A strong network - A strong patient.

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A strong network - A strong patient.

Master thesis

MSc Supply Chain Management

Faculty of Economics and Business

University of Groningen

July 10

th

2017

By

Elroy St.Jago

S2356708

Supervisor

A.C. (Bart) Noort, MSc

Co-assessor

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Abstract

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DATA COLLECTION 11 DATA ANALYSIS 12 RESULTS 14 EXPERTISE 14 DIAGNOSIS 14 INTERACTION 15 FUNCTIONS OF INTERACTION 15 CENTRAL POSITION OF PRIMARY CARE 15 RELATIONAL TIES 16 BENEFITS OF RELATIONAL TIES WITHIN CARE PROVIDER’S OWN SETTING 16 BENEFITS OF RELATIONAL TIES ACROSS SETTINGS 17 THE PROXIMITY OF RELATIONAL TIES TOWARDS THE PATIENT AND ITS INFLUENCE ON CONTINUITY OF CARE 18 ALLOCATED TIME 18

INTERRELATEDNESS: EXPERTISE, INTERACTIONS, RELATIONAL TIES, ALLOCATED TIME 20

NETWORK RESOURCE UTILIZATION 20

SYNERGY EFFECTS WITHIN THE SUPPLY CHAIN 21

POSITION OF COORDINATION AND ITS INFLUENCE ON CONTINUITY OF CARE 22

DISCUSSION & CONCLUSION 23

LIMITATIONS & FUTURE RESEARCH 24

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Introduction

Chronic obstructive pulmonary disease (COPD) is a major cause of morbidity and death and is expected to be the third largest cause of mortality worldwide by 2020 (Trappenburg et al., 2011; Longfonds, 2015). Care providers in the COPD supply chain are faced with the challenge of treating the world’s most severe chronic illness in terms of mortality (WHO, 2017). Recent developments call for integrated care chains in order to improve chronic care by enhancing access, coordination and continuity of care (Waibel et al., 2015). Coordination of care aims to “integrate patient care services between two or more participants involved in a patient’s care to facilitate the appropriate delivery of care services" (Bodenheimer, 2008). This study claims that the way coordination is positioned in the supply chain plays an important role with regard to the continuity of care.

The results of integrated care models results are scarce considering continuity of care across care settings (Waibel et al., 2015). Continuity of care refers to the extent to which services are received as part of a coordinated and uninterrupted succession of events consistent with the medical care needs of the patient (Shortell, 1976). In order to provide such uninterrupted services, coordination is of vital importance (Bodenheimer, 2008). Sampson et al. (2015) point out that coordination plays a critical role in a chronic health care context because of the numerous interactions taking place between entities in the network. These interactions occur both between care providers as well as between providers and patients. Coordination is the function that manages these interactions and ensures that patient needs and preferences for services and information sharing across people, functions and sites are met (Bodenheimer, 2008). Therefore, coordination of care is a prerequisite for coherent and connected care. Examples from both primary and secondary care settings show differences with regard to coordination within the COPD supply chain (Zorgpad COPD-longaanval met ziekenhuisopname, 2017). On the one hand practice provides examples of care initiated by primary care, while on the other hand, practice provides examples of care initiated by secondary care. Care providers in a primary or secondary care setting vary in their degree of expertise, interactions, relational ties and allocated time within the supply chain. It is yet unclear how these differences relate to continuity of care.

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differences in expertise as primary care providers possess general expertise and secondary care providers specialized expertise (Starfield et al., 2005). Next to expertise, providing coordinating activities requires time (Bodenheimer, 2008). The assumption is that the allocated time differs between primary and secondary care providers. Furthermore, differences in interactions between primary and secondary care providers are identified (Bodenheimer, 2008). Primary and secondary care providers have different counterparties with whom they interact through, for example, face-to-face conversations, phone calls, emails and referrals. These differences in interactions are assumed to lead to differences in relational ties between care providers. It is the varying interactions and relational ties between care providers that result in differences between coordination initiated by either primary or secondary care. Sampson et al. (2015) support this by stating that the care coordinator is a conduit for interaction within the network, thereby influencing the interactions that take place between the care providers. Network theory suggests that strategically positioning coordinating activities within the supply chain is an influential factor regarding interactions the supply chain (Rowley, 1997; Håkansson & Snehota 1995). This study explores the different positions of coordination within the COPD supply chain and how this influences continuity of care. It addresses the ongoing call to further investigate continuity of care within integrated care networks (Waibel et al., 2015).

