Accountability in healthcare in the Netherlands: A scoping review.

For better serving people's complex needs the subsequent movement to person-centred integrated care, requires inter-organisational cooperation and service provision by domain-overarching networks and alliances. In the development to these networks, it is relevant to explore which accountability approaches are appropriate for local inter-organisational healthcare governance. Therefore, in a scoping review we studied the current state of knowledge and practice of accountability in healthcare in the Netherlands. We found that two of the included 41 studies show characteristics of accountability towards healthcare with characteristics of integration care components, such as integration of services with accompanying accountability arrangements and development of networked accountability. The first studies are found in the literature which report on accountability in integrated care. With this we add to the international discussion about accountability as an aspect of integrated care governance, by providing insight into the current state of art of accountability in Dutch healthcare.

Toward Responsible Artificial Intelligence in Long-Term Care: A Scoping Review on Practical Approaches.

BACKGROUND AND OBJECTIVES: Artificial intelligence (AI) is widely positioned to become a key element of intelligent technologies used in the long-term care (LTC) for older adults. The increasing relevance and adoption of AI has encouraged debate over the societal and ethical implications of introducing and scaling AI. This scoping review investigates how the design and implementation of AI technologies in LTC is addressed responsibly: so-called responsible innovation (RI). RESEARCH DESIGN AND METHODS: We conducted a systematic literature search in 5 electronic databases using concepts related to LTC, AI, and RI. We then performed a descriptive and thematic analysis to map the key concepts, types of evidence, and gaps in the literature. RESULTS: After reviewing 3,339 papers, 25 papers were identified that met our inclusion criteria. From this literature, we extracted 3 overarching themes: user-oriented AI innovation; framing AI as a solution to RI issues; and context-sensitivity. Our results provide an overview of measures taken and recommendations provided to address responsible AI innovation in LTC. DISCUSSION AND IMPLICATIONS: The review underlines the importance of the context of use when addressing responsible AI innovation in LTC. However, limited empirical evidence actually details how responsible AI innovation is addressed in context. Therefore, we recommend expanding empirical studies on RI at the level of specific AI technologies and their local contexts of use. Also, we call for more specific frameworks for responsible AI innovation in LTC to flexibly guide researchers and innovators. Future frameworks should clearly distinguish between RI processes and outcomes.

Decision-Making Dilemmas within Integrated Care Service Networks: A Systematic Literature Review.

Introduction: The diverse nature of people's care needs requires collaboration between different organisations and sectors. One way of achieving such collaboration is through integrated care service networks. Decision-making is considered an important aspect of network governance and key to achieve further integration of care services. As integrated care scholars only implicitly seem to touch upon the issue of decision-making, we aimed to identify multiple decision-making dilemmas. Theory and Methods: A systematic literature review was conducted of eighteen empirical studies in which decision-making dilemmas in integrated care service networks were inductively identified. To frame and understand these dilemmas, we partly drew on Provan and Kenis' governance models and their hypothesised decision-making dilemma for service networks. Results: Identified decision-making dilemmas included 1) autonomy versus interdependence, 2) diversity versus coherence, and 3) self-interest versus common goals. In line with Provan and Kenis' hypothesis, we highlight a cross-cutting dilemma of inclusiveness (all viewpoints are considered hence widely supported decisions) vs. efficiency (reaching timely decisions). Discussion and conclusion: We believe that network- and 'systemic' stakeholders both need to reflect upon and learn from decision-making dilemmas to work towards widely supported and adequate decisions. This is important for achieving aligned and holistic care services that many people desire.

Values Underpinning Integrated, People-Centred Health Services: Similarities and Differences among Actor Groups Across Europe.

Introduction: In addition to the functional aspects of healthcare integration, an understanding of its normative aspects is needed. This study explores the importance of values underpinning integrated, people-centred health services, and examines similarities and differences among the values prioritised by actors across Europe. Methods: Explorative cross-sectional design with quantitative analysis. A questionnaire of 18 values was conducted across Europe. A total of 1,013 respondents indicated the importance of each of the values on a nine-point scale and selected three most important values. Respondents were clustered in four actor groups, and countries in four European sub-regions. Results: The importance scores of values ranged from 7.62 to 8.55 on a nine-point scale. Statistically significant differences among actor groups were found for ten values. Statistically significant differences across European sub-regions were found for six values. Our analysis revealed two clusters of values: 'people related' and 'governance and organisation'. Discussion and conclusion: The study found that all 18 values in the set are considered important by the respondents. Additionally, it revealed distinctions in emphasis among the values prioritised by actor groups and across sub-regions. The study uncovered two clusters of values that contribute to a conceptually based definition of integrated, people-centred health services.

