How interorganisational collaboration can be held

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responsible for unnecessarily emergency department

admissions by older patients in the acute care network

Master Thesis Supply Chain Management

Faculty of Economics and Business

University of Groningen

“The only thing you can do is to clarify the unclarity”

Jehannes J. Gietema S3205274

J.J.Gietema@student.rug.nl

First supervisor: Prof. Dr. J. T. Van der Vaart Second supervisor: Dr. A. G. Regts

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Abstract

Purpose: This research focuses on explaining why elderly are being admitted unnecessarily to

emergency departments (ED) by taking an interorganizational collaboration approach. The goal is to create better understanding about the patient flow coordination processes responsible for unnecessary ED admissions. Method: This research has employed a single case study conducting 12 semi-structed interviews among partners of both secondary as primary care providers in the acute care network within the Northern Netherlands. Findings: This research shows that elderly do not always receive the right care by the right provider, especially during evening, night, and, weekend hours. This is explained by having a shortage of collaborative relationships, limited information availability, and an absence of interorganizational coordination protocols. Contribution: This study provides a better understanding about why unnecessary visits by elderly on the ED occurs by elaborating on interorganizational collaboration processes within (1) the general practitioner, (2) general practitioner cooperatives and, (3) the emergency controlling room pathway in the acute care network.

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Acknowledgement

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1.Introduction

Hospitals are experiencing an increase of elderly visiting their emergency departments (ED), pressuring both ED-capacities as quality standards (Legramante et al., 2016). Undesirable outcomes are long waiting times, and situations where patients’ situations deteriorate due to the unavailability of receiving appropriate acute care (Hesselink et al., 2019; Memari et al., 2016). Research in Dutch hospitals, containing 800.000 ED visits of patients aged 65 years and older, shows that 19% of these older patients could have received community care, 17% could have received primary care (17%) and 24% could have been prevented by better screening (Fluent, 2017). These are considerable percentages burdening expensive acute care resources and together with an aging population, the acute healthcare network became aware that the current way of admitting elderly to EDs is unsustainable (McGeoch et al., 2019)

To improve the allocation of care, healthcare researchers developed the concept of care coordination (Reader & Starfield, 1993). Care coordination is an approach to overcome healthcare fragmentation and consultation of the right care provider at the right place (McGeoch et al., 2019). This can be achieved by forming strategic alliances or by linking healthcare providers both horizontally as vertically into one healthcare network (Axelsson & Axelsson, 2006; PwC, 2019). In both cases, interorganizational collaboration has a key function in connecting multiple healthcare organizations (Keyton et al., 2008). As a result, interorganizational collaboration facilitates the coordination of providing the right care at the right time for older patients. Additionally, where interorganizational collaboration can be used to explain successful patient flow coordination, it can also be used to explain cases where older patients are not receiving appropriate care and, for, example end up unnecessarily on the ED.

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Having the high admission rates of older patients in mind, this research has employed a single case study aiming to answer the following research question: “How can interorganizational

collaborations be held responsible for unnecessarily ED visits by elderly within the acute care network?”

By answering the research question, this research provides a better understanding about why unnecessary visits of elderly on EDs occur by elaborating on interorganizational collaboration patient flow processes within (1) the general practitioner, (2) general practitioner cooperatives and (3) the emergency controlling room pathway in acute care network. By exposing the current problems of different patient flow coordination processes, this research can serve as a starting point to improve and establish better and more interorganizational collaboration relationships. This has the potential to reduce high ED admission rates, prevent unnecessary ED visits by elderly and hence, improve both cost efficiencies as the quality of care in the acute care network (PwC, 2019).

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2.Theoretical Background

This chapter provides literature about the origin of interorganizational collaboration in healthcare, its facilitating factors, care coordination and the impact from the environment. Finally, a conceptual model is presented to guide the research.

2.1 The need for interorganizational collaboration in healthcare

With healthcare sectors being exposed to strong fragmentation and competitive pressures, awareness was raised that collaboration and coordination in healthcare would become more rewarding in networking environments than having conflicts in competition (Axelsson & Axelsson, 2006). Consequently, interorganizational collaboration in healthcare gained importance and is be defined as “the set of communicative processes in which individuals

representing multiple organizations or stakeholders engage when working interdependently to address problems outside the spheres of individuals or organizations working in isolation.”

(Keyton et al., 2008, p. 381). Interorganizational collaboration builds on collaborative relationships and is distinguished from a normal relationship as such that a collaborative relationship is a strategic alliance, which is more pervasive and durable than a regular relationship (Mishan & Prangley, 2014).

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2.2 Conditions facilitating interorganizational collaboration

Since interorganizational collaboration both between and within primary and secondary care sector can be quite complex, the process model of McCann (1983) is used to understand how sustainable interorganizational collaboration can be achieved. The model is used since it provides a systematic and a process-focused view on interorganizational collaboration. Additionally, creating more knowledge about processes and coordination activities might lead to improved healthcare supply chain performances (de Vries & Huijsman, 2011).

