INTRODUCTION
Building informal relationships that is what youth care professionals find the most important when realising integrated care for adolescents in the Netherlands. Yet the harsh reality of a biting absence of informal relationships hampers their good efforts to bring about the integration of care that is necessary. That is the main conclusion of this study. Integrated care has proven to be a relevant subject of interest as it plays such an important role in the recent Dutch welfare reform. A reform that was urgently necessary due to the fragmentation and complexity of care and the rising welfare costs. The costs in the welfare sector grew exponentially due to the policies’ of the classical welfare state and later due to the policies’ of New Public Management (Gestel, et al, 2009; Tonkens, 2014). The Dutch welfare reform and its focus on the activation and empowerment of citizens in order to allow them to participate in society is part of a larger rhetoric of ‘the activating welfare state’ that also exists in the United Kingdom (Iskanian, Szreter, 2012). In the Netherlands integrated care plays an important role in realising the objectives of the activating welfare state (Hilderdink, Daamen &Vink, 2015). Integrated care is expected to combat the sectorial divides in the welfare sector, bring care closer to the citizen, allow for tailor-made solutions for the client and reduce costs (Rijksoverheid, 2014). However in the Netherlands integrated care is proving difficult to realise. The Dutch adolescents are being hit particularly hard by the difficulty to organise integrated care in the transition from youth to adult care (de Koster, 2017). An issue that the Dutch government has shown interest in the past couple of years and has attempted to address in an national plan of action at the start of this year (Tweede Kamer, 2017). Due to the recent welfare reform in the Netherlands there is a lack of literature that addresses the problem of realising integrated care in practice.
Integrated care is conceptualised in the literature but has still proven to be an ambiguous term. There are multiple definitions of integrated care that exist in the literature that contribute to the ambiguity surrounding the term. Firstly, integrated care can be operationalised on three societal levels: macro, meso, micro levels (Valentijn et al., 2013). Secondly, integrated care can be defined both horizontally and vertically. The horizontal definition entails the organisation of care around the client and the vertical the organisation of follow-up care and continuous care between professionals (Warmelink, et al., 2017).
A primary example of integrated care is the transition from youth to adult care. It is for this reason that this research has studied how youth care professionals in Rotterdam evaluate, experience and deal with the problematic of realizing integrated care. Professionals are considered to be ‘street level bureaucrats’ that develop tacit knowledge when translating policy into daily practice (Brandsen et al., 2012; Durose, 2009). Fifteen youth care professionals from the municipality of Rotterdam were therefore interviewed for this study. They are considered to be ‘street level bureaucrats’ that have developed tacit knowledge in their daily activities as they realise integrated care by transferring their clients from youth to adult care. By using an interpretative approach this tacit knowledge can be translated into managerial knowledge. Thereby bridging the knowledge gap that has been created between the professionals and the policy-makers due to the separation of purchasing and supplying care (Duyvendak, Knijn, Kremer, 2006). The municipality of Rotterdam was chosen as a single case study as it, like other municipalities in the Netherlands, is struggling to organise integrated care in the transition from youth to adolescent care. It is an ambitious municipality and is involved in the creation and realisation of the national action plan for the transition of youth to adult care (Tweede Kamer, 2017). Rotterdam was previously in the spotlights for its sector-overarching policies in the transition from youth to adult care (Het roer om, 2017). It is therefore a particularly interesting case for answering the question central to this study:
why integrated care is proving difficult to achieve in the transition from youth to adult care in the municipality of Rotterdam from the perspective of the youth care professionals.
Of the fifteen respondents, nine respondents participated in semi-structured in-depth interviews and six respondents participated in a focus group. This multi method approach enriched the data with descriptions of daily practice and allowed for more validation of the data than a single method approach might yield (Lambert, Loiselle, 2008). From the data it becomes clear that informal relationships are crucial to organising both horizontal and vertical integrated care. The professionals experience trust and commitment to be two important preconditions for forming the informal relationships and networks necessary for successful integrated care. In order to support professionals realising integrated care in the future the municipality of Rotterdam might consider facilitating these informal networks by providing the professional more time and discretionary space in which to build the informal relationships that they require.
CHAPTER ONE
Theoretical Framework
The welfare state is changing, but how is it changing and why? I will address this question in the four sections of this chapter. In section one I will discuss how in the Netherlands, the welfare state is changing into an activating welfare state, and how that change is expressed in the Dutch health care reform. I begin with a description of the classical welfare state and its development over time. I then move on to discuss why the Netherlands is transforming to an activating welfare state. I argue that the bureaucracy, which characterised the classic welfare state, eventually led to its downfall. With the implementation of New Public Management (NMP) governance in the nineties, the government eventually caused the ineffectiveness it was trying to prevent. I then discuss how the Netherlands is moving towards becoming an activating welfare state, and how it’s new health care reform is a reaction to the previous NPM policy. In section two, I discuss how the Dutch welfare reform is expected to realise an ‘activating welfare state’, and the pivotal role that integrated care plays in the realisation of that objective. I illustrate how integrated care is proving rather difficult to achieve in the Netherlands, particularly in the transition from youth to adult care. In section three, I define integrated care, and how it is conceptualised in the literature. I then outline the characteristics and preconditions of integrated care in relation to network governance theory. Finally, I describe the challenges that have already been faced when realising integrated care. Lastly, in section four, I summarize the arguments made in the literature that have led to my research question.
1.
The change to an ‘activating welfare state’
The welfare state is in the midst of a transition. The current move towards a new type of welfare state is dominated by a diminished reliance on the state by the citizen, therefore changing the concept of ‘care’. This reformation of the welfare state and the ramifications of that change can only be understood in
light of what the welfare state was like ‘before’ and what prompted the change.
The classical welfare state, as referred to as the Keynesians model, was characterised by its enormity, its bureaucracy and by its inherent incentive to rely on benefits, essentially a reliance on the state (Duyvendak, Knijn, Kremer, 2006). This stimulus resulted from the normative drive behind the classical welfare state to shelter and support the weak, fragile and dependent citizens of society. While this moral sentiment was appreciated, the costs were not. In the years after the Second World War the Dutch government wanted to stimulate the economy. Therefore, it practiced a Keynesian welfare policy of state intervention, trying to prevent and combat unemployment and supporting the weak, fragile and elderly. It is from this normative sentiment that the stimulus for a reliance on benefits arose. However, this policy caused state expenditure to rise as unemployment and disabilities rose in the years after the Second World War, dramatically increasing dependence on social security (Gestel et al., 2009). As a reaction to the rising costs, the Dutch government installed austerity measures in the welfare sector in the seventies and eighties. However, according to Gestel, et al. (2009) in their book on the reform of the welfare state, the structure of the welfare sector remained the same and measures to reduce social benefits were not enough. In the nineties, the welfare state was characterised by marketisation and consumerism. Clients were now perceived as consumers who demanded freedom of choice. They wanted to choose which type of care they desired and who provided it. Marketisation brought New Public Management to the healthcare sector, forcing health care providers to become profit- and result-oriented (Pollit, 2003). The implementation of New Public Management policy was expected to significantly benefit the health care sector by its focus on efficiency and result-oriented management (Duyvendak, Knijn, Kremer, 2006). In reality, the NPM policy had an adverse effect on the health care sector, which I will continue to discuss in the next paragraph.
