Examining preconditions for integrated care: a comparative social network analysis of the structure and dynamics of strong relations in child service networks.

BACKGROUND: To help ensure that children and families get the right support and services at the right time, strong and stable relationships between various child service organizations are vital. Moreover, strong and stable relationships and a key network position for gatekeepers are important preconditions for interprofessional collaboration, the timely and appropriate referral of clients, and improved health outcomes. Gatekeepers are organizations that have specific legal authorizations regarding client referral. However, it is largely unclear how strong relations in child service networks are structured, whether the gatekeepers have strong and stable relationships, and what the critical relations in the overall structure are. The aim of this study is to explore these preconditions for integrated care by examining the internal structure and dynamics of strong relations. METHODS: A comparative case study approach and social network analysis of three inter-organizational networks consisting of 65 to 135 organizations within the Dutch child service system. Multiple network measures (number of active organizations, isolates, relations, average degree centrality, Lambda sets) were used to examine the strong relation structure and dynamics of the networks. Ucinet was used to analyze the data, with use of the statistical test: Quadratic Assignment Procedure. Visone was used to visualize the graphs of the networks. RESULTS: This study shows that more than 80% of the organizations in the networks have strong relations. A striking finding is the extremely high number of strong relations that gatekeepers need to maintain. Moreover, the results show that the most important gatekeepers have key positions, and their strong relations are relatively stable. By contrast, considering the whole network, we also found a considerable measure of instability in strong relationships, which means that child service networks must cope with major internal dynamics. CONCLUSIONS: Our study addressed crucial preconditions for integrated care. The extremely high number of strong relations that particularly gatekeepers need to build and maintain, in combination with the considerable instability of strong relations considering the whole network, is a serious point of concern that need to be managed, in order to enable child service networks to improve internal coordination and integration of service delivery.

HIGHLIGHTS: More than 80% of the organizations in the network has strong relations.Gatekeepers need to maintain an extremely high number of strong relations.Child service networks need to cope with major internal dynamics.These insights offer leads for optimizing how a network functions.

Getting ready to act: theorising a stepwise transition into crisis response at points of entry based on interviews with COVID-19 responders and a military preparedness framework.

INTRODUCTION: Points of entry (POE) have an important role in timely national response to infectious diseases threats. However, a guiding framework is lacking for the transition from generic preparedness into optimally specified response for an imminent infectious disease threat, a step called 'operational readiness'. OBJECTIVE: We aim to contribute to the conceptual closure of this preparedness-response gap for infectious disease control at POE by providing content to the operational readiness concept. DESIGN: We first explored the NATO Combat Readiness (NCR) concept for its applicability on infectious disease control at POE, as the military discipline faces the same need of being flexible in preparing for unknown threats. Concepts of the NCR that support the transition into response to a specific threat were integrated into the operational readiness concept. To explore the added value of the concept in practice, we conducted and analysed semistructured interviews of professionals at European POE (n=24) responsible for the early COVID-19 response. RESULTS: Based on the NCR, operational readiness builds on the fact that activating the response capabilities and capacities to a specific threat requires time. For professionals at POE, the transition from generic preparedness into the COVID-19 response led to challenges in specifying response plans, dealing with an overload of information, while experiencing shortages of public health staff. These challenges could be covered within operational readiness by defining the time and the specific staging needed to upgrade response capabilities and capacities. DISCUSSION: We conclude that a guiding framework for operational readiness seems appropriate in relation to the many activities and challenges POE have had to face during the COVID-19 response. Operational readiness is mainly defined by the time dimension required to deploy the response to a specific threat. However, integrating this conceptual framework into practice requires structural and sustainable investments in outbreak preparedness.

Actors' awareness of network governance in Child Welfare and Healthcare service networks.

