Table 1
Dimensions of the different projects.
| PROJECT | A | B | C | D |
|---|---|---|---|---|
| Direction of integration | Vertical | Vertical | Horizontal | Horizontal |
| Level of integration | Coordination | Full integration | Full integration | Coordination |
| Prevalence of the disease | Low | High | High | High |
| Envisioned degree of change in care provision | Moderate (commonly accepted treatment) | High (innovative treatment) | High (innovative treatment) | Moderate (commonly accepted treatment) |
| Number of care organisations involved | Six | Seven | Three | Eight |
| Crossing specialties | No | Yes | Yes | No |
| Crossing tiers | Yes (secondary and tertiary care) | Yes (primary, secondary, and tertiary care) | No (secondary care only) | Yes (secondary and tertiary care) |
Table 2
Project descriptions.
| PROJECT | A | B | C | D |
|---|---|---|---|---|
| Care providers in project group | Two tertiary care and five secondary care providers treating children with a rare blood disease. | Two tertiary care providers, eight secondary care providers and two GPs treating allergies. | Two secondary care providers treating people experiencing dizziness. | One tertiary care and thirteen secondary care providers treating inflammatory bowel disease (IBD). |
| Initial motivation | High-risk patients combined with very limited knowledge in secondary care resulted in many phone calls to tertiary care. | An innovative treatment provided in secondary care could partly be given by GPs to achieve better quality for the patients and a cost reduction for society. | The disease is complex and requires multiple specialists, which resulted in patients traditionally falling through the cracks of the healthcare system. | There is a lot of regional variation in care provision, which was believed to have a negative impact on quality and/or costs of care. |
| Objectives | To improve the knowledge of providers in the region concerning this rare disease, make clear agreements regarding the referral of these patients, document a care pathway for this disease and disseminate the protocol both regionally and nationally. | To standardize the provision of the treatment amongst the different types of providers in secondary care involved in the treatment, educate GPs about the treatment, promote the transition of patients from secondary and tertiary to primary care for the continuation phase, and develop a shared EHR between the providers in all tiers. | To set up a multidisciplinary consultation hour, and to design clear triage and treatment protocols regarding the care pathway. | Overall: To increase transparency in care provision, share knowledge and expertise, to collaborate on scientific research and to improve patient information provision. Specific: To develop and implement a uniform care pathway in all hospitals in the region. |
| Ambition regarding level of integration | Low (alignment of care provision). | High (shared care provision). | High (shared care provision). | Low (alignment of care provision). |
| Process duration | One year and finalized. | Five years and finalized. | Five years and ongoing. | Four years and ongoing. |
| Funding and changes in reimbursement | No funding and no changes in reimbursement were provided. | Private funding was provided to finance the shared EHR and a project manager, but the investments were finite. Furthermore, existing reimbursement fees were inadequate to cover the costs for providers, resulting in a financial conflict of interest. | Sufficient funding was provided by the hospitals to develop and implement the project. Reimbursement agreements (a registration code and adequate fee) were made with the insurer involved. Agreements about the distribution of reimbursement within hospitals have not yet been finalized. | Private funding was provided to finance a PhD candidate, who managed the project. There were no changes in reimbursement. |
| Achievements |
|
Not achieved:
|
|
Not achieved:
|
| Outcome | Objectives and integration reached to the level envisioned. | Neither all objectives nor integration reached to the level envisioned. | Objectives and integration were reached beyond the level envisioned. | Objectives reached to a large extent, but integration not reached to the level envisioned. |
Figure 1
Framework on the influence of ambition and reality on the outcomes of integrated care projects.
Table 3
Key conditions and associated factors (financial and other) influencing project outcomes.
| CONDITIONS | PROJECT A – OUTCOME POSITIVE | PROJECT B – OUTCOME NEGATIVE | PROJECT C – OUTCOME POSITIVE | PROJECT D – OUTCOME NEGATIVE |
|---|---|---|---|---|
| 1. Project members willing to change | Yes
| No
| Yes
| No
|
| 2. Aligned interests and univocal goal | Yes
| No
| Yes
| No
|
| 3. Resources to change | Yes
| No
| Yes
| Yes
|
| 4. Effective management of (dependency on) external actors | Yes
| No
| Yes
| No
|
Figure 2
Aligning ambition and reality cycle.