Interventions to Improve Clinical Coordination between Levels: Participatory Experience in a Public Healthcare Network in Xalapa, Mexico INTEGRATED CARE CASE JULIETA LÓPEZ-VÁZQUEZ DAMIÁN-EDUARDO PÉREZ-MARTÍNEZ INGRID VARGAS MARÍA-LUISA VÁZQUEZ *Author affiliations can be found in the back matter of this article ABSTRACT CORRESPONDING AUTHOR: Julieta López-Vázquez Introduction: Coordination of care can be improved through an intervention or a Instituto de Salud Pública, combination of several ones. In addition, it is recommended to encourage the active Universidad Veracruzana, Av. involvement of professionals in the design, implementation and assessment of Dr. Luis Castelazo Ayala s/n. coordination mechanisms. Col. Industrial Ánimas, 91190 Xalapa, Veracruz, México Objective: To analyse the factors that influence the implementation of participatively julieta_lv_uv@hotmail.com designed interventions and their effects on clinical coordination between levels of care in a public healthcare network of health services in Xalapa, Veracruz, Mexico. Methods: A qualitative, descriptive-interpretative study, for which individual interviews KEYWORDS: and discussion groups with a criterion sample of participants: Local Steering Committee care coordination; care and the Professional Platform. A content analysis, with mixed category generation integration; participatory action research; qualitative and segmentation by intervention and topics, was carried out. According to the evaluation; health services problem analysis, participants designed two sequential interventions: offline virtual research consultation, and joint training meetings on maternal health and chronic diseases. Results: Respondents perceived a differentiated impact on clinical coordination TO CITE THIS ARTICLE: according to intervention: greater in the case of joint maternal health trainings and López-Vázquez J, Pérez- limited for the chronic diseases meetings, as they were the offline virtual consultation Martínez D-E, Vargas I, Vázquez M-L. Interventions to was rarely used. Improve Clinical Coordination Conclusion: The involvement of professionals in designing the interventions, as well as between Levels: Participatory Experience in a Public institutional support and reflexive methods for training, all decisively improved clinical Healthcare Network in Xalapa, coordination between levels. Mexico. International Journal of Integrated Care, 2021; 21(4): 12, 1–17. DOI: https:// doi.org/10.5334/ijic.5892 López-Vázquez et al. International Journal of Integrated Care DOI: 10.5334/ijic.5892 2 PURPOSE care to a patient throughout the continuum of care in order to achieve a common objective without conflict The purpose of this manuscript is to share the learnings [23]. Three cross-level coordination types are considered: of the implementation process of two participatively information coordination, clinical management designed interventions to improve coordination between coordination and administrative coordination; the first levels of care, and to identify the key elements for the two are related to clinical aspects. The coordination application of this type of strategies in Mexico and of information refers to the transfer and use of clinical other contexts. information from patients, while the coordination of clinical management involves the consistency of care, the accessibility and adequate patient follow-up [24]. INTRODUCTION One way in which care coordination can be improved is by conducting clinical management interventions at Coordination between levels of care represents a challenge the micro level, with the introduction of a coordination for improving the effectiveness of health services in Latin mechanism or the combination of several. Those might be America [1]. Recent studies have shown that in countries based either on standardising skills (continuous training), with fragmented health systems, such as México, there work processes (Clinical Practice Guidelines), or the are poor information transfer, clinical disagreements outcome; or based on feedback between professionals and a limited accessibility between levels of care [2, 3]. (direct: telephone, e-mail), or through other mechanisms The causes of this include: organisational factors, such (inter-consultation, hospital discharge report or shared as insufficient time to carry out coordination activities [2, electronic medical record). 4] or the availability of coordination mechanisms [5, 6] As in other areas of quality improvement, the active and interactional factors between professionals such as, participation of professionals in the design, execution, lack of mutual knowledge and trust [2, 4]. Although the and evaluation of strategies is recommended [25]. policies aiming at strengthening primary care in Mexico However, existing evaluations on the implementation [7–9] contemplate the improvement of coordination of coordination mechanisms between levels of care between levels of care, the few existing evaluations have using qualitative research approaches, are more shown a limited and difficult implementation of strategies common in high-income countries [26, 27]. In Mexico, and coordination mechanisms, attributed to the lack studies are limited to the use of mechanisms in one of context adaptation (i.e. insufficient technological level of care [10–13, 28, 29] without considering the resources or supplies to meet the recommendations interaction between levels, despite its relevance for provided by the Official Mexican Standards/Clinical clinical coordination [30]. Clinical practice guidelines is Practice Guidelines) [10, 11], or the use of more as an the most-analysed mechanism, and the one for which administrative requirement (for referring to another barriers and facilitators to its implementation have been level of attention [referral and reply letter] or discharge identified during implementation [10, 11, 28, 29]. In [discharge report]), than for clinical coordination [12, 13]. contrast, referral and reply letters and hospital discharge The limited adaptation of interventions to improve reports are only evaluated as part of the clinical record care coordination, which are designed and implemented (whether or not they are physically available, and without vertically (top-down), into a local context is common in analysing the quality and relevance of the information) many health systems, not only in Mexico, and has been [12, 13]. However, analysing the process to implement strongly criticised for being ineffective [14]. In contrast, interventions, from the perspective of users (health participatory action research is characterized by cyclical, professionals), plays a key role when identifying the reflexive and flexible processes of planning, action results of care coordination, as well as in understanding and evaluation [15], and includes the participation of the factors influencing their adoption, dissemination, professionals in decision-making [16], this has proven to and potential sustainability and replication [29, 31]. be effective to: a) motivate professionals to incorporate The study is part of a broader investigation [30] interventions