1.2 The pitfalls of New Public Management
New Public Management promised to combat the inefficiency of the public sector by doing away with bureaucracy and promising accountability and result oriented policy (Pollit, 2003).
1. The terms ‘welfare’ and ‘health care’ are often used interchangeably. In this study, I define welfare as that which leads a citizen back to society. Therefore, I include both the health care sector and re-employment sector in this definition. Health
oriented policy meant that suppliers and demanders had to set goals and policies in advance and measure the progress of the suppliers with benchmarks and other monitoring instruments. In actuality, ‘being accountable’ turned out to require extensive bureaucratic procedures. Therefore, NPM eventually ended up being time- and cost-intensive rather than effective. Apart from being ineffective, NPM was one of the primary instigators of the fragmentation of care. Tonkens (2014) discusses how the assessment of care and the supply of care were separated. In practice, the separation caused clients to receive separate care for every different diagnosis or request for help. For example, a client could be diagnosed with a mental health care disorder and receive mental health care. The same client would be unable to clean, and therefore would be provided with home care. He could also be in debt and would then receive budget counselling. Being unable to take care of his children due to the aforementioned issues, child protective services would then be called in. In this hypothetical case, the client has four different professionals who are unaware of each other and are therefore not in cooperation with each other. This fragmentation was initially combated by regulation policy, which only resulted in more bureaucracy and inefficiency, as several professionals operating in a disharmonious way in one case did not realise favourable outcomes for the client (Tonkens, 2014). As an example of a regulation policy, Tonkens described how clients were sent to one ‘counter’ through which to access care. Having one counter was intended to combat the fragmented care system by creating one point of access. However, according to Tonkens the counter was “like a décor of the wild west: a cardboard façade with the desert
behind it in which you still get lost.” (Tonkens, 2014, p. 86). The regulation measures did little
to combat the sectoral divide and bureaucratic compartmentalisation that had resulted from the fragmentation of care to which NPM had contributed.
The already complex welfare sector was not simplified by NPM. Change on a large scale seemed necessary. The fragmentation and medicalisation of care was leading to the exponential growth of health care expenditure (Rijksoverheid, 2013). These factors lead to the Dutch healthcare reform (CBS, 2014). Firstly, the division of care in several sectors was proving costly and ineffective. Secondly, the medicalisation of care meant that relatively simple care issues were treated with specialised procedures or professional interventions without considering and addressing contributing factors to the problem. A client could be burnt out and would then be treated by a psychologist but the client’s debt, which could
be a main factor causing the stress, would not be addressed. Between 2004 and 2013, the national costs for care rose from approximately 63 million to 94.2 million euros (CBS, 2014). Health care expenditure was expected to continue to increase in the upcoming years due to the ageing population and increasing complexity of care. Hence, the welcoming of the Dutch health care reform, the design of which I will address in the following paragraph.
1.3 The Activating Welfare State
The reform of the Dutch welfare system is the biggest reorganisation of welfare in the history of the Netherlands. As previously discussed, the reform stems from the need to reduce the complexity of care and reduce costs. The general aim of the Dutch welfare reform is to create an activating welfare state by activating its citizens to be self-reliant and therefore enable them to participate in society. In order to achieve this aim, the Dutch government passed three bills in 2015: De Participatie Wet 2, De Wet Maatschappelijke Ondersteuning 3 and de
Jeugdwet 4 (NJI, 2017). These bills are viewed as a package deal and are expected to realise an
‘activating welfare state’ by fulfilling the following objectives. Firstly, care needs to be realised in smaller networks of care that operate closer to the citizen, in contrast to, for example, health insurance companies, who operate nationally. The expectation is that smaller networks of care can provide tailor-made solutions for the client, which is the second important objective of the legislation. In order to organise care closer to the citizen, the majority of care has been decentralised to the municipalities. Thirdly, the legislation aims to provide more ambulatory and preventative care rather than specialised care (see Table 1.1). Fourthly, the legislation is meant to realise an integrated health care system. Lastly, all of the above-mentioned objectives are expected to reduce the costs of health care (SPB, 2015). An important side-note: something that has had a considerable influence on the ability of the municipalities to
2. ‘De Participatie Wet’ translates into English as ‘the participation law’. The aim of the bill is to help adults participate in society by leading them (back to) employment or supplying them with benefits.
3. ‘De Wet Maatschappelijke Ondersteuning’ translates into English as ‘the social welfare act’. The aim of the bill is to help adults to participate in society by using supporting them with domestic care and personal coaching.
4. ‘De Jeugdwet’ translates into English as ‘the youth law’. The aim of the bill is to help children and youth with special needs who may live in unstable environments to grow up in a stable family environment in order to later actively participate in society.
realise these objectives is the large austerity measures accompanying the bills in an attempt to pre-emptively reduce costs. These austerity measures have placed enormous pressure on the municipalities to reform and economise simultaneously (Kempernink, Bruijning, 2015). The development of an ‘activating welfare state’ is a larger trend and is not limited to the Netherlands. The objectives of the Dutch welfare reform and the development towards an ‘activating welfare state’ are also shared ‘across the pond’ in the United Kingdom.
1.3.1 Health Care Reform in Context
The activated welfare state is not merely a Dutch phenomenon. It is part of a broader rhetoric containing terminology such as ‘the big society’ and ‘the participation society’. The United Kingdom, for example, has also embarked on a new welfare journey in the form of Tony Blair’s ‘Third Way’ and David Cameron’s ‘Big Society’. Blair’s Third Way was a policy that promoted market values in a previously public healthcare sector, while simultaneously promoting individual responsibility, active participation in society and community support as a counter to the increase of welfare benefits of the past decades (Jorden, 2000). The introduction of Cameron’s ‘Big Society’ represented an even greater move away from classical welfare system. This policy promoted a small government but a strong, active and community-oriented society. According to Iskanian & Szreter (2012), ‘Big Society’ includes characteristics of austerity, rhetoric of individualism, a responsibility for one’s own wellbeing, and participation within society. They argue that the rhetoric of ‘the Big Society’ which espouses empowerment, active participation in society and community building, is a tool to implement major budget-cuts in the healthcare system by placing the primary responsibility of care on the individual and their social network (Iskanian & Szreter, 2012). When comparing the case of the United Kingdom, the policies are very similar. In the Netherlands, there is a focus on the strengths of a client, which in the United Kingdom is translated as empowerment and individualism. The policy in the United Kingdom speaks of community building that in the Netherlands is translated to ‘smaller networks of care’. Overall there is a striking similarity between the two cases in the focus on activation, participation and austerity measures.
