Abstract

Objective

To analyse doctors’ opinions on clinical coordination between primary and secondary care in different healthcare networks and on the factors influencing it.

Methods

A qualitative descriptive-interpretative study was conducted, based on semi-structured interviews. A two-stage theoretical sample was designed: 1) healthcare networks with different management models; 2) primary care and secondary care doctors in each network. Final sample size (n = 50) was reached by saturation. A thematic content analysis was conducted.

Results

In all networks doctors perceived that primary and secondary care given to patients was coordinated in terms of information transfer, consistency and accessibility to SC following a referral. However, some problems emerged, related to difficulties in acceding non-urgent secondary care changes in prescriptions and the inadequacy of some referrals across care levels. Doctors identified the following factors: 1) organizational influencing factors: coordination is facilitated by mechanisms that facilitate information transfer, communication, rapid access and physical proximity that fosters positive attitudes towards collaboration; coordination is hindered by the insufficient time to use mechanisms, unshared incentives in prescription and, in two networks, the change in the organizational model; 2) professional factors: clinical skills and attitudes towards coordination.

Conclusions

Although doctors perceive that primary and secondary care is coordinated, they also highlighted problems. Identified factors offer valuable insights on where to direct organizational efforts to improve coordination.

Keywords:
Clinical coordination between care levels; Integrated health care; Interprofessional relations; Organizational models; Qualitative research

Resumen

Objetivo

Analizar la opinión de los médicos sobre la coordinación entre la atención primaria (AP) y la atención especializada (AE) en diferentes redes de servicios de salud, e identificar los factores relacionados.

Método

Estudio cualitativo descriptivo-interpretativo basado en entrevistas semiestructuradas. Se diseñó una muestra teórica en dos etapas: 1) redes de servicios de salud con diferentes modelos de gestión; 2) en cada red, médicos de AP y AE. El tamaño muestral se alcanzó por saturación (n = 50). Se realizó un análisis temático de contenido.

Resultados

En las tres redes, los médicos expresaron que la atención está coordinada en términos de intercambio de información, consistencia y accesibilidad de AE tras derivación urgente. Sin embargo, emergieron problemas relacionados con el acceso no urgente y cambios en prescripciones, y en dos redes la inadecuación clínica de las derivaciones entre ambos niveles. Se identificaron los siguientes factores relacionados: 1) organizativos: facilitan la coordinación, la existencia de mecanismos de transferencia de información, de comunicación y de acceso rápido, y la proximidad física que promueve actitudes positivas a la colaboración; la obstaculizan el tiempo insuficiente para el uso de mecanismos, incentivos no compartidos en la prescripción y, en dos redes, un cambio del modelo organizativo; 2) relacionados con los profesionales: habilidades clínicas y actitudes frente a la coordinación.

Conclusiones

Aunque los médicos perciben que la atención entre niveles está coordinada, también señalan problemas. Los factores identificados muestran hacia dónde dirigir los esfuerzos organizativos para su mejora.

Palabras clave:
Coordinación clínica entre niveles de atención; Prestación integrada de atención de salud; Relaciones interprofesionales; Modelos organizativos; Investigación cualitativa

Introduction

Care fragmentation is considered one of the main obstacles’ health services have to face in the current context of rapid medical and technological breakthroughs and increasing specialization. The provision of suboptimal care in terms of quality and efficiency is associated with care fragmentation,¹1. McDonald K, Sundaram V, Bravata D, et al. Care coordination. In: Shojania KGMK, Wachter RM, Owens DK, editors. Closing the quality gap: a critical analysis of quality improvement strategies. Rockville: Agency for Healthcare Research and Quality; 2007.^,22. Øvretveit J. Does clinical coordination improve quality and save money? London: Health Foundation; 2011.thus clinical coordination across care levels is becoming a priority issue in health services around the world.³3. World Health Organization. Integrated health services - what and why? Geneva: WHO; 2008.