The model consists of three processes respectively, which are problem-setting, direction-setting, and structuring, respectively. During the problem-setting phase, legit stakeholders are identified creating considering a certain problem based on mutual acknowledgment. “The primary objective of problem-setting is to give the situation an explicit

form or identity that allows stakeholders to communicate about it and eventually act upon it”

(Mccann, 1983, p. 18). It is important that in case of complex situations, information must come from multiple sources to create a comprehensive understanding of the problem. After the problem-setting phase, the direction-setting phase starts concerning the articulation of values and creating a sense of common purpose (Gray, 1985). It is about managing expectations and guiding hope as such that their desires can be achieved. The last of the three processes relates to the creation of long-term arrangements and guiding protocols that sustain and incorporate collective goals into problem-solving structures and activities. After creating normative agreements in the previous phases, this phase is about formalizing these normative orders as such that stakeholders regard each other as potential co-producers of desirable changes in their shared environments (Gray, 1985; Williams, 1982). This is supported with structural formal organizational arrangements, task elaboration and role clarification and assignation to stakeholders. An external powerful force can guide the formalization processes and resource allocation to support (Gray, 1985; Van de Ven & Walker, 1984).

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facilitating function for interorganizational collaboration and are expected to be of importance for interorganizational collaboration in the acute care network.

2.2.1 Communication

Communication is defined as “the way messages and information are exchanged among

people, reducing gaps, ambiguity, or the effort needed to understand, establish or continue a conversation” (Steinmacher et al., 2010, p. 187), and is found to be both a key factor in

interorganizational collaboration, since it is the core of the processes facilitating the flow of information for both the organizational as professional levels (Karam et al., 2018). Moreover, emergency work in the acute care network involves providing care for patients with highly variable complaints and collaboration with multiple healthcare providers, this requires high levels of communication (Eisenberg et al., 2005). Additionally, communication is used to convince the stakeholders that the benefits outweigh the costs and are worth the efforts and to participate in the interorganizational collaboration (Gray, 1985). In addition, communication links key concepts as trust, power, and professional roles but also influences organizations and helps them involve to share values (Karam et al., 2018). Furthermore, the crucial role of communication spans the discipline of boundaries, clarifies roles (Day, 2012), and promotes relationships of professionals between and within organisations (Gaboury et al., 2009). Communication can both be formal (e.g. team meetings and reports ) as informal (e.g. chats and email exchanges) (Hepp et al., 2015). Communication is supported by the amounts of trust in others and the way professionals appreciate the knowledge others possess (Kessler et al., 2012). To improve collaboration, communication must be regular, active and must take place in comfortable situations both being formal as informal (Bradley et al., 2012; Crowley & Sabatelli, 2008).

2.2.2 Trust, respect, mutual awareness, and power

Where communication plays a key role in creating interorganizational collaboration, it also facilitates trust, mutual awareness, and fair distribution of power (Karam et al., 2018). Trust accumulates over time building on the experiences of previous collaboration activities and is supported by mutual awareness in a way that trust only can be achieved in familiar worlds (Bradley et al., 2012). Mutual awareness is defined as by Schmidt et al. (2014) as “the mutual

understanding of each other’s intentions, beliefs and activities”. Additionally, using the

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are result of trust since the premise that each profession has an unique expertise, trust first begins to build into reliance and then into interdependence (Bronstein, 2003). Acknowledging interdependencies add to the proposition of Gray (1985), as such that there must be an understanding and recognitions about each other’s interdependence and the stronger the awareness and understanding of the interdependence, the stronger the support for collaboration and respect for power distribution (Karam et al., 2018).

2.3 Care coordination

The main motive behind interorganizational collaboration in healthcare networks is to improve patient centred care by taking a “holistic” approach where also the needs of patients are considered in the provision and coordination of care services (Evans & Stoddart, 1990). Coordination is defined as “the process of managing dependencies among activities” (Malone & Crowston, 1994, p. 87) and care coordination as “the deliberate organization of patient care

activities between two or more participants involved in a patient’s flow to facilitate the appropriate delivery of health care services.” (McDonald et al., 2007, p. 5). Coordination of

care can be achieved by both horizontal as by vertical interorganisational collaboration (Schultz & McDonald, 2014). The first one connects care between two organizations at the same level of delivering care such as collaboration between two EDs and the latter one connects the care provision between organizations at different levels like primary and secondary care providers (Ham & Curry, 2011). In both cases, interorganizational collaboration is acknowledged an important and crucial element to achieve the effective coordination of care and could lead to a better patient flow performances across the healthcare supply chain (Auschra, 2018; de Vries & Huijsman, 2011).

2.4 Environmental factors

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organizational collaboration in healthcare can be subdivided in demographical, technological, political-legal, economic / market factors (Golonka, 2013).

