Health Policy 119 (2015) 9–16

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Implementing care programmes for frail older people: A project management perspective Jill Bindels a,∗ , Karen Cox a,b , Tineke A. Abma c , Onno C.P. van Schayck d , Guy Widdershoven c a Department of Health Services Research, CAPHRI School for Public Health and Primary Care, Maastricht University, P.O. Box 616, 6200, Maastricht MD, The Netherlands b Fontys University of Applied Sciences, School of Nursing, P.O. Box 347, 5600, Eindhoven AH, The Netherlands c Department of Medical Humanities, EMGO Institute for Health and Care research, Vu University Medical Centre, Van der Boeschorststraat 7, 1007, Amsterdam MB, The Netherlands d Department of General Practice, CAPHRI School for Public Health and Primary Care, Maastricht University. P.O. Box 616, 6200, Maastricht MD, The Netherlands

a r t i c l e

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Article history: Received 11 June 2014 Received in revised form 15 September 2014 Accepted 16 September 2014 Keywords: Implementation Care for older people Frailty Management Qualitative research

a b s t r a c t Objective: To examine the issues that influenced the implementation of programmes designed to identify and support frail older people in the community in the Netherlands. Methods: Qualitative research methods were used to investigate the perspectives of project leaders, project members and members of the steering committee responsible for the implementation of the programmes. Interviews were conducted in 2009 (n = 10) and in 2012 (n = 13) and a focus group was organised in 2012 (n = 5). Main Findings: The interviews revealed that the implementation was influenced by the extent and quality of collaboration between organisations, adaptation to existing structures, future funding for the programmes and project leadership. A good relationship between participating organisations and professionals is required for successful implementation. A lack of clear project leadership and structural funding hampers the implementation of complex programmes in primary care settings. Implications for practice: The findings of this study are useful for organisations and professionals who are planning to implement complex programmes. Identifying barriers concerning institutional collaboration, adaptation to existing structures, leadership and continuation of financial support at an early stage of the implementation process can support practitioners in overcoming them. © 2014 Elsevier Ireland Ltd. All rights reserved.

1. Introduction

∗ Corresponding author. Tel.: +31 43 38 81 983; fax: +31 43 38 84 162. E-mail addresses: [email protected] (J. Bindels), [email protected] (K. Cox), [email protected] (T.A. Abma), [email protected] (O.C.P. van Schayck), [email protected] (G. Widdershoven). http://dx.doi.org/10.1016/j.healthpol.2014.09.008 0168-8510/© 2014 Elsevier Ireland Ltd. All rights reserved.

With an ageing population, the number of people who suffer from multiple, chronic diseases and social problems increases as well [1]. Multimorbidity is strongly associated with adverse health outcomes and increased health service use. Improving the integration of services and primary care for older people is necessary for improving their quality of care [2]. Although the discipline of geriatric medicine has advanced on many fronts, older people are still more likely

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than any other group to receive inadequate and fragmented care [1,2]. As a response to the ageing population and related challenges, the Dutch government launched the Dutch National Care for the Elderly Programme to improve care for frail older people living in the community which involves the development and implementation of new care programmes [3]. In three regions in the Netherlands, care programmes were developed and implemented in which practice nurses and general practitioners collaborated with other professionals and organisations to detect health problems and provide community-dwelling frail older people with tailor-made care and support [4,5]. Effective implementation is necessary in order to integrate complex programmes into daily health care practice [6]. Poor implementation could lead to a negative appraisal of the programmes. To develop an effective care programme, a good understanding is needed of the enablers that foster and barriers that hinder successful implementation [7]. In other settings, a lack of manpower, poor collaboration and communication [8] staff-turnover, high workload and concurrent projects [9] are identified as barriers in implementing programmes that involve multidisciplinary collaboration. Furthermore, the implementation of multidisciplinary programmes can be hindered by organisational boundaries [10]. For successful implementation, health care professionals should have the knowledge and skills needed to adopt the programme, and organisational conditions have to make this adoption possible [11,12]. The role of project leaders is crucial to the success of the implementation of programmes [13]. Although many of the factors that inhibit or support successful implementation are related to project-leadership and facilitation [14], little information is available on the experiences of managers, project leaders and project members who fulfil important roles in the implementation of care programmes for older people. This paper focuses on the implementation process of care programmes for community-dwelling frail older people in the Netherlands. This study investigated which issues were relevant in the implementation of care programmes for frail older people at two phases in the implementation process from the perspective of the stakeholders responsible for the implementation. By using qualitative methods we got insight into the experiences of the managers, project leaders and project members responsible for the implementation of the programmes for community-dwelling frail older people. 1.1. Research setting This study evaluated the implementation of programmes for frail older people in three regions in the Netherlands. Care programmes were implemented that focus on the identification of frail older people in the community and provide them with the appropriate support and care. The main elements of the programmes in the three regions were similar although they used different instruments to assess frailty and different tools to support and care for older people. Furthermore, the programmes were adapted to existing health care structures in the region. The programmes are described below. More detailed