Professionals' views on shared decision-making in severe aortic stenosis.

OBJECTIVE: To provide insight into professionals' perceptions of and experiences with shared decision-making (SDM) in the treatment of symptomatic patients with severe aortic stenosis (AS). METHODS: A semistructured interview study was performed in the heart centres of academic and large teaching hospitals in the Netherlands between June and December 2020. Cardiothoracic surgeons, interventional cardiologists, nurse practitioners and physician assistants (n=21) involved in the decision-making process for treatment of severe AS were interviewed. An inductive thematic analysis was used to identify, analyse and report patterns in the data. RESULTS: Four primary themes were generated: (1) the concept of SDM, (2) knowledge, (3) communication and interaction, and (4) implementation of SDM. Not all respondents considered patient participation as an element of SDM. They experienced a discrepancy between patients' wishes and treatment options. Respondents explained that not knowing patient preferences for health improvement hinders SDM and complicating patient characteristics for patient participation were perceived. A shared responsibility for improving SDM was suggested for patients and all professionals involved in the decision-making process for severe AS. CONCLUSIONS: Professionals struggle to make highly complex treatment decisions part of SDM and to embed patients' expectations of treatment and patients' preferences. Additionally, organisational constraints complicate the SDM process. To ensure sustainable high-quality care, professionals should increase their awareness of patient participation in SDM, and collaboration in the pathway for decision-making in severe AS is required to support the documentation and availability of information according to the principles of SDM.

Optimising Integrated Stroke Care in Regional Networks: A Nationwide Self-Assessment Study in 2012, 2015 and 2019.

BACKGROUND: To help enhance the quality of integrated stroke care delivery, regional stroke services networks in the Netherlands participated in a self-assessment study in 2012, 2015 and 2019. METHODS: Coordinators of the regional stroke services networks filled out an online self-assessment questionnaire in 2012, 2015 and 2019. The questionnaire, which was based on the Development Model for Integrated Care, consisted of 97 questions in nine clusters (themes). Cluster scores were calculated as proportions of the activities implemented. Associations between clusters and features of stroke services were assessed by regression analysis. RESULTS: The response rate varied from 93.1% (2012) to 85.5% (2019). Over the years, the regional stroke services networks increased in 'size': the median number of organisations involved and the volume of patients per network increased (7 and 499 in 2019, compared to 5 and 364 in 2012). At the same time, fewer coordinators were appointed for more than 1 day a week in 2019 (35.1%) compared to 2012 (45.9%). Between 2012 and 2019, there were statistically significantly more elements implemented in four out of nine clusters: 'Transparent entrepreneurship' (MD = 18.0% F(1) = 10.693, p = 0.001), 'Roles and tasks' (MD = 14.0% F(1) = 9.255, p = 0.003), 'Patient-centeredness' (MD = 12.9% F(1) = 9.255, p = 0.003), and 'Commitment' (MD = 11.2%, F(1) = 4.982, p = 0.028). A statistically significant positive correlation was found for all clusters between implementation of activities and age of the network. In addition, the number of involved organisations is associated with better execution of implemented activities for 'Transparent entrepreneurship', 'Result-focused learning' and 'Quality of care'. Conversely, there are small but negative associations between the volume of patients and implementation rates for 'Interprofessional teamwork' and 'Patient-centredness'. CONCLUSION: This long-term analyses of stroke service development in the Netherlands, showed that between 2012 and 2019, integrated care activities within the regional stroke networks increased. Experience in collaboration between organisations within a network benefits the uptake of integrated care activities.

Parkinson Network Eastern Saxony (PANOS): Reaching Consensus for a Regional Intersectoral Integrated Care Concept for Patients with Parkinson's Disease in the Region of Eastern Saxony, Germany.