into their healthcare practice [17], b) (Equity-LA II; www.equity-la.eu/en/), which combines influence interactional factors that impact coordination quantitative methods to analyse the effectiveness of between levels of care, such as mutual knowledge and interventions in improving care coordination [32] and trust [18, 19] and c) design interventions adapted for continuity [33], with qualitative methods to evaluate the the local context [16], which is decisive to favour their design and implementation process and the perceived adoption and effectiveness [20, 21]. Despite the potential contributions of interventions to improving coordination benefits of participatory action research for the design between levels of care from the perspective of the and implementation of interventions, its application in participants [34]. This article focuses on the experience health services is practically non-existent [19, 22]. in Mexico, delving into the similarities and differences Care coordination is here defined as the harmonious between interventions, and complements previous connection of the different services needed to provide local publications on care coordination [3, 6, 35] and López-Vázquez et al. International Journal of Integrated Care DOI: 10.5334/ijic.5892 3 continuity [36, 37]. The objective of this article is to (which was reduced from eight to six members, from analyse the factors that influenced the implementation which five members were new, no changes in the of participatively designed interventions and their effects research team). The Professional Platform was also on clinical coordination between levels of care in a public reduced (from 31 to 17). The offline virtual consultation network of health services in Xalapa, Veracruz, Mexico. would allow the identification of training needs, but due to the low use of the system, a survey was carried out to detect participating physicians training METHODS needs, their willingness to participate in joint training STUDY AREA activities and other topics of interest. Maternal health The study was is located in Veracruz, one of the and chronic diseases were among the most requested most populated states in the country, with more than topics and 94% of primary care physicians and 100% eight million inhabitants [38] and a prevalence of chronic of secondary care physicians (participating as training diseases and maternal mortality that exceeds the facilitators) expressed their willingness to participate. At national average [39]. The study healthcare network is the end of the first cycle, the Local Steering Committee located in the capital of the state of Veracruz, Xalapa. membership was changed by the incoming health This municipality is one of the most populated in the authorities (two members remained, while seven were state, with 480,841 inhabitants, from which 59.46% incorporated, and one member of the research team lacks social security [38]. This population is cared for in was also replaced). the State Health Services network, object of this study. Based on the joint analysis (between the new Local This healthcare network was chosen as it provides a Steering Committee and Professional Platform) of the continuum of health services, including primary care results of the first cycle, and the review of the training (seven units) and secondary care (two hospitals) services, needs identified, the Local Steering Committee decided for a defined population living in an urban area with a to maintain and expand the offline virtual consultations predominantly low or medium-low socioeconomic level and introduced the joint training meetings between and that was willing to participate [30]. levels (Table 1), starting the second cycle. These meetings, which were jointly planned for 12 sessions between the INTERVENTION DESIGN AND IMPLEMENTATION Local Steering Committee and facilitators, consisted of PROCESS three-day seminars (eight hours/day) outside of the state The participatory process began when the Local health services, with the involvement of primary care Steering Committee was established. The Local Steering physicians and facilitated by specialists in the network. Committee led the design and implementation process The joint training meetings were based on the of interventions and was integrated by state health joint analysis of clinical cases from the health care, managers and middle managers, with the research team through the application of reflexive training methods. acting as the facilitator. The Local Steering Committee These methods allow the analysis/reflection of one’s the results of the baseline study on care coordination and own practice to improve it, so they require the active then held 11 meetings with primary care professionals participation of the clinician and facilitator [40]. This and four with secondary care professionals (totalling type of method stimulates communication, feedback, 225 participants), in order to present those results within and clinical agreement, which contributes to increasing the healthcare network. From these meetings, a group the resolution capacity of first care level physicians and of volunteer professionals from both healthcare levels, improves the interaction and coordination between involved in healthcare practice and interested in action, primary and secondary care [14]. was consolidated. This group, called the Professional Platform, included 31 professionals from both levels STUDY DESIGN (mostly physicians), whose role was to delve into the A qualitative descriptive-interpretive study was carried out problems identified, select one and select the intervention to analyse the factors that influence the implementation to address it, as well as design and implement it, together of the participatively designed interventions and their with the Local Steering Committee). effects on clinical coordination between levels of care, The intervention design and implementation process from the perspective of the participants. were developed during two participatory action research cycles. During the first cycle, the Professional Platform ANALYSIS FRAMEWORK and Local Steering Committee designed the offline The evaluation framework includes: the analysis of virtual consultation between primary and secondary the effectiveness and perceived impact in relation to care physicians, the description and implementation of the coordination and continuity between levels of care which are shown in Table 1. When the intervention began (final and intermediate result) and, the analysis of the to be implemented, restructuring in the State Ministry of implementation process of the interventions (process Health caused changes in the Local Steering Committee results). López-Vázquez et al. International Journal of Integrated Care DOI: 10.5334/ijic.5892 4 OFFLINE VIRTUAL CONSULTATION BETWEEN LEVELS 1ST CYCLE 2ND CYCLE Content Asynchronous virtual consultations in chronic diseases care Maternal and perinatal health is incorporated as a via digital platform and protocol repository between primary an area for consultation care and secondary care physicians Trained 68 primary care physicians 