MAIA Method

The MAIA method (Method of action for the integration of healthcare and support services in the field of Autonomy) was launched in 2008, with the aim of overcoming the barriers of service systems fragmentation regarding populations in vulnerable situations. The implementation of the method was assigned to the regional health agencies (ARS).

If several coordination mechanisms have been tested before the MAIA method in France, the MAIA method especially differs from these mechanisms by the inclusion of a case management system which supports home-isolated elderly. It creates value directly for the final user (his/her well-being, respect of the will of elderly people, restore home care).

The MAIA method aims to ensure the decision-making process between stakeholders by setting up meetings at a local level between decision-makers and funders of gerontological policies (strategic level), and between the local operators responsible for the healthcare and support services that help seniors to stay at home (operational level). Currently, the MAIA method is a public policy institutionalized in the Family and social action code.

Stakeholders & Beneficiaries

The value creation of the MAIA method is first to improve the efficiency of the elderly pathway and the well-being of users (by improving the quality of care, the accessibility to services). The value creation is also directed towards professionals (as users of the MAIA office) and user’s family as it seeks to avoid the bad quality of answers given to the user’s family, to caregivers and health professionals. The MAIA method also create value via the professional dynamics generated through the harmonization and standardization of professional practices (by working on shared common tools, sharing knowledge, implementing protocols as a means to improve quality and equity). Partnership value is created over time by the mobilization of professionals, the pilot, and the case manager (identification of new resource persons). This dynamic should improve the service system (by identifying missing services, to avoid service disruption and wrong orientations, creating co-responsibility, by adjusting the offer to the needs). Finally, at an economic scale, it concerns citizens as taxpayers, the reduction of non-quality costs should reduce the amount of taxes.

Co-creation process

If the MAIA method is originally top-down, the deployment is left to the initiative of the MAIA pilot: this approach requires a bottom up process because the priorities and drivers of actions, which enable this method to be implemented, must emerge from the partners themselves. The MAIA system requires the commitment and the co-empowerment of stakeholders of the health, medico-social and social sectors. However, this co-empowerment is not spontaneously developed, especially in the context of instability of the ARS teams. In the MAIA system, the value is created by the whole set of professional partners who participate to the working groups to create common communication tools (e.g. orientation forms), who also try to articulate and adjust the existing committees with the tactical table. For example, the development of an integrated, one-stop service, can only be done with the partners (meetings, training). The value is created by all the stakeholders. They create the final value for the benefit of the user (through training, tool sharing, but also by transmitting information about dysfunctions of the system or transferring information about elderly people in precarious situation). They also use the MAIA framework themselves to find contacts and to orient patients towards case managers.

Digital Transformation Process

The MAIA method is more a social innovation, rather than digital transformation, which seeks to transform the health system by implementing new forms of organization of collective work. Nevertheless, it implies a digital innovation related to MAIA’s three communication tools. (a) A shared Multidimensional Analysis Form (used by professionals from the one-step services) and the multidimensional assessment tool (used by case managers). (b) The Individualized Service Plan (PSI). It is a case management tool used to define and to plan in a consistent manner all the interventions provided to the elderly in a complex situation. (c) Shared information systems (it gathers information from the one-stop service, from the MAIA pilot, and from the case managers …). It requires the development of a common shared information system and action-steering tools, to create a directory database to identify local resources, and to be able to create the integrated, one-stop service.

Results, Outcomes & Impacts

One of the main value creations of the MAIA method is the improvement of the accessibility to services by providing an adapted answer to a problem. The aim is to avoid the bad quality of answers given to users, user’s family and caregivers. Thus, monitoring indicators have been developed and used during the implementation stage of the MAIA method especially to assess the number of contacts a senior must have established to access to the right resource. The result is that the integration of orientation counters into a one-step services simplifies people’s pathway and substantially reduce the number of contacts. At the local level, the impact in terms of organization is measured in different ways, such as the participation rate of partners at the tactical table, or the territorial distribution of seniors being managed for the case management. Regarding the participation rate of partners, the results indicate that the participants to the tactical tables are always the same volunteers, actors who encounter difficulties in their daily practice do not often wish to participate (as this could be viewed as failure) and general practitioners are rarely part of the table.

