Collaborative challenges in integrated care: Untangling the preconditions for collaboration and frail older people's participation

Abstract: Introduction: Frail older people often have comprehensive and complex care needs involving different caregivers and professionals. Deficits in integrated caretaking often result in hospital readmission. Aim: The aim of this thesis was to describe and analyze preconditions for collaboration and participation in integrated care for frail older people from the professionals’ perspective. Methods: In study I patient participation was examined with a case study, including face-to-face interviews with health and social care professionals and audio-recordings of discharge planning conferences. Study II explored inter-professional and inter-organizational collaboration using a focus group technique, focusing discharge planning conferences. Study III was quantitative, and described and compared the influence of different factors on the importance of inter-organizational collaboration within the integrated care process program “Continuum of care for frail older people.” Study IV quantitatively evaluated the preconditions for implementation of the program. Results: Study I showed that frail older people’s participation in discharge planning conferences was achieved when the older people took or were supported to be active participants, the professionals had clear roles, authority, they created a structured, calm atmosphere, and older people and professionals were well prepared before discharge planning takes place. Study II demonstrated that conflict in collaboration arose between professionals and organizations, implicating a tacit framework, e.g. who is responsible and has the authority to make decisions and what are the prioritizations in relation to the choice of care actions for older people. In Study III, educational level i.e. post-secondary education, influenced inter-organizational collaboration more than organizational affiliation. Study IV showed that the preconditions for the program implementation were limited with regard to the professionals’ understanding and ability to change their work procedure, and their commitment decreased. Conclusion: Inter-professional and inter-organizational collaboration need improvements to ensure a continuum of high-quality care and frail older people’s participation in the discharge process. Insufficient knowledge among the professionals obstructed collaboration in favor of organizationally related norms and values and professional boundaries. Implementing complex interventions in organizations with high employee turnover and competing projects takes time and dedication.