information concerning these programmes can be found elsewhere [4,5]. In each region, primary care practices had a central role in the identification of and support for frail older people. In one region, these people were identified using a 15item postal screening instrument (the Groningen Frailty Indicator) that included items concerning the physical and psychosocial factors of frailty [15]. In the other regions, general practitioner and practice nurses selected people who, according to their opinion, might be frail. Practice nurses performed home visits and assessed the health status of the frail older people. Together with the general practitioner, the practice nurse analysed the situation and negotiated with the older people to agree on an action plan [16]. If necessary, other professionals were involved in the assessment of the older people and the development and execution of the action plan. In one region, a toolbox was developed around five topics (e.g. meaningful activities, social network and social activities) that supported the practice nurses in providing appropriate care [17]. Each region, independently, organised the implementation of the programmes. In each region, a project leader and project team were appointed. Within the total budget of the project, salary for the work of the project leader and other professionals was available. To develop the programme (including protocols and screening instruments), geriatric nurses, practice nurses and general practitioners were involved in the project teams. In addition, a crossregional steering committee was set up which comprised directors and managers of the organisations involved in the care programmes. 2. Methods 2.1. Design This study aims to evaluate the implementation of care programmes for frail older people and is part of a wider responsive evaluation. In this type of evaluation, all possible stakeholder perspectives should be included when evaluating a programme [18,19]. In previous work we evaluated the perspectives of frail older people and the practice nurses involved in the care [20]. Furthermore, we developed a Community of Practice in which all perspectives are brought together to create a dialogue and enhance mutual understanding and learning [21]. We used a qualitative design involving in-depth, semistructured interviews and a focus group to get insight into the views and experiences of project leaders and project members and members of the steering committee to identify barriers and enablers that influenced the implementation process. The study obtained approval from the Medical Ethics Committee of the Maastricht University Medical Centre, and was executed between 2009 and 2012. 2.2. Participants Participants were selected by the researchers through purposive sampling [22]. We selected participants who had an active role in the development and implementation of the care programmes for frail older people.

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Table 1 Participants of the interviews and focus group. Participants interviews 2009

Participants interviews in 2012

Participants focus group in 2012

Project leader (3) Project member (4) Steering Committee (3) Total (10)

Project leader (2) Project member (6) Steering Committee (4) Total (12)

Project leader (1) Project member (1) Steering Committee (3) Total (5)