Challenges & Bottlenecks

Before the denomination of “Method of action for the integration of healthcare and support services in the field of autonomy”, the acronym MAIA was used for “House for autonomy and integration of Alzheimer disease”. The use of the first denomination of « MAIA » as a « House » resulted in a misunderstanding of the method. Beyond the misunderstanding of the denomination, the notion of integration is not well understood by a lot of actors. Actors are often seeking for interstitial measures, such as accommodation solution after hospitalization, Psychogeriatric mobile team, night nurse, etc. But these interstitial measures are clinical solutions instead of an integration system. Moreover, the MAIA method needs time to be implemented, because trust and relationships between actors take time to appear. Another barrier comes from the competition between the MAIA project and other national projects from which objectives are close to the MAIA method. On the top of that, there is a problem with the choice of the territory. The MAIA pilot must first choose the geographical territory that will be affected by the method and within which professionals will be contacted. This choice is important because it has to correspond to Regional Health Authorities, which are coordinating the project. The result of the experimental phase showed that the private actor as a holder of the project is not appropriate because it could lead to conflict of interest. It also poses a problem of data confidentiality.

Transferability & Replicability

The MAIA method is transferable. MAIAs were tested on 17 sites in France to refine tools, work procedures, and training content for case managers. Following this experiment, the method was extended on the French territory. Currently, the MAIA method is a public policy institutionalized in the Family and social action code.

Success Factors

The MAIA method as social innovation led to a methodological and organizational method: The MAIA project is a working method disseminated all over the territory so that the healthcare, social and medico-social actors of local territories work better collectively. Therefore, it leads to organizational local innovation: various stakeholders innovate together in order to find corrective measures to organizational dysfunctions observed on the local territory. This method promotes the mutual adjustment of each other actor’s missions. Otherwise, the actors may ignore each other by lack of legibility of the system, or may feel in competition with each other.

Lessons learned

A partially unexpected result is about the role of private partners and the data privacy issue raised by the concept of integration. The integration process implies the participation of private partners. The private partners could be the holder of the MAIA project. During the experimental phase, the “Private holder” management did not work for reasons of conflict of interest, which results in a problem of credibility of the (private) holder. The other professionals of the territory do not accept the holder and its practices. This lack of credibility is compounded with the problem of confidentiality of patient data. The private holder may use this data to charge services or may not protect these data enough.

Stakeholders & Beneficiaries

Policy makers

Public health managers

Health professionals

Chronic Patients

Co-creation process

The interaction between professional health providers and chronic patients is of great value in order to improve quality of life of patients and the evolution of their illness. At the same time, health policy makers and health managers affect this process with their understanding of the relationship between health providers and patients and their allocation of the scarce resources in the public health system.

Digital Transformation Process

This project is not about digital transformation process.

Results, Outcomes & Impacts

Value created in the provision of health services to chronic patients is much more than curing individuals. The main goal is to improve quality of life of the elderly taking into account both physical and mental capacities. Quoting one of our health managers, “it is about filling the years with life and not filling the life with years” Value is created in all stages (co-design, co-production, co-construction and co-innovation) and by all stakeholders. In fact , the stage at which co-creation is more important mostly depends on the type of service. However, the most important interaction is that of public service staff and patients. Quoting another of our health managers, “about 70% of the quality of life of the elderly has to do with their lifestyles (diet and habits), which are much more important than genetics. Therefore it is very important that the elderly takes a leading role in the provision of public service provision through prevention, and through the patient empowerment”.

Challenges & Bottlenecks

Each stakeholder performs differently in the co-creation of value. Health policy makers allocate the resources and decide which services are the priority for their health policies. Their interaction and communication with health managers but also with the society in general will make them more sensitive to their needs. Chronic patients find that the Community is not engaged with them, and in a sense, they feel a bit abandoned. This is important as the Community may affect the direction of health policies. There is room for increasing the importance of the role of patients in the provision of health services. Even if in the last decades, there has been a continuous process of taking more and more into account the patient, in what has been named as a patient centred health system, they still feel that they are not sufficiently asked about their needs and levels of satisfaction.

Transferability & Replicability

Even if this case study was performed with a special focus on Parkinson patients, with the collaboration of Asociación Parkinson Madrid (an association of Parkinson patients in Madrid), most of the lessons are applicable, with limitations, to the co-creation of value in the interaction of the different stakeholders in the organisation and provision of care for patients with other chronic conditions.

