1. How Is Service Delivery Structured To Meet The Needs Of Clients?

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J Soc Serv Res. Author manuscript; available in PMC 2011 Oct 1.

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PMCID: PMC2992332

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Defining Service Coordination: A Social Work Perspective

Alicia C. Bunger

NIMH Pre-doctoral Trainee, The Brown School of Social Piece of work, Washington University, Campus Box 1196, 1 Brookings Drive, St Louis, MO 63130

Abstract

To address fragmentation, social workers are encouraged to "coordinate." This pilot study explores the meaning of, and factors that facilitate or prevent "coordination" and is intended as a first step toward future conceptual refinement, theory development, and system interventions. Using data from treatment guidelines archived by the National Guideline Clearinghouse (n=nine) and semi-structured interviews with social workers (n=4), themes related to the definition, indicators, and perceptions of coordination were explored using a grounded theory approach. Data suggest the need for coordination is driven by complex client needs, but the quality of providers' personal relationships influence coordination. Future enquiry might examine the impact of standardization of roles, referral procedures, and handling philosophies.

Keywords: Service coordination, social piece of work, service commitment, fragmentation

Fragmentation presents 1 of the biggest service delivery challenges for a range of human service delivery systems including adult and children'due south behavioral wellness (U.Due south. Department of Health and Human Services, 2003a), early childhood care and education (U.S. Department of Health and Human being Services, 2003b), general and specialty health similar HIV/AIDS intendance and treatment (IOM, 2005), to name a few. As different functions of human services become fragmented or siloed into distinct service categories, clients fall through the cracks of the arrangement because the connections between services are either absent or problematic, or needed services are missing all together (Gillespie & Murty, 1994; Tausig, 1987).

Every bit a result, human service agencies are encouraged to 'coordinate' their services with i another under the supposition that collaborative activity can facilitate access to services, reduce unnecessary duplication of effort, and produce a more effective and efficient social service system. By extension, it is believed that more than constructive systems volition ultimately atomic number 82 to improvements in client level outcomes, although positive furnishings of coordinated service delivery have yet to be captured consistently by empirical enquiry despite considerable investments in large-scale demonstration projects designed to evaluate systems-level reforms (Bickman, Lambert, Andrade, & Penaloza, 2000; Morrissey et al., 1994; Morrissey et al., 2002).

In our roles as instance managers, counselors, and other direct service providers, social workers are uniquely positioned to coordinate services by creating pathways to needed services and working across disciplines to integrate care. However, "service coordination" is rarely divers explicitly which can create confusion for social workers in the field who are responsible for coordinating services and ambiguity in how coordination is divers and measured in research examining the bear upon of service coordination and all-time practices.

Despite conceptual ambivalence and disappointing empirical findings, policy makers, funders, and public administrators have forged ahead with efforts to facilitate coordination amidst service providers including system transformation initiatives and mandates. Therefore, an understanding of the conceptualization and measurement of service coordination is critical for studying the impact of strategies for promoting coordination likewise as the effect of coordination on service delivery and client outcomes.

This article describes a small preliminary qualitative study on coordination in human services. The purpose is to explore the pregnant of "coordination" and inform future conceptual refinement, theory development, and system interventions to improve service delivery. Nonetheless the existing coordination theory and definitions from the organizational literature is presented showtime followed by a discussion of how coordination is defined and discussed in the human services literature.

Existing Coordination Theory and Definitions in the Organizational Literature

Coordination has been studied past a variety of academic disciplines including sociology, public assistants, economics, informatics, and organizational behavior (Crowston & Malone, 1993). Historically, coordination has been discussed in the organizational behavior literature as a joint procedure of taking activity whereby organizations adapt in response to i some other to accomplish shared tasks or goals. While definitions of service coordination have varied across disciplines, the construct is frequently defined as a process of managing interdependencies; where agencies appoint in a procedure of exchanging needed resources, and arrange in response to one some other to reach shared tasks or goals (Crowston & Malone, 1993; Whetten, 1981). At the heart of coordination is a relationship between organizations, and theories of inter-organizational relationships, specifically resource dependence and transaction cost economics have provided the underlying framework for studying coordination.

Resource Dependence

Resources dependence is the dominant theoretical framework in the inter-organizational relationship and coordination literature, and examines relationships based on resource exchanges betwixt agencies (Alexander, 1995; Alter & Hage, 1993; Levine & White, 1961). Co-ordinate to this framework, agencies depend on the external environment, including other organizations, for the resource needed to meet their objectives. These resources may include funding, facilities, personnel, services, data, and client referrals (Reid & Zald, 1965). At an individual case-level, a worker may not accept the expertise to run into all of the client's service needs, or a all the relevant information near a customer and the service that s/he is receiving. When one or more of these resources is lacking, organizations are likely to partner with other agencies to meet these needs, and gain control over resources flows in the external environs (Hall, Clark, Giordano, Johnson, & Van Roekel, 1977; Van de Ven & Walker, 1984). Every bit providers exchange needed resource (such as information, funding, or customer referrals), they become increasingly interdependent over time which requires them to manage their linkages through coordination mechanisms (Cho & Gillespie, 2006).