This study addresses the position of coordination and its influence on continuity of care within the COPD supply chain. Current healthcare literature addresses the importance of coordination regarding continuity of care (Bodenheimer, 2008). It is the function of coordination to manage the numerous interactions within the supply chain with the aim of achieving coherent and connected care for the patient. Sampson et al. (2015) define different types of coordination, either initiated by the patient, care providers or through a third-party coordinator. However, the position from which coordination is initiated has received little attention. The fact that practice provides examples of different positions of coordination strengthens the assumption that it could be an important factor contributing to continuity of care. Therefore, this study aims to answer the following question:

How does the position of coordination within the COPD supply chain influence continuity of care?

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Theoretical background

Coordination

Coordination of care is vital in order to manage the numerous interactions within the supply chain. Within the COPD supply chain the coordinator of care manages interactions and integrates patient care activities in order to facilitate connected and coherent care services (Bodenheimer, 2008). According to Dutch COPD guidelines this coordinator of care does not have to be provider that is responsible for treatment of the patient (COPD Zorgstandaard, 2016). Therefore, coordination can assume different positions within the COPD supply chain

Strategic positioning of coordination within the network

Practice suggests that a general practitioner or practice nurse within primary care or a pulmonary nurse within a secondary care setting adopts the role of coordination. Because a practice nurse is more closely linked to primary care and a pulmonary nurse to secondary care, the differences in expertise, interactions, relational ties and allocated time are influential with regard to continuity of care. For example, Bischoff et al. (2012) mentioned differences between nurses in their education, experiences and attitudes. It is these differences that determine the degree of expertise of care providers. This background of care providers is often not specified in studies yet is an important factor (Baker and Fatoye, 2017). Furthermore, Bourbeau and Saad (2013) mention the differences of positioning coordination either within a primary or secondary care setting. They state that more complex patients might be better placed within a secondary care setting because of the need for expertise and follow-up care services. The suggestion follow-up care differs according to whether the patient is coordinated from a primary or secondary care setting implies differences regarding the extent to which care services are received as part of a coordinated and uninterrupted succession of events. This strengthens the claim that the position of coordination influences continuity of care within the COPD supply chain.

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within the COPD supply chain. The care provider acting as coordinator is a central point for both the patient and other care providers involved in treating the patient (COPD Zorgstandaard, 2016). It is through this position that interactions within the supply chain are managed. In addition to interactions, Rowley (1997) also states the importance of relational ties with other actors in the network. Relational ties between care providers are suggested to provide opportunities regarding the use of available resources within the supply chain (Håkansson & Snehota, 1995). This suggests that by positioning coordination either in a primary or secondary care setting may provide different ways to utilize available resources, such as information and expertise, within the COPD supply chain through the use of relational ties. The perspective of Rowley (1997) is helpful as he states that treating “an actor’s position as a variable in a complex social system provides an opportunity to understand more fully how patterns of stakeholder interactions impact the organization.” This perspective is used for this study by treating the position of coordination as a variable. Additional insights can be gathered by investigating this position and how it influences continuity of care within the COPD supply chain.

Continuity of care

While continuity of care generally refers to the perception of coherent and connected care, Haggerty et al. (2003) point out two different perspectives. From the perspective of the patient, continuity of care is the perception that the different providers involved know what has happened and that they agree on the care required. From the perspective of care providers, the experience of continuity relates to their perception of having sufficient knowledge and information about a patient to best apply their professional competence, including the confidence that their input will be recognized and pursued by other providers. This study combines the two perspectives because the patient has to perceive care as continuous, but in order to provide the patient with the right treatment at the right time, continuity of care is of significant importance for the care providers.

