Towards a framework for trust-based management of municipal home care. A realist informed evaluation.

Abstract Background This study reports on a two-step service innovation project commissioned by the City Council of Oslo, coined as the Trust Model (TM). The aim was to develop a trust-based management model in municipal home care as an alternative to the purchaser-provider split (PPS), which has been the prevalent model in Norwegian and most European health services since the introduction of New Public Management in the 1990s. The TM was developed through a comprehensive participatory process.Methods The objectives were to a) identify important mechanisms facilitating or preventing the development and implementation of the trust model, and b) identify participants perceived outcomes. A realist informed process evaluation using mixed methods was performed in two iterations. The first (autumn 2016) included three districts, three teams and 80 patients. The second (2017) included four districts, eight teams and 160 patients.Results The TM was developed across the four districts. Team members, team leaders and managers found the TM promising, and no one wanted to return to the PPS. Patient satisfaction improved significantly during the first iteration. The TM iterations were complex, involving a series of agents interacting on different levels; interactions which in turn influenced the processes and ongoing interactions. The evaluation displayed a variety of interpretations of the TM and of trust as an organizational value. A series of needs for improvements were identified, including (1) develop a clear description of the model and its managerial principles, (2) develop a culture for trust-based management on all levels, (3) build team leaders’ competence, especially in trust-based management and coaching of team-members (4), clarify roles and responsibilities among team-members, (5) develop common procedures for allocation and distribution of services, and (6) build team-members communication competence in active listening and shared decision-making.Conclusions/implications Complex, values-based organizational innovation and change (like TM) challenge existing institutional logics (like NPM) and an organization’s ability to cope with institutional hybridization. The complexity of organizational innovation in home care and of researching this topic is understudied. The importance of recognizing the complexity of trust-building and the inherent slowness of radical service innovation should be further explored.