Conditioning factors for
integrated care
development in
Osakidetza
(Basque Health Service)
Nuria Toro Polanco
Senior Researcher, Basque Institute of Healthcare Innovation
(O+berri)
13th International Conference on Integrated Care, Berlin
13th International Conference on Integrated Care
Conditioning factors for integrated care development in
Osakidetza
Key words
 Chronic care models
 Assessment tools
 Structural
integration vs
functional
integration
 Integrated care
 ARCHO
 Leadership
 Osakidetza-Basque
Health Service
13th International Conference on Integrated Care
Conditioning factors for integrated care development in
Osakidetza
Content
 ARCHO
 Aims
 Literature review and hypothesis development
 Materials and methods
 Results
 Managerial implications
 Conclusions
13th International Conference on Integrated Care
Conditioning factors for integrated care development in
Osakidetza
ARCHO-Background
 In Spain, almost 20 million people have chronic conditions
 Chronicity involves rethinking on the way in which health
services are provided and the role that the patient has to play
 There is a great consensus on the need to design new provision
models, different from the ones we have now, searching for
more proactive, continuous and integrated care
 One of the models that has been most widely acknowledged
and discussed is the Chronic Care Model (CCM)
13th International Conference on Integrated Care
Conditioning factors for integrated care development in
Osakidetza
ARCHO-Background
 The CCM identifies the essential elements required by
healthcare systems to provide quality care to people with
chronic conditions. It is based on productive interactions
between informed, empowered chronic patients and a
prepared proactive health team.
 The essential elements are:






The organisation of the healthcare system
The community
The delivery system design
Self-management support
Decision support
Clinical information systems
13th International Conference on Integrated Care
Conditioning factors for integrated care development in
Osakidetza
ARCHO-Background
 The CCM is a theoretical and quite abstract model that must be
operationalised in healthcare organisations
 To do so, several tools have arisen in the USA.
 For example, the ACIC (Assessment of Chronic Illness Care) was
developed as a practical tool to help teams improve care for
chronic illness.
 However, these tools have been designed in a very different
healthcare system, so contextual adaptation is needed
13th International Conference on Integrated Care
Conditioning factors for integrated care development in
Osakidetza
ARCHO
ARCHO (Assessment of Readiness for Chronicity in Healthcare Organisations)
 Developed by O+berri, MSD and MH University
 Based on Chronic Care Model
 A tool that:
 provides healthcare organisations a roadmap of interventions to be
implemented for the management of chronic conditions (based on
integrated care evidence)
 enables healthcare organisations to self-assess their degree of
readiness to provide integrated care to cope with chronicity. Adapted
to NHS context
 Consists of 6 dimensions and 80 interventions (items)
 Rating scale from 0 to 100 (max. 8000 points)
13th International Conference on Integrated Care
Conditioning factors for integrated care development in
Osakidetza
ARCHO
ARCHO (Assessment of Readiness for Chronicity in Healthcare Organisations)
www.iemac.org
13th International Conference on Integrated Care
Conditioning factors for integrated care development in
Osakidetza
ARCHO-Results in Osakidetza
ARCHO (Assessment of Readiness for Chronicity in Healthcare Organisations)
PC District 1 (average: 28/100)
PC District 2 (average: 27/100)
IHO 1 (average: 7/100)
IHO 2 (average: 22/100)
13th International Conference on Integrated Care
Conditioning factors for integrated care development in
Osakidetza
ARCHO-Results in Osakidetza
ARCHO (Assessment of Readiness for Chronicity in Healthcare Organisations)
PC District 3 (average: 29/100)
PC District 4 (average: 19/100)
IHO 3 (average: 25/100)
IHO 5 (average: 22/100)
13th International Conference on Integrated Care
Conditioning factors for integrated care development in
Osakidetza
Aims
 Primary aim:
 Identify the factors that underlie the observed differences
in the score for each organisation; these factors should
explain the different degree of readiness to provide
integrated care that have shown the evaluated
organisations.