Types of Interdependence

Thompson (1967) outlined iii types of interdependencies: pooled, sequential, and reciprocal. Each type of interdependency is coordinated differently. Pooled interdependencies develop in situations where each service provider works independently, only the cumulative sum of their work contributes to the issue. A worker at the welfare department may assist a customer in applying for a Section 8 housing voucher at the aforementioned time a example managing director from a local housing agency is profitable the client locate housing. Both efforts are necessary for the client to find stable housing. This type of interdependency is managed through standardization activities that identify and define the scope of responsibility, rules, and procedures for each provider. Pooled interdependency requires the least intense interactions considering organizations keep to function independently then long as their tasks accept been adequately defined (Nylen, 2007).

When the work of one provider is dependent upon the prior completion of some other provider's task, or resources commutation, a sequential interdependency develops (Thompson, 1967). For example, sequential interdependencies occur when separate providers are responsible for screening and treatment: an HIV medical clinic is dependent upon agencies that provide HIV counseling and testing services first, before treatment. In addition to standardization, planning and sequencing assist manage sequential interdependencies. Organizations that work together by sequencing their services or activities have interactions that are slightly more intense than those that simply pool their resource because they must time their activities (Nylen, 2007).

Finally, reciprocal interdependencies result when the final outcome of collaborative work depends on providers to adjust services in response to the resources received or given (Thompson, 1967). In a case briefing with a substance utilise treatment provider and mental health clinician, both service providers exchange information virtually a customer with a co-occurring disorder and coordinate care past mutually adjusting the mental health and substance employ handling plans. In addition to mutual adjustment, reciprocal interdependencies may need to exist managed through standardization and planning coordination mechanisms every bit well, and therefore is the most difficult interdependency to manage, requiring intense interactions.

Governing Interdependence

The specific rules, procedures and conditions that guide and control the relationship between organizations (Ring & Van de Ven, 1994) are the governance structure (Thomson & Perry, 2006) and are the focus of transaction price economics (TCE) perspectives in the inter-organizational literature (Williamson, 1979; Williamson, 1981). TCE explains that organizations work together to maximize efficiency and the governance structure is a key mechanism for helping organizations marshal themselves so that resources tin be smoothly transferred from one organisation to the other thus reducing the costs of coordination. Improper alignment can lead to gaps, friction, and delays which are inefficient. For case, client referrals exchanged between organizations can be lost, information exchanges tin can exist delayed, and conflict and confusion tin can arise between staff who are co-located at some other bureau. These inefficiencies are considered transaction costs (Williamson, 1979; 1981).

To reduce transaction costs, organizations negotiate the goals of the relationship, resources to be exchanged or obtained (money, clients, space), procedures for interactions, and accountability mechanisms (Mitchell & Shortell, 2000). The appropriate governance structure must reverberate a balance betwixt the need for organizations to adapt quickly to environmental incertitude and the need to develop highly specific infrastructures to jointly produce a service through coordination of tasks, which requires safeguards to protect organizations from opportunism (Jones, Hesterly, & Borgatti, 1997; Williamson, 1981). These governance details can be highly formal and codified in legal contracts and or extremely informal, and based social norms. While formal contracts offer more protection, more informal relationships allows more than flexibility and mutual adjustment which characterizes the type of coordination often called for in human services (Jones, Hesterly, & Borgatti, 1997).

Coordination in the Human Services Literature

The organizational literature describes how multiple organizations work across traditional organizational boundaries to access needed resource and managed their increasing interdependence via coordination activities, the rules and procedures for which (or the govnernance) are negotiated by the partnering organizations. Descriptions of coordination activities in homo services suggests that coordination appears differently depending on whether the system or community, organization or program, or individual customer services is the targeted level for coordination activities (Bolland & Wilson, 1994; Mulford, Rogers, & Whetten, 1982). Of particular interest to social workers in direct practise, coordination at the example-level oft involves an exchange of referrals and information amongst providers and other actors in the network on behalf of the same client (Reid & Zald, 1965).

Two distinct types of coordination at the case or individual client-level have been referenced in the literature: service and care coordination. In general, service coordination takes identify among multiple agencies or organizations to accomplish a common goal (Martinson, 1999). Service coordination responsibilities typically include assisting clients admission needed and entitled services by identifying service needs and potential providers, serving every bit the bridge between multiple service organizations, advocating on behalf of clients, and evaluating the services provided (Bruder et al., 2005).

Intendance coordination is used frequently in health services and divers by the Agency for Healthcare Research and Quality (AHRQ) as, "… the deliberate organization of patient care activities between 2 or more participants (including the patient) involved in a patient'southward care to facilitate the appropriate delivery of wellness care services. Organizing care involves the marshalling of personnel and other resource needed to bear out all required patient care activities, and is often managed by the commutation of information amongst participants responsible for different aspects of care" (McDonald et al., 2007). Thus service coordination is a procedure of organizing services, and care coordination is a specialized type of service coordination more than narrowly focused on delivering health intendance and treatment.

Toward a Definition and Theory of Coordination in Human Services

Despite organizational theories and the discussion in the literature, the definition of service coordination in human being services is even so ambiguous with trivial clarity and consistency in identifying and characterizing service coordination, contributing to the potential for inconsistent operationalization. Therefore, the purpose of this commodity is to inform theory development via two aims: the first aim is to explore the significant of coordination from the perspectives of the organizations that encourage or recommend service coordination in handling or exercise protocols and social workers in the field. The second aim is to identify and explore factors that facilitate or forestall coordination and build a preliminary working theory.

