Refining Program Theory for a Place-Based Integrated Care Initiative in Sydney, Australia

John Eastwood; Salwa Barmaky; Sally Hansen; Erin Miller; Suzanne Ratcliff; Penelope Fotheringham; Heidi Coupland; Denise De Souza

doi:10.5334/ijic.5422

Figures & Tables

Table 1

Context, Mechanisms, Outcomes, modified from [33].

Context	Mechanisms related to	Outcomes
Structure – Institutional/Organisational	roles, practices, resources, processes	(T), (I) or (R) of institutional/organisational structure
Culture – Institutional/Organisational	group ideas and propositional formulations about the institution/organisation	(T), (I) or (R) of institutional/organisational culture
Agency	individual beliefs and reasons for actions or non-action	(T), (I) or (R) of individual agency within the institution/organisation
Relations	maintaining, adjusting or redistributing power/duties/responsibilities	(T), (I) or (R) of institutional/organisational relations

[i] Note:

a. Transformation (T): indicates mechanisms related to different parts of context, and activated by the social program, are producing some anticipated/desired outcomes.

b. Invariance (I): indicates that mechanisms related to different parts of context, undergo changes in attributes irrelevant to transformation or reproduction of the context (e.g. doctor-patient relation remains, though different persons may fill the roles)(cf. Sayer, 1992).

c. Reproduction (R): indicates relevant mechanisms related to different parts of context have not been adequately activated by the social program, thereby reproducing outcomes the social program aimed to change.

Key elements of the adapted development and evaluation process.

Table 2

CIMO-logic – the Components of Design Propositions [42].

Component	Explanation
Context (C)	The surrounding (external and internal environment) factors and the nature of the human actors that influence behavioural change. They include features such as age, experience, competency, organizational politics and power, the nature of the technical system, organizational stability, uncertainty and system interdependencies. Interventions are always embedded in a social system and, as noted by Pawson and Tilley (1997), will be affected by at least four contextual layers: the individual, the interpersonal relationships, institutional setting and the wider infrastructural system.
Interventions (I)	The interventions managers have at their disposal to influence behaviour. For example, leadership style, planning and control systems, training, performance management. It is important to note that it is necessary to examine not just the nature of the intervention but also how it is implemented. Furthermore, interventions carry with them hypotheses, which may or may not be shared. For example, ‘financial incentives will lead to higher worker motivation’.
Mechanisms (M)	The mechanism that in a certain context is triggered by the intervention. For instance, empowerment offers employees the means to contribute to some activity beyond their normal tasks or outside their normal sphere of interest, which then prompts participation and responsibility, offering the potential of long-term benefits to them and/or to their organization.
Outcome (O)	The outcome of the intervention in its various aspects, such as performance improvement, cost reduction or low error rates.

Geospatial analysis of perinatal family stress – SLHD, 2014.

Table 3

CIMO propositions for Whole of Family Involvement intervention.

Present contextual mechanisms activated produce the following outcomes [C_M]	Proposed Intervention Design Elements [I]	Postulated Intervention Programme Mechanisms activated at the Level of Situated Activity [M_P]	Postulated psychological, motivational and behavioural Outcomes [O]
– Intergenerational trauma – Children being assumed into care – Disconnection from services – Significant Aboriginal and Torres Strait Islander people as clients of HHAN	– Whole of family involvement – Families participating in decision making – Fostering trust and collaboration between services, HHAN and families Cultural sensitivity	– Trust	Client outcomes: – Increased family stability – Increased family cohesion – Establishment of greater trust in services

Table 4

CIMO propositions for flexibility of service intervention.

Present contextual mechanisms activated produce the following outcomes [C_M]	Proposed Intervention Design Elements [I]	Postulated Intervention Programme Mechanisms activated at the Level of Situated Activity [M_P]	Postulated psychological, motivational and behavioural Outcomes [O]
Client characteristics: – Complex health and social needs – Distrust of previous services – Disconnection from services – HHAN programme’s characteristics	Flexible programme model: – No strict referral criteria – No prescriptive evaluation tool – No time frame – Prioritise client need rather than service objectives – Clinician autonomy and adaptability	– Flexibility	Client outcomes: – Better engagement in services – Improved outlook andplanning for the future

Table 5

CIMO propositions for Intervention focus on building trust.

Present contextual mechanisms activated produce the following outcomes [C_M]	Proposed Intervention Design Elements [I]	Postulated Intervention Programme Mechanisms activated at the Level of Situated Activity [M_P]	Postulated psychological, motivational and behavioural Outcomes [O]
– Distrust and disconnection from previous services – The power imbalance between client and service provider	– Building rapport and responding to need – Attentive to client concerns – Flattening the power base – Informal client-clinician interactions – Non-judgemental interactions – Favourable interpersonal skills	Trust	– Empowerment for clients – Establishment of greater trust in services for clients – Better engagement in services for clients

Table 6

CIMO propositions for connecting services intervention.

Present contextual mechanisms activated producing the following outcomes [C_M]

Proposed Intervention Design Elements [I]

Postulated Intervention Programme Mechanisms activated at the Intermediate Level of Social and Service organisation [M_P]

Postulated psychological, motivational and behavioural Outcomes [O]

– Silo-working
– Complex health system
– Clients having complex health and social needs
– Services having little understanding of the health system
– Competing priorities
– Services’ distrust of other services

– Connecting services
– Informal and formal communication
– Employment of experienced clinicians
– Interpersonal skills of clinicians
– Recognition of established networks rather than creating new systems

– The motivation of clinicians and services to collaborate

Positive outcomes:
Clients:

– Better engagement in services for clients

Services:

– Increased collaboration between services
– Foundations for the integration of services
– Improved relationship between HHAN and other services
– Avoid service duplication
– Introduction of new health services to Redfern

– Confidentiality and privacy concerns over sharing data about clients and integrating systems
– The unwillingness of organisations to take a risk or change current structures to integrate

Negative Outcomes
Services:

– Systems not yet integrated
– Difficulties with information sharing

Table 7

CIMO propositions for co-location of services intervention.

Present contextual mechanisms activated [C_M]

Proposed Intervention Design Elements [I]

Postulated Intervention Programme Mechanisms activated at the Macro-Level of Social and Service organisation [M_P]

Postulated psychological, motivational and behavioural Outcomes [O]

– Redfern as a hotspot for vulnerability
– Disconnection from community

– Co-location
– Accessibility for clients
– Proximity
– Recognition by clients of Redlink hub as part of the community

“crossing of paths”
Increased personal interaction

Positive outcomes
Clients:

– Better access to services
– Better engagement in services for clients

– Complex health, social, economic and environmental issues
– Siloed and complex health system
– Complex health, social, economic and environmental issues
– Siloed and complex health system

– Co-location
– Engagement of a diverse range of services

– communication between services
– collaboration (e.g. acceptance of shared risk)
– Flexibility (e.g. accommodate diverse objectives)

Positive outcomes:
Services:

– Better integration of services
– Improved relationship between HHAN and other services

Negative outcomes
Services:

– Difficulty evaluating the impact of HHAN/difficulty determining discrete impact/outcomes of HHAN
– Reception of HHAN dependent on the reputation of all services at Redlink

Refining Program Theory for a Place-Based Integrated Care Initiative in Sydney, Australia

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