A vision for integrated social and healthcare services: An experience from Bulgaria

Abstract

This article presents the results of a study of practitioners’ and experts’ vision for implementing integrated services that combine healthcare and social work in Bulgaria. Sixty-four respondents (n = 64) were recruited to participate in interviews (n = 17) and focus groups (n = 47). The need for a conceptual clarification and a common vision for integrated social and healthcare services was evident, including the approaches to organization, service provision, management, and funding. More extensive studies about the perspectives for successful integration of healthcare and social services in Bulgaria, based on the analysis of current needs and resources, are required.

Keywords

Complex needs integrated care integrated social and healthcare service inter-sectoral approach quality services

Introduction

Integration between health and social services is on the national policy agenda in many countries and is emerging in Bulgaria. This approach to service integration was initiated on a project basis and introduced innovative practices by providing improved care for vulnerable populations. Development and provision of integrated cross-sectoral services is said to be one of the key priorities of the current government’s agenda, with the focus on the development of innovative integrated services for early childhood development (Ilieva and Vasileva, 2016: 4). Ilieva and Vasileva referred to the network of innovative services established in 66 municipalities under the Social Inclusion Project and defined them as integrated ‘in terms of joint work between different specialists and in terms of the nature of the services (social, health, educational)’ (2016: 5). Todorovska and Karsheva (2017: A602) noted that home care services developed under the Bulgarian Red Cross initiatives ‘represent an integrated model for providing professional community-based health and social services tailored to the needs of the patients’ and that collaborative efforts focus to ‘fully integrate home care services within the health and social systems’.

The development of integrated services that are intended to provide more efficient care for vulnerable populations is stipulated in key strategic political documents and legal regulations, such as the Health Act and the Law on Medical Institutions. This approach aligns with the priorities of the National Strategy ‘Vision for deinstitutionalization of children in the Republic of Bulgaria’ (2010). The National Strategy for Long-Term Care (2014) envisages the establishment of affordable, quality community and home-based services to ensure the social inclusion of people with disabilities and the elderly and, at the same time, to prevent the institutionalization of these persons.

The progressive inclusion of an integrated approach to the complex needs of service users, articulated in documents and publications, implemented in projects and practices, and adopted at the national and regional levels, implies the existence of the necessary political will to take this approach forward. However, the effective operationalization of such an approach also presumes a common philosophy, a shared vision, and effective communication and coordination among all stakeholders. This led us to focus our enquiry on understanding whether a common or mutually shared philosophy or concept of integrated care and services exists in the main systems concerned with the integration. The main research questions were as follows:

What is the understanding of integrated care and services?

What are the main challenges to the effectiveness of integrated services?

Based on the study results, this article aims to shed light on the understanding of integrated social and healthcare services, including personal concepts and perceptions, as well as reflections on the challenges facing the effectiveness of these services shared by people concerned with the integration between social and healthcare services.

A brief summary on the state of the art in the field of integrated care and services

We started our study by exploring how the topic of integrated care and services is being articulated in current literature. It was important to use it as a point of reference regarding our participants’ views about integrated care and services. In this respect, we focused our attention on the ways in which integrated care and services in more advanced countries are conceptualized and implemented. We also examined the Bulgarian experience in available publications on the topic.

Integrated care is a worldwide trend in health and social care reforms and presents a real challenge (Korpela et al., 2012; Sarquella et al., 2016). Analysis of the literature reveals a wide spectrum of definitions and approaches for the realization of integrated care and services (Amelung et al., 2014; Goodwin, 2016; Kodner, 2009; Korpela et al., 2012; Leichsenring, 2004; Minas, 2016). Sutton and Long (2014: 6) reported on a 2009 literature review which yielded approximately 175 definitions. Kodner (2009) noted that the meanings of integrated care are ‘as diverse as the numerous actors involved’ (p. 12).

Furthermore, the concept of integrated care varies from country to country and has different names, such as seamless care, transmural care, case management, care management, and networking (Leichsenring, 2004: 3). These terms correspond to the accepted approaches to integration. There are two trends in the integrated care – developments within the healthcare domain with a focus on ‘managing care discourse’ and ‘public health discourse’ on the one hand, and on the other, a wider approach that puts greater emphasis on social services and social integration, such as ‘the person centered approach’ and ‘the whole system approach’ (pp. 3–4). These approaches are complemented by the so-called institutional discourse, which focuses primarily on ‘organizational strategies to realize integration and/or co-ordination of services’ (pp. 3–4).

There are also a number of conceptual frameworks and taxonomies of integrated care, according to the type, level, process, and breadth and intensity of integration (Goodwin, 2016; Kodner, 2009), and various forms of integrated care, ranging from horizontal integration between services from different sectors based on multidisciplinary teams and/or care networks; vertical integration across the hierarchical levels; sectoral integration within one sector combining horizontal and vertical programs; people-centered and a whole-system integration (Goodwin, 2016: 2). The forms of integration might be structural or virtual. Linkage, coordination and full integration between services are mentioned as the most cited degrees of integration (Kodner, 2009; Minkman et al., 2011; Richardson and Patana, 2012; Sutton and Long, 2014). It is assumed that full integration involving a single organization will be the most effective (Goodwin, 2016; Kodner, 2009).