Success Factors

The interaction between health professionals, providing health services and patients is a success in the creation of value, which is not only to cure patients (many times unfeasible solution for chronic conditions) but to improve the quality of life of patients. They, through a better engagement in the process of health provision, may understand better their condition and improve their quality of life through their lifestyle and habits, delaying the progression of the disease.

Lessons learned

The interaction of the different stakeholders is key in all stages, from realizing the need of a change or innovation to the design of the service provision, or to the actual production and construction of the health service provision. The clearest interaction is that of health professionals with chronic patients. However, health policy makers and the Community, are somewhat disengaged with the real needs of patients.

INTRAS-IDES

INTRAS Foundation is a private NGO that was established in 1994 thanks to the effort of various professionals strongly involved (both through direct intervention and research) with people suffering from mental illness and cognitive impairment.

In order to fulfil this goal, the Foundation hosts a vast care infrastructure (e.g, nursery homes, day-care centres, teams of personal autonomy promotion, a special employment centre) mostly based in Castile-Leon (Northwest of Spain), even though the region of Madrid has been also benefitted.

In this context, IDES is the spin-off of the INTRAS Foundation and was born with the basic aim of promoting knowledge transfer through different activities, such as training, the development of care-based technologies, the promotion of the usability lab and the IDES Living Lab, whose activity is the core of the present analysis.

Stakeholders & Beneficiaries

The main goal of INTRAS Foundation is thus helping people suffering from mental illness and cognitive impairment restore their life project through the delivery of an integral circuit of care resources and services and the deployment of different R&D&I activities. This integral circuit of care resources involves: a) prevention/intervention/rehabilitation; b) monitoring & evaluation; c) education & training; d) self-management & empowerment; e) fight against stigma; f) labour integration; g) management and coordination.

Co-creation process

Even though the activity is focused on people suffering from mental illness and cognitive impairment, IDES provides help and “guidelines” in the living lab sessions, but final decisions are ultimately taken by patients so as to ensure that they live the life they wish, taking into account that users’ capabilities are rather different according to the degree of impairment, which obviously is conditioning the degree of involvement. IDES vision advocates that the best ideas come from involving people, and without the insights gained through the lived experiences, policy makers and professionals run the risk of developing costly services that do not meet the needs of those who will be using them. Notwithstanding this, co-creation as a concept has fairly evolved along with different key projects implemented so far at IDES. In fact, two different periods may be distinguished. Thus, a first period (2007-2014) is characterized by the creation of a new stakeholders´ ecosystem. In this first stage, user was fairly considered a tester. The second period, which started in 2014 and is still on-going, strongly advocates participatory design and user co-creation. Different projects implemented throughout the period have helped gear this major shift (e.g CAPTAIN or MinD). Period 2019-2028 is set to evolve through an encompassing community-based approach, where co-creation is not focused merely on users, but on citizens.

Digital Transformation Process

This case study is not about digital transformation

Results, Outcomes & Impacts

Outstanding effort is being devoted to come up with metrics aimed at measuring contribution of users in co-creation processes and experiences. IDES do provide evaluation of sessions in terms of, for example, usefulness or satisfaction, but they lack systemic/overall evaluation tools. Furthermore, evaluation is very much anchored on qualitative (subjective) indicators that do not provide robust evidence for comparison (i.e. levels of satisfaction and/or empowerment), whereas quantitative indicators are not usually considered because they are not easy to obtain as co-creation deal with perceptions and people interactions. ROI type of impact measurement would be also quite necessary in terms of accountability, thus providing evidence that projects do work, which eventually may imply higher attention by the public sector and better project funding. Notwithstanding this, some specific and pioneering assessment methodologies are being developed in the context of specific projects where IDES is engaged (e.g., CAPTAIN, where a new protocol of cost-effectiveness indicators is being created). Finally, it should be mentioned that users´ level of engagement (recurrence) is also considered a way of measuring performance by IDES projects. As such, if users are keeping on attending subsequent co-creation sessions, this is a clear sign of good performance.

Challenges & Bottlenecks

A major challenge is how effectively measure outcomes and impacts of IDES activity and how to gauge user co-creation according to the level of impairment. Furthermore, IDES living lab is at the centre of a vast ecosystem bridging healthcare service providers, research and technological centres, technology-based companies and users and the public sector, whereby a major challenge is how to arrange this ecosystem in a meaningful and useful way to achieve IDES goals. In that sense, IDES role as a “network/linking infrastructure” is paramount.

