key: cord-0981540-mdal0hr5 authors: Minderhout, Rosa Naomi; Baksteen, Martine C.; Numans, Mattijs E.; Bruijnzeels, Marc A.; Vos, Hedwig M.M. title: Effect of COVID‐19 on health system integration in the Netherlands: a mixed‐methods study date: 2021-05-01 journal: J Am Coll Emerg Physicians Open DOI: 10.1002/emp2.12433 sha: ad2a19640a431558ef0707542caeabb5b5d62e62 doc_id: 981540 cord_uid: mdal0hr5 OBJECTIVES: Overcrowding in acute care services gives rise to major problems, such as reduced accessibility and delay in treatment. In order to be able to continue providing high‐quality health care, it is important that organizations are well integrated at all organizational levels. The objective of this study was to to gain an understanding in which extent cooperation within an urban acute care network in the Netherlands (The Hague) improved because of the COVID‐19 crisis. METHODS: Exploratory mixed‐methods questionnaire and qualitative interview study. Semistructured interviews with stakeholders in the acute care network at micro (n = 10), meso (n = 9), and macro (n = 3) levels of organization. Thematic analysis took place along the lines of the 6 dimensions of the Rainbow Model of Integrated Care. RESULTS: In this study we identified themes that may act as barriers or facilitators to cooperation: communication, interaction, trust, leadership, interests, distribution of care, and funding. During the crisis many facilitators were identified at clinical, professional, and system level such as clear agreements about work processes, trust in each other's work, and different stakeholders growing closer together. However, at an organizational and communicative level there were many barriers such as interference in each other's work and a lack of clear policies. CONCLUSION: The driving force behind all changes in integration of acute care organizations in an urban context during the COVID‐19 crisis seemed to be a great sense of urgency to cooperate in the shared interest of providing the best patient care. We recommend shifting the postcrisis focus from overcoming the crisis to overcoming cooperative challenges. The overcrowding of acute care services gives rise to major problems in health care because of many factors. [1] [2] [3] One factor is the growing influx of patients combined with a lack of health care personnel causes reduced accessibility and delays in treatment, often resulting in suboptimal quality of care, an increased workload for health care professionals, and a higher complication rate. 1, 2, 4 Another factor is the large number of health care organizations leads to fragmentation. A study found that fragmentation was associated with increased costs of care, a lower chance of being subjected to clinical best practice care, and higher rates of preventable (re-)hospitalizations. 5 The coronavirus disease 2019 (COVID- 19) pandemic poses a threat to already overstretched acute care services worldwide. Organizations have been forced to cooperate and restructure quickly, to deal with the growing number of patients with threatening medical conditions, the lack of personal protective equipment (PPE), and staff loss due to disease. 6, 7 Across the Netherlands, the acute care network involves many different organizations, including emergency departments, general practice cooperatives (GPCs), ambulance services, acute mental health services, and home care and nursing home organizations. Dutch citizens are required to have a basic health insurance package to guarantee the quality of care, leading to insurance companies having substantial influence on the network's organization and function. 8 Because of the large number of organizations involved, there are multiple entrance and exit routes for patients in the acute care network. The general practitioner (GP) acts as a gatekeeper at the primary care level, deciding whether to refer a patient to secondary health care, resulting in lower health care costs for the society as a whole. 9 With a referral from their GP, patients are able to use secondary health care and are eligible for reimbursement. 10 Patients with medical problems typically visit their own GP during office hours, even when problems are perceived as urgent or threatening. 11 After-hours patients with an acute care request can report to a GPC. When a request is considered urgent, they can self-refer directly to the ED at all hours or be transported to the ED by ambulance following a GP visit or as a result of calling the national emergency telephone number 112. 12 After receiving assistance at an ED, a patient can be hospitalized, referred to a nursing home, receive care at home if necessary, or be referred back home. 13 These multiple entrance and exit routes increase the pressure on the acute care network. 14, 15 In the region of The Hague, the third largest city in the Netherlands with a population of around 800,000 people, the large number of health care providers involved additionally increases the challenges of effective cooperation by fragmentation caused by health care providers working independently and with too little communication. 