BMC Pregnancy & Childbirth, 2017; 17(2000): 1–14. in terms of the range of existing barriers). The fact that my friend was even seeking professional help and sharing her experience on social media is not the norm. Introducing inter-organizational relations. book chapters, monographs), thereby also omitting further barriers. Hardy, B, Mur-Veemanu, I, Steenbergen, M and Wistow, G. Inter-agency services in England and The Netherlands. DOI: https://doi.org/10.1111/cch.12322, Dinesen, B, Seeman, J and Gustafsson, J. Download page. Despite their various potential benefits, many inter-organisational collaborations fail [according to 19 around 50–70%], and the implementation of collaboration proves to be a managerial challenge. International Journal of Integrated Care, 2011; 11(7): 1–12. DOI: https://doi.org/10.1111/1467-9302.00088, Johnson, P, Wistow, G, Schulz, R and Hardy, B. Interagency and interprofessional collaboration in community care: The interdependence of structures and values. This barrier was especially mentioned in studies on integrated mental healthcare provision [25, 26]. The shared leadership challenge in strategic alliances: Lessons from the U.S. healthcare industry. Integrated care in its various forms can produce benefits such as quality enhancement, increased system efficiency and cost reduction, higher client satisfaction, and better access to care [1, 6]. Barriers to behavioral health integration, they said, included cultural differences with mental health providers and impediments to the flow of information between medical and behavioral health providers. Alliances in health care: What we know, what we think we know, and what we should know. Washington, D.C.: IBM Center for The Business Development; 2013. Second, this systematic literature review can guide further empirical research on the occurrence of barriers and their causes. This helps to explain why some inter-organisational collaborations that aim for the integration of care make slow or no progress. For instance, barriers in the formation phase of a collaboration can prevent collaboration before it even begins, one example being a lack of organisational resources and financial uncertainties [18, 58]. This first search produced a total of 914 potentially relevant hits. Fourthly, the partners follow certain rules, norms, and structures within the relationship – rendering the relationship either formal or informal [34]. Removing barriers to integrated care. DOI: https://doi.org/10.5334/ijic.1437. DOI: https://doi.org/10.5465/AME.2001.4614907, Auschra, C., 2018. Sociology, 1972; 6(1): 1–22. Third, the context-dependence of barriers and their interrelatedness are discussed. DOI: https://doi.org/10.1093/hsw/23.1.53, Behruzi, R, Klam, S, Dehertog, M, Jimenez, V and Hatem, M. Understanding factors affecting collaboration between midwives and other health care professionals in a birth center and its affiliated Quebec hospital: A case study. International Journal of Integrated Care 18, no. DOI: http://doi.org/10.5334/ijic.3068, Auschra C. Barriers to the Integration of Care in Inter-Organisational Settings: A Literature Review. Copenhagen: WHO; 2012. Actively raised barriers are deliberately activated by actors who want to sustain a desired state or prevent another and, hence, are similar to personal resistance to organisational change (e.g. According to Kodner and Spreeuwenberg [1], integration in healthcare “is a coherent set of methods and models on the funding, administrative, organisational, service delivery and clinical domains designed to create connectivity, alignment and collaboration within and between the cure and care sectors” (p. 3). Incompatible organisational structures: Differing organisational structures and processes can impede inter-organisational collaboration, e.g. Barriers to behavioral health integration included cultural differences and incomplete information flow between behavioral and nonbehavioral health clinicians on patients’ electronic health … that the absence of a barrier or its opposite (e.g. DOI: http://doi.org/10.5334/ijic.3068, Auschra C, ‘Barriers to the Integration of Care in Inter-organisational Settings: A Literature Review’ (2018) 18 International Journal of Integrated Care 5 DOI: http://doi.org/10.5334/ijic.3068, Auschra, Carolin. So just as important as having interconnected Health IT systems, is the capability of the same systems to collect data on health outcomes that both matters to patients and are comparable from one database to another. Chronic diseases are responsible for 7 of 10 deaths each year, killing more than 1.7 million Americans annually. Agreed sets of standardised outcomes measures implemented across integrated health IT systems would enable almost real-time analysis of how different organisational changes and the introduction of new methods