To ensure that families with social and behavioral health problems get the support they need, organizations collaborate in child service networks. These networks are generally lead-organization governed. It is assumed that network members have relatively accurate information about the governance mode. However, discrepancies between the formally administered and perceived governance mode could raise legitimacy questions and lead to conflicts, and ultimately affect network effectiveness. Therefore, we investigated to what extent such discrepancies exist and how they might be explained. Hereby, the focus was on the concepts level of trust, interaction, and strength of relationship with the lead organization in the network. A comparative case study was conducted of three inter-organizational networks of child services in different-sized municipalities in the Netherlands in 2018 and 2019. A multiple generalized linear mixed model analysis was used. We found that only a minority of the network members had an accurate perception of the governance mode. This awareness did improve over time. The level of interaction and relationship strength with the lead organization were independently associated with an accurate perception of the governance mode. Trust of a network member in the network, however, had no significant association. These insights underline the necessity to consider network information accuracy as an important variable for understanding network behavior and as crucial for the effective delivery of child services.

Intersectoral collaboration at a decentralized level: information flows in child welfare and healthcare networks.

BACKGROUND: As needs of families with social and behavioral health problems often exceed the expertise and possibilities of a single professional, service or organization, cross-service collaboration is indispensable to adequately meeting those needs. Despite the progressive focus on organizing integrated care, service fragmentation and service duplication remain persistent problems in child welfare and healthcare service delivery systems. A crucial factor to overcome these problems is information exchange between organizations. This study explores and compares the development over time of structures of information exchange in networks, concerning both material and knowledge-based information. METHODS: A comparative case study and social network analysis of three inter-organizational networks of child welfare and healthcare services in different-sized municipalities in the Netherlands. The research population consisted of organizations from various sectors participating in the networks. Data were collected at two moments in time with a mixed method: semi-structured interviews with network managers and an online questionnaire for all network members. Density and degree centralization were used to examine the information exchange structures. Ucinet was used to analyze the data, with use of the statistical tests: Compare Density Procedure and Quadratic Assignment Procedure. RESULTS: This study shows that different structures of information exchange can be distinguished, concerning both material and knowledge-based information. The overall connectedness of the studied structures of the networks are quite similar, but the way in which the involvement is structured turns out to be different between the networks. Over time, the overall connectedness of those structures appears to be stable, but the internal dynamics reveals a major change in relationships between organizations in the networks. CONCLUSIONS: Our study yields empirical evidence for the existence of and the differences between structures and dynamics of both material and knowledge-based information exchange relationships. With a loss of more than a half of the relations in a year, the relationships between the organizations in the network are not very stable over time. The contrast between major internal dynamics and the stable overall connectedness is an important point of concern for network managers and public officials, since this impermanence of relations means that long-term integrated care cannot be guaranteed.

Cross-sectoral collaboration: comparing complex child service delivery systems.

PURPOSE: To help ensure that children with social and behavioral health problems get the support services they need, organizations collaborate in cross-sectoral networks. In this article, the authors explore and compare the structure of these complex child service delivery networks in terms of differentiation (composition) and integration (interconnection). In particular, the authors investigate the structure of client referral and identify which organizations are most prominent within that network structure and could therefore fulfill a coordinating role. DESIGN/METHODOLOGY/APPROACH: The authors used a comparative case study approach and social network analysis on three interorganizational networks consisting of 65 to 135 organizations within the Dutch child service delivery system. Semi-structured interviews with the network managers were conducted, and an online questionnaire was sent out to the representatives of all network members. FINDINGS: The networks are similarly differentiated into 11 sectors with various tasks. Remarkably, network members have contact with an average of 20-26 organizations, which is a fairly high number to be handled successfully. In terms of integration, the authors found a striking diversity in the structures of client referral and not all organizations with a gatekeeper task hold central positions. ORIGINALITY/VALUE: Due to the scarcity of comparative whole network research in the field, the strength of this study is a deeper understanding of the differentiation and integration of complex child service delivery systems. These insights are crucial in order to deliver needed services and to minimize service silos and fragmentation.

Assessing training needs in infectious disease management at major ports, airports and ground-crossings in Europe.

