Bengt Åhgren earned his PhD in Public Health at the Nordic School of Public Health in Gothenburg. He has also a Master of Political Science at the University of Lund and a diploma in health management from the Health Executives Development Program at Cornell University, USA.
He has been working as a management consultant at the Swedish Institute for Health Service Development (Spri), the Scandinavian Institute of Administrative Research (SIAR) and Bohlin & Strömberg Ltd. His main areas of experience are in health management and organisational development. He has participated in assignments for the European Commission and several European health care organisations.
His research interest is in the creation of integrated care with an orientation towards management and organisational issues.
Abstract: Objective: It is the ambition of this thesis to contribute to the growing interest in integrated care and to the ongoing research in this area by exploring the Swedish development of inte-grated health care. The general purpose is to study the different strategies to improve integration in the Swedish system of health care in order to identify some of the key issues and conditions in the creation of integrated care.
Methods: For the purpose of exploring the status of chains of care, the determinants of integrated health care development, and workable ways of evaluating integrated health care, a combination of different quantitative and qualitative methods was used, and the research was guided by a philosophy of triangulation, that is, an application and combina-tion of several research methodologies in the study of the same phenomenon.
Results: The results show that chain of care development has a high priority in Swedish health care. Though, regardless of the high official priority and several years of experience, chain of care development is making slow progress. Seven of ten county councils regard themselves as unsuccessful in developing and implementing chains of care. Even so, it seems that chains of care are here to stay. All the county councils declare that they will continue to develop chains of care.
It is clear that top-down approaches seem to obstruct the chain of care development. Con-versely, if a chain of care project is initiated locally by dedicated professionals there is a good chance that it will have a successful outcome. The legitimacy of the development work among colleagues and stakeholders is of vital importance to the success of the work. It also applies to for confidence among participating organisations and authorities. This attitude includes giving space for prime movers and also trusts between the participants.
A chain of quality data of input/structure, process and outcome, where the latter is depend-ent on the previous links in the chain, made it possible to evaluate integration from three perspectives: the patient, the professional and the management. Furthermore, a model measuring clinical functional integration, the foundation for developing integration synergy and effectiveness, was successfully validated in a local health care organisation.
Conclusions: Chains of care are increasingly regarded as building stones of local health care. In this sense, chains of care may have a renaissance, after assuredly being high on the policy agendas but with several years of modest development results. However, as development of local health care has predominantly had a top-down approach, new ways have to be found to create change bottom-up by engagement of health care professionals and, fur-thermore, to facilitate professional dedication, legitimacy and confidence in the develop-ment work. Moreover, clinical integration is the foundation of integrated health care and must therefore get prime attention. Thus, the validated measurement model can provide managers with crucial evaluation data. Especially for extensive evaluations, the quality chain matrix has proven to be a helpful framework to understand the logic of integrated health care solutions.
Abstract: Despite of an insignificant track record of quasi-market models in Sweden, new models of this kind have recently been introduced in health care; commonly referred to as "choice of care". This time citizens act as purchasers; choosing the primary care centre or family physician they want to be treated by, which, in turn, generates a capitation payment to the chosen unit. Policy makers believe that such systems will be self-remedial, that is, as a result of competition the strong providers survive while unprofitable ones will be eliminated. Because of negative consequences of the fragmented health care delivery, policy makers at the same time also promote different forms of integrated health care arrangements. One example is "local health care", which could be described as an upgraded community-oriented primary care, supported by adaptable hospital services, fitting the needs of a local population. This article reviews if it is possible to combine this kind of integrated care system with a competition driven model of governance, or if they are incompatible. The findings indicate that some choice of care schemes could hamper the development of integration in local health care. However, geographical monopolies like local health care, enclosed in a non-competitive context, lack the stimulus of competition that possibly improves performance. Thus, it could be argued that if choice of care and local health care should be combined, patients ought to choose between integrated health care arrangements and not among individual health professionals.
Abstract: INTRODUCTION: DELTA was launched as a project in 1997 to improve intersectoral collaboration in the rehabilitation field. In 2005 DELTA was transformed into a local association for financial co-ordination between the institutions involved. Based on a study of the DELTA service users, the purpose of this article is to develop and to validate a model that can be used to assess the integration of welfare services from the perspective of the service users. THEORY: The foundation of integration is a well functioning structure of integration. Without such structural conditions, it is difficult to develop a process of integration that combines the resources and competences of the collaborating organisations to create services advantageous for the service users. In this way, both the structure and the process will contribute to the outcome of integration. METHOD: The study was carried out as a retrospective cross-sectional survey during two weeks, including all the current service users of DELTA. The questionnaire contained 32 questions, which were derived from the theoretical framework and research on service users, capturing perceptions of integration structure, process and outcome. Ordinal scales and open questions where used for the assessment. RESULTS: The survey had a response rate of 82% and no serious biases of the results were detected. The study shows that the users of the rehabilitation services perceived the services as well integrated, relevant and adapted to their needs. The assessment model was tested for reliability and validity and a few modifications were suggested. Some key measurement themes were derived from the study. CONCLUSION: The model developed in this study is an important step towards an assessment of service integration from the perspective of the service users. It needs to be further refined, however, before it can be used in other evaluations of collaboration in the provision of integrated welfare services.