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Table 1 Dimensions of continuity of care

Throughout this study the position of coordination within the supply chain is treated as a variable. Additional insights are gathered by investigating this position either within a primary or secondary care setting. This difference in positioning is a determining factor towards the level of expertise, interactions, relational ties and allocated time of care providers. The differences between these factors are suggested to be influential towards continuity of care. How these differences influence continuity of care within the COPD supply chain is investigated to the three dimension of continuity of care (Table 1).

Informational Continuity (IC)

This is the use of information from past events and personal circumstances to appropriate care for the individual patient.

Information focuses both on the medical condition as well as the patient context (preferences and values). This information makes it possible to ensure that care services are responsive to needs of individual patients. Management continuity (MC)

Continuity is achieved when services are delivered in a complementary and timely manner. This is especially relevant for chronic care supply chains in which patients require care from several care providers.

Shared management plans or care protocols facilitate management continuity, providing a sense of predictability and security in future care for both patients and providers.

Relational continuity (RC)

This refers to an ongoing therapeutic relationship between a patient and care provider.

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Research Methodology

This study investigates how the position of coordination influences continuity of care by considering the supply chain as a whole to be the unit of analysis. By conducting a multiple case study new knowledge and insights are gained regarding this aim. According to Voss et al. (2002), the strengths of case research applicable to the current study are the ability to explore a certain phenomenon and answer a “how” question, the ability to understand the context surrounding the phenomenon, and to generate relevant theory through observing the phenomenon in its natural setting. This study is of an explorative nature because the position of coordination in relation to continuity of care within the COPD supply chain has received little attention. By conducting multiple case studies, propositions are formulated based on the data collected (Eisenhardt and Graebner, 2007). Using a multiple case study approach increases the external validity and generalizability of this study’s findings (Meredith, 1998). The next paragraph provides an introduction to the organization of COPD care. The case descriptions, method of data collection and data analysis are then discussed.

Organization of Dutch COPD supply chains

Chronic obstructive pulmonary disease is a complex, slow-progressing chronic lung condition requiring long-term care from various healthcare professionals. Care for COPD in the Netherlands is well organized through frameworks. Guiding examples are the COPD Zorgstandaard from the Long Alliantie Nederland (LAN) , and the Nederlandse Huisartsen Genootschap (NHG) Standaard COPD (Zorgstandaard COPD, 2016; NHG, 2015). The aim of these is to provide a framework for providers and patients with regard to COPD care delivery and the organization of the supply chain (COPD Zorgstandaard, 2016). However, these frameworks leave room for interpretation regarding the position of coordination within the supply chain. Therefore, investigating the different positions of coordination is suggested to provide the opportunity to explore the concepts of coordination and continuity of care and to develop propositions based on these observations.

Case Selection & Description

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similarities between the cases regarding coordination and continuity of care within the COPD supply chain.

Table 2 Case selection

Two cases were selected according to the criteria presented above:

Case A is a COPD supply chain that represents an integrated health care network. In addition to primary and secondary care professionals, the supply chain contains an organization responsible for the chain care. This organization is an association of general practitioners who operate within their own practices with the association operating as an umbrella organization, facilitating transmural care for chronically ill patients. In other words, there are clear efforts toward integration of the COPD supply chain. The most noticeable integration effort is the availability of a shared information system (IS). Care providers included in the IS are general practitioners, practice nurses, dieticians and the pulmonary analyst from the leading hospital in the region. This IS serves multiple purposes as care providers are able to interact both within and across settings, provide referrals for other disciplines and e-consult the pulmonary analyst for a quality check of the diagnosis. Pulmonary doctors and nurses from the hospital are not included in the IS.

Constant factors between cases _{• One leading hospital in the region} • Clear efforts regarding care coordination

• Clear efforts with regard to a certain level of integration of the COPD supply chain

• Patient-centered care and a care plan formulated together with the patient

• The delivery of acute care considered to be constant for all patients

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Case B was chosen first of all for a specific project that is currently being conducted in which the pulmonary nurse serves as a COPD coach. This function requires the nurse to actively coordinate care. The nurse provides patients with information and guidance and actively integrates care services between the participants involved in providing care for the patient. The two selected cases provided the opportunity to investigate the position of coordination. Case A provided the opportunity to explore the position of coordination within a primary care setting, whereas Case B provided the opportunity to explore the position of coordination from within a secondary care setting. Table 3 presents an overview of the interviewees from both cases.