Analysis of the literature reveals a lot of challenges, for various reasons, in the work of multidisciplinary teams. Montero et al. (2016: 71) stressed the importance of professionals being clear about the purpose of integrating services, and on the usefulness of a collectively developed and shared vision or aim for the practitioners to work toward. Different philosophies, values, and cultures, typical for the social and healthcare systems and the professionals employed in them, are discussed extensively (Barnes et al., 2007; Heenan and Birrell, 2006; Miller, 2016; Montero et al., 2016; Rämgard et al., 2015). The lack of clear understanding and allocation of roles and responsibilities between participants negatively affects collaboration (Widmark et al., 2011). The domination of a certain profession over another is mentioned as a threat to the efficiency (Richardson and Patana, 2012). Furthermore, the complex nature of integrated care and the maintenance of a traditional way of working rather than collaboration between sectors and duality of roles is noted (Montero et al., 2016: 23). The success or failure of integration depends on the motivation of those involved in the provision of care (Nies and Beersma, 2016). In that sense, Hendry (2016: 2) sees the greatest challenge as being the transformation of the workforce.

Current focus on integrated care and services in Bulgaria

While there is an abundance of studies on the components, models, strategies, successful practices, and challenges in integrated care and services in other countries, Bulgarian research on these subjects is still in its infancy. Petrova et al. (2015) explored the awareness of integrated care and attitudes toward its implementation of medical doctors and other professionals in northeastern cities in Bulgaria. They found that a larger percentage of respondents understand integrated care as ‘a coordinated and holistic complex of services provided by different healthcare and social care specialists and agencies’, while a smaller percentage perceive it as a concept that unites management, support, implementation, and organization of services for diagnosis, treatment, care, and rehabilitation of health (Petrova et al., 2015: 5). The authors mention the lack of coordination between different structures and the lack of a legal framework among the main barriers to its implementation (p. 5).

Petrova (2016), in her presentation, cites numerous challenges to integrated care, including high costs, legal and technical performance limitations, resistance to change, underdeveloped teamwork skills for provision of integrated care, unclear functions of the health system for the treatment of chronic diseases, lack of an integrated information system for data exchange between different levels of healthcare, and the chronic underfinancing of healthcare. Todorovska (n.d.) stated that the main challenges and risks facing the provision of integrated health and social services are connected with a misunderstanding of the nature of these services, the provision or lack of provision of quality services, and the shortage of workforce in the health sphere.

Salchev (2015: 11–18) noted that legislation in Bulgaria allows for the creation of models of integrated and coordinated long-term care ‘united under one core and developing multiple services focused on the needs of people, i.e. uniting the efforts of social and health care systems to provide care for the needy’.

Method

Research design and sampling methods

Aim of the study

This study focused on the practice of integrating social and healthcare services and the associated challenges by exploring the interpretations and experience of experts and practitioners in the social and healthcare domains.

Methods

Qualitative methods for data collection – in-depth interviews and focus groups – and analysis were used. These methods provide a quick but extensive study of the concepts and perceptions held by the respondents. An in-depth interview is usually used to examine new or little-studied subjects, processes, and phenomena. Its purpose is to gather information that enriches the existing notions and concepts or leads to the creation of such if the phenomenon is entirely new and unfamiliar (Chengelova, 2016). A focus group is a research technique that collects data through group interaction on a topic determined by a researcher (Morgan, 1996). This method is particularly useful for exploring people’s knowledge and experiences (Kitzinger, 1995).

Sample

The study included a total of 64 participants, recruited from central and local structures and services in the capital city of Sofia, and six other cities in the southwestern region of Bulgaria. Forty-seven participated in six focus groups. Interviews were undertaken with 17 people working in state and local government structures who are in management and expert positions and involved in elaboration, implementation, and/or control of policies, services, and practices in the field of care for children, the elderly, and people with disabilities. Experts from the non-governmental sector involved in promoting and/or providing integrated services for vulnerable populations were also included (Table 1).

Table 1.

In-depth interview participants (n = 17).

Type of expertise	Total	Central/national structures	Regional and municipal structures	Non-governmental organization
Social workers	6	3	3	1
Healthcare practitioners	7	3	3	1
Other experts	4	1		2

Focus group participants were selected for their professional expertise and participation in projects and practices involving integrated service provision. Specific participants were identified following an analysis of the structures at the local and national levels responsible for planning and delivering social and healthcare services, and with the support of heads of Regional Health Inspectorates (territorial administrative structures subordinated to the Minister of Health), Social Assistance Directorates (territorial divisions of the Social Assistance Agency), and Social Activities (or similar) Directorates to municipalities (Table 2).

Table 2.

Focus group participants (n = 47).

Type of expertise	Total	Central/ national structures	Regional and municipal structures, including services in the community	Non-governmental organization
Social workers	31	1	28	2
Healthcare practitioners	4		4
Other experts	12		10	2

Data collection and procedures

The research questions were broken down into a series of sub-questions. Detailed guidelines for conducting in-depth interviews and focus groups were elaborated. Interviews and group discussions were recorded using a voice recorder with the informed consent of the participants. The records were transcribed verbatim. Where audio recording was not possible, a technical person or a second interviewer kept detailed notes during the interview. Interviewers were instructed to compare their notes immediately after the interview in order to achieve maximum completeness, clarity, and accuracy of the data. For five interviews, manual notes were provided; the remaining 12 were accompanied by a voice recording.

In the focus group, the presence of an experienced moderator and co-moderator was particularly important. Only those researchers who had previous experience and training in the area were identified as focus group moderators. Co-moderators served as resource persons and lead note takers. All focus groups were audio recorded. Verbatim transcripts were made by students in the Bachelor of Social Work program.