Transferability & Replicability

This “user co-creation” based framework is is set to evolve through an encompassing community-based approach, where co-creation is not focused merely on users, but on citizens. As such, according to this scenario, co-creation is far from being a “niche” concept intended to be operated by users to become the centre of many citizenry-based settings. That is, it will imply using co-creation as the raison d’etre of providing participatory solutions where the citizen (and not the user) is the ultimate protagonist. As it may be noticed, this is to be a major shift at IDES activity in the future, since co-creation practices are meant to be somewhat different and the role of the different stakeholders would need to be accordingly adapted. In this sense, IDES is working on evolving the concept of living lab into “impact hubs” that will combine innovation deployment with the introduction of further levels of citizen´s participatory models to build upon the very concept of community (instead of “group”).

Success Factors

The motto of IDES is “nothing about us without us”. Involving users in a participatory process creates commitment, empowerment and appropriateness, thus making up a “convincing case”, a “service ambassador” and an incentive against sceptical people. Massive collaboration and participation are in the DNA of IDES, as “cross-fertilisation” is a major driver of success (i.e., more than 2,000 people of different nationalities do collaborate in different initiatives put forward by INTRAS-IDES). Heavy involvement in different projects (some of them European-based, such as CAPTAIN, MIND or PROCURA) has enabled the deployment of innovative and pioneering methodologies & technologies spurring co-creation.

Lessons learned

Co-creation unleashed by IDES Living Lab activity allows the achievement of higher levels of trust, self-empowerment, self-autonomy or perception of identity on the user side. Furthermore, public value is also created by improving social engagement (with other patients, staff, family and friends) and community building.

Stakeholders & Beneficiaries

Municipality and hospital

Co-creation process

The idea is to develop and implement healthcare innovations through a living lab approach in which an external consultancy leads the co-creation process which is the living lab. The living lab is anchored in and owned by a stakeholder organization. The main stakeholders are asked to define a problem and develop hypothesis concerning the cause of the problem. They also generate ideas as to its solution. In one case, citizens from a municipality have involved in setting priorities for health care through a street lab approach. Though the living lab approach, ideas are generated and developed into innovations within problem-framework defined the main stakeholders. Trusted users test the ideas and ideas are experimentally implemented in a real-life context.

Digital Transformation Process

Innovations may involve digital technology such as mobile technology.

Results, Outcomes & Impacts

Results are specific innovations in health care. Further, the living lab approach is changing the mindset of the healthcare organisations towards thinking healthcare in a new way and becoming more outward oriented taking users situation more into consideration. The overall idea is, however, to create public value by changing the healthcare system towards a more patient-oriented approach.

Challenges & Bottlenecks

A main challenge is that it takes time and efforts to change healthcare. Some user-oriented innovations may be easy to implement; however, some can take several years because they involve scientific projects. Scientific evidence for the effectiveness of the proposed solutions must be provided.

Transferability & Replicability

An innovation method has been developed that draws on other methods and the scientific literature about innovation and change management, and for which there is some scientific evidence. This method may work in other contexts as well.

Success Factors

Providing new solutions in healthcare that change the healthcare system towards involving users more in taking care of own health. This must lead to fewer hospital admissions and higher perceived quality of healthcare.

Lessons learned

Living labs can be a method of collaborative innovation that involves strategic changes of the healthcare system towards a more outward oriented approach.

The Clinical Centre NeMO (NeuroMuscular Omnicentre)

The Clinical Centre NeMO (NeuroMuscular Omnicentre), a highly specialised medical centre part of the public Italian healthcare system (Sistema Sanitario Nazionale). The center manages four clinical facilities distributed from the North to the South of the Italian territory, located in Milan (Lombardy Region), Rome (Lazio Region), Messina (Sicily Region) and Arenzano (Liguria Region). Nemo responds specifically to the needs of those affected by neuromuscular diseases, implementing a multidisciplinary approach that puts users’ needs at the center. Its main purpose is to improve the quality of life of patients, providing them and their families with clinical and psychological support. Its mission is to create a network for the diagnosis, cure, and care of neuromuscular diseases based on the excellence of medical services and the centrality of the patient’s needs. Its objectives are about preserving the autonomy of the patient as long as possible, preventing and/or slowing down the evolution of the disability, improving the general quality of life. In particular, the individual rehabilitation plan is managed by a multidisciplinary team (composed by neurologists, neuropsychiatrists, psychologists, pulmonologists, and physiatrists) that takes care of the patient and his/her family along all the stages of the disease. Another novelty is the “nurse coach” who helps the family in taking care of the patient once come back home and manages the relations between the caregivers and NeMO and other medical services. The Centre’s 4 medical facilities reach out to approximately 3,200 patients/year. Its operating model relies, amongst other principles, on provision of funds from associations whose members are people with neuromuscular diseases and their families. Its operating model relies, amongst other principles, on provision of funds from the associations of people with neuromuscular diseases. That, allied with the fact that its operations are carried out necessarily inside of facilities/hospitals owned by the National Healthcare System, allows Nemo to provide free services to its patients.