Data Collection

Semi-structured interviews with care providers form the primary source of data. An interview protocol derived from the theory section and consisting of open-ended questions was established in order to guide the data collection process (see Appendix A). Conducting interviews with care professionals from primary and secondary care settings provides a comprehensive view of the COPD supply chain. The interviews were conducted with general practitioners, practice nurses, a district nurse, a pulmonary doctor and pulmonary nurses. The semi-structured interviews resulted in two-way communication and the ability to go more

in-Table 3 Interviewees included

Case A Role Specifics

Primary care A: General practitioner

B: Practice nurse C: Practice nurse

D: Practice nurse & Quality consultant

Quality consultant within chain care

Secondary care E: Pulmonary nurse

F: Pulmonary analyst Diagnosis

specialist Case B

Primary care G: General practitioner

H: Practice nurse I: District nurse

Secondary care J: Pulmonary doctor

K: Pulmonary nurse L: Pulmonary nurse

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depth when necessary during the interviews. Semi-structured interviews provide rich and new data, without the risk of collecting information that is too broad or general (Voss et al., 2002). All the interviews were conducted face-to-face with the permission of the interviewee, with notes taken and the interview audio recorded. Finally, once the interview was transcribed, the transcription was sent back to the interviewee to check for completeness and accuracy.

Data Analysis

A key issue in analyzing case research is the volume of data (Karlsson, 2016). In order to address that issue and to identify important concepts, data was reduced into categories through coding. An integrated approach of inductive and deductive coding was applied. First order coding was performed according to predetermined deductive codes. However, the views of the interviewees were given a prominent representation to integrate an inductive approach while coding the data. As Gioia et al. (2013) suggest, this creates opportunities to discover the context, rather than confirming existing concepts.

Therefore, in addition from the deductive starting point, coding of data progressed along the following three steps (Gioia et al., 2013):

1. First order coding: deductive while staying close to comments of interviewees 2. Second order themes: identifying more abstract concepts

3. Finding relationships through data structure, narratives and construct tables

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Quotes were selected from the interviews that matched the deductive code descriptions. Based on these codes a thorough analysis was performed to identify differences, commonalities and the interrelatedness between primary and secondary care settings in relation to continuity of care within the COPD supply chain. The next section discusses the results of the data analysis. Topic Deductive code Description

Position of coordination

Expertise Level of knowledge and experience of the care provider

Interaction Interactions between care providers

Relational ties Professional relationship between care providers

Allocated time Time capacity of care professionals

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Results

In this section the results of the data analysis are presented in five sections. The first four sections present the data from both cases on the four factors of expertise, interaction, relational ties and allocated time and how the position of coordination in either a primary or secondary care setting influences continuity of care. The fifth section addresses the interrelatedness between these four factors that emerged from the data analyses.

Expertise

Diagnosis

Both cases suggest that diagnosis is an important factor concerning future care services. The diagnosis functions as a base line because it determines both the medical condition of the patient and follow-up care. Providing a correct and reliable baseline is linked to IC because the quality and reliability of the diagnosis provides information regarding the patient’s medical condition. It makes it possible to adapt future services in a way that responds to the needs of the patient. Furthermore, the data suggests that the care provider’s expertise relates directly to the quality of the diagnosis and its reliability as a baseline for further coordination of care. Discussing the level of expertise in relation to the quality of diagnosis within primary care settings, it was a pulmonary analyst who commented that after following a course on diagnostics only 60% of the performed diagnostics were of acceptable quality (F). The comment of another interviewee illustrates that reliable diagnoses impacts continuity of care: “Because now it is often that a spirometric diagnosis has taken place, but yes, was it actually good? And then we will use that again as a base line, and then the next measurement a year later, that one was okay or was it not?” (F). It has been mentioned during multiple interviews that a secondary care setting makes more reliable diagnosis possible.

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Therefore, both the level and availability of expertise influence the provision of care appropriate for the individual patient. In order to provide care services consistent with the medical needs of the patient, positioning diagnosis within a secondary care setting would benefit continuity of care.