1.3.2 Breaking away from the past
The objectives of these welfare reforms speak of an attempt to break with the past. By focusing on an integrated system of care that is closer to home and tailor-made to the client, the Dutch government wants to break away from the fragmented system of care that was partly caused by NPM. The focus on preventative and ambulatory care rather than specialised care seeks to combat the medicalization of care. Overall, the welfare reform is meant to reduce costs that had risen due to bureaucratisation and the complexity of care, problems that NPM had only added to. In general, both the United Kingdom and Dutch government are moving away towards a new system of care in which the client’s needs are met closer to home in an integrated way, the client’s strengths are activated rather than relying on the government, the client is able to become an activated member of society and welfare expenditure is reduced.
1.3.3 The Dutch Welfare Reform
In the following paragraph, I will give a more detailed description of the Dutch welfarereform in order to provide a context from which to analyse one of the primary objectives of the legislation, namely organising integrated care. Previously, I have outlined what the welfare reform aims to realise as a whole. Each bill has, however, its own specific aims. The Youth Care Act aims to bring care closer to the client, provide tailor-made care, to create an integrated care system and to lower costs. Furthermore, the Youth Care Act aims to diminish the use of specialised care (Rijksoverheid, 2014). In youth care, which the municipalities now govern, several services have been brought together that previously operated separately: for example, child protection services and mental health care. Now the municipalities are responsible for providing almost the entire spectrum of youth care: parenthood and childrearing support, child protection services, mental health care and juvenile detention and rehabilitation services. Long-term care for chronic illness is the only exception and remains under the jurisdiction of the health insurance companies. Combining the fragmented youth care system under the jurisdiction of the municipalities is expected to realise an integrated system of youth care. The aim of the Social Support Act passed in 2015 is similar to the previous bill of
2007 5. In 2007, the Social Support Act was passed, entrusting the Dutch municipalities
with social support. In practice the municipalities supplied domestic care, personal care, and enabled volunteers and informal caregivers to provide these services by personal client-linked budgets, and residential facilities for those who cannot care for themselves (SCP, 2010). The aim of the legislation was to enable people with a disability or impairment to participate actively in society and enhance their quality of life by providing care and support at home, and encouraging them to participate in their local community. The municipalities still provide domestic care, support volunteers and informal caregivers and provide personal client-linked budgets. In the new bill, ‘support and coaching’ is separated from ‘personal care and nursing’. The first is provided through the Social Support Act, and the latter is supplied for the majority by health care insurance. In the new bill there is a much larger focus on providing tailor-made solutions for the clients (Movisie, 2015).
The Participation Law is designed to lead people (back) to employment. People who are unable to work for a period of time, or are deemed unable to work on a structural basis, receive social benefits 6.. The aim of the participation law is to
help people participate in society by coaching people with or without a disability to get a job in a regular workplace. Employers are provided with an incentive to create more jobs for people with a so-called ‘employment handicap’ (Divosa, 2015).
2.
The failure of integrated care in the Dutch Youth Policy
In the Netherlands, integrated care is an “underlying principle” of the Dutch welfare reform (Hilderdink, Daamen, Vink, 2015). As stated previously, organising a system of integrated care is one of the shared objectives of the Dutch welfare reform. Care was fragmented under the regime of the classical welfare state, and that fragmentation was exacerbated by the policy of NPM. The realisation of that system of integrated care is meant to combat the fragmentation of care. The other objectives of the Dutch welfare reform such as organising care closer to the client, organising tailor made care and reducing costs become much easier to realise if the organisations
6. See footnote two
and professionals work together in organising care and support for a client. In section number two I will discuss how and why integrated care is such an important part of the Dutch health care reform. Secondly, I will discuss how integrated care is proving difficult to organise in the Dutch welfare sector in general and in the transition from youth to adult care in particular.
1.4 Healthcare in general
‘One family, one plan and one case-manger’ is the slogan of the Dutch health care reform. It illustrates how the municipalities mean to realise integrated care (Hilderdink, Daamen, Vink, 2015). This slogan refers to aim of the Dutch welfare reform to combat the fragmentation in care that existed under the classical welfare state. As Tonkens (2014) described in her article, the welfare reform aims to get professionals to work together around a client, rather than the many professionals that in the past worked the same case yet did not work together. That is why the municipalities promote ‘One family, one plan and one case-manger’. Unfortunately, this ‘underlying principle’ has not yet been realised despite the new health care reform. According to a rapport of the ‘Toezicht Sociaal Domein/Samenwerkend Toezicht Jeugd’, the realisation of an integrated approach to care is thwarted by bureaucratisation and lack of knowledge amongst the professionals. The inspectors mentioned for example that the case-managers are unable to adequately coordinate care due to their heavy caseloads. This influences the realisation of ‘one family, one plan, and one case-manager’. According to the inspectors the municipalities should investigate whether the policy they have designed to realise integrated care is adequate and being executed in practice (de Koster, 2017).
1.5 Integrated care in the transition to adult care
In the Netherlands, the population of youth between sixteen – twenty-seven years old is being hit particularly hard by the difficulties municipalities experience in their attempts to organise integrated care. This year the Dutch government has expressed its concern of the lack of integration between youth and adult care (Tweede Kamer, 2017) 8.
In the following paragraphs I argue how there is still a sectorial divide between youth a and adultcare. This makes the transition for the client very difficult.
The realisation of integrated care in the transition from youth to adult care is a highly relevant subject at the moment in the Netherlands, which is why I have chosen to examine it in further detail. In the following section I will discuss how the transition from youth to adolescent care is operationalised in the Netherlands and why from a psychological point of view integrated care is crucial for the adolescent. After that I will discuss how the Netherlands is coping with difficulties surrounding the transition from youth to adult care at the moment. There are two main arguments that I will discuss in the following paragraphs why this target population feels the lack of integrated care so keenly. Firstly, adult care is still quite fragmented in the Netherlands, whereas the youth care is almost completely governed by the municipalities. Secondly, according to ‘transition psychology’ major life events and brain developments occur around the age of eighteen. These phenomena together with disharmonious care or a discontinuation in care can have disastrous effects on adolescents in their later lives. Youth care in the Netherlands stops when one legally enters adulthood in the Netherlands: on the eighteenth birthday. After their eighteenth birthday youth in care can transition to several different welfare sectors: social care, the employment sector, long-term care and education for special needs. (Ebben, Berghuis, 2017). The transition from the youth care system to the fragmented adult care can be daunting for an adolescent as it is a complex process. Youth encounter difficulties because of the diversity of procedures they have to go through in order to access care and because of the different points of access. In the youth care the municipalities manage all the services, which limits the bureaucracy that a transfer of care brings. Table 1.1 illustrates how the youth care was previously fragmented and how since 2015 the municipalities have been able to integrate the majority of the youth care sectors. I have translated this table from Dutch. It is a table that is used internally by the municipality of Rotterdam. As the table indicates, the only aspect that is not integrated is the care for youth with a chronic illness who need long-term care. This is provided by health care insurance. Table 1.2 is an illustration of the care pathways in the municipality of Rotterdam but most of the care pathways are applicable for all municipalities in the Netherlands. I have translated this table from Dutch. The municipality of Rotterdam uses this table internally. It gives a good overview of the relative simplicity in care up till the eighteenth birthday after which care become fragmented again. Up until the age of eighteen a child either receives youth care or long-term care. Long-long-term care can continue indefinitely and in some cases adolescents can received
extended youth care until the age of twenty-three in the case of child protective services or juvenile crime law. In Rotterdam, adolescents specifically can receive coaching and support until the age of twenty-seven. The Youth Counter is a counter that Rotterdam has created and therefore case specific. Through this counter youth can access social support, coaching to (re)employment and social benefits from eighteen to twenty-seven. From eighteen onwards adolescents receive care through a host of other organisations. Adolescents can receive support and financial aid from health insurance companies. They can enter homeless shelters and receive social support, coaching to reemployment and social benefits from the municipalities. Adolescents who are following an education receive scholarships from the Dutch government after eighteen until their study is completed
Table 1.1 Overview of decentralisation and integration of youth care services by the Dutch municipalities in 2015 9.