and technology affect the health outcomes of patients, thereby enabling comparisons between hospitals, care organisations and even countries. DOI: https://doi.org/10.1016/S0306-4603(00)00127-1, Goldman, HH. Additionally, hospital providers often have a good reason not to foster collaboration with community social care providers, as a following shift from patients to these providers would make hospital beds redundant, leading to a loss of resources for the hospitals (organisational vs. collective interests, meso-level, agent-driven barrier). good vs. poor management) can facilitate an implementation process [10, 12]. DOI: https://doi.org/10.1186/1472-6963-12-21, Provan, KG and Lemaire, RH. Organizational path dependence: Opening the black box. DOI: https://doi.org/10.5334/ijic.234, Andersson, J, Bengt, A, Axelsson, SB, Eriksson, A and Axelsson, R. Organizational approaches to collaboration in vocational rehabilitation – An international literature review. on inter-professional collaboration, but not with a focus across organisational boundaries), and articles not addressing the study question in other ways (e.g. More often than not, the integration of care faces barriers [8–11] caused by contextual, institutional and professional factors in different domains of integrated care [1]. talks with experts. public vs. private) does not exclude or favour the occurrence of certain types of barriers, as both kinds of health systems may require mandatory inter-organisational collaboration, which could cause resistance to this change. Institutions and organizations: Ideas, interests and identities. Thomas Allvin is Executive Director for Strategy and Healthcare Systems at EFPIA. Examples in different countries show the importance of inter-organisational collaboration for the delivery of integrated care. Health Care Management Review, 2012; 37(3): 267–79. It is important to note that barriers do indeed represent obstacles, but obstacles which can be overcome, often in a gradual, processual way. A lack of information exchange can, in turn, increase the risk of errors and mistakes and, in certain areas such as that of mental health care, jeopardise the job security of employees [69]. In care organisations all over Europe, and the world, great work is being done in experimenting with new, innovative models that can solve these issues. However, different barriers reported in academic literature seem to hinder the formation and development of such collaboration. Thirdly, the relationships allow for and result from exchange [33], e.g. This discussion paper focuses on some particularly challenging aspects of bridging primary care and oral health care for low health literacy populations. DOI: https://doi.org/10.1016/S0168-8510(02)00205-1, Ling, T, Brereton, L, Conklin, A, Newbould, J and Roland, M. Barriers and facilitators to integrating care: Experiences from the English integrated care pilots. Academy of Management Executive, 2001; 15(2): 71–9. Lack of trust: A lack of inter-personal trust typically impedes collaboration [64]. International Journal of Integrated Care, 2011; 11(11): e137. Third, it seems vitally important to develop a comprehensive and more realistic understanding of the formation, development and/or failure of inter-organisational collaboration in the context of integrated care and the precise sources of barriers during this process. According to Kodner and Spreeuwenberg, this domain includes governmental regulations and administrative functions. Health Services Research, 2014; 49(6): 1883–99. BMC Health Services Research, 2012; 12(21): 1–11. The methodological approach used in this paper is informed by previous similar studies in the field of research on inter-organisational relationships and networks [24], integrated care [42, 43], and – to improve transparency and replicability – is based on the PRISMA-guidelines for reporting on systematic reviews [44]. 2018;18(1):5. DOI: https://doi.org/10.1007/s11414-014-9448-1, Axelsson, SB and Axelsson, R. From territoriality to altruism in interprofessional collaboration and leadership. The purpose of this paper is to report on the findings of the first stage of a project seeking to evaluate and overcome inter-professional barriers between health and social care staff within a single, co-located, integrated community team. As the focus of this review is on collaboration across organisational boundaries, it seems feasible to add a sixth inter-organisational domain that accounts for the peculiarities of inter-organisational collaboration, e.g. DOI: https://doi.org/10.1287/orsc.1100.0578, Doz, YL. Public Money & Management, 1997; 17(4): 25–30. Within this domain, characteristics of and practices within single organisations can play an important role, e.g. Some studies addressing barriers to inter-organisational collaboration