1. 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

2. 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

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

4. 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)

5. 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

6. 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

7. 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 – 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

8. 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)

9. 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)

10. 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).

11. 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)

12. 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)

13. 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)

14. 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