BACKGROUND: The implementation of core capacities as stated in the International Health Regulations (IHR) is far from complete, and, as the COVID-19 pandemic shows, the spreading of infectious diseases through points of entry (POEs) is a serious problem. To guide training and exercises, we performed a training needs assessment on infectious disease management among professionals at European POE. METHODS: We disseminated a digital questionnaire to representatives of designated airports, ports, and ground-crossings in Europe. Topics were derived from the IHR core capacities for POEs. Based on the importance (4-point Likert scale) and training needs (4-point Likert scale), we identified the topics with the highest priority for training. These results were put in further perspective using prior experience (training < 3 year, exercise < 5 years, events < 5 years). Also, preferences for training methodologies were assessed. RESULTS: Fifty questionnaires were included in the analyses, representing 50 POEs from 19 European countries. Importance is high for 26/30 topics, although scores widely vary among respondents. Topics with a high training need (16/30) are amongst others the handling of ill travelers; using and composing the public health emergency contingency plan, and public health measures. Respondents from ports and airports attribute equal importance to most topics, but respondents from ports showed higher training needs on 75% of the topics. POEs are unevenly and generally little experienced. The most preferred training methods were presentations. Simulation is the preferred methodology for training the handling of ill or exposed travelers. CONCLUSIONS: The European workforce at designated ports, airports and ground-crossings has a different level of experience and perceives varying importance of the topics assessed in our study. We identified the topics on which training is required. We call for European collaboration between POEs to agree upon the importance of infectious disease management, and to jointly build a trained and prepared workforce that is ready to face the next crisis.

Educating, training, and exercising for infectious disease control with emphasis on cross-border settings: an integrative review.

INTRODUCTION: Points of entry and other border regions educate, train, and exercise (ETEs) their staff to improve preparedness and response to cross-border health threats. However, no conclusive knowledge of these ETEs' effectiveness exists. This study aimed to review the literature on ETEs in infectious disease control concerning their methods and effect, with an emphasis on cross-border settings and methods that enlarge ETEs' reach. METHODOLOGY: We systematically searched for studies in the databases Embase, Medline, Web of Science, PsycInfo, ERIC, and Cinahl. After successively screening titles and abstracts, full-texts, and citations, 62 studies were included using in- and exclusion criteria. Data were extracted using a data-extraction form. Quality assessment was performed. We developed a theoretical framework based on which we analyzed the ETE context (target group, recruitment, autonomy, training needs), input (topic, trainers, development and quality of materials), process (design, duration, interval, goals), evaluation (pre-, post- follow-up tests), and outcome (reaction, learning, behavior, and system). RESULTS: We found a limited number of published evaluations of ETEs in general (n = 62) and of cross-border settings (n = 5) in particular. The quality assessment resulted in seven ETE methodologies and 23 evaluations with a 'good' score. Both general studies and those in a cross-border setting contain a low-moderate detail level on context, input, and process. The evaluations were performed on reaction (n = 45), learning (n = 45), behavior (n = 9) and system (n = 4), mainly using pre- and post-tests (n = 22). Online learning methods have a high potential in enlarging the reach and are effective, particularly in combination with offline training. Training-of-trainer approaches are effective for learning; new ETEs were developed by 20-44% of participants until six months after the initial training. CONCLUSION: Our study reveals a limited number of publications on ETEs in infectious disease control. Studies provide few details on methodology, and use mainly short-term evaluations and low level outcomes. We call for more extensive, higher-level evaluation standards of ETEs, and an easy and sustainable way to exchange evaluations within the workforce of infectious disease control in cross-border settings. The theoretical framework developed in this study could guide future development and evaluation of ETEs in infectious disease control.

Development of a competency profile for professionals involved in infectious disease preparedness and response in the air transport public health sector.