Participants in the interviews comprised project leaders and project members including a geriatrician, geriatric nurses, general practitioners and practice nurses. Managers and directors of contributing organisations (who were part of the steering committee) also participated in the study. These organisations included the interregional Public Health Service, an organisation representing and lobbying on behalf of patients, disabled and older people, hospitals in the three regions and three regional general practitioner organisations. We aimed to interview at least one participant from each participating organization in which the programmes were implemented to ensure that as many viewpoints as possible were represented. In total, more than half of the individuals responsible for the implementation participated in our study. The first author (JB) interviewed ten participants at the start (2009), and twelve at the final stage of the implementation (in 2012). More participants were recruited for data collection in 2012, because of new participants in projects management. Not all people who were interviewed in 2009 could be interviewed in 2012, because of changes in staff. A majority of participants (n = 7) was involved in the study both in 2009 and in 2012. A focus group was organised in which all participants at the final stage of the implementation process were invited. Five out of the twelve participated in this focus group (Table 1). 2.3. Data collection and analysis Data were gathered at two different points in time in 2009 and in 2012. Interviews were conducted at a convenient location for the participants and lasted between 60 and 90 min. The topics that were used during the two interview rounds are included in Table 2. By asking open ended questions, the researcher (JB) encouraged Table 2 Topic guide used during the interviews and focus group. Interviews at early stage of implementation Expectations concerning the implementation Aims of the implementation Progress of the implementation Interviews at last stage of implementation Background information respondent and organization Aims of the implementation Progress of the implementation Results of the implementation Barriers Facilitators Collaboration with other stakeholders/organizations. Focus group Results of the programmes Perceived barriers and enablers Future of the care programmes

the respondents to recount their experiences in their own words and address issues that were important to them. A focus group was organised after all interviews were analysed. The aim of this focus group was to elaborate further on the themes that emerged out of the interview data. The focus group lasted two hours and was moderated by the last author (GW) and facilitated by the first and second author (JB and KC). Topics included the following: results of the implementation, perceived barriers and enablers and future of the programmes. The topics are included in Table 2. All interviews and the focus group interview were recorded on tape and transcribed verbatim. The transcripts of the interviews and focus group were analysed by multiple researchers (JB and KC). Content analysis was used to analyse the data making use of constant comparative analyses [23]. Two researchers (JB and KC) read the entire transcripts to identify emerging (sub)themes and allocated open codes to text fragments. After consensus was reached on those open codes, the codes were clustered into (sub)categories and discussed with a third researcher (GW). Text fragments, the emerging codes and (sub)categories were visualised in a data matrix to prepare for reporting the findings [24]. 3. Results This section describes the results of the interviews and the focus group with participants involved in the implementation of the care programmes for frail older people at two different points in time, in three Dutch regions. We first elaborate on the progress of the care programmes as perceived by the respondents. Then the issues are described that played a role in the implementation: collaboration, adaptation to existing structures, securing future funding and leadership (see Fig. 1.) 3.1. The progress of the care programmes In this section, we will first describe the implementation goals at the start of the programmes in 2009. Next we will go into the progress of the implementation in 2012. 3.1.1. Implementation goals At the time of the interviews in 2009, goals related to implementation were expressed as creating ‘optimal collaboration with existing structures’ and ‘support among the professionals who have to carry out the programme’. How can we make the programme fit in with the already existing care that is offered by the municipalities? Advisors for older people also visit older people, and that

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Fig. 1. Main results.

overlaps with the job that the practice nurses have to do in our programme. (Interview, project leader)

care, but we didn’t achieve that here. (Interview project member)

Respondents also mentioned that programmes should become part of the daily practice of the practice nurses and the general practitioners.

In this region, the managers and project members involved had no insight into the execution of the programme in practice. They lacked information if the GP practices were still working with the provided protocols and tools, and performing home-visits.

The aim is that the professionals automatically use the approach and that they feel the approach works for them. (Interview, project member) The ultimate aims of the programmes were expressed as ‘creating integrated care for frail older people’ and detection of health problems in older people at an early stage: Eventually we want older people to live and function independently and identify problems in time and anticipate on those problems. (Interview, project leader)

3.1.2. Implementation outcomes In the interviews in 2012, respondents in two of the three regions reported positively on the implementation of the programmes. As a measure for success they mentioned the number of practices involved, the number of home-visits performed and the response of the professionals and older people. Furthermore, the awareness among professionals concerning the importance of proactively identifying problems around frail older people was experienced as a positive outcome. This awareness seemed necessary to provide proactive care to older people: Something has really changed: the professionals in this region are aware of the problems that exist within the group of frail older people and where they should focus. (Project member, focus group) One project leader pointed out that the programme was appreciated by the older people and professionals: The evaluation showed that the older people valued the care programme but also the professionals experienced less crisis situations. However, the effect on the health status of the frail older people is still unclear. Therefore the time-frame is too short. (Project leader, focus group) In the third region the programme was ‘on hold’ and described by some respondents as unsuccessful: We wanted the programme to come alive in the general practices and that it would be embedded in their daily