Interaction

Functions of interaction

The results reveal three coordinating functions of interaction with regard to IC. The first and second functions are the collection of information in a transparent and consistent manner. When discussing the use and sharing of information, interviewee (E) commented by: “That you could get a better picture of the disease burden; change in medication, smoking cessation, patient lifestyle. That you have quicker understanding of such factors” (E). The transparency and consistency of information contributes to appropriating care for individual patients. The third function is signaling, referring to a situation where another provider notices relevant issues: “If we see and hear things, we still ask the GP. Can you do anything with that?” Do you know something that we can do? It’s really a consultation about what we see or hear” (I). This exchange of information through interactions provides the opportunity to appropriate care services for the patient.

Central position of primary care

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Both case studies regarded primary care as the central communicator in interactions. This implies that, except for severe lung attacks, primary care is typically a patient’s first source of help. Primary care providers receive, collect and manage all interactions concerning the patient, not the secondary care professionals. This is the reason why it is primary care providers that are able to provide consistency and transparency of information. Therefore, primary care is the most logical place to serve as the center of interactions.

Relational ties

Both cases highlighted relational ties between care providers as important when dealing with continuity of care. This was apparent in both cases as well as primary and secondary care settings. As suggested in the introduction, the relational ties of care providers provide the opportunity to use the available resources within the supply chain. The relational ties of each care provider create the opportunity of unique resource combinations, the opportunity to connect care in a complementary manner, and the opportunity to combine information between care providers. These relational ties and the resulting opportunities of using these ties influence both IC and MC. The influence of relational ties is discussed below in three sub-sections. First the benefit of relational ties within a care provider’s own setting is discussed. Second, the benefits of relational ties across settings are discussed. Third, an overview is provided regarding the position of coordination and how relational ties influence continuity of care.

Benefits of relational ties within care provider’s own setting

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problem. The moment you clearly see a problem, you can make it a lot easier by making a plan right away. Because if a social worker or a psychologist needs to find out what is it from? We often are 3 or 4 conversations further. Now we can just tackle it right away” (L).

The clarification regarding the importance of relational ties within care settings is found within the current organization of COPD care. One interviewee commented regarding relational ties across care settings: “Yes, I'm all for it . . . transmural how I work, I have to look for it myself . . . But if you look at the new Care Path (COPD longaanval met ziekenhuisopname, 2017), that's just out. It has now been set up transmural, so I actually expect that to change” (K). This implies that a recent shift has occurred focusing on closer integration between primary and secondary care settings (transmural). Therefore, relational ties across care settings and resulting influences on continuity of care are discusses next.

Benefits of relational ties across settings

Every interviewee explicitly mentioned the importance of relational ties that cross the boundaries of primary and secondary care settings. These relational ties and the resulting potential of utilizing them influence both IC and MC.

Regarding IC, relational ties across settings create the ability to use others’ information to make current care appropriate for the individual: “Then you will get additional information that is important for your care provision” (I). Another situation that demonstrates the influence of relational ties on IC is the potential of quick problem solving: “In case of doubt, it is the practice nurse who checks much easier. So it takes less time in which care is continued in mistakes or doubts … If the practice nurse doesn’t have that tie to me, and thinks I cannot directly call the pulmonary doctor, because then, I have to refer again. I will first consult with the general practitioner and I will perform another spirometric test. It can then maybe take 4 weeks. While it could actually be resolved quickly with one short tie.” (F).

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to or not. So if they've been with us, they also understand, oh, they're also doing these and these lung functions and then they can evaluate the lung tissue much better. Well, in that case it is worth it to refer in such a case or for that doubt. So, then that it is referring that is much more flexible” (F). The previous quote is in line with the concept of MC as it refers delivery of services in a complementary and timely manner. The knowledge of care services delivered by others is important for achieving MC. These examples suggest that relational ties between care providers and the access to resources they entail are key to achieving both IC and MC.