use no theoretical conceptualization at all [e.g. between different professions, team members or across teams [30]. Not all of these barriers emerge passively, some are set up intentionally. It is of importance to consider that the integration of care can be achieved by employing different forms of governance [3], ranging from the integration of tasks within organisational hierarchies (e.g. Inter-organisational collaborations – as opposed to market or hierarchical relationships – feature certain characteristics: firstly, partners within the inter-organisational relationship follow either a common goal or purpose [20, 23]. inter-professional collaboration within a single organisation such as a hospital) through collaborative inter-organisational relations [e.g. Lack of Awareness. BMJ Open. Martin Sandberg Buch, Project Director, VIVE, Denmark. Some scholars argue that a lack of common goals or leadership inhibits collaboration [20]. Stigma, or a fear of how others will perceive you, is a hurdle to mental health care for so many people. DOI: https://doi.org/10.1186/s12913-017-2018-5, Bang Christensen, JK. They can provide a helpful framework for the analysis of barriers to the integration of care in inter-organisational settings and are described in the following in greater detail. Cultural distance between organisations: Organisations develop their own specific cultures, which can create barriers to inter-organisational collaborations if organisations are not capable of managing these differences. DOI: https://doi.org/10.1111/j.1540-6210.2007.00866.x, Berends, H, van Burg, E and van Raaij, EM. These criteria help to get an overview of the applied research methods, and theoretical and contextual embedding of the reviewed studies. Clinical guidelines are often established for major chronic diseases, but the guidelines can vary between regions and countries, and they are not always implemented in the same way (or at all). DOI: http://doi.org/10.5334/ijic.3068, Auschra, Carolin. Figure 1 gives an overview of the review approach. Lack of information exchange: Closely related and sometimes caused by confidentiality concerns, a lack of information exchange can hinder joint working across organisations. During coding, the author was sensitive to potential sources of barriers, which could be rooted both in structure and in agency [37]. Around 75% of healthcare spending in Europe is directed towards managing and treating chronic diseases. also 37]. Barriers of inter-organisational integration in vocational rehabilitation. when they referred only to barriers to the interoperability of IT systems or IT-networks. Despite linguistic differences, the terms barrier, impediment, hurdle or obstacle are often used interchangeably [39]. DOI: https://doi.org/10.1007/s10926-009-9205-0, Loisel, P, Durand, MJ, Baril, R, Gervais, J and Falardeau, M. Interorganizational collaboration in occupational rehabilitation: Perceptions of an interdisciplinary rehabilitation team. Tackling barriers to integration in Health and Social Care. DOI: https://doi.org/10.1007/s11301-014-0109-5. Financial barriers: costs associated with development, implementation and optimization of health IT to comply with health care program requirements that change frequently. For instance, the failure to include a local hospital in a network of integrated care can cause difficulties. To increase the consistency and robustness of the findings, monographs [20] and edited volumes [32], with a similar focus and which were mentioned in the articles, were also surveyed. Historical developments: Historical developments and critical junctures, often on the macro level, influence the behaviour of organisational and individual actors. studies referring to vector-borne disease outbreaks or barriers in IT-networks). Swedish rehabilitation professionals’ experiences of interorganizational cooperation. For instance, the legally required focus on bureaucratic procedures by organisations within the public sector can slow down collaboration [10]. DOI: https://doi.org/10.1111/j.1447-0748.2005.00198.x, Hosman, CMH. A very broad definition in organisation theory describes inter-organisational collaboration in the middle of a continuum delimited by market and hierarchy as “a cooperative, inter-organisational relationship that is negotiated in an ongoing communicative process, and which relies on neither market nor hierarchical mechanisms of control” [31, p. 323]. Almost all of the works included in this literature review – as far as they are documented – deal with barriers during the implementation or later stages of a collaboration, and none of them gives reasons for the failure of a collaboration. Second, the review illustrates that these barriers can either be actively raised by certain actors, or emerge more passively due to structural