It is unclear to me how many home-visits take place and which general practices still organise home visits. (Interview, project member) Yet, in that region, some of the respondents remained positive and saw the growth in collaboration between organisations and general practitioners as a positive result and as a fertile breeding ground for innovations and new programmes. We created a network with all the players in the field of elderly care, and that can be seen as a successful result of the project. We are actively consulting each other about new project ideas and exchange knowledge. (Focus group, member steering committee) The success of the implementation of the care programmes in the three regions varied considerably. The interviews with the different stakeholders revealed issues that influenced the implementation. We will now go into these issues. 3.2. Quality of collaboration The respondents perceived a good relationship between the organisations involved in the care of frail older people, including the hospital, public health services, general care practices and the local authorities, as a requirement for the implementation of programmes that aim to integrate services. Primary care practices are mainly responsible for the care, but as Public Health Service we also tried to collaborate since the programme also concerns prevention. (Focus group, member steering committee) A project leader explained that the implementation of the new programme is supported in their region, because of the existing high quality relationship between the hospital and the general practices. Establishing new collaborative initiatives is found to be easier if stakeholders have collaborated successfully before.

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In our region, we have a long-lasting good relationship between general practitioners and the hospital. There is a multidisciplinary expertise team and that really helps in creating a network. (Interview, project member) Given the interdisciplinary character of the programmes, it is found to be important to involve many disciplines in the development of the programmes. However, it is perceived difficult to engage and motivate all these disciplines at the same time, which is seen as a potential barrier for implementation by some respondents. We cannot involve everyone at the same moment, because that would take too much time. So we have to start and involve disciplines subsequently. But we have to be careful in telling other disciplines what to do. They have to get interested in the care for older people over time. (Interview, project member) The different organisations operate side by side without a hierarchical structure, which also makes it difficult to collaborate since no organization is to lead the collaboration. And the management of such a network is not always unambiguous, because that is related to control of the different stakeholders. (Focus group, member steering committee) The large number of health care organisations present in the three regions was considered a barrier by two respondents, since many organisations offer the same services. Two project leaders found it particularly difficult to gather information on the services of mental health care organisations which might hamper the establishment of good relationships with those organisations. The difficult thing is that, because of the free market, many mental health care organisations offer the same or similar services and the patient can choose where to go, and in the protocols we have to give the professionals guidelines to whom they should refer their patients to, but I do not have insight in the services that are offered by those organisations. (Interview, project leader) We may conclude that collaboration is perceived as a necessary condition for successful implementation but is hampered by the large number of organizations and the hierarchical structure between those organizations. 3.3. Adaptation to existing structures A perceived barrier was the adaptation of the programmes to the existing structures in the general practices involved. Although general practitioners were motivated, the practical implementation of the programme in their practice seemed difficult, resulting in a potential drop-out of several general practitioners. On paper everything is figured out, but how do we implement that blueprint in the individual general practices that all have their own infrastructure? (Interview project leader) Other care programmes like the Cardiovascular Risk Management Programme were implemented in the same

