Unpacking Workforce Mechanisms in Integrated Care: a Realist Evaluation of the Dutch TARGET Program

Background: Integrated care programs partly show positive outcomes, but evaluations also report mixed effects on healthcare costs and patient outcomes (1), as well as healthcare providers’ work stress and job satisfaction (2, 3). The mechanisms that shape how integrated care is implemented in daily practice, and how these processes influence the professionals delivering it, are still a black box; this knowledge is important, however, for sustaining workforce engagement in times of staff shortages.

 

Approach: To open this black box, we evaluate the TARGET program, a Dutch integrated care initiative in the province of Drenthe, during three years of implementation (2021–2023). The program was co-designed by scientists, primary care providers, and the regional primary care organization Dokter Drenthe. Rather than only asking whether TARGET works, we used realist evaluation to investigate how it works: what mechanisms are triggered for primary care providers, under what conditions, and with which outcomes.

 

Building on the initial program theory of TARGET (4), we conducted interviews with primary care providers and analyzed practice-level data. We combined three data sources:

• Interviews to capture experiences and mechanisms underlying practice change
• Questionnaires on professionals’ perceptions of care integration, work pressure, and job satisfaction
• Care use data to objectively assess workload and contextualize perceived changes in work pressure

 

Results: We analyzed questionnaires of 677 primary care providers. Descriptive quantitative results show a small but consistent increase in providers’ perceived integration of care. Job satisfaction remained stable, while perceived work pressure slightly decreased. Care use data suggest that the care consumption of patients who participated in person-centred needs assessments (PCNAs) decreased more sharply compared to high-need chronic patients who did not have PCNAs. Interviews with 23 care providers suggest that the program’s interventions helped providers to work in a more integrated, population-oriented and meaningful way and can help strengthen collaboration across disciplines.

For instance, the PCNA with patients promoted care provider energy. However, implementing interventions required a context of time, adaptation, and ongoing support from the regional primary care organization.

Furthermore, practices tailoring implementation to their own routines experienced greater ownership and engagement, especially when most team members shared a vision of person-centered care. Despite experienced benefits, perceived work pressure did not always decrease, as new tasks often replaced time saved.

 

Implications: Our findings suggest that integrated care implemented through, amongst others the PCNAs, can support healthcare professionals’ work experience. Our study also revealed preconditions for integrated care interventions to work successfully: professional autonomy is important for adoption. Practices need freedom to tailor program elements based on their own context, balanced by guidance and support from regional organizations.

 

These insights highlight the importance of co-design and regional collaboration to enable effective implementation. The Realist Evaluation perspective was essential for understanding how TARGET -grounded in international principles of integrated care- functions in practice. As integrated care takes time to mature, our ongoing evaluation will explore its long-term effects and include patients’ perspectives, since integrated care can only be considered successful if it is also valued by those receiving it.