Creating value through (re)organization. An applied approach to integrated patient pathways between primary and secondary care

Abstract

Patients in need of primary care services upon discharge from the hospital often experience a bottleneck in quality care delivery in the Norwegian healthcare system. Services are fragmented and the sectors are largely disconnected in their perspectives, organization, provision, and goals. This has adverse effects for patients in terms of unnecessary fragmentation of service from (too) many providers, creating a system that is difficult to navigate and/or understand. This fragmentation also has consequences for care providers as they often lack a clear route and capacity for information sharing. Healthcare institutions have experienced unnecessary penal fees and high, avoidable readmission rates, resulting in each organization focusing on their own outcomes in their “fragmented silos”. There has been, and is, what Michael Porter calls zero-sum competition, i.e. self-serving patient and cost shifting. There is a broad spectrum of literature addressing these problems, and several good initiatives to ensure safe discharge from secondary to primary care in Oslo have been identified; however, they fail to address the need for integration and only provide suggestions on how to organize care within the current delivery system. My research explores how primary and secondary care providers can integrate their provision of services to a greater extent to create more value for the patients and the organizations. My empirical research draws on semi-structured interviews with eleven clinical and administrative informants working in both sectors (primary and secondary care) in the Diakonhjemmet sector in Oslo. The data was analyzed through the use of a thematic framework. Four major themes where identified: Coordination, Cooperation, Quality, and Economy. A solution put forward in this thesis is the integration of services for my population of interest, emphasizing on patient-centered healthcare delivery throughout the entire care pathway. Introduction of bundled payments for an episode of care and one cross-sectoral electronic patient record, are also discussed. My normative suggestions are based on the healthcare delivery theories of Michael Porter and Clayton Christensen. I suggest how Diakonhjemmet hospital and its boroughs can address their immediate problems on a short-term basis, while they wait for national legislation on integrative initiatives. This study also provides a basis for further work in this field