Stakeholders & Beneficiaries

NEMO exists to take care of patients with neuromuscular diseases and their families. They are frequently grouped in family associations. The team of doctors, specialists, nurses and the management are all devoted to putting the patients at the centre of the treatment / care. The city of Messina is talso an important community for Nemo in terms of local support, because the city is small, so the Centre is more representative within that context and all the community is involved in the project. When patients die, the family raise donations for the Centre, and all of the persons involved participating in all the stages, even in the death moment. Professionals also mention ASL – the local public healthcare institution, but maybe even more important are the suppliers/home care providers, that understand the functioning and the bureaucracy to which they are subject to and are flexible in efficiently providing Nemo with necessary supplies.

Co-creation process

Co-creation is taking place in all three phases: planning, structuring and service delivery. Not yet in the part when patients go home (domicile phase), as the Centre is not completely well structured for that yet. According to patients, value is created in both the design and the delivery of services, as Nemo works, in co-creation, co-production with them, on innovation, listening to their needs and treating them with dignity. The importance of the families’ integral participation in the process is highlighted in the professionals’ testimonial as well. All stakeholders also agree on the evaluation of services, as it allows the professionals to redesign and adapt their service, which do not exist separately, but it is a result of all phases in which the patient is present.

Results, Outcomes & Impacts

The patients and families are all very satisfied with the non-standardised, or individualised, care model applied in Nemo. They rate each professional they meet during their treatment on a scale from 1 to 7 as follows: nurse coach: 6,71; physiotherapist: 6,65; nurse: 6,76; speech therapist: 6,69; doctor: 6,75. According to page 21 of the CSS report, their perception of the treatment received from their arrival through their stay in Nemo’s facilities is as follows: possibility of accessing Nemo 24/7: 6,69; respect to their privacy: 6,67; their perception of being treated as a person, and not just as a patient: 6,60; respect and approach regarding their religious beliefs: 6,59; dedicated spaces to leisure time (recreation, tv, games): 6,56.

Challenges & Bottlenecks

In spite of the unarguable evidence collected in the different fieldwork approaches regarding value creation, the question of value destruction was also brought up by some of the involved parts. Nurse coach brought up the risk from the part of healthcare professionals of being too involved in their jobs and ultimately “loosing” their sense of personal life. Also, the “excess” of care can highlight a consequence of value destruction for the patients as they could expect too much care and forget that they have a brute, degenerative pathology that needs an active role from them too to be fought. Political relations must be carefully managed too, otherwise a wrong move can lead to value destruction, like in the nonprofit world, where egoism of its actors can sometimes lead to conflicts and disruption, or in the social media world, with the propagation of various news, which can generate conflicts and disruption in the value creation process. Finally, the risk of creating excessively high expectations and not delivering what patients expect, i.e. the cure, because it has not yet been found for neuromuscular diseases, also represents a big challenge.

Transferability & Replicability

The model of the nurse coach is already inspired from something that is well-known in the U.S. Model. Also, the methodologies is applied in four different clinical facilities throughout Italy. So, the clinical medical concept it not related to any very specific, local context and can be replicated or transferred.

Success Factors

Creating a symbiosis among all the stakeholders is what makes the individualised care system work: patients must be aware and feel confident towards the multidisciplinary team; healthcare professionals must carry certain types of value (respect, dignity, etc.) not only in their professional life but also in their personal one to be able to use them with the patients; family associations play a crucial supporting role (financially, emotionally, in research); the supplier/home care providers, that understand the functioning and the bureaucracy to which they are subject to and are flexible in efficiently providing Nemo with necessary supplies, are facilitators; the local health public institutions need to be involved as well; and the citizens and communities are key too. All stakeholders work hand in hand towards the same goal, i.e. allowing people with neuromuscular diseases to not only survive but actually live quality lives.