Concerning the demographical environment, this can have a high impact on interorganizational collaboration. Especially in the acute care network since due to having an ageing population, the demands for more elderly centred patient care increases in the acute care network (PwC, 2019). In 2017 18% of the Dutch population is over 65 years old and this expected to rise to 26% in 2050 (CBS, 2014; Garssen & Duin, 2011). Older patients often have complex needs, demanding collaborating services from different providers, particularly within and between health care and social services (Orvik et al., 2016). With an ageing population, also the group of frail elderly increases. Frailty is commonly used in healthcare literature characterizing the weakest and most vulnerable subset of older patients (Fried et al., 2001). Over time, they have an overabundance vulnerability to stressors together with a reduced ability regain or maintain homeostasis after a disrupting event (Walston et al., 2006). This kind of patients often have comorbidities and constraints on either of more of the psychological, functional, social, and clinical domains burdening the acute care network (Reeves et al., 2015). The nature of the complexity of frail elderly is important to be aware of considering interorganizational collaboration.

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only realizable when these information systems are developed and are made available in the healthcare sector of interest (Bourgeois et al., 2010).

Thirdly, at the political and legal level, interorganizational collaboration is affected by service delivery models and government policies such as the patient’s access to care and referral guidelines (Mior et al., 2010). This includes the criteria a patient has to fulfil to be admitted to hospital or emergency departments and in which cases the received care is reimbursed policies (Shepherd & Meehan, 2012). For example, in 2012, the Dutch healthcare system spent two times more on chronic care than France and three times more than Germany. This resulted in politically justified budgetary cuts and resulted in a lower amount of nursing homes available and more workload for GP and homecare nurses (Stellinga & Weeda, 2012). Besides the determined policies and models, interorganizational collaboration is influenced by economical and market factors. For example, having a private healthcare system where profit is the main driving force is a major barrier to collaboration, compared to a public healthcare system. In addition to the type of market, the availability of resources also has a high impact on interorganizational collaboration. For example, the availability of subsidies for interorganizational collaboration initiatives or other market resources such as educated personnel (Shepherd & Meehan, 2012).

2.5 Theoretical implications

In the light of the above, literature shows the importance for interorganizational collaboration and proposes possible factors influencing the care coordination processes for elderly in the acute care network. With the environmental factors being expected to influence this relation, figure 1 present the conceptual model guiding the research.

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3.Research Setting

Before the methodology chapter elaborates on how the research is performed, this chapter first provides knowledge about the research’s context.

3.1 Acute care domain in the Netherlands

This research is performed in the acute care domain in The Netherlands which is organized by the National Acute Care Network (in Dutch: Landelijk Acute Zorg Netwerk; LAZN). The LNAZ coordinates and supports the 11 underlying Regional Acute Care Networks (in Dutch:

Regionaal Overleg Acute Zorg; ROAZ). These regional networks create agreements with care

providers and focus on improving the quality and accessibility of acute care. Within this network, the most common patient and information flows are visualized in figure 1 (Jansen et al., 2019)

Figure 2: Possible care paths that patients can take in the acute care chain (Jansen et al., 2019)

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4.Methodology

This research aims to explore how interorganizational collaboration influences the coordination of elderly in the acute care network. Therefore, this section elaborates on the research design, data collection, and data analysis.

4.1 Research Design

For this research, a single case study is chosen to be an appropriate research method due to its exploratory and in-depth examination of real-life situations (Karlsson, 2016; Yin, 1994). In addition, a case study is proven to be effective in addressing complex healthcare practices since not only individual phenomena is analyzed and observed, but also the integrated whole (Bullock, 1986; Siggelkow, 2007). Furthermore, an inductive research is used since observations made will lead to theories (Karlsson, 2016) and this fits the research design because this research aims to explain how interorganizational collaboration affects acute care coordination processes in the acute care network. To gather information, semi-structured interviews are used. This kind of conducting research allows interviewees to express themselves and to come up with new insights while at the same time maintaining structure and guidance (Patton, 2002) . This way, semi-structured interviews can obtain rich and useful data (Karlsson, 2016). The unit of analysis in this research are patients aged 65 years and older. By following the patient through the acute care network, different care coordination activities are exposed. Consequently, each coordination activity can be explained by interorganizational collaboration factors. As such, interorganizational collaboration can be used to explain how coordination facilitates the provision of providing the right care at the right time.

4.1.2 Case description

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secondary healthcare sector, such as general practitioners, general practitioner cooperatives, district nursing, ambulance services and multiple departments within hospitals. The central and connecting position of AZNNN in the acute care network makes them an important organization to collaborate with. Additionally, collaborating with AZNNN provides access to both relevant stakeholders as accumulated know-how and experiences in the acute care network.

