Understanding relationships between hospital- and community ...

Understanding relationships betweenhospital- and community-baseddiabetes programs in a new model ofdiabetes care delivery in OntarioRene WongPetra BreinerMaria MylopoulosUniversity of Toronto

Acknowledgements• AFMC• SACME

Diabetes epidemic

Context of diabetes care in Ontario(pre 2009)TerminologyHoused withinStaffingAccountabilityHospital-basedprogram (HPs)Diabetes EducationCenters (DECs)Hospitals (typicallyacademic)Endocrinologists, RN,RD +/- social worker,chiropodistHospitals

Context of diabetes care in Ontario(2009 - )TerminologyHoused withinStaffingHospital-basedprogram (HPs)Diabetes EducationCenters (DECs)Hospitals (typicallyacademic)Endocrinologists, RN,RD +/- social worker,chiropodistCommunity-basedprogram (CPs)Diabetes EducationPrograms (DEPs)Primary care teams orcommunity healthcentersRN/RD team(s)[no medical care]Accountability Hospitals Government (1000enrolled patients/year)

Objective• Gain empirical understanding of the experiencesof new community diabetes programs (CPs) toinform hospital diabetes programs (HPs)planning CPD activities

Methodology: grounded theory• Exploratory study• Purposive and theoretic sampling untilsaturationSemi-structured interviews with members ofCPs and HPs• Constant comparative analysis• Inductive analysis

THREATENED REPUTATIONESTABLISHING LEGITIMACYSENSE OF VULNERABILITY

ESTABLISHING LEGITIMACY

ESTABLISHING LEGITIMACY‘we work…in a more holistic way…thatincludes advocacy, social justice, and reallymore integrated patient-centered care. It’s acomplete different notion in the hospital’

ESTABLISHING LEGITIMACY‘I think the idea was we would just lob onto thecommunity health center like a piece of gum onthe side and that’s what it actually felt like…’.

ESTABLISHING LEGITIMACY‘…we were really struggling with how to define acomplex patient. So at one point we had said it wouldbe somebody with co-morbidity, but seriously, allpeople with diabetes have comorbidities.’

THREATENED REPUTATION

‘….it would be wonderful if I were able to get anequivalent salary to a hospital nurse working in ahospital program, because really we’re doing the samething, if not more, here.’THREATENED REPUTATION

‘…when I first presented to the endocrinologists thatwe were going to the community to do our care: “howdo we know that the quality is the same?” ’THREATENED REPUTATION

‘…negative stories [from] patients who weren’t served well [atCPs]…that one encounter, people will hear about it at the coffeeshops….doctor’s waiting rooms… They’re not serving you at…thatbig bad hospital being stingy with its generous resources [laughs].’THREATENED REPUTATION

SENSE OF VULNERABILITY

SENSE OF VULNERABILITY‘…diabetes is a human experience; gives us some feedback and somevalidation around that, because that’s why we’re in thecommunity….[instead] evaluation is saying saying: ‘… you’re notreaching your thousand people…target… it’s kind of counterproductiveand uninspiring right..…we’re like gerbils…” ’

SENSE OF VULNERABILITY‘…[the patient] shouldn’t have even beendischarged from the hospital in the firstplace and then were thrown in our lap andwe’re like…oooo….’

SENSE OF VULNERABILITY‘....without backup…that feeling of insecurity, especiallyfor younger, less experienced nurses….they’ll get out ofthat job as fast as they can for fear of losing their licenseor they’ll feel completely overwhelmed and notsupported’

THREATENED REPUTATIONESTABLISHING LEGITIMACYSENSE OF VULNERABILITY

Implications• “Top-down” approach is inappropriate• “Boundary work” (Gieryn 1983, 1995)how knowledge boundaries are created andmaintainedto study contested authority in institutionaland professional domains

Conclusions• Hospital-community relationship is nothierarchal• Programs using different means toestablish boundaries• Interorganizational collaborative care:consideration of boundary issues

Understanding relationships betweenhospital- and community-baseddiabetes programs in a new model ofdiabetes care delivery in OntarioRene.Wong@utoronto.ca