Lessons learned

Evaluations are critical to constantly improve the services and keep as close as possible to the patients’ needs. Through constant monitoring of how much they offer to every patient, they can improve the answers to treatment needs. Based on this principle, they have developed a system for evaluating the satisfaction of patients accessing the services, based on their perception of the care/operating model. In concrete, Nemo has developed a customer satisfaction survey which is the result of a multidisciplinary work, through which the professionals of Nemo have expressed their point of view on the issues to be evaluated. For the first time, topics such as the respect for the individual and his/her choices, the perception of being ‘at the center of care’, welcoming to the patient’s family nucleus, were studied. This system also allows for the healthcare professional to redesign their role based on the indicators that are measured not only by the patients, but also by the public healthcare system.

Bispebjerg-Nørrebro (BIN) Project

The research setting of the case study is the elderly care sector in the municipality of Copenhagen, Denmark. The municipality has been undergoing a paradigm shift towards an increased focus on what a good life contains to elderly citizens (Københavns Kommune 2015b). This is discursively constructed in the elderly care policy as a move from “passive to active” implying an increased focus on self-determination and participation of citizens (Københavns Kommune 2015a). An experiment with improving elderly care services were organized by the municipality over a three-year period in 2015-2017. The project was called “Quality of life for elderly people in non-profit housing areas” targeting loneliness amongst elderly people living in their own homes. The point of departure was three residential areas for elderly, but the focus in this case study is on one specific area, the sub-project Bispebjerg-Nørrebro (BIN). The project is an illustration of the interplay between “prolonged” activities (taken place in the residential area) and activities maintained by the same employees in the local Activity Centre (Activity Centre Bispebjerg). The main aim of the project is: to enhance life quality and lessen loneliness among residents by creation of residence-near activities, which promote the creation of network and friendships, that the residents themselves want to engage in and manage after project completion (Project description, 2015). The project activities ended in the beginning of 2018, but the findings of the project continues as spin offs at different levels in the municipality e.g. as a loneliness foundation and a new initiative at the Activity Centre focusing on how the elderly to a larger degree can use the city of Copenhagen.

Stakeholders & Beneficiaries

Policymakers define the strategy. Front-line employees implement the physical training and relationship building courses (in their own words, they “make an offer” to the benefiairies – the seniors) and senior participate in the activities. Sometimes, external actors are involved too, as with the Cycling Without Age, a voluntary programme initiated by one citizen (to take elderly citizens on bicycle trips in the city), where the municipality responded positively, by purchasing some bikes to scale up the initiative. Finally, private funds and private firms play a role in research projects in the municipality (via living labs activities), as well as in the development of welfare technology.

Co-creation process

Policymakers define the strategy for healthcare policy for the elderly. Based on this framework, the front-line employees of the Activity Centre design training sessions with the elderly who take part. After a long period of time, the elderly can take charge and interact with each other on their own.

Digital Transformation Process

The municipality further participates in several living lab activities, where welfare technology developed by private firms are tested by citizens.

Results, Outcomes & Impacts

The main success criteria of the project is that it is perceived as meaningful for the elderly and that the municipality ensures that the findings and the learning of the project are applied prospectively. The success of the Activity Centre is mainly measured by its occupancy rate and members receive a phone call on a yearly basis as part of a satisfaction survey. In both cases the Centre gets high scores, but there is a caveat: the evaluators do not visit the centre and don’t see how the activities and the daily life unfold. Also, the employees think there is a lack of focus on what they perceive to be main objective of their work; i.e. the measurement of parameters that can embrace relationship building, life quality, degree of loneliness, the excitement of the elderly in the daily activities, etc. They propose to measure the amount of readmissions among the elderly that use the centre, testing of functional ability and to use the start-up dialogue with the elderly and the subsequent evaluation dialogues (each year) to see if they have experienced a change in life perspective.

