Journal of Community Health, Vol. 2, No. 2, Winter 1976
BUILDING A COMPREHENSIVE GERIATRIC H E A L T H CARE SYSTEM: A CASE STUDY L a u r a Bleiweiss, Ph.D., and S h a r o n S i m s o n , Ph.D.
ABSTRACT: This case study focuses on the efforts of three urban medical care institutions--a Health Maintenance Organization, a nursing home, and a university hospital--to form an interorganizational relationship. The purpose of the relationship was to utilize the services of the three organizations in order to respond to the comprehensive health needs of an urban geriatric population. Movements in this triadic organizational relationship are described and analyzed in terms of four conceptual stages--exploration, negotiation, interaction and performance, and termination. Problems arising during these stages were not resolved and the relationship was terminated after approximately two years of existence. A sociological discussion of the case focuses on why the relationship failed. The organizational relationship was disrupted by three stresses that occurred during the four stages of the relationship. Stresses emerged for each organization in the areas of organizational integration, professional coordination, and environmental adaptation, making it difficult for the three to become integrated into an organizational system. As a result, th e HMO, the nursing home, and the hospital did not benefit from relationships that could have enabled them to develop the multi-organizational system necessary to sustain an innovative, comprehensive geriatric health project. If, as Whitehead said, the greatest invention of the nineteenth century was the invention of the method of invention, the task of the succeeding century has been to organize inventiveness. The difference is not in the nature of invention or of inventors, but in the manner in which the context of social institutions is organized for their support. 1 T h e p r o b l e m facing the delivery o f h e a l t h care t o d a y is the organization o f inventiveness. F r a g m e n t e d and diffuse discoveries in t h e field o f h e a l t h n e e d to be o r g a n i z e d i n t o a c o m p r e h e n s i v e o p e r a t i o n a l s y s t e m t h a t is responsive to the diverse needs o f varied p o p u l a t i o n s . One o f the p o p u l a t i o n s t h a t e n c o u n t e r s serious difficulties in seeking health care is the u r b a n aged. F r e q u e n t l y afflicted b y a c o n s t e l l a t i o n o f i n t e r r e l a t e d p r o b l e m s t h a t i n c l u d e l o w i n c o m e , social isolation, p o o r n u t r i t i o n , and i n a d e q u a t e housing, the aged find it difficult to secure n e e d e d p r i m a r y care, e m e r g e n c y services, h o s p i t a l i z a t i o n , h o m e care, or e x t e n d e d care. Medical care o r g a n i z a t i o n s p r o v i d i n g these t y p e s o f care have e n c o u n t e r e d obstacles in a t t e m p t i n g to develop, i m p l e m e n t , and m a i n t a i n the services n e e d e d b y the aged. This case s t u d y focuses o n the efforts o f three u r b a n medical care Dr. Bleiweiss is with the University of Pennsylvania, 415 South 19th Street, Philadelphia, Pennsylvania, 19146. Dr. Simson is with the University of Pennsylvania School of Medicine, Philadelphia, Pennsylvania, 19174. This project was partially supported by a Research Fellowship Award, National Institute of Mental Health, No. 5 F22 MH57626-02. 141
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institutions, a university-affiliated Health Maintenance Organization (HMO), a university hospital, and an extended care facility, to form an interorganizational relationship. The purpose of the relationship was to utilize the services of the three organizations in order to respond to the comprehensive health needs of an urban geriatric population.
