Understanding the dynamics of sustainable change: A 20-year case study of integrated health and social care

Understanding the dynamics of sustainable change: A 20-year case study of integrated health and... Background: Change initiatives face many challenges, and only a few lead to long-term sustainability. One area in which the challenge of achieving long-term sustainability is particularly noticeable is integrated health and social care. Service integration is crucial for a wide range of patients including people with complex mental health and social care needs. However, previous research has focused on the initiation, resistance and implementation of change, while longitudinal studies remain sparse. The objective of this study was therefore to gain insight into the dynamics of sustainable changes in integrated health and social care through an analysis of local actions that were triggered by a national policy. Methods: A retrospective and qualitative case-study research design was used, and data from the model organisation’s steering-committee minutes covering 1995-2015 were gathered and analysed. The analysis generated a narrative case description, which was mirrored to the key elements of the Dynamic Sustainability Framework (DSF). Results: The development of inter-sectoral cooperation was characterized by a participatory approach in which a shared structure was created to support cooperation and on-going quality improvement and learning based on the needs of the service user. A key management principle was cooperation, not only on all organisational levels, but also with service users, stakeholder associations and other partner organisations. It was shown that all these parts were interrelated and collectively contributed to the creation of a structure and a culture which supported the development of a dynamic sustainable health and social care. Conclusion: This study provides valuable insights into the dynamics of organizational sustainability and understanding of key managerial actions taken to establish, develop and support integration of health and social care for people with complex mental health needs. The service user involvement and regular reviews of service users’ needs were essential in order to tailor services to the needs. Another major finding was the importance of continuously adapting the content of the change to suit its context. Hence, continuous refinement of the change content was found to be more important than designing the change at the pre-implementation stage. Keywords: Implementation, Organisational sustainability, Change management, Integrated care, Mental health * Correspondence: Charlotte.klinga@ki.se Department of Learning, Informatics, Management and Ethics (LIME), Medical Management Centre (MMC) | Karolinska Institutet, 171 77 Stockholm, Sweden © The Author(s). 2018 Open Access This article is distributed under the terms of the Creative Commons Attribution 4.0 International License (http://creativecommons.org/licenses/by/4.0/), which permits unrestricted use, distribution, and reproduction in any medium, provided you give appropriate credit to the original author(s) and the source, provide a link to the Creative Commons license, and indicate if changes were made. The Creative Commons Public Domain Dedication waiver (http://creativecommons.org/publicdomain/zero/1.0/) applies to the data made available in this article, unless otherwise stated. Klinga et al. BMC Health Services Research (2018) 18:400 Page 2 of 12 Background and the ecological system through appropriate improve- Because organisational change requires investments of ments [13]. This is an iterative, dynamic process in time, money and human resources, the lasting impact of which continued learning and development are central. this type of change is generally of great interest to care Thus, ongoing quality improvement is the ultimate goal providers, funders and other stakeholders. Change initia- of such interventions. tives, however, face many challenges, and only a few of One area in which the challenge of achieving long- them lead to long-term sustainability [1]. Knowledge of term sustainability is particularly noticeable is integrated whether program outcomes are beneficial and sustainable health and social care. In the contemporary system, is also valuable when spreading and supporting such pro- which was constructed to provide diverse, unconnected grams across several settings [2]. In the health sector, the health and social care services, those who protect these prior research has mainly been focused on the early stages systems’ separate regulations and policies may constantly of the change process – initiation, resistance and imple- challenge the idea that the systems should be integrated mentation [3–5] – and longitudinal studies are sparse [1, [17]. Additional challenges include organisations’ con- 5, 6]. The research on strategies for achieving sustainabil- flicting objectives and values as well as professionals’ dis- ity in change initiatives is rather scant [7], and studies that tinct cultures [18]. Hence, there is neither a universal explicitly address sustainability are almost absent [8]. definition of integrated care nor a one-size-fits-all model Therefore, knowledge on how to achieve long-term main- [19, 20]. However, evidence has demonstrated that inte- tenance of organisational changes is needed [2, 9]. grated health and social care leads to care that is more The recent research highlights several factors’ influ- people-centric and holistic; this can be achieved by de- ences on sustainability, including the content of the veloping cross-sectoral and inter-professional collabor- change and its contextual, political, organisational, pro- ation [21]. Such services is of great value for people who cessual and temporal factors [5, 10]. Certain enabling have complex health and social care needs, such as those factors have been highlighted, including a supportive who are suffering from mental illness. One major object- context, capacity building, effective relationships among ive that the World Health Organisation (WHO) set forth the actors, and rigorous planning and decision making in its Mental Health Action Plan 2013-2020 [22]was to [11]. However, few investigations of these factors or of provide comprehensive, integrated mental health and so- the possible interrelationships between them have been cial care services in community-based settings. Hence, conducted [12]. Thus, the ways in which these factors innovative approaches are needed in both technical and interact and impact sustainable change remain unclear. relational aspects [23]. To facilitate long-term organisa- A conventional way to study sustainability is to de- tional sustainability, policies must address the entire scribe the extent to which the change content is main- health system, including incentive structures and per- tained over a period of time – for instance, after initial formance measures [17]. A 2016 review concluded that or external support is removed [2, 13]. This approach as- no complete, peer-evaluated longitudinal studies have sumes that the change content is constant over time. been conducted on integrated health and social care However, adaptations to changes in local conditions are [24], so the uncertainty regarding long-term effects common and sometimes necessary. Thus, interventions remains. are rarely implemented as they were originally intended, In Sweden, the responsibility for the provision of and their content often varies over time [14]. This makes health and social care services is managed on three the concepts of fidelity and adaptation to intervention levels: the government (national level), the 21 county important in sustainability studies [13]. These two con- councils (regional level) and the 290 municipalities (local cepts are inherently linked [15] ways of overcoming or- level). The county councils have the responsibility for ganisational inertia while adapting to contemporary provision of health care and the municipalities for the environmental changes [16]. provision of care for elderly and disabled people, as well Chambers [13] recently proposed a more dynamic people in need of long-term mental health care. Munici- view on sustainability called the Dynamic Sustainability palities and county councils have a substantial freedom Framework (DSF); in this view, change is an ongoing to organise health and social care services [25]. Since the adaptation process in which the intervention is continu- 1990s several structural changes have aimed to move ously refined and improved in relation to its context. from inpatient care towards outpatient care [26]. That The context comprises the practice setting, its surround- was also the case in 1995 when Sweden launched a na- ings and the ecological system [13]. Thus, the DSF ad- tional policy which was manifested in the Health and dresses the paradox of sustainability amid ongoing Medical Care Act, Social Services Act and The Swedish change. The fit between the intervention and the local Act concerning Support and Service for Persons with context can be optimized by continuously matching the Certain Functional Impairments to create more inte- characteristics of the intervention to the practice setting grated services for people with mental illnesses. The Klinga et al. BMC Health Services Research (2018) 18:400 Page 3 of 12 policy’s goals were to improve the coordination and indi- health and social care through an analysis of local ac- vidualisation of care and by service user involvement in- tions that were trigged by a national policy. tegrate them into society. The policy clarified the municipality’s responsibility for planning and coordinat- Methods ing interventions and for developing housing and em- Design ployment for those who suffer from mental disorders. To study inter-sectoral cooperation, a retrospective and As before, the county council’s responsibilities were the qualitative case-study research design was applied based prevention, investigation and treatment of psychiatric on data from the model organisation’s steering-committee conditions [27]. The continued sectoral division of care minutes from 1995 through 2015. and support meant that the county and municipal social care organisations have to develop cooperation to meet Study setting the service users’ complex needs. However, the author- The area of Sweden in which the inter-sectoral cooper- ities in Sweden interpreted the policy differently. ation took place has a long record of providing inte- More than 20 years have passed since the policy was grated health and social care, with the county council introduced. In that time, much has changed, but the providing psychiatric care and the municipality provid- division of responsibilities between the municipality ing social services. The population in this urban area is and the county remains a key challenge in providing just over 96,000; the proportion of the population with a cohesive health and social care [28]. A recent study foreign background is 51%; the average age is 39 years; found that, at a policy level, establishing an overall per- the employment rate of 20-64 years is 72% [33]. This spective on healthcare and social support for people case was chosen because it represented a unique ex- with mental illness has been difficult. The reasons for ample of long-lasting, inter-sectoral cooperation. Since this include shortcomings in cooperation between the the introduction of the national psychiatric policy, the levels of care and inadequate coordination between so- cooperating agencies have striven to overcome fragmen- cial services, primary care, employment services and ted health and social care. Through the policy, the obli- the nation’s social insurance agency. The focus remains gation of people for those with long-term psychiatric split among various components rather than on the disorders upon their discharge from closed-environment whole picture [29]. mental health institutions was transferred from the Nevertheless, examples of sector-related barriers being county council to the municipality. During the policy’s overcome exist. For instance, one geographical area has establishment period (1996-1998), funding was available sustained its extensive integration of mental health and for both the county council and the municipality, pro- social care services since the policy was implemented vided that they presented a shared plan for how the [30]. For the purpose of this paper we use the definition money would be used to facilitate organisational and op- from WHO for integrated health services [18]. erational changes. The original idea behind this integration was to create “Integrated health services are health services that are a single point at which all service users could receive managed and delivered in a way that ensures people help and support, regardless of which authority had the receive a continuum of health promotion, disease competence or means to address the problem. Initially, prevention, diagnosis, treatment, disease management, this plan was to offer services to those over 18 years old rehabilitation and palliative care services, at the who had chronic, severe mental illnesses that caused different levels and sites of care within the health permanent disabilities, as well as to those who were in system, and according to their needs throughout their need of both psychiatric treatment and social services. life course ”. Today, the integration has evolved to also include people with neuropsychiatric diagnoses, people with addiction The abbreviation IC will be used, referring to integrated problems and other target groups. Since 1995, a steering mental health and social care services. Based on our pre- committee has governed the integrated organisation, vious research [30–32], we anticipated that this case with representatives from the county council’s psychi- would be particularly interesting to study from a sustain- atric care and the municipality’s social services. The ability perspective. By viewing sustainability as a process committee’s mission is to develop cooperation between in a constantly changing context, the DSF is a relevant the municipality’s social care and the county council’ psy- means through which to explore the mechanisms of sus- chiatric care. The services consist of geographically dis- tainability in this integrated mental health and social persed co-located centres and mobile units for specific care organisation. target groups. Although separate legislation regulates the The specific objective of this study is to gain insight services, they are all organised based on inter- into the dynamics of sustainable changes in integrated professional teams and are managed, at all levels, Klinga et al. BMC Health Services Research (2018) 18:400 Page 4 of 12 through co-leadership of two leaders, one from each or- Table 1 Stages of the thematic analysis ganisation. Access to services is mainly via primary care Stage 1 Description of the process but also from emergency care. Inpatient care is provided 1. Learn about the data set Read and reread data, take notes and 2. Create an initial code list mark ideas for coding by the regional hospital. 