Which Inter-Organisational Characteristics Supported More Effective Implementation of a New Zealand Falls and Fractures Prevention Programme? Applying and Adapting the Context and Capabilities for Integrated Care Framework

Background on falls prevention and the FFPP in New Zealand

Similar to other high-income countries, falls are the leading cause of injury-related hospitalisations among adults aged 65 years and over in NZ [15, 20]. An evaluation of NZ’s Injury Prevention Strategy in 2010 estimated the annual cost of falls was 18% of the total cost of injuries in the country [16].

In response to this issue, the NZ Government implemented the FFPP to reduce the incidence of falls and fall-related injuries in 2016. This programme targets falls among the elderly by using extensive primary (Community Strength and Balance (S&B) and In-Home S&B programmes and Fracture Liaison Service) and secondary prevention (effective rehabilitation, review medications and Vitamin D in residential aged care facilities) initiatives (See Figure 2). At an individual patient level, the FFPP coordinates services across community, or In-Home service, and secondary care providers based on whether the patient is at low or high risk of falls and fractures [19]. This focus on prevention is reinforced by cross-agency collaboration both nationally and locally. At the national level, government agencies such as Ministry of Health (MoH), Accident Compensation Corporation (ACC), and Health Quality and Safety Commission (HQSC) work together to coordinate the design, funding, and strategic oversight of the programme. Meanwhile, at the local level, a diverse array of organisations is involved in implementing various programme components. These include community-led agencies, District Health Boards (DHBs), which were government agencies responsible for managing hospitals and funding services locally, Primary Health Organisations (PHOs) comprising primary healthcare providers, private physiotherapy organisations, tertiary hospitals, and publicly funded non-government ambulance service providers (e.g., St John or other regional providers). This collaborative effort aims to deliver a comprehensive approach to falls and fracture prevention.

Figure 2

Ethical approval for this study

Ethical approval for this research was obtained from the University of Auckland Human Participant Committee UAHPEC22004.

Data collection and analysis

Between March 2021 and November 2021, semi-structured interviews were conducted with participants from each district including managers, clinical leads, coordinators, and planning and funding representatives. Participants were identified through consultation with national experts in falls and fracture prevention and public information sources; purposive recruitment ensured a balance of governance, clinical, and operational perspectives across all relevant organisations involved in FFPP implementation. All participants provided written informed consent before taking part in interviews, which were conducted either in person or via online platforms such as Zoom, depending on participant preference. The interview guide was informed by the CCIC framework’s domains (basic structures, people and values, and key processes) which include 17 organisational capability factors. We adapted the CCIC toolkit’s interview template to reflect the specific context of the FFPP in New Zealand. The final guide comprised three sections: (1) organisational structures and governance arrangements, (2) programme characteristics and implementation strategies, and (3) perceived outcomes and sustainability. The interview guide was piloted with two senior FFPP implementation stakeholders before finalisation. The full interview guide is available in Appendix 1. Recorded interviews were then transcribed with the assistance of an AI-generated transcription service (Otter.ai.) and all transcripts were edited to ensure their quality. NVivo 12 (QSR International Pty Ltd., Melbourne, Australia), a qualitative data analysis software, was used to manage qualitative data analysis due to the considerable amount of data. Transcripts were organised into separate files for each district, facilitating systematic data coding, grouping, and cross-site comparison.

Thematic analysis followed Braun and Clarke’s (2006) six-phase approach. First, the lead researcher (MP) familiarised herself with the transcripts through repeated reading and note-taking. We applied a primarily deductive coding strategy based on the CCIC framework’s 17 organisational capability factors, while remaining open to inductive codes where participants raised issues inadequately captured by the CCIC framework. To support comparative analysis, a coding matrix was created that listed each factor against participant roles (e.g., coordinators, funders, clinical leads) and sites, enabling systematic cross-case comparison.

As a final step, we interpreted how participants described changes in collaboration and implementation over time and synthesised these accounts into three broad stages of programme development: pre-engagement, service development, and business-as-usual. This stage-based view was not part of the formal coding structure but emerged as a useful lens for interpreting how organisational factors varied across phases.