2 secondary care physicians physicians 13 secondary care physicians Number of 6 consultations; accessed 43 times to look up information 5 consultations; accessed 165 times to look up consultations information conducted Duration 6 months (October 2016 – April 2017) 8 months (May – December 2017) JOINT TRAINING MEETINGS Content Joint training meetings, based on clinical cases, on maternal and perinatal care and chronic diseases Number of 4 maternal and perinatal health sessions caried out 1 chronic diseases Maternal and perinatal health: 52 primary care 12 Gynecologists, 1 Clinical nutritionist Participants Chronic diseases 20 primary care 2 Internists 1 Clinical psychologist, 1 Pneumologist, 1 Ophthalmologist, 1 Emergency physician, 1 Integralist physician Duration of 8 months (May – December 2017) implementation Table 1 Description of the interventions and their implementation process. The evaluation framework used in this study is based variation according to their role in the intervention. The on the three dimensions identified by Pettigrew and sample consisted of 15 informants: nine members of Whipp [41, 42]: the context of the intervention -health the Local Steering Committee (four managers and five system and policy (outer setting) and health services middle managers) and six of the Professional Platform networks (inner setting)-, the content or characteristics (three primary care and three secondary care physicians) of the intervention and the process of implementation. who were interviewed individually, in a discussion group The last two are grouped into a single dimension in the or in both (Table 2). participatory action research process Over time, the context and process of implementation DATA COLLECTION elements interact in a complex way, influencing the Data collection was carried out through discussion groups results of the intervention implementation process and individual semi-structured interviews, to delve into (process outcomes) and the intermediate and final some issues. Topic guides were developed for each cycle results on coordination and continuity, between levels and intervention, the guides included: opinions on the of care (health services outcomes). The focus was the design and implementation process; influencing factors results as from the point of view of the participants on the implementation of interventions (content of the interventions, process, and context related to the health SAMPLE system and its policies, healthcare or professionals); and A sample was designed by criterion of key actors who perceived results on care coordination and influencing had participated in any of the different stages of the factors. According to the established criteria, informants process of selection, design and implementation of the were identified and then asked to join by considering interventions, in order to have all the possible discursive their attendance at meetings held by the Local Steering variants (members of the Local Steering Committee and Committee and Professional Platform as well as at joint members of the Professional Platform), with maximum training meetings. There were no refusals to participate. López-Vázquez et al. International Journal of Integrated Care DOI: 10.5334/ijic.5892 5 STATE MIDDLE-RANKING SECONDARY CARE PRIMARY CARE MANAGERS OFFICIALS PHYSICIANS PHYSICIANS Individual Local Steering 2 (Male)/ – – – Interview| Committee 1 (Female) Professional Platform – – – 1 (Male) Discussion Group 1 Local Steering – 2 (Male)/1 (Female) – – Committee Discussion Group 2 Local Steering – 1 (Male)/1 (Female) – – Committee Professional Platform – – 3 (Male) 2 (Female) Discussion Group 3* Local Steering 1 (Male) 3 (Male) – – Committee Professional Platform – – – 1 (Male)/1 (Female) Table 2 Final composition of the sample of informants. * Discussion Group conducted in 2 sessions. The discussion groups were carried out outside their differences in the factors influencing the implementation institution (90 min on average), while individual interviews process, emerged from in the informants discourses. were conducted at the workplace of the informants (45 Differences were observed according to the informant min average duration) and were literaly recorded and profile. transcribed. The fieldwork took place between March and July of 2018. OFFLINE VIRTUAL CONSULTATIONS Limited results were obtained in terms of improved DATA ANALYSIS AND QUALITY OF coordination or influencing factors. Several unfavourable INFORMATION contextual factors related to the healthcare network Thematic analysis was carried out using ATLAS.ti® were identified, which, in conjunction with the software. Data were segmented by intervention and weaknesses shown in the participatory process regarding topics. Analysis categories were generated in a mixed design and content of the offline virtual consultations, way (from the topic guide and emerging from the explain why it was rarely used (Figure 1). discourses). Topics were identified, coded, re-coded and classified, in order to find out similarities and differences Results on inter-level coordination and related among informants. To ensure good quality of results, the factors information was triangulated using several techniques The limited impact of the offline virtual consultations on and various analysts who had a good understanding of coordination between levels of care and related factors, the context were involved. The preliminary results were which was attributed to its limited use, emerged in the presented, and feedback was given over two meetings informants’ discourse: (with seven informants), allowing us to confirm the findings by taking into account the participants opinions “I am terribly sorry, because only two questions on the analysis. were asked during the whole process, no more questions…no changes regarding referrals, not at ETHICAL CONSIDERATIONS all, they don’t use the system, two questions, after A confidentiality agreement was signed with the many months, actually it’s critical.” (Professional institution. Involvement of each informant was free Platform/Primary Care) and voluntary expressed in written form by signing a an informed consent. The recordings and transcriptions However, a professional platform/primary care were coded to guarantee the anonymity of informants. physician considered that their clinical management of patients had improved due to the specialist’s response (Table 3a), while some Professional Platform informants RESULTS pointed out its impact on using other coordination mechanisms between levels of care, such as the A differentiated impact of each type of intervention Official Mexican Standards/Clinical Practice Guideline on care coordination and related factors, as well as (Table 3b). López-Vázquez et al. International Journal of Integrated Care DOI: 10.5334/ijic.5892 6 Figure 1 Offline virtual consultations: results perceived on care coordination and related factors. Factors influencing its implementation In addition, informants identified that there was no Informants identified contextual factors related to time available for primary care physicians to use the the