BACKGROUND: Recent infectious disease outbreaks highlight the importance of competent professionals with expertise on public health preparedness and response at airports. The availability of a competency profile for this workforce supports efficient education and training. Although competency profiles for infectious disease control professionals are available, none addresses the complex airport environment. Therefore, the main aim of this study is to develop a competency profile for professionals involved in infectious disease preparedness and response at airports in order to stimulate and direct further education and training. METHODS: We developed the competency profile through the following steps: 1) extraction of competencies from relevant literature, 2) assessment of the profile in a national RAND modified Delphi study with an interdisciplinary expert group (n = 9) and 3) assessment of the profile in an international RAND modified Delphi study with an airport infectious disease management panel of ten European countries (n = 10). RESULTS: We systematically studied two competency profiles on infectious disease control and three air transport guidelines on event management, and extracted 61 relevant competencies for airports. The two RAND modified Delphi procedures further refined the profile, mainly by specifying a competency's target group, the organizational level it should be present on, and the exact actions that should be mastered. The final profile, consisting of 59 competencies, covers the whole process from infectious disease preparedness, through the response phase and the recovery at airports. CONCLUSION: We designed a profile to support training and exercising the multidisciplinary group of professionals in infectious disease management in the airport setting, and which is ready for use in practice. The many adaptations and adjustments that were needed to develop this profile out of existing profiles and air transport guidelines suggest that other setting-specific profiles in infectious disease control are desirable.

Towards a values framework for integrated health services: an international Delphi study.

BACKGROUND: In order to organize person-centered health services for a growing number of people with multiple complex health and social care needs, a shift from fragmented to integrated health services delivery has to take place. For the organization of governance in integrated health services, it is important to better understand the underlying factors that drive collaboration, decision-making and behavior between individuals and organizations. Therefore, this article focuses on these underlying normative aspects of integrated health services. This study investigates the values that underpin integrated health services delivery as a concept, by examining the extent to which an initial literature based set of underlying values underpins integrated care and the relevance of these values on the different levels of integration. METHODS: An international Delphi study with 33 experts from 13 different countries was carried out to examine the initial set of underlying values of integrated health services. In addition, the relevance of the values was assessed on the different levels of integration: personal level, professional level, management level and system level. RESULTS: The study resulted in a refined set of 18 values of integrated health services developed in three Delphi study rounds. In addition, the results provided insight into the relevance of these values on the personal level (e.g. 'trustful'), professional level (e.g. 'collaborative'), management level (e.g. 'efficient') and system level (e.g. 'comprehensive') of integration. Some of the values score consistent across the different levels of integration while other values score inconsistent across these levels. CONCLUSIONS: The Delphi study resulted in an international normative basis for integrated health services delivery as a concept. The values can be used as ingredients for a values framework and provide a better understanding of the normative aspects of integrated health services delivery. Future research could focus on associated behaviors in practice, the relationship between normative integration and governance, and differences between the value priorities of stakeholder groups.

How prepared are we for cross-border outbreaks? An exploratory analysis of cross-border response networks for outbreaks of multidrug resistant microorganisms in the Netherlands and Germany.

BACKGROUND: The emergence and spread of multidrug resistant microorganisms is a serious threat to transnational public health. Therefore, it is vital that cross-border outbreak response systems are constantly prepared for fast, rigorous, and efficient response. This research aims to improve transnational collaboration by identifying, visualizing, and exploring two cross-border response networks that are likely to unfold during outbreaks involving the Netherlands and Germany. METHODS: Quantitative methods were used to explore response networks during a cross-border outbreak of carbapenem resistant Enterobacteriaceae in healthcare settings. Eighty-six Dutch and German health professionals reflected on a fictive but realistic outbreak scenario (response rate ≈ 70%). Data were collected regarding collaborative relationships between stakeholders during outbreak response, prior working relationships, and trust in the networks. Network analysis techniques were used to analyze the networks on the network level (density, centralization, clique structures, and similarity of tie constellations between two networks) and node level (brokerage measures and degree centrality). RESULTS: Although stakeholders mainly collaborate with stakeholders belonging to the same country, transnational collaboration is present in a centralized manner. Integration of the network is reached, since several actors are beneficially positioned to coordinate transnational collaboration. However, levels of trust are moderately low and prior-existing cross-border working relationships are sparse. CONCLUSION: Given the explored network characteristics, we conclude that the system has a promising basis to achieve effective coordination. However, future research has to determine what kind of network governance form might be most effective and efficient in coordinating the necessary cross-border response activity. Furthermore, networks identified in this study are not only crucial in times of outbreak containment, but should also be fostered in times of non-crisis.