3. Group the codes Organise data into meaningful codes 4. Search for themes based on potential interest 5. Create a timeline Search for relationships between codes Data collection and data characteristics to create sub-themes Sort codes and sub-themes into data- Data were collected from the minutes of all steering- dependent themes committee meetings held from 1995 through 2015. The Extract activities related to the area of minutes were available in digital form (n = 98; approxi- interest using a timeline mately 3-5 meetings per semester, fewer in recent years) Stage 2 Description of the process and followed the same basic structure. However, some 6. Investigate using theory Analyse the data through specific variation regarding the content occurred due to the rele- 7. Search for themes questions based on DSF 8. Refine the themes Sort codes into theory-dependent vance of certain topics and questions at certain times. themes related to integration This variation in content determined the committee’s Consider the coded data extracts composition; in addition to the permanent members – and the individual themes in relation to the entire data set representatives from the county, the municipality and the stakeholder associations (e.g. patients’ and relatives’ associations) – other relevant stakeholders were invited. Case findings The same person wrote all the minutes, which were pri- The individual organisations had a history of collabor- marily for the internal use of the organisation’s managers ation prior to the launch of the psychiatric policy. That and professionals. However, the minutes were also avail- policy, however, triggered the development of an inte- able to cooperating partners outside the organisation grated health and social care organisation, with project and to other interested stakeholders. funding provided for both the county council and the municipality. In 1995, both the inter-sectoral steering committee and the two project managers (one from each Data analysis organisation) were put in place. One guiding principle Thematic analysis, as Braun and Clarke [34] described, was that all service users should be at the centre of – is used to handle extensive data sets. This study’s data and participate in – the planning of care and support. included a large amount of information generated over The integrated organisation started by inventorying the twenty years, which required condensation; a semantic need for staff training and for a cooperative model to approach was used to handle this rich data set. Based on apply with each service user. Stakeholder associations the study’s objective, an initial orientation was devel- were involved, and the central role of the service users oped, and a search for codes and meaningful groups was (i.e. the patients and clients), their families and the performed. Based on the predetermined area of interest, stakeholder associations was emphasised. A co- actions not directly linked to integration were excluded. leadership model was created in which the leaders from This first stage of the analysis was explorative and in- each sector jointly managed all services. Joint trainings, ductive [35]; data were used to map the steering com- information sessions, outdoor excursions and confer- mittee’s actions. The resulting analysis was intended to ences were arranged. The continuous exchange of com- illustrate the trend in integration over time and to serve petencies and experiences was given high priority, and as a basis for the subsequent analysis in stage 2, which co-run projects targeted to specific groups, such as was intended to mirror the findings regarding the key el- people with substance abuse, were initiated. ements of the DSF. This procedure resulted in a detailed In 1996 and 1997, several changes were introduced to data analysis that would aid in identifying the empirical integrate the services. For instance, three co-located and themes from the narrative description. The thematic jointly managed centres were opened, mainly for persons analysis-process is illustrated in Table 1. with psychosis and complex needs. Furthermore, each service user received coordinators from each organisa- tion; these coordinators shared the responsibility for all Results of the user’s health and social care planning. Data on the The results are presented in two parts. The first, Case service users’ needs (the Camberwell Assessment of findings, provides a chronological case narrative of Needs [CAN] scale) were used for these purposes. Indi- the key events related to the integration. The second, vidualised care and rehabilitation plans were introduced Empirical themes, is based on identified chains of to personalise care and to support service users. In actions that are reflected in DSF. addition, shared clinical guidelines and agreements Klinga et al. BMC Health Services Research (2018) 18:400 Page 5 of 12 concerning financial issues were established. The over- managed in close collaboration and based on formal arching vision, in which service users would be active agreements – in contrast to earlier, verbal agreements. co-producers, triggered the development of a consistent An example of concrete integration was the announce- terminology; the term ‘customer’, instead of ‘patient’ or ment of a vacant manager position on a psychiatric ad- ‘client’, was suggested. Nevertheless, the term ‘customer’ diction team. The organisational affiliation for that was incompatible with then-current national regulations, position was decided based on the selected candidate’s and the terms ‘patient’ (for psychiatric care) and ‘client’ profession (nurse or social worker) rather than in ad- (for social care) were kept. The importance of a shared vance, when announcing the position. The integrated IT system was recognised, and much effort was spent in services were expanded with the opening of a day centre trying to achieve this. However, the Swedish Data Pro- for people with borderline personality disorder. tection Authority did not permit the use of such a During 2002 and 2003, the integrated services were shared register for service-users assessment data (using further expanded by developing services for elderly the CAN scale) because of questions regarding data people and for some new target groups (e.g. those with ownership. Thereafter, the possibility of digitally sharing long-lasting depression and those who were unemployed care and rehabilitation plans was examined. or on sick leave due to mental health problems). Fur- In 1998, challenges related to financing surfaced, partly thermore, a joint home-support group with staff from because the initial funding had ended. In addition, difficul- both organisations was proposed. In addition, several ties concerning the management of the integrated services structural changes were made in the integrated organisa- were noted, as differences in managers’ decision-making tion. For instance, social workers and assistance officers mandates varied between the organisations. To meet these were decentralised and sent to the individual units, and challenges, additional training in integration was offered; co-location was planned for some administrators. The for instance, the two project managers received support in steering committee proposed further expansion to in- how to manage integrated projects, and the coordinators clude a representative for service users who were cov- were trained in case management. The expansion of inte- ered by the law that regulated support and service for gration to include new groups of service users (e.g. those people with certain functional impairments. with severe mental disabilities) was considered. In During 2004 and 2005, actions were taken to further addition, a new organisation was proposed that would be develop the practical work such as by opening a new aimed at outsourcing cooperative units to the municipal coach position. The coach would support the managers districts, but the steering committee rejected this proposal in designing processes for shared service planning. New due to the risk of losing coordination and the knowledge groups in need of integrated services were identified: required for rehabilitation in the event of a disruption in people with Asperger’s disease or ADHD, those at risk the organisation’s integration. of criminality or with addiction problems, asylum In 1999, the steering committee reviewed the integrated seekers with mental health problems, and individuals fa- organisation’s costs. Savings from the previous year en- cing deportation. In addition, the organisation expanded abled the financing of additional training to facilitate the by establishing a neuropsychiatric team and new accom- handover of service users from external locations to the modations for people with double diagnoses. The ques- local municipality’s care. Actions were planned to simplify tion was raised over whether to institute a common title the practical work and to increase collaboration. For in- – coordinator – for all employees, regardless of profes- stance, the plan was for decisions about housing support sion. This was considered to have a symbolic import- to be transferred to the unit level (i.e. as close to the ser- ance, as it would indicate that cooperation was central vice users as possible) with the goal of improving collabor- and that responsibilities could not be transferred across ation among social workers, assistance officers and organisations. The steering committee continued to occupational therapists. The integrated organisation con- expand, this time with representatives from child and tinued to grow; it initiated a mobile team and developed adolescent psychiatry. the coordinator role to enhance focus on the entire re- In 2006, efforts were made to overcome evolving habilitation process. The shared use of the CAN data was macro-level challenges. The integration agreement was re- further developed to tailor both health and social care to vised to further clarify the organisations’ equal status and meet the service users’ individual needs. responsibilities concerning costs. Participation in further In 2000 and 2001, efforts were made to make the two education became compulsory for all inter-professional organisations’ economic steering mechanisms equivalent. team members, and opportunities for shared research and The steering committee also expanded to include mem- improvement activities were investigated. The senior bers who represented areas that had recently been inte- county council managers decided to close one of the units. grated, such as elder care. It was agreed that all new However, to avoid the closure, the municipality took over projects within the integrated organisation would be responsibility for the unit. Another example of integration Klinga et al. BMC Health Services Research (2018) 18:400 Page 6 of 12 development was the evolution of the coordinator role increase the service users’ involvement in care and sup- into the case manager role, as advocated in the national port were also on the agenda. The overall integration clinical guidelines on psychosis. agreement was again revised, this time to clarify the steer- In 2007, a statement was made regarding the import- ing committee’s responsibilities. In addition, attention was ance of giving equal value to the service users’ existen- drawn to subgroups that were not yet included in the tar- tial, medical, psychological and social well-being rather get population of the integrated organisation. Planning for than emphasising only some of these depending on the the housing of people with long-term substance abuse and organisation. The steering committee and the stake- extensive care needs started with a guiding principle that holder associations presented a revised vision that these individuals would be able to maintain the accommo- highlighted how service users and the two organisations dation regardless of which organisation had the formal re- would cooperate to provide flexible and need-based sup- sponsibility for the individual. Further contacts were made port. This vision also