healthcare network, as well as the content of the system due to excessive bureaucratic burden: intervention that influenced implementation of the offline virtual consultations. “Primary care (…) they said that the form required Healthcare network. Several factors that limited a lot of time. It’s just that they have to fill out too the use of the offline virtual consultations emerged many forms, so they are filling out all the forms from the discourse of both groups of informants: 1) while treating patients. So I think this is the reason Structural factors, such as the lack of computers and why the system was not used correctly.” (Local intermittent internet connection, mainly for primary care Steering Committee/Manager) use, and limited or prevented access at the workplace (Table 3c). Professionals. The limited ability of some physicians to Organisational factors. According to Professional use computers manifested as resistance toward using Platform informants, changes in the Local Steering them: Committee and Professional Platform (due to changing of managers) delayed the start of implementation: “(The physicians) are reluctant to use the computers, that is, I don’t even know how to turn “Staff turnover in both levels of care, change of it on, I don’t know how to use it, I’m going to officials, training people all the time to continue break it and the staff has been trained over and the project, well, yes, it was going to affect the over again.” (Local Steering Committee/Manager) project (was delayed), but then this occurs at the institutional level.” (Professional Platform/Primary Moreover, primary care physicians were afraid of criticism Care) from specialists. Both factors contributed to a lack of interconsultations being generated (Table 3e): Moreover, Local Steering Committee informants identified a lack of institutional support, with the new “We complained about the dialogue with the managers showing little interest during the first months secondary care, which was not adequate to of implementation, as they did not provide computers provide integrated care service as physicians… and internet in some primary care units during the first maybe also, we are afraid to ask questions to cycle; thus, the offline virtual consultation were not used specialists as we can be ridiculed.” (Professional (Table 3d). Platform/Primary Care) López-Vázquez et al. International Journal of Integrated Care DOI: 10.5334/ijic.5892 7 Results on improved coordination of clinical management a- Interconsultation improves clinical “The interconsultation helped me exchange management concepts with the specialist, management of patients and. obviously, his responses about the patient to keep him under control and happy.” (Professional Platform/Primary Care) Factors that influenced on offline virtual consultations implementation Contextual b- The system improves access to Official “If I had any doubts, then I checked the Official Mexican Standards Clinical Practice Guideline Mexican Standards Clinical Practice to get answers … then I practically accessed to get information … [which was] very useful Guideline for me” (Professional Platform/Primary Care). “Moreover, in the system we could also make enquiries about pregnancy, childbirth and puerperium, since the official standards were there, no many problems. Regarding chrome diseases, we began to focus on manuals and the Clinical Practice Guideline.” (Professional Platform/Primary Care) Related to the healthcare network Structural c- System access is limited due to a lack of “First, we didn’t have internet in fact we just got internet a few months ago, and because infrastructure there was none… at the health centre you couldn’t ask questions. If I consulted information from the system I had to connect fron home” (Professional Platform/Primary Care). “The internet system implied connectivity in the units, which they have, but that connectivity is not very efficient, computers are necessary, not all of the units had computers… and many units with computers did not have connectivity. That connectivity was even paid by physicians.” (Local Steering Committee/Manager) Organisational d- Providing technological infrastructure is “When we spoke with the authorities, some situations that could hinder the system (the influenced bymanager’s limited support or offline virtual consultations) were perceived. One of them was the lack of computers and interest internet at the Health Centres, for which a census was carried out… and after the census, the Ministry of Health committed to correct this situation… when a government institution is committed, there is 20% of certainty they will comply, while 80% they won’t comply. That happened here or at least primary care physicians still complain about this and they still report that they do not have a convenient internet access and they sometimes do not even have computers.” (Local Steering Committee/Manager). “After all the paperwork one has to fill out (in primary care), in the end you are going to forget about the system (offline virtual consultationes), it was not intentional. However, somehow SESVER got involved and focused much more on obstetrics, so the training in obstetrics was very good. If SESVER would engage with the system (offline virtual consusltations) or with chronic patients, or with comprehensive care… not only with obstretics, I think it would really be much easier for us… I still feel that the main cause is that SESVER did noy join this, as is not part of their work plans.” (Professional Platform/Primary Care). Related to professionals e- Fear of criticism diminishes “I think the problem (that the system would not work) is they are afraid of being criticised, interconsultations they will criticise us… criticism is not going to favour absolutely anything, the idea was to unite in order to establish a more open and cordial dialogue, avoiding precisely that feeling that we are annoying.” (Professional Platform/Secondary Care) Related to participatory action research process and intervention content f- Directionality when selecting causes for “The research team had already visualised that they wanted to implement this system… the system to be rarely- used, as problems surely they had already planned to do so…this is an important issue”. (Professional Platform/ identified are not adequately responded Primary Care) “It seemed to me that this search (for interventions to be implemented) by some members of the university team was biased…with the causes that were identified in those studies, then the action plan began to be designed …we were taking risks to start designing solution strategies that might not solve the problem and at the end of the period we were going to realise it did not work, but hey, it is part of the investigation, if something is set in motion and does not work, well, at least it is proven.” (Professional Platform/Primary Care) g- Too many items in the interconsultation “At first I was involved, I tried to type info of patients, do the summaries and all that, but the form diminishes interest of participants truth is that I could devote that time to make my