Abstract: OBJECTIVES: Swedish hospital mergers seem to stem from a conviction among policy makers that bigger hospitals lead to lower average costs and improved clinical outcomes. The effects of mergers in the form of multisited hospitals have not been systematically evaluated. The purpose of this article is to contribute to this area of knowledge by exploring responses to the merger of Blekinge Hospital. METHODS: The evaluation was guided by the philosophy of triangulation. A questionnaire was sent to 597 randomly selected employees, that is 24% of the health care staff. Four hundred ninety-eight employees answered the questionnaire, giving a response rate of 83%. Furthermore, interviews of different groups of stakeholders were conducted. RESULTS: A moderate increase of quality was assessed, which, a low proportion of the employees perceived had decisively or largely to do with the merger. The majority perceives economical incentives as the drivers of change, but, at the same time, only 10% of this group believes this target was reached completely or to a large extent. CONCLUSIONS: The employees believe the merger has neither generated economy of scale advantages nor substantial quality improvement. Instead, it seems more rewarding to promote cross-functional collaboration together with clinical specialisation. Needs for both integration and differentiation could thereby be fulfilled.
Abstract: It seems impossible to create a comprehensive
evaluation model which fully takes into account
the multi-dimensional context of integrated
health and social care. Clinical integration,
as a prerequisite for efficient outcomes of
integration, must nonetheless get special
attention. For more extensive evaluations,
a quality chain matrix, including co-operating
acts by different providers, has proven to be
useful. Examples of evaluated services in
Sweden are given, and the management benefits
of the use of evaluation data are highlighted.
Abstract: Local health care in Sweden is an emerging form of integrated care, linked together by chains of care. Experiences show, however, that the development of chains of care is making slow progress. In order to study the factors behind this development, an embedded multiple-case study design was chosen. The study compared six health authorities in Sweden, three with successful and three with unsuccessful chain of care development. Three major determinants of integrated health care development were identified: professional dedication, legitimacy and confidence. In more detail, space for prime movers and trust between participants were crucial success factors, while top-down approaches targeting at the same time a change of management systems were negative for the development of chains of care. Resistance from the body of physicians was a serious obstacle to such a development. Local health care depends on developed chains of care, but it seems that health care managers do not have the management systems necessary to run these clinical networks, mainly due to a lack of acceptance from the medical profession. This is an impossible situation in the long run, since the number of chains of care is likely to increase as a result of the emerging local health care.
Abstract: PURPOSE: In the development of integrated care, there is an increasing need for knowledge about the actual degree of integration between different providers of health services. The purpose of this article is to describe the conceptualisation and validation of a practical model for measurement, which can be used by managers to implement and sustain integrated care. THEORY: The model is based on a continuum of integration, extending from full segregation through intermediate forms of linkage, coordination and cooperation to full integration. METHODS: The continuum was operationalised into a ratio scale of functional clinical integration. This scale was used in an explorative study of a local health authority in Sweden. Data on integration were collected in self-assessment forms together with estimated ranks of optimum integration between the different units of the health authority. The data were processed with statistical methods and the results were discussed with the managers concerned. RESULTS: Judging from this explorative study, it seems that the model of measurement collects reliable and valid data of functional clinical integration in local health care. The model was also regarded as a useful instrument for managers of integrated care. DISCUSSION: One of the main advantages with the model is that it includes optimum ranks of integration beside actual ranks. The optimum integration rank between two units is depending on the needs of both differentiation and integration.
Abstract: Chains of Care are today an important counterbalance to the ever-increasing fragmentation of Swedish health care, and the ongoing development work has high priority. Improved quality of care is the most important reason for developing Chains of Care. Despite support in the form of goals and activity plans, seven out of ten county councils are uncertain whether they have been quite successful in the development work. Strong departmentalisation of responsibilities between different medical professions and departments, types of responsibilities and power still remaining in the vertical organisation structure, together with limited participation from the local authorities, are some of the most commonly mentioned reasons for the lack of success. Even though there is hesitation regarding the development work up to today, all county councils will continue developing Chains of Care. The main reason is, as was the case with Chain of Care development up to today, to improve quality of care. Although one of the main purposes is to make health care more patient-focused, patients in general seem to have limited impact on the development work. Therefore, the challenge is to design Chains of Care, which regards patients as partners instead of objects.
Abstract: The former routines for co-ordinated patient care planning in Blekinge Countymeant that information was transferred by faxed forms. This in turn led tocommunication problems due to the large number of actors involved and afragmented health care delivery system, caused by three major driving forces in Swedish health care development: decentralisation, sub-specialisation, and theprinciple of professional organisation. The main purpose of the project Unbroken Chain of Care was to improve patient care and make it rapid and effective. The project began as a joint venture between Blekinge County Council and two local authorities in Blekinge County. The target group was patients, primarily older persons, discharged from Blekinge County Hospital with a need of special care and rehabilitation provided by the local authorities and/or primary care. An ICT-solution was developed that gives a rapid and secure transfer of information between the different actors in the patient care planning process.Evaluations of the project show considerable improvement in the state of: safe procedures, cross-border collaboration, quality of patient care plans, time savingsand quality of information (it reaches the right person in time and it is easy to access and read). Today Unbroken Chain of Care is a practice and it includes all local authorities and primary care centres in Blekinge County. Furthermore, evaluations of Unbroken Chain of Care indicate that a low value based resistance during the development work is a key success factor. The Unbroken Chain of Care is owned and completed by all clinical staff involved. Harmony and concordance between the values of health care personnel and goals, activity plans, etc., create opportunities to develop organisational efficiency. But this is not enough since effectiveness of care also needs to result in positive developments for patients and relatives.
