Like “42” in The Hitchhikers Guide, one might be led to believe that integrated care is the ultimate answer to the failings of many health and supportive care systems: namely, poor coordination of services and benefits, cost shifting, and frustration for users in accessing services they need when they need them. Policymakers, planners, researchers, and providers have long promoted integrated care as a goal, especially for people with complex, long-term problems; yet few providers have moved in this direction. This thesis aims to contribute to the ongoing interest in integrated care by investigating both the factors associated with adoption of integrated aged care delivery structures and, more generally, the other mechanisms that have been adopted by aged care providers to integrate aged care services across community and residential settings. To investigate these topics, three separate but complementary studies were conducted in New South Wales (NSW).
From the data, it was found that in NSW, of the 619 aged care service providers studied, only six percent adopted formal shared management structures of integrated service delivery; although some others created alternative informal structures or brokerage arrangements to offer a continuum of care. In the first study, multinomial logistic regression models were used to explore what internal (tax status, chain, size) and external factors (planning region, urban/rural) were associated with a provider’s formation of an integrated aged care structure—that is to say, a structure where the range of services from supportive home care services through to residential care are all offered under the same management structure. Care providers that are part of a common sponsor (or ‘chain’), who are non-profit, and have greater capacity in HACC services, package size and, to a lesser extent, residential bed size, are more likely to offer integrated care across the full array of services available in NSW.
Second, by conducting an online survey on the culture of innovation in a subset of eight aged care providers, a factor analysis revealed that senior leadership plays the key role in promoting innovation and that direct supervisor support was necessary for trying new ideas regardless of whether the idea succeeds or fails.
Finally, focus group insights about paths toward integrated structure were sought. Some providers under-appreciated certain integration mechanisms: while an organisation offering the full array of care under a shared management structure has the capacity to offer integrated care, without other integrating mechanisms (consolidated finance, care coordination, and IT), this capacity is perceived to be limited as to its true innovativeness. So, shared management structures (e.g. shared risk and infrastructure) are less obvious to providers than the advantages associated with the other three integrating mechanisms. Another finding was that different kinds of providers attribute successes to different things: non-profit organisations perceive this to be the ability to cross-subsidise from certain programs (especially packaged care). The opportunities for this distribution of risk grow with the size of the organization. Shared infrastructure and learning also characterise larger organizations. In contrast, smaller organisations attribute their success to being nimble and responsive to their community.
Australia is poised to create new opportunities for integrated care following policy changes and investments in mechanisms necessary to support it (i.e., consolidated financing, care coordination and information systems). The keys to success are to appreciate that local conditions will drive what the integrated care model looks like and to manage expectations about what sorts of improved outcomes may be achieved, keeping them in line with the completeness of the model utilised.