4.2 Data collection

Before the interviews were conducted, one ROAZ meeting is attended to become familiar with the current problems and the state mind in the acute care chain. Thereafter, 9 documents are received from AZNNN providing more information about current challenges and working projects. These documents were not used for analysis but served for contextualization and assisted in creating higher external validity by comparing with other regions. Furthermore, these documents served as an information source which were consulted to gain more knowledge about ambulance services, general practitioner, emergency controlling room, and general practitioner cooperatives. Based on the information needs from the conceptual model, interviewees were selected in collaboration with AZNNN. Interviewees were chosen based on their work area, background, and experiences in the acute care network to achieve internal validity. Additionally, both interviewees at the operational level as on the managerial level were interviewed to improve internal validity and to create an extensive and realistic view. On behalf of AZNNN, interviewees were approached (Table 1). All were willing to cooperate in the research.

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only accessible for supervisors and are deleted after the research.

TABLE 1

Characteristics of the interviewees Interviewee Gender Profession Interviewee 1 F ED- Manager

Interviewee 2 M General Practitioner

Interviewee 3 M Ambulance Services Manager Interviewee 4 F Emergency Room Manager Interviewee 5 F Specialist Elderly care Interviewee 6 F Nursing home Manager Interviewee 7 F District nursing Manager Interviewee 8 M Geriatrician

Interviewee 9 F GGZ Manager crisis cluster Interviewee 10 F Practice support elderly care Interviewee 11 F GPC manager

Interviewee 12 M Ambulance Nurse

The research is performed in times of Covid-19 creating high time pressures on the interviewees. In consultation with the interviewees is determined not to send the transcribed interviews back for verification to minimize asked efforts. Instead, interviewees agreed on engaging in email contact when there were questions or ambiguities. Email exchanges have taken place between the researcher and interviewees 3, 4 and 11 for clarification and confirming reasons. The questions related to characteristics of interorganizational collaboration protocols. All 3 interviewees confirmed the researcher’s assumptions as such that no further corrections had to take place. Furthermore, two-weekly meetings with supervisor of AZNNN have been performed to discuss and evaluate findings to increase validity and to reduce researcher biases (Yin, 2009).

4.3 Data analysis

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TABLE 2

Part of coding tree for the GP pathway

Interviewee Quote Theme Type of care Category

GP " Acute care is organized well, I can easily

consult ambulance services via the emergency controlling and they will bring the patient fast to the emergency

department." Effective interorganizational protocols to process patients to EDs Acute GP Ambulance service manager

“The emergency care is extremely safe and super strong, we should not want to change anything about that”

Acute GP

GP "When an older patient is brought to the

ED by day, I’m not consulted and that is a shame because I have lot of knowledge about the older patients"

No information exchange protocols between ambulance services and GP Acute GP Ambulance nurse

“We only have access to patient’s information when we are consulted by the GP or if we call the GP. But these are active actions, we are not able to see any patient related information in the ambulance”

Acute GP

Practice support nurse elderly care

“Let’s say you get a cardiac arrest, ambulance services are not able to access your advanced care planning, if recorded, to see whether you want to be resuscitated

Acute GP

GP "Everybody acknowledges that GPs are

the main practitioners for elderly and we also have the final responsibility"

Role clarity of GP Semi-acute GP

Nursing home manager

“The final decision whether a patient should receive district nursing or should go to a nursing home is the responsibility of the general practitioners”

Practice support nurse elderly care

"But there are a lot of district nursing organizations and nursing homes i have to keep in contact with, but each has its own patients’ files and procedures. As such I my job often consist more about remembering passwords and procedures than taking care for."

Hindering

information systems

Semi-acute GP

GP “There are also different information

systems at pharmacies which each its own medical patient list, however they are not automatically synchronised with the patient’s medication list in our system. Creates a lot of extra work to synchronize”

Semi Acute GP

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5.Findings

While conducting the interviews and during data analysis three interorganizational collaboration and care coordination processes were discussed. These three patients’ flows are related to the first step a patient can make (Figure 3). Since most of the time care is performed by the general practitioner (Step 1), this process is discussed at first followed by care path taken by calling general practitioner cooperatives (Step 2) and finally by the emergency controlling room (Step 3).

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5.1 Acute care pathway via general practitioners

The first coordination process starts when a patient calls for acute care to the general practitioner. In general, the GP has 3 options (Figure 4). Here, a distinction is made between acute care and semi-acute care. Performing semi-acute care was explained as cases where patients are not medically necessary to see doctors in the hospital but are in the need for time pressured care. Here the general practitioner can provide care autonomously (1) or is able to transfer a patient to emergency beds in first line stay institutions (2). On the contrary, when the patient called with acute care demands, this was experienced as more life threatening and GPs needed to call the emergency number to consult ambulance services for transportation to the hospital (3).

Figure 4: Acute care pathways via General Practitioners

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to coordinate the right care at the right time for older patients. The following paragraph elaborates on the experienced hindering factors.