specified the planning, develop- with the primary health care to develop care for elderly ment and evaluation of the units and the teams, people with mental illness, substance abuse and drug ad- emphasising that the professionals’ roles needed to be diction. Another central group was people with ADHD, streamlined so that they would become experts. All ser- for whom integrated health and social care were consid- vice users’ needs were analysed to inform the organisa- ered to be essential. Cooperation was under development tion about whether its services should be revised. Some with the municipal unit around disabled people and a changes in the needs were noticed; consequently, the correctional care unit. units revised their services to better suit people who In 2011, the ability to cooperate with primary care was lacked long histories of inpatient care. The organisation hampered as the number of private care providers in- continued to expand by including services for young, creased. Nonetheless, new forms of cooperation within self-harming people; the focus was on improving cooper- subgroups, such as people with substance abuse and ation regarding young people and those with bipolar within the neuropsychiatry, were successfully estab- disorder or complex needs. lished. In this development work, a mobile team was In 2008, the integration agreement was once again re- launched for supporting young people with neuropsychi- vised, and the shared routines for risk assessments were atric diagnoses, and the care centre for addicts was ad- included. The steering committee actively requested the vanced. The steering committee continued to find stakeholders’ views on the integrated services. They in- solutions to the funding of the integrated services. An vited partners, stakeholder associations and service-user example was a new, integrated type of employment form representatives to discuss these issues. In addition, ser- where a manager was formally employed by the munici- vices continued to be developed for people with neuro- pality, but the costs were shared through the county psychiatric diagnoses and elderly people with mental council purchasing the manager’s services. illnesses or health problems related to drug abuse and In 2012, a regional agreement on how to support addiction. For the latter, local guidelines clarifying the people with a mental illness and disability was reached, shared responsibility were developed. The neuropsychi- which strengthened the integration of focusing on the atric staff members were trained accordingly. needs and shared responsibilities of service users. The In 2009, the stakeholder associations’ roles were integrated organisation was reviewed in two evalua- strengthened by increasing their participation in the meet- tions. An external evaluation concluded that cost- ings and by gathering their views on the new integration effective and high quality care was provided and that agreement. Substantial work was done to develop inte- the steering committee served an important role in grated services for new user groups. For instance, an ini- overviewing the integration. The internal evaluation tiative was launched to develop collective, overall support underlined that the resources of the relatives and the for users of the care and habilitation service for people families could be more optimally used. Consequently, with disabilities. In addition, this service expanded to han- stakeholder associations were invited to take part in dle the increasing number of service users with neuro- discussions of their role and the revision of the services. psychiatric disorders. A growing group in need of health A new function, a multi-case manager, was also estab- and social care comprised traumatised refugees, who re- lished to handle service users with highly complex quired new and well-adjusted integrated services. To treat needs. Furthermore, clarification of the shared respon- this group, the organisations co-applied for project fund- sibility for service users with psychiatric diagnoses and ing to develop a care program. substance abuse was made, and a newly diagnosed psy- In 2010, continual efforts were made towards the im- chiatric patients’ team was initiated to provide inte- provement of stakeholder associations. This action was grated services at a care centre for addicts. Further, an consistent with the search for shared and streamlined ser- operational management group of representatives from vice activities focusing on cost reduction. The efforts to the units for adults and elderly people was created and Klinga et al. BMC Health Services Research (2018) 18:400 Page 7 of 12 supplemented with a representative from the psychiatry rather, by involving stakeholder associations and other centre. key actors, the organisational development was co- In 2013, attention was drawn to savings opportunities created in a dynamic process through the years. The by further developing the integration. For instance, inte- integration work was characterised by continuous adap- gration of services with the neighbouring municipalities tations of interventions on multiple levels. Adjustments was discussed. The cooperation agreements were revised were made in order to continuously adapt the organisa- regarding elderly users, children and adolescents, and ef- tion and the services to changes in context. For in- forts were made to improve cooperation between the stance, new services were started based on the change psychiatry centre for adults and a centre for children in service users’ needs. When financial savings were re- and adolescents to better meet the needs of children, quired, the two organisations streamlined the processes young people and their families. Other areas of improve- together. All internal improvement work was also made ment included clarifying the primary care and psychiatry with participation in various improvement projects and responsibilities and reorganising neuropsychiatric care in with external partners. The thorough work carried out order to make it more cost-effective. An inter-sectoral aimed at bringing the municipality and county closer in co-located neuropsychiatric outpatient clinic was pro- the pursuit of a shared IT system, aligned steering posed. Despite the economic challenges, the willingness mechanisms (score cards), service outcome measures, to further integrate health and social care for people shared routines, common referral forms and shared with mental illness continued. For example, a “house of clinical guidelines. External influences recognised to health” with all services co-located at one place was cause fragmentation were handled by strengthening co- planned together with web-based network-gathering operation, for example, by underlining the equal state activities. of the organisations in the cooperation agreement and In 2014, the steering committee decided to only meet by emphasising the equal value to the service users’ ex- once per semester. The role of the committee had become istential issues of medical, psychological and social more “consultative” and less of a working group due to an well-being. The following excerpt from the steering increased number of members, which in turn was an ef- committee minutes exemplifies this: fect of the increased number of services included in the organisation. Meanwhile, the steering committee function The county council and the municipality are two changed, however, the practical integrated work at the unit organizations that complement each other. […] levels continued intensively. For instance, procedures for The things we do, we do together. […] The reform coordinated individual rehabilitation plans were devel- requires functioning forms of cooperation and oped, and various improvement projects were launched. creation of shared goals along with a union of our In 2015, attention was again drawn to the needs of cultures and decision-making systems. But still, the elderly service users and to unaccompanied refugee chil- two cooperating organisations need to continuously dren. Integration with geriatric psychiatry care, primary develop their own working methods. care and elder care continued to be of high priority but challenging. The economy was strained for both organi- sations. A new review of the services and the service Continuous learning users’ needs was made. The number of service users in The integration of health and social care emerged as a need of health and social care had decreased, while some fusion of norms, values, assumptions and behaviours changes in their needs were also noticed. As a conse- from two different sectors, which had certain challenges quence, efforts were made to reduce costs by streamlin- to overcome. A mutual understanding of the differences, ing the integrated processes. At the end of the year, the including the mission of each sector, was recognised and steering committee decided to schedule two meetings respected. Formal structures for learning were created per semester since the time between the meetings was by allowing employees, managers and service users to concluded to be too long. exchange experiences and knowledge. The financial sup- port of learning activities was strategically used over the Empirical themes years to promote and develop integration. The develop- Shared structure and ongoing refinement ment of new ways of working such as teamwork and The services of the municipality and county were inter- case management was given financial support. Managers’ linked at both structural and functional levels, and the need for development was also recognised, and their foundation was built on shared mission and agree- professional development was among other things sup- ments, co-leadership and by creating inter-professional ported through the coaches who provided support in teams in co-located services. The question of how the managing shared service planning. The managers were integration would take place was not predetermined; also innovative in implementing new working methods Klinga et al. BMC Health Services Research (2018) 18:400 Page 8 of 12 and functions before these methods and functions were the committee early on and set the goal to collaborate decreed by the national government. Data from all levels around each service user. The formal agreements stated of the organisation were continuously collected to assess that service users should be at the centre. The services progress. These measurements enabled immediate were therefore organised around each service users’ per- reactions, which in turn contributed to continuous opti- sonal needs, rather than from the perspective of the or- misation of the conditions for sustainability of the inter- ganisations. For instance, this was achieved by having sectoral cooperation. The following excerpt from the ongoing stakeholder involvement through representa- steering committee minutes exemplifies this: tives from the stakeholder associations in the steering committee and local service user groups at the service The psychiatric reform requires mutual respect centres. Thus, the service users took part in co-creating and trust for the cooperating health and social care the services. On an individual level, coordinators were professionals’ different conditions, tasks and methods. introduced early on in the process, and a multi-case Only thus, it is possible to achieve a common set of manager was appointed for service users with complex values upon which the concrete work should rest. In needs. The content of the care and support was also co- order for this respect and understanding to be produced according to individual rehabilitation plans, maintained, ongoing, mutual knowledge and health and social care interventions were continu- development is required. ously followed up by the use of CAN data. As new service user groups were added over time, new inter- professional teams were arranged to meet the specific Cooperation as a guiding principle for management needs of the new groups. The following excerpt from the The composition of the steering committee could be de- steering committee minutes exemplifies this: scribed as dynamic since it constantly adapted to match the service users. Permanent members were representa- The services should be formed and developed based tives from the mental health services at the municipality on the service users’ needs. [...] The organisational and the county, along with the stakeholder associations. and economical conditions should therefore be The continuity among the core members was high, and arranged to enable long-term care and support, other temporary members were determined by the con- based on the service users´ need of continuity. tent of each meeting. The two project managers had a central role for the creation of the integration. They, representing both municipality and county council, Discussion made key contributions in the creation of a culture and The study aimed to gain insights into the dynamics of the shared values. Also, the line managers (i.e., co-leaders) sustainable change of integrated health and social care. functioned as opinion leaders and cultural carriers and Five main factors were found to be essential for the therefore had a strong symbolic value. In addition, they achievement of the 20 years of inter-sectoral cooperation. worked closely together in applying co-leadership, as all First, the integration was characterised by ongoing leaders on all levels, and thereby served as role models. adaptations. The services provided and the work of The decision-making process was based on dialogue and the steering committee was constantly improved based negotiation, and