BACKGROUND
A model comprehensive health care program, a Health Maintenance Organization, was established by a private eastern university in July 1972 as part of a long-range program for improving the delivery of health services to an urban population. The development of the HMO has followed four principles: (1) the facets of a comprehensive health services system include primary care, hospital back-up, emergency services, home care, and extended care; (2) the disciplines needed to provide family-oriented health care are adult medicine, pediatrics, obstetrics-gynecology, mental health, and dental health; (3) the necessary characteristics of a health system are comprehensiveness, accessibility, accountability, and continuity; and (4) the functions of a university health system are to provide a service system as the base upon which education and research operate. In order to develop these principles, the HMO took several steps. It was established as an integral component of the 330-bed hospital of the university, thereby insuring necessary support in emergency services, hospital care, and ancillary services such as radiology and laboratories. As one of seven provider points of a city-wide health plan, the HMO became eligible to deliver care to subscribers drawn from a residential population of 275,000. The HMOs multispecialty, interdisciplinary group practice was designed to accomodate 25,000 consumers by providing comprehensive care directed toward prevention, early treatment, and rehabilitation. To attain its wide range of goals, the HMO formed relationships with numerous medical, philanthropic, educational, social, and governmental organizations. One of these was a center city nursing home. The nursing home was chartered by the state in 1957 as a skilled nursing facility? The home was under a proprietary form of ownership. At the time of the relationship with the HMO it was certified by Medicare but was not accredited by the Joint Commission on Accreditation of Hospitals. 3 The nursing home rendered 24-hour comprehensive nursing care under the direction of licensed practical nurses to patients occupying 138 licensed beds. THE CASE STUDY
The relationship involving the HMO, the university hospital, and the nursing home lasted from July 1975 to March 1975. The formal, contractual
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relationship extended from mid-July 1974 until early March 1975. Movements in the organizational relationship can be described and analyzed in terms of four conceptual stages-exploration, negotiation, interaction and performance, and termination. The time periods of the stages overlap to some extent and vary in duration. Exploration. During the summer and fall months of 1973, leaders in the three organizations met with each other and with members of their respective organizations to explore the possibility of a triadic liaison. This exploration was initiated when the Director of the HMO and the Director of Social Service at the hospital met with the chief nurse/administrator from the nursing home to discuss the concepts and goals of the HMO. Information from this meeting was relayed to the Director of the nursing home. He expressed interest in securing hospital privileges for his four osteopathic attending physicians but declined any further involvement at that time. However, in the fall of 1973, the Executive Director of the hospital and the Director of the nursing home did establish a linkage; two hospital physicians began attending patients at the nursing home. Communication between the organizations was dormant in spring 1974, while each organization evaluated its reasons for establishing a formal relationship. The nursing home was faced with the necessity of satisfying state certification requirements and improving its financial situation. The nursing home's strategy for solving these problems was to improve the quality of medical care, to upgrade in-service education to staff, and to increase the ratio of private patients to public sector patients. The HMO identified several reasons for entering into a relationship. It hoped to be able to develop and integrate extended care into a comprehensive health services system, to serve a defined geriatric population of the city, and to test its model of the geriatric nurse practitioner. The hospital was seeking a solution to its dilemma of securing transfers and satisfactory placements for aged patients who had exhausted their hospital benefits and no longer required acute care. The hospital had found nursing home beds to be at a premium because of a low turnover rate and resistance to accepting medical assistance patients. Each organization-the HMO, the nursing home, and the h o s p i t a l had determined its set of reasons for forming a triadic relationship. A growing crisis over the licensing of the nursing home propelled the three organizations into the next state of organizational relationship. Negotiation. The nursing home's license from the state to operate a Skilled Nursing Facility expired on March 22, 1974. It was not renewed. Deficiencies at the nursing home were stated to be jeopardizing the health, safety, and welfare of patients in a report by the Field Representative, Standards and Licensure, of the State Department of Public Welfare, Southeastern Region.* The nursing home requested and was granted additional *Data were later recorded in a letter dated November 22, 1974, from the Field Representative to the Administrator of the nursing home.