5.1.1 Absence of having a central patients medical information file

The biggest hinder the GP experienced was the low amount of information availability. During working hours, GPs are having final responsibilities of coordinating care for elderly and are in touch with a lot of different healthcare providers. But each healthcare provider has its own electronic patient file and often its own information system. For GPs, it is therefore the responsibility to keep track of all different patient files and make sure the one the GP uses, is up to date. Additionally, the ageing population makes it only more difficult, since there is a need to keep track of a growing number of older patients. According to the interviewees, having no guiding protocols to ease information exchanges, heavily hindered the semi-acute care coordination between GPs and other care providers. An explanation was found in having no guiding party as the GP said: “You would expect that someone would take the lead in creating

one shared information system, who would say this is what are going to do, and this is what should look like, some guiding would be useful.”.

Another explanation for the having low information availability was found in laws hindering information exchange. One law all interviewees implicit or explicitly mentioned was the general data protection regulation law (GDPR) and known in the Netherlands as the AVG (Algemene Verordening Gegevensbescherming). This law contains regulations for processing personal data for private companies and public authorities. As a result, even when a link between software systems would be realized, laws prevent patient data exchange except when the patient gives permission. As the general practitioner said: “We cannot easily access and

exchange patient files of care and nursing homes, district nurses and vice versa, there are laws protecting privacy”. A direct consequence of fragmented information systems and limited

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interviewees mentioned that there were good communication protocols between GPs and ambulance services, the GP and the ambulance nurse did not experience this. Sometimes, when the GP called the emergency number, the GP could assist in the providing appropriate care. But in situations where older patients called autonomously the emergency number during working hours, the GP is structural being consulted by ambulance services nor are ambulance services allowed to access the electronic patient file of the patient. This was experienced to be hindering factor to decide where an older patient should go to for ambulance services because having an absence of appropriate medical information results in suboptimal decisions-making. As such, that when the patient’s own GP is not accessible, older patients sometimes got brought unnecessary to the ED.

5.1.2 High nursing home acceptance thresholds

Another factor explaining the high admission rates according to the interviewees were the high nursing home acceptance thresholds. To illustrate; a practice support nurse elderly care was busy arranging a medical indication for an older patient who was intended to move to a nursing home since he was need for more specialized care and his own house was not elderly friendly. In the Dutch healthcare system, a patient needs to have a medical indication to be able to apply for a place in a nursing home. Such an indication is needed to ‘buy’ a nursing home bed, determined by healthcare policies. But due to the high acceptance standards, high amount of paperwork, communication with multiple care providers and waiting times, the indication did not make it through on time. Unfortunate, the older patient fell due to unsuitable circumstances at home, broke his/her hip, and was transported to an emergency department. This is an example of an older patient who has sincere needs to receive acute care at an emergency department, yet it also demonstrates that it could have been prevented when arranging a nursing home place for older patients would be easier. Interviewees often experienced that ED admission could have been prevented by earlier patient transferal to nursing homes.

5.1.3 Scarcity of Advanced Care Planning records

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there are no records available of the wishes of elderly when demand escalates, they probably end up at the emergency department. To counter this, all interviewees emphasized the importance of having an advanced care planning (ACP). An ACP is a dossier including plans about future healthcare situations. Such a plan provides decisions for healthcare professionals when a patient is not in the position to communicate and or to make their own healthcare choices. But there were high levels of inconsistency about who is responsible for performing advanced care planning. Interestingly to see is that every interviewee except the GP and support nurse elderly care, thought it was the GPs responsibility to record elderly. The GP and support nurse elderly care thought it was the responsibility of the entire primary care sector. However, all agreed that having a clear and available advanced care planning could prevent ED admissions when a patient has documented that he/she do not wants to an ED. Furthermore, it improves care coordination since it documents where a patient wants to go to and formalizes responsibilities.

5.1.4 Lack of healthcare resources

An explanation of the high thresholds of nursing homes and the low amounts of performed advanced care plannings was found in the scarcity of resources. For nursing homes both workforce shortages as a lack of capital were found to be an important barrier to interorganizational collaboration. There were both a lack of experienced personnel as a lack of money to hire qualified personnel. The GP experienced also heavy budgetary cuts in first line stays, with the result that it was harder to get emergency bed for an older patient. The same counts for GPs, as they did not have enough time to participate in interorganizational collaboration, this directly impacted the care coordination negatively. But there is support from practice support nurses elderly care, geriatricians, and specialists elderly care. However, according to the interviews, GP have difficulties consulting those specialisms both due to shortage of these specialisms, lack of financial resources and unfamiliarity with consulting them. Unfamiliarity resulted in a lack of interorganizational collaboration and consequently, roles stayed unclear to the extent of what they could mean for each other and no interorganizational protocols were created.

5.2 Acute care pathway via general practitioner cooperatives

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evening, night, and weekend. The process of care coordination by general practitioners’ cooperatives starts when an older patient calling to the GPCs triagist. As stated in the research setting, there are four possibilities a GPC triagist can do; 1 postponing to GP by day, 2; consultation of ambulance services, 3; receiving patient at GPC and 4; visit the patient by car (figure 5). Here, the problems of information availability experienced by GPs and ambulance nurses get even worse.