Data collection and transcription took place during May–August 2017. Chronologically, interviews preceded the focus groups. Both interviews and focus groups followed similar plans. In the focus groups, more specific attention was put on the concrete practices, target groups, purposes, activities, and expected outcomes for the beneficiaries, as well the sustainability of the integrated services.

Data analysis

Qualitative content analysis was applied to the transcripts based on coding categories that derived directly and inductively from the data through an open coding technique. Detailed coding guidelines were created. Nine coders were instructed to code all emerging themes relevant to the research questions without predefined codes. The unit of analysis was the whole interview and focus group transcript. The transcripts were read line by line. After determining the codes, they were summarized and grouped into higher order categories (Elo and Kyngäs, 2008). Sentences or phrases were used as category labels (Mayring, 2014). Coding was done manually.

The coders were required to follow the coding rules and guidelines to achieve an inter-rater agreement (Campbell et al., 2013). The main categories were generated after the complete analyses had been thoroughly discussed and agreed upon in a follow-up session with the research team.

Ethical considerations

Ethical issues were considered prior to and during the study. Agreement to participation was elicited and written informed consent obtained from individual participants at the beginning of the interview and focus group discussion. Participants were informed about their rights during the sessions.

Reliability and validity

Study design, sample recruitment and data analysis showed the issues of reliability and validity had been considered prior to and during the research work, or ‘during the inquiry (constructive) rather than only post hoc evaluation’ (Cypress, 2017: 254). To minimize possible sources of researcher bias (Brink, 1993), we utilized several strategies. Two principal investigators and seven doctoral students, all experienced in carrying out interviews, conducted the individual in-depth interviews. Additional measures were taken to eliminate researcher bias by providing rigorous written guidelines, with specific attention placed on the preparation, implementation, interview schedule, and recording of answers. For the sake of maximum objectivity, neutrality, and focus on participants’ understanding, knowledge, and attitudes, interviewers were advised to let the respondents speak as much as they wanted to on the proposed topics. As Cypress (2017) noted, ‘the understanding of the phenomenon is valid if the participants are given the opportunity to speak freely according to their own knowledge structures and perceptions’ (p. 261).

Validity issues were further addressed by using a verification strategy, with the main findings having been discussed with the large sample of study participants at a feedback roundtable held 4 months after the study. The participants were asked to provide comments and evaluate the results in two smaller groups, with flip chart notes provided for each of them. The feedback confirmed the main inferences of the analysis and added a stronger insight into some of the themes.

Research positionality

Service integration is a relatively new and under-researched area in Bulgaria. We chose to explore this topic based on our desire to offer a perspective grounded on research findings. The topic integrates social and health issues, intertwined on the one hand into the essence of integrated care, and on the other, into the expertise of the research team. The diverse profile and previous experience of the researchers implied complementarity and a search for a balance, and we felt that in doing so we would offer a truly comprehensive perspective both in the design and implementation of the study and in the interpretation of the results. The team consisted of nine female researchers involved in the doctoral program of Organization and Management of Social Work. Only one of them has had previous experience with the provision of integrated services. Two of the researchers were engaged in non-governmental organizations (NGOs) and four served in the social system local structures in various positions. The study design and methods used for both data collection and analysis were shaped by our expertise in social work research. We were aware of the possible interference of our background and power positions in the process of interaction with the participants, and tried to avoid personal biases in the process of data interpretation.

Results

According to demographic characteristics, a total of 4 males and 60 females participated in the study. The mean age of the participants was 45 years. Most of them had had relatively short experiences within the integrated approach and services – no more than 5–6 years prior to the date of involvement in the study.

The analysis covered the common themes emergent from the participants’ views. When there were differences both among and between interviewees and the focus group participants in the way in which these common themes were interpreted, they are evident from the analysis below.

Presentation and discussion of the results are supported by excerpts from the individual and focus group interviews and feedback discussion. To comply with the anonymity rules, the following abbreviations were used for the separate contributions: interview with a social worker (I, SW), healthcare practitioner (I, HP), participant with another expertise (I, AE); focus group (FG); and feedback discussion (FD).

Participants’ perspective of integrated care and service

Integration as an inherent characteristic of the quality service

The majority of participants shared an understanding that integrated care was a response to the individuals’ complex needs and their requirement for quality care and a higher quality of life. Some noted that it covered a continuum across the life span from early years to adulthood and old age without interruption. The vast majority of respondents expressed the view that individuals with their unique and complex needs were at the heart of the integrated approach to care and services.

Participants commented that integration is driven by ‘necessity’, which can be illustrated by the following excerpts from interviews with a social worker and a medical practitioner:

These changes . . . they come from necessity . . . There is no way I can say: ‘I apologize very much, but we are a social service and I do not care what happens to your health’. Whether it is written down or not, [integration] should happen because I’m interested in providing the best quality service. (I, SW)

For an intervention to be as effective as possible for the health, something that is important for the health – and the practice also confirms that – other disciplines should be included. Medicine alone cannot give answers to all the options for the health protection. (I, HP)

For most of the participants, integration was embedded within the nature of the service itself. Thus, an integrated service was defined as quality service, and ‘in order for a service to be a quality one, it must always be provided in a comprehensive way’. It was also seen as a matter of rights fulfillment. Moreover, as part of the results achieved by integrated services, the person would no longer have the needs they had had at the start of integrated service provision (FG). An integrated service makes sense only if it is provided in a quality way.