This study is oriented by the conceptual framework of Vazquez et al.⁴4. Vázquez ML, Vargas I, Unger JP, et al. Integrated health care networks in Latin America: toward a conceptual framework for analysis. Rev Panam Salud Publica. 2009;26:360-7.^,55. Terraza R, Vargas I, Vázquez ML. La coordinación entre niveles asistenciales: una sistematización de sus instrumentos y medidas. Gac Sanit. 2006;20:485-95., which considers clinical coordination an intermediate objective of healthcare networks as a means by which to reach the ultimate objectives of quality of care, efficiency and equity of access. To analyse the achievement of these objectives, both external and internal processes and contextual factors are taken into account, as well as the different perspectives (services, users).⁴4. Vázquez ML, Vargas I, Unger JP, et al. Integrated health care networks in Latin America: toward a conceptual framework for analysis. Rev Panam Salud Publica. 2009;26:360-7. 5. Terraza R, Vargas I, Vázquez ML. La coordinación entre niveles asistenciales: una sistematización de sus instrumentos y medidas. Gac Sanit. 2006;20:485-95.^-66. Aller MB, Vargas I, Coderch J, et al. Development and testing of indicators to measure coordination of clinical information and management across levels of care. BMC Health Serv Res. 2015;15:323.Clinical coordination is defined as the harmonious connection of the different health services needed to provide care to a patient throughout the care continuum in order to achieve a common objective without conflicts.⁵5. Terraza R, Vargas I, Vázquez ML. La coordinación entre niveles asistenciales: una sistematización de sus instrumentos y medidas. Gac Sanit. 2006;20:485-95.Two types of clinical coordination are distinguished:⁷7. Vázquez ML, Vargas I, Unger JP, et al. Evaluating the effectiveness of care integration strategies in different health care systems in Latin America: the EQUITY-LA II quasi-experimental study protocol. BMJ Open. 2015;5:e007037.clinical information coordination, which refers to the use of patients’ clinical information in order to harmonize activities between providers; and clinical management coordination, which refers to the provision of care in a sequential and complementary way by the different services and healthcare levels involved.

Despite the numerous interventions introduced to improve care coordination between the primary care (PC) and secondary care (SC), few evaluations are available and generally based on the analysis of indicators.⁶6. Aller MB, Vargas I, Coderch J, et al. Development and testing of indicators to measure coordination of clinical information and management across levels of care. BMC Health Serv Res. 2015;15:323.^,88. McDonald K, Schultz E, Albin L, et al. Care coordination measures atlas. Rockville: Agency for Healthcare Research and Quality; 2010.Studies which focus on the opinion of health professionals usually explore their experiences in the use of coordination mechanisms. Some studies explore professionals’ perception using a qualitative approach, which tend to focus on patients with a specific condition, such as those with cancer,⁹9. Walsh J, Harrison JD, Young JM, et al. What are the current barriers to effective cancer care coordination? A qualitative study. BMC Health Serv Res. 2010;10:132.^,1010. Admi H, Muller E, Ungar L, et al. Hospital-community interface: a qualitative study on patients with cancer and health care providers' experiences. Eur J Oncol Nurs. 2013;17:528-35.or mental health problems¹¹11. Fleury MJ, Imboua A, Aube D, et al. Collaboration between general practitioners (GPs) and mental healthcare professionals within the context of reforms in Quebec. Ment Health Fam Med. 2012;9:77-90.^,1212. Benzer JK, Beehler S, Miller C, et al. Grounded theory of barriers and facilitators to mandated implementation of mental health care in the primary care setting. Depress Res Treat. 2012;2012:597157.or only a specific type of transition, such as hospital discharges.¹³13. Tandjung R, Rosemann T, Badertscher N. Gaps in continuity of care at the interface between primary care and specialized care: general practitioners' experiences and expectations. Int J Family Med. 2011;4:773-8.^,1414. Johnson JK, Farnan JM, Barach P, et al. Searching for the missing pieces between the hospital and primary care: mapping the patient process during care transitions. BMJ Qual Saf. 2012;21 (Suppl 1):i97-105.These studies identify diverse organizational factors which affect clinical coordination, such as economic incentives to collaborate;¹¹11. Fleury MJ, Imboua A, Aube D, et al. Collaboration between general practitioners (GPs) and mental healthcare professionals within the context of reforms in Quebec. Ment Health Fam Med. 2012;9:77-90.^,1515. McHugh S, O'Mullane M, Perry IJ, et al. Barriers to, and facilitators in, introducing integrated diabetes care in Ireland: a qualitative study of views in general practice. BMJ Open. 2013;3:e003217.as well as factors related to professionals, such as attitudes towards coordinating care and mutual knowledge.⁹9. Walsh J, Harrison JD, Young JM, et al. What are the current barriers to effective cancer care coordination? A qualitative study. BMC Health Serv Res. 2010;10:132.^,1111. Fleury MJ, Imboua A, Aube D, et al. Collaboration between general practitioners (GPs) and mental healthcare professionals within the context of reforms in Quebec. Ment Health Fam Med. 2012;9:77-90.^,1212. Benzer JK, Beehler S, Miller C, et al. Grounded theory of barriers and facilitators to mandated implementation of mental health care in the primary care setting. Depress Res Treat. 2012;2012:597157.Little research has been conducted in the context of national health systems,¹⁶16. Andvig E, Syse J, Severinsson E. Interprofessional collaboration in the mental health services in Norway. Nurs Res Pract. 2014;2014:849375.^,1717. Henao D, Vázquez ML, Vargas I. Factores que influyen en la coordinación entre niveles asistenciales según la opinión de directivos y profesionales sanitarios. Gac Sanit. 2009;23:280-6.which may present particular opportunities and challenges in clinical coordination.