Equally a starting bespeak, a modest pilot study was conducted using qualitative research methods anchored in a grounded theory approach which uses inductive reasoning to build theory. The purpose was to uncover meaning by allowing concepts and theories to emerge from the data and then compare the results with existing definitions, theories, and practice standards, rather than a pure deductive approach that tests pre-adamant hypotheses (Bernard & Ryan, 2000; Strauss & Corbin, 1998). Theory is built from the data nerveless, and every bit each case is examined information technology is compared to the working theory which is constantly refined to fit the observations. Therefore, new meanings, concepts and relationships that might not be expected based on current theory or previous research can be uncovered.

In this pilot, beginning, perceptions, and mental models of coordination were explored from the perspectives of social workers in the field. Second, data and examples of service coordination described by professional person organizations that fix standards and protocols for practice were explored in an analysis of publicly available practice guidelines. The two data sources reflect perceptions of the ideal and real coordination experiences in the field and were intended to be complementary.

Method

This article draws on ii information sources. First, interviews with social workers were conducted to gather information regarding participants' perceptions of the primary conceptual definitions, domains and factors related to coordination to help develop a preliminary definition and theory grounded in the realities of working in the field. Second, treatment guidelines were examined to understand how "coordination" is divers, described and explained to human service professionals. The interview protocols were reviewed by the IRB.

Sample

Four social workers with feel working in human services were asked to participate in an interview. To ensure that the definition and theory of service coordination reflected the realities of the field, it was of import to recruit participants who felt comfy talking openly about their piece of work experiences All participants were known to and had a previously established rapport with the PI. Participants were approached by the author in person and through e-mail service to participate in an interview. The purpose and voluntary nature of the projection was explained and participants gave verbal consent.

Two participants were male, and two were female. All 4 had MSW degrees and practice experience. Although the sample was small, the participants were purposefully selected to ensure that the themes that emerged from the data were not overly biased by organisation blazon or region, and could serve as a starting betoken for understanding coordination experiences in general. The sample reflects social piece of work experience in 4 different systems (adult mental health, children's behavioral health, child welfare and specialized healthcare) and three different regions (Midwest, Mid-Atlantic and Northeast). All four participants had feel providing direct services although two were serving in supervisory/administrative roles at the time of the interview.

Interview Instrument

A semi-structured interview schedule based on the report aims was used in light of the exploratory nature of this project (Schensul, Schensul, LeCompte, & LeCompte, 1999). There were 4 main sections of each interview. There were four main sections of each interview. Starting time, participants were commencement asked to describe their job. These responses yielded data most job responsibilities, the populations they serve, types of services they provide, and the general organizational context. In their descriptions, participants likewise tended to describe elements of their piece of work where they were engaged in coordination activities. This phenomenon may have been influenced by their awareness of the topic of this study.

The next phase of questioning was designed to arm-twist participants' perceptions, understanding and meaning fastened to the concept of "coordination." All participants were asked, "What does coordination hateful to y'all?" and "In an platonic world, what would coordination look like?" Responses were followed by addition probing questions to break downwards the participants' definition in order to uncover deeper meanings associated with the concept. Typically, participants provided examples of situations where services were coordinated or conversely, examples of situations in which services were not coordinated well. In improver, participants tended to identify the end goals or outcomes of coordination.

The third section of the interviews was intended to explore factors related to coordination. Participants were asked to share their ideas regarding factors that that facilitated or prevented coordination. Although participants shared relevant information most facilitators and barriers throughout the discussion, a direct line of questioning was intended to orient the participant to call up of relationships between actions and conditions in their practice and their ability to coordinate. Participants shared both conditions nether which coordination occurred, issues that prevented providers from analogous, as well as strategies utilized to facilitate coordination.

The quaternary department of the interview asked participants to list indicators of coordination activity. Participants were asked to describe what they would look for if they were required to assess whether their section, unit, staff or program was coordinated. The interviews concluded with an opportunity to share any last information or thoughts on the topic that were non addressed in the previous chat.

With each interview, the writer was increasingly able to hone in on the topics of involvement and refine the language of the questions to arm-twist responses. This focus also immune for the free deviation from the list of interview topics to explore meanings and metaphors that arose in conversations. The information provided by the first interview participant provided a foundation for understanding and probing the responses by the other participants. This allowed for differences in respondents' information to be probed to improve sympathize the differences too every bit similarities.

Treatment Guidelines – Definition and Access

Treatment guidelines are documents outlining recommendations for clinical exercise and communicate expectations for practice to providers based on available evidence of constructive handling (Howard & Jenson, 1999) and have been a useful source for analyzing content related to practice standards (Perron, Bunger, Bender, & Howard, 2010). Guidelines are developed by a multifariousness of professional person organizations including the American Academy of Pediatrics, the Substance Abuse and Mental Health Services Administration (SAMHSA) and others to convey practice standards and expectations. The content of guidelines recommending coordination was analyzed for descriptions and examples of service coordination every bit intended for practice.