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time to correct deficiencies. However, visits on May 9, 10, and 15, 1974, and June 3, 4, and 5, 1974, by the State representatives revealed a lack of improvement. Confronted with the loss of license and an insufficient capability to correct deficiencies, the nursing home sought the assistance of the HMO and the hospital. Discussions took place for several weeks between the Director of the nursing home, the Director of the HMO and its main administrators, and the Executive Director of the hospital and several of his top staff members including the Director of Social Service and the Assistant Director for Finances. All the parties approved a relationship between the three organizations, and the terms of the basic agreement were spelled out in two letters of correspondence. In a letter dated July 16, 1974, the Director of the HMO communicated the provisions of the organizational relationship to the Director of the nursing home. The main points were: (1) The Director of the HMO would function as the medical director of the nursing home. The HMO would provide a full-time nurse practitioner and physician services to the nursing home. (2) The HMO would assess the health needs of patients, review clinical data, and arrange it into a health management profile. (3) The HMO would develop written policies of care that would be reviewed by a Utilization Review Committee. Utilization Review would also do a medical audit, thereby creating a Quality Assurance Program. (4) The HMO would develop admission procedures and record information. (5) The HMO would assume an active role in discharge planning. (6) The HMO would be responsible for educational programs to improve the skills of professional staff at the nursing home. (7) The HMO would provide emergency services and physician-on-call coverage. A second letter focusing on the geriatric nurse practitioner was sent by the Director of the HMO to the Director of the nursing home on July 16, 1974. The geriatric nurse practitioner would: (1) be a member of the HMO staff assigned to the nursing home (the HMO would bill the nursing home for her services); (2) be responsible for carrying out the nurse practitioner role in developing patient care programs at the nursing home while working with an HMO physician; (3) develop with other colleagues health care policies for nursing home patients; (4) participate with other personnel in implementation of these policies; and (5) be responsible to the Director of the HMO for her activity. The leaders of the newly related organizations were optimistic. This was apparent in their correspondence with each other during July of 1974. The Director of the nursing home stated: "I consider [this to be] one of the most progressive nursing home]hospital relationships that I have ever encountered. I am confident that all those interested, most importantly the patient, will benefit." The Director of the HMO wrote: "We look forward indeed to working with you and with the nursing s t a f f . . , it should be an exciting project." The Executive Director of the hospital commented: "I
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truly believe this is a most important relationship that will be valuable and productive for both of our institutions and will repay its cost m a n y times over in better care." With hopes of regaining the nursing home's license, with the terms of the basic agreement established, and with expressed optimism, the three contractually bound organizations entered into another stage of relationship, interaction and performance. Interaction and performance. The contractual relationship began in mid-July 1974 and was terminated in early March 1975. During this time, efforts were made to delineate work schedules, professional duties and responsibilities, financial arrangements, training programs, and other structural details of the organizational relationship. These efforts were punctuated by several problems, which leaders of the organizations identified as the manifest reasons for eventually terminating the relationship. The initial activities of the HMO at the nursing home were directed toward formulating and putting into practice the roles and work schedules of a health team consisting of physicians, medical nurse practitioners, and administrators. In September 1974 a geriatric nurse practitioner was recruited to the HMO staff to work at the nursing home full time. The HMO health team established a routine that included three types of patient visits: monthly visits, admissions work-ups, and treatment for episodic illness. The hours of services rendered were: physicians, 1-1½ hours daily; nurse practitioners, 4 hours daily, increased to 8 hours daily in October; and administrative personnel, 2 hours