The data showed variations in the readiness factors of frontline providers as well as similarities and differences between frontline providers and middle managers. Table 2 provides an overview of the readiness factors and how they were manifested. Although these factors are shown as distinct from each other, it should be noted that they are not mutually exclusive, and that there might be areas of overlap between them.
Discrepancy, participants’ perceptions of a gap between the current state and the desired state was experienced similarly by both frontline providers and middle managers. Most participants – regardless of their role – noted that the prevailing organization of health service delivery and the current operations of the Senior Care Program (the status quo) were not optimized to provide care to patients who had multiple chronic disorders and required continuous care. Most participants described the shortcomings of the current state, focusing on the challenges of communication between health care providers and of information sharing and coordination among agencies. These factors contributed to a perception of discrepancy.
So let’s say I have a client and I go to the specialist with him and he is asked all these questions that he’s already been asked beforehand, or you go to the family doctor and he didn’t get the report or I didn’t know that [Geriatric Society] was involved because the person didn’t remember. You’re trying to work together, but if you don’t have all the pieces of information, sometimes you do the same work as someone else so you’re duplicating the service. It’s a lot of work now but if we’re all working together and everyone is informed, then ideally it’s going to be a lot less work later. – Frontline provider
It’s because of poor communication among agencies. When we see these people, sometimes they have multiple services and it’s just a lack of coordination as well. Nobody knows who’s doing what. – Manager, Satellite Site
Appropriateness, the second readiness factor, denotes the perception that the specific change is the most appropriate course of action. In this case, although participants recognized the need for a change (i.e., perceived there to be discrepancy), not all of them believed that integrating the Health Links approach with the Senior Care Program was the most appropriate course of action. Middle managers, champions, and newer employees of the Senior Care Program tended to say they viewed the integration as appropriate, and Health Links as complementary to the Senior Care Program. Managers were more closely linked to the Regional Authority, which strongly advocated for the integration. More importantly, as ambassadors for the change, managers and champions were responsible for leading the implementation of Health Links in their sites and likely would have bought in to the integration. Alternatively, managers may project the notion that the integration is the appropriate course of action in order to bolster employee morale and create a sense of appropriateness among employees given that the integration was mandated and the change was to occur regardless of individual opinions of the change. When “selling” the appropriateness of the Health Links–Senior Care Program integration, managers and champions emphasized the enhanced relationships with partner agencies.
Some Senior Care Program people tend to work in silos and just do outreach to primary care providers, and just decide to do everything themselves. If we use the Health Links approach, at least we get more people connected with our client. I think it is a good approach and people should give it a try. –Frontline provider (champion)
Health care providers who noted the implementation of Health Links to be an appropriate course of action also appeared to have a better rapport with both local and Lead Site Senior Care Program managers. For new employees, the perception of appropriateness was linked to their joining the Senior Care Program during a time of change, and the messaging that they received from management and change champions during this time. Newer employees were generally more open to change as they did not operate under the older way of providing services.
[Health Links is] to get everybody talking, everybody who’s involved, and make sure the information doesn’t slip through the cracks. We get a lot of information when we do our home visits and we go back and put it in our charting system, but not everybody has access to it. Health Links is really trying to make sure that the care plan, once it’s completed, is going to be out to as many people as possible and get the integration. – Frontline provider (working with Senior Care Program for 3 months)
Individuals who perceived the implementation of Health Links to be an inappropriate course of action believed that Health Links did not add any value to the work being done through the Senior Care Program. While these individuals identified discrepancies with the current state, they did not believe that integration of Health Links would resolve these discrepancies.
What I’m hearing is that we’re doing it to lessen our workload… so I can do this whole document up and it says who’s part of my health care team and I know that we’re saying okay, if you’re from Meals on Wheels I want you to have a certain responsibility to make sure you get the meals to the client, but we’re already doing that as Senior Care Program staff, like I’m already coordinating that circle. – Frontline provider
Individuals who held these opinions tended to more frequently mention poor communication from management about the change, which led to poor understanding of the Health Links approach. Individuals who did not perceive Health Links to be appropriate also expressed some confusion about how Health Links differed from the Senior Care Program.
Valence refers to an individual’s assessment of whether or not the proposed change is beneficial and worthwhile. Participants discussed valence on three levels: the individual/personal level, the patient level, and the health system level. Frontline providers and middle managers who spoke about benefits of the integration on more than one level were more likely to perceive the change as valuable. It is interesting to note that frontline providers mostly discussed benefits of the integration to their patients while the managers tended to focus on the benefits of the change to the health system (e.g., reduced resource consumption).
Especially in the senior population when you start taking away their driver’s licence, taking away some of their rights to decide whether to stay home or go into residences, people tend to be a lot more resistant. But for us to be presenting them with all the facts and all the options, they’re able to make these important decisions about their own health and they feel like they’re being heard. – Frontline provider
I’ve been kicking the can a long, long time…and this is the first time I believe there’s ever been a program that can make a systems change. – Manager, Lead Site
Among the frontline providers who did not perceive the integration to be valuable, was the view that the Senior Care Program was already doing the work of Health Links and that the integration would bring additional workload. Hence, these individuals viewed the change as having negative valence. Another factor contributing to lower perceptions of valence from the frontline was poor communication from management on the objectives of the integration which resulted in some individuals not clearly understanding the entirety of the change, in turn creating a perception of low value of the change.
“I: For planning of Health Links integration with the Senior Care Program, were there any objectives that you wanted to reach?