Table 1.2 Interventions, legislation and instruments per age group municipality of Rotterdam To conclude, the transition from youth to adolescent care is still fragmented, making it a difficult transition for adolescents. The conclusion of the Toezicht Sociaal Domein/ Samenwerkend Toezicht that municipalities have not yet been able to realise integrated care is correct 10. In the case of the transition to youth and adult care however, it is
not only municipal policy that is to blame. The fragmentation of the adult care system contributes to the difficulty to organise integrated care. I stated earlier the lack of integrated care in the transition from youth to adolescent care could have a detrimental effect on adolescents. In the following paragraphs I first discuss why integrated care is crucial in this transition and secondly how the lack of it is currently a relevant subject in Dutch politics.
1.6 Integrated care in the transition to adult care
The transition from youth care to the adult mental health care system can be a rough transition for the adolescent. Ensuring continuity of care is viewed in the youth care sector as a prerequisite for the quality of youth care and at the same time it is also an important aspect of integrated care (Valentijn et al., 2013). Providing continuity of care means the continued provision of the same healthcare professionals and the organising of an on-going line care, as opposed to a gap in care, in the transition from child to adult care (Naert et al., 2017). Integrated care can improve outcomes for the clients as it closes the gap in care
mentioned above and facilitate a continuous line of care. A continuous line of care prevents people leaving care prematurely. According to Therese van Amelsvoort (2014), a leading transition psychologist in the Netherlands, most psychiatric problems manifest themselves around the age of eighteen years old. It is precisely in this period that the transition of care takes place and the likelihood of leaving care is the largest. A continuous line of care is therefore essential to prevent a worsening of the problematic potential care leavers (Amelsvoort, 2014).
Furthermore, the transition of care to adult care at 18 years of age coincides with big life events such as finishing (high) school, independent living and entering employment. In both the United Kingdom and Australia those who leave care between 16 and 18 years old are significantly disadvantaged in later life and have a shorter life expectancy than youth who have a social network (Mendes and Moslehuddin, 2004). The resulting poor outcomes for youth in the United Kingdom and Australia lead to believe that there are still major steps to be made in providing continuity of care to youth in health care. According to Munson, et al. (2011) youth with mental health disorders transitioning into adult care in the USA experience mistrust towards the system. This proved a significant barrier to care use. About 60% of youth with a mental health problems left care in the month before or after their transition to adult mental health care. According to their study important facilitators of care were family members, physicians and health care professionals. Loss of these facilitators often promoted ‘care-leaving’. In their research Munson, et al. (2011) conclude that many youth experience “fragmentation of and/or discontinuation of services.” (Munson et al., 2011, p. 2261). As I have mentioned previously the Dutch government have found the transition from youth to adult care to be problematic and have identified some considerable steps that need to be taken in order to organise a continuous line from youth to adult care. I discuss these in the following paragraph.
1.7 The transition from youth to adult care as a problematic
The lack of integrated care in the transition from youth to adult care is a recognised issue in the Netherlands. This problem was already addressed during the legislative process of the youth care act in 2015 and the social care act. Vera Bergkamp, a Dutch politician for the political left wing party D66, called for the municipalities to synchronise their policy plans
between youth and adult care in order to organise a smooth transition of care for 18-plussers. This was in April of 2014 (Tweede Kamer, 2014). Six months into the health care reform, in July of 2015, the secretaries of state from the health and justice departments called for better care for youth in the transition to adult care in a letter to the House of Representatives of the Dutch parliament (Tweede Kamer, 2015). In January of 2017 the secretaries of state sent a letter to the House of Representatives stating that the transition from youth to adult care is a priority that will be addressed by the national government, municipalities and health care in a national plan of action (Tweede Kamer, 2017). There is now a broad consensus in the Netherlands, which is confirmed by this plan of action, that transition from youth to adult care is fragmented and an integrated approach has not yet been successful for this target population. Of the 2,5 million youth between 16 – 27 years old in the Netherlands fifteen percent receive care (Jeugdhulp, 2015). This is a large number of young people that are being affected by the difficult transition from youth to adult care (Jeugdhulp, 2015). To conclude, integrated care in the transition from youth to adult care is a highly relevant subject in the Netherlands. There is a political consensus that integrated care is difficult to achieve for youth in the transition to adult care. Integrated care is also recognised as a critical factor in the health care of the adolescent who may need more and not less support around the age of eighteen. The sectorial divide and fragmented care between youth and adult care is a recognised phenomenon in the Netherlands and it is actually that phenomenon that integrated care should be bridging. After all, realising integrated care is one of the main objectives of the Dutch welfare reform. So why is integrated care so difficult to achieve? In order to answer this question, I will outline what integrated care entails in the following section.
3.
What is integrated care?
As I have mentioned above the Dutch reforms aim to achieve an ‘activating welfare state.’ A state in which citizens actively participate in society and are empowered to do so. The realisation of integrated care is expected to contribute to the activation of citizens by simplifying the welfare system and simultaneous also realising cost-reduction. Integrated care therefore is a pivotal success factor in realising an ‘activating welfare state’. It is, however proving difficult to realise in the Netherlands. In an attempt to find an answer the Dutch health care inspectors
have identified bureaucratisation and lack of knowledge by the health care professionals. There is political recognition by the Dutch government for sectorial divide between youth and adult care and the transition from youth to adult care is particularly disharmonious. Given how relevant the realisation of integrated care is in the Netherlands, it is topic that warrants further research. In the following section I therefore discuss how integrated care can be defined why it proves difficult to realise in practice. I will first discuss the various definitions and characteristics of integrated care and the preconditions necessary to organise it. Lastly I will discuss several challenges that occur when organising integrated care in the Netherlands.