Foci and aims of the integrated service

Integrated care might focus on diverse groups of clients across the whole range of ages and vulnerabilities: children, families, people with disabilities and/or chronic conditions, and disadvantaged minority populations. Thus, depending on the focus, integrated care aimed to achieve prevention, support, quality-of-life improvement (or all the above), and better control of public health protection for groups of clients and the entire community, expressed by the following two definitions of integrated care:

A complex care that provides access to social, health, education, and cross-sectoral services to prevent and support. (I, HP)

When all institutions work for the benefit of the relevant target groups or their individual representatives so that to achieve a quality change in the living conditions felt at both the individual and the community levels. (I, AE)

Respondents largely shared the view that integrated services were user-centered, tailored to the needs of the particular client in the context of their natural environment, and directed toward social inclusion:

Services for social inclusion provided in the community or home setting so as to optimally meet the consumer’s individual needs. (I, HP)

Prevention featured as one of the major aims and components of the integrated services (FD). In that sense, integrated services might both cover specific population groups and have a universal scope – for instance, ‘to be accessible to all potential users, to have a fair geographical location, accessible environment, and to be financially accessible, it is important to have a wide entrance and to give a choice’ (FG).

Nature and content of the integrated service

The majority of participants associated integrated service with a set of activities that can be realized in ‘different places’, a combination of ‘certain social practices with the required health care’ that could achieve the ultimate goal only if implemented in parallel. Parallel implementation implied a combined action of institutions and organizations, and interaction between the professionals from the established social services network (FG) in a ‘coordinated manner’ (FG) which had in common the character and level of organization and provision of integrated services:

We are talking about a spectrum of services that we accept as integrated services and a very strong interplay across the different spheres of public welfare, with a flexibility, and a very good awareness of the role and responsibilities of the various actors. (FG)

The respondents were unanimous that the balance between the components of the integrated service depended on the identified primary needs. Thus, the major component in the health and social service was a medical one, as far as the service was concerned: ‘People who have a medical or health problem, or those who are vulnerable to a health or medical problem’ (I, HP). Most of the participants noted, however, that an integrated service should respond to the complexity of a client’s needs and implied not only social and health, but also educational, psychological, and other types of services. It was equally important for early childhood and family services and adult care. When it concerned families in which both children and adults need support, then

integrated services for the whole family as a social package is preferable because of the greater effect – housing, healthcare, support for employing parents, support for children, etc. (I, AE)

A respondent said that goals were those that determine the content of the activities and whether a service was integrated or not. In this sense, when the goal was to develop and prevent, universal/mainstream services such as nurseries and kindergartens could also be considered as integrated services, since ‘different needs are addressed, starting with food, education, medical care’ (I, AE).

Approaches to realization of integrated social and healthcare services

The most common belief was that integrated care involved joint working in multidisciplinary teams. This was expressed by, for example, the notions of a ‘multidisciplinary approach’ in each case, a ‘mixed team’, ‘shared responsibility’, when (people) ‘speak the same language’, communication between services and systems.

An inter-sectoral approach was referred to as ‘innovative’, ‘holistic’, ‘coordinated care of different spheres of life’, ‘a higher degree of coordination between existing services’, ‘building a working partner network to effectively support the service users’. Respondents often defined it as multi-sectoral, including ‘cooperation of sectors – education, health, justice, social care’.

In a focus group, the inter-sectoral approach was perceived as the management level, whereas the integrated services were the flexible operational level of care integration. In that sense, the latter represented the recognizable manifestation of cross-sectoral interaction.

While there was consensus on what is an integrated approach, there was disagreement on the way of organizing and delivering integrated services. Several different opinions were shared. Some of the respondents believed that integrated services could be provided by one professional undertaking the additional functions of another professional sphere (in which they are not specialists). Most of the participants said that integrated services could be provided by many professionals from different spheres operating out of one facility.

Another suggested option was to integrate sectoral services, by ‘exchanging information and interaction’ (I, AE) or creating ‘collaboration, with a common vision for working on a specific case, and clearly defined obligations for each service’ (I, HP). Services might be under different subordinations and funding,

but they are part of one place where these services are received, and actually, the family, going there, can get the whole [set of services] without going to different places to look for [them]. (I, AE)

While some participants spoke of integrated programs added to existing health and social services and ‘upgrading existing services with profiled programs with a pronounced health or social component’ (I, AE; I, SW), others discussed the need to create entirely new services (I, HP), ‘instead of expanding or supplementing existing social services’ (FG).

At the management level, some respondents pointed out that effective integration could happen through a single structure under clearly defined management rules. Most common was the understanding of effective integration as a matter of coordination between different responsible structures and professionals. Particular emphasis was placed on integration resulting from ‘the mutual sharing of resources – financial, human, material – from different services – social, health, educational and others’ (FD).

Location and types of existing integrated services and practices

Respondents shared at least three options for integrated service provision: at the client’s home using mobile teams to provide hourly services; at a single facility – for example, a center in the community; and beyond a single facility. How existing community services and practices were described as integrated depended on individual perceptions and understanding. These were described as providing both social and medical, and other types of support depending on the type and scope of the service. Many community social services mentioned were identified according to the type of service and target group, for example early childhood development service, early intervention center, center for maternal and child health, center for social rehabilitation and integration, day care center, mobile support for independent living, home care, sheltered home, residential homes of family type. Some participants placed emphasis on inclusion in mainstream services, such as nurseries, kindergartens, municipal hospitals, and others.