Practice guidelines archived by the National Guideline Clearinghouse (world wide web.guidelines.gov) were searched using the terms "coordinate" and "coordination." A uncomplicated give-and-take search yielded 79 hits nevertheless, not all were relevant to this research topic and many were duplicated in the two searches. Guidelines were limited to recommendations developed past domestic entities, and mentioned coordination in the context of service delivery (as opposed to neuromuscular, motor, or other types of coordination). The selection strategy was intended to recollect guidelines relevant to practice fields of the key informants interviewed in the study (specifically those that addressed adult mental health or substance abuse issues, children's behavioral health, and HIV intendance and treatment). The treatment guidelines referenced in this article are listed in alphabetical lodge by programmer in Appendix A.

Appendix A

Treatment Guidelines Analyzed

Guideline	Abbreviation	Citation
A	AACAP, 2007	Winters NC, Pumariga A, Piece of work Grouping on Community Child and Boyish Psychiatry, Piece of work Group on Quality Bug (2007). Practice parameter on kid and adolescent mental wellness care in community systems of care. Journal of the American Academy of Child and Adolescent Psychiatry 46(2):284–99.
B	AAP, 2003	Percelay JM, American Academy of Pediatrics, Committee on Hospital Intendance (2003). Physicians' roles in coordinating care of hospitalized children. Pediatrics, 111(3), 707–ix.
C	AAP, 2004	Taras HL (2004). School-based mental wellness services. Pediatrics, 113(6), 1839–45.
D	ICSI, 2007	Institute for Clinical Systems Improvement (ICSI) (2007). Diagnosis and management of attention arrears hyperactivity disorder in primary intendance for schoolhouse-age children and adolescents. Bloomington (MN): Institute for Clinical Systems Comeback
E	NYSDH, 2006	New York State Section of Health (2006). Working with the active user. New York (NY): New York State Department of Health.
F	NYSDH, 2007	New York State Department of Health (2007). Main intendance arroyo to the HIV-infected patient. New York (NY): New York State Department of Health.
Thousand	PHSTF, 2007	U.S. Public Health Service Task Strength, Perinatal HIV Guidelines Working Group (2007). Public Health Service Task Strength recommendations for apply of antiretroviral drugs in pregnant HIV-1-infected women for maternal health and interventions to reduce perinatal HIV-ane transmission in the United States. Rockville (Dr.): U.S. Public Health Service.
H	SAMHSA, 2005a	Peters RH, Wexler HK (2005). Substance abuse handling for adults in the criminal justice system: Handling improvement protocol (TIP); no. 44.. Rockville (MD): Substance Abuse and Mental Wellness Services Administration (SAMHSA)
I	SAMHSA, 2005b	Middle for Substance Corruption Handling (2005). Substance corruption treatment for persons with co-occurring disorder: Treatment Improvement Protocol no. 42. Rockville (MD): Substance Corruption and Mental Health Services Assistants (SAMHSA)
J	ICSI, 2008	Institute for Clinical Systems Improvement (2008). Major low in adults in primary intendance. Bloomington (MN): Institute for Clinical Systems Improvement
K	NHCHC, 2003	Conanan, B., London, K., Martinez, Fifty., Modersbach, D., O'Connell, J., O'Sullivan, M., Raffanti, S., Ridolfo, A., Postal service, P., Santillan, R.K., Vocal, J., Treherne, L. (2003). Adapting your do: Handling and recommendations for homeless patients with HIV/AIDS. Nashville, TN: Wellness Care for the Homeless Clinicians' Network, National Health Care for the Homeless Quango, Inc.

Procedure

There were iii stages of information collection and assay. First, the interviews with social workers were conducted in person and over the telephone. Due to fourth dimension and travel constraints two interviews were conducted in person and 2 were conducted over the phone. Interview length ranged from 30–45 minutes and detailed interview notes were taken and afterward transcribed. Detailed interview notes were reviewed and major themes that emerged across participants were coded into free nodes, or free-continuing categories using NVivo. This process was iterative: transcripts were coded and recoded two additional times until the author felt confident that the near relevant information shared by the participants was organized into meaningful categories. Data in each node was compared for similarities and differences. At this point, it became clear that nodes could exist grouped together into broader categories such as "definitions," "characteristics," "factors," and "mechanisms." Therefore the information were restructured into tree nodes, where each broad category contained several subnodes.

Second, the handling guidelines were selected and analyzed. Nine guidelines were downloaded into MS Word format, and imported into NVivo. Traditional content analytic techniques were used. First, the words "coordinate" and "coordination" were queried to identify usage of the term. Second, the rest of the guideline texts were reviewed in their entirety and other passages were identified and considered that referred to similar topics such as "collaboration" and "integration. These results were reviewed, compared, and coded into free nodes that reflected general themes. The free nodes were grouped into five full general categories: definitions, recommendations, mechanisms for increasing coordination, purpose of coordination, and service delivery models.

Finally, the tertiary phase combined the analysis of the interview and guidelines. An boosted review of the interview and guideline nodes was conducted past hand to identify relationships among the concepts, specifically those that had potential to explain why and how social workers coordinate. Therefore, the data and nodes in the broad categories of "factors" and "mechanisms" were the focus of this third phase of analysis. Consistent with grounded theory approaches, a conceptual model was developed by refining the nodes (Oktay & Padgett, 2004; Strauss & Corbin, 1998). Some of the relationships amid the concepts appeared to be interrelated, forming feedback loops, where sure variables may reinforce (creating exponential growth) or balance (causing plateaus or leveling off) one another over fourth dimension. Consequently, the concepts were mapped as a causal loop diagram using principles of systems dynamics modeling. Causal loop diagrams are tools for illustrating complication and interrelationships to gain insight about how processes and systems operate over fourth dimension (Sterman, 2000). The relationships amidst the concepts are described in the next section.