P4: If there were objectives of the implementation, they were not shared with us.” – Frontline provider
Self-efficacy refers to an individual’s belief in their ability to undertake activities associated with a change. Strength of self-efficacy varied across participants, whose accounts showed one or more of the following experiences: feeling efficacious, feeling trained but not equipped with the tools/resources necessary to actively undertake the change, having a sense of “learning as you go”, and having a sense of confusion and lack of direction. Some people exhibited aspects of higher and lower efficacy depending on the activity they were talking about. Both frontline providers and middle managers exhibited a variety of experiences of efficacy.
The formal training delivered was not consistent across sites and most participants referred to its shortcomings, regardless of its format:
Honestly, [training] was a waste of my time… Like it’s all straightforward…, the two hour training…our training we did was basically going through the coordinated care plan. – Frontline provider
It was jam packed full of information, I think it was a two day training I had but I still had a lot more questions than I had training. – Frontline provider
In contrast to formal training, informal training – i.e., learning from other individuals who had had success using the Health Links approach and “wading through the mud together,” as an interviewee described it – tended to enhance participants’ sense of efficacy.
In my first case conference, I had a care coordinator sit in with me and she helped facilitate that, but she also does her job in geriatric mental health so I was able to see her wear her two hats in the meeting. It was interesting, just to get everybody together. – Frontline provider
Participants mentioned “jumping in with both feet” or learning as you go as a way to enhance self-efficacy. This was consistently noted by both frontline providers and managers. In the ambiguous context of this particular change, it was not surprising that individuals’ belief in their abilities to implement the change increased as they participated in the change.
I don’t know how you get ready because as messy as it’s been, until you jump into something and you get into the messiness of it, I don’t know how we would’ve gotten there. – Manager, Satellite Site
Interestingly, managers noted the importance of feeling efficacious in relation to the process of change management (which was not achieved in this case), and not only in relation to how to become proficient in the Health Links approach.
This is a change process and I think there almost should have been training around change management and how to support an organization around that, versus just Health Links. This is a potential system overhaul for all of us, so that would have been helpful. – Manager, Satellite Site
Fairness refers to the perceived justness and equitableness of the process and outcome of the change. Lack of procedural fairness was mentioned by both frontline providers and middle managers, who stated they were not consulted on matters related to the change that directly impacted their work:
When Health Links was introduced, we were not involved in the planning at all. It was more of a ‘we’re doing Health Links’ and that was the end of the conversation. – Frontline provider
There was a lot of talk about Health Links coming, but I was not invited to be involved in any of the planning … There was a lot of stuff I had questions about and [their expectations for me] weren’t clear so that made things even more confusing. – Frontline provider
Frontline providers and middle managers also mentioned lack of outcome or distributive fairness, typically in reference to disparities in training and administrative resource allocations. Perceptions of training disparities were associated with the amount and quality of training offered. At the regional meeting that we observed, a frontline provider said, “I know that some sites are receiving training that we didn’t even know was available to us. We’re supposed to be in this together, but we’re not. It’s hard to go through the fog when we’ve got mud in our eyes.” Another frontline provider stated in interview that the individuals who were supposed to provide training “went around and visited all the sites to provide a bit of training on Health Links. They kept rescheduling our training and when they did come in, it was not even 15 minutes, when I know they spent a lot more time at the Lead Site.” Consistently with disparities in training, one middle manager told us that she participated in a lengthy Health Links training program, while other managers did not:
The Business School was paid by the [Regional Authority] to deliver a course around Health Links - what’s collaborative, what leadership looks like and skill building exercises. Within that, the conversations were always about what does Health Links look like… At the end of the 3 months, all of us had a much clearer vision about Health Links. – Manager, Satellite Site
There were also perceptions of administrative support disparities – specifically uneven availability of project management and administrative support – that contributed to a sense of lack of fairness among some individuals. At the regional meeting, this issue became clearly evident when it was disclosed that some sites received complete administrative support while others received part time administrative support or none at all. Only some sites had access to Health Links coordinators who took on the task of care coordination, which created workload disparities:
“We have no admin support. We have to do all of our [document work] ourselves, but other people I talk to don’t have to do that.” – Frontline provider
Trust in management refers to the belief that those managing the change are capable of providing support and implementing the change. This factor emerged from the data and, interestingly, was mentioned by frontline providers and managers in the satellite and Lead sites. While many frontline providers tended to view the management team at the Lead Site as unhelpful in terms of providing information and direction, they frequently shared that they trusted local managers:
We have a great director who embraces change or anything that enhances patients’ health. And there's tremendous support and go-to people here that if you have a question they’re here to assist you. – Frontline provider
An impediment to trust in higher levels of management was ambiguity in terms of who was exercising leadership. Both frontline providers and middle managers referred to leadership ambiguity as a challenge. The leadership structure of the integration included various actors with different and sometimes unclear roles. In some instances, the Regional Authority provided directives to the Lead Site, which then disseminated information to the satellite sites, and in other instances, the Regional Authority provided information to all sites directly. In addition, management in the Lead Site indicated that they were not given sufficient information to relay to other sites, and that they were in the dark regarding central issues related to the integration:
I think directions haven’t been clear in the last two years. I am looking back at notes and questions we had a year ago at meetings, and they are still the same questions [today]. – Manager, Lead Site
Leadership ambiguity and lack of understanding of the roles played by different managers was a common theme as described by a frontline provider: “I know a lot of people who don’t know exactly who to turn to.” There was much confusion about administrative processes pertinent to the integration. Frontline providers and middle managers alike complained about lack of clear directives for their role in the integration. Several participants mentioned that there were no clear directives with respect to double documentation (having to chart in both Senior Care Program and Health Links systems) and information sharing with community partners who had not yet adopted the Health Links approach – all of which contributed to a sense of lack of support from some levels of management.