The development, application and evaluation of a framework as a change methodology in implementing integrated care for older persons: from rhetoric to reality through action research

peer-reviewedWith people living longer and associated increased multi-morbidity and social care needs, implementing a change in balance was required between the prevalent hospital-focused model designed for acute episodic care, and longitudinal, population-based care. ‘Barometric’ indicators such as emergency department attendance, self-referrals, and trolley waits for those aged 75+ indicated poorer outcomes rooted in this mismatch and fragmentation. History indicated fragmentation to be persistent. Integrated Care was proposed as a policy solution, but systemic examples in practice were limited. Integrated care faces two challenges: it is polymorphous, with confusion over objectives among different actors and stakeholders; health and social care occurs within a complex adaptive system, complicating any change of the magnitude required. Adopting an Action Research methodology, a programme to design and test a systemically scalable model of integrated care was led by the author. A literature search addressed two simultaneous questions: (1) what were the key ingredients required to integrate care for older persons? and (2) what is a more-effective methodology to support systemic implementation? Consensus on the first, but not on the second, and drawing on the balanced socio-technical perspective of Greenhalgh et al. (2004), led to a research hypothesis that a framework methodology incorporating ‘soft edges’ and ‘hard edges’ identified in the literature (DixonWoods, 2011b) would solve this ‘wicked problem’ in practice. Literature review yielded five key ingredients: Personal/ Professional, Culture, Process, Leadership, Organisational. In multiple rounds of collaboration with practitioners, a resultant 10-step framework was evolved, incorporating elements including governance, population planning, mapping resources, service/care pathways, new ways of working, multi-disciplinary teams/ambulatory hub, person-centred planning and delivery, supports to live well, monitoring/evaluation, and national enablers on workforce, information technology, and finance. It functioned as both conceptual model and an implementation roadmap, and was mobilised at six pioneer sites, later thirteen, in tandem with a choreographing methodology which included communicating vision, and a deep and active programme of engagement in loco comprising networking events and timely key metrics, for example, with a core principle of ‘direction without dictat’. A mix of quantitative and qualitative data was collected over two years, including surveying the utility of the framework to participant actors, and capturing and presenting timely data on emergent care-process performance. Pioneer sites demonstrated fidelity to the model, improving access and efficiencies. Site specific changes included bed use saving (1,000 bed days), reduced length of stay (2-5 days) and improved access (49% seen within 7 days), and growth in multi-disciplinary teams (101 posts) and age attuned pathways (45). The framework has shown a high degree of utility to the local clinical and managerial leaders tasked with implementation. The contribution of the thesis is to provide a means of bridging the intent-realisation gap in systematic implementation within the complex adaptive system that delivers older persons’ health and social care. It facilitates balance between latitude and prescription, emergence and fidelity, especially for high autonomy actors tasked with implementation in a context of professional regulation and accountability on the one hand, and the lived experience of older population on the other. In consonance with Action Research, further research on discrete aspects are identified