Delivering Across Boundaries: Social and Structural Features of Service Integration

Abstract

The ability to integrate services across settings and time is increasingly important for healthcare delivery organizations. This dissertation explores the organizational structures and social behaviors that enable service integration in chronic disease care. Its findings can inform practitioners and policymakers that aim to improve care and lower cost, and they lend insight to organizational research on cross-boundary teamwork. In Chapter One, I quantitatively examine the relationship between structural features of medical groups and care integration for elderly patients with multiple chronic illnesses. My coauthors and I develop and administer a survey to over 12,000 Medicare beneficiaries to measure care integration from the patient’s perspective, and we combine their responses with data on structural features of medical groups. We find that measures of patient-perceived integration are not consistently related to structural features of medical groups that are commonly referred to as promoting integrated care, such as centralized ownership and large size. Our findings suggest caution at a time of great policy interest in the potential for structural integration to yield patient benefits. In Chapter Two, I explore the conditions associated with effective collaboration among clinical and community-based organizations for chronic disease management programs. I develop and administer a novel survey to a sample of 247 nonprofit organizations that collaborate with clinics on a diabetes program. I find that group learning across organizations is significantly associated with performance, that learning is positively associated with perceptions of respect among community organization members, and that this relationship is moderated by communication behaviors. Complementing past studies that have focused on incentives and resources in such collaborations, my findings suggest that social behaviors may be important in service integration, particularly for their role in enabling learning across organizations. In Chapter Three, I use a multi-method approach to develop and test theory about teamwork in cross-boundary process innovation. I draw on 76 interviews across 14 teams of clinical and community organization staff, and I collect survey data on 307 similar clinic-community teams. Qualitatively, I identify and describe a joint problem-solving orientation on teams as a key social factor that may enable integration across expertise and organizational boundaries when teamwork is fragmented by membership fluidity. Quantitatively, I develop a valid measure of joint problem-solving orientation, and I find that it is significantly associated with team effectiveness. These findings suggest that teams operating with fluidity and boundaries can make progress through a joint problem-solving orientation, even when opportunities to develop familiarity remain limited.