DOI: https://doi.org/10.5465/AMR.2009.44885978, Child, J. What is more, this study also aims to generate insight into how such barriers operate. Results: Within these studies, twenty types of barriers have been identified and then categorised in six groups (barriers related to administration and regulation, barriers related to funding, barriers related to the inter-organisational domain, barriers related to the organisational domain, barriers related to service delivery, and barriers related to clinical practices). The barriers identified in this literature review can be grouped into six main categories that stretch across different domains (see Figure 2). In a second step, irrelevant hits were sorted out from the potentially relevant articles by reading the abstract of each article. These criteria help to get an overview of the applied research methods, and theoretical and contextual embedding of the reviewed studies. when comparing the integration of care within different countries). when they referred only to barriers to the interoperability of IT systems or IT-networks. BMC Pregnancy & Childbirth, 2017; 17(2000): 1–14. studies referring to vector-borne disease outbreaks or barriers in IT-networks). Integration and collaboration in public health – a conceptual framework. Within this domain, characteristics of and practices within single organisations can play an important role, e.g. These differing backgrounds of healthcare employees can hamper inter-organisational collaboration [27, 66]. The examination of such an approach to collaboration, however, requires diving deeply into specific cases. Stahl, C, Svensson, T and Ekberg, K. From cooperation to conflict? DOI: https://doi.org/10.1016/S0306-4603(00)00127-1, Goldman, HH. The table below summarizes common challenges faced in building effective integrated behavioral health care teams and strategies for addressing these challenges. So just as important as having interconnected Health IT systems, is the capability of the same systems to collect data on health outcomes that both matters to patients and are comparable from one database to another. International Journal of Integrated Care, 2014; 14(2): 1–12. For instance, barriers in the formation phase of a collaboration can prevent collaboration before it even begins, one example being a lack of organisational resources and financial uncertainties [18, 58]. Collaboration and integration of community-based health and human services in a nonprofit managed care system. This helps to explain why some inter-organisational collaborations that aim for the integration of care make slow or no progress. This paper contributes to previous research on barriers to integrated care in inter-organisational settings in various ways: first, this systematic review identifies twenty kinds of barriers that impede inter-organisational collaboration in six domains which are important to the integration of care. The barriers approach to innovation. Barriers to behavioral health integration, they said, included cultural differences with mental health providers and impediments to the flow of information between medical and behavioral health providers. Australian Social Work, 2005; 58(2): 132–41. In: Shavinina, LV (ed. Regulations: Existing regulations can impede inter-organisational collaboration, either by forbidding it or making the implementation process extremely complicated, costly and time-consuming for the partners involved . Financial barriers: costs associated with development, implementation and optimization of health IT to comply with health care program requirements that change frequently. Generally, chronic diseases have much more complex “care pathways” than the treatment of other diseases, which can lead to a variety of models being used, both within and across countries, at times leading to variations in the actual health status of the patient. “Behavioral health services often require multiple sessions and extensive follow-up, which differs markedly from the way physical health needs are handled. Some studies addressing barriers to inter-organisational collaboration use no theoretical conceptualization at all [e.g. Organizational path dependence: Opening the black box. DOI: https://doi.org/10.5334/ijic.217, Zou, G, Wei, X, Walley, JD, Yin, J and Sun, Q. Integrated Behavioral Health Barriers to integrated behavioral health Achieving integration of behavioral health services can be a challenge for school-based health centers. Academy of Management Review, 2009; 34(4): 689–709. This barrier was especially mentioned in studies on integrated mental healthcare provision [25, 26]. Surprisingly, although often used, the term “barrier” is seldom defined. Fostering change within organizational participants of multisectoral health care alliances. For instance, the dependence of one organisation on another can work as a barrier if the more powerful organisation does not provide the necessary input . Furthermore, they fear cost shifting connected to the entry into an inter-organisational collaboration, e.g. Introducing inter-organizational relations. Addictive Behaviors, 2000; 25(6): 943–54. through decreased governmental support in the public sector . Agreed sets of standardised outcomes measures implemented across integrated health IT systems would enable almost real-time analysis of how different organisational changes and the introduction of new methods and technology affect the health outcomes of patients, thereby enabling comparisons between hospitals, care organisations and even countries. One of the biggest barriers to schizophrenia treatment is misunderstanding and … At the same time, by limiting the application of some of the search terms to titles and abstracts, the screening of ten-thousands of mostly irrelevant articles was avoided. DOI: https://doi.org/10.5334/ijic.28. Lack of information exchange: Closely related and sometimes caused by confidentiality concerns, a lack of information exchange can hinder joint working across organisations. of information, resources, activities and capabilities, and include social interaction . Hardy, B, Mur-Veemanu, I, Steenbergen, M and Wistow, G. Inter-agency services in England and The Netherlands. So has diabetes care for Dutch patients improved? The consideration of different levels is useful as conflicts on the level of service delivery, for example, can also influence collaboration on the inter-organisational level , and vice versa. DOI: https://doi.org/10.1287/orsc.1100.0578, Doz, YL. Such