The proximity of relational ties towards the patient and its influence on continuity of care

The results provide it is not the difference in a care provider’s relational ties that is interesting; it is the position of those ties within the supply chain. It is the proximity towards the patient that is suggested to be of importance regarding the use of relational ties. To oversimplify for the sake of argument, both a practice nurse and a pulmonary nurse have ties with physiotherapists, dieticians, psychologists, and, in some cases, home care and district associations. It is for this reason that the data does not reveal immediate differences between the relational ties of either a primary or secondary care provider. The following comment serves to illustrate the proximity, and subsequent use, of relational ties: “The moment we arrived at home, we also saw that it was no longer normal care, but had to be more specifically aimed towards palliative care. And that is sometimes much clearer and faster to the general practitioner than when I do that through the lung doctor. That is what makes it very nice and very disciplined. That you are also able to address the dietitian. Then you can see much clearer what care is actually provided, also from the physiotherapist” (E). This provides it is the proximity to the patient that is influential towards the use of relational ties. Therefore, the potential benefits of relational ties are more clear and immediate in a primary care setting compared to a secondary care setting.

Allocated time

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Allocated time of care providers is an important factor related to the establishment of a therapeutic relationship between provider and patient. The positive influence of this relationship on continuity of care is illustrated by the following comment by a practice nurse: “I usually know people longer before they go to the dietitian and then you have the ability to discuss with the dietitian, you have suggested that and that diet, but I do not know if that is feasible for this patient. Past experiences with the patient have already shown that certain things cannot be sustained or something. Isn’t there a different approach that we can think of?” (H). This comment illustrates how an ongoing relationship between provider and patient provides valuable information towards appropriating current and future care services for the patient.

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Interrelatedness: expertise, interactions, relational ties, allocated time

During the data analysis it was discovered that the dimensions of expertise, interactions, relational ties and allocated time are not independent. Interrelatedness between these dimensions emerged from the data analysis influencing continuity of care within the supply chain. The following sub-sections address that interrelatedness and the resulting influences on continuity of care.

Network resource utilization

The first interrelation was found in the opportunity for combining resources through interactions and relational ties. Such interactions and relational ties between care providers provide access to resources within the supply chain. An illustrative example of resource utilization through relational ties was found within the medical diagnosis of patients. The interviewees set diagnoses in four different ways, as can be seen in Table 5. Configurations two and three suggest interrelatedness between relational ties, interactions, and the access to expertise as a resource. Configuration two describes the diagnostic phase being carried out within a primary care setting. When doubts occur, the primary care provider has the ability to e-consult the pulmonary analyst positioned within a secondary care setting. This pulmonary analyst functions as a back up who can be accessed and used for medical expertise as required by primary care providers. This configuration provides a way to utilize expertise across settings through relational ties and interaction. The bundling of resources and access to other care providers through interactions and relational ties improves MC. Using such expertise across settings provides the necessary information to appropriate care services for patients. This positively affects IC.

Table 5 Different configurations of medical diagnosis

Description Source Case

1 Diagnostics in primary care setting H B

2 Diagnostics in primary care setting with pulmonary analyst as potential back-up through IS

A-D A

3 Diagnostics at laboratory, results send to pulmonary doctor, analysis by pulmonary doctor, results send to general practitioner who discusses the results with the patient.

G B

4 Diagnostics in secondary care setting E, F, J,

K, L

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Configuration three also suggests interrelatedness between the three dimensions of relational ties, interactions and expertise as a resource. The following comment serves as an illustration: “If the lung function is done and we run the tests at the lab, it is electronically sent to the pulmonologist who evaluates it and sends me the advice. So you're hugely covered there. And the pulmonary doctor sometimes comes up with suggestions of which I think yes, you can look that way as well. Or ok, nice suggestion, so could I do it like that” (G). This example highlights the interaction across settings (laboratory, pulmonary doctor, general practitioner), the use and bundling of expertise across settings, and the relational tie between pulmonary doctor and general practitioner. By interacting, suggestions are exchanged between the pulmonary doctor and general practitioner in order to appropriate care for individual patients. This third configuration reveals a synergy that is achieved between care providers through the interrelatedness between expertise, interactions and relational ties. That synergy is beneficial to continuity of care.

