1. Inter-organizational collaboration in the primary care of frail seniors David Patrick Ryan, Ph.D. C.Psych. Director of Education & Knowledge Processes, Regional Geriatric Program of Toronto Assistant Professor, Faculty of Medicine, University of Toronto

2. What is frailty? Complex bio-psychosocial and functional difficulties co-occur. Risk of adverse health events is high Independence and self-worth are easily compromised Risk of institutionalization is high The fastest growing demographic group in Canada Frailty brings increased need for health care services and demands high levels of teamwork and inter- sectoral collaboration.

3. Build-a-case on frailty Patient characteristics Clinical characteristics The circle of care

4. Our frail patients are served by many teams, agencies and organizations. They think we talk to one another But we seldom do, lost as we are within our particular silos This is the dilemma that local health integration networks are struggling to resolve

5. When environments require complex interdependency the quality of collaborative alliances may predict outcomes better than the internal processes of individual teams (Pfeiffer, 86)

6. But, just as simply putting health professionals together to work in teams often doesn’t produce effective teamwork so simply putting teams to together to work seldom leads to effective inter-organizational collaboration (Ryan, et al. 1996) Like teamwork, inter-organizational collaboration may be slow to develop and quick to decline (Burt, 2002) Like teamwork inter-organizational collaboration requires ongoing care and tending

7. The GiiC Inter-Organizational Collaboration Tools Team culture and models of reality Boundary spanning functions Expectation dynamics Systems theory & the internal organization of subsystems Social network analysis

8. Teams and organizations develop unique cultures that represent their working reality. Seldom fully conscious to team members, distinct cultural differences can prompt in-group bias and inter-team rivalry Awareness of the sources of differentiation can help teams anticipate issues that could threaten collaboration

9. Sources of diversity between collaborating teams Developmental Stage Forming Storming Norming Performing Cognitive model Logic of assessment Breadth of focus Perception of time Geography of practice Language Style of documentation Focus of team culture Power focused Role focused Task focused Relationship focused Customer focused

10. Interorganizational collaboration and boundary functions Scout Modeling the external environment Gathering information and resources Keeping an eye on change Gathering feedback AmbassadorOpening up channels of communication Coordinating and negotiating Marketing the team Guardian Gate keeping Translating Filtering Ensuring delivery Adapted from Ancona & Caldwell (1988)

11. Expectation dynamics and interorganizational collaboration The expectation of a win/win outcome The expectation that scarce resources will be shared The expectation that the burden of work will be distributed

12. When collaborating organizations differ in their degree of internal structure and organization. When information is exchanged across the boundaries of subsystems that differ in their level of internal organization, the effect of the exchange is an increase in the level of organization of the more highly organized subsystem, often at the expense of the less organized subsystem

13. Interorganizational collaboration and social network theories Structural holes (Burt) Resource mobilization and connectedness (Lin) Peripheral participation (Wenger) Strength of weak ties (Granovetter) Trust and strong ties (Uzzi) Networked individualism (Wellman)

14. A simple network diagram (Burt, 1999) FHT or CHC Seniors Day Program A Community Hospital

15. Social Network Diagram of a Family Practice (from Scott et al 2005)

16. Social Network diagram of another family practice (from Scott et al 2005)

17. Health Professional Advice Network ( from Coleman et al 1966 p. 75)

18. Health professional discussion network ( from Coleman et al 1966 p.76)

19. Health professionals friendship network ( from Coleman et al 1966 p. 78)

20. What would our patients network look like?

21. The GiiC Interorganizational collaboration toolkit Through the project evaluation we will construct two network analyses of your FHT/CHC practice and send them back to you The network of relationships within your team The interorganizational network The GiiC consultants will help you to reflect on the meaning of these analyses along with the issues of cultural differentiation, boundary functions, expectation dynamics and systems functions

22. Please find a copy of the reference list for this talk online at the url below http://rgp.toronto.on.ca/article.pl?sid=05/08/30/1936247