Staffan Blomberg

Fidelity and moderating factors in complex interventions: a case study of a continuum of care program for frail elderly people in health and social care

BackgroundPrior studies measuring fidelity of complex interventions have mainly evaluated adherence, and not taken factors affecting adherence into consideration. A need for studies that clarify the concept of fidelity and the function of factors moderating fidelity has been emphasized. The aim of the study was to systematically evaluate implementation fidelity and possible factors influencing fidelity of a complex care continuum intervention for frail elderly people.MethodsThe intervention was a systematization of the collaboration between a nurse with geriatric expertise situated at the emergency department, the hospital ward staff, and a multi-professional team with a case manager in the municipal care services for older people. Implementation was evaluated between September 2008 and May 2010 with observations of work practices, stakeholder interviews, and document analysis according to a modified version of The Conceptual Framework for Implementation Fidelity.ResultsA total of 16 of the 18 intervention components were to a great extent delivered as planned, while some new components were added to the model. No changes in the frequency or duration of the 18 components were observed, but the dose of the added components varied over time. Changes in fidelity were caused in a complex, interrelated fashion by all the moderating factors in the framework, i.e., context, staff and participant responsiveness, facilitation, recruitment, and complexity.DiscussionThe Conceptual Framework for Implementation Fidelity was empirically useful and included comprehensive measures of factors affecting fidelity. Future studies should focus on developing the framework with regard to how to investigate relationships between the moderating factors and fidelity over time.Trial registrationClinicalTrials.gov, NCT01260493.

The flight from universalism

Abstract Up to the beginning of the 1990s Sweden had been considered a paragon welfare state in its realisation of universalist principles and an institutional welfare model. This seems to be changing rapidly. Mass unemployment, welfare expenditure cuts and institutional transformation have introduced several selective mechanisms into the Swedish welfare system, adding up to a retreat from universalism. New forms of selectivity can be seen in all layers of the welfare system, both transfer benefits and social security, public personal social services and the relation between state and voluntary organisations. The shifting of burdens from universal social security and insurance-based welfare onto local means tested systems has already meant a restigmatisation of unemployment, as the unemployed lose eligibility for the insurance-based systems, and an increase in the proportion of people who have to rely on poor relief instead of rights-based welfare, and when unemployment has gone up, so have work requireme...

The withdrawal of the welfare state: elderly care in Sweden in the 1990s

In Sweden, clear changes in the care of the elderly have occurred during the 1990s, with fewer people being provided public care, although greater efforts are now directed towards those most in need of help. Elderly people are cared for increasingly in other ways: by the family, by means of market-provided care, and by voluntary and informal means. Differences between municipalities are considerable. A comparative study was conducted in eight Swedish municipalities, four of them characterized by extensive reorganization of home-help services, and the other four constituting a reference group where such changes had not occurred. The aim was to examine processes of setting local priorities and adjustments in a period of marked structural change. Interviews with local politicians, administrators, professionals, and union representatives, and with the elderly themselves, were the main sources of data. The process of determining the extent and content of home care services in the municipalities was found to be a complex process, one involving a number of partly interdependent factors. Restructuring was found to be greatest in the context of a traditionally strong reliance on home-help services, rather than in the context of institutionalized care, where administrative decision-making and a medical and rehabilitative perspective dominated.

Older people's views of quality of care: a randomised controlled study of continuum of care

AIMS AND OBJECTIVES To analyse frail older peoples views of quality of care when receiving a comprehensive continuum of care intervention, compared with those of people receiving the usual care (control group). The intervention included early geriatric assessment, case management, interprofessional collaboration, support for relatives and organising of care-planning meetings in older peoples own homes. BACKGROUND Prior studies indicate that tailored/individualised care planning conducted by a case manager/coordinator often led to greater satisfaction with care planning among older people. However, there is no obvious evidence of any effects of continuum of care interventions on older peoples views of quality of care. DESIGN Randomised controlled study. METHODS Items based on a validated questionnaire were used in face-to-face interviews to assess older peoples views of quality of care at three, six and 12 months after baseline. RESULTS Older people receiving a comprehensive continuum of care intervention perceived higher quality of care on items about care planning (p ≤ 0·005), compared with those receiving the usual care. In addition, they had increased knowledge of whom to contact about care/service, after three and 12 months (p < 0·03). CONCLUSIONS The study gives evidence of the advantages of a combination of components such as organising care-planning meetings in older peoples own homes, case management and interprofessional teamwork. RELEVANCE TO CLINICAL PRACTICE The results have implications for policymakers, managers and professionals in the area of health and social care for older people to meet individual needs of frail older people.

The specialisation of needs-assessment in Swedish municipal care for older people: the diffusion of a new organisational model

The 1990s were characterised by strong pressure for organisational reform at the municipality level in the Swedish welfare provision. In social care services for older people, care management reform was one of the many proposals circulating. Within a short time span, a large number of municipalities had implemented this new model and this paper reports and analyses the process of change. A key finding was that the success of the new organisational model was ascribed to new problem-solving functions and a lack of internal (professional) resistance.

Organizing integrated care for older persons: strategies in Sweden during the past decade

PURPOSE The purpose of this paper is to describe and analyse ways of organizing integrated care for older persons in Sweden during the past decade. DESIGN/METHODOLOGY/APPROACH The data consist of 62 cases of development work, described in official reports. A meta-analysis of cases was performed, including content analysis of each case. A theoretical framework comprising different forms of integration (co-ordination, contracting, co-operation and collaboration) was applied. FINDINGS Co-operation was common and collaboration, including multiprofessional teamwork, was rare in the cases. Contracting can be questioned as being a form of integration, and the introduction of consumer choice models appeared problematic in inter-organization integration. Goals stated in the cases concerned steering and designing care, rather than outcome specifications for older persons. Explicit goals to improve integration in itself could imply that the organizations adapt to strong normative expectations in society. Trends over the decade comprised development of local health care systems, introduction of consumer choice models and contracting out. RESEARCH LIMITATIONS/IMPLICATIONS Most cases were projects, but others comprised evaluations of regular organization of integrated care. These evaluations were often written normatively, but constituted the conditions for practice and were important study contributions. PRACTICAL IMPLICATIONS Guiding clinical practice to be aware of importance of setting follow-up goals. SOCIAL IMPLICATIONS Awareness of the risk that special funds may impede sustainable strategies development. ORIGINALITY/VALUE A theoretical framework of forms of integration was applied to several different strategies, which had been carried out mostly in practice. The study contributes to understanding of how different strategies have been developed and applied to organize integrated care, and highlights some relationships between integration theory and practice.

Significance of scientific evidence in organizing care processes

Purpose - The purpose of this paper is to analyze how staff and managers in health and social care organizations use scientific evidence when making decisions about the organization of care practices. Design/methodology/approach - Document analysis and repeated interviews (2008-2010) with staff (n=39) and managers (n=26) in health and social care organizations. The respondents were involved in a randomized controlled study about testing a continuum of care model for older people. Findings - Scientific evidence had no practical function in the social care organization, while it was a prioritized source of information in the health care organization. This meant that the decision making regarding care practices was different in these organizations. Social care tended to rely on ad hoc practice-based information and political decisions when organizing care, while health care to some extent also relied in an unreflected manner on the scientific knowledge. Originality/value - The study illustrates several difficulties that might occur when managers and staff try to consider scientific evidence when making complicated decisions about care practices.