Figure 5; Acute care pathways via GPC

5.2.1 Lack of patient’s medical information

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loggings from other care providers besides the patient’s own GPs. This is no problem in life threatening cases when it is clear what kind of care an older patient should receive, but the semi-acute care cases are more difficult and there are no interorganizational protocols to further coordinate patients to first line stays.

5.2.2 Impact of doubt on care coordination

Consequently, when the triagist of a GPC does not know everything and in cases when patients are not aware or not able to tell all their relevant medical information, doubt is created in the process of coordinating care for elderly. As a result, the triagist consults in some cases redundant, too intensive healthcare resources to minimize the risk. Whereas sometimes an older patient could wait to the next day, will now visit the GPC. In cases where an older patient normally would visit a GPC, the patient would now sometimes get consulted by ambulances and in the worst case is being brought to the emergency department. As the ambulance nurse said: “We do have some communication with GP’s by day, that’s relatively all right, but the

problem is during evening night and weekend-hours, then it’s terrible, the GP in the GPC often does not have access to all information or does now know everything, so we do not know everything too, and in case of doubt, we provide care and transport a patient to the hospital”.

These are far-reaching consequences of limited information availability. The GPC manager was aware of this doubt and sees that often care provision resources are consulted who were with hindsight not necessary. The GPC manager explained that previous research showed that ambulance services got consulted too often without being necessary, mostly due incorrect triaging by GPC triagist. Nowadays, there are incentives to reduce doubts and to prevent unnecessary ambulance service consultations by more information exchange between GPC and ECR, but they are not live yet.

5.2.3 No structural protocols with first line stays

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over care by GPCs since older patients are often in the need for reassurance of their medical circumstances during evening, night, and weekend hours as explained by GPC and nursing home managers. However, there are no structural and efficient protocols between GPCs, and district nursing and first line stays. In cases when an older patient is not capable of visiting the GPC center, and there are no GPs available to visit them (figure 5), GPC’s triagist always choose to minimize doubt and consult ambulance services since one wrong decision can have severe consequences. But initiatives are running to create more protocols with district nursing and nursing homes. For example, GPCs in Friesland are going to collaborate with district nurses around certain clinical domains, such as catheter care. However, this is not live yet too.

5.3 Acute care pathway via emergency controlling room

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Figure 6; Acute care pathway via the emergency controlling room

5.3.1 Minimal information availability

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5.3.2 Limited ECR consultation possibilities

When an older patient calls to the ECR, the provided information by the patient is inserted into a triage system creating a certain output activity (Figure 6). Only when the patient has no life-threatening symptoms, the patient is kindly but firmly asked to call the GPC or to wait until the patients GP is available. In other cases, the emergency controlling room is obligated by law to consult ambulance services to further examine the patient’s health status. But, as mentioned in paragraph 5.2, ambulance services often were consulted without being necessary. This also counts for consultations from the emergency controlling room and is partly explainable due to the limited amount of choices an emergency controlling centralist has. Where GPCs can still make patients come to their station or to visit them by care, the ECR-centralist only can decide to refer the patient back to the GPC or to send ambulance services. A direct consequence of this are the two distinct worlds between primary and secondary care acknowledged by all interviewees. As such, interorganizational collaboration facilitates upscaling of healthcare resources. A GP or GPC triagist can easily refer patients to the emergency number or consult ambulance services. But the ECR can only refer patients back to the GPC when there is no change of life-threatening circumstances and besides this there are no other consultation possibilities. Interviewees said that there are no interorganizational protocols for ECR established with primary care which directly impacts the coordination of care for elderly and ED admission rates. An important and worrying consequence is explained by the ambulance service manager; “When an ambulance visits a patient during evening night and weekend

hours, often a patient is not required to go to ED and the own GP is not available, but considering the social aspect we cannot leave older patient alone so we bring the patient to the ED”. This is also confirmed by the ambulance nurse and this found to be one of the causes

elderly patients are brought to emergency departments while this was not medically necessary.

5.3.3 Unfamiliarity

Besides having limited consultation possibilities, all interviewees experienced a high gap between the acute and primary care. This is also stated above as having two distinct worlds, but this needs more explanation in the light of care coordination. As interviewee 3 states: “ A

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can talk about all kinds of linkages between information systems, but I think we first must link ourselves, to know the professional with whom we are working with”. This might be a little bit

exaggerated, but the core of the problem is that if you do not know how care professionals of other organizations work, you are also not able to interact appropriately. This is exactly one of the things that is needed while performing both acute as semi-acute care. Interviewees expressed their wishes to just know what the other was doing, what protocols they used and how they respond to different kind of acute care cases.