1.8 Definitions of integrated care
‘Integrated care’ is an umbrella term used in the health care sector to define the merging of care (Shaw, et al., 2011). The term ‘integrated care’ is used to describe the merging of care on different levels. Integrated care can also be split in different types of integrated care; namely horizontal care and vertical care. In the following paragraph I will describe how these various distinctions of the term ‘integrated care’ are made.
1.8.1 Macro, Meso and Micro Level
Integrated care is used to describe the merging of different health care sectors. It is used as a term sometimes to refer to an intervention that merges different types of care providers or one that coordinates between care procedures. Integrated care is also used to describe the coordination of care between professionals. The word ‘integrated’ is often applied to describe what is happening at different levels of society: the macro, meso and micro levels. What are these levels? The macro level is a systemic integration of care, the meso level is organisational integration and the micro level is a professional integration (Valentijn, et al., 2013). The astute listener may perhaps realise which level is being referred to when it is used, but it is often not clear. This lack of clarity contributes to the ambiguity of the definition of integrated care.
When the term integrated care is used on a macro level it is most often used to describe the process of the healthcare reform in which integrated care is seen as one of the main tools. Integrated care on a macro level is expected to decrease healthcare expenditure but also improve quality of care, improve continuity of care and stimulate social participation and empowerment (Armitage, et al. 2009). This macro definition of integrated care is also the definition used to
describe the ‘activating welfare state’, discussed earlier in this chapter. Integrated care has been used on the macro level for a while now. Already in 2002 Kodner and Spreeuwenberg stated that integrated care was “an international health care buzzword” (Kodner & Spreeuwenberg, 2002, p. 2). In the decades before that term ‘integrated care’ was used politically and by health care providers as “a process” to address sectoral divides and combat the complexity of care amongst the elderly and the disabled, while simultaneously reducing costs. (Veeman et al., 2002).
Integrated care on a meso level is organisational integration, meaning the collaboration of organisations in order to realise a harmonious and continuous care (Valentijn, et al., 2013). Organisational integration is often organised by working in network-like structures and its realised by “contracting, strategical alliances, knowledge networks and mergers.” (Valentijn, et al., 2013, p. 6). According to Valentijn et al. (2013) organisation integration can be complicated to the different cultures that exist between welfare organisations. For example, health social care organisations can differ in their organisational structure and their approach towards clients. Integrated care on a micro level is the collaboration of professionals but it can also be a type of care. It can be an evidence-based practice that improves the health outcomes of the individual’s with a multi-problematic disorder (de Voursney & Huang, 2016). Integrated care on a micro level is meant to improve the care-experience of the client. In order to improve the experience of the client professionals needs to work together (Valentijn et al., 2013). “Essentially the connecting and merging
of sectors, systems and interventions of care are all meant to improve outcomes (clinical, satisfaction and efficiency) of the client.” (Valentijn, et al. 2013, p. 2).
1.8.2 Horizontal and Vertical Integrated Care
Integrated care is an ambiguous term that is used to describe procedures in different levels of society, the macro, meso and mirco levels. To make matters even more complicated, other scholars do not so much differentiate between different levels of perspective, but between ‘horizontal’ and ‘vertical’ integration. Within the concept of integrated care horizontal care and vertical care are two separate types of integrated care that should not be confused. I will therefore continue to use these separate distinctions throughout this study. Integrated care on a horizontal axis means the coordination and collaboration between professionals, organisations and sectors (Warmelink, et al., (2017). Integrated
care was previously embodied in concepts such as medical home, health home and Wraparound care (de Voursney, Huang, 2016; Sondeijker, et al. 2016). These are all systems of data-collection and professional interventions of care designed to ensure professional collaboration around a client (de Voursney, Huang, 2016). The horizontal axis refers to providing integrated care at one moment in time between various partners whereas the vertical axis has a sequential component. It refers to the transfer of care from one partner to the next in an integrative manner. While integrated care on the vertical axis is also characterised by collaboration and coordination between professionals and organisations, it is always done in service of the continuous pathway of a client (Warmelink, et al., 2017). As previously stated vertical care is the organisation of a continuous line of care. That continuous line of care is particularly important for the transition from youth to adult care. The sectoral divide between youth and adult care has in the Netherlands resulted in a discontinuous line of care. In their systematic review on studies of continuity of care Neart et al. (2017) make an additional distinction in vertical care by separating it into relational, managerial and informational continuity of care. They found that the majority of studies focus on managerial continuity. Managerial continuity is the seamless transfer of care from one partner to the next. Yet for vertical integration relational and informational continuity are also relevant. An example of relational and informational continuity is the transfer of care between a midwife and an obstetrician where not only the administration is handed over but also the patient is handed over in person (Warmelink, et al., 2017). The relational transfer of care especially contributes to the patients feeling of safety (Neart et al., 2017). According to Neart et al. (2017) managerial continuity occurs between organisations (meso level) whereas relational and informational continuity occurs between professionals and clients (mirco level).
In summary the term integrated care can be used on three levels of society and can also be defined by horizontal and vertical care. In addition several types of continuity define vertical care. Clarifying on which level integrated care is being operationalised and whether one is discussing horizontal or vertical integrated care can remove the ambiguity that exists around the term. In order to be able to fully understand how integrated care works the levels on which integrated care is operationalised need to be separated and the different types of integrated care need to be stated clearly. I will therefore continue to use these conceptualisations of integrated care throughout the remainder of this research.
1.9 The characteristics and preconditions of integrated Care
The differing aspects of integrated care mentioned above when viewed together give rise to the observation that integrated care is essentially the successful coordination of different parties. The essential element of both horizontal and vertical care is that professionals need to work together. They need to either gather in unity around a client (horizontal) or they need to work in collaboration to organise a continuous line of care for the client (vertical). On all societal levels governments, organisations and professionals need to collaborate in order to create the merger needed to realise integrated care. Coordination and collaboration are two general characteristics of integrated care that can be distilled from conceptualisations of integrated care. Another characteristic of integrated care is interdependence. Networks are used as the format in which integrated care is operationalized because they enable the actors to coordination, collaborate and to become interdependent. Networks are therefore generally the most applied format in which to operationalize integrated care as they allow for flexibility as well as commitment (Valentijn, et al., 2013). Actors in the network need to see a mutual benefit in working together to ensure their ongoing commitment. The mutual benefit is a shared outcome. Rhodes (2007), one of the founding fathers of network governance says that networks are governed by the cooperation mechanism in which the participants are indeed mutually dependent on a shared outcome. Due to their interdependence participants need to trust each other and to cooperate and negotiate to reach a shared outcome (Rhodes, 2007). Interdependence is a crucial element of integrated care because it creates trust and commitment, which are the two preconditions of integrated care. In the following paragraphs, I will discuss how the absence of trust and commitment can make integrated care difficult to realise. The competition involved in a privatised health-care network can negatively influence trust and commitment. Commitment, trust and interdependence in such a network are subjected to the ever-changing market demands. A fickle market makes it difficult for the actors in the network to set long-term goals therefore commitment, trust and interdependence become difficult to achieve. In the Netherlands however, while the municipalities govern youth care, social care and the reemployment sector these sectors are also regulated by market demands due to procurement procedures.