notes, organise my files, I did it for a while, when I realised that it really took away a lot of my time.” (Professional Platform/Primary Care) “The items were practical for me (interconsultation format), those considered as necessary to make consultations during the meeting held by primary, secondary and tertiary physicians were included.” (Local Steering Committee/Manager) Table 3 Examples of textual quotations regarding opinions on the results of the offline virtual consultations and factors influencing their implementation. López-Vázquez et al. International Journal of Integrated Care DOI: 10.5334/ijic.5892 8 Participatory action research process and intervention development of this coordination were identified; a content. Although most informants considered that the change in authorities to ones with new priorities led to choice of the offline virtual consultations had been by institutional support for the intervention, in conjunction consensus, several Professional Platform members stated with the participatory nature of its design, and the that it was rarely used, due ti the directionality when the use of a reflexive method was implemented. On the research team chose this intervention, resulting in an other hand, regarding the joint training meetings on intervention that did not address properly the problems chronic diseases, a low impact was observed due to its detected (Table 3f). limited implementation, which was related to the lower institutional support; thus, neither coordination nor its “The institutional decision-makers, researchers factors were affected (Figure 2). and people working for the primary and secondary services of the network…saw several lines of Results on coordination between levels of care action, linking the primary and secondary care and related factors using some electronic mechanism the one The contribution of joint training meetings on maternal that was seriously considered.” (Local Steering health to the coordination of clinical management Committee/Manager). and clinical information between levels and to the interactional factors between primary care and On the other hand, the Professional Platform secondary care physicians, in contrast from joint training considered, unlike the Local Steering Committee, that meetings on chronic diseases, was emerged from the the information required by the form to carry out the discourse of informants. offline virtual consultations was excessive and required a long time to complete. Thus, interest in carrying out Clinical coordination interconsultations was diminished (Table 3g). One According to informants, the joint training meetings member of the Professional Platform stated that the on maternal health improved clinical management lack of obligation and supervision also contributed to the of patients, with a better adaptation and timeliness of system rarely being used: their referral to secondary care and of the exchange of information between levels (Table 4a). There was “Unfortunately, if people are not spurred, also an improvement in the exchange of clinical then they don’t work, but if you implement, information via direct communication, in order to adapt a well-implemented program, but above all a obstetric care behaviours (via personal telephone and demanding one…well look, we have a system WhatsApp): for you to communicate with the internist, you do it, because I am demanding that you do it for “We began to notice after the seminar…that me, but if I am indulgent with you, things won’t the primary care physician consulted more the move on, this is what I detected.” (Professional network leader (consultant), consulted more Platform/Primary Care) and asked questions related to referrals, came closer to the hospital, but it was not just the fact Finally, several informants of the Professional of making referrals and that’s it! No! Now it is to Platform group stated that checking information on make referrals so that they aren’t rejected” (Local Official Mexican Standards/Clinical Practice Guideline Steering Committee/Manager). consultation via the system resulted in the resolution of doubts, making the issuance of an offline virtual Factors influencing coordination consultations unnecessary: The informants perceived that joint training meetings had an impact on interactional factors, since personal “Practically if I had any doubts, when I checked knowledge between physicians was allowed; thus, the clinical practice Guideline or the standards my collaboration was favoured: doubts were solved…then I practically accessed to check the information…very, very useful for me.” “This close relationship among people working (Professional Platform/Primary Care) here is fostered, because we no longer perceive them so distant…we perceive them as members JOINT TRAINING MEETINGS of the same team…attitude towards the Had joint training meetings on maternal health patient changes when you know that he is had an impact on the coordination of care and its received by someone you know” (Professional influencing factors. Several factors favourable for the Platform/Primary Care). López-Vázquez et al. International Journal of Integrated Care DOI: 10.5334/ijic.5892 9 Figure 2 Joint training meetings: results perceived on care coordination and influencing factors. Results on improved coordination of clinical management a- Treatment, adequacy and relevance of “Something very important is that (in a referral) the woman was there with both the proper referrals were improved documentation and the clamp-crush technique well done Then they had already learned this in the seminar, so, how have you noticed this? Changes may be very subtle, but can be noticed” (Local Steering Committee/Manager). “There was an impact on matters regarding delicate patients, who have arrived at the hospitals in better conditions and they were previously treated, that means that there was a positive result in terms of contact between the secondary, tertiary and primary levels of care.” (Local Steering Committee/Secondary Care) Results on improved factors related to coordination b- Use of direct communication “Today everyone has a phone with WhatsApp… they take a photo and send me the referral and I’ll send you the reply letter back and I’ll tell you this, send that send, give me that very quickly.’’ (Local Steering Committee/Manager) Factors that influenced on holding joint training meetings Contextual related to policies and political cycle c- Alignment with policies favoured “When it turns to maternal death, the first seminar was in large part due to the support institutional support when considered as received by the Directorate of Medical Care – we have to abate this problem that is screwing an opportunity us up, and, suddenly, the problem became bigger, and, well, we have to see how to resolve.” (Local Steering Committee/Manager) Related to participatory action research process and intervention content d- Attitude of facilitators, clinical case “Even during the same seminar, some of the secondary care physicians were really conflicted resolutions and practical activities with the relationship between primary and secondary care, but in the last seminars no longer. enhanced involvement and fostered a Even I think that the word spread about – those who attend (specialists.) They are not going to climate of equality ask questions or be rude – but in the last seminar one or two took out their frustrations… but most of them attended with an open perspective to leans and improve, that’s what interaction is about” (Local Steering Committee/Secondary Care). “Training dynamics shown by secondary care physicians was important, as they were perceived as equals’ And that was the difference from other trainings.” (Local Steering Committee/Manager) (Contd.) López-Vázquez et al. International Journal of Integrated Care DOI: 10.5334/ijic.5892 10 e- Topics (maternal health) and curricular “Everything related to maternal and child health is much more frequent, it is a priority, I am value encouraged involvement not saying that chronic degenerative diseases are not important in fact, they are one of the main causes of morbidity and mortality… the staff have a certain affinity with health problems, it seems that when chronic degenerative diseases see the problem with the user is not going to be solved immediately, our mentality seems to change” (Professional Platform/ Primary Care). “It was fortunate that maternal health is now considered, because it is a daily walk, perhaps we don’t receive many chronic degenerative patients, but pregnant women do, every day.” (Professional Platform/Primary Care) “(The incentive) for the primary care physicians was to give them their duly registered certifications, so that they can use them for job promotion and so on.” (Local Steering Committee/Manager) Related to the healthcare network (organisational and individuals) f- Freeing up and protecting time of “In order for me to get fully involved, I only had to say I was approved (by the Directorate of participants facilitated design and Medical Care), so I can enjoy a certain autonomy of the staff under my command, use the implementation resources I was allocated for activities for both (the joint naming meetings) and the strategic plan” (Local Steering Committee/Manager). “It was our turn to establish the leadership in terms of training, managing with the health jurisdiction the call for the groups of participants, discuss with the directors and managers of the regional hospitals the participation of the teams of facilitators and see how to move forward (because of resistance).” (Local Steering Committee/Manager) g- Resistance from some primary “There was a certain resistance (from management positions), obviously, to allow the primary and secondary care beads delayed care physicians to be out for three days, and for the secondary care… no way you are going to involvement of physicians take away my specialist that gets the job done, because he has to deliver a gaining course.” (Local Steering Committee/Manager) h- Less support resulted in cancelling “That political support for other programs, which perhaps does not occur for COPD or chronic seminars on chronic diseases degenerative diseases, because they always have programs for diabetes, but they aren’t a priority… (The second replication of the course on chronic diseases) was cancelled in December.” (Professional Platform/Secondary Care) i- Less seniority encourages interest to “In the last courses we saw more involvement, more acceptance by physicians, which has a get involved lot to do with staff s seniority, staff that is very old have many tricks and, indeed, are very resistant to methodology.” (Local Steering Committee/Manager) Table 4 Examples of verbatin regarding opinions on results on coordination of joint training meetings and factors that influenced their implementation. However, only joint training meetings pertaining to facilitate agreement on clinical management between maternal health increased trust between primary care physicians from both levels of care: and secondary care physicians: “Under this structure we have designed courses, “It is important that contact between specialists obviously with other contents a little more and primary care physicians continues to exist, practical…workshops that are more experiential since trust between both levels is built, closer ties than the simple case review, but the same are created and the path to treat patients is better for all general practitioners, gynaecologists, managed, so a better conversation without fear of surgeons who involved in gynaecology, teasing can get started… that shouldn’t get lost” and anaesthesiologists” (Local Steering (Local Steering Committee/Secondary Care). Committee/Manager). And favoured the use of direct communication (personal And this practice was subsequently replicated in the rest phone number and WhatsApp) (Table 4b): of the state: “They call me directly, they send me a message “Since the research was planned for 10 and and then they say, ‘Hey, I’m…from this health reached 20, then it is even more satisfactory. centre, there is a female patient with me that… It reached 20 because, as you say, something so do I send it just like this? What do I do?’ that was intended to be done in, in a few health There is a very close contact” (Local Steering centres of the network, it turns out that it was Committee/Secondary Care). extended state wide, to all centres located in the state, and to all primary and secondary physicians Additionally, informants stated that joint training from the state of Veracruz” (Local Steering meetings were a new form of institutional training to Committee/Manager). López-Vázquez et al. International Journal of Integrated Care DOI: 10.5334/ijic.5892 11 Factors influencing implementation of joint times the vertical interventions are not going to training meetings flourish, because they were probably conceived Differences were found in the factors influencing joint by a single person, but if we consider the needs training meetings implementation according to the type of all parties and, obviously, also the solutions of informants; the Local Steering Committee focused that each party can provide…it’s like making on those related to the political context, while the a tailored suit. Thus, I think that the opinion, Professional Platform emphasised those related to the the involvement of everybody in the different intervention content. To a lesser extent, other factors positions and fields of action, because obviously related to the healthcare network also emerged. they made a tailored suit for needs of primary Policies and political cycle. Informants noted that and secondary physicians, as well as the same the new health authorities prioritised maternal health area, our medical care area and the medical over chronic diseases, as this was were aligned with the teaching department” (Local Steering Committee/ Maternal Health State Plan, which increased institutional Manager). support for maternal health seminars (Table 4c): In contrast, for chronic diseases, the involvement of state “The Directorate of Medical Care is in charge of managers who were members of the Local Steering addressing the strategic plan for maternal and Committee was lowered