Results and Discussion

Exploring Coordination

Throughout the treatment guidelines and interviews, several words and phrases were used in conjunction with coordination such as "working together," "same page," "multiple providers," and "active." The cardinal characteristics of coordination are further explained and illustrated.

Multiple Providers, Interdependence and Aforementioned Goal

Both treatment guidelines and the interview participants illustrated situations in which coordination was necessary. These examples highlighted a condition in which there were multiple actors that needed to piece of work together to serve a common client or client population which is consistent with conceptualizations of service and care coordination in the literature. When asked what coordination means, one participant responded, "It ways that I need assistance from some other bureau – we take to talk together to get something done." Similarly, one participant noted that it is a "shared investment" helping clients and some other noted that coordination is "one agency or group providing a network of services that an individual needs. Working with another entity to brand whatever you want to happen. It'southward something positive."

The treatment guidelines conveyed that multiple providers from different service systems are needed to achieve a common goal. For example, information technology is recommended that "every member of the clinical team should appoint in care planning and coordination" (Guideline Grand in Appendix A) when caring for homeless individuals with HIV/AIDS. Similarly incarcerated adults with substance abuse disorders "will all-time exist served by substance abuse treatment and criminal justice systems that are working together to help them in recovery and in condign law-abiding citizens" (Guideline H in Appendix A).

The guidelines provided further detail on the caste of multidisciplinary interest expected of providers perhaps because of the prescriptive role of guidelines in shaping practice. Guidelines called for the articulation involvement of mental health, substance abuse, medical, welfare, and school-based services to name a few and ane guideline warned that declining to work with other providers or "Practicing in isolation runs counter to system-of-care principles and does not support coordination and integration of intendance" (Guideline A in Appendix A).

Consistency and Continuity

Participants acknowledged that pooling their efforts to support a client was insufficient for coordination. Social workers highlighted the importance of consistency or similarity in treatment approaches, and continuity of services. Coordination meant that care was delivered in a consequent manner where "everyone is on the same page," "talking in the same vocalisation," which might resemble "a dance." These responses reflect the idea that coordinated multidisciplinary intendance is more than providing multiple services, only that each provider conveys the same message to the client.

Coordinated care also refers to continuous or seamless service delivery. This definitional theme emerged in both interview transcripts and the text of treatment guidelines. In interviews this phenomenon was described in terms of a "handoff" or helping a customer "get to the next level of intendance" within a "seamless service delivery organisation." Treatment guidelines provided examples of transitions from one service to the next and information technology was divers as "continuity of care refers to coordination of intendance as clients move beyond dissimilar service systems" (Guideline A).

Types of Coordinated Service Delivery

Several potential strategies of delivering coordinated intendance were described in the treatment guidelines including integration, wrap-around and case direction services. All three types of service delivery methods contain the active, multidisciplinary and shared goal environment that was used to characterize coordination only vary in the degree to which services are combined.

Integration

Service integration requires that services are combined and provided simultaneously. Particularly within the field of adult mental wellness, guidelines for treating co-occurring mental health and substance use disorders (Guideline I in Appendix A) mention the integration of both types of services every bit a manner of delivering coordinated care and is described equally follows:

Integrated treatment coordinates substance abuse and mental wellness interventions to treat the whole person more effectively; the term refers broadly to any machinery by which treatment interventions for COD are combined inside a primary handling relationship or service setting.

Wrap Around

Wrap around services involve multiple providers and services that may overlap in some means, only are not combined to the same degree every bit integrated services. Guidelines for delivering coordinated mental health care to children (Guideline A in Appendix A) recommend wrap-around care as a method which is defined equally:

…integrated assessment and planning process that knits together services from all of the involved providers to address the strengths and needs of the child and family.

Case Direction

Finally, case management involves linking a client to several needed services: a method of bridging clients from one type of service to some other. Several guidelines noted that coordinated intendance was delivered via case managers in reference to belch planning and other service transitions. Instance management involves services that are not combined and may or may not overlap: "Clinicians should refer substance using patients for case-management to enhance service coordination of care when care is provided past multiple disciplines and in multiple settings" (Guideline E in Appendix A). Case or care management is projected to facilitate patient-centered intendance and implementation of recommended handling (Guideline J in Appendix A).

Connecting a Social Work Definition of Coordination to the Literature

Based on the information in this airplane pilot written report, coordination is characterized equally a process involving multiple entities working toward a shared goal. The definition of coordination that emerged from the information is consequent with resource dependence theory which explains inter-organizational relationships in terms of interdependence (Pfeffer & Salancik, 1978). From an organizational perspective organizations or providers from dissimilar units work together when they depend on one some other for complementary resource (such equally service expertise).

The potential strategies for coordinating these service interdependencies that are described in the treatment guidelines somewhat reverberate coordination mechanisms in the organizational literature (Thompson, 1967). Case-management might stand for pooling resources, while wrap-around and integration correspond progressively more circuitous coordination mechanisms that involve planning and reciprocal or mutual adjustment.