daily. Further coverage was provided by the hospital's emergency and inpatient services. The involvement of the HMO's primary care center and home care program with the nursing home was under discussion. The next set of activities were a n u m b e r of projects aimed at expanding the range of services offered at the nursing home and improving the quality of patient care. A social worker associated with the HMO and the hospital was asked in August 1974 to evaluate the need for social work input into the proper management and disposition of HMO patients at the nursing home. A report of October 1974 r e c o m m e n d e d that a full-time social worker, with a M.S.W. degree, should be employed at the nursing home. Discussions were underway in September with dentists from the HMO and its affiliated university regarding the provision of dental services to nursing home patients. Research and evaluation projects were in process regarding the various aspects of the organizational relationship. The progress of these efforts to establish an operational program for attaining mutual goals was interrupted on September 30, 1974, when the Director, Division of Long-Term Care Standards Enforcement, United States Department of Health, Education, and Welfare, wrote the nursing home: It is our determination that the provider agreement with the Nursing Center not be renewed at the end of its expiration date [October 31,
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1974] . . . . the Nursing Center has such deficiencies as to place in jeopardy the health and safety of its patients. T h e n o n - r e n e w a l o f the p r o v i d e r a g r e e m e n t at the federal level was f o l l o w e d on O c t o b e r 21, 1974, b y a n o t h e r letter f r o m the state i n d i c a t i n g t h a t the nursing h o m e ' s license was in j e o p a r d y . A licensure s u r v e y h a d b e e n cond u c t e d on O c t o b e r 1, 2, 3, and 4, 1 9 7 4 , and deficiencies were f o u n d in m u l t i p l e areas: o r g a n i z a t i o n , m a n a g e m e n t , nursing services, p h a r m a c e u t i c a l services, h o u s e k e e p i n g , d i e t a r y , a n d disaster p r e p a r e d n e s s . T h e a d m i n i s t r a t i v e leadership at the nursing h o m e was d i s t u r b e d b y these c e r t i f i c a t i o n difficulties a n d c o n s e q u e n t l y also displeased w i t h the p e r f o r m a n c e o f the H M O a n d the hospital, w h i c h it h a d called in to help secure n e c e s s a r y licensure. T h e D i r e c t o r o f the nursing h o m e a s k e d the E x e c u t i v e D i r e c t o r o f the h o s p i t a l to d o c u m e n t the role o f the n u r s i n g h o m e in the long-range plans o f the hospital. T h e h o s p i t a l ' s E x e c u t i v e D i r e c t o r r e p l i e d o n N o v e m b e r 22, 1974: The Hospital serves the oldest patient population of any hospital in the city. Approximately forty-five percent of our inpatient days are accounted for by Medicare-eligible individuals. We are thus extremely concerned about provision of chronic care and extended care. This substantive concern is heightened by the financial reality that we are increasingly being scrutinized by third party payers about the appropriate level of care of our patients. With this background, we entered into discussions with you about developing a closer relationship.., we are quite pleased by the improvement in the ease of transferring patients to your institution. In the long run, we would like to see this improved even more in terms of physician care continuity, which we hope [the HMO] is addressing with the [nursing home] . . . . From the hospital's point of view, then, the relationship with [the nursing home] is working out well . . . . I n a d d i t i o n to this r e s p o n s e , the h o s p i t a l ' s E x e c u t i v e D i r e c t o r a s k e d the D i r e c t o r o f the H M O to set o u t in writing the p r o g r a m m a t i c r e l a t i o n s h i p b e t w e e n the n u r s i n g h o m e a n d the H M O . T h e D i r e c t o r o f the H M O w r o t e o n N o v e m b e r 22, 1974: We accordingly entered into discussions with y o u . . , because we think there is a mutuality of interest around the issues of improved patient care and because of the geographic proximity of our facilities . . . . As we have discussed at a number of meetings, we think we can help you in this upgrading process in areas such as in-service education, exposure to functioning systems at the hospital, and informal quality review analysis. In summary, we think we have established a good working relationship with your organization, have jointly identified a number of areas needing improvement, and have mutually begun the difficult process of bringing about the necessary changes.