during planning: perinatal health in the state to reduce maternal death and infant death…so who is going to “They said: ok, let’s get started by (planning) help me? The project, of course” (Local Steering the seminars on chronic conditions…there, there Committee/Manager). has been a lack of communication between the directorates, for example, we could say Public In this sense, the informants perceived less support in Health, the Directorate of Medical Care… and the the joint training meetings on chronic diseases, as they Sub-directorate of Education” (Local Steering were not a priority for the state: Committee/Manager). “And it is also very evident that the change was Regarding the training method, informants considered more noticeable for pregnancy, childbirth and that the open attitude and absence of hierarchies puerperium care than for the chronic conditions, shown by facilitators of the joint training meetings on perhaps that is why, because of the same interest, maternal health, as well as including practical activities as they had already set their sight on this, then and resolution of clinical cases, enhanced dialogue, they are working flat out and it already occurs interest and involvement in the sessions. Thus, the initial for chronic conditions, but to a lesser extent” defensiveness of primary care physicians was eliminated, (Professional Platform/Primary Care). a climate of equality (Table 4d) was fostered, and the resolution of doubts via direct communication between Moreover, they were addressed by other institutional peers was promoted: trainings: “Now, I was able to stay in touch with a “At least in the health centre we try to update gynaecologist, and any particular doubt I could our knowledge, we are continuously attending not solve by reading (regarding CPG), so I could refresher courses, especially for chronic diseases.” trust them, I was able to detect a greater close (Professional Platform/Primary Care) relationship” (Professional Platform/Primary Care). Participatory action research process and intervention On the other hand, informants agreed that, during the content. In the Local Steering Committee’s discourses, meetings on chronic diseases, some facilitators showed that the joint planning of joint training meetings on a lower level of commitment, while some primary maternal health by both the Local Steering Committee care participants were less interested in the meeting´s and the facilitators (specialists) played a key role in contents: adapting them to the training needs stated by physicians from both levels and getting managerial support and “No, I think (that the seminar on chronic diseases) interest of participants: it did not favour the link between the levels (…) here I saw an attitude of some colleagues, kinda “I believe it is ideal, that is, everybody should get I already know that, I´ve been told that, come on! involved, participants, stakeholders, because I That it’s gonna be the same old rehash as usual” observed before filling this position that in many (Professional Platform/Secondary Care). López-Vázquez et al. International Journal of Integrated Care DOI: 10.5334/ijic.5892 12 From the Local Steering Committee’s discourse, emerged considers these types of interventions [7]. The results that the joint evaluation (following each seminar) show the importance of the involment of professionals allowed adjustments in the content and dynamics, in in the design of interventions, institutional support and order to improve involvement: methods reflexive training, as determinants to improve clinical coordination between levels. “Observing either participants or non-participants Thus, a differentiated impact between interventions was going to give us a lot of feedback (teaching), and topics is shown: joint training meetings on maternal while the satisfaction and the diagnostic surveys health contributed to improve coordination of clinical would let us know in which topics they were management and of, as well as information interactional having the best results and so by exchanging our factors, and these training were replicated in other state observations with the trainers – how you perceive healthcare networks (60 seminars, approximately 1600 this group, more proactive, less proactive – participants). In contrast, joint training meetings on although we had that kind of feedback with them” chronic diseases and the offline virtual consultations, in (Local Steering Committee/Manager). particular, did not greatly improved care coordination. These differences made it possible to identify process Likewise, being trained within the working hours, and the factors (adequate development of the participatory curricular value encouraged involvement (Table 4e): process in the design), context (institutional support and alignment with policies) and content (implementation of “(Were required) the necessary time and adequate reflexive methods) that influenced the results yielded by permission so that they could fully spend three the implemented interventions. days to be trained and also their labour times and rights were respected, you have to receive train PROPER DEVELOPMENT OF THE during work hours” (Local Steering Committee/ PARTICIPATORY COMPONENT IS AN ESSENTIAL Manager). ELEMENT IN ADAPTING TO THE CONTEXT The results seem to suggest a limited involvement of Healthcare network. According to informants’ discourse, professionals in the design and implementation process joint training meetings on maternal health, made of the offline virtual consultations, which may have possible by freeing up and protecting both planning contributed to the selection of an intervention that and execution time, received the greatest institutional did not meet the needs of participants, affecting its support. Physicians from both levels also received implementation and use. In the very early stages of the support to attend these joint training meetings (Table 4f). participatory processes, it is common to be oriented by the However, some informants also pointed out the limited research team, and may result in decisions not resulting support provided by some primary care and secondary from consensus, decreasing the interest of professionals care middle managers, who delayed physician assistance, [15, 16]. Furthermore, the barriers identified to implement due to work overload and shortage of personnel (Table 4g). the offline virtual consultations, such as complexity of the Meanwhile, seminars on chronic diseases received the form and some physicians having limited ability to use least support, and some were cancelled (Table 4h). At the computers, are coincident with those described in the individual level, the Local Steering Committee pointed adoption of technological tools by health professionals out that less time working in the network encouraged [43, 44]. These barriers can be bridged if those who will primary care personnel to become involved and display use them are involved in the design [44]. a better attitude (Table 4i). Likewise, the importance of involving health professionals and managers when adapting interventions to a particular context was