Challenges & Bottlenecks

1) There is a disconnect between the policymaking level and the operational level on value co-creation: when reacting to what the role of staff is in value creation, policymakers emphasize strongly both the need for political structures and for development work at the strategic level as a basis for public service staff in creating value, but, at the level of the projects, there is much more emphasis on the competencies, enthusiasm and the mood of the front-line staff in co-creating value in direct interaction with the elderly users. 2) Policymakers state that, at the strategic level, there is strong interest in user involvement. Yet the potential of user involvement is not realised in a systematic way in practice. There is a lot of rhetoric rather real user involvement. Whilst the municipality is making an effort to listen to the users, the impact of this approach is still weak. 3) Projects like this one are meant to become driven by the users/citizens over time. Citizens should create the value and take responsibility for it. But here, the elderly citizens do not see themselves as having a key role creating value for others. And it takes time for the front-line employees to build trust with the seniors (1.5 year, according to the log-books), so that, later on, they can slowly withdraw as main actors and let the elderly themselves be drivers – based on their new social relations.

Transferability & Replicability

The objective of the project is to foster the ability of the elderly to stay as long as possible in their own home and to be self-sufficient as long as possible thanks to a good mental and physical health – which are stimulated by physical training and relationship building. This very general objective is replicable in other municipalities.

Success Factors

1) To let the surrounding community (associations, evening schools) use the facilities of the Activity Centre, outside opening hours. 2) A condition for creating value to the elderly, is to work network-oriented in the municipality and to open up between the different institutions at an individual level. 3) Create platforms where it is possible as an individual to be something for the elderly – e.g. supported by digitalisation. 4) To counteract the practice of the public sector that classifies people and puts them into boxes (e.g. the box of an elderly that starts at 65+) more flexible housing areas for people across generations could be developed – also to support the changing family structures. 5) If there were resources to support the relationships outside of the Centre, improvements could be greater 6) Invite other Activity Centres and their events to our place or to do activities together with groups of elderly that have the same challenges/oppurtunities. 7) To increase the visibility of the Activity Centre – and to create opportunities for being or becoming e.g. a visitor. 8) To make sure the local environment is designed for the needs of the Centre’s participants (e.g. having a hairdresser, a grocery shop, a church, in the whereabouts).

Lessons learned

1) It seems as if the lingo of public services and value co-creation, as part of the policy terminology of the welfare state, is mainly mirrored at a tactical and strategic level, but less at the operational level. The danger is that policies might become detached from practice, which is why it seems pertinent to contextualize what is meant by value and to whom. Or to discuss whether the term value are analytically suitable if it becomes a straitjacket to understand the logic of public services from an employee perspective. 2) There is a change that has taken lace from a partial patronizing approach towards a more responsive approach to care. However, to provide care must still first of all correspond to professional standards, and then next be responsive to users’ expectations and experiences. It’s less advanced than in the MAIA approach, where the senior’s need are placed above the professional’s diagnostic. 3) There is a generational effect: the elderly of today come from a frugal generation. They do not expect the public sector to solve their problems and are therefore quite thankful for all initiatives they perceive to be beyond their rights as citizens e.g. medical care and hospitalisation. An offer such at the Activity Centre and being part of the BIN-project falls within these not-expected-categories.

The MAIA method (Method of action for the integration of healthcare and support services in the field of Autonomy)

The case study examines the MAIA method (Method of action for the integration of healthcare and support services in the field of Autonomy). It is an organisational model adapted to local specificities. The increase in life expectancy and the ageing of the population have led to the problem of old-age dependency. Gerontological answers exist, but in France, coordination between the healthcare, social and medico-social fields is not sufficiently articulated and remains hospital-centred. These institutional, organisational and clinical fragmentations have serious consequences for the health pathways of elderly people. They cause discontinuities in elderly care (healthcare, support, waiting list in specialised institutions [Ehpad]), as well as contradictory decisions between professionals. This poor coordination makes the health system more expensive (emergency hospitalisation, hospital re-admission). To manage these dysfunctions, researchers have proposed to public decision-makers to establish an integration strategy, according to the Quebec concept, by adapting it to the features of the French system, and specifically by maintaining the centralised health insurance system. The purpose is not to create new structures but to organise and enhance the clarity of the healthcare and support system by ensuring the articulation and coherence of existing resources in the healthcare, social and medico-social fields.

Stakeholders & Beneficiaries

MAIA aims to ensure the decision-making process (interaction, collaboration) between stakeholders at two levels: at a strategic level – in order to develop a collaborative and decision-making space between decisionmakers and funders of gerontological policies (ARS, departmental councils, and others); at a tactic level – in order to create a collaborative and decision-making space between the operators responsible for the healthcare and support services that help seniors to stay at home. For seniors in complex situations, an intensive and long-term follow-up (including during hospitalisation periods) is implemented by a case manager (a new professional skill). This professional is the direct contact with the senior, with the general practitioner, with the professionals working at the senior’s home, and becomes the referent of complex situations.