The Flemish government, which has also been implementing an integrated youth care policy over the past years, has been hampered by bureaucracy, institutionalisation and heavy government involvement (Voets, Verhoest and Molenveld 2015). Eventually the networks did not develop trust and commitment and therefore the realisation of integrated care failed. The youth care in Flanders was fragmented in a similar way as in the Netherlands. Youth were being sent from pillar to post, and ended up with multiple caregivers and a lack of continuous care. Specialised care had grown exponentially and there were long waiting lists. The Flemish government acted as meta-governors: framing, designing and managing the Integrated Youth Care (IYC) policy themselves. The policy aimed at creating institutionalised networks in order to ensure an integrated youth care system. Yet extensive government involvement prevented organisations from getting to know one another, discovering shared interests and overcoming sectoral and organisational interests. Joint action was further crippled by a lack of financial resources and (political) leadership (Voets, Verhoest, Molenveld, 2015). Top-down government involvement can hamper the collaboration between the actors in the network. In order for collaboration between stakeholders to be effective the stakeholders need to transcend their interests and discover shared interests. In the Flemish case the actors in the network did not discover the mutual benefits of working together and therefore did not develop trust and commitment, the preconditions for integrated care. Both Voets et al. (2015) and Berwick et al. (2015) have concluded that a lack of collaboration and the lack of interdependence between the actors of a network contribute to the lack of integrated care.
1.9.1 Steering towards a balance in integrated care
Rhodes’s (2007) theory of network governance shows that in order for integrated care
to work, networks need to have a certain amount of autonomy from the state and to
be self-organising. The shared interests and shared outcomes need to be highlighted.
Within networks, actors exchange resources and negotiate towards a shared outcome,
all the while being regulated by trust and rules of the game that are agreed upon by
all partners. Rhodes does argue that despite the autonomy of these networks the
state still governs by “steering” with and through networks (Rhodes, 2007, p. 1247).
An example of how the government can ‘steer’ in the health care sector is
illustrated by the Triple Aim theory. The Triple Aim theory is a meta-governance
theory. It argues that the health care system has three goals: to improve the healthcare
experience of the individual, lower the costs and improve the health of the general
population. These three goals are however mutually dependent. A successful health
care system needs a dynamic where the goals balance each other out (Berwick,
Nolan and Whittington, 2008). For example, investment in new methods of care
can improve the healthcare experience of the individual but will raise the overall
cost of healthcare: a careful consideration that the government has to make.
Berwick, Nolan and Whittington (2008) argue that an important precondition
of reaching the triple aim is an integrator who operates with one budget, and who can
coordinate the policy of the healthcare providers in order “to work as a system. In their
article, they discuss the need for an integrator in the US healthcare system, which is
fragmented and focuses on the individual rather than health care of the population as a
whole. The most relevant argument of the Triple Aim theory for this study is that in order
to create a balance in the health care sector, you need an integrator. The Netherlands
has appointed the municipalities as the integrator, meaning that they are ‘at the helm’
having to steer the health care sector towards the balance suggested in the Triple Aim
theory. As mentioned previously the goals of the health care reform in the Netherlands
are indeed to improve health care outcomes, lower costs and encourage the individual to
participate actively in society. The autonomy of networks and steering towards a
balance between these objectives are therefore important conditions in realising integrated care.To summarize coordination, collaboration and interdependence are the three main characteristics of integrated care. As integrated care is often realised in networks, network governance is an important theory from which to consider the realisation of integrated care. According to network governance trust and commitment between the actors that need to be present in order for the network to function. The Flemish case illustrates how a lack of trust, commitment, interdependence and heavy state involvement can thwart the realisation of integrated care. As the Flemish case indicates and Rhodes (2007) theory of network governance confirms, networks need to operate autonomously and the state needs to steer and not row.
1.10 Challenges in realising integrated care
There are some challenges that have arisen in the realisation ofintegrated care. In this paragraph I will discuss two of them and relate them back to the characteristics and preconditions of integrated care that I discussed in the previous paragraphs. Van der Veer (2013) describes the difficulty that professionals have experienced when organising integrated care in the social support sector before the Dutch welfare reform of 2015. According to Van der Veer (2013) conflicting legislation, institutional tensions and lack of financial means were the main obstructions to organising integrated care in the social support sector. By engaging with respondents from various sectors, including a partial municipality of Rotterdam Kralingen-Crooswijk, Van der Veer (2013) sought to uncover the obstacles that currently prevent integrated care in the social support sector. The participant’s biggest fear was that organisations would continue to view healthcare from their own perspective, protecting their own interests and therefore impeding the realisation of integrated care. She notes that the majority of the participants felt their own organisation sufficiently contributed towards integrated care whereas other organisations in their opinion did not (van der Veer, 2013). In the terms of network governance: the participants lacked trust and commitment. The professionals were suspicious of one another and protected the interests of their organisation rather than their shared interests. They were therefore unable to cooperate in a network, work together towards a shared outcome and be interdependent of one another. Va n d e r Ve e r ( 2 0 1 3 ) s h o w s t h a t l u c k o f t r u s t a n d t h e p r o t e c t i o n of one’s own interest can negatively impact the realisation of integrated care. A second challenge in the realisation of integrated care is the gap of knowledge that exists between the integrator of care (the policy-maker) and the policy-executor (the health care professionals). In the Dutch welfare system, the municipalities are responsible for managing youth-care, social support and re-employment. They should operate as integrators, and as integrators they have two tools: they make policy and purchase health care. The health care sector is partly privatised and therefore the municipalities have to enter a contractual relationship with a health care provider through tender procedures. These tender procedures allow the municipalities to dictate financial incentives and policy regulations that stimulate health care providers to better their quality of care and reduce costs. Municipalities however purchase care and dictate policy whereas health care providers
supply. This means that the practical knowledge that health care providers have is separated from the policymaking process (Duyvendak, Knijn, Kremer, 2006). On the positive side the separation of policymaking and professionalism keeps the professional accountable and stimulates the continual innovation of care through the financial incentive of contracting (Duyvendak, Knijn, Kremer, 2006). On the negative side however, the knowledge gap between the tacit knowledge the professional generates in his daily activities on a micro level, and the managerial knowledge that the integrator uses to make policy on a macro-level is unhelpful. (Duyvendak, Knijn, Kremer, 2006). In order for policy-maker to create policy that facilitates the realisation of integrated care this gap of knowledge needs to be bridged.
4.