Demonstrating a contrary view, one interviewee noted the following:

If someone can show me such a social-health service where this [integration] is happening – there is simply no such social-health service . . . It is a privilege of the rich countries. (I, AE)

Constraints for the development of integrated healthcare and social services

Legislation and policy

Participants pointed to the lack of a unified concept and a common understanding of integration among the main actors, that is, ‘people in power’. The vast majority of respondents commented on the absence of secondary regulation as a major structural problem. Although there is a definition of health and social services in the Health Act (2015) and legal provisions for an inter-sectoral approach are partially available, ‘considerable legal constraints that narrow the notion of a health-social service’ were noted. A medical professional who provides integrated services mentioned,

Legal formulations for health and social services are very limiting and it would be good to have a broader idea of what [integrated] health and social services are . . . (I, HP)

Some participants did not consider the existing provisions in the Health Act as conceptually reasonable. A social worker who managed services for children in an NGO said,

The Ministry of Health seeks to integrate within itself, to bring other professionals, psychologists, speech therapists, social workers into the healthcare facility . . . The philosophy of the integrated care is missing. (I, SW)

Another emerging concern was associated with the lack of effective inter-sectoral policies and funding. Participants noted that sectoral budgeting at national and local levels persisted and thus integration is not felt by ‘ordinary people’ and could not be evidenced or measured. The sectoral approach persisted because of associated legal and budgetary constraints, including differences in the regulations, norms, values, and attitudes in the separate sectors. There was widespread consensus on the need for a unifying concept. As one respondent said, ‘We need some conceptual clarification on what we understand, how we understand it, and where we have started from, we seem to be working other way round’ (I, AE).

Communication at all levels and structures

Effectiveness of integrated services was recognized as a function of inter-institutional communication, and furthermore that ‘things are not settled there’. Most participants were critical of the communication between systems. They discussed the ‘encapsulated character’ of the healthcare system and the ‘more flexible capabilities’ of the social system, while others noted that service integration was not happening because the initiative did not belong to the two line ministries but was demanded from the non-governmental sector (I, AE).

Most commonly, participants used words and phrases such as ‘encapsulation’, ‘division of territories’, and ‘the fear of letting someone else in our house’ to explain the difficult communication between participants in the integration process.

Professional engagement

The most recurring concern was related to the shortage of medical practitioners, generally, and for the integrated services, particularly. A deficit of other staff to form multidisciplinary teams in small municipalities and settlements was also mentioned as a problematic issue. An interviewee asked the following:

Who will you do it [integrate] with? There is [already] a shortage of healthcare workers, municipal hospitals are being closed down, [how] will you provide social and health care service . . .? (I, AE)

Another emerging theme concerned the lack of motivation of medical specialists to work in integrated services resulting from poor payment, excessive workload, lack of time, bureaucracy, and seeing the patient only as a ‘medical case’. Overlooking the social and psychological dimension of the user’s problems was emphasized as a major challenge to ensuring full involvement and empowerment of the individual and the community.

Nuances of rivalry and tension between the two systems were expressed in the majority of interviews and focus groups. It was mentioned that with its current capacity, the social system, which is in charge of the integration, could not fulfill the task in a qualitative and effective way (I, HP). People mentioned that the balance between the medical and social sides could be achieved after the two groups of professionals start recognizing the role and importance of the other system. Thus, in the management of cases among other professionals, efforts should be directed at overcoming both the traditional model of thinking among medical practitioners and the overestimation of ‘the social role’ (I, HP). As a medical practitioner said,

Medicine itself does not possess the ‘repertoire’ of other professions’ opportunities such as psychologists and social workers to influence the thinking, values formation, work on beliefs and attitudes . . . Many other components are required, and other disciplines are responsible for this. (I, HP)

The role of various actors in integrated service provision

According to the participants, planning and management of integrated services should take place at both municipal/local and regional/district levels following a sound needs assessment analysis. Thus, the risk of small municipalities and settlements with no specialists for multidisciplinary teams remaining without services should be avoided. This also included decentralization of integrated services delivery, which was to become a commitment of the local government. Thus, the role of the state was seen in establishing the institutional framework, controlling mechanisms, and clear rules and conditions for the implementation of an integrated cross-sectoral approach: the role of local authorities was in the planning, organizing, implementing, and coordinating of services in an effective manner based on the needs and resources according to local conditions.

Several interviewees stressed the option to outsource the management and delivery of services to NGOs, for they are the only ones that ‘try to bring some quality’ and are ‘much more flexible, independent, adequate and potentially able to meet and satisfy the needs of everyone . . .’ (I SW). However, there was also a comment that few of the existing NGOs work effectively to solve social problems.

Need for additional training

A frequent theme was that people involved in the provision of integrated services were not cognizant of what other professions did, grounded in the separate theoretical frameworks, practice fields, education, and training. The need for additional training was articulated in most of the interviews and focus groups, with no agreement on the level of training required. Some respondents suggested a university program–level training was required to achieve a common ‘integrated’ vision. Other training options included induction, continuous professional development, and upgrading courses to motivate staff and to embed the concept for both the employees in administrative structures and for the service delivery teams. The participants’ suggestions also included ‘follow-up training’, ‘supervision’, and ‘exchange of experience’ (FD).