and institutional arrangements. The theory and practice of collaborative advantage. Additionally, the review only includes the results of the reviewed studies, which could limit its scope (e.g. Health Care Management Review, 1995; 20(1): 54–64. Cambridge: Polity Press; 1984. Thus, the analysis of barriers to inter-organisational collaboration may benefit from a clear distinction between the organisational and inter-organisational domain. This is indeed a problem not just for evaluating integrated care, but also for assessing the real impact of all care pathways and healthcare interventions. To sum up, when analysing barriers (either for research purposes or in order to overcome them), it seems helpful to assume that a barrier which is visible could be caused by one or several other barriers that are not obvious at first glance [41]. Missing actors: The lack of important actors can be a barrier to successful collaboration in a certain nexus of health service delivery [12]. Journal of Occupational Rehabilitation, 2005; 15(4): 581–90. A taxonomy of accountable care organizations for policy and practice. A third domain relevant for the integration of care is the organisational domain. as dyadic relationships between two partner organisations or as inter-organisational networks, implying relationships between at least three partners [24]. DOI: https://doi.org/10.1111/j.1540-6210.2012.02595.x, Stahl, C, Svensson, T, Petersson, G and Ekberg, K. A matter of trust? This leaves room for further conceptual work, as the last section will show. Studies of integrated programs show success, but they’re still a rarity for multiple reasons. Furthermore, it can help practitioners engaged in the planning or implementation of inter-organisational, integrative health care services to avoid or overcome such barriers by promoting awareness and enabling more reflective action. Core concepts and key ideas for understanding public sector organizational networks: Using research to inform scholarship and practice. Thereby, the study offers the following contributions: first, it deepens our understanding on barriers to the integration of care in inter-organisational settings by providing a systematic overview on several kinds of barriers that can occur, on their contextual embedding, as well as underlying mechanisms that lead to their existence. Barriers. Public Administration, 2011; 89(2): 265–84. Minkman, MMN. [65] describe how, in the case of occupational rehabilitation, obstacles arose when different collaborating stakeholders such as the employer, the physicians or insurers had no understanding of the actions of the rehabilitation team, which delayed communication and hampered information exchange. Lack of mutual understanding: Inter-organisational collaborations do not materialize, are hampered, or fail if one partner has little understanding of the goals, procedures and behaviour of the other(s). Separate funding is another barrier. Taking this view into account, inter-organisational relationships undergo an evolution, ranging from their initiation and formation to their development and then to possible dissolution [22, 23, 35, 36]. Generally, chronic diseases have much more complex “care pathways” than the treatment of other diseases, which can lead to a variety of models being used, both within and across countries, at times leading to variations in the actual health status of the patient. “Barriers to the Integration of Care in Inter-organisational Settings: A Literature Review”. Methods for the thematic synthesis of qualitative research in systematic reviews. Nevertheless, this analysis offers insights into the most important aspects of the academic discourse on barriers that impede the integration of care in inter-organisational settings. Journal of Clinical Epidemiology, 2009; 62(10): 1006–12. These barriers occur on the inter-organisational domain of analysis and differ from barriers reported in other settings such as markets or hierarchies. International Journal of Integrated Care, 2014; 14(4): 1–2. One can argue that the most extensive domain affecting the integration of care is administration, also including regulations, on a very macro or environmental level of analysis. 24] as parts of the context influence the existence of barriers and vice versa. The fifth domain relevant for the integration of care is the clinical domain, involving, for instance, common professional languages, agreed understandings, practices and standards related to certain diseases, and ongoing communication with patients [1]. The study examined co-occurring disorder service delivery for mental health clients in Los Angeles County, California. The articles were first coded line by line with rather descriptive codes, representing barriers that occurred. 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