Testing contingency theory to drive organizational change in community care: A case study in the Emilia Romagna Region

Introduction

Waves of organizational re-design of primary care health systems around the world are numerous and frequent, especially after the devastating effects of poor primary care networks during the recent pandemic.^1–3 By now, it is widely understood that ageing populations, with multiple chronic conditions, in an era of strong financial pressures necessarily require healthcare systems that are no longer “hospital-centric”, but rather focused on preventive, proximity assistance. In general, national, and international policies are frequently focusing on re-shaping primary care systems so to foster truly sustainable healthcare systems, built around early detections and early interventions on patients’ needs.

In this vein, the Recovery and Resilience Plan ⁴ issued in 2021 has given impulse to a re-organization of the Italian primary healthcare system. The RRP is the instrument through which Italy intends to use the Next Generation Europe funds to foster equitable, sustainable, and inclusive features in its economy. In particular, with specific reference to the healthcare sector, one of the main priorities is to develop “Community homes” (CHs) in all regional primary care systems. These are physical places, which are in proximity of people and easy to identify, to which the population can have access to get in touch with the health care system. CHs are a first point-of-contact centres aimed at assisting, orienting, and following patients during and beyond a clinical pathway. CHs are not a new construct in the Italian healthcare scenario. Previous reforms introduced various typologies of “healthcare homes” ever since 2007, aimed at providing integrated solutions for chronic conditions. Nevertheless, CHs are not only aimed at sustaining (or improving) this objective, but they are also more focused on a strong integration between clinical and social services, in the perspective that these should be managed jointly to foster long-lasting health in the population.

In particular, the Emilia Romagna Region in Northern Italy, was among the first to introduce healthcare homes (and in turn CHs) in its primary care system. These were divided into Hub ones, which provide a medium/high complexity of assistance, and Spoke ones, with a low complexity of assistance provided. The coordination of these structures was entrusted to an organizational manager, preferably a nursing coordinator, with organizational-managerial skills and a managerial board was held responsible for their overall management. These characteristics are passed on to CHs. Therefore, these constitute the most recent primary care setting in the Italian scenario and are responsible of implementing integrated care for chronic patients by providing (socio-clinical) services themselves and coordinating them with those provided in other (formal and informal, clinical and non-clinical) settings when necessary.

This paper builds on contingency theory while studying the concrete organizational models of CHs within a specific area of the Emilia Romagna region.

Theoretical background

The intrinsic complexity of healthcare organizations is widely testified in literature. ⁵ Such complexity is boosted by the large variety of organizational solutions that organizations adopt, even when they are apparently similar in their mission, size, and ownership. ⁶ Such heterogeneity is ascribable to several dimensions, such as their organizational chart as well as their numerous managerial approaches, including their human resource management tools, their information communication technologies or even, more in general, the design of procedures and “ways of working” within the organization.

This variability in organizational and managerial solutions can be explained by contingency theory. A contingency perspective of organizational development recognizes that the structure of an organization develops in accordance with, or contingent upon, differentiation of tasks and environmental constraints.^7,8

Variability, as opposed to standardization, is therefore frequently desirable. Organizations whose structures and managerial approaches better fit the demands of their environment, are expected to perform better than organizations in which the structure does not align as well. ⁸ This implies there is no one best way to structure an organization, but rather a best fit: some ways of organizing are better than others and the best way of organizing depends on the environment.^9,10 Organizations try to improve their performance by seeking alignment with defined contingencies factors and, as a result, the changing external environment. ¹¹ The fit process is viewed as a dynamic and ongoing process, particularly in complex and highly dynamic business environments such as the healthcare one.

Several studies have addressed contingency theory in healthcare organizations.^3,12–14 Findings suggest that contingency of technological uncertainty ¹⁵ is key in the healthcare sector. This means that technologies are not always going to lead to their intended objectives, rather they too should be selected, implemented, and dismissed in coherence with the internal and external environment of the organization.^16,17 Though most attention is given to the analysis of healthcare organizations for acute patients, it is more and more urgent to re-focus on organizational variability in primary care settings. ¹⁸ This is because their role and complexity are currently facing deep changes. ¹⁹ Indeed, many healthcare systems worldwide need greater investments in primary care to guarantee the systems’ sustainability. Recent studies, for example, have shown the dramatic consequences of the COVID-19 pandemic on highly hospital-centric healthcare systems. On the contrary, healthcare systems with strong primary care assets, have frequently faced the pandemic more effectively. ²⁰ Moreover, primary care settings must face highly complex and interconnected processes. Following Stabell and Fjeldstad, ²¹ services with predominant reciprocal interdependency involve costly manual exchanges. These processes concern different professionals in different physical settings, requiring a highly effective organizational response to guarantee integrated and patient-centered delivery of care. Therefore, a prominent literature gap concerns exactly the application of contingency theory to structures and process optimization of multi-professional primary care teams. ¹⁸ Even more seldom has contingency theory been applied to community care. This includes the idea that health and social assistance are strictly interconnected and should be managed jointly. ²²

Objectives

Given the relevance of CHs (and of analogous settings) within the Italian (international) healthcare system(s), this study provides an exploration of the organizational solutions and of the coordination/managerial approaches adopted by CHs in an area of the Emilia Romagna region. The objective is to test contingency theory in this scenario, so to shed light on the degree of organizational convergence/divergence also within a limited geographical area, with a common regional legislative framework. This, in turn, may foster food for thought on the extent to which organizational variability may be expected, accepted, or even supported.

