Flexible and individually tailored homebased healthcare services – with the trust model as context

Abstract

This thesis draws attention to home-based healthcare services and the trust model as a new means of structuring these services into interdisciplinary teams; it also discusses the involvement of next of kin in the process of striving to provide flexible and individually tailored healthcare services. The changing demographics both nationally and internationally, particularly the increase in the population of older adults, necessitates a restructuring of primary healthcare services worldwide. Norwegian health policies have prompted a need for innovative thinking and one solution that has been adopted is the trust model. This model aims to increase frontline workers’ motivation, service users’ satisfaction, and public trust in home-based healthcare; improve professionalism; and enhance the quality of healthcare by granting professional autonomy and placing trust in frontline workers. The model encourages a shift from a silo-based structure of professions or shared tasks and responsibility to smaller interdisciplinary self-managed teams with the case manager as an equal member. The trust model challenges the typical sectorial division of home-based healthcare services in Norway. The model’s intention is to enable a rapid response to service users’ fluctuating needs, bypassing time-consuming bureaucratic procedures. The trust model places trust in the professional competence and experience of frontline workers who interact directly with service users and their next of kin, thereby improving the flexibility and individual tailoring of healthcare services. This thesis adopts an explorative, interpretive qualitative approach based on a constructivist epistemology and presents four articles. The first article discusses the needs-led research process that was conducted when devising the research question for this thesis. The process was inspired by James Lind Alliance (JLA) and other involved representatives from the homebased healthcare service, service users, next of kin, and other stakeholders within the field. Between March 2021 and April 2023, empirical data were collected through observations of meetings in the context of home-based healthcare, individual- and focus-group interviews with frontline workers, and individual interviews with next of kin within a large municipality in Norway. Thematic analysis was used to systematise and interpret patterns across the data. The theory of Street-level bureaucracy, inspired by Lipsky, combined with previous research were used in the discussions. The results reveal that aiming for flexible and individually tailored services through the structure of home-based services described within the trust model is complex and intricate. The previous work frames, such as purchaser-provider model and other organisational frames, limited the frontline workers’ professional autonomy to provide flexible and individually tailored services. Furthermore, being separated from peers of professions or those related to tasks and responsibilities resulted in a need for dual belonging for the frontline workers. In order to exploit the professional competence or knowledge for specific tasks and responsibilities, the frontline workers emphasise the importance of not only being organised into an interdisciplinary team but simultaneously also maintaining a belonging to their peers. Lastly, the trust model points to the involvement of service users and next of kin as a necessary task in the service tailoring. This thesis indicates that the involvement process has numerous facets; however, unspoken expectations and a wish for situational partnership appear to be important challenges. In summary, this thesis argues that the trust model’s aim of creating flexible and individually tailored services meets barriers regarding the structures that frame the frontline workers’ possibilities to fully enact the professional autonomy and discretion they are given. It is recommended that policymakers, managers, and employees within home-based health services keep these results in mind and incorporate them into future planning of new solutions, altered work methods, or restructuring of home-based health services.