5.4 Lack of financial incentives

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6. Discussion

The aim of this research was to further extent the knowledge of how interorganizational collaboration can be held responsible for elderly being admitted unnecessary to emergency departments in the acute care network. This chapter puts the findings in perspective to what already is known in the literature

6.1 Acute vs semi-acute

The findings present differences in interorganizational collaboration in different acute care coordination processes. Where interviewees experienced that acute care is organized relatively well and can provide the right care at the right moment, the semi-acute care has more troubles realizing this. This does however not imply that older patients are not unnecessary referred to EDs, it implies that is a lot less compared to semi-acute cases. The only way an older patient does not receive appropriate care at the ED while meeting the medical requirements for EDs, is when the patient has documented that the patient did not want to go to the ED. In other acute care cases, there are clear responsibilities and guiding protocols between different organization in the acute healthcare sector. Additionally, in times of life-threatening circumstances there are fixed communication protocols between the emergency department, the emergency controlling room and ambulance services making sure elderly are efficient and effective being transported to the hospital. However, in cases of semi-acute care there are less protocols for consultation between these three actors.

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where clear protocols are in place for ED practitioners to process incoming patients, there are no structural protocols with ambulance services to engage in consultation of situations when ambulance nurses or not sure whether an older patient would benefit ED admission. Having no clear protocols for how to coordinate care for patients with semi acute care demands can be explained by having no overarching force taking responsibility for semi-acute care for older patients in evening, night, and weekend hours.

6.2 Impact of information availability on care coordination

Another important factor hindering the interorganizational collaboration for elderly is the inequality of information availability between healthcare providers. Where general practitioners possess the most knowledge of all other healthcare providers, they are not able to share this with other care providers. This has to do with hindering laws which forbid the exchange of electronic patient files, but also a scarcity of performed advanced care plannings. Legislations are there for an important external factor to consider and is acknowledged in healthcare literature (Spronk et al., 2019), but to the best of the researcher’s knowledge, no research has yet addressed the high influence privacy legislation has on coordination processes in the acute care network. Furthermore, where current literature confirms the need for information exchanges, and the problem of vertical and horizontal organizational fragmentation (Kern et al., 2018), this study shows that both horizontal as vertical information fragmentation and availability is an important barrier to care coordination in all three acute care coordination processes. Different information systems hinder the exchange of information due different technological characteristics, but also different formats of how information about elderly is documented. Therefore this research adds to findings of Sofia Pereira and Soares (2007) for the need to create a system that supports collaboration and information management and links different healthcare providers.

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has some restrictions and a lot of medical information is not available, disregarding the wishes from older patients when they are not able to communicate them by themselves. Therefore, the GPC triagist has less information available compared to a GP and this directly influences the decision-making process in care coordination. But problems get worse when an older patient calls to the emergency number. Comparing to the information availability from LSP for GPC triagists, an ECR centralist only has the information available which the older patient provides to them at the time. Based on this information, the ECR centralist must decide to refer an older patient back to the GPC when the triage system says there are no changes of life-threatening circumstances and all other cases, ECR centralists are obligated to consult ambulance services. As stated by the interviewees, more available information provides better interorganizational collaboration and more provisions of right care at the right moment. Because in cases of doubt, healthcare providers always consult ambulance services. Where current literatures especially promotes information exchange within healthcare organizations and domains (Heath et al., 2017), this research therefore finds that exchange between healthcare sectors such as secondary and primary care is at least as important. Because exchange of information between secondary and primary care providers is needed to facilitate appropriate care coordination.

6.3 The amount of interorganizational relationships

The last topic that needs to be discussed is the amount of interorganizational collaboration relationships between care providers in the different pathways of providing acute care. First, by the taking the general practitioner pathway, the GP has interorganizational relationships with almost all care providing institutions in the acute care network. This enables further role clarification, protocols development and coordination for older patients so that when it is needed, they can go to the right care provider. However, the consultation of specialist elderly care and geriatricians were found to be difficult. This could be explained by the fact that geriatricians are often approached as being employed in the secondary care (Conroy & Parker, 2017), but this research found they are also of high importance in primary care and can, besides building a bridge between primary and acute care, also assist in recording advanced care plannings.

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organizations and nursing homes. Therefore, GPCs were found to have some relationships with other relationships with nursing homes and district nurses, yet they were only regular relationships due to their experiences with them as general practitioner by day. In terms of GPC, there were no collaborative relationships with district nursing or nursing homes to coordinate older patients to. Furthermore, the GPC was found to have no interorganizational relationships with geriatricians, practice support nurses elderly care, specialist elderly care or with emergency department professionals. Where the first three actors are not available by evening, night, and weekend hours, emergency department professionals are able to assist in the coordination processes but only if collaborative relationships are established with clear protocols.