all solutions were consensus-based. The on changes in the surrounding context. The needs of following excerpt from the steering committee minutes the service users were frequently reviewed in order to exemplifies this: create new services or to adapt the existing ones. Ser- vice users and stakeholder associations were consid- Cooperation is necessary to realize the reform. It ered important partners in this. This also applied to applies to several levels, county, municipality, team the view of other collaborators (e.g., Primary Care, and at the individual level. [...] In our services, service Social Insurance Agency, Public Employment Service users, municipality and county council cooperate for etc.) who came to change over time depending on the flexible and needs-based support for the different service users’ needs. The importance of using bottom- target groups. The cooperation includes planning, up strategies for implementation of new intervention development and evaluation of operations. has been emphasised by others [36]. In this case, the steering committee worked actively to align the organ- isational characteristics with actual needs, meaning Service user centeredness that inappropriate structures were removed. This is in Over the years, the steering committee recognised the line with the DSF, which also recommends contextua- interdependence of physical, psychological and social lising or removing non-outcome-focused intervention factors in health and illness, which was manifested in components [13]. Klinga et al. BMC Health Services Research (2018) 18:400 Page 9 of 12 Secondly, the ambition for ongoing learning among strategy used by the steering committee to align inter- all stakeholders was highly present. Continuous feed- ventions to the service users’ needs and to create em- back on performance was provided with the measures powerment. Furthermore, equal importance was given on the organisational, professional and service user to all of the service users’ needs (medical, psycho- level, which was one step in the creation of a culture logical, social etc.) rather than prioritising one of these for learning. Previous studies on collaboration have based on sectorial priorities. The shared holistic view shown that arenas for dialogues and exchange of rele- on service users and, consequently, an identified need vant knowledge is important [35], and we found that to organise health and social care in a cohesive manner the decision to co-locate all health and social services enabled the creation of a shared vision and strategy in co-run centres required interdisciplinary teamwork formulation, which in turn set the direction for the or- on a very practical level, which also surfaced as an im- ganisation and its priorities. It also seemed that the portant step in the continuous learning and integration two organisations could always make up for the needs of the services. The issue of culture is highly relevant by putting the service users’ needs first, which helped for multi-sectoral collaboration (e.g., between health them to solve potentially sensitive issues in funding and social care), since the organisations often have dif- and managing the integrated services. This may have ferent cultural lenses. In a similar manner, each profes- caused them to become more solution focused and less sional group tends to have its own professional protective, enabling the establishment of a shared or- culture, which makes this type of organisation even ganisational culture that includes roles, norms and more multicultural [37]. Protectionism and scepticism values, which is also underlined by Schein as important towards other professional groups are commonininte- [43]. In the research examples of service users being grated services [38]. The current organisation was no active, the contributors of skills and knowledge in the exception to this, but it had a clear ambition on tack- development of healthcare services can be found [44, ling these challenges together through collaboration, 45]. The interaction between service users and health education and experience exchange, which has been and social care providers forming a partnership is shown to contribute to successful multidisciplinary referred to as co-production [46], co-creation [47], ex- integration [39]. perienced based co-design [48]and patientand public Thus, the third issue characterising this sustained in- involvement [49], to mention a few. Hence, research tegration of services was the emphasis on collaboration. has shown that the consultative approaches are more This was one of the most essential guiding principles in common than partnership [50]. However, it seems that the steering group’s work over time. This manifested in this integrated health and social care organisation was considering the dissimilarities, conditions and needs of an early adopter of this involvement approach enabling each organisation in decision making. Thereby, the service user participation. steering committee was long-term-oriented with collab- Lastly, the steering committee’s work was dynamic, oration in mind, while also continuously solving the and new members were invited to participate depend- problems at hand to enable collaboration on a practical ing on what services were included in the integrated level. The many actions that the steering committee organisation. At the same time, their work was charac- took initially and the persistent work for the continu- terised by a low turnover since the core individuals in ation of cooperation reflect a firm belief in inter- the steering group were the same during the entire 20- sectoral cooperation. These findings relate to prior year period. For instance, the minutes were written by research showing a relation between committed leaders thesamepersoninall cases. Thestablestepofindivid- across the organisation and successful long-term uals with a shared vision certainly had a great impact change [40]. The role of managers and leadership, to- on the sustained integration. Furthermore, the two pro- gether with the leadership system, is repeatedly ject managers, holding key functions in the process of highlighted as crucial for change, especially for sustain- integration, were the same individuals throughout the able change [41]. The leadership system in this case years. These functions, called opinion leaders or pro- was based on co-leadership and cooperation. The work gram leaders in other studies [51], have had a great im- tasks were regarded as a joint responsibility, which is pact on integration. Previous research has also consistent with previous research on shared leadership highlighted the importance of stability on a strategic showing that a close leadership created space for for- and operational level to overcome sector-related chal- ward thinking and a long-term approach to work [42]. lenges in integrated health and social care [52]. How- Fourthly, the service users, their families and the ever, the current study does not reveal whether the stakeholder associations were key partners in the col- impact of the stakeholders derives from what they did, laboration and in forming the services. Their engage- thefactthattheywerethe same people over theyears ment in the development of processes was a core or a combination of these factors. Klinga et al. BMC Health Services Research (2018) 18:400 Page 10 of 12 Methodological considerations to explore the importance of leadership during different The main strength of the study was the long time period stages of change). In regard to practical implications, the in which we were able to complete a thorough docu- findings suggest that service user involvement and the ment analysis. This provided valuable insight into the critical review of service users’ needs on a regular basis steering committees’ work over time. A potential limita- are essential in order to tailor to the current needs and tion with the minutes afforded for study in each meeting services. Furthermore the importance of continuously was that we were restricted to the information provided adapting the content of the change to suit its context, in the documents. It’s possible that other data sources was clear, and it’s suggested that continuous refinement such as interviews could have provided a broader picture of the change content was found to be more important of the actions taken by the steering committee. Never- than designing the change at the pre-implementation theless, the minutes were rich and provided insights into stage. how the committee members perceived their context, the organisation and their actions rather than only con- Conclusion sisting of decisions and actions. As these minutes were This study provides some valuable insight into the dy- not designed with research in mind, the bias from leav- namics of sustainable change and the understanding of ing out certain information such as disagreements and key managerial actions in order to establish, develop conflicts must be considered. Furthermore, the same and support the integration of health and social care person wrote out the minutes of the meeting throughout for people with complex mental health needs. The de- the study period. This can be considered a strength since velopment of inter-sectoral cooperation was charac- the minutes followed the same structure and had an terised by a participatory approach in which a shared equal amount of information throughout the years. At structure was created to support cooperation and on- the same time, it can limit the type and information pro- going quality improvement and learning focused on the vided since one person made decisions on what to note, service user’s needs. The key management principle in- although the minutes were always reviewed by the other cluded cooperation on all organisational levels as well committee members. Generally, the overall framework as with service users, stakeholder associations and helped to identify several factors related to the dynamics other partner organisations. This study shows that all of sustainable change. More precisely, the framework these parts were interrelated and collectively contrib- was found useful as a tool to limit the scope of relevant uted to the creation of a structureand aculturethat data and in interpreting our findings. While the frame- supported the development of dynamic and sustainable work focused our attention to some specific components health and social care. we still strived to remain open for unexpected findings Abbreviations and alternative explanations. One example was the iden- CAN: the Camberwell Assessment of Needs scale; DSF: Dynamic tification of service user centeredness as an enabling fac- Sustainability Framework tor for the achievement of long-lasting cooperation. By Acknowledgements this the services were organised around each service We would like to thank the municipality for providing us with all the Steering users’ personal needs, rather than from the perspective Committee minutes. In addition we would like to thank Karin Solberg Carlsson for helping with the initial assortment of the collected data. of the organisations. A limitation to generalisability of the findings can be that the study was conducted in one Funding specific geographical area, which was characterised by This research was funded by a grant from The Swedish Research Council (521-2014-2710), the involvement of the second author was funded by a long-term integrated health and social care services. research grant from FORTE (2014-0303). Suggestions for future research and implications for Availability of data and materials The datasets used and/or analysed during the current study are available practice from the corresponding author on reasonable request. As this study primarily addresses the steering committee decisions and actions, future research could build on Authors’ contributions CK, MAS, HH, JH: conception and design of the study; CK: data collection; CK, our findings by including perspectives on organisational MAS, HH, JH: data analysis; CK, MAS, HH, JH: drafting the article. All authors champions and the meaning of organising networks for read and approved the final manuscript. achieving sustainability. As the knowledge on champions Ethics approval and consent to participate and networks increases, we stress that organisations and This study has been reviewed and approved by The Regional Ethics Committee services adjust accordingly. We suggest three main areas in Stockholm (Dnr 2014/612-31/5). The data in the study consists of public of future research: 1) studies on the sustainability of documents, no files containing personal data were compiled and the results are presented at aggregated level. change; 2) studies on the interrelatedness of factors impacting sustainable change; and 3) longitudinal studies Consent for publication on the impact of different factors on sustainability (e.g., Not applicable. Klinga et al. BMC Health Services Research (2018) 18:400 Page 11 of 12 Competing interests apps.who.int/iris/bitstream/handle/10665/155002/WHO_HIS_SDS_2015.6_ The authors declare that they have no competing interests. eng.pdf;jsessionid=3BBDDBC72FF786E5623D3540E9F06326?sequence=1 19. Sun X, Tang W, Ye T, Zhang Y, Wen B, Zhang L. Integrated care: a comprehensive bibliometric analysis and literature review. Int J Integr Care. 2014;14:1–12. https://doi.org/10.5334/ijic.1437. Publisher’sNote Springer Nature remains neutral with regard to jurisdictional claims in 20. Ouwens M. 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Understanding the dynamics of sustainable change: A 20-year case study of integrated health and social care