The study will allow a better understanding of the extent to which normative interventions in this field may produce more or less binding organizational solutions and, in turn, whether organizational variability is indeed present due to contextual contingencies. In other words, we want to investigate the extent to which a normative intervention causes standardized rather than variable organizational solutions to a specific challenge. Insofar as the legal framework is unique for all healthcare homes, it is interesting to understand whether they are designed and implemented in similar ways or if, on the contrary, they present individual features that are suitable tailored to their specific contingencies. This may provide food for thought on managerial approaches that are effective in implementing strategic change in healthcare.

Methods

As a first stage, a review of the international, national (Italian) and regional (of the Emilia-Romagna Region) normative documents and of scientific literature was carried out to explore guiding principles of community-based care and its settings. The review was conducted through the analysis of all relevant regulations at the national and regional levels, and through a tailored search on Web of science at the international level. The literature review on Web of Science was conducted through a search string made up of different combinations of key words such as “community care”, “proximity care”, “patient-centered care”, “community homes”, “healthcare homes”, “socio-clinical integration”. A total of 28 papers was downloaded and assessed.

Based on the main evidence emerging from this data, a questionnaire to gather data for our case study was built addressing the most relevant topics detected in the first step. In particular, the questionnaire investigated the following topics: general information, location and size; configurations of hub & spoke networks; key professional roles; board of directors; communication flows; clinical and social integration.

The topics of the questionnaire were selected based on the main dimensions of organizational variability detected in the literature review. They were administered to key stakeholders of the CHs through onsite interviews which lasted approximately 1 hour each. These were carried out between May and June 2022 in a sample of seven Hub CHs out of a total of 38, representative of the different geographical zones of the area, which encompasses a population of almost 1,2 million inhabitants, covering more than 5.000 km². The professionals interviewed were a total of 14 people (7 nurse coordinators and 7 heads of ambulatory care in each CH), while CHs were selected by the Local Health Unit, based on the availability of staff to take part in the study.

Qualitative data was analysed by content analysis by two researchers separately, while a third researcher resolved any divergence. Results of the interviews were subsequently validated in two communities of practices: the first involved managers of the Local Health Unit and other key stakeholders of the local community-based care system (i.e., General Practitioners, specialized physicians, social services professionals); the second nurse coordinators of the 38 CHs.

Results

The normative and literature review stressed some major clusters of topics to be assessed when studying organizational and managerial solutions in community health settings. These may be summarized in the following macro categories: configurations of networks of settings and actors; key professional roles; leadership approaches; communication flows; social integration.

Following these clusters, it was detected that the organizational and managerial solutions at the local area are in part homogeneous but in large part variable from setting to setting.

Social integration

Finally, variability is evident in the clinical and social aspects of CHs interventions. Some CHs provide services that are merely clinical in nature and are in touch with external (public or private) entities which cover social matters. In these cases, CHs usually detect patients with unmet social needs and connect them to these external entities on a one-to-one basis. In other cases, CHs directly manage social activities within their own organization. This is the case, for example, of a CH which carries out cooking lessons or walking programs for obese and isolated patients. Nevertheless, even when these activities are carried out directly, these are usually limited in number and no CH has completely encompassed social intervention within its direct management. Therefore, more or less formal connections to external entities are usually present at least to some extent. Table 1 summarizes the main items of variability detected across CHs.

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Table 1.

Items of variability across Community Homes.

Item of variability	Possible configurations
Size and composition of networks	• 1 hub, 3 spokes
	• 1 hub, 2 spokes
	• 1 hub, 1 spoke
	• 1 hub
Role of hub and spoke	• Hub encompasses more specialities and services than spoke
	• Complexity and size varies independently from being hub or spoke
Key professional roles of coordination	• Organizational leader and Nurse coordinator are two distinct roles
	• Organizational leader and Nurse coordinator merged into one role (Nurse coordinator)
Number of CHs managed by coordinators (from 4 to 9)	• All belonging to the same hub and spoke network
	• Belonging to different networks
Features of Board of Directors	• Dedicated operational
	• Dedicated strategic
	• Shared operational
	• Shared strategic
	• Mixed
Communication with GPs	• Full information provided to CH
	• Partial information provided to CH
	• No information provided systematically to CH
Communication with specialists	• Fully integrated communication system (when service is within CH)
	• Non- fully integrated communication system
Social interventions	• No internal social interventions
	• Some internal social interventions

Discussion

CHs in the studied sub-area of the Emilia Romagna region are characterized by common objectives and regulations. Yet, very different organizational, managerial, and procedural solutions have emerged. This seems to confirm that contingency plays a key role in the development of the concrete configurations of CHs. CHs provide very interesting settings in which to test contingency theory given that they are a relatively new construct in Italy and are currently experiencing strong pressures to clarify their configurations and organizational assets. Indeed, it is possible to hypothesize contextual factors that may explain the different configurations detected.

