Implementation of a cross-sector stroke rehabilitation reform: embedded case study of municipalities and hospitals' perspectives in a Danish health region

Background : Concentration of acute care, early discharge, and moving care to the community are a global trend. In May 2012, the Central Denmark Region decided to transfer inpatient rehabilitation for stroke patients to the community, as part of a major stroke care reform. The objective was an integrated care pathway with early discharge stroke teams bridging the two sectors. The main tool was implementation of a collaboration agreement. This study analyses the top-down implementation process and to what extent integrated care has been achieved. Method : An embedded case study was designed, with cases of municipalities (n=7), and early discharge stroke teams (n=5). Municipalities were selected on the basis of theory-based criteria. Data was gathered from October 2013 to April 2014 by means of semi-structured interviews, and document analysis. Results : Both sectors accepted the change, as they believe the reform will benefit the patient. The implementation process has been experienced as head over heels by the stroke teams, and as non-involving by the municipalities. The respondents were not involved in developing the collaboration agreement, and did not feel ownership. Stroke teams experienced opposition of municipalities to their existence. Municipalities were not informed about the financial consequences of the reform. Care is provided by both parties, but it is not coordinated or shared. Conclusion and discussion : The collaboration agreements have been implemented at the administrative level, but haven’t resulted in integrated care at the practice level. Active involvement of health care professionals at the practice level would have led to smoother processes with a better result, because the rationale for the reform was supported by the practice level. The implementation process should focus on achieving shared values across sectors and the collaboration agreements could be used as input for that, rather than be viewed as output of the process.