Synergy effects within the supply chain

The relational ties between care providers, the utilization of resources through relational ties and accompanying interactions result in the opportunity to benefit from synergies. This can again be illustrated by focusing on the third configuration of setting the medical diagnosis (Table 5). Normally the process would be as described in Table 5, involving separate and sequential services. However, the actual process consists of a situation where interaction between two care providers results in additional suggestions and advice regarding care services for individual patients. It is not just the services and subsequent outcomes of each individual care provider. An added value is achieved through the use relational ties and interactions, which results in an exchange of information and expertise between care providers. The ability to combine resources, such as expertise and information through interactions and relational ties not only makes it possible to connect care services in a complementary way. It also provides the opportunity to benefit from resulting synergies within the supply chain. Therefore, the first proposition is as follows:

Proposition 1: The ability to combine resources, such as expertise and information, through interactions and relational ties, provides the opportunity to benefit from synergies within the

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Position of coordination and its influence on continuity of care

It has been revealed that it is not just the position of coordination that leads to significant differences of the dimensions themselves (except for expertise). Rather, the position of coordination also leads to interesting differences regarding interrelatedness between the dimensions of expertise, interactions, relational ties and allocated time. This interrelatedness allows for utilization of resources across settings through relational ties and interaction with the opportunity to benefit from resulting synergies. Furthermore, as previously indicated, the proximity to the patient is influential towards the use of relational ties. The potential opportunities of interaction and relational ties to utilize and combine resources are more clear and immediate in a primary care setting compared to a secondary setting. This results in the second proposition:

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Discussion & Conclusion

This section first discusses the results in order to answer the research question: How does the position of coordination within the COPD supply chain influence continuity of care? Second, the limitations and directions for future research are provided. Finally, managerial implications and the conclusion are provided.

The results suggest that coordination is best positioned within primary care in order to achieve continuity of care. The use of the interrelatedness between relational ties and interactions and the subsequent opportunity to bundle resources, such as expertise and information, are more clear and immediate in a primary care setting compared to a secondary care setting. This is due to the fact that the primary care setting functions as the center of interactions within the supply chain. All interactions by care providers are linked back to the general practitioner, who has the ability to manage interactions and to provide transparency and consistency regarding information flow in the supply chain. Therefore, the primary care provider functions as the so-called “information hub” (Bodenheimer, 2008). This function of primary care makes it possible to quickly and clearly bundle resources and information in order to ensure appropriate, coherent, and timely care services. Second, the ongoing therapeutic relationship between the care provider and patient provides the opportunity for gaining information regarding a patient’s needs and wants regarding appropriate care services. This information makes it possible to provide care services that respond to the needs of the patient. This relationship is ongoing in a primary care setting and is temporary in secondary care (Freeman, 2000).

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both within and across cares settings, together with the potential of resulting synergies, is a yet little addressed topic within the COPD health care literature.

Limitations & Future research

The foremost limitation of this study is the absence of patient interviewees. This was a pragmatic decision as the study had to be conducted within a limited time frame. The absence of patient interviewees resembles a lack of depth regarding the concept of continuity of care. This becomes evident when examining the definition of continuity of care, that “the unit of measurement of continuity is fundamentally the individual” (Haggerty et al., 2003). It would be an interesting approach for future research to evaluate the findings of this study according to patient experiences. Second, in order to assess how the position of coordination influences continuity of care, this study has not placed significant emphasis on the individual disease burden of the patient. It is the assumption that this would not alter the findings of this study. It could however be interesting for future research to investigate the findings of this study between COPD patients with different degrees of burden. Third, triangulation of evidence has not been achieved. This method involves the use of multiple and different sources of information (Creswell & Miller, 2010). This study finds its foundation in primary data as collected through semi-structured interviews. If one of the propositions or suggestions for future research is followed, it is suggested that those researchers aim for triangulation of evidence as a procedure to increase validity.

Managerial implications

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Conclusion

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Voss, C., Tsikriktsis, N., & Frohlich, M. (2002). Case research in operations

management. International journal of operations & production management, 22(2), 195-219. Waibel, S., Vargas, I., Aller, M. B., Gusmão, R., Henao, D., & Vázquez, M. L. (2015). The performance of integrated health care networks in continuity of care: a qualitative multiple case study of COPD patients. International journal of integrated care, 15(3).