Major threats to the effectiveness of integrated services

The lack of instruments for monitoring, control, and evaluation of effectiveness and outcomes was considered one of the most crucial threats, provided that ‘the impact in the social sphere is not immediate (it is postponed)’. Furthermore, poor coordination between systems and strongly developed sectoral services might lead to a duplication of services, dilution of responsibilities, and loss of focus on the needs of the specific users (FG). In addition, there were concerns about a possible ‘segregation’ of the user within service boundaries (FG). The division of areas of competence between ministries and agencies has had a negative impact on the activities of local authorities and has scattered efforts and resources, which in turn has had an impact on the effectiveness of support. Among the other general threats, the most commonly mentioned were the lack of sustainability; funding only in the framework of projects under EU programs; unfair distribution of funds through ‘a vicious cycle of control’; non-working models; and incompetence (I, FG).

Discussion

This study aimed to reveal the concepts held of integrated care and services and the challenges to their effectiveness through the eyes of experts and professionals. The results demonstrated that there is common agreement for the need to introduce an integrated approach based on an understanding of the interconnected nature of human needs. The following common elements are present: a focus on the individual needs of a consumer; consideration of the needs of a consumer is complex and exists in a continuum; quality of care is only achievable in an integrated manner. Although there is a definition of integrated healthcare and social service in the Health Act (2015), it has not been referred to or been viewed as being too narrow. The conceptual scheme for the implementation of the integrated approach includes the operation of multidisciplinary teams; covering a wide range of target groups; a broad spectrum of activities that meet various needs (e.g. health, social, educational); coordination and communication between professionals, services and systems; motivation and engagement in a unified approach and teamwork; training in a common (comprehensive) approach to understanding the user’s needs and a common (consistent) approach to meeting those needs; and mixed funding. The specific experiences of participants, as well as the relatively short practice time within pilot initiatives in the field of integrated services, probably determine the different emphasis of the understanding of integrated care and services. In this sense, while there is a consensus on the essence and appropriateness of an integrated approach, there are different ideas about how it should be organized and implemented: whether by complementing existing services with integrated programs or programs with a pronounced social or health component; whether by creating entirely new integrated services; whether through common organization and management within a single structure; whether through the case management approach; whether through teams of professionals under one hat or under different subordination, and others.

Participants were unanimous about the need to introduce integrated care and services, but raised many concerns regarding the necessary prerequisites for this approach to be effective. Much of these challenges have been identified in previous studies cited above (Petrova, 2016; Todorovska, n.d.). On the one hand, they are linked to the absence of common regulations and, above all, specific standards developed at the national level, which not only define uniquely integrated services, but also lay down specific rules and procedures in order for them to function. On the other hand, one of the most serious challenges relates to one of the main components of an integrated approach, namely good coordination and communication between systems and professionals which determines the effectiveness of the approach. In most cases, however, participants are skeptical of its presence, especially at the level of systems and structures. It is likely that the introduction of a clear regulation on the responsibilities of each participant would minimize the risks and optimize the quality of collaboration at all levels. However, the problem remains, with a lack of qualified medical staff not only for integrated services, but also across the country. This is a serious risk factor for the quality of healthcare in general. As one participant in the study noted, ‘while reforms in the social system are going on, this is not the case with the reform of the health system’ (I, SW).

Based on the research findings, we can summarize that integration is perceived as an inherent characteristic of the quality care, embedded within the ‘heart’ of the service itself, focused on diverse groups of clients and realized in various ways. It is evident from this study that integration is seen in broader terms, including not only health and social services, but also other needs. The latter resonates with the ideas for combining health and social care with other ‘players’ if we refer to the term used by Goodwin (2016).

The availability of good practices and the recognition of the need to introduce an integrated approach indicate that certain conditions exist. However, the serious concerns relate to the lack of control and evaluation mechanisms, poor communication between systems and structures, and poor distribution of funds, all of which threaten the effectiveness of the integrative practice. It requires serious efforts and a common will to overcome the identified challenges and ensure the sustainability of an integrated approach. As Rutschmann (2017) noted with respect to the lessons learnt from the implementation of the ‘Integrated Home Care’ project in Eastern Europe, in order to achieve sustainability many changes need to occur, among them changes in the relevant legislation and regulations, and the introduction of new professions and quality standards.

Weaknesses and strengths of the study

There were several limitations to the study. First, it covered only one region in Bulgaria and the results cannot be seen as reflecting the views of the professional community as a whole. Participants from different professional groups were disproportionately represented. In comparison with the social workers enrolled in the study, the number of other professionals was relatively small, particularly those from healthcare professions. Most of the participants had expertise in child care and less in care for adults with complex needs. The various professional expertise, alongside the lack of particularly diverse and extensive experience gained from the pilot implementation of integrated practices, might have influenced the results and may have affected interpretations.

On the other hand, the involvement of specialists providing social services has enabled more in-depth disclosure of their perspectives, even more so given that the main commitment to implementing the integrated approach belongs currently to the social system.

Conclusion

This article aims to shed light on the personal concepts and perceptions held of integrated social and healthcare services, and reflections on the challenges facing their effectiveness that are shared by people concerned with the integration of social and healthcare services. The results from our study show the need for conceptual clarification and a common vision for integrated social and healthcare services and approaches to organization, service provision, management, and funding. It has further considered that a number of challenges should be taken into consideration in advancing an integrated approach in Bulgaria.