 These factors can be:
 Organisational
 Professional
 Others
13th International Conference on Integrated Care
Conditioning factors for integrated care development in
Osakidetza
Literature review and hypothesis development
1. Degree of structural and functional integration
 Fragmentation in healthcare is one of the main barriers to
provide proactive, continuous and integrated care
 Structural integration: involves the merger between
organisations from different healthcare levels (primary and
specialised care)
 Functional integration: implies clinical processes coordination
between different healthcare levels around the patient
H1: “Those organisations that consider providing coordinated care to chronic
patients as a priority and therefore show high levels of structural and
functional integration, should have higher scores in ARCHO than those that
don´t”
13th International Conference on Integrated Care
Conditioning factors for integrated care development in
Osakidetza
Literature review and hypothesis development
2. Organisational culture and Leadership style
 Organisational culture may have an influence on the processes
oriented to improve performance in healthcare systems
 It is the task of managers/leaders to facilitate the necessary
changes to achieve the expected results according to the
strategies and plans that must be implemented to address
chronicity
 Four culture types: rational, hierarchical, clan and
developmental culture
 Two leadership styles: directive vs. facilitative leaders
13th International Conference on Integrated Care
Conditioning factors for integrated care development in
Osakidetza
Literature review and hypothesis development
2. Organisational culture and Leadership style
Facilitative style
Directive style
H2: “The less hierarchical and centralised leadership styles promote the
implementation of integrated care models to a greater extent than directive styles.
Therefore, in those organisations that are featured by facilitative styles higher
scores in ARCHO are expected”
13th International Conference on Integrated Care
Conditioning factors for integrated care development in
Osakidetza
Literature review and hypothesis development
3. Attitude towards integrated care
 Based on the “Expectancy Theory”, three concepts are
developed
 Instrumentality: refers to the perception of the link between
integrated care implementation with the achievement of patient,
professionals and system outcomes
 Valence: it is the value that organisational members assign to the
outcomes associated with successful implementation of integrated care
 Attitude: combination of two variables
H3: “Positive attitudes from professionals towards integrated care is key to carry out
the implementation of new models to chronic disease management. The better
attitude, the higher score will be expected”
13th International Conference on Integrated Care
Conditioning factors for integrated care development in
Osakidetza
Literature review and hypothesis development
4. Training in integrated care
 As well as positive attitude and motivation, skills are needed in
order to implement the new management models
 “Willingness is not enough but also know-how is needed”
H4: “Training in integrated care is relevant in order to carry out the implementation
of new models that address chronicity. The higher the level of training, the higher
ARCHO score will be expected”
13th International Conference on Integrated Care
Conditioning factors for integrated care development in
Osakidetza
Materials and Methods
 Quantitative study that aims to investigate the relationship
between the dependent variable (ARCHO score) and the
independent variables (degree of structural and functional
integration, leadership style, attitude and training)
 Based on a 61-item questionnaire designed for that purpose
13th International Conference on Integrated Care
Conditioning factors for integrated care development in
Osakidetza
Sample profile (n=156)
7 Organisations
Professional group
Experience on chronic management
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Conditioning factors for integrated care development in
Osakidetza
Results. Descriptive Statistics
13th International Conference on Integrated Care
Conditioning factors for integrated care development in
Osakidetza
Results. Correlation matrix
13th International Conference on Integrated Care
Conditioning factors for integrated care development in
Osakidetza
Results. Linear regression model
13th International Conference on Integrated Care
Conditioning factors for integrated care development in
Osakidetza
Results. Hypothesis testing
H1: “Those organisations that consider providing coordinated care to chronic
patients as a priority and therefore show high levels of structural and
functional integration, should have higher scores in ARCHO than those that
don´t”
The structural integration level is not statistically related to the variations
found in ARCHO scores. For that reason, the first part of the hypothesis is
rejected.
However, we find statistical significance in relation to the development of the
functional integration level and the ARCHO scores.
For that reason, we conclude that the more functional integration level we
have, the higher scores can be expected in an organisation.