While the handling guidelines, peculiarly, emphasize the interdependence of service activities and coordination mechanisms reflect the resource dependence perspectives in the organizational literature, social workers went a step further past highlighting how consistency and continuity are important, potentially indicating how coordination is unique in human service settings.

Facilitators and Barriers

Factors that facilitate or prevent coordination emerged from the interview and guideline data including client-level factors, personal relationships, and institutional factors. These concepts and their relationships to ane some other are explained and mapped below. (A full diagram of the concepts explored is contained in Appendix B).

Comprehensive Model of Service Coordination

Client-Level Factors

Both the social work participants and the handling guidelines mentioned the role of client-level factors, in particular severity of symptoms and multiplicity of service needs on the need for coordinated services. The guideline for practice in children's mental health systems (Guideline A in Appendix A) explains, "Children with circuitous needs are mostly served past multiple agencies and without active coordination of care, these children are at risk of receiving fragmented care that fails to accost their overall needs."

Social workers described how the severity of disease or symptoms and the complexity of service needs drove the demand for services from multiple types of providers, creating conditions where providers depend on the aggregate impact of one another's service expertise on customer outcomes. Having "many providers… meant that they were really ill," and "as the patient becomes more astute, there are more players involved" which "… tested this kind of coordination." However, sometimes the multidisciplinary nature of coordination and the complexity of the problem meant that in that location are "besides many people involved" which presents a barrier to effective coordination. Therefore, while customer needs drive the need for coordination, the difficulties and challenges of multiple providers involved in care remainder the driving client-level factors of coordination (Effigy i).

Need for Service Coordination

The Role of Personal Relationships on Data Sharing and Referrals

In each interview, participants discussed the interpersonal relationships amidst providers, the substitution of information, and referrals patterns and provided rich data near how the interconnectedness of service provider networks influence coordination of care over time. The impact of personal relationships on the exchanges of data and referrals that facilitated service coordination became clear and these relationships are explained further (Effigy ii).

Facilitators and Barriers of Coordination

Personal Relationships

The personal relationships that providers develop with ane another are cardinal drivers of service coordination, at to the lowest degree according to the social workers in the field. When asked how coordination happens, one social worker paused and explained, "I call up information technology's about… on my microlevel, most relationships between individuals and agencies. That occurs before and after yous get a client." On an organizational level, another respondent pointed out "[I] require linkages only a lot of things become coordinated because of the directors. They know each other." These relationships are reinforced over fourth dimension because:

… what happens is that you coordinate with people you have good relationships with, and then hopefully it becomes a reciprocal thing. You piece of work with someone on a client and so the next client comes in and y'all're similar, "oh, let me telephone call your caseworker, I know him or her and we can work together to assistance y'all stay well."

The data suggest a reinforcing feedback loop where good personal relationships drive coordination, which in turn enhances the personal relationship over time. Theoretically, negative relationships may stifle coordination, and the development of a positive personal relationship which is explored adjacent.

Conflict

While relationships are important in relation to service coordination, there is potential for conflict and personal or professional politics to negatively influence personal relationships, which could affect service coordination. In particular, working with medical providers or psychiatrists who may be higher in the service bureaucracy, or entities with greater authorization (like court systems) can brood tension and conflict which "creates a hostile working relationship. You talk about whose mistake it is and you lot get-go pointing fingers."

Two strategies for addressing potential conflicts were noted: 1 strategy involves negotiating procedures for working together while the other involves matching or aligning treatment approaches. Start, social workers described the importance of clear role definitions and expectations: "Nosotros are constantly stepping on each others' toes. It's not clear what everyone'south role is and we need to define a way of doing things." Second, consistent, congruent or complementary treatment philosophies were perceived to reduce conflict. Situations where "there are very real disagreements most what should happen with a given client" create the potential for conflict where, "one of the providers does not agree with that approach to clients… so they are less likely to desire to kind of play with yous." This aforementioned social worker discussed the importance of an "underlying treatment framework that spanned the programs or coordinators."

A consequent treatment philosophy could heighten coordination because providers would approach treatment from a similar framework, potentially minimizing disagreements. The developers of the treatment guidelines recognize this difficulty besides and recommend a unified approach (Guideline I in Appendix A). However, this strategy is difficult: "That's hard because programs don't share a theoretical framework… some of them don't even have a theoretical framework!"

Shared Data

Personal relationships are important for sharing information amongst providers and this shared data directly impacts service coordination. Although the social workers highlighted the importance of being "on the aforementioned folio," expectations for data exchanges to facilitate this common agreement were plant in the treatment guidelines. I guideline (A) explicitly states, "Information sharing across service providers in the example of multiagency-involved youth is essential to effective service coordination."

Social workers as well expected that information nigh a client and the treatment goal would exist shared with them. Participants discussed the utility of interagency or treatment squad meetings and instance conferences as "a mechanism for communication." Treatment guidelines (Guideline A in Appendix A) besides recommended that providers attend meetings to "facilitate the consistency of advice across providers."

However, the fourth dimension needed for regular meetings, telephone conversations and other forms of communication was a drawback. Ane of the participants recounted, "…she would encounter with outside providers all the fourth dimension for like an 60 minutes. The problem is that it really required some time." Another participant discussed how some professionals rarely attended treatment squad meetings because of the fourth dimension commitment and the fact that they were not compensated for their time spent coordinating. Although communication is essential to coordination, the time costs associated with communicating with providers (which is amplified when there are multiple providers involved) is a cost of coordination which may negatively bear on service coordination.