Van Walraven, C., Oake, N., Jennings, A., & Forster, A. J. (2010). The association between continuity of care and outcomes: a systematic and critical review. Journal of evaluation in clinical practice, 16(5), 947-956.

Books, guidelines and reports

Freeman, G., Shepperd, S., Ehrich., K., Robinson, I., Richards, S., Sand, H., Pitman, P. (2000). Report of a Scoping Exercise for the National Co-ordinating Centre for NHS Service Delivery and Organisation R & D (NCCSDO)

Karlsson, C. (Ed.). (2016). Research Methods for Operations Management. Routledge. Snehota, I., & Hakansson, H. (Eds.). (1995). Developing relationships in business networks. London: Routledge.

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Appendix A Interview Protocol

Functie

1) Wat is uw functie binnen de COPD zorgverlening?

a) Wat zijn uw verantwoordelijkheden omtrent de zorg voor de patiënt? Zelfmanagement

2) Wat verstaat u onder zorg gericht op het stimuleren van zelfmanagement voor COPD patiënten?

a) Bent u betrokken bij zorg gericht op zelfmanagement? b) Zo ja, wat is uw rol hierin?

c) Wat verwachtte u van tevoren van dit soort zorg?

d) In hoeverre is de zorgcoördinator in staat om de patiënt te monitoren en ondersteunen met betrekking tot:

i) Het wel of niet behalen van de gestelde doelen? ii) Het toepassen van ‘gezond gedrag’?

Rol van zorgcoördinator

3) Welke zorgverlener moet volgens u de rol van zorgcoördinator invullen, en waarom? a) In hoeverre dragen de kennis en expertise van de zorgcoördinator bij aan de zorg voor

de patiënt?

i) Kunt u hier een voorbeeld van geven?

b) In hoeverre dragen de contacten van de zorgcoördinator bij aan de zorg voor de patiënt? i) Kunt u hier een voorbeeld van geven?

Multidisciplinair contact

4) In hoeverre is er multidisciplinair contact binnen de COPD zorgverlening? a) Ervaart u toegevoegde waarde van multidisciplinair contact/overleg? b) Zijn er eventuele barrières?

i) Zou u hier een voorbeeld van kunnen geven? Multidisciplinaire samenwerking

5) Hoe vindt u dat de samenwerking verloopt tussen verschillende zorgverleners?

a) Met welke zorgverleners is er contact met betrekking tot de behandeling van COPD: i) huisarts/PoH

ii) longarts iii) fysio iv) psycholoog v) thuiszorg

b) Is er hier een rol voor de zorg coördinator? c) Zo ja, hoe vervult deze coördinator die rol?

d) In hoeverre gebruikt deze coördinator informatie van andere zorgverleners in zijn/haar taken?

e) Indien nodig: “In hoeverre heeft u ervaringen met de zorgcoördinator?” i) Zou u hier een voorbeeld van kunnen geven?

Multidisciplinaire samenwerking m.b.t. patiënt

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a) Waarom wel/niet?

b) Kunt u hier een voorbeeld van geven?

c) Vervult de zorgcoördinator hier een bepaalde rol? Verandering

7) Wie is er uiteindelijk verantwoordelijk voor de behandeling?

a) Voert de huisarts/longarts/PoH/fysio/thuiszorg/psycholoog wel eens veranderingen door in behandeling?

i) Zorgt dit wel eens voor moeilijkheden? ii) Voorbeeld?

8) Heeft u het gevoel dat patiënten vaak navraag doen bij andere zorgverleners over door u gegeven advies?

Informatie deling

9) In hoeverre zijn er protocollen voor het delen van wijzigingen, patiënt-gerelateerde of medische kennis?

a) Welke informatie wordt er wel of niet gedeeld? i) Waarom?

ii) Tussen wie zijn deze uitwisselingen? iii) Wordt hier ook ICT voor gebruikt?

iv) Wat voor invloed heeft dit op de communicatie met de patiënt? Financiering

10) In hoeverre speelt de financiering van zorg een rol in de manier waarop zorg wordt geleverd aan de patiënt?

a) Hoe is dat dan geregeld?

A strong network - A strong patient.