We have too many cooks in the kitchen… Analysis of mandated regional implementation of integrated rehabilitation care pathway between stroke teams and municipalities Karla Douw HTA and HSR dept., CFK, Århus, Denmark June, 2014

Outline Context: stroke reform in Central Denmark Region Complex innovation: Mandated cooperation agreement and resulting cooperation between municipalities and stroke teams to establish integrated rehabilitation care pathway for stroke patients Case study with embedded cases Analytic framework combination of Greenhalgh’s conceptual model and Winter’s integrated model of policy implementation Findings: factors influencing implementation Conclusion on policy implementation to practice

Context Central Denmark Region (1,2 mln inhabitants) Region responsible for hospital care Municipalities responsible for home care, rehabilitation, prevention

Context: Stroke care pathway reorganisation Reform:Cost cut, while improving quality of care Top-down approach to implementation Municipalities had no influence on policy design Implementation delegated to implementation committee Municipalities involved but late in the process (3 months before impl)

Region’s strokeplan (May, 2012) Centralisation of care Shortening hospital stay Shift of inpatient rehabilitation care to community-based rehabilitation = closure of 40 beds Early discharge stroke teams established at all 5 hospitals in region

Focus and objective of the study Analysis of implementation: mandated cooperation agreements the resulting coordination of rehabilitation care of stroke patients To understand: the process of implementation of the cooperation agreements identify relevant determinants for (mandated) cross-sector implementation Arranging which types of pts stroke teams will take care of Organisation of stroke team Inter-sectoral cooperation, incl. communication between acute care hospital, stroke teams, municipalities, GPs

Design and methods Case study with embedded cases Municipalities: 7 theoretically-based selected cases out of 19 municipalities Stroke teams: all 5 stroke teams Data collected by means of semi-structured interviews (12 of 1½-2 hrs) and document analysis Oct. 2013 – april 2014 Stroke teams, and coordinators or managers at rehabilitation dep. in municipalities Interviewscheme based on Greenhalgh’s conceptual model and Cook et al’s operationalization Qualitative analysis

Finding – Cooperation agreement Involvement The cooperation agreements were written by staff of the hospitals Municipalities commented on them Status of the agreement Well, we got this as informational material. (…) (Mun1) One respondent describes it as: ‘it is merely paper.’ But with good intentions behind it.’ (Mun2)

Finding - No influence ..on the change on activities stroke team ‘As manager, I must say that it was ’take it or leave it”, and that is to say: I am a member of the cluster steering group, which means that I was present at the levels were it was taken up, and it was not up for discussion. I experienced it as, it has been decided and now you have to take over.’ (Mun4) on activities stroke team It is very interesting, because in reality it is very frustrating seen from our perspective, that we cannot say that there is no need for them to come. It is their choice. Sometimes it is useful that they come. But we could first discuss it.(Mun5)

Finding - Resistance to stroke team Resistance in municipality ’Our biggest problem in the beginning was to convince the managers in the municipalities that it was okay what we were doing. We used 2012 to convince them (…) that it would not be costly for them…’ (stroke team 1). ’It is not at the therapist level that we perceive resistance, it is practically that it comes from the management’ (stroke team 2).

Finding – Unclear consequences and time horizon Not clear what the consequences are But it was really difficult to relate to, because there were many questions that we couldn’t get answer to. Therefore it was difficult to make a strategy or any changes or reorganisations (Mun3). Time-horizon ‘Well, I found the time-horizon to be very short (Mun3)

Finding – No resistance at ground floor But no resistance at ground floor I don’t think there is much resistance against this here (…) I have regular meetings with the therapists (…) and there is nothing that is perceived as a problem.’ (Mun4) (…) we actually experience a very good cooperation with the staff we meet (in the municipalities) and that is really nice. It isn’t there we experience resistance, that is actually coming from higher-up, from the management (stroke team 4)

Findings – Cooperation and coordination for stroke patients at home ’We really have problems with getting into dialogue with home care staff. And equally with physio- and occupational therapists’ (Stroke team 5) ’Maybe they contact us at the wrong time, the stroke team. They got all our telephone numbers, so they should be able to come into contact, but often we notice, when we come out to the patient in the afternoon, that they have been there in the morning. And so could it have been better to coordinate.’ (Mun6) ’We have too many cooks in the kitchen’ (Mun6)

Conclusions Cooperation agreement was not implemented but disseminated to mainly the strategic and tactical level at municipalities the agreement has not been actively used to implement the necessary change: cooperation and coordination, at the operational level It was primarily an administrative tool to communicate and authorize the change Top-down policy-implementation has worked for the region, but has not yet resulted in coordinated rehabilitation care for the patient Implementation approach needs to involve the operational level