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period in the general practices, which was perceived as a barrier for implementation. Due to the higher revenues of other programmes, general practitioners were often prioritizing those programmes above the care programmes for frail older people. Things were going fine in the general practices but then the cardiovascular programme was implemented, which generated higher revenues for the general practitioners. (Interview, project member) In conclusion, the simultaneous implementation of other programmes hampered the implementation of care programmes for frail older people. 3.4. Need for structural funding The lack of structural funding was considered as a barrier to most of the participants. To receive structural funding and to embed the funding of the programme in existing financial structures, it was necessary to closely cooperate with the health care insurance companies. One programme, which was experienced as successful, was implemented in close cooperation with a health care insurance company. This resulted in approval by the insurance company and financial support for the participating general practices in carrying out the programme. The insurance company has a finance structure for care for older people. Then we asked them what the requirements were for that module and told them what our requirements within the programme were. We wanted those requirements to be the same. From the beginning we negotiated with the insurance company in good collaboration to let the general practices who implemented the programme enrol in this module. (Interview, project leader) In one region structural funding remained a problem: That is one of the reasons why the implementation failed, because the insurance company has another interpretation of the requirements for structural finance. There was no linkage between their requirements and the requirements of the programme. (Interview, member steering committee) This lack of structural funding made it difficult to introduce the programme in more general practices: When general practitioners do not know that they will receive the appropriate funding they do not invest in appointing a practice nurse. (Interview, project leader) In conclusion, the lack of structural funding hampered the implementation. Yet, in one region early collaboration with insurance companies helped to overcome this barrier. 3.5. Leadership Respondents emphasised the importance of widespread support among the professionals who should adopt the programme and that it was the task of a project leader to create such widespread support: one project member

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described the result of professionals being motivated and supportive towards the programme: The programme is greatly supported by the professionals. The professionals are the ambassadors of the programme. That became clear when we wanted to enrol the programmes in more practices; many general practitioners want to participate. (Focus group, project member) In the region where implementation was considered unsuccessful, many respondents mentioned the lack of a clear project leader as barrier in the implementation process. In this region, the project leader was not embedded in the regional organisation of the general practitioners. When the project leader resigned, there was no clarity about who should take over that role. I have the feeling that the professionals and older people are committed to the project, but it is important that there is a frontrunner who can lead the project. But that is missing here. (Interview, project member) One project member explains that the position of the project leader is important: The project could be led by each organisation, but the best would be to lead the project from the organisation of the general practitioners. It is important to bring the general practitioners on board and that works only if someone who is close to the general practitioners has the lead. (Interview, project member) One member of the steering committee summarised the main barriers as follows, stressing that commitment from the management of the involved organisations is required: The lesson we have learned here is that if there isn’t enough commitment from the management, and not enough support from the Health Insurance Companies, a project like this will cease to exist. Innovation will cease to exist. (Focus group, member steering committee) In conclusion, clear leadership was described as a facilitator for successful implementation. The absence of a project leader in one of the regions remained a problem throughout the whole implementation process.

4. Discussion The findings of this study shed light on the implementation process of programmes for frail older people in primary care settings and the experiences of those responsible for the development and implementation of the programmes. The perception of the outcomes of the implementation was diverse. In two regions the implementation was experienced as successful; the involved professionals were positive and older people appreciated the care, and the programmes were enrolled in more general practices. In one region, continuation of the programme was uncertain. Participants of our study mentioned that collaboration is a key condition for successful implementation, but is also difficult to realize since many organizations are involved in the care for frail older people. A lack of structural funding