15 Two insurance companies have substantial market share in urban The Hague. Cooperation and integration are presumed to be the key to successfully overcoming the practical, organizational, and medical challenges we have outlined here. 19 20 These dimensions of integration play complementary roles on the micro (clinical integration), meso (professional-and organizational integration), and macro levels (system integration). To achieve connectivity and to add overall value, functional and normative integration should ensure the linking of the micro, meso, and macro levels with the system. Functional integration includes planning, human resource, information, and financial management. Normative integration includes a shared mission, vision, and culture between different individuals, organizations, and regulatory bodies (Figure 1 ). 20 The dimension of normative integration can be further explored by using the ''5 lenses on cooperation'' model by J. Bell et al. 22 This model offers a comprehensive view of methods used to manage cooperation successfully, based on the premise that the best cooperation requires an integral approach with 5 balanced building blocks: shared ambition, mutual gains, relationship dynamics, organization dynamics, and process management. The COVID-19 crisis confronted the acute care network with a challenge requiring fragmentation to be set aside. We performed an exploratory mixed-methods study using questionnaires and semistructured interviews to gain an overview of perspectives from stakeholders in our acute care network. The stakeholders were recruited using a snowball sampling strategy. 23 The first 4 important, visible stakeholders were selected by the research team (a GP, a manager of the GP partnership, and a specialist from hospitals 1 and 2 and asked to name other important cooperation partners. This procedure went on until no new names were mentioned. The final research group consisted of 22 stakeholders: 10 clinicians, 4 managers, 5 administrators, and 3 insurance company representatives (Table 1) . We added 2 additional parties: the Dutch Red Cross and the regional medical relief organization (in Dutch, GHOR), which coordinates the regional acute care network during crises. Both were asked only about their experiences as an external party and, therefore, are not counted as stakeholders. The addition of a questionnaire to the qualitative study is done to Nineteen semistructured interviews were conducted using a topic list to standardize interviews between July and September 2020 Following exclusion of 5 questionnaires not completed within the allotted time before the interview and 3 questionnaires from the insurers who were not able to answer the questions about clinical practice because of a lack of insight into the entire network, we included 14 questionnaires in our study to provide a baseline overview. Table 3 shows the results of our statistical analysis on the exploratory questionnaire data. The mean during-COVID scores were higher than the pre-COVID scores in 5 of the 6 integration levels, though none of the differences were statistically significant. Along all 6 integration levels, both pre-and during-COVID integration scores were lower than the scores describing the preferred situation. All interview results are substantiated with quotes of the stakeholders, are found in Supplement I, and indicated in the following text by Q1 through Q56. Some quotes also are shown in the result section. Research question 1: What changes in cooperation took place during the crisis? The driving force behind all changes in cooperation seemed to be a great sense of urgency during the crisis and therefore there was a need for increased contact and clear policies (Q1 was improved to facilitated patient outflow from hospital to nursing homes. Another improvement concerning technology was that GPs at the COVID GPC were given access to the patients' GP records to improve efficiency. Improvements also were made at the professional level. Very early on, a regional crisis team was formed, including specialists from both hospitals, GPs, and managers from the GP partner- ship. This could be set up very quickly as these working partnerships already existed. Furthermore, the GP partnership played an important role in bringing both hospitals together as they wanted to make joint agreements. Previously, this was often done separately per hospital (Q5). In the organizational dimension, administrators and policy makers used the existing regional counsel for the acute care network, called the "ROAZ" (regional organization of acute care), as a platform for discussion and decision-making. At a national level, these ROAZs were encouraged to take responsibility for the region. As such, the ROAZ also rapidly formed a crisis team, which consisted of administrators with a certain mandate for making quick decisions (Q6). Q6: "You know, they acted, they set up a crisis team, they made decisions (and maybe they weren't always the best decisions, in retrospect), In the professional dimension, the regional crisis team consisting of professionals and managers from different organizations met regularly. It was very easy to share feedback at the professional level. For example, specialists felt that GPs in general were too quick to send COVID patients to the hospital. The regional crisis team was a good place for discussing these issues. Another improvement was the creation of shared protocols between professionals. For example, the pulmonologists from both hospitals