Evaluation of the implementation of integrated care for people with chronic conditions

Introduction. It is now well-documented that the organisation of care delivery for adults living with chronic conditions is suboptimal. Therefore, many healthcare systems in OECD countries are implementing whole-system changes to try to improve the health, the individual healthcare experience and efficiency of the population (also known as “Triple Aim”). In Belgium, bottom up programmes of integrated care for people living with chronic conditions will start to include patients in June 2017. While targeting the Triple Aim, programmes are also expected to improve the wellbeing of care providers and target equity. As part of a global evaluation of the programmes, this paper presents the protocol of the implementation study, to evaluate the implementation of those programmes, in their diverse contexts. The programmes. Twenty programmes are expected to design system changes at the micro and meso-level, as they will include populations from 100000 to 200000 persons, for which components of integrated care will be implemented at several levels. At the micro-level, this includes patient empowerment, support to the informal caregiver, case management, socio-professional (re)integration and prevention. At the meso (i.e. loco-regional) level, components target interactions and governance between providers. This includes negotiation and coordination, seamless care, valuing the experience of patient organisations, integrated patient files, multidisciplinary guidelines, development of a culture of quality. To support this governance at the loco-regional level, adaption of financing, change management and risk and resources stratification of the population are expected. Because of their design and embeddedness, those programmes can be seen as complex adaptive systems (CAS,(1)). Evaluation method. To evaluate the implementation process of the CAS, we will use a realist approach, which aims at responding to the questions about how, for whom and why the implementation of those programmes will reach the expected outcomes - or not (2). Guided by the RAMESES II framework, the first step was to choose an initial theory, explaining the logic of the implementation (3). A first choice of the multidisciplinary research team was to use the Normalisation Process Theory (4), which provides a good starting point to explain how the elasticity of the context may influence the coherence, cognitive participation, action and reflexion of the actors involved at the micro, meso and macro level. This theory will be tested and refined by the means of a multiple, embedded case study (5, 6). Stakeholders involved in the refining and maybe adjudicating between rival theories, include members of the research team (sociologists, nurses, doctors and economists), programme coordinators and their local partners, during a three-year lasting, iterative process, using data about the process and the impact of those programmes. Expected results. First, a thick and narrative description of each pilot programme in its local context, about the decisive drivers of success or non-success of the implementation of the programme. Second, an explanatory mid-range theory about the drivers of integrated care programmes, in order to allow theoretical replication. Discussion. Focusing on underlying mechanisms “in situation”, we will aim at unearthing generative causality. Identified mechanisms will be contextualised, i.e. mechanisms which are only triggered under specific conditions or in specific contexts and lead to specific outcomes. Key words: implementation – NPT – chronic – realistic Suggested authors Thérèse Van Durme, Sibyl Anthierens, Ann Van Hecke, Elien Colman, Roy Remmen, Isabelle Bragard, Benoît Petré, Michèle Guillaume and Jean Macq 1. Plsek P, Greenhalgh T. The challenge of complexity in health care. BMJ. 2001;323. 2. Pawson R, Tilley, N. Realistic Evaluation. London: Sage; 2013. 3. Wong G, Westhorp G, Manzano A, Greenhalgh J, Jagosh J, Greenhalgh T. RAMESES II reporting standards for realist evaluations. BMC medicine. 2016;14(1):96. 4. May CR, Johnson M, Finch T. Implementation, context and complexity. Implementation science : IS. 2016;11(1):141. 5. Yin R. Case study research/ Design and methods. In: Thousand Oaks, editor. CA2009. 6. Gerring J. Case Study Research: Principles and Practices. Cambridge University Press; 2007