Referrals

Discussions of coordination elicited feedback on referrals. In fact, it was often 1 of the commencement thoughts about coordination shared in the interviews, "For me, some of information technology has to do with referrals. Who gets the patient next? You know that'due south sort of a weird way of looking at it simply, who is adjacent responsible for the person'due south treatment?" Referrals are a mode of linking clients to services. The program ambassador who participated in the project noted the importance of referrals in coordinating care and that linkages are critical for helping clients access services from multiple providers.

Several concepts related to referral processes emerged. First, timely responses especially for children's services could have immediate bear upon on prophylactic: "kids are high priority and it'south expected that [referrals] are turned over in a sure amount of time." Second, standard or set processes for referrals were described. Treatment guidelines (Guideline C in Appendix A) called for "coordination of mental health referrals through effective written protocols" and social workers as well noted that having "a set way of doing things" or a plan helped the referral process. Finally, an administrator talked about linkage agreements among organizations: "Information technology strengthens coordination considering it forces people to work together. It specifies what tasks are to be completed and is a formal agreement."

Other Straight Factors

2 boosted factors perceived to direct influence service coordination were discussed throughout the interviews (Figure three): power to brand decisions and incentives for coordination. Starting time, one social worker noted that treatment decisions were made and "things got done considering in that location were people with power." Often, resources must exist exchanged to provide care and forepart line-staff involved in a team of providers may not take the authority in their work environment to make such decisions. When individuals who have ability to make decisions on behalf of their agency are involved, services tin can be coordinated more easily.

Outcomes of Service Coordination

Government grants that encourage or provide incentives to providers to create linkages, or piece of work together to deliver services was also noted as a strategy that can be used to coordinate services at the case-level past "encouraging coordination between systems." An example was offered past one of the participants of a grant opportunity from the United states Department of Housing and Urban Evolution where an HIV intendance and treatment services program leveraged their funds in order to obtain boosted vouchers for people living with HIV/AIDS who were homeless. The availability of these opportunities may lead to coordination at administrative levels and provide incentives for additional coordination amongst providers at the case-level.

Connecting Identified Facilitators and Barriers with the Literature

Throughout the interviews with social workers, the exchange of information and referrals (or the resource needed to provide services and care) emerged every bit the ways by which services are coordinated remaining consistent with resource dependence. Although the information appear to support the dependence and exchange perspectives, the social workers highlighted how "softer" personal relationships among providers influence how clients are referred, data is shared, and services are coordinated.

Familiarity and the quality of personal relationships amongst providers have been more recently examined by wellness services researchers (as opposed to more traditional inter-organizational theories that explicate partnerships in terms of economic science, or resources dependence). For example, Gittell and colleagues have adult the concept and measure out of "relational coordination" amid multi-disciplinary professionals within health care settings (Gittell, 2000; Gittell, 2002). Gittell defines constructive coordination every bit frequent, timely, and accurate communication in addition to relationships characterized by shared goals, shared cognition, and mutual respect. In addition, other inquiry in human services has highlighted the frequency of conflict (Zapka et al., 1992) due to conflicting treatment philosophies (Gillespie, Colignon, Banerjee, Murty, & Rogge, 1993), resistance to irresolute philosophies and approaches (Ryan, Garnier, Zyphur, & Zhai, 2005) and other ideological differences amid clinicians and organizations. The more diverse the group of organizations and individuals, the greater potential for conflicts.

As the social workers in this pilot study noted, specifying procedures for working together, or the governance construction may help reduce conflict (or the "costs" of coordination) amidst providers. Transaction cost economics scholars (Williamson, 1979; 1981) typically emphasize the need for a governance structure which may be as formal as a written contract or highly informal such every bit a exact understanding. Regardless, the fashion the partnership is structured can help minimize conflict, while allowing providers the flexibility in their human relationship to adjust in response to one another and coordinate their services.

Outcomes of Service Coordination

In both the interviews and handling guidelines, expected outcomes of coordinated activities were discussed in the form of goals, purposes, and intent. There were two main types of outcomes that emerged: system-level and client-level (Effigy 3).

Service coordination was perceived to impact system-level outcomes such as continuity, comprehensiveness, and quality of intendance. First, enhanced coordination facilitates transitions to dissimilar services where the indicator of success is a "handoff" where the client reaches "the next level of care." Second, equally noted in the interviews coordination leads to "comprehensive services in the network" where "clients get the services that they want," and is a authentication of quality care.

Ultimately, the purpose of coordinating services for clients is to ameliorate outcomes. Improvements in client-level outcomes result in a reduction of symptom severity and problem complication, which reduces the need for service coordination. Handling guidelines were clear almost the office that coordination has on individual client-level indicators. For case, "The members of the TIP consensus console feel strongly that effective collaboration betwixt the criminal justice and substance corruption treatment systems tin can result in improve treatment for offenders and ultimately, a reduction in law-breaking" (Guideline H in Appendix A). In effect, constructive coordination (or treatment) works as a balancing feedback loop in the system which has the potential to reduce the need for such circuitous partnerships. However, interviewees were less optimistic:

Does coordination lead to different outcomes? … I don't mean to downplay coordination or intersystem intendance. I simply think that similar, if you are sick and at that place aren't that many ways to cure y'all, coordination isn't going to assistance that. If you lot are less ill, information technology isn't going to cure you but… there are a lot of handling options. it [coordination] just isn't going to be the lynchpin for outcomes. I recall in that location are imperfect interventions. Not as perfect as people call back they are. Especially for people whom a lot of coordination is going to exist required.