got together to create a shared protocol for treating COVID patients with pulmonological comorbidities (Q14-Q15). The regional crisis team felt that they were better able to make quick decisions than the administrative level, because organizational interests did not seem as relevant at the professional level. Professionals and managers also felt that their sense of urgency was stronger than that of administrators, as they were closer to the workplace (Q16-Q17). Q16: "I think it's important that you don't only tackle these kinds of crises at the administrative level, but also, especially, at a doctor-level. also grew by seeing other organizations putting in their best efforts. In general, stakeholders agreed that "trust takes years to build, seconds to break, and forever to repair." As a solution for improving trust, a clean, competition-free foundation might be necessary (Q27). The government had encouraged the ROAZs to take responsibility in handling the crisis. As such, a regional council, previously with little mandate, became the platform upon which many decisions were made (Q28). As Q32: "At the end of the day, there is only one interest and that is that we provide the best patient care. And that is what brings you together, that is what you share with the other parties, that must always be the starting point." Administrator, GP partnership In the system dimension, the national association for insurers sent a "comfort letter" to the organizations in which they explained they would fairly compensate fairly any extra expenses due to the crisis (Q38). However, in response to the growing costs of arrangement of COVID care hotels, insurers made the regional ROAZs responsible for financial approval of these plans (Q39). Insurers felt that the crisis brought the insurers as a group closer to the rest of the acute care network (Q40). The issues experienced concerning the fragmentation are not as relevant for the insurance companies as they have the same vision for the future (Q41). However, this practice is not entirely flawless as several stakeholders felt that pilots and initiatives are still often hindered by the fact that certain decisions cannot be made on behalf of the other parties (Q42-Q43). Q40: "We did become more involved. I don't know if that will be a long-term effect, that remains to be seen. But at that moment we were really closer than we were before." Ins An overview of the results is given in Table 4 . A representative of The Hague Red Cross was positive about the partnership with the acute care network during the crisis. It was very easy to find and make the right contacts, resulting in good communication. Abbreviations: GPC, General Practitioner Cooperative; PC+, Primary Care Plus; C-GPC, COVID-GPC; H1, hospital 1; ROAZ, Regional organization of acute care. A few barriers were mentioned, as such volunteers from the Red Cross helped out at the COVID GPC, but staff at the GPC was not always apprised of the volunteers' tasks and limitations. Furthermore, arrangements with the Red Cross were made separately per organization as no organization played an overarching managerial role. They had expected the GHOR, responsible for coordination of the regional acute care network, to take up this role. A representative of the GHOR was present at meetings of the ROAZ to oversee the proceedings on behalf of the government as a regional As such, the questionnaire is intended to provide a baseline overview of the changes seen in integration during the crisis and is therefore secondary to the qualitative results. Another limitation is the fact that we interviewed only 1 or 2 stakeholders per dimension per organization. Finally, as no patients or patient organizations were included in our study, it summarizes the influence of COVID-19 on clinical practitioners only. Our exploratory mixed-methods study shows that better integration is possible when all organizations experience a sense of urgency and dependency. For a good integrated system, improvements on all levels of integration are needed. Previous studies like Suter et al. determined principles of integration, such as the need for a population health focus in which an integrated health care system should be easy for patients to navigate, the importance of integrated EHR, and the need for good financial management that allows pooling of funds across services. 26 Breton et al. concluded that the funding model is "inadequate for centering care around the needs of patients." 27 Lindner et al. observed the COVID-19 pandemic from a broader, European perspective and came to the conclusion that the pandemic has acted as an accelerator for redesigning and integrating care pathways. 28 Our research adds a new aspect: a shared sense of urgency is essential if better integration is to be achieved. 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Some preliminary lessons learned from the European VIGOUR Project This study was sponsored by ZonMw. ZonMw did not play any part in the design, analysis, or decision to publish the results of this study. The authors declare no conflict of interest. Practitioner in training and a PhD candidate at the LUMC Campus in The Hague, The Netherlands. Additional supporting information may be found online in the Supporting Information section at the end of the article.