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Medicine & Public Health; Public Health; Health Administration; Health Informatics; Nursing Research
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Abstract

Background: Change initiatives face many challenges, and only a few lead to long-term sustainability. One area in which the challenge of achieving long-term sustainability is particularly noticeable is integrated health and social care. Service integration is crucial for a wide range of patients including people with complex mental health and social care needs. However, previous research has focused on the initiation, resistance and implementation of change, while longitudinal studies remain sparse. The objective of this study was therefore to gain insight into the dynamics of sustainable changes in integrated health and social care through an analysis of local actions that were triggered by a national policy. Methods: A retrospective and qualitative case-study research design was used, and data from the model organisation’s steering-committee minutes covering 1995-2015 were gathered and analysed. The analysis generated a narrative case description, which was mirrored to the key elements of the Dynamic Sustainability Framework (DSF). Results: The development of inter-sectoral cooperation was characterized by a participatory approach in which a shared structure was created to support cooperation and on-going quality improvement and learning based on the needs of the service user. A key management principle was cooperation, not only on all organisational levels, but also with service users, stakeholder associations and other partner organisations. It was shown that all these parts were interrelated and collectively contributed to the creation of a structure and a culture which supported the development of a dynamic sustainable health and social care. Conclusion: This study provides valuable insights into the dynamics of organizational sustainability and understanding of key managerial actions taken to establish, develop and support integration of health and social care for people with complex mental health needs. The service user involvement and regular reviews of service users’ needs were essential in order to tailor services to the needs. Another major finding was the importance of continuously adapting the content of the change to suit its context. Hence, continuous refinement of the change content was found to be more important than designing the change at the pre-implementation stage. Keywords: Implementation, Organisational sustainability, Change management, Integrated care, Mental health * Correspondence: Charlotte.klinga@ki.se Department of Learning, Informatics, Management and Ethics (LIME), Medical Management Centre (MMC) | Karolinska Institutet, 171 77 Stockholm, Sweden © The Author(s). 2018 Open Access This article is distributed under the terms of the Creative Commons Attribution 4.0 International License (http://creativecommons.org/licenses/by/4.0/), which permits unrestricted use, distribution, and reproduction in any medium, provided you give appropriate credit to the original author(s) and the source, provide a link to the Creative Commons license, and indicate if changes were made. The Creative Commons Public Domain Dedication waiver (http://creativecommons.org/publicdomain/zero/1.0/) applies to the data made available in this article, unless otherwise stated. Klinga et al. BMC Health Services Research (2018) 18:400 Page 2 of 12 Background and the ecological system through appropriate improve- Because organisational change requires investments of ments [13]. This is an iterative, dynamic process in time, money and human resources, the lasting impact of which continued learning and development are central. this type of change is generally of great interest to care Thus, ongoing quality improvement is the ultimate goal providers, funders and other stakeholders. Change initia- of such interventions. tives, however, face many challenges, and only a few of One area in which the challenge of achieving long- them lead to long-term sustainability [1]. Knowledge of term sustainability is particularly noticeable is integrated whether program outcomes are beneficial and sustainable health and social care. In the contemporary system, is also valuable when spreading and supporting such pro- which was constructed to provide diverse, unconnected grams across several settings [2]. In the health sector, the health and social care services, those who protect these prior research has mainly been focused on the early stages systems’ separate regulations and policies may constantly of the change process – initiation, resistance and imple- challenge the idea that the systems should be integrated mentation [3–5] – and longitudinal studies are sparse [1, [17]. Additional challenges include organisations’ con- 5, 6]. The research on strategies for achieving sustainabil- flicting objectives and values as well as professionals’ dis- ity in change initiatives is rather scant [7], and studies that tinct cultures [18]. Hence, there is neither a universal explicitly address sustainability are almost absent [8]. definition of integrated care nor a one-size-fits-all model Therefore, knowledge on how to achieve long-term main- [19, 20]. However, evidence has demonstrated that inte- tenance of organisational changes is needed [2, 9]. grated health and social care leads to care that is more The recent research highlights several factors’ influ- people-centric and holistic; this can be achieved by de- ences on sustainability, including the content of the veloping cross-sectoral and inter-professional collabor- change and its contextual, political, organisational, pro- ation [21]. Such services is of great value for people who cessual and temporal factors [5, 10]. Certain enabling have complex health and social care needs, such as those factors have been highlighted, including a supportive who are suffering from mental illness. One major object- context, capacity building, effective relationships among ive that the World Health Organisation (WHO) set forth the actors, and rigorous planning and decision making in its Mental Health Action Plan 2013-2020 [22]was to [11]. However, few investigations of these factors or of provide comprehensive, integrated mental health and so- the possible interrelationships between them have been cial care services in community-based settings. Hence, conducted [12]. Thus, the ways in which these factors innovative approaches are needed in both technical and interact and impact sustainable change remain unclear. relational aspects [23]. To facilitate long-term organisa- A conventional way to study sustainability is to de- tional sustainability, policies must address the entire scribe the extent to which the change content is main- health system, including incentive structures and per- tained over a period of time – for instance, after initial formance measures [17]. A 2016 review concluded that or external support is removed [2, 13]. This approach as- no complete, peer-evaluated longitudinal studies have sumes that the change content is constant over time. been conducted on integrated health and social care However, adaptations to changes in local conditions are [24], so the uncertainty regarding long-term effects common and sometimes necessary. Thus, interventions remains. are rarely implemented as they were originally intended, In Sweden, the responsibility for the provision of and their content often varies over time [14]. This makes health and social care services is managed on three the concepts of fidelity and adaptation to intervention levels: the government (national level), the 21 county important in sustainability studies [13]. These two con- councils (regional level) and the 290 municipalities (local cepts are inherently linked [15] ways of overcoming or- level). The county councils have the responsibility for ganisational inertia while adapting to contemporary provision of health care and the municipalities for the environmental changes [16]. provision of care for elderly and disabled people, as well Chambers [13] recently proposed a more dynamic people in need of long-term mental health care. Munici- view on sustainability called the Dynamic Sustainability palities and county councils have a substantial freedom Framework (DSF); in this view, change is an ongoing to organise health and social care services [25]. Since the adaptation process in which the intervention is continu- 1990s several structural changes have aimed to move ously refined and improved in relation to its context. from inpatient care towards outpatient care [26]. That The context comprises the practice setting, its surround- was also the case in 1995 when Sweden launched a na- ings and the ecological system [13]. Thus, the DSF ad- tional policy which was manifested in the Health and dresses the paradox of sustainability amid ongoing Medical Care Act, Social Services Act and The Swedish change. The fit between the intervention and the local Act concerning Support and Service for Persons with context can be optimized by continuously matching the Certain Functional Impairments to create more inte- characteristics of the intervention to the practice setting grated services for people with mental illnesses. The Klinga et al. BMC Health Services Research (2018) 18:400 Page 3 of 12 policy’s goals were to improve the coordination and indi- health and social care through an analysis of local ac- vidualisation of care and by service user involvement in- tions that were trigged by a national policy. tegrate them into society. The policy clarified the municipality’s responsibility for planning and coordinat- Methods ing interventions and for developing housing and em- Design ployment for those who suffer from mental disorders. To study inter-sectoral cooperation, a retrospective and As before, the county council’s responsibilities were the qualitative case-study research design was applied based prevention, investigation and treatment of psychiatric on data from the model organisation’s steering-committee conditions [27]. The continued sectoral division of care minutes from 1995 through 2015. and support meant that the county and municipal social care organisations have to develop cooperation to meet Study setting the service users’ complex needs. However, the author- The area of Sweden in which the inter-sectoral cooper- ities in Sweden interpreted the policy differently. ation took place has a long record of providing inte- More than 20 years have passed since the policy was grated health and social care, with the county council introduced. In that time, much has changed, but the providing psychiatric care and the municipality provid- division of responsibilities between the municipality ing social services. The population in this urban area is and the county remains a key challenge in providing just over 96,000; the proportion of the population with a cohesive health and social care [28]. A recent study foreign background is 51%; the average age is 39 years; found that, at a policy level, establishing an overall per- the employment rate of 20-64 years is 72% [33]. This spective on healthcare and social support for people case was chosen because it represented a unique ex- with mental illness has been difficult. The reasons for ample of long-lasting, inter-sectoral cooperation. Since this include shortcomings in cooperation between the the introduction of the national psychiatric policy, the levels of care and inadequate coordination between so- cooperating agencies have striven to overcome fragmen- cial services, primary care, employment services and ted health and social care. Through the policy, the obli- the nation’s social insurance agency. The focus remains gation of people for those with long-term psychiatric split among various components rather than on the disorders upon their discharge from closed-environment whole picture [29]. mental health institutions was transferred from the Nevertheless, examples of sector-related barriers being county council to the municipality. During the policy’s overcome exist. For instance, one geographical area has establishment period (1996-1998), funding was available sustained its extensive integration of mental health and for both the county council and the municipality, pro- social care services since the policy was implemented vided that they presented a shared plan for how the [30]. For the purpose of this paper we use the definition money would be used to facilitate organisational and op- from WHO for integrated health services [18]. erational changes. The original idea behind this integration was to create “Integrated health services are health services that are a single point at which all service users could receive managed and delivered in a way that ensures people help and support, regardless of which authority had the receive a continuum of health promotion, disease competence or means to address the problem. Initially, prevention, diagnosis, treatment, disease management, this plan was to offer services to those over 18 years old rehabilitation and palliative care services, at the who had chronic, severe mental illnesses that caused different levels and sites of care within the health permanent disabilities, as well as to those who were in system, and according to their needs throughout their need of both psychiatric treatment and social services. life course ”. Today, the integration has evolved to also include people with neuropsychiatric diagnoses, people with addiction The abbreviation IC will be used, referring to integrated problems and other target groups. Since 1995, a steering mental health and social care services. Based on our pre- committee has governed the integrated organisation, vious research [30–32], we anticipated that this case with representatives from the county council’s psychi- would be particularly interesting to study from a sustain- atric care and the municipality’s social services. The ability perspective. By viewing sustainability as a process committee’s mission is to develop cooperation between in a constantly changing context, the DSF is a relevant the municipality’s social care and the county council’ psy- means through which to explore the mechanisms of sus- chiatric care. The services consist of geographically dis- tainability in this integrated mental health and social persed co-located centres and mobile units for specific care organisation. target groups. Although separate legislation regulates the The specific objective of this study is to gain insight services, they are all organised based on inter- into the dynamics of sustainable changes in integrated professional teams and are managed, at all levels, Klinga et al. BMC Health Services Research (2018) 18:400 Page 4 of 12 through co-leadership of two leaders, one from each or- Table 1 Stages of the thematic analysis ganisation. Access to services is mainly via primary care Stage 1 Description of the process but also from emergency care. Inpatient care is provided 1. Learn about the data set Read and reread data, take notes and 2. Create an initial code list mark ideas for coding by the regional hospital. 