
conception of levels of care to develop the professional relationships between
the general practitioners and medical specialists in the hospital. It also became obvious
that we had to complete our analysis at the organizational level, as the professionals
frequently mentioned the organizational framework as a barrier.
Organizational dimension of integration between levels of care
The same analysis process was developed for the organizational dimension of integration
between levels of care : identification of existing structures (Chapter 5) and empirical
evaluation with a participatory action research (PAR) (Chapter 6).
Primary care is fragmented and poorly organized while the hospital is a highly structured
and multidisciplinary organization. For general practice in particular, in Belgium,
local GP’s organizations, GP’s circles, are asked to play a key role in local health policies
but have limited resources, considering governance and leadership. Moreover,
existing networks of health organizations covering large areas fail to take local specificities
of the health system into account.
In this context the participatory action research SYLOS has started in some urban
settings in Belgium (Chapter 6). The aim was to organize integration between levels
of care at the local level, using a recognised model built on a functional conception of
levels of care.
The Local Health System model, used in this PAR, is a decentralized and functional
unit of the health care system at the local level. It integrates activities of health care
services in order to provide primary health care to a determined population. This unit
is galvanised and coordinated by a steering group.
We followed Grodos & Mercenier’s methodology of participative action research that
is recognized on the field of health system research.
Our hypothesis was as follows: organizational representatives, initially from hospital
and one GPs’ circle, and researchers as moderators, could be the steering group implementing
and coordinating local integrated activities. We considered various urban
settings, including one with several hospitals.
The dynamic of integration initiated by some researchers and hospital and GP’s representatives
extended rapidly: other local primary care organizations and hospitals
were included This process recreated the complexity of local health system in an urban
setting with a multidisciplinary primary care and a multi-hospital secondary care.
We still identified reluctance of the actors to include other organizations during the
process. This may be explained by the isolation of the medical profession among other
caregivers and the market-based organization of secondary care in Belgium.
This research allowed us to draw two different models of care territories involved in
professional and organizational integration of care.
The moderator’s function, detached from both primary and secondary care, was essential
during the process. It has been defined during the research action: it requires
specific competencies of coordination, group dynamics and technical support to integration
of levels of care. This function also compensated structural weakness of primary
care in our context.
Temporal sequence of activities, observed during this action research, demonstrated
the dynamic of the various dimensions of integration of care. It also increased our
knowledge of the RMIC.
Two of the explored local context in the PAR did not succeed into implementing a
steering group. However, it brought useful information concerning motivation and
necessary leadership.
We also showed that the dynamics of this action research is the result of top-down
policies (promoting collaboration of the hospital with other partners and structuring
primary care) and bottom-up local initiatives, such as participative action research,
acting synergistically.
Conclusion
The knowledge of professional and organizational integration of levels of care, obtained
through this analysis, can directly influence professional practice, professionals’
training and health system organization.
If differentiation is an answer to complexity of care, integration between levels of care
is necessary and has to be built on strong bedrock composed by common conceptual
framework, reciprocal knowledge and recognition of professionals and organizations’
complementarity and synergy.
On this basis, implementation of supporting tools and mechanisms for integration of
care should be facilitated. The added value of a coordination structure, for the organizational
dimension of integration of care at the local level, should also be considered
in the Belgian health system.