Meanwhile, a new Social Services Act (2018) in Bulgaria has been developed, which is an important step forward in promoting an integrated approach to the provision of support to individuals, with comprehensiveness, integration, and continuity of support being postulated among its main principles. Integrated healthcare and social services are defined as the sole cross-sectoral services to be provided under a common organization and management. Other integration options include coordination and interaction within the social services system and with other systems. Generally, the document reflects part of the views shared by the participants in this study and confirms the need for further and more extensive studies on the perspectives held on successful integration of healthcare and social services in Bulgaria.

This study also showed that the views and evaluations of both experts and practitioners should be taken into consideration in the planning, implementing, and financing of integrated services. In many ways, they touch on the same important topics. It should be noted that, in addition to a common and clear vision, there must also be investment in ensuring the sustainability of already proven good models and practices. Very often, good practices cease to exist when project funding is over. This means that despite the identified focus on the users’ needs, they are not yet at the center of services’ efforts. In other words, assuming that user-centeredness is at the heart of the integrated care, there is still a long way to go until a truly integrated approach is implemented in Bulgaria.

Supplemental Material

Supplementary_File – Supplemental material for A vision for integrated social and healthcare services: An experience from Bulgaria

Supplemental material, Supplementary_File for A vision for integrated social and healthcare services: An experience from Bulgaria by Maya Tcholakova and Vaska Stancheva-Popkostadinova in International Social Work

Footnotes

Declaration of conflicting interests

The author(s) declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.

Funding

The author(s) disclosed receipt of the following financial support for the research, authorship, and/or publication of this article: This study was supported by the South-West University ‘NeofitRilski’ under the research project RP-B7/17 ‘A Study of Challenges Facing the Effectiveness of Integrated Social and Health Care Services’.

ORCID iD

Maya Tcholakova

Supplemental material

Supplemental material for this article is available online.

Author biographies

Maya Tcholakova, PhD, is Associate Professor in Social Work. Her research interests are in the fields of cultural diversity, anti-oppressive practice and empowerment.

Vaska Stancheva-Popkostadinova, PhD, is Professor in Child Mental Health, head of the Department of Medico-Social Sciences. Her experience and publications are in the areas of violence prevention, play and disability, and psychosocial interventions.

References

Amelung

V.E.

Reichert

Urbanski

Matejevic

O’Riordan

Duggan

(2014) ‘Integrating Health and Social Care: A Global Perspective of Experience, Best Practices and the Way Forward’, in IBM Cúram Research Institute Commission Paper, Version: 17 November, Institute for Applied Health Services Research. Available online at: ftp://public.dhe.ibm.com/software/download/INAV_Paper_Final.pdf (accessed 17 September 2017).

Barnes

Green

Hopton

(2007) ‘Guest Editorial: Social Work Theory, Research, Policy and Practice – Challenges and Opportunities in Health and Social Care Integration in the UK’, Health & Social Care in the Community 15(3): 191–4.

Brink

H.I.L.

(1993) ‘Validity and Reliability in Qualitative Research’ (Conference Paper), Curationis 16(2): 35–8. Available online at: https://www.researchgate.net/publication/14824314_Validity_and_reliability_in_qualitative_research (accessed 2 December 2018).

Campbell

J.L.

Quincy

Osserman

Pedersen

O.K.

(2013) ‘Coding In-Depth Semistructured Interviews: Problems of Unitization and Intercoder Reliability and Agreement’, Sociological Methods & Research 42(3): 294–320.

Chengelova

Е.

(2016) ‘Интервюто в социалните науки [Interview in the Social Sciences]’, Sofia. Available online at: http://www.newmedia21.eu/content/2016/01/E-Chengelova-Interview-v-socialnite-nauki-Omda-PDF-2016.pdf (accessed 22 January 2017).

Cypress

B.S.

(2017) ‘Rigor or Reliability and Validity in Qualitative Research: Perspectives, Strategies, Reconceptualization, and Recommendations’, Dimensions of Critical Care Nursing 36(4): 253–63.

Elo

Kyngäs

S.H.

(2008) ‘The Qualitative Content Analysis Process’, Journal of Advanced Nursing 62(1): 107–15.

Goodwin

(2016) ‘Understanding Integrated Care’, International Journal of Integrated Care 16(4): 1–4.

Heenan

Birrell

(2006) ‘The Integration of Health and Social Care: The Lessons from Northern Ireland’, Social Policy & Administration 40(1): 47–66.

10.

Hendry

(2016) ‘Creating an Enabling Political Environment for Health and Social Care Integration’, International Journal of Integrated Care 16(4): 1–3.

11.

Ilieva

Vasileva

(2016) ‘Prevention and Early Intervention Services to Address Children at Risk of Poverty’ (Dublin, 18–19 February 2016), Comments Paper – Bulgaria. Available online at: ec.europa.eu/social/BlobServlet?docId=15146&langId=en (accessed 1 August 2018).

12.

Kitzinger

(1995) ‘Qualitative Research: Introducing Focus Groups’, The British Medical Journal 311(7000): 299–302.

13.

Kodner

(2009) ‘All Together Now: A Conceptual Exploration of Integrated Care’, Healthcare Quarterly (Special Issue) 13: 6–15.

14.