Conclusion: from a problem to a question
1.10 Conclusion
The Netherlands is moving towards an ‘activating welfare state’. The changing welfare state is a larger trend that aims to empower and activate the citizen so he can participate in society. In order for the citizen to participate actively in society the Dutch government aims to rid the welfare sector from the fragmentation, complexity of care and rising costs that existed under the classical welfare state. The Dutch welfare reform of 2015 expects the realisation of an integrated system of care to realise these objectives. Integrated care however is proving difficult to realise particularly in the transition from youth to adult care. Why is this? As the health care in the Netherlands was only recently reformed (2015) there are few studies examining and commenting on the success and effect of the reforms and the level of integrated care. There are no clear answers to the question regarding the reasons it is proving so difficult to achieve. There have been several studies mentioned in this chapter that have lead to the conceptualisation of integrated care. Network governance has clearly identified trust and commitment as preconditions without which integrated care proves difficult to realise. There remains however a gap of knowledge as to why integrated care in the Netherlands is proving so difficult to achieve in practice. This difficulty is particularly evident in the transition from youth to adult care. It has become a high profile problem for the Dutch government. By studying why integrated care is proving difficult to realise in the Netherlands in the transition from youth to adult care I will be bring a valuable contribution
to academic research while simultaneous addressing a relevant problem experienced in the Dutch health care sector. The question central to this study therefore, is why integrated care is proving difficult to achieve in the transition from youth to adult care in the Netherlands.
CHAPTER TWO
Methodology
There is a gap between the theorisation of integrated care and its practical implementation. The literature examined above describes and explains this gap. This gap is especially evident in the Dutch welfare sector reform, where integrated care is proving difficult to realise, especially for the transition from youth to adult care. There is a lack of research in the Netherlands as to why integrated care is proving difficult to achieve, despite it being one of the main goals of the welfare reforms. The question central to this study is therefore: why integrated care is proving difficult to
achieve in the transition from youth to adult care? In order to answer this question, I interviewed
fifteen youth care professionals from the municipality of Rotterdam. Nine of the respondents were interviewed with semi-structured in-depth interviews, and six respondents partook in a focus group. This multi-method approach led to an enriched and validated data set (Lambert, Loiselle, 2008). In this chapter I address my research method, and examine its strengths and its weaknesses. I will first discuss my case and participant selection. Then I will discuss my research method and, lastly, I will discuss the strengths and weaknesses of my research design.
2.1 Case Selection
I have chosen the municipality of Rotterdam, a single case, in which to research the difficulties experienced in realising integrated care in the transition from youth to adult care. Single case studies are often believed to generate specific knowledge and therefore lack the ability to make general conclusions, but they actually generate ‘context dependent knowledge’ which helps us to grasp abstract concepts like ‘integrated care’ (Flyvbjerg, 2006). As stated in the literature, ‘integrated care’ is an ambiguous term. While it has been conceptualised in the literature, it still remains abstract. “This is the limitation of analytical
rationality: It is inadequate for the best of results in the exercise of a profession, as student, researcher or practitioner.” (Flyvbjerg, 2006, p. 222). Context dependent knowledge helps
the human understand complex phenomena as it is based on concrete examples and cases like those generated in a case study (Flyvbjerg, 2006). Examining integrated care in a case study will generate the practical knowledge that is needed to bridge the gap in the literature. Single case studies are often used as a pre-study to uncover significant connections that
could be applied to a general population, hypotheses that can then be tested in multiple cases (Seawright, Gerring, 2007). A strategically chosen single case study, however, can sometimes conclude as much as a collection of cases (Flyvbjerg, 2006). The municipality of Rotterdam is a strategically chosen case, as it is a large and progressive municipality whose adolescents have relatively complex issues. The municipality has already undertaken significant steps in order to organize a continuous line of care for its adolescents (Jeugdhulp 2015, 2016). It is also one of the first three municipalities to create a youth counter, which in Rotterdam is called ‘het JongerenLoket’, where adolescents from eighteen to twenty-seven years old can organize their care, be lead to (re)employment and apply for social security instead having to go to separate counters (Schalkwijk, 2004) 11. If the municipality of Rotterdam
is already facing particular challenges and dilemmas in organizing integrated care despite its progressivity, we might expect similar issues to be present in other municipalities.
2.1.1 The municipality of Rotterdam
The municipality of Rotterdam has an interesting youth care sector that warrants further examination. In this paragraph I give an indication of the amount of children in care for which successfully integrated care and continuous line of care is relevant in the Netherlands, and in the municipality of Rotterdam.
Rotterdam is one of the four largest municipalities in the Netherlands. In 2015, there were 348 000 thousand children between the ages of zero and eighteen in youth care in the Netherlands. Of those 348 000 thousand children, 13 000 thousand were children from Rotterdam (Jeugdhulp 2015, 2016). Rotterdam has the largest number of children in youth care in the Netherlands, but it does not rank the highest when comparing the amount of youth in care relative to its size (CBS, 2016). Rotterdam has 10.8 percent of its children in youth care. In comparison, the municipality
of
Zoetermeer has the most children in care relative to its size. It has 15,4 percent of its children in youth care. These national statistics do not include the youth from ages nineteen to twenty-seven years old because traditionally youth care in the Netherlandsstops when a youth reaches eighteen years of age. There are no statistics for the municipality of Rotterdam on the number of eighteen-year-old adolescents. Therefore, there are no statistics on how many clients will transition to adult care.
2.2 Participant Selection
In order to answer the question central to this study ‘why integrated care is proving
difficult to achieve in the transition from youth to adult care, I have chosen to
study integrated care from the perspective of the youth care professional from the municipality of Rotterdam. By interviewing youth care professionals, I have gathered the contextual knowledge that is required in order to bring integrated care from an abstract phenomenon into daily practice.
I gathered my data in two phases. In the first phase, I conducted nine semi-structured in-depth interviews with professionals from various health care providers. In the second phase, I conducted a focus group with professionals from the same type of organisations as the respondents with whom I conducted the interviews. In the following paragraphs, I will firstly discuss why I have chosen to use the perspective of the professional. Then I will discuss the selection criteria. Lastly, I will describe which respondents have participated in this study.
2.2.1 The tacit knowledge of the professional
Youth care professionals generate tacit knowledge when implementing integrated care in their daily activities. In the following paragraph, I discuss how professionals generate tacit knowledge and why this tacit knowledge is relevant for the realisation of integrated care in the case of Rotterdam.
In 1980, Michael Lipsky published his renowned book on ‘Street level Bureaucrats’. The term ‘Street level Bureaucrat’ refers to the professional who often has to translate policy to a workable tool that suits his daily reality. An example is a teacher at a public school who adapts the curriculum to fit the level of their class. The essence of Lipsky’s argument is that street-level bureaucrats are in actuality the executors of public policy, and therefore often fill ambiguous or conflicting policy regulations. This can create a tension between the street-level bureaucrat and his managers (Brandsen et al., 2012). Brandsen et al. (2012) see a renewed relevance to Libsky’s work in their study of Dutch social workers that assess the
needs of their clients through home visits. While these new ‘street-level bureaucrats’ do not operate in the same public sector that Lipsky based his work on, the current public sector gives an added dynamic to Lipsky’s work.