3. Group the codes Organise data into meaningful codes 4. Search for themes based on potential interest 5. Create a timeline Search for relationships between codes Data collection and data characteristics to create sub-themes Sort codes and sub-themes into data- Data were collected from the minutes of all steering- dependent themes committee meetings held from 1995 through 2015. The Extract activities related to the area of minutes were available in digital form (n = 98; approxi- interest using a timeline mately 3-5 meetings per semester, fewer in recent years) Stage 2 Description of the process and followed the same basic structure. However, some 6. Investigate using theory Analyse the data through specific variation regarding the content occurred due to the rele- 7. Search for themes questions based on DSF 8. Refine the themes Sort codes into theory-dependent vance of certain topics and questions at certain times. themes related to integration This variation in content determined the committee’s Consider the coded data extracts composition; in addition to the permanent members – and the individual themes in relation to the entire data set representatives from the county, the municipality and the stakeholder associations (e.g. patients’ and relatives’ associations) – other relevant stakeholders were invited. Case findings The same person wrote all the minutes, which were pri- The individual organisations had a history of collabor- marily for the internal use of the organisation’s managers ation prior to the launch of the psychiatric policy. That and professionals. However, the minutes were also avail- policy, however, triggered the development of an inte- able to cooperating partners outside the organisation grated health and social care organisation, with project and to other interested stakeholders. funding provided for both the county council and the municipality. In 1995, both the inter-sectoral steering committee and the two project managers (one from each Data analysis organisation) were put in place. One guiding principle Thematic analysis, as Braun and Clarke [34] described, was that all service users should be at the centre of – is used to handle extensive data sets. This study’s data and participate in – the planning of care and support. included a large amount of information generated over The integrated organisation started by inventorying the twenty years, which required condensation; a semantic need for staff training and for a cooperative model to approach was used to handle this rich data set. Based on apply with each service user. Stakeholder associations the study’s objective, an initial orientation was devel- were involved, and the central role of the service users oped, and a search for codes and meaningful groups was (i.e. the patients and clients), their families and the performed. Based on the predetermined area of interest, stakeholder associations was emphasised. A co- actions not directly linked to integration were excluded. leadership model was created in which the leaders from This first stage of the analysis was explorative and in- each sector jointly managed all services. Joint trainings, ductive [35]; data were used to map the steering com- information sessions, outdoor excursions and confer- mittee’s actions. The resulting analysis was intended to ences were arranged. The continuous exchange of com- illustrate the trend in integration over time and to serve petencies and experiences was given high priority, and as a basis for the subsequent analysis in stage 2, which co-run projects targeted to specific groups, such as was intended to mirror the findings regarding the key el- people with substance abuse, were initiated. ements of the DSF. This procedure resulted in a detailed In 1996 and 1997, several changes were introduced to data analysis that would aid in identifying the empirical integrate the services. For instance, three co-located and themes from the narrative description. The thematic jointly managed centres were opened, mainly for persons analysis-process is illustrated in Table 1. with psychosis and complex needs. Furthermore, each service user received coordinators from each organisa- tion; these coordinators shared the responsibility for all Results of the user’s health and social care planning. Data on the The results are presented in two parts. The first, Case service users’ needs (the Camberwell Assessment of findings, provides a chronological case narrative of Needs [CAN] scale) were used for these purposes. Indi- the key events related to the integration. The second, vidualised care and rehabilitation plans were introduced Empirical themes, is based on identified chains of to personalise care and to support service users. In actions that are reflected in DSF. addition, shared clinical guidelines and agreements Klinga et al. BMC Health Services Research (2018) 18:400 Page 5 of 12 concerning financial issues were established. The over- managed in close collaboration and based on formal arching vision, in which service users would be active agreements – in contrast to earlier, verbal agreements. co-producers, triggered the development of a consistent An example of concrete integration was the announce- terminology; the term ‘customer’, instead of ‘patient’ or ment of a vacant manager position on a psychiatric ad- ‘client’, was suggested. Nevertheless, the term ‘customer’ diction team. The organisational affiliation for that was incompatible with then-current national regulations, position was decided based on the selected candidate’s and the terms ‘patient’ (for psychiatric care) and ‘client’ profession (nurse or social worker) rather than in ad- (for social care) were kept. The importance of a shared vance, when announcing the position. The integrated IT system was recognised, and much effort was spent in services were expanded with the opening of a day centre trying to achieve this. However, the Swedish Data Pro- for people with borderline personality disorder. tection Authority did not permit the use of such a During 2002 and 2003, the integrated services were shared register for service-users assessment data (using further expanded by developing services for elderly the CAN scale) because of questions regarding data people and for some new target groups (e.g. those with ownership. Thereafter, the possibility of digitally sharing long-lasting depression and those who were unemployed care and rehabilitation plans was examined. or on sick leave due to mental health problems). Fur- In 1998, challenges related to financing surfaced, partly thermore, a joint home-support group with staff from because the initial funding had ended. In addition, difficul- both organisations was proposed. In addition, several ties concerning the management of the integrated services structural changes were made in the integrated organisa- were noted, as differences in managers’ decision-making tion. For instance, social workers and assistance officers mandates varied between the organisations. To meet these were decentralised and sent to the individual units, and challenges, additional training in integration was offered; co-location was planned for some administrators. The for instance, the two project managers received support in steering committee proposed further expansion to in- how to manage integrated projects, and the coordinators clude a representative for service users who were cov- were trained in case management. The expansion of inte- ered by the law that regulated support and service for gration to include new groups of service users (e.g. those people with certain functional impairments. with severe mental disabilities) was considered. In During 2004 and 2005, actions were taken to further addition, a new organisation was proposed that would be develop the practical work such as by opening a new aimed at outsourcing cooperative units to the municipal coach position. The coach would support the managers districts, but the steering committee rejected this proposal in designing processes for shared service planning. New due to the risk of losing coordination and the knowledge groups in need of integrated services were identified: required for rehabilitation in the event of a disruption in people with Asperger’s disease or ADHD, those at risk the organisation’s integration. of criminality or with addiction problems, asylum In 1999, the steering committee reviewed the integrated seekers with mental health problems, and individuals fa- organisation’s costs. Savings from the previous year en- cing deportation. In addition, the organisation expanded abled the financing of additional training to facilitate the by establishing a neuropsychiatric team and new accom- handover of service users from external locations to the modations for people with double diagnoses. The ques- local municipality’s care. Actions were planned to simplify tion was raised over whether to institute a common title the practical work and to increase collaboration. For in- – coordinator – for all employees, regardless of profes- stance, the plan was for decisions about housing support sion. This was considered to have a symbolic import- to be transferred to the unit level (i.e. as close to the ser- ance, as it would indicate that cooperation was central vice users as possible) with the goal of improving collabor- and that responsibilities could not be transferred across ation among social workers, assistance officers and organisations. The steering committee continued to occupational therapists. The integrated organisation con- expand, this time with representatives from child and tinued to grow; it initiated a mobile team and developed adolescent psychiatry. the coordinator role to enhance focus on the entire re- In 2006, efforts were made to overcome evolving habilitation process. The shared use of the CAN data was macro-level challenges. The integration agreement was re- further developed to tailor both health and social care to vised to further clarify the organisations’ equal status and meet the service users’ individual needs. responsibilities concerning costs. Participation in further In 2000 and 2001, efforts were made to make the two education became compulsory for all inter-professional organisations’ economic steering mechanisms equivalent. team members, and opportunities for shared research and The steering committee also expanded to include mem- improvement activities were investigated. The senior bers who represented areas that had recently been inte- county council managers decided to close one of the units. grated, such as elder care. It was agreed that all new However, to avoid the closure, the municipality took over projects within the integrated organisation would be responsibility for the unit. Another example of integration Klinga et al. BMC Health Services Research (2018) 18:400 Page 6 of 12 development was the evolution of the coordinator role increase the service users’ involvement in care and sup- into the case manager role, as advocated in the national port were also on the agenda. The overall integration clinical guidelines on psychosis. agreement was again revised, this time to clarify the steer- In 2007, a statement was made regarding the import- ing committee’s responsibilities. In addition, attention was ance of giving equal value to the service users’ existen- drawn to subgroups that were not yet included in the tar- tial, medical, psychological and social well-being rather get population of the integrated organisation. Planning for than emphasising only some of these depending on the the housing of people with long-term substance abuse and organisation. The steering committee and the stake- extensive care needs started with a guiding principle that holder associations presented a revised vision that these individuals would be able to maintain the accommo- highlighted how service users and the two organisations dation regardless of which organisation had the formal re- would cooperate to provide flexible and need-based sup- sponsibility for the individual. Further contacts were made port. This vision