As integrated care is recognized as crucial to meet the challenges of chronic conditions such as Parkinson's disease (PD), integrated care networks have emerged internationally and throughout Germany. One of these networks is the Parkinson Network Eastern Saxony (PANOS). PANOS aims to deliver timely and equal care to PD patients with a collaborative intersectoral structured care pathway. Additional components encompass personalized case management, an electronic health record, and communicative and educative measures. To reach an intersectoral consensus of the future collaboration in PANOS, a structured consensus process was conducted in three sequential workshops. Community-based physicians, PD specialists, therapists, scientists and representatives of regulatory authorities and statutory health insurances were asked to rate core pathway-elements and supporting technological, personal and communicative measures. For the majority of core elements/planned measures, a consensus was reached, defined as an agreement by >75% of participants. Additionally, six representatives from all partners involved in the network-design independently assessed PANOS based on the Development Model for Integrated Care (DMIC), a validated model addressing the comprehensiveness and maturity of integrated care concepts. The results show that PANOS is currently in an early maturation state but has the potential to comprehensively represent the DMIC if all planned activities are implemented successfully. Despite the favorable high level of consensus regarding the PANOS concept and despite its potential to become a balanced integrated care concept according to the DMIC, its full implementation remains a considerable challenge.

Towards a values framework for integrated health services: an international Delphi study.

BACKGROUND: In order to organize person-centered health services for a growing number of people with multiple complex health and social care needs, a shift from fragmented to integrated health services delivery has to take place. For the organization of governance in integrated health services, it is important to better understand the underlying factors that drive collaboration, decision-making and behavior between individuals and organizations. Therefore, this article focuses on these underlying normative aspects of integrated health services. This study investigates the values that underpin integrated health services delivery as a concept, by examining the extent to which an initial literature based set of underlying values underpins integrated care and the relevance of these values on the different levels of integration. METHODS: An international Delphi study with 33 experts from 13 different countries was carried out to examine the initial set of underlying values of integrated health services. In addition, the relevance of the values was assessed on the different levels of integration: personal level, professional level, management level and system level. RESULTS: The study resulted in a refined set of 18 values of integrated health services developed in three Delphi study rounds. In addition, the results provided insight into the relevance of these values on the personal level (e.g. 'trustful'), professional level (e.g. 'collaborative'), management level (e.g. 'efficient') and system level (e.g. 'comprehensive') of integration. Some of the values score consistent across the different levels of integration while other values score inconsistent across these levels. CONCLUSIONS: The Delphi study resulted in an international normative basis for integrated health services delivery as a concept. The values can be used as ingredients for a values framework and provide a better understanding of the normative aspects of integrated health services delivery. Future research could focus on associated behaviors in practice, the relationship between normative integration and governance, and differences between the value priorities of stakeholder groups.

Shared decision making in older patients with symptomatic severe aortic stenosis: a systematic review.

This review provides an overview of the status of shared decision making (SDM) in older patients regarding treatment of symptomatic severe aortic stenosis (SSAS). The databases Embase, Medline Ovid, Cinahl and Cochrane Dare were searched for relevant studies from January 2002 to May 2018 regarding perspectives of professionals, patients and caregivers; aspects of decision making; type of decision making; application of the six domains of SDM; barriers to and facilitators of SDM. The systematic search yielded 1842 articles, 15 studies were included. Experiences of professionals and informal caregivers with SDM were scarcely found. Patient refusal was a frequently reported result of decision making, but often no insight was given into the decision process. Most studies investigated the 'decision' and 'option' domains of SDM, yet no study took all six domains into account. Problem analysis, personalised treatment aims, use of decision aids and integrating patient goals in decisions lacked in all studies. Barriers to and facilitators of SDM were 'individualised formal and informal information support' and 'patients' opportunity to use their own knowledge about their health condition and preferences for SDM'. In conclusion, SDM is not yet common practice in the decision making process of older patients with SSAS. Moreover, the six domains of SDM are not often applied in this process. More knowledge is needed about the implementation of SDM in the context of SSAS treatment and how to involve patients, professionals and informal caregivers.

Active Involvement of People with Dementia: A Systematic Review of Studies Developing Supportive Technologies.