13th International Conference on Integrated Care
Conditioning factors for integrated care development in
Osakidetza
Results. Hypothesis testing
H2: “The less hierarchical and centralised leadership styles promote the
implementation of integrated care models to a greater extent than directive
styles. Therefore, in those organisations that are featured by facilitative styles
higher scores in ARCHO are expected”
The results suggest that there is an statistically significant negative
relationship between the hierarchical culture and the ARCHO score. For that
reason, we can confirm the second hypothesis: organisations featured by a
dominant hierarchical leadership style exhibit a lower degree of readiness to
provide integrated care to chronic patients
13th International Conference on Integrated Care
Conditioning factors for integrated care development in
Osakidetza
Results. Hypothesis testing
H3: “Positive attitudes from professionals towards integrated care is key to
carry out the implementation of new models to chronic disease management.
The better attitude, the higher score will be expected”
A positive attitude towards integrated care is significantly and positively
related to the ARCHO score.
As predicted, the better the perception of the link between integrated care
implementation and the expected outcomes in patients, professionals and
system outcomes, the higher the motivation and readiness to implement
models that provide integrated care to chronic patients.
13th International Conference on Integrated Care
Conditioning factors for integrated care development in
Osakidetza
Results. Hypothesis testing
H4: “Training in integrated care is relevant in order to carry out the
implementation of new models that address chronicity. The higher the level of
training, the higher ARCHO score will be expected”
Training has not been found to be significant when it comes to explaining
variations in ARCHO scores. For that reason, the hypothesis has been
disproved.
13th International Conference on Integrated Care
Conditioning factors for integrated care development in
Osakidetza
Managerial implications (I)
 It can be stated that Osakidetza-Basque Health Service is on the
integrated care pathway, developing projects and initiatives
that are yielding promising results; evaluation, however, is not
carried out in a systematical way.
 Basque health professionals are very familiar with chronic
management models and integrated care (93 % of them state to
have received information about these concepts).
 Integrated care positive outcomes in patients, professionals and
the healthcare system are widely recognised.
13th International Conference on Integrated Care
Conditioning factors for integrated care development in
Osakidetza
Managerial implications (II)
 According to the ARCHO instrument, the degree of readiness to
provide integrated care to cope with chronicity differs across
different settings.
 Not just between organisations but also within them, we have
found differences when it comes to scoring the six dimensions
and the 80 interventions that derive from them.
 In general terms, it can be stated that top managers tend to
score higher than doctors and nurses. This trend is even
stronger in Primary Care (although not statistically significant).
13th International Conference on Integrated Care
Conditioning factors for integrated care development in
Osakidetza
Managerial implications (III)
 In relation to leadership culture, it is clear how it has an
influence on the integrated care development.
 Leaders´ style, values and behaviours may determine the
degree in which organisations and professionals participate and
are committed to the promotion of integrated care.
 Therefore, the great challenge would be the development of
leadership models that facilitates the healthcare paradigm
transformation through the change in organisational values,
shared decision-making and teamworking.
13th International Conference on Integrated Care
Conditioning factors for integrated care development in
Osakidetza
Managerial implications (IV)
 Last but not least, both structural and functional integration
should be carefully analysed.
 According to this study, it is functional integration and not
structural integration the factor that promotes integrated
management of chronicity.
 Based on this, the merger of healthcare structures (mainly
primary and specialised care) will only make sense if it is to
facilitate the integration and coordination of clinical processes;
structural integration alone will not assure coordinated care to
the chronic patients.
13th International Conference on Integrated Care
Conditioning factors for integrated care development in
Osakidetza
Conclusions
 The topic addressed is a rather complex issue in which
organisational, professional and other type of factors can play a
role in the development of integrated care.
 We have tried to shed some light on it, testing a limited
amount of variables that, according to literature, can have an
influence on the degree of readiness to provide integrated
care.
 However, the amount of variation that is not explained yet is
quite high (adjusted R2=0,19).
 For that reason, more research is needed in order to extend
the knowledge in this interesting and challenging area.
13th International Conference on Integrated Care
Conditioning factors for integrated care development in
Osakidetza
Thank you for your attention
toro@bioef.org
13th International Conference on Integrated Care