Integrated care for people with complex health needs : practice in the making

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Improving health service delivery through integrated care has been the aim of governments in Australia and internationally for three decades. Implementing policy changes in practice is challenging and it is still unclear how integrated care can be achieved. This study examines how a model of integrated care evolved as an approach to caring for people with complex conditions and vulnerabilities. The specific case is HealthOne, a NSW government healthcare initiative, located in primary health care. The ethnographic study extended over 21 months and across many locations in western Sydney. It drew on complementary conceptual resources and empirical data collected through shadowing of HealthOne liaison nurses, observation of meetings, semi-structured interviews and collection of documents. The multi-sited, mobile ethnographic fieldwork spanned acute care, primary care and community-based services, encountering 60 professionals from health and social care. This study advances knowledge about the complex phenomenon of integrated care by exploring the translation of policy into practice. Against a backdrop of upheaval and change, the enactment of integrated care through HealthOne emerged as a relatively unstructured form of integration, understood as linkage. In this study, integrated care was accomplished in practice as an ongoing, fluid process of negotiation and adaptation. Thus the study challenges policy expectations about achieving integrated care as a triumphant, stable endpoint. Practice change evolved in uneasy tension with stability, rather than as a straightforward replacement of old with new. Practitioners struggled to understand the HealthOne model of care. Making sense of HealthOne arose through practice over time and was central to this developing form of care. Integrated care unfolded through an interwoven array of embedded, revived, remade and emergent practices. The tension between stability and change as practice altered was foregrounded in an interplay between practices that concurrently promoted and reacted to this model of integrated care. Enacting integrated care entailed relational practices beyond those that were envisaged in the model of care. Integrated care was accomplished in practice in a fluid way, where care was adapted and attuned to clients’ health status and practitioners’ immediate concerns. HealthOne liaison nurses and case conferences acted as key mechanisms of integration, holding together shifting relations and emerging practices, despite the absence of structural and funding arrangements to sustain coordination, communication and collaboration. In drawing together practice theory, actor–network theory and integrated care literatures, this study contributes to better understandings of integrated care and how it can be achieved.
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