1- Basic structure

In the CCIC framework, the basic structure domain includes resources, governance, accountability, information technology, and organisational design. Among these, the presence of a well-organised governance team with clear roles and responsibilities emerged as the most critical structural factor in this study. In the early stages of implementation, regular steering group meetings were essential for coordination and decision-making. Districts varied significantly in their governance arrangements. For example, Site A established a dedicated service-level alliance for falls prevention with clear direction over three years. Once established, this team merged into broader workstreams (e.g., community services, health for older people) to support programme continuity. In contrast, Sites C and D created a joint steering group but lacked strong leadership and role clarity. These limitations reduced engagement with partner organisations and weakened coordination across entities. Participants noted challenges in inter-organisational contracting, especially between DHBs and PHOs, where collaborative and contractual roles became blurred, complicated decision-making. This lack of clarity hindered alignment and created tension among stakeholders, impeding effective programme governance.

Furthermore, adequate allocation of staff and optimization of human resources are crucial factors for ensuring streamlined service delivery and enhancing the quality of patient care. Our assessment identified differences between districts: Site B faced a shortage of human resources for almost all components, while Site D lacked personnel specifically for the Falls Liaison Service (FLS). Conversely, Sites A and C had sufficient staffing to cover all three components of the program. Interestingly, while these districts allocated adequate human resources, not all chose to hire additional staff; instead, they leveraged available resources by empowering local private organisations. However, while having enough human resources was important for programme functionality and continuity, enabling the existing workforce, such as training health assistants for specific programme components, enhanced its sustainability.

Moreover, establishing an efficient e-referral system between community, primary, and secondary care providers was essential. This system facilitated seamless communication and coordination, strengthening inter-organisational relationships and ensured efficient patient transfers and information exchange. However, while there were e-referral systems between primary and secondary care providers in all districts, none of them achieved a fully mature approach to connecting community, primary, and secondary services. The challenges of establishing e-referral systems between organisations especially between private organisations, has also been highlighted by participants.

Interestingly, financial resources (as part of resources factor in CCIC) did not emerge as a primary influencing factor in FFPP implementation. This may link to similar financial support across four case study sites as all were large districts, removing it as a distinguishing factor. Instead, the study scrutinizes the complex dynamics between districts and external funding from ACC to discern their reliance and associated challenges. There were also diverse funding models applied to different components of the program. For example, in the community S&B program, contracts between the DHB and leading sports organisations funded coordinators rather than service delivery itself, resulting in positive responses from participants involved in the program. In Site B, General Practitioners received funding for screening individuals at risk of falling, and referring them to relevant programme components, illustrating a more proactive approach to primary care engagement.

2- People and values

According to the CCIC framework, the people and value category encompass seven key factors: leadership approach, clinical leadership and engagement, patient-centeredness and engagement, commitment to learning, organisational culture, work environment, and readiness to change. All but two of the seven CCIC factors were raised by participants. We observed variations between districts in leadership approach, clinical leadership, and commitment to learning, however, attitudes toward collaboration and common vision and values were similar and positive. Among these, collaborative leadership and clinical engagement were the most important factors in implementing falls prevention initiatives. Collaborative leadership focuses on building an environment that brings together all professionals and organisations and facilitates open conversations. We found that districts with collaborative leadership showed a higher level of clinical engagement in all programme components.

While all participating organisations showcased a supportive and positive attitude toward collaboration, instances of prior negative collaboration experiences with central government agencies, and the intermittent focus on falls prevention over two decades led to some skepticism among participants, particularly in Site B. Across all sites, organisations shared a common vision and goals centered around preventing falls among older individuals and supporting their independent living at home,. For example, the involvement of the largest ambulance service in the FFPP represents a significant shift in their operational focus. Traditionally focused on providing emergency acute care, St. John had embraced a role in proactive health prevention. This change underscores their enthusiasm and commitment to broadening their contribution within the healthcare system, aligning well with the shared objectives of the FFPP.

The commitment to learning and knowledge-sharing played a crucial role in establishing connections among providers within and across organisations or districts. However, its direct influence on improving outcomes was relatively limited, for instance in efforts in sites C and D to enhance connections among Community Strength and Balance providers through formal and informal sessions.

However, this did not result in increased engagement of older participants in classes or higher completion rates of strength and balance sessions, which represented a key indicator on the outcomes dashboard.

3- Key processes

Among factors in the key process category, the partnership process stands out as a fundamental element in the successful implementation of the FFPP. It required active involvement from primary care, community providers, and private organisations. Districts in which PHOs were engaged at the governance level and community providers were empowered, had better outcomes and a sustainable programme. For instance, site A demonstrated proactive involvement with primary care from the program’s outset, collaborating with local In-Home service providers to engage proactively with GPs in their regions and simplified risk assessments process. However, in the low performing district, (Site C) engagement with primary care providers at the governance level was not consistent.