The third option is the ECR pathway. They only have collaborative interorganizational relationships with ambulance services and with the emergency departments. However, there are relationship with GPCs, yet, they are not experienced to be good enough to provide better care coordination for elderly. More guiding protocols, financial incentives and less hindering laws would support this collaborative relationship. A counterargument was also given by the interviewees, as such research finds that in bigger networks, such as acute care network including both acute care as primary care providers, creating trust and collaborative relationships between all partners would not be feasible. Yet, having clear guidelines, overarching protocols, financial incentives and clear responsibilities would already improve the relationship and would foster interorganizational collaboration making sure older patients are not being admitted unnecessarily to EDs and therefore will receive better care.

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7. Conclusion

This research has tried to gain more understanding about how interorganizational collaboration can be held responsible for unnecessarily ED visits by elderly can in the acute care network. This done by a single case study conducting 12 semi-structed interviews among partners of both acute as primary care providers in the acute care network in the Northern Netherlands. The research question is explained by taking an interorganizational collaboration approach on the acute care coordination processes including the GP, GPC and ECR pathways in the acute care network.

Regarding the execution of acute care, older patients are rarely unnecessarily brought to EDs, unless they have stated otherwise. In cases where this occurs, this is explained by having no direct access to patients’ medical files by; GPCs triagists, ECR centralists and ambulance nurses. Regarding semi-acute care, interorganizational collaboration is working at its best during working hours. This is explained by the availability of patients’ own general practitioner. They are in control of interorganizational collaboration facilitating the coordination of semi-care for older patients. Their roles are clear, have collaborative interorganizational relationships, and they have the authority to consult district nursing, first line stays and can arrange medical indications for nursing homes. In more difficult situations of performing semi-acute care, consult help from geriatricians and specialists elderly care. However, these collaboration efforts are hindered by low information availabilities, nursing acceptance thresholds, scarcity of resources and having a lack of advanced care plannings who can be consulted in case of care escalation. During evening, night, and weekend hours, interorganizational collaboration is becoming less due to the disappearance of GPs. This is directly experienced to have a negative influence on the provision of care. As such, interorganizational collaboration can be held responsible for unnecessarily emergency department admissions due to having a lack of interorganizational collaborative relationships, protocols, and a scarcity of information exchanges.

7.1 Theoretical implications

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controlling room pathway in acute care network. It therefore extents the scope, span, and intensity of the interorganizational collaboration in healthcare literature. Findings reveal that role clarification, supporting protocols, information exchanges and collaborative interorganizational relationships are important facilitators in situations where semi-acute care needs to be performed. In situations where there is a lack of the above, this result in barriers to interorganizational collaboration hindering coordination of care. This research also emphasizes the role of environmental factors such as a changing demographics and having an absence of central patient files, shared information systems and hindering laws.

7.2 Managerial implications

First, findings of this research should create awareness among policy makers, healthcare managers but also healthcare practitioners for the for more interorganizational collaboration in the acute care network to provide appropriate care for older patients. This should especially be done for performing semi-acute care. Therefore, this research can be uses as a starting point tackling the abundance of interorganizational relationships by creating interorganizational protocols and clarify roles between healthcare organizations. Furthermore, this research confirms the needs for more information exchanges about patients’ medical files and the importance of advanced care plannings. Lastly, an important factor policy maker in healthcare need to consider are the creation of financial incentives for stimulating more interorganizational collaboration.

7.3 Limitations and future research

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Since the exploratory nature of this research, this research has only identified whether interorganizational collaboration relationship existed and how they are designed while both performing acute as semi-acute care. Future research should provide more in-depth information about how interorganizational collaborative relationships between GPCs, ECRs, ambulance services but also geriatricians and specialists elderly care can be established or motivated by financial incentives in cases of performing semi-acute care. Furthermore, future research is needed to see how advanced care plannings can be performed and together with electronic patients’ files can be shared across the acute supply chain without experiencing difficulties from information systems or laws. Lastly, future research could examine the feasibility and effectiveness of how third parties can be used to formalize overarching guidelines to coordinate care (Liberati et al., 2016; Sampson et al., 2015).

In the light above, this research attempted to explain how interorganizational collaboration can be held responsible for unnecessarily ED admissions by elderly. This is done by clarifying the unclarity of performing both acute as semi-acute care in the acute care network. Yet, more research and practical solutions are needed to prevent unnecessary ED admissions for elderly and to improve their quality of care.

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How interorganisational collaboration can be held

responsible for unnecessarily emergency department

admissions by older patients in the acute care network

Master Thesis Supply Chain Management

Abstract

Contents

Acknowledgement

1.Introduction

2.Theoretical Background

2.1 The need for interorganizational collaboration in healthcare

2.2 Conditions facilitating interorganizational collaboration

2.3 Care coordination

2.4 Environmental factors

2.5 Theoretical implications

3.Research Setting

4.Methodology

4.1 Research Design

4.2 Data collection

4.3 Data analysis

5.Findings

5.1 Acute care pathway via general practitioners

5.2 Acute care pathway via general practitioner cooperatives

5.3 Acute care pathway via emergency controlling room

5.4 Lack of financial incentives

6. Discussion

7. Conclusion

8. References