Examining preconditions for integrated care: a comparative social network analysis of the structure and dynamics of strong relations in child service networks

BACKGROUND: To help ensure that children and families get the right support and services at the right time, strong and stable relationships between various child service organizations are vital. Moreover, strong and stable relationships and a key network position for gatekeepers are important preconditions for interprofessional collaboration, the timely and appropriate referral of clients, and improved health outcomes. Gatekeepers are organizations that have specific legal authorizations regarding client referral. However, it is largely unclear how strong relations in child service networks are structured, whether the gatekeepers have strong and stable relationships, and what the critical relations in the overall structure are. The aim of this study is to explore these preconditions for integrated care by examining the internal structure and dynamics of strong relations. METHODS: A comparative case study approach and social network analysis of three inter-organizational networks consisting of 65 to 135 organizations within the Dutch child service system. Multiple network measures (number of active organizations, isolates, relations, average degree centrality, Lambda sets) were used to examine the strong relation structure and dynamics of the networks. Ucinet was used to analyze the data, with use of the statistical test: Quadratic Assignment Procedure. Visone was used to visualize the graphs of the networks. RESULTS: This study shows that more than 80% of the organizations in the networks have strong relations. A striking finding is the extremely high number of strong relations that gatekeepers need to maintain. Moreover, the results show that the most important gatekeepers have key positions, and their strong relations are relatively stable. By contrast, considering the whole network, we also found a considerable measure of instability in strong relationships, which means that child service networks must cope with major internal dynamics. CONCLUSIONS: Our study addressed crucial preconditions for integrated care. The extremely high number of strong relations that particularly gatekeepers need to build and maintain, in combination with the considerable instability of strong relations considering the whole network, is a serious point of concern that need to be managed, in order to enable child service networks to improve internal coordination and integration of service delivery.