Although there are promising benefits of supportive technology in dementia care, use of these technologies is still limited. It is challenging for researchers and developers in this field to actively involve people with dementia in development. This review updates and builds on existing knowledge by including a contemporary and relevant perspective. This perspective was gained by including search words and search databases from the field of Human Computer Interaction (HCI) and Design, as these fields were expected to supply novel insights in the complex task of actively involving people with dementia in developing supportive technologies. A total of 49 out of 3456 studies were included which describe the development of a great variety of technologies. Often people with dementia were involved in the generative or evaluative phase of the development. Interviews and observations were most commonly used methods. In seven articles the people with dementia were co-designers. This literature review reflects that people with dementia can influence the development of technology in regards to content, design, and even the initial idea, although the impact on how they experience their own involvement remains largely unknown. There is a lack of specific knowledge on appropriate methods and materials for active involvement of people with dementia in supportive technology development, even when including articles from the field of HCI and Design. Future research is needed to further appreciate and improve the desired role of people with dementia in meaningful technology development.

Assessing the maturity of the healthcare system for integrated care: testing measurement properties of the SCIROCCO tool.

BACKGROUND: The Scaling Integrated Care in Context (SCIROCCO) tool has been developed to facilitate knowledge transfer and learning about the implementation and scaling-up of integrated care in European regions. To adequately test the functionality of the tool in assessing the maturity for integrated care within regions, this study evaluated its structural validity, internal consistency and convergent validity. METHODS: Exploratory factor analysis was used to investigate the structural validity of the 12-items of the SCIROCCO tool. Hereafter, the internal consistency was assessed by calculating Cronbach's and ordinal alpha. The convergent validity was explored by testing 23 pre-hypothesized relationships between items of the SCIROCCO tool and items of an instrument measuring a similar construct. RESULTS: Factor analysis revealed a one-factor structure. Cronbach's alpha of the overall instrument was 0.92, ordinal alpha was 0.94. Only 30.34% of the hypotheses for testing the convergent validity were met. CONCLUSION: The one-factor structure is considered relevant in representing the structural validity of the SCIROCCO tool. The scale of the SCIROCCO tool shows good internal consistency. The tool (DMIC Quickscan) used to assess the convergent validity might measure a different aspect of integrated care than the SCIROCCO tool. Further research is needed to continue investigating the validity and reliability of the tool.

Values of Integrated Care: A Systematic Review.

INTRODUCTION: Although substantial generic knowledge about integrated care has been developed, better understanding of the factors that drive behaviour, decision-making, collaboration and governance processes in integrated care networks is needed to take integrated care forward. To gain more insight into these topics and to understand integrated care in more depth, a set of underlying values of integrated care has been developed and defined in this study. THEORY AND METHODS: A systematic literature review was conducted to identify the underlying values of integrated care. Values theory was used as a theoretical framework for the analysis. RESULTS: This study identified 23 values in the current body of knowledge. The most frequently identified values are 'collaborative', 'co-ordinated', 'transparent', 'empowering', 'comprehensive', 'co-produced' and 'shared responsibility and accountability'. DISCUSSION AND CONCLUSION: The set of values is presented as a potential basis for a values-driven approach to integrated care. This approach enables better understanding of the behaviours and collaboration in integrated care and may also be used to develop guidance or governance in this area. The practical application of the values and their use at multiple levels is discussed. The consequences of different stakeholder perceptions on the values is explored and an agenda for future research is proposed.

The development of integrated diabetes care in the Netherlands: a multiplayer self-assessment analysis.

BACKGROUND: Since recent years Dutch diabetes care has increasingly focused on improving the quality of care by introducing the concept of care groups (in Dutch: 'zorggroepen'), care pathways and improving cooperation with involved care professionals and patients. This study examined how participating actors in care groups assess the development of their diabetes services and the differences and similarities between different stakeholder groups. METHODS: A self-evaluation study was performed within 36 diabetes care groups in the Netherlands. A web-based self-assessment instrument, based on the Development Model for Integrated Care (DMIC), was used to collect data among stakeholders of each care group. The DMIC defines nine clusters of integrated care and four phases of development. Statistical analysis was used to analyze the data. RESULTS: Respondents indicated that the diabetes care groups work together in well-organized multidisciplinary teams and there is clarity about one another's expertise, roles and tasks. The care groups can still develop on elements related to the management and monitoring of performance, quality of care and patient-centeredness. The results show differences (p < 0.01) between three stakeholders groups in how they assess their integrated care services; (1) core players, (2) managers/directors/coordinators and (3) players at a distance. Managers, directors and coordinators assessed more implemented integrated care activities than the other two stakeholder groups. This stakeholder group also placed their care groups in a further phase of development. Players at a distance assessed significantly less present elements and assessed their care group as less developed. CONCLUSIONS: The results show a significant difference between stakeholder groups in the assessment of diabetes care practices. This reflects that the professional disciplines and the roles of stakeholders influence the way they asses the development of their integrated care setting, or that certain stakeholder groups could be less involved or informed.