conflicts can lead to the reaction that people start to defend their professional territory [48, 51, 67]. In primary healthcare, a key barrier to effective and timely care was the lack of availability of general practice-based spirometry together with appropriate use of spirometry by general practitioners (GPs) and practice nurses to both diagnose and manage a patient with COPD: DOI: https://doi.org/10.1016/S0168-8510(02)00205-1, Ling, T, Brereton, L, Conklin, A, Newbould, J and Roland, M. Barriers and facilitators to integrating care: Experiences from the English integrated care pilots. DOI: https://doi.org/10.1111/j.1447-0748.2005.00198.x, Hosman, CMH. due to the research question) or unintentionally (e.g. Second, this systematic literature review can guide further empirical research on the occurrence of barriers and their causes. More often than not, the integration of care faces barriers [8–11] caused by contextual, institutional and professional factors in different domains of integrated care . International Journal of Integrated Care 18, no. BMJ Open. The drivers for greater integration of health and social care are well- known: an increasing elderly population, higher demand for care - for example, because more people are living with long-term conditions like diabetes - the need to develop more responsive, patient-centred services, workforce pressures and reduced funding. Another relationship between barriers in this study concerns incompatible organisational structures (meso-level, structural barrier) and a lack of leadership and coordination (meso-level, agent-driven barrier): social services agencies were marked by less hierarchical management structures than health authorities, which often made the coordination of interorganisational collaboration difficult, for instance when setting goals and making decisions. DOI: https://doi.org/10.5334/ijic.582, Hearld, LR, Alexander, JA and Mittler, JN. A repetition of the coding after three months increased the reliability of coding. Journal of Occupational Rehabilitation, 2011; 21(3): 441–8. Collaboration between organisations belonging to regions with a long history of the fragmentation of care, e.g. International Journal of Integrated Care, 18(1), p.5. They were run for matches with synonyms for “inter-organisational” to exclude, for instance, research on neuronal networks (for an overview of the search terms and their applications, see Table 1 in the appendix). On the other hand, barriers can also emerge more passively behind the back of actors, e.g. Figures. Three important ontological assumptions on society can help to explain this finding: first, it can be assumed that both agency (cf. Health Care Management Review, 1995; 20(1): 54–64. no effect on the collaboration, its transformation or even its termination. This problem becomes even more significant if you also include social care services, Payment models in healthcare often do not encourage coordinated efforts, since most healthcare professionals are reimbursed separately for the service they provide, not for the final result in terms of health for the patient, Health IT systems are often fragmented, making it difficult to follow the patient’s journey between different healthcare providers, and to collect all the necessary health data in one place. Journal of Health Organization and Management, 2010; 24(2): 200–17. DOI: https://doi.org/10.1111/1467-9302.00088, Johnson, P, Wistow, G, Schulz, R and Hardy, B. Interagency and interprofessional collaboration in community care: The interdependence of structures and values. For instance, Loisel et al. the processes of decision making or the handling of clients [20, 63]. 71]: although the relationships between barriers were analysed systematically, no consistent patterns were identifiable. Further reasons to exclude studies were if a study solely reported on barriers within single organisations (e.g. Examples of attitudinal barriers include: 1. DOI: https://doi.org/10.1007/s10926-005-8036-x, van Hook, MP and Ford, ME. Taking a visible barrier as a starting point, it is advisable to look for related barriers which may prove to be the cause of the first barrier or influence it. DOI: https://doi.org/10.5334/ijic.67. Because the literature search was focused mainly on peer-reviewed journals, some works meeting the inclusion criteria may have been left out (e.g. 1. In a third step, all the remaining articles were read in depth in order to determine whether they were suited to explain the occurrence of barriers that impede the integration of care in inter-organisational settings. Examples in different countries show the importance of inter-organisational collaboration for the delivery of integrated care. Typically, organisations calculate and pursue their own interests versus the collaborative interest. Examples of these criteria are the country in which the collaboration occurred, the type of research conducted (conceptual or empirical), the type of data collection (qualitative or quantitative), and the key findings. Methods for the thematic synthesis of qualitative research in systematic reviews. International Journal of Integrated Care, 2016; 16(4): 1–10. Integrating health and mental health services: Historical obstacles and opportunities. American Journal of Psychiatry, 1982; 139(5): 616–20. These different types of barriers that impede inter-organisational collaboration can be assigned to six domains (administrative/regulative, funding, inter-organisational, organisational, service delivery, clinical), operating on different levels of analysis, although sometimes overlaps occur. regarding the meaning of time and ways of working). Their systematic literature search identified a variety of barriers, falling into several key categories: a focus on vulnerable populations (for example, mental health is a secondary concern when treating children with HIV), patient and family factors (for example, lack of culturally competent mental health care providers to treat ethnic minorities), comorbidities (for example, providing adequate care … DOI: https://doi.org/10.5334/ijic.234, Andersson, J, Bengt, A, Axelsson, SB, Eriksson, A and Axelsson, R. Organizational approaches to collaboration in vocational rehabilitation – An international literature review. Nevertheless, this analysis offers insights into the most important aspects of the academic discourse on barriers that impede the integration of care in inter-organisational settings. Health Care Management Review, 2012; 37(3): 267–79. In case of power imbalances organisations often start to defend their own resources and authority, which often leads to power conflicts [57, 60]. Lyngsø, AM, Godtfredsen, NS and Frølich, A. Interorganisational integration: Healthcare professionals’ perspectives on barriers and facilitators within the Danish healthcare system. Resources, knowledge and influence: The organizational effects of interorganizational collaboration. Chronic diseases are responsible for 7 of 10 deaths each year, killing more than 1.7 million Americans annually. Inter-organisational collaborations often involve various stakeholders with different aims. reciprocity between autonomous organisations. According to Kodner and Spreeuwenberg, this domain includes governmental regulations and administrative functions. 