Co-creation process

At the institutional level, there is a top-down approach to co-creation, designed to better fit the realities of the territories: the Regional Health Agency selects, via a call for application, an infra-departmental institution (non-profit organisation) which can mobilise local actors. This non-profit will be in charge of implementing the MAIA pilot on its territory, by connecting the professionals in healthcare to fit the territorial reality. At the user level, the co-creation materialises through the dialogue between the senior (the user) and the case manager, who becomes the spokesperson for the user and translates the user’s needs and wishes to the healthcare professionals (sometimes against the advices of the health professionals).

Results, Outcomes & Impacts

In its interactions with the users and professionals, the care manager helps to improve the organisation of the care system by identifying any dysfunctions observed on the territory.

Challenges & Bottlenecks

According to Policy maker, MAIA activity reports are done by the MAIAs but require a thorough understanding. Starting to introduce indicators for measuring value creation raises problems relating to the instrumentalisation of such indicators. Ideally, a territorial roadmap used by all the operational actors would be interesting to develop, but given the fact that data would be analysed on a very small territorial scale and then structured at a regional and national level, it requires money and tools. This is not done today. Monitoring indicators have been developed and used during the implementation stage of the MAIA method (e.g. number of contacts a senior must have established to access to the right resource). Currently at the local level, the impact in terms of organisation is measured (participation rate of partners at the tactical table, or for the case management, the territory distribution of seniors being managed). It has been noted that the participants to the tactical tables are always the same volunteers, actors who encounter difficulties in their daily practice do not often wish to participate (as this could be viewed as failure) and general practitioners are rarely part of the table. According to the pilot at the local level, a tool has been evaluated, but there is no local evaluation of the value creation of the MAIA for the territory. It would be interesting to know for example the impact of MAIA on the reduction of hospitalisation in emergencies, the reduction of user orientation towards wrong services. The partners should be involved to create these indicators. For the case management, the value creation is evaluate via the decreasing needs of the senior that the case manager has to fulfill. The creation of value can be measured via satisfaction surveys but this is not a global value creation, that is, the medico-social system as a whole. Care Pathways Operational Committees are currently working on impact indicators (non-use of emergency, scheduled hospitalisation). The current problem is that the databases are currently partitioned between the medico-social, social and sanitary field, so there are difficulties to measure the impacts on a pathway of a user. Finally, MAIA is on a voluntary basis, so there is no incentive (legal, financial), for professionals who are solicitated to take part in brainstorming sessions and one can find always the same people involved.

Transferability & Replicability

This initiative is applicable to the various sub-territories of the French regions, because of its very locally-oriented – and even user-oriented approach. The concept is therefore replicable to other territories. Also, the MAIA project was already copied from a similar initiative in Quebec, Canada.

Success Factors

An integrated, one-stop service provides, at any place of the territory, a harmonised answer adapted to the needs of the users, by directing them towards the adequate resource. It integrates all the reception and orientation counters of the territory. The MAIA method includes the development of common information-sharing tools and action-steering tools (a shared multi-dimensional analysis form, a standardised multidimensional needs assessment tool, and individualised service plan). If the MAIA method is originally top-down, once the project holder chosen by the network, the deployment is left to the initiative of the Maia pilot. Thus, this method is deployed on territories in very different even innovative ways, depending on the diversity of actors and networks already existing on the territory. Thus, the approach is considered as “help-it happen” by the policymakers. Various forms of MAIA multi-stakeholder networks have emerged at a territorial level.

Lessons learned

All respondents have stressed that it is difficult to determine the moment of value creation. National and regional public manager, partners, pilots agree on the fact that the creation of value of the MAIA method is mostly upstream, as a back-office function, during the constitution of the network, when the pilot and the partners discuss together to facilitate the articulation between services (creation of a professional dynamic). The users here are the partners. Thus, the value creation takes place before the services are delivered. However, the respondents point at that the value creation is also continuous, throughout the accompaniment of seniors all over the care process (according to the national and regional public manager and partners). When a single patient joins the healthcare system, this is value creation. According to the case manager, the value is created once the professional chain around the senior is stable and complete. Thus, mostly once the service is delivered, even if the senior monitoring continues to be provided.