Designing an Integrated Care Initiative for Vulnerable Families: Operationalization of realist causal and programme theory, Sydney Australia

Abstract

Introduction: In July 2015 Sydney Local Health District (SLHD) implemented an integrated care initiative for vulnerable families in the inner West region of Sydney, Australia. That initiative was designed as a cross-agency care coordination network that would ensure that vulnerable families: had their complex health and social needs met; kept themselves and their children safe; and were connected to society. We will describe the development of the integrated care design that drew on earlier realist causal and program theoretical work. Theory/Methods: Realist causal and program theory were used to inform the collaborative design of initiatives for vulnerable families. The collaborative design process included: identification of desirable and undesirable outcomes and contextual factors, consultation forums, interagency planning, and development of a service proposal. Results: The program theory mechanisms identified included: family-provider trust, willingness to share power, co-operation, Information, and building self-help skills. The Design Elements included: Wrap around services, place-based initiatives, care coordination, sustained nurse home visiting, primary care support, family group conferencing, targeted parenting, social media, outcome monitoring, workforce development and realist program evaluation. Discussion: The Design Elements included: identification of vulnerable families; care coordination; evidence-informed intervention(s); general Practice engagement and support; family health improvement; placed-based neighbourhood initiatives; interagency system change and planning; monitoring of individual and family outcomes; and evaluation. Conclusions: The design study described advances our earlier empirical and programme design studies toward the implementation of a full whole-of-government integrated health and social care initiative. That initiative was designed as a cross-agency care coordination network that would ensure that vulnerable families: had their complex health and social needs met; kept themselves and their children safe; and were connected to society. In so doing we aim to break intergenerational cycles of poverty, violence and crime, poor education and employment opportunities, psychopathology, and poor lifestyle and health behaviours, through strengthening family resiliency, improving access to services, and addressing the social determinants of health and well-being. Lessons learned: In undertaking this study we identified the importance of our earlier hierarchal program analysis for identifying the elements for the full design. The application of theory added rigour to the design of integrated care initiatives. The design benefited from the inclusion of elements of population health, primary care, consumer engagement, community engagement and social determinants of health. Limitations: The analysis and design process did not include a full critical realist analysis of pre-existing context. Consequently existing structural, cultural, relationship and agency barriers and enablers were not fully analysed as part of the design process. Suggestions for future research: Further methodological research to develop: 1) tools that can be rapidly applied during the design process to identify pre-existing contextual barriers and enablers; and 2) approaches to build the knowledge of context into the final design.