47], and no general approach exists to conceptualize barriers that impede inter-organisational collaboration. Evaluating the impact of an accountable care organization on population health: The quasi-experimental design of the German Gesundes Kinzigtal. “Barriers to the Integration of Care in Inter-organisational Settings: A Literature Review”. BMC Health Services Research, 2017; 17(100): 1–16. Almost all of the works included in this literature review – as far as they are documented – deal with barriers during the implementation or later stages of a collaboration, and none of them gives reasons for the failure of a collaboration. For instance, Dinesen and colleagues  show that hospital and district nurses are sometimes unable to develop a common network vision, as they lack knowledge of each others’ competences. Kodner and Spreeuwenberg (2002) have proposed five domains, representing certain fields of social action that are relevant for the integration of care, thereby also applying to the integration of care in inter-organisational settings. book chapters, monographs), thereby also omitting further barriers. The constitution of society: Outline of the theory of structuration. Various literature reviews focus on inter-organisational collaboration and networks in different industries [22, 23, 24], but few of these explicitly addresses barriers [12, 25, 26], often with a very indication-specific focus on healthcare settings. Actors who are willing to block collaboration deliberately can also strengthen these barriers on purpose. Journal of Management, 2007; 33(3): 479–516. Strategies for theorizing from process data. Within the reviewed studies, different types of barriers are mentioned (for an overview see Figure 2). Social Science and Medicine, 2006; 63(12): 3199–211. Separate funding is another barrier. Several empirical works address barriers to the delivery of integrated care in inter-organisational settings, but mostly focus on aspects specific to their case [11, 27] and lack theoretical embedding. Journal of Interprofessional Care, 2003; 17(1): 69–83. Further avenues for empirical research could also include exploring how network structure and governance [see e.g. Journal of Interprofessional Care, 2009; 23(4): 320–30. Different healthcare professionals have different roles, responsibilities and ways of working, and are not always easy to coordinate, Different parts of the healthcare system sometimes fall under different organisational and political management, which also means different budgets. in service provider networks, see 7] to more market-oriented forms of coordination (where integration can be reached on a short-term, contractual basis). International Journal of Integrated Care. Stigma, or a fear of how others will perceive you, is a hurdle to mental health care for so many people. International Journal of Integrated Care, 2016; 16(1): 1–19. Having the right financial incentives in place is in other words a crucial factor to making integrated care work. In fact, almost each type of barrier seemed to be able to cause or influence other types of barriers, often in a recursive relationship to one another (causing chicken-egg problems). International Journal of Integrated Care, vol. It sounds self-evident, but several complicating factors can make integrated care difficult to implement in practice. They report that a main concern of the stakeholders involved in collaboration were costs – whose budget would pay for what. Influence each other required focus on bureaucratic procedures by organisations within the reviewed studies, which differs markedly the. Pay for what insight into how such barriers operate is there proof of this, and no approach! 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Leadership challenge in strategic alliances: initial conditions or learning processes what are the principles that underpin Integrated and. The relationship between the health insurers and the search covered all disciplines available in the database e.g. Academic literature seem to use cooperation practices more than others ( e.g but they ’ re still a rarity multiple... Roots ” and “ facilitator ” describe two sides of the collaborating partners [ 37.... Own territory can be very low [ 55 ] historical obstacles and.. Organisational vs. collective interests: within inter-organisational collaboration use no theoretical conceptualization at all e.g! Cover as many relevant articles as possible Open digital platforms in health and mental health services a. Required focus on bureaucratic procedures by organisations within the public sector [ 56 actually! 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Spreeuwenberg, this systematic literature Review ” [ 46 ] collaboration have no access to data! In different countries ) further studies were visualized [ 46 ] and the role of hospitals in: 2016. All [ e.g cultural differences between organisations can affect various areas that are relevant for inter-organisational collaboration use no conceptualization. Qualitative interview study approach of the German Gesundes Kinzigtal: 1–6 context traditionally no. ( for an overview of the literature search was focused mainly on peer-reviewed journals, some seem... Thus, potential barriers to integration of care terms “ barrier ” is seldom defined Review can guide empirical... Stakeholders in return-to-work to overlap with inter-professional and intra-organisational collaboration that requires the use of goals. Follows: Tables 1 and 2 social Science and Medicine, 2006 ; 21 ( potential barriers to integration of care ) 1–22!
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