Monitoring performance and establishing feedback mechanisms, both internally and externally, are vital for continual quality enhancement, especially in multifaceted programs involving multiple organisations. Despite quarterly reports collected from various entities, there was considerable room for improvement across all districts regarding the development of effective feedback mechanisms between organisations involved in different components of the programme as well as between national and local organisations. Moreover, all districts maintained similar patient flows for community and In-Home services based on clinical guidelines, ensuring consistent service quality across diverse districts.

4- Programme characteristics

The CCIC framework is designed to provide a general overview rather than a detailed exploration of specific programme or intervention characteristics, so the factors we presented here are specifically about the characteristics of programme. The findings of this study revealed that the most impactful characteristic of FFPP was districts adopting a population-based approach to prevention. This approach involved identifying patients at risk through comprehensive community training and awareness sessions, which significantly contributed to the programme’s success.

Additionally, the existence of a pre-existing falls prevention program, rather than general experience with integrated care, was a crucial factor. For example, there was no nationwide falls prevention initiative in New Zealand for people over the age of 65, except for what was established in Site A in 2012. This locally driven programme represented a proactive response to the growing issue of falls among older adults. It involved early recognition of the problem, strategic planning, and implementation of targeted interventions. These efforts helped build local capacity and engage established private organisations in delivering services. This historical experience with falls-specific initiatives is distinct from broader collaboration history discussed in Section 5 and was instrumental in shaping Site A’s leadership and programme delivery approach.

5- Additional factors beyond the CCIC Framework

In addition to the CCIC factors, participants emphasised the importance of previous collaboration experiences in integrated care initiatives. This factor, which reflects past collaboration experience (between organisations), significantly influenced the success or hindrance of new initiatives or partnerships. As expressed by a Community Strength and Balance coordinator from Site B, community groups experienced frustration with ACC-funded initiatives, particularly a strength and balance initiative through Tai Chi that was canceled despite initial enthusiasm. This history of funding withdrawal led to a sense of mistrust among community members, prompting questions about the longevity of new initiatives. Consequently, rebuilding trust emerged as a crucial aspect of fostering successful collaboration in the implementation of integrated care programmes.

While prior collaboration experience overlaps with the “People and Values” domain of the CCIC framework, we argue it functions as a cross-cutting contextual factor. It reflects the embedded history and inter-organisational memory that predate current collaboration, distinguishing it from emergent values or cultural traits. In our study, this was evident in the mistrust linked to earlier ACC-funded initiatives (Site B) and in contrasting histories of collaboration between DHBs and PHOs. For example, Site A’s long-standing relationships supported integration and programme uptake, whereas in other districts, unclear roles and strained DHB–PHO dynamics hindered collaboration. We therefore propose prior collaboration experience as a distinct factor shaping trust, engagement, and strategic alignment across CCIC domains.

Modified CCIC Framework

To capture this, we adapted the CCIC framework by adding prior collaboration experience (Figure 3). Historical relationships can strongly influence implementation by affecting trust-building, communication, and governance. Incorporating this dimension enables a more comprehensive understanding and management of integrated care initiatives, especially those involving multiple organisations.

Figure 3

Life cycle approach in the implementation of integrated care

Through our thematic analysis, we identified shifts in districts’ focuses over time, this led us to determine three main stages in the implementation of the FFPP: (i) pre-engagement and engagement; (ii) development of service delivery; and (iii) establishment of the programme as a usual business. We identified the factors frequently mentioned by participants at various stages of the programme and their roles in facilitating collaboration. Then, we ordered factors based on their importance in different stages of the implementation (see Figure 4).

Figure 4

The initial stage involves introducing local partner organisations to the programme, setting up contracts, and establishing steering groups. Strong collaborative leadership and a well-structured governance team were important, along with the identification and engagement of key partners (primary care and private organisations) and adoption of a population-based prevention approach. The second stage focuses on developing service delivery, creating referral pathways, setting outcome targets, and resolving inter-organisational conflicts. Clinical engagement and effective conflict management were identified as crucial. In the third stage, the programme is established as a normal part of service delivery, and at this stage quality improvement, monitoring, and knowledge sharing become the most important factors. Effective monitoring and reporting systems facilitate continuous improvement and inter-organisational collaboration.

It’s important to highlight that the placement of key factors at various stages of programme implementation does not diminish their significance in other stages. Rather, it signifies that their role may be more prominent during that particular stage. By recognizing the significance of these factors and their alignment with the corresponding implementation stages, we were able to discern patterns, challenges, and areas of focus that are vital for achieving successful outcomes in integrated care interventions.