Although the model illustrates a link between service coordination and client outcomes, the complexity of the model and the multitude of factors (included and not yet included) illustrate the claiming ahead for researchers and practitioners to improve service delivery.

Connecting Social Workers' Intended Outcomes with the Literature

The system and client-level goals of coordination that were identified by social workers and in the treatment guidelines differ from the hypothesized touch on of coordination based on inter-organizational theories. Resources dependence theory and transaction price economics posit that coordination helps organizations access resources and maximize efficiency (respectively): both of these outcomes are organizational-level economic outcomes which stand up in contrast to the system and customer-level outcomes that relate to admission, quality and symptom improvement. In homo services, the ultimate goal of service coordination is to brand an affect at the client level and has cipher to exercise with economic benefits for the organization. Therefore, coordination theories from the organizational literature may not provide an adequate explanation and framework for understanding and studying coordination in human being services, and a setting-specific theory may be warranted.

Conclusions

This initial research was intended to contribute to a greater understanding of the significant, related factors, and outcomes of service coordination. Based on the results of this preliminary study, service coordination is characterized past multiple providers working together to serve the same client (interdependence) in a consistent and continuous manner. Thus coordination is a process that involves more than just organizing services. To do and then effectively, providers may use several types of coordination mechanisms depending on the service needs of the client. Therefore, hereafter research evaluating the extent to which services are coordinated may consider using several process indicators such every bit the number of providers involved, the amount of information, referrals or other resources shared, time to follow up with a new referral, or adjust services in response to information learned from a colleague.

The results also provide new insight into the weather condition, strategies and issues that arise when providers work together to coordinate their services on behalf of a client, laying the groundwork for a preliminary theory of coordination in man services. The causal loop diagram demonstrates how the need for service coordination is driven by astringent and circuitous client needs, but the quality and history of providers' relationships with one another (and the information and referrals exchanged) drive the coordination process. Interventions targeting providers' interactions such as standardization and formalization of roles, expectations, referral processes, agreements and treatment philosophies could facilitate coordination, and ultimately improved client-level outcomes.

This airplane pilot study highlights how relational qualities shape coordination, which has been the focus in other human services research. As highlighted by other human service researchers, coordination depends on more than the need for resources or complementary service expertise. Human services inquiry can brand a unique contribution to the coordination knowledge-base by continuing to examine the complex interactions among client needs, interdependence, the quality of provider relationships and coordination.

Furthermore, traditional resource-based views of inter-organziational coordination may not exist entirely relevant when examining coordination in human being services. The goal of coordination in human services is to improve client-level outcomes however, resource dependence and transaction toll economic science explain how organizations coordinate to achieve economic goals such as accessing resources and maximizing efficiency. Therefore the weather and factors related to coordination that are highlighted by these organization theories may non exist similarly salient in analogous human services at the client-level.

Methodological Limitations and Future Directions

I of the primary limitations of this report is the small sample of interview participants. Although the iv participants touched upon similar topics and themes lending some trustworthiness to the data, in that location was even so variation in responses to indicate that there are additional relationships and ideas to be explored. All participants were known to the author which might have influenced the information offered in the interviews. For instance, one of the participants assumed the author's familiarity with her job responsibilities and situations where she coordinated services. This written report was also express by the inability to comport all four interviews contiguous. This limitation may exist balanced past the previously-established rapport between the writer and participants.

Moving across the abstract definition adult in this written report to an operational definition and theory will exist a challenge given the ambiguity and multi-dimensionality of coordination. This written report is a get-go step of a grounded theory arroyo for understanding service coordination. Continuing with the grounded theory approach begun in this airplane pilot, subsequent phases of this line of research should continue to examine social piece of work perspectives to determine whether similar patterns of major themes and relationships emerge. Alternative qualitative approaches could help "unpack" service coordination. In particular, ethnographic approaches might be useful for agreement service coordination in settings such as treatment team meetings. Using different sampling approaches to capture voices from service sectors across those highlighted in this study (east.1000. welfare, developmental disabilities, veteran's affairs, disaster management) would assist uncover new insights that emerge from the information and ensure applicability beyond systems. Finally, the conceptual framework can be refined through a serial of fellow member-checking activities where the causal loop diagram is shown to social workers to compare the relationships in the model to their own practice experiences.

Service coordination is a disquisitional process for social workers and other professionals who work beyond the boundaries of multiple systems on behalf of clients with severe and multiple service needs. This pilot study offers a preliminary conceptualization of service coordination as a process driven by interpersonal relationships merely influenced past facilitating factors and barriers in organizations and systems. However, further evolution of definition and framework of service coordination is necessary for building a sound body of practice cognition that can inform effective solutions for addressing fragmentation in homo service delivery systems.

Acknowledgments

Supported by NIMH grants T32 MH19960 and F31 MH088037-01.

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Source: https://www.ncbi.nlm.nih.gov/pmc/articles/PMC2992332/

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