In Catalonia (Spain), the healthcare system is characterized by a split of the financing and provision functions. The provision is the responsibility of a number of contracted providers: a public company, the Catalan Health Institute, and public consortia, municipal foundations and private (mostly non-profit) foundations.¹⁸18. Departamento de Salud. Decreto 196/2010 del 14 de diciembre. Sistema sanitari integral d'utilizació pública de Catalunya (SISCAT) (12/16/2010, 2010). DOGC n 5776 de 16 de diciembre de 2010.This diversity has originated, on the one hand, a risk of fragmentation and, on the other, different management models, including the joint management of both PC and SC.¹⁹19. Vázquez ML, Vargas I. Organizaciones sanitarias integradas. Un estudio de casos. 2a ed. Barcelona: Consorci Hospitalari de Catalunya; 2009.

Previous research have approached the analysis of clinical coordination in health care networks with different management models, exploring the patients’ perceptions of continuity across care levels and quantifying the degree of clinical coordination based on the application of clinical coordination indicators.²⁰20. Aller MB, Vargas I, Waibel S, et al. A comprehensive analysis of patients perceptions of continuity of care and their associated factors. Int J Qual Health Care. 2013;25:291-9.^,2121. Aller MB, Vargas I, Waibel S, et al. Factors associated to experienced continuity of care between primary and outpatient secondary care in the Catalan public healthcare system. Gac Sanit. 2013;27:207-13.These studies pointed to high levels of continuity and coordination across care levels in Catalonia, although they also indicated room for improvement, including insufficient information transfer and long waiting times for secondary care after referral. These studies did not explore the factors influencing clinical coordination or include the perception of doctors, both scarcely analysed in the Catalan health care context.¹⁷17. Henao D, Vázquez ML, Vargas I. Factores que influyen en la coordinación entre niveles asistenciales según la opinión de directivos y profesionales sanitarios. Gac Sanit. 2009;23:280-6.The aim of this article, which forms part of a wider project,⁶6. Aller MB, Vargas I, Coderch J, et al. Development and testing of indicators to measure coordination of clinical information and management across levels of care. BMC Health Serv Res. 2015;15:323.^,2222. Waibel S, Vargas I, Aller MB, et al. Continuity of clinical management and information across care levels: perceptions of users of different healthcare areas in the Catalan national health system. BMC Health Serv Res. 2016;16:466.is to analyse the opinions of doctors on clinical coordination between PC and SC and on the factors influencing it in different healthcare networks of the Catalan National Health System.

Methods

A qualitative and descriptive-interpretative qualitative study was conducted with PC and SC doctors.

Study sample

A theoretical sample,²³23. Patton Q. Qualitative evaluation and research methods. 4th ed. London: SAGE; 2015.i.e. criteria was defined to ensure that contexts and profiles that could provide information which is different and relevant to the study's objectives are included, was selected through a two-stage process. In the first stage, the contexts healthcare networks were selected to represent the diversity of management models in Catalonia: Baix Empordà, the city of Girona and the Ciutat Vella district of Barcelona (Table 1). A single entity manages both PC and SC in Baix Empordà and in Girona. In Ciutat Vella, two public entities manage PC and a different public entity manages SC.

In the second stage, in each network PC and SC doctors who perform clinical activities and with a minimum labour linkage to the organization of a year and a half were selected. Maximum variation with regard to age and sex was sought, and for SC doctors also to speciality. The sample was selected in a sequential way, so profiles that emerged as relevant in initial interviews were also included in the study. No contacted doctor declined or showed reluctance to participate in the study. The final sample size was between 15 and 18 doctors per network (Table 2).

Data collection

Individual, semi-structured interviews were carried out using a topic guide adapted from previous studies.¹⁷17. Henao D, Vázquez ML, Vargas I. Factores que influyen en la coordinación entre niveles asistenciales según la opinión de directivos y profesionales sanitarios. Gac Sanit. 2009;23:280-6.^,2424. Vargas I, Mogollón AS, De Paepe P, et al. Barriers to care coordination in market based and decentralized public health systems: a qualitative study in healthcare networks of Colombia and Brazil. Health Policy Plann. 2016;31:736-48.The topic guide addressed doctors’ opinions on clinical coordination between PC and SC and factors influencing it through open questions. Interviews were conducted by the first author, an anthropologist/pharmacist with a good knowledge of qualitative methods, the research topic and the context, who worked in close collaboration with the second and last authors. The interviews lasted between 45 and 80 minutes and were recorded and transcribed.

Doctors were contacted by telephone or email either by a contact in the health organization or by the researcher. Interviews were performed in the healthcare facilities. Data collection stopped when saturation was reached in each study network. Fieldwork took place between July and September 2012 (Baix Empordà) and between December 2013 and May 2014 (Ciutat Vella and Girona).

Data analysis and quality of information

A thematic content analysis²⁵25. Miles MB, Huberman AM. Qualitative data analysis: an expanded sourcebook. Thousand Oaks (California): SAGE; 1994.was conducted with the support of the Atlas-ti software. Data were segmented by healthcare network and level of care. The process of category generation was mainly inductive, i.e. it was oriented towards the identification of emergent patterns in the data.²³23. Patton Q. Qualitative evaluation and research methods. 4th ed. London: SAGE; 2015.Themes were identified, coded, re-coded and classified, identifying common patterns by looking at regularities, convergences and divergences in data, through a process of constant comparisons, going back and forth between data. Data quality was ensured through triangulation, by comparing different networks, groups of informants, and sources (literature).

The first author was responsible for the analysis, and worked in close collaboration with the second (a health economist) and last authors (public health doctor). Differences were discussed and resolved by going back to the data. The rest of the authors contributed to the interpretation of data.

Ethical considerations

This study was approved by the ethics committee of Parc de Salut Mar (2010/412/1). Written consent was obtained from every participant prior to interview. Confidentiality and anonymity were guaranteed.

Results

Due to similarities in the discourse, results are presented jointly for the three healthcare networks. When existing, differences between networks are outlined.

Doctors’ experiences of clinical coordination between PC and SC

In all three healthcare networks, doctors considered that care provided to patients was generally coordinated across that levels, and described it in terms of the availability and uptake of clinical information generated at the other care level through the shared EMR, the resolution of doubts regarding diagnosis and treatment through direct communication, and rapid access to SC following a referral in urgent cases. However, certain limits to clinical coordination emerged, which varied depending on the network and care level.

According to the informants, the availability and uptake of clinical data generated at the other level on the EMR meant that tests and treatments are not duplicated or contraindicated (Table 3a). This information also facilitated an adequate follow up of the patient when they pass from one level to another, for example following a referral. However, doctors pointed out that some doctors from the other care level failed to transfer all the information needed in patient referral (reason for referral) and reply letters to PC (diagnoses or recommendations for follow-up) (Table 3b).

Doctors considered that direct communication, through virtual consultations via EMR or email, telephone, and joint clinical case conferences encouraged greater consistency in medical instructions, prevented unnecessary patient referrals and helped to speed up the diagnostic process and treatment (Table 3c). Likewise, difficulties in communicating with certain SC doctors, translated into delays in diagnosis and treatment (Table 3d). Disagreements regarding prescriptions also emerged, which were described as frequent changes in prescriptions from the other care level, creating confusion in patients and conflict between doctors of the two levels (Table 3e).

The rapidity of access to SC when the reason for referral was urgent, was considered to contributes to a timely diagnosis and treatment (Table 3f). However, PC doctors and some SC doctors considered that the waiting times for non-urgent SC and, in Girona, for hospital tests, were long, which caused delays in diagnosis and treatment and sometimes forced the patients to seek help for their problems in inappropriate places, such as hospital emergency services or PC (Table 3g-h). In this sense, in Girona and Ciutat Vella, PC doctors considered that the patient did not always receive care in the most appropriate place due to being prematurely discharged from hospital or emergency services (Table 3i) and, in Girona, due to the rejection of certain referrals, a factor which they also associated with delays in diagnosis and treatment (Table 3j). However, SC doctors considered referral rejections a consequence of unnecessary referrals (Table 3k).

Factors influencing clinical coordination across care levels

In the informants’ discourse, various types of factors related to the organization and professionals emerged that influenced clinical coordination across care levels. The majority of these factors emerged in all networks, although with some differences in organizational factors. Differences were also observed depending on the care level, mainly in factors related to professionals.

Organizational factors

The existence of coordination mechanisms between care levels emerged as one of the main facilitators of clinical coordination between levels. They identified mechanisms that facilitate access to the information generated at the other level (shared EMR) or enable problem-solving communication and agreement on clinical approaches (clinical case conferences between PC and SC doctors [Girona], virtual consultations via EMR [Ciutat Vella and Baix Empordà] or email, and telephone [Table 4a-b]). Joint clinical case conferences also contribute to improve mutual knowledge, both in terms of the skills and roles of the other level, fostering a more positive attitude towards collaboration. In addition, they identified the rapid diagnosis pathway for suspected cancer to guarantee rapid access to urgent SC (Table 4c).

Lastly, the lack of shared clinical criteria for prescription and incentives only for PC doctors emerged as a barrier, as it makes it difficult to reach an agreement on a treatment plan for the patient (Table 4d).

Physical proximity to each other was highlighted by doctors from both care levels as a factor that facilitates clinical coordination. Various organizational elements, which differed according to the network, ensured proximity: the co-location of SC doctors in PC centres in Ciutat Vella, working in a small organization in Baix Empordà and in centres that are close to each other in Baix Empordà and Girona. Physical proximity increases contact and mutual knowledge, fostering a more favourable attitude towards collaboration. It also facilitates informal communication and a greater use of coordination mechanisms (Table 4e).

Insufficient time for coordination due to work overload was mentioned as the main barrier to clinical coordination by doctors from all networks. Doctors highlighted having insufficient time to use coordination mechanisms to communicate and to participate in joint meetings (Table 4f). Furthermore, PC doctors pointed out that inappropriate referrals were a result of the insufficient consultation time per patient.

Changes in the organizational model in the context of the economic crisis emerged from the discourse of PC doctors and, with less intensity, in that of the SC doctors, in Ciutat Vella and Girona. They attributed these changes to cuts in the healthcare budget, which translated into a cut in resources (reducing the number of hospital beds). They considered that coordination mechanisms which present an alternative to conventional referrals, such as virtual consultations, were implemented with the purpose to reducing the number of patients who access SC. In addition, PC doctors perceived that hospital stays and emergency admissions have been curtailed (early discharges) and the volume and complexity of patients treated in PC had increased. Moreover, sometimes the patient was referred back to PC without the problem having been resolved (Table 4g).

Professional factors

Insufficient training and clinical skills of PC doctors was related to clinically inappropriate referrals by some SC doctors, especially those who are not in regular contact with PC doctors (Table 4h). However, according to PC doctors and other SC doctors, this perception is built on SC doctors prejudices and their scant knowledge of the function and the resources available at PC.

Attitudes of doctors towards coordination emerged as a factor which influences the use of coordination mechanisms: specifically, telephone and email to communicate, the EMR to share medical data and their participation in joint meetings (Table 4i). It also influences their willingness to perform tasks aimed at making the other care level more effective, such as requesting tests so that the SC doctor can see the results on the patient's first visit (Table 4j). The informants considered that these values are conditioned by mutual knowledge and contact between professionals, which foster a more positive attitude towards coordination.

Discussion

Few differences between networks in doctors’ perceptions of clinical coordination across care levels

In general, doctors considered that care provided to patients is coordinated across PC and SC in all three networks, with some limitations and their perception of clinical coordination was similar across networks, although some differences were identified between networks and professionals. In two networks, Ciutat Vella and Girona, problems in the adequacy of patient care transitions in terms of early discharges and the rejection of referrals were described, mainly by PC doctors. However, these problems were attributed to changes introduced in the context of the economic crisis, thus, this difference could be due to the fact that the field work was carried out at different times: at the start of the economic crisis in Baix Empordà and over a year later in the other two networks, when the main reductions in public health spending budget took place.

Similar factors influencing clinical coordination between PC and SC in all three networks

Doctors of all three networks also identify similar organizational factors; most importantly, physical proximity between doctors and the implementation of similar coordination mechanisms.

Among organizational factors highlighted by informants were the implementation of coordination mechanisms to foster information transfer and problem-solving communication. In addition, it became evident that physical proximity was important, since it promotes mutual knowledge and trust among doctors that encourage direct communication and foster a better attitude towards coordination. A positive attitude towards coordination emerges in this and other studies¹²12. Benzer JK, Beehler S, Miller C, et al. Grounded theory of barriers and facilitators to mandated implementation of mental health care in the primary care setting. Depress Res Treat. 2012;2012:597157.^,2626. Willumsen E, Ahgren B, Odegard A. A conceptual framework for assessing interorganizational integration and interprofessional collaboration. J Interprof Care. 2012;26:198-204.as one of the most relevant factors influencing collaboration among professionals, as it contributes to the better use of coordination mechanisms and makes them more willing to perform tasks destined to make care more effective at the other level.

On the other hand, the results reveal various factors, which hinder coordination across care levels. Most importantly, lack of time for coordination activities emerges as the main organizational obstacle to clinical coordination, also pointed out in the scientific literature.¹⁰10. Admi H, Muller E, Ungar L, et al. Hospital-community interface: a qualitative study on patients with cancer and health care providers' experiences. Eur J Oncol Nurs. 2013;17:528-35.^,2727. Berendsen AJ, Benneker WH, Schuling J, et al. Collaboration with general practitioners: preferences of medical specialists - a qualitative study. BMC Health Serv Res. 2006;6:155.^,2828. Berendsen AJ, Benneker WH, Meyboom-de JB, et al. Motives and preferences of general practitioners for new collaboration models with medical specialists: a qualitative study. BMC Health Serv Res. 2007;7:4.. This problem seems to have become more severe as a result of the change in the organizational model, aimed at reducing the activity of SC, and change that has gone hand in hand with a higher level of referral rejections and early discharges.

The discourse highlights incentives in drug prescription, which are heavily weighted towards the PC. These incentives, along with a lack of shared prescription guidelines or a lack of awareness, lead to frequent changes in treatments. This problem points to the need to implement a more global focus involving both care levels by making doctors of both levels equally responsible for prescribing drugs to the population they serve.²⁹29. Lillo Fernández de Cuevas J, Rodríguez Blas M. Estadística de Gasto Sanitario Público 2013. Principales resultados. Madrid: Ministerio de Sanidad, Servicios Sociales e Igualdad; 2015.^,3030. Peiró S, Sanfélix-Gimeno G. La prescripción inducida, un falso problema que esconde las carencias de la gestión de la prescripción. Rev Calid Asist. 2010;25:315-7.

Finally, the three networks form part of a national health system, and thus share many of the contextual factors that can influence coordination, such as the same healthcare model; almost universal coverage and the same type of financing and incentive systems. This might be explaining the coincidence in discourses.

Limitations

Despite the heterogeneity of the population interviewed in terms of certain characteristics, such as medical speciality and type of centre, we cannot rule out the possibility that information saturation was not fully reached, although the main arguments are represented in the results. Furthermore, a contact in the organizations participated in the selection process, so they could have introduced a bias towards a more positive discourse. However, the research team also participated in the selection process, discussing the profiles of the informants, and some informants were identified in a sequential way as part of the sampling strategy. Finally, the fact that the field work in one network was performed at a different time to the other two may be the reason for the differences observed between study areas, especially those related to changes in the socioeconomic context seen in recent years.

Conclusions

This study shows that doctors perceived that care provided to patients is generally coordinated, with similarities in the networks analysed, although it also highlights several areas for improvement. In addition, the study has allowed us to identify the factors that doctors relate to clinical coordination between care levels, with differences depending on care level and, to a lesser degree, network. The most important enablers are organizational, and among them, the implementation of coordination mechanisms that facilitate information exchange (EMR) and problem-solving communication, and those that guarantee rapid access to SC, as well as doctors’ physical proximity. Main barriers are a lack of time for coordination, the change in the organizational model in the context of the economic crisis and the existence of unshared incentives in drug prescription. Future interventions strategies for improvement in coordination across care levels should take these factors into consideration in order to guarantee a suitable and effective response to the problems encountered in clinical coordination across care levels.

Acknowledgements

The authors wish to thank all informants for their thoughtful and open participation in the study. We thank Nuria Martinez and Isabel Serra for their administrative support and Kate Bartlett for her help in correcting the English version of this article.

References

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