Today, the ‘street-level bureaucrat’ is referred to as ‘the professional’, which is the term I shall use in the remainder of my study. The professional now operates in an inter-organisational environment where he or she is often expected to be a multi-tasker. Within that inter-organisational environment the tension Lipsky identified between the needs of the client and the rules and regulations the professional has to operate with is still relevant today (Brandsen et al., 2012).
Lipsky put the importance of the ‘street-level bureaucrat’ on the map; namely their ability to reformulate policy as they go about their daily activities. This translation of policy to practical reality is called ‘local knowledge’ (Durose, 2009). In her article on front-line workers in the United Kingdom, Durose (2009) argues that the narrative of the front-line worker of their ‘mundane yet expert understanding’ is an example of how they reconcile the difficulties of implementing policy with workable everyday solutions for the community. In order to discover why integrated care is so difficult to achieve in the transition from youth to adult care, I have chosen to analyse the perspective of the professional as they are realising integrated care. As they guide their clients towards adult care, youth care professionals generate ‘local knowledge’ and are therefore in a unique position to relay why, in their opinion, integrated care is difficult to achieve on ‘the front line’. In capturing the obstacles and dilemmas that youth care professionals are confronted with on a daily basis, I have been able to answer why, according to the youth care professionals of the municipality of Rotterdam, integrated care is proving difficult to achieve in the transition from youth to adult care.
2.2.2 Selection Criteria
At the beginning of 2015, Rotterdam pooled resources with other municipalities in the region and contracted 133 youth care providers, the majority of which employ hundreds of youth care professionals (RegioRijnmond, 2014). It is from this population that the youth care professionals of this study have been selected.
I gathered respondents by approaching various health care providers. I approached a variety of health care providers who together represented the variety of care that exists in
the youth care sector. I wanted to allow for the different perspectives on integrated care that participants with different youth care professions may have. The general conclusions of this study will therefore apply to the majority of the youth sector in the municipality of Rotterdam rather than a small segment of it. I approached fifteen organisations, of which ten are represented in this study. Five organisations chose not to participate in this study, due to lack of time or an unwillingness to do so because of the tender procedures that the municipality of Rotterdam and the health care organisations are currently engaged in. I have chosen not to disclose the names of the five organisations that did not participate, as this type of information might be sensitive to contract negotiations. The organisations that did participate are: Prokino, Trivium Lindenhof, Stek, Intensieve Jongeren Coaching (Neighbourhood Team Feynoord), Willem Schrikker Groep, Pameijer, Fier, Lucertis/Parnassia Groep, the facility Schakenbos run by Jeugdformaat and Ipse de Bruggen. The participants from Prokino, Trivium Lindenhof, Stek and Intensieve Jongeren Coaching provide ambulatory care. The Willem Schrikker Groep and Pameijer provide ambulatory and specialised care for children with (mild) mental impairments. Fier, Lucertis/Parnassia Groep and Schakenbos provide highly specialised care. Fier provides care especially for people who are in co-dependent and abusive relationships. Lucertis/Parnassia Groep provides highly specialised mental health care and Schakenbos is a facility that provides care for children with (mild) mental handicaps and severe behavioural issues.
I requested these organisations to select participants on the basis of their previous experience in the youth care sector before the health care reform, and their caseload had to contain youth transitioning or having transitioned to adult care. The first requirement, ‘previous experience in youth care before the health care reform’ ensured that the professional had a context from which to appreciate integrated care. The second requirement ‘youth transitioning or having transitioned into adult care’ ensured that the professional had to organise integrated care for their clients in this transition, and therefore has enough relevant cases on which to reflect.
The respondents are all involved in the organisation of the the transition from youth to adult care. Most of the respondents have several clients whom they prepare for adulthood and adult care. They do this by assessing the future needs of the client and determining which care they need after coming of age. The professionals also
coach their clients to be self-reliant, and provide an adequate assessment of the degree of this self-reliance to the future care provider. Three of the respondents turned out to be regional managers with few or no caseload of clients. I will address this issue in together with two other issues that may have caused selection bias.
There are three issues that may have caused a selection bias. Firstly, I found out during three interviews that the respondents were regional managers. The managers proved more removed from the daily interactions with clients, and I found that the amount of concrete data they yielded to be less than that of the other participants. Moreover, regional managers do not match the definition of a ‘front-line worker’. However, they did yield relevant contextual information about the organisations they worked for. Secondly, several of the organisations had already organised a continuous line of care by providing adult care for clients after eighteen years of age, and transferring the client internally to follow-up care (R2, R4, R8). They experienced the internal transition of care relatively easily. The other organisations have to transfer their clients externally in order to organise follow-up care. The difference between organising a continuous line of care internally and having to externally transfer clients yielded interesting data. I found that this selection contributed to the conclusions of this study. Thirdly, the zorgmiddelingstafel is not a health care provider but the chairwoman of the zorgbemiddelingstafel is a youth care professional 12. The zorgbemiddelingstafel does play a large role in transferring youth
to adult care. I decided, therefore, to include this data in this study. These three issues may have resulted in a selection bias.
I found that because the organisations selected the professionals themselves, the participants were motivated to participate in the study. I had two instances of participants cancelling due to lack of time. The organisations then found replacements. The selection of participants therefore proceeded quite smoothly.
After receiving contact information, I addressed the participants via email explaining the purpose of the research. I also explained that the data was for
12. The ‘zorgbemiddelingstafel’ translates in English to the ‘care mediation table’. It is a structural meeting between the care coordinators of various organisations with residential care facilities in which they discuss where to place urgent cases.
the purposes of this study but that the dataset would also be used to formulate a recommendation to the municipality from my position as an intern. In my experience, the participants who responded were the ones who were motivated to solve the problematic of transitioning to adult care and were willing to spare the time.
2.2.3 The respondents
In order to shed more light on the various types of care the professionals give I have provided an overview of the organisation and job-description of the respondents in Table 2.1. The organisations the professionals work for provide different services. In training centres for assisted living, such as Prokino and Stek have, the clients are taught the basics of independent living such as completing domestic chores and getting up on time. In a facility for assisted living that Prokino and Pameijer have, the clients are expected to be more independent. The coach may help the client with applying for adult care, organising health insurance, or making a financial plan. These are also tasks that the neighbourhood coach or a professional from Timon might complete with his clients. The more specialised professionals from Willem Schrikker Groep, Lucertis, Fier, and Schakenbosch also work towards self-reliance and may do the same thing, but in addition they provide more specialised care. Lucertis has clients with severe psychiatric needs for whom daily activities are already a struggle, and for which education or employment can prove a step too far. Some adolescents have such complex issues that they may never be fully self-reliant. The task of the professional in the transition to adult care is to find a suitable residential care facility that suits the future needs of the client. The zorgbemiddelingstafel coordinates care for urgent cases when youth need to be placed in a residential facility.