also specified the planning, develop- with the primary health care to develop care for elderly ment and evaluation of the units and the teams, people with mental illness, substance abuse and drug ad- emphasising that the professionals’ roles needed to be diction. Another central group was people with ADHD, streamlined so that they would become experts. All ser- for whom integrated health and social care were consid- vice users’ needs were analysed to inform the organisa- ered to be essential. Cooperation was under development tion about whether its services should be revised. Some with the municipal unit around disabled people and a changes in the needs were noticed; consequently, the correctional care unit. units revised their services to better suit people who In 2011, the ability to cooperate with primary care was lacked long histories of inpatient care. The organisation hampered as the number of private care providers in- continued to expand by including services for young, creased. Nonetheless, new forms of cooperation within self-harming people; the focus was on improving cooper- subgroups, such as people with substance abuse and ation regarding young people and those with bipolar within the neuropsychiatry, were successfully estab- disorder or complex needs. lished. In this development work, a mobile team was In 2008, the integration agreement was once again re- launched for supporting young people with neuropsychi- vised, and the shared routines for risk assessments were atric diagnoses, and the care centre for addicts was ad- included. The steering committee actively requested the vanced. The steering committee continued to find stakeholders’ views on the integrated services. They in- solutions to the funding of the integrated services. An vited partners, stakeholder associations and service-user example was a new, integrated type of employment form representatives to discuss these issues. In addition, ser- where a manager was formally employed by the munici- vices continued to be developed for people with neuro- pality, but the costs were shared through the county psychiatric diagnoses and elderly people with mental council purchasing the manager’s services. illnesses or health problems related to drug abuse and In 2012, a regional agreement on how to support addiction. For the latter, local guidelines clarifying the people with a mental illness and disability was reached, shared responsibility were developed. The neuropsychi- which strengthened the integration of focusing on the atric staff members were trained accordingly. needs and shared responsibilities of service users. The In 2009, the stakeholder associations’ roles were integrated organisation was reviewed in two evalua- strengthened by increasing their participation in the meet- tions. An external evaluation concluded that cost- ings and by gathering their views on the new integration effective and high quality care was provided and that agreement. Substantial work was done to develop inte- the steering committee served an important role in grated services for new user groups. For instance, an ini- overviewing the integration. The internal evaluation tiative was launched to develop collective, overall support underlined that the resources of the relatives and the for users of the care and habilitation service for people families could be more optimally used. Consequently, with disabilities. In addition, this service expanded to han- stakeholder associations were invited to take part in dle the increasing number of service users with neuro- discussions of their role and the revision of the services. psychiatric disorders. A growing group in need of health A new function, a multi-case manager, was also estab- and social care comprised traumatised refugees, who re- lished to handle service users with highly complex quired new and well-adjusted integrated services. To treat needs. Furthermore, clarification of the shared respon- this group, the organisations co-applied for project fund- sibility for service users with psychiatric diagnoses and ing to develop a care program. substance abuse was made, and a newly diagnosed psy- In 2010, continual efforts were made towards the im- chiatric patients’ team was initiated to provide inte- provement of stakeholder associations. This action was grated services at a care centre for addicts. Further, an consistent with the search for shared and streamlined ser- operational management group of representatives from vice activities focusing on cost reduction. The efforts to the units for adults and elderly people was created and Klinga et al. BMC Health Services Research (2018) 18:400 Page 7 of 12 supplemented with a representative from the psychiatry rather, by involving stakeholder associations and other centre. key actors, the organisational development was co- In 2013, attention was drawn to savings opportunities created in a dynamic process through the years. The by further developing the integration. For instance, inte- integration work was characterised by continuous adap- gration of services with the neighbouring municipalities tations of interventions on multiple levels. Adjustments was discussed. The cooperation agreements were revised were made in order to continuously adapt the organisa- regarding elderly users, children and adolescents, and ef- tion and the services to changes in context. For in- forts were made to improve cooperation between the stance, new services were started based on the change psychiatry centre for adults and a centre for children in service users’ needs. When financial savings were re- and adolescents to better meet the needs of children, quired, the two organisations streamlined the processes young people and their families. Other areas of improve- together. All internal improvement work was also made ment included clarifying the primary care and psychiatry with participation in various improvement projects and responsibilities and reorganising neuropsychiatric care in with external partners. The thorough work carried out order to make it more cost-effective. An inter-sectoral aimed at bringing the municipality and county closer in co-located neuropsychiatric outpatient clinic was pro- the pursuit of a shared IT system, aligned steering posed. Despite the economic challenges, the willingness mechanisms (score cards), service outcome measures, to further integrate health and social care for people shared routines, common referral forms and shared with mental illness continued. For example, a “house of clinical guidelines. External influences recognised to health” with all services co-located at one place was cause fragmentation were handled by strengthening co- planned together with web-based network-gathering operation, for example, by underlining the equal state activities. of the organisations in the cooperation agreement and In 2014, the steering committee decided to only meet by emphasising the equal value to the service users’ ex- once per semester. The role of the committee had become istential issues of medical, psychological and social more “consultative” and less of a working group due to an well-being. The following excerpt from the steering increased number of members, which in turn was an ef- committee minutes exemplifies this: fect of the increased number of services included in the organisation. Meanwhile, the steering committee function The county council and the municipality are two changed, however, the practical integrated work at the unit organizations that complement each other. […] levels continued intensively. For instance, procedures for The things we do, we do together. […] The reform coordinated individual rehabilitation plans were devel- requires functioning forms of cooperation and oped, and various improvement projects were launched. creation of shared goals along with a union of our In 2015, attention was again drawn to the needs of cultures and decision-making systems. But still, the elderly service users and to unaccompanied refugee chil- two cooperating organisations need to continuously dren. Integration with geriatric psychiatry care, primary develop their own working methods. care and elder care continued to be of high priority but challenging. The economy was strained for both organi- sations. A new review of the services and the service Continuous learning users’ needs was made. The number of service users in The integration of health and social care emerged as a need of health and social care had decreased, while some fusion of norms, values, assumptions and behaviours changes in their needs were also noticed. As a conse- from two different sectors, which had certain challenges quence, efforts were made to reduce costs by streamlin- to overcome. A mutual understanding of the differences, ing the integrated processes. At the end of the year, the including the mission of each sector, was recognised and steering committee decided to schedule two meetings respected. Formal structures for learning were created per semester since the time between the meetings was by allowing employees, managers and service users to concluded to be too long. exchange experiences and knowledge. The financial sup- port of learning activities was strategically used over the Empirical themes years to promote and develop integration. The develop- Shared structure and ongoing refinement ment of new ways of working such as teamwork and The services of the municipality and county were inter- case management was given financial support. Managers’ linked at both structural and functional levels, and the need for development was also recognised, and their foundation was built on shared mission and agree- professional development was among other things sup- ments, co-leadership and by creating inter-professional ported through the coaches who provided support in teams in co-located services. The question of how the managing shared service planning. The managers were integration would take place was not predetermined; also innovative in implementing new working methods Klinga et al. BMC Health Services Research (2018) 18:400 Page 8 of 12 and functions before these methods and functions were the committee early on and set the goal to collaborate decreed by the national government. Data from all levels around each service user. The formal agreements stated of the organisation were continuously collected to assess that service users should be at the centre. The services progress. These measurements enabled immediate were therefore organised around each service users’ per- reactions, which in turn contributed to continuous opti- sonal needs, rather than from the perspective of the or- misation of the conditions for sustainability of the inter- ganisations. For instance, this was achieved by having sectoral cooperation. The following excerpt from the ongoing stakeholder involvement through representa- steering committee minutes exemplifies this: tives from the stakeholder associations in the steering committee and local service user groups at the service The psychiatric reform requires mutual respect centres. Thus, the service users took part in co-creating and trust for the cooperating health and social care the services. On an individual level, coordinators were professionals’ different conditions, tasks and methods. introduced early on in the process, and a multi-case Only thus, it is possible to achieve a common set of manager was appointed for service users with complex values upon which the concrete work should rest. In needs. The content of the care and support was also co- order for this respect and understanding to be produced according to individual rehabilitation plans, maintained, ongoing, mutual knowledge and health and social care interventions were continu- development is required. ously followed up by the use of CAN data. As new service user groups were added over time, new inter- professional teams were arranged to meet the specific Cooperation as a guiding principle for management needs of the new groups. The following excerpt from the The composition of the steering committee could be de- steering committee minutes exemplifies this: scribed as dynamic since it constantly adapted to match the service users. Permanent members were representa- The services should be formed and developed based tives from the mental health services at the municipality on the service users’ needs. [...] The organisational and the county, along with the stakeholder associations. and economical conditions should therefore be The continuity among the core members was high, and arranged to enable long-term care and support, other temporary members were determined by the con- based on the service users´ need of continuity. tent of each meeting. The two project managers had a central role for the creation of the integration. They, representing both municipality and county council, Discussion made key contributions in the creation of a culture and The study aimed to gain insights into the dynamics of the shared values. Also, the line managers (i.e., co-leaders) sustainable change of integrated health and social care. functioned as opinion leaders and cultural carriers and Five main factors were found to be essential for the therefore had a strong symbolic value. In addition, they achievement of the 20 years of inter-sectoral cooperation. worked closely together in applying co-leadership, as all First, the integration was characterised by ongoing leaders on all levels, and thereby served as role models. adaptations. The services provided and the work of The decision-making process was based on dialogue and the steering committee was constantly improved based