The Development of Integrated Stroke Care in the Netherlands a Benchmark Study.

INTRODUCTION: Integrated stroke care in the Netherlands is constantly changing to strive to better care for stroke patients. The aim of this study was to explore if and on what topics integrated stroke care has been improved in the past three years and if stroke services were further developed. METHODS: A web based self-assessment instrument, based on the validated Development Model for Integrated Care, was used to collect data. In total 53 coordinators of stroke services completed the questionnaire with 98 elements and four phases of development concerning the organisation of the stroke service. Data were collected in 2012 and 2015. Descriptive-comparative statistics were used to analyse the data. RESULTS: In 2012, stroke services on average had implemented 56 of the 89 elements of integrated care (range 15-88). In 2015 this was increased up to 70 elements on average (range 37-89). In total, stroke services showed development on all clusters of integrated care. In 2015, more stroke services were in further phases of development like in the consolidation and transformation phase and less were in the initiative and design phase. The results show large differences between individual stroke services. Priorities to further develop stroke services changed over the three years of data collection. CONCLUSIONS: Based on the assessment instrument, it was shown that stroke services in the Netherlands were further developed in terms of implemented elements of integrated care and their phase of development. This three year comparison showed unique first analyses over time of integrated stroke care in the Netherlands on a large scale. Interesting further questions are to research the outcomes of stroke care in relation to this development, and if benefits on patient level can be assessed.

A survey study to validate a four phases development model for integrated care in the Netherlands.

BACKGROUND: The development of integrated care is a complex and long term process. Previous research shows that this development process can be characterised by four phases: the initiative and design phase; the experimental and execution phase; the expansion and monitoring phase and the consolidation and transformation phase. In this article these four phases of the Development Model for Integrated Care (DMIC) are validated in practice for stroke services, acute myocardial infarct (AMI) services and dementia services in the Netherlands. METHODS: Based on the pre-study about the DMIC, a survey was developed for integrated care coordinators. In total 32 stroke, 9 AMI and 43 dementia services in the Netherlands participated (response 83%). Data were collected on integrated care characteristics, planned and implemented integrated care elements, recognition of the DMIC phases and factors that influence development. Data analysis was done by descriptive statistics, Kappa tests and Pearson's correlation tests. RESULTS: All services positioned their practice in one of the four phases and confirmed the phase descriptions. Of them 93% confirmed to have completed the previous phase. The percentage of implemented elements increased for every further development phase; the percentage of planned elements decreased for every further development phase. Pearson's correlation was .394 between implemented relevant elements and self-assessed phase, and up to .923 with the calculated phases (p < .001). Elements corresponding to the earlier phases of the model were on average older. Although the integrated care services differed on multiple characteristics, the DMIC phases were confirmed. CONCLUSIONS: Integrated care development is characterised by a changing focus over time, often starting with a large amount of plans which decrease over time when progress on implementation has been made. More awareness of this phase-wise development of integrated care, could facilitate integrated care coordinators and others to evaluate their integrated care practices and guide further development. The four phases model has the potential to serve as a generic quality management tool for multiple integrated care practices.

The implementation of integrated care: the empirical validation of the Development Model for Integrated care.