for the care programmes and the simultaneous implementation of other care programmes were experienced as barriers for successful implementation. Leadership was identified as an important factor in implementation, and the absence of a project leader in one region was experienced as a barrier. A good relationship among participating organisations was perceived as a requirement for successful implementation. This is in line with work of Grol [25] who states that collaboration is essential in developing and implementing guidelines and care programmes. This collaboration is particularly important in care services that are experienced as fragmented and where integration of services is required [26]. However, due to the myriad of organisations and services present in the regions, establishing a good relationship was considered difficult. Besides the large number of stakeholders, collaboration can be discouraged by budget constraints, the ability to share power and conflicting loyalties among stakeholders [27]. Changes are more likely to be adopted if they are supported by the target population, therefore collaboration should also be sought with organizations that represent older people [28]. Furthermore, the different organisational structures of general practices were seen as a barrier to implementing ‘one blue print’ of the programme in the different practices. According to Rycroft-Malone et al. [29], successful implementation can be enhanced if programmes align with already existing activities within an organisation. Structural obstacles may influence the implementation in practice where it is not always possible to control all activities [30]. Obtaining structural funding was perceived as a barrier by the respondents in our study. Research has shown that lack of financial benefit is experienced as a huge barrier by general practitioners when implementing quality improvements in primary care [31]. Health insurance companies are described in the literature as having a key role in removing financial barriers [32]. Our findings show that this financial barrier could be alleviated by cooperating with the health care insurers (or other financing structures) earlier – by integrating the requirements of the insurance companies into the programme from the start. The implementation of other programmes was another barrier for implementation. The results of interviews with professionals – as part of the larger responsive evaluation – confirm these findings; practice nurses felt inhibited due to financial constraints and other programmes, and felt they had limited time to provide care for older people [20]. Here we identify a responsibility for the funding agencies and policy makers who, besides the funding of research and implementation projects, should monitor and support the development of structural funding agreements. The respondents in our study emphasised the importance of the role of project leaders. They considered that the project leader should be positioned close to the professionals who are to carry out the programmes in order to create widespread support. The lack of a clear project leader, after the first project leader resigned in one region, was perceived as a barrier to implementation. According to Wagner et al. [33], a lack of leadership or turnover in leadership is a predictor of implementation failure. Leadership

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mainly resided in the three appointed project leaders, and after one of them resigned a clear project leader was missing. A lack of clarity on the role of leadership is identified as a barrier to change [14]. Gifford et al. [34] argue that leadership should be a shared group process in which several individuals share the responsibility of influencing others towards a goal. Furthermore, the commitment from management is described as a requirement for successful implementation.

better informed about the current state of the projects and the details. The programmes were implemented within a Dutch setting and the findings of this study cannot automatically be transferred to other settings. However, if account is taken of the context and experiences, readers may be able to transfer insights to other contexts [37].

4.1. Implications

The interviews revealed that implementation was experienced as successful in two of the three regions. Issues that influenced the implementation were the quality of the collaboration between institutions, the adaptation to existing structures, project leadership and securing future funding. A good relationship between participating organisations and professionals is required for successful implementation. The structure in the primary care setting and other care programmes being carried out at the general practices influenced the implementation process of the care programs for frail older people. A lack of clear project leadership and structural funding hampers the implementation of complex programmes in primary care settings.

The findings of this study are useful for organisations and professionals who are planning to implement complex programmes. The results show that quality of the collaboration between institutions, the adaptation to existing structures, project leadership, and securing future funding influence the implementation process. Identifying barriers (concerning, existing structures, leadership, financial structures and collaboration) at an early stage of the implementation process can support practitioners in reacting to those barriers. Using instruments like a SWOT analysis (analysing strengths, weaknesses, opportunities and threats) or a context analysis tool like the Context Assessment Index (CAI) [35] could support them in identifying barriers at an early stage in the implementation process and develop strategies to overcome them [36].

4.3. Conclusion

Conflict of interest The authors declare that there are no conflicts of interest.

4.2. Limitations The results of this study should be interpreted in the light of certain limitations. This study only included the perspectives of the project leaders, project members and steering committee members responsible for the implementation; it did not address the perspectives of health care professionals and the target population who should adopt the new approach. As this study is part of a responsive evaluation that includes multiple perspectives, the latter perspectives are published elsewhere. Although the perspective of the project leaders, project members and steering committee members were open about the experienced barriers and enablers, it should be noted that the respondents were also responsible for the implementation. As a consequence, this study required them to reflect on their own competences and functioning. In one of the interviews, the issue of the timing of the evaluation was mentioned. The respondent mentioned that it is too early to evaluate the effects of the care programmes on the frail older people. The aim of our study was to evaluate the implementation and explore the issues that played a role during the implementation process, therefore the two different time points of data gathering seem appropriate. However, to evaluate the effects on the health status of the older people it is necessary to choose the appropriate timing for the evaluation considering the implementation phase. Although this study incorporated the perspectives of different stakeholders, there were no noticeable differences between the perspectives of the project leaders, project members and members of the steering committee. We did notice that the stakeholders who were involved in the implementation process on a daily basis, were often

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