observed. Maternal health DISCUSSION and the participation of managers resulted in an intervention that responded to institutional needs, and This study contributes to the knowledge on the the participation of professionals had a positive impact implementation of participatory interventions to improve on its adoption and effectiveness [20, 21]. In contrast, care coordination in health services by analysing the for joint training meetings on chronic diseases, the factors that influenced their implementation from lower involvement of managers may have affected the perspective of the participants and their effects their adaptation and limited their impact. The flexibility on improving care coordination, which has been little of the participatory action research method became explored internationally [21, 22] and is non-existent relevant when it allowed the intervention to be adapted in Mexico. Recently, Mexico has tried to move from to incorporate another strategy for the new institutional vertical implementation towards a participatory objectives, which were aligned with the interest of approach, promoted by its health care policy that professionals in the face of changing authorities. López-Vázquez et al. International Journal of Integrated Care DOI: 10.5334/ijic.5892 13 INSTITUTIONAL SUPPORT IS ESSENTIAL STUDY LIMITATIONS FOR DEVELOPMENT AND RESULTS OF INTERVENTIONS The high turnover of health professionals, members of It is well-known that managerial changes, derived from the Local Steering Committee and Professional Platform, the political cycle or institutional modifications, influence caused that very few informants remained throughout healthcare priorities [25, 45]. This was demonstrated the process of design and implementation of the in this study by the differentiated institutional support interventions, so the opinion of some, regarding the factors towards implementing the interventions and their that influenced and the results on coordination, could results. The offline virtual consultations received little be limited to the moment and/or intervention in which managerial support, which is essential for technological they participated. These limitations were addressed by strategies, during its execution [44, 46] due to the interviewing the participants from each phase; however, resources required. Meanwhile, as joint training meetings it could affect the depth of the information collected. on chronic diseases were not an institutional priority, the low level of support received was evident, as just one seminar was conducted, while the rest of them were CONCLUSIONS cancelled (this should also be considered when analysing their impact). This may have originated from the limited The results show an uneven impact on cross-level clinical involvement of managers when designing these two coordination of two participatory action research-based strategies. On the other hand, the joint training meetings interventions, which were also different in design and on maternal health were greatly promoted, as they implementation. Due to professional and managerial were aligned with institutional interests and responded involvement in the design and flexibility of the participatory to a priority policy of the state [47]. This was coincident action research method, it was possible to adapt the with other studies reporting that both alignment with interventions to the context of the healthcare network by priorities of the organisation and institutional support aligning the needs of the professionals with institutional are determining factors for interventions to be effective, priorities in a complex scenario where needs were including participatory ones [10, 48–50]. constantly changing. Likewise, the institutional support was a determining factor for their execution, development IMPLEMENTING REFLEXIVE METHODS and results. Finally, implementing reflexive methods for FOR JOINT TRAINING CONTRIBUTES TO training professionals in the health field contributed to IMPROVEMENT IN CLINICAL COORDINATION strengthening interactional factors between primary and BY INFLUENCING INTERACTIONAL FACTORS secondary care physicians, a key aspect to improve clinical Participants noted improved trust and knowledge among coordination between levels of care. primary care and secondary care physicians, according to the reflexive methods implemented in the joint training meetings, which are factors that influence care ETHICS AND CONSENT coordination by promoting the interest of professionals in collaborating and communicating with others levels of The research conditions were approved by the Research care [2, 51]. Therefore, it is important to spread this type Ethics Committee of the State Health Services of Veracruz of intervention in order to improve clinical coordination (Number SEI/2013/06/26). by promoting agreement on treatments and establishing joint reference criteria, resulting in more appropriate and timely referrals [52, 53], which occurred during the ACKNOWLEDGEMENTS joint training meetings on maternal health, compared to conventional training [54–57]. This aspect is especially We thank the professionals and directors of the relevant for the Veracruz context, in which the results institution who generously shared their time and of the baseline study showed low values for mutual opinions in order to contribute to improving the quality of trust (11.5%) and personal knowledge (49.9%) among care. To the European Commission, Seventh Framework physicians in the healthcare network [3, 4]. On the other Program (FP7/2007–2013) for the financing of the Equity hand, given that the offline virtual consultations were LA II project with grant number 305197. rarely used by primary care physicians, as they were wary of conducting interconsultations with unknown colleagues, the importance of promoting, before or REVIEWERS in parallel, personal knowledge and trust between physicians from both levels of care, became evident. Roberto Nuño-Solinís, Director Área Health, Deusto This aspect has been poorly explored in other studies on Business School, Bilbao, Spain. these types of interventions [44]. One anonymous reviewer. López-Vázquez et al. International Journal of Integrated Care DOI: 10.5334/ijic.5892 14 COMPETING INTERESTS A-I, et al. Understanding communication breakdown in the outpatient referral process in Latin America: a cross- The authors decalre thet they have no known competing sectional study on the use of clinical correspondence in interests or personal relationships that could have public healthcare networks of six countries. Health Policy influenced the work reported in this document. Plan. 2018 May 1; 33(4): 494–504. Available from: https:// pubmed.ncbi.nlm.nih.gov/29452401/. DOI: https://doi. org/10.1093/heapol/czy016 AUTHOR AFFILIATIONS 5. Miranda-Mendizábal A, Vargas I, Mogollón-Pérez Julieta López-Vázquez orcid.org/0000-0003-1018-0386 A-S, Eguiguren P, Samico I, López J, et al. Knowledge Instituto de Salud Pública, Universidad Veracruzana, Av. Dr. and use of mechanisms for clinical coordination of Luis Castelazo Ayala s/n. Col. 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