Collaborative emergency preparedness and response to cross-institutional outbreaks of multidrug-resistant organisms: a scenario-based approach in two regions of the Netherlands.

BACKGROUND: The likelihood of large-scale outbreaks of multidrug-resistant organisms (MDRO) is growing. MDRO outbreaks can affect a wide range of healthcare institutions. Control of such outbreaks requires structured collaboration between professionals from all involved healthcare institutions, but guidelines for cross-institutional procedures are, however, often missing. Literature indicates that such multi-actor collaboration is most promising when effective network brokers are present, and when the collaborative actors have clarity about the different roles and responsibilities in the outbreak response network, including collaborative structures and coordination roles. Studying these factors in an imaginary MDRO outbreak scenario, we gained insights into the expectations that health professionals in the Netherlands have in regard to the procedures required to best respond to any future cross-institutional MDRO outbreaks. METHODS: For exploration purpose, a focus group discussion with ten healthcare professionals was held. Subsequently, an online-survey was conducted among 56 healthcare professionals in two Dutch regions. The survey data was analysed using social network analyses (clique analysis and centrality analysis), which provided insights into the collaborative structures and potential brokers in the outbreak response networks. Additionally, respondents were asked which healthcare institutions and which professions they would prefer as coordinating actors in the collaborative network. RESULTS: Our results show a relatively high level of perceived clarity about the roles and responsibilities that healthcare professionals have during a joint outbreak response. The regional outbreak response networks which were studied appeared inclusive and integrated, with many overlapping groups of fully-connected healthcare actors. Social network analyses resulted in the identification of several central actors from different healthcare institutions with the potential to take on a brokerage role in the collaboration. Actors in the outbreak response networks also showed to prefer several healthcare professionals to take on the coordination roles. CONCLUSION: Expected collaborative structures during an imaginary regional MDRO outbreak response are relatively dense and integrated. In regard to the coordination of an MDRO outbreak response, based on both the network analysis results and the preferred coordination roles, our findings support a governance structure with several healthcare institutions involved in responding to future cross-institutional MDRO outbreaks.

Participation and coordination in Dutch health care policy-making. A network analysis of the system of intermediate organizations in Dutch health care.

This study explores the system of intermediate organizations in Dutch health care as the crucial system to understand health care policy-making in the Netherlands. We argue that the Dutch health care system can be understood as a system consisting of distinct but inter-related policy domains. In this study, we analyze four such policy domains: Finances, quality of care, manpower planning and pharmaceuticals. With the help of network analytic techniques, we describe how this highly differentiated system of >200 intermediate organizations is structured and coordinated and what (policy) consequences can be observed with regard to its particular structure and coordination mechanisms. We further analyze the extent to which this system of intermediate organizations enables participation of stakeholders in policy-making using network visualization tools. The results indicate that coordination between the different policy domains within the health care sector takes place not as one would expect through governmental agencies, but through representative organizations such as the representative organizations of the (general) hospitals, the health care consumers and the employers' association. We further conclude that the system allows as well as denies a large number of potential participants access to the policy-making process. As a consequence, the representation of interests is not necessarily balanced, which in turn affects health care policy. We find that the interests of the Dutch health care consumers are well accommodated with the national umbrella organization NPCF in the lead. However, this is no safeguard for the overall community values of good health care since, for example, the interests of the public health sector are likely to be marginalized.