In the first place it must be clarified that CHs are usually derived from the re-conversion of previous primary care settings. Clearly, this constitutes the most relevant contingency factor to be considered. The presence (or absence) of relatively similar pre-existing structures clearly affects the concrete configuration of both the hub and spoke network as well as of the services to be managed within each CH. In other words, configurations highly depend on the “starting point”, i.e., on the existing span of settings before CHs were introduced in the Italian healthcare system.

Moreover, although this study is focused on a relatively limited geographical area, within its boundaries many differences exist in epidemiological and socio-economic terms. The more mountainous areas of the region are generally characterized by smaller networks (or by isolated CHs which do not belong to a network). Services and specialties, therefore, tend to be concentrated within one or few CHs. This is, of course, connected to the populousness of the area and to the intrinsic difficulty of moving in it.

The previous missions of pre-existing settings clearly play a role in current configurations. The decision of where to allocate services also depends on the expertise and consolidated practices each setting has had in the past. Moreover, leadership styles and organizational culture may also explain why some areas have developed articulated and highly effective networks, with services properly spread across CHs, while others have, de facto, continued to work in rather autonomous ways, at times replicating services in CHs located nearby. In other words, there may exist an array of cultural or managerial traits that affect the concrete ability of working in networks. A few examples of these may include: how professionals are assigned to positions (i.e., Are positions strictly connected to a specific setting or, rather, to transversal processes that cross more settings?); how managerial accounting and performance assessment are carried out (i.e., Are performance indicators tied to a setting’s performance only, or rather to joint efforts by more settings?); meetings and communication flows (i.e., are professionals involved in meetings or in other moments of interaction mainly at the setting or inter-setting level?). In general, many organizational changes were introduced through pro-active thinking and direct action of CHs’ organizational leaders and professionals at all levels. Where leadership was weaker and organizational culture more tied to a highly formalized context, transition towards networks may have been hindered.

In addition, organizational assets were highly affected by external actors. For example, the presence of solid entities active in the provision of social assistance tended to encourage configurations based on a more limited internalization of social matters withing the CH. Strong partnerships with these actors possibly made it less urgent to respond to patients’ needs through internal initiatives. Other factors that have affected concrete organizational solutions include the efficacy of home care or the presence of other types of primary care settings in the area.

It is interesting to see that all these contextual factors have possibly contributed to driving CHs towards different practical configurations. Therefore, attempts to classify them in more or less effective and adequate, may appear rather ambiguous and misleading. Rather, it seems that each CH (and network) has been designed, at least to some extent, based on the contingent pillars that affect organizational design. It is interesting to note that this phenomenon may also occur in a rather limited geographical area (i.e., a sub-region) which, however, is still characterized by relevant variability in geographical, social, and cultural matters as well as in the expertise of provision of care to its population.

Conclusions and practical implications

The findings of this paper may lead to various conclusions and implications. From a strictly theoretical point of view, contingency theory should be further studied in the sector of primary and community care. As mentioned, although large hospitals have frequently been object of organizational attention, the way of organizing networks of providers in primary care shall most probably be crucial in the years to come. This study provides a first attempt to cover the literature gap due to the lack of evidence on contingency theory in this area.

The tendency to adapt organizational design to contingencies should be detected, understood, managed, and possibly even supported by managers and policy makers, at least to some extent. Although local regulations may aim at reaching converging solutions within a given area, it should not be overlooked that adaptation to contingencies may indeed improve performance and quality of services. However, of course, uncontrolled variability is likely to be dangerous given its risk of hindering the provision of integrated care as well as a fair distribution of resources to settings. This might result in a concrete difficulty of enhancing equity, with patients receiving services of different quality, depending on the setting in which they happen to arrive. Nevertheless, variability may also encompass a positive acceptation insofar as it may provide the best fit between organizations’ missions and their specific contextual characteristics. Impeding such variability per se, therefore, could result, in turn, into non optimal solutions for patients.

It is interesting to question whether these phenomena are totally exogenous or if, on the contrary, professionals may affect contingencies in the first place. Although contingency theory focuses on items that are mainly external to the organization, or at least do not depend on its managerial team, at least two further considerations could be made. The first is that understanding contingencies and their effects on an organization’s success is key in designing a strategic configuration of the latter. The second is that, to some extent, some contingencies may be affected by professionals, at least in the long run. For example, enhancing a clear vision within the organization is likely to affect contingencies too, insofar as the overall acceptance of new organizational models may be better supported. Or also, investing in solid communication flows (within and outside the organization) may push policy makers to adapt normative interventions towards emerging models, thereby affecting the contingent context.

Future studies should build on this preliminary evidence, extending the analysis to other types of settings and geographical areas. Finally, they should link different organizational and managerial solutions to organizational performance, so to provide clear guidance on the extent to which standardization/variability are indeed desirable in these contexts.