Korpela

Elfvengren

Kaarna

Tepponen

Tuominen

(2012) ‘Collaboration Process for Integrated Social and Health Care Strategy Implementation’, International Journal of Integrated Care 12: e42. Available at: www.ncbi.nlm.nih.gov/pmc/articles/PMC3440255 (accessed 22 January 2017).

15.

Leichsenring

(2004) ‘Developing Integrated Health and Social Care Services for Older Persons in Europe’, International Journal of Integrated Care 4(3): 1–15.

16.

Mayring

(2014) Qualitative Content Analysis. Theoretical Foundation, Basic Procedures and Software Solution. Available online at: https://www.ssoar.info/ssoar/bitstream/handle/document/39517/ssoar-2014-mayring-Qualitative_content_analysis_theoretical_foundation.pdf (accessed 5 October 2017).

17.

Miller

(2016) ‘Crossing the Cultural and Value Divide Between Health and Social Care’, International Journal of Integrated Care 16(4): 10.

18.

Minas

(2016) ‘The Concept of Integrated Services in Different Welfare States from a Life Course Perspective’, International Social Security Review 69(3–4): 85–107.

19.

Minkman

Vermeulen

Ahaus

Huijsman

(2011) ‘The Implementation of Integrated Care: The Empirical Validation of the Development Model for Integrated Care’, BMC Health Services Research 11: 177.

20.

Montero

L.A.

van Duijn

Zonneveld

Minkman

Nies

(2016) ‘Integrated Social Services in Europe’. European Social Network, Brighton. Available online at: https://www.esn-eu.org/publications_import/IntegratedServicesReport_FINAL.pdf (accessed 26 February 2018).

21.

Morgan

D.L.

(1996) ‘Focus Groups’, Annual Review of Sociology 22: 129–52. Available online at: https://www.researchgate.net/profile/David_Morgan19/publication/261773532_Focus_Groups/links/0deec5314d8bd0836c000000/Focus-Groups.pdf (accessed 11 February 2018).

22.

National Strategy for Long-Term Care. (2014) Available online at: www.strategy.bg (accessed 26 April 2020).

23.

Nies

Beersma

(2016) ‘Social Decision Making in Integrated Care’, International Journal of Integrated Care 16(6): A3718.

24.

Petrova

(2016) ‘Интегрираните грижи – един възможен отговор на съвременните предизвикателства в здравеопазването [Integrated Care – a Possible Response to the Contemporary Healthcare Challenges]’, Available online at: http://mu-varna.bg/BG/akad-lekcii (accessed 4 April 2017).

25.

Petrova

Kostadinova

Teneva

(2015) ‘Challenges for the Implementation of Integrated Care Model in Bulgaria’, Medical and Health Science Journal 16(1): 2–7.

26.

Rämgard

Blongvist

Petersson

(2015) ‘Developing Health and Social Care Planning in Collaboration’, Journal of Interprofessional Care 29(4): 354–8.

27.

Richardson

Patana

(2012) ‘Integrating Service Delivery: Why, for Who, and How?’ Discussion Paper, Draft. Available online at: https://www.oecd.org/els/soc/Richardson_Patana%20INTEGRATING%20SERVICE%20DELIVERY%20WHY%20FOR%20WHO%20AND%20HOW.pdf (accessed 16 September 2017).

28.

Rutschmann

(2017) ‘Care at Home for Elderly – Lessons Learnt from the Swiss Red Cross “Integrated Home Care” in Eastern Europe/CIS’, International Journal of Integrated Care 17(5): A348.

29.

Salchev

(2015) ‘Анализ на възможности за развитие на дългосрочната интегрирана и координирана грижа за нуждаещите се [Analysis of the development of long term integrated and coordinated care giving in Bulgaria]’, Technical Report 1–19. Available online at: https://www.researchgate.net/publication/278404220_Analysis_of_the_development_of_long_term_integrated_and_coordinated_care_giving_in_Bulgaria_ANALIZ_NA_VZMOZNOSTI_ZA_RAZVITIE_NA_DLGOSROCNATA_INTEGRIRANA_I_KOORDINIRANA_GRIZA_ZA_NUZDAESITE_SE (accessed 14 September 2017).

30.

Sarquella

Henderson

Fabà

Mead

Solanes

Plaza

Contel

J.C.

(2016) ‘Health and Social Integrated Care in Practice: Local Partnerships in Action’, International Journal of Integrated Care 16(5): A64.

31.

Sutton

Long

(2014) ‘Integration of Health and Wellbeing Services with General Health Services’, Health Research Board. Available online at: https://www.hrb.ie/fileadmin/publications_files/IntegrationHealthWellbeing2014.pdf (accessed 11 February 2017).

32.

Todorovska

(n.d.) ‘Общински базираните домашни грижи – успешен модел за интегрирани здравно-социални услуги в общността [Municipality-Based Home Care: A Successful Model for Integrated Community-Based Health and Social Services]. Available online at: http://pubdocs.worldbank.org/en/438421466771762343/Home-Care-Project-WB-Aging-Event-22June.pdf (accessed 4 April 2017).

33.

Todorovska

Karsheva

(2017) ‘Introduction of Home Care Services in Bulgaria – A Chance for Transformation of the Primary Health Care System’, International Journal of Integrated Care 17(5): A602.

34.

Widmark

Sandahl

Piuva

Bergman

(2011) ‘Barriers to Collaboration Between Health Care, Social Services and Schools’, International Journal of Integrated Care 11(16): 1–9.

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