negotiation, and all solutions were consensus-based. The on changes in the surrounding context. The needs of following excerpt from the steering committee minutes the service users were frequently reviewed in order to exemplifies this: create new services or to adapt the existing ones. Ser- vice users and stakeholder associations were consid- Cooperation is necessary to realize the reform. It ered important partners in this. This also applied to applies to several levels, county, municipality, team the view of other collaborators (e.g., Primary Care, and at the individual level. [...] In our services, service Social Insurance Agency, Public Employment Service users, municipality and county council cooperate for etc.) who came to change over time depending on the flexible and needs-based support for the different service users’ needs. The importance of using bottom- target groups. The cooperation includes planning, up strategies for implementation of new intervention development and evaluation of operations. has been emphasised by others [36]. In this case, the steering committee worked actively to align the organ- isational characteristics with actual needs, meaning Service user centeredness that inappropriate structures were removed. This is in Over the years, the steering committee recognised the line with the DSF, which also recommends contextua- interdependence of physical, psychological and social lising or removing non-outcome-focused intervention factors in health and illness, which was manifested in components [13]. Klinga et al. BMC Health Services Research (2018) 18:400 Page 9 of 12 Secondly, the ambition for ongoing learning among strategy used by the steering committee to align inter- all stakeholders was highly present. Continuous feed- ventions to the service users’ needs and to create em- back on performance was provided with the measures powerment. Furthermore, equal importance was given on the organisational, professional and service user to all of the service users’ needs (medical, psycho- level, which was one step in the creation of a culture logical, social etc.) rather than prioritising one of these for learning. Previous studies on collaboration have based on sectorial priorities. The shared holistic view shown that arenas for dialogues and exchange of rele- on service users and, consequently, an identified need vant knowledge is important [35], and we found that to organise health and social care in a cohesive manner the decision to co-locate all health and social services enabled the creation of a shared vision and strategy in co-run centres required interdisciplinary teamwork formulation, which in turn set the direction for the or- on a very practical level, which also surfaced as an im- ganisation and its priorities. It also seemed that the portant step in the continuous learning and integration two organisations could always make up for the needs of the services. The issue of culture is highly relevant by putting the service users’ needs first, which helped for multi-sectoral collaboration (e.g., between health them to solve potentially sensitive issues in funding and social care), since the organisations often have dif- and managing the integrated services. This may have ferent cultural lenses. In a similar manner, each profes- caused them to become more solution focused and less sional group tends to have its own professional protective, enabling the establishment of a shared or- culture, which makes this type of organisation even ganisational culture that includes roles, norms and more multicultural [37]. Protectionism and scepticism values, which is also underlined by Schein as important towards other professional groups are commonininte- [43]. In the research examples of service users being grated services [38]. The current organisation was no active, the contributors of skills and knowledge in the exception to this, but it had a clear ambition on tack- development of healthcare services can be found [44, ling these challenges together through collaboration, 45]. The interaction between service users and health education and experience exchange, which has been and social care providers forming a partnership is shown to contribute to successful multidisciplinary referred to as co-production [46], co-creation [47], ex- integration [39]. perienced based co-design [48]and patientand public Thus, the third issue characterising this sustained in- involvement [49], to mention a few. Hence, research tegration of services was the emphasis on collaboration. has shown that the consultative approaches are more This was one of the most essential guiding principles in common than partnership [50]. However, it seems that the steering group’s work over time. This manifested in this integrated health and social care organisation was considering the dissimilarities, conditions and needs of an early adopter of this involvement approach enabling each organisation in decision making. Thereby, the service user participation. steering committee was long-term-oriented with collab- Lastly, the steering committee’s work was dynamic, oration in mind, while also continuously solving the and new members were invited to participate depend- problems at hand to enable collaboration on a practical ing on what services were included in the integrated level. The many actions that the steering committee organisation. At the same time, their work was charac- took initially and the persistent work for the continu- terised by a low turnover since the core individuals in ation of cooperation reflect a firm belief in inter- the steering group were the same during the entire 20- sectoral cooperation. These findings relate to prior year period. For instance, the minutes were written by research showing a relation between committed leaders thesamepersoninall cases. Thestablestepofindivid- across the organisation and successful long-term uals with a shared vision certainly had a great impact change [40]. The role of managers and leadership, to- on the sustained integration. Furthermore, the two pro- gether with the leadership system, is repeatedly ject managers, holding key functions in the process of highlighted as crucial for change, especially for sustain- integration, were the same individuals throughout the able change [41]. The leadership system in this case years. These functions, called opinion leaders or pro- was based on co-leadership and cooperation. The work gram leaders in other studies [51], have had a great im- tasks were regarded as a joint responsibility, which is pact on integration. Previous research has also consistent with previous research on shared leadership highlighted the importance of stability on a strategic showing that a close leadership created space for for- and operational level to overcome sector-related chal- ward thinking and a long-term approach to work [42]. lenges in integrated health and social care [52]. How- Fourthly, the service users, their families and the ever, the current study does not reveal whether the stakeholder associations were key partners in the col- impact of the stakeholders derives from what they did, laboration and in forming the services. Their engage- thefactthattheywerethe same people over theyears ment in the development of processes was a core or a combination of these factors. Klinga et al. BMC Health Services Research (2018) 18:400 Page 10 of 12 Methodological considerations to explore the importance of leadership during different The main strength of the study was the long time period stages of change). In regard to practical implications, the in which we were able to complete a thorough docu- findings suggest that service user involvement and the ment analysis. This provided valuable insight into the critical review of service users’ needs on a regular basis steering committees’ work over time. A potential limita- are essential in order to tailor to the current needs and tion with the minutes afforded for study in each meeting services. Furthermore the importance of continuously was that we were restricted to the information provided adapting the content of the change to suit its context, in the documents. It’s possible that other data sources was clear, and it’s suggested that continuous refinement such as interviews could have provided a broader picture of the change content was found to be more important of the actions taken by the steering committee. Never- than designing the change at the pre-implementation theless, the minutes were rich and provided insights into stage. how the committee members perceived their context, the organisation and their actions rather than only con- Conclusion sisting of decisions and actions. As these minutes were This study provides some valuable insight into the dy- not designed with research in mind, the bias from leav- namics of sustainable change and the understanding of ing out certain information such as disagreements and key managerial actions in order to establish, develop conflicts must be considered. Furthermore, the same and support the integration of health and social care person wrote out the minutes of the meeting throughout for people with complex mental health needs. The de- the study period. This can be considered a strength since velopment of inter-sectoral cooperation was charac- the minutes followed the same structure and had an terised by a participatory approach in which a shared equal amount of information throughout the years. At structure was created to support cooperation and on- the same time, it can limit the type and information pro- going quality improvement and learning focused on the vided since one person made decisions on what to note, service user’s needs. The key management principle in- although the minutes were always reviewed by the other cluded cooperation on all organisational levels as well committee members. Generally, the overall framework as with service users, stakeholder associations and helped to identify several factors related to the dynamics other partner organisations. This study shows that all of sustainable change. More precisely, the framework these parts were interrelated and collectively contrib- was found useful as a tool to limit the scope of relevant uted to the creation of a structureand aculturethat data and in interpreting our findings. While the frame- supported the development of dynamic and sustainable work focused our attention to some specific components health and social care. we still strived to remain open for unexpected findings Abbreviations and alternative explanations. One example was the iden- CAN: the Camberwell Assessment of Needs scale; DSF: Dynamic tification of service user centeredness as an enabling fac- Sustainability Framework tor for the achievement of long-lasting cooperation. By Acknowledgements this the services were organised around each service We would like to thank the municipality for providing us with all the Steering users’ personal needs, rather than from the perspective Committee minutes. In addition we would like to thank Karin Solberg Carlsson for helping with the initial assortment of the collected data. of the organisations. A limitation to generalisability of the findings can be that the study was conducted in one Funding specific geographical area, which was characterised by This research was funded by a grant from The Swedish Research Council (521-2014-2710), the involvement of the second author was funded by a long-term integrated health and social care services. research grant from FORTE (2014-0303). Suggestions for future research and implications for Availability of data and materials The datasets used and/or analysed during the current study are available practice from the corresponding author on reasonable request. As this study primarily addresses the steering committee decisions and actions, future research could build on Authors’ contributions CK, MAS, HH, JH: conception and design of the study; CK: data collection; CK, our findings by including perspectives on organisational MAS, HH, JH: data analysis; CK, MAS, HH, JH: drafting the article. All authors champions and the meaning of organising networks for read and approved the final manuscript. achieving sustainability. As the knowledge on champions Ethics approval and consent to participate and networks increases, we stress that organisations and This study has been reviewed and approved by The Regional Ethics Committee services adjust accordingly. We suggest three main areas in Stockholm (Dnr 2014/612-31/5). The data in the study consists of public of future research: 1) studies on the sustainability of documents, no files containing personal data were compiled and the results are presented at aggregated level. change; 2) studies on the interrelatedness of factors impacting sustainable change; and 3) longitudinal studies Consent for publication on the impact of different factors on sustainability (e.g., Not applicable. Klinga et al. BMC Health Services Research (2018) 18:400 Page 11 of 12 Competing interests apps.who.int/iris/bitstream/handle/10665/155002/WHO_HIS_SDS_2015.6_ The authors declare that they have no competing interests. eng.pdf;jsessionid=3BBDDBC72FF786E5623D3540E9F06326?sequence=1 19. Sun X, Tang W, Ye T, Zhang Y, Wen B, Zhang L. Integrated care: a comprehensive bibliometric analysis and literature review. Int J Integr Care. 2014;14:1–12. https://doi.org/10.5334/ijic.1437. Publisher’sNote Springer Nature remains neutral with regard to jurisdictional claims in 20. Ouwens M. 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BMC Health Services ResearchSpringer Journals

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