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Before these letters were received the state sent an order to the nursing home to "Cease and desist operation." The deficiencies noted in visits conducted on March 19 and 20, 1974, and on three subsequent occasions were again validated in October 1974. An 18-page report levelled criticisms in m a n y areas. 4 Responding to this report, which threatened its survival, the nursing home marshalled its work activities toward attaining the certification goal and criticized the HMO and the hospital for their efforts in this regard. Although the HMO and the hospital strengthened their involvement at the nursing home, they communicated to each other increasing reservations about the organizational goals and priorities expressed by the nursing home in its intensive drive to gain certification rather than to improve the quality of health care. The certification crisis was accompanied by other problems. In January 1975 the Director of the HMO wrote to the Administrator of the nursing home advising him that the patients on the HMO service at the nursing home had reached 87 in number, 17 b e y o n d the HMO's capacity. A request was made for a reduction to 70 patients, the n u m b e r agreed upon previously. This need to reduce the overload on the HMO service and to place all hospital patients admitted to the nursing home into the HMO service was discussed on January 17, 1975, by the Director of the I-IMO and a top administrator from the nursing home. Although progress was made during the next two weeks to correct these problems, the situation was viewed by the parties in the relationship as symptomatic of a deeper schism that had developed regarding leadership of the triadic relationship. Tensions emerged over the issue of patient transfer on January 29, 1975.** The HMO and hospital officials found it essential that a viable mechanism be established which would guarantee the transfer of their patients from the hospital to the nursing home. They also wanted assurance that nursing home patients who entered the hospital for acute medical care would be readmitted to the nursing home immediately upon hospital discharge. A policy statement aimed at attaining these goals was sent by the Director of the HMO to a top administrator at the nursing home. It consisted of four points: (1) Every patient who is transferred to the hospital will have top priority on coming back to the nursing home. (2) No patient can be discharged from the HMO Service unless an order is written by the HMO. (3) E m p t y beds on the HMO Service must be filled by hospital patients. (4) The HMO makes admission decisions regarding patients onto the HMO Service. To the HMO and hospital officials, this policy was essential for two reasons: one, to build a model health care system linking primary care, extended care, **Information gathered through personal interviews, February to May 1975, with the directors, top administrators, and practitioners of the HMO, university hospital, and nursing home.
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and hospital care; and two, to maintain their financial viability by placing exhausted benefit patients not needing acute hospital care into reimbursable nursing home care. Nursing home administrators did not accept the policy. The nursing home did not want to relinquish control over patient admissions for financial reasons. The nursing home had to maintain a balance between private sector patients, for whom the nursing home was fully reimbursed, and public-welfare sector patients, for whom the nursing home was reimbursed below cost. The nursing home feared that if the HMO and hospital controlled admissions, this balance would be upset and the nursing home would be burdened with non-paying patients who would bring financial difficulties to the proprietary home. These problems were not resolved by the three organizations. The relationship moved into its final stage. Termination. To contractual relationship between the nursing home, the HMO, and the university hospital was dissolved on January 30, 1975, when the Director of the HMO and the Director of the nursing home met and reached the conclusion that the HMO should no longer provide medical service to the patients at the nursing home. A subsequent review of existing issues on February 7, 1975, by the Director of the HMO and the top administrator at the nursing home could not restore the organizational relationship. Medical, financial, and administrative plans were drawn up to terminate the relationship as smoothly as possible. Final termination came on March 7, 1975.
D I S C U S S I O N OF T H E C A S E : W H Y T-HE R E L A T I O N S H I P F A I L E D
The attempt by the HMO, university hospital, and nursing home to form an organizational relationship that would enable them to provide comprehensive health services to an urban geriatric population was disrupted by three stresses, which occurred during the four stages of the relationship. The stresses were: organizational integration, professional coordination, and adaptation to environmental uncertainty. Organizational integration. The HMO, hospital, and nursing home were three distinct organizational entities that joined together to form a system through which they could exchange resources for their common purpose. To attain this end, organizational integration of the three parties in the system was critical. This could be accomplished by the development of shared values, norms, and attitudes that would integrate them into a viable system, s However, integration was inhibited by problems in three areas: processes of decision making, patterns of communication, and managerial styles of the organizations in the relationship. Problems in the processes of decision making emerged at the very beginning