BACKGROUND: Integrated care is considered as a strategy to improve the delivery, efficiency, client outcomes and satisfaction rates of health care. To integrate the care from multiple providers into a coherent client-focused service, a large number of activities and agreements have to be implemented like streamlining information flows and patient transfers. The Development Model for Integrated care (DMIC) describes nine clusters containing in total 89 elements that contribute to the integration of care. We have empirically validated this model in practice by assessing the relevance, implementation and plans of the elements in three integrated care service settings in The Netherlands: stroke, acute myocardial infarct (AMI), and dementia. METHODS: Based on the DMIC, a survey was developed for integrated care coordinators. We invited all Dutch stroke and AMI-services, as well as the dementia care networks to participate, of which 84 did (response rate 83%). Data were collected on relevance, presence, and year of implementation of the 89 elements. The data analysis was done by means of descriptive statistics, Chi Square, ANOVA and Kruskal-Wallis H tests. RESULTS: The results indicate that the integrated care practice organizations in all three care settings rated the nine clusters and 89 elements of the DMIC as highly relevant. The average number of elements implemented was 50 ± 18, 42 ± 13, and 45 ± 22 for stroke, acute myocardial infarction, and dementia care services, respectively. Although the dementia networks were significantly younger, their numbers of implemented elements were comparable to those of the other services. The analyses of the implementation timelines showed that the older integrated care services had fewer plans for further implementation than the younger ones. Integrated care coordinators stated that the DMIC helped them to assess their integrated care development in practice and supported them in obtaining ideas for expanding their integrated care activities. CONCLUSIONS: Although the patient composites and the characteristics of the 84 participating integrated care services differed considerably, the results confirm that the clusters and the vast majority of DMIC elements are relevant to all three groups. Therefore, the DMIC can serve as a general quality management tool for integrated care. Applying the model in practice can help in steering further implementations as well as the development of new integrated care practices.

Promoting thrombolysis in acute ischemic stroke.

BACKGROUND AND PURPOSE: Thrombolysis with intravenous recombinant tissue plasminogen activator is an effective treatment for acute ischemic stroke, but the number of treatable patients is limited. The PRomoting ACute Thrombolysis in Ischemic StrokE (PRACTISE) trial evaluated the effectiveness of a multidimensional implementation strategy for thrombolysis with intravenous recombinant tissue plasminogen activator in acute ischemic stroke. METHODS: The PRACTISE trial was a national multicenter cluster-randomized controlled trial with randomization after pairwise matching. Twelve hospitals, both urban and community, academic and nonacademic, in the Netherlands participated. All patients admitted with stroke within 24 hours from onset of symptoms were registered. The intervention included 5 implementation meetings based on the Breakthrough Series model. The primary outcome was treatment with thrombolysis. Secondary outcomes were admission within 4 hours after onset of symptoms, death or disability at 3 months, and quality of life. RESULTS: Overall 5515 patients were included in the study' 308 patients (12.2%) in the control centers and 393 patients (13.1%) in the intervention centers were treated with thrombolysis (adjusted OR, 1.25; 95% CI, 0.93 to 1.68). Among the 1657 patients with ischemic stroke admitted within 4 hours from onset, 391 (44.5%) of 880 in the intervention centers were treated with thrombolysis and 305 (39.3%) of 777 in the control centers; the adjusted OR for treatment with thrombolysis was 1.58 (95% CI, 1.11 to 2.27). CONCLUSIONS: An intensive implementation strategy increases the proportion of patients with acute stroke treated with thrombolysis in real-life settings. An apparently pivotal factor in the improvement of the treatment rate is better application of contraindications for thrombolysis.

Integrated dementia care in The Netherlands: a multiple case study of case management programmes.

The number of dementia patients is growing, and they require a variety of services, making integrated care essential for the ability to continue living in the community. Many healthcare systems in developed countries are exploring new approaches for delivering health and social care. The purpose of this study was to describe and analyse a new approach in extensive case management programmes concerned with long-term dementia care in The Netherlands. The focus is on the characteristics, and success and failure factors of these programmes.A multiple case study was conducted in eight regional dementia care provider networks in The Netherlands. Based on a literature study, a questionnaire was developed for the responsible managers and case managers of the eight case management programmes. During 16 semistructured face-to-face interviews with both respondent groups, a deeper insight into the dementia care programmes was provided. Project documentation for all the cases was studied. The eight programmes were developed independently to improve the quality and continuity of long-term dementia care. The programmes show overlap in terms of their vision, tasks of case managers, case management process and the participating partners in the local dementia care networks. Differences concern the targeted dementia patient groups as well as the background of the case managers and their position in the local dementia care provider network. Factors for success concern the expert knowledge of case managers, investment in a strong provider network and coherent conditions for effective inter-organizational cooperation to deliver integrated care. When explored, caregiver and patient satisfaction was high. Further research into the effects on client outcomes, service use and costs is recommended in order to further analyse the impact of this approach in long-term care. To facilitate implementation, with a focus on joint responsibilities of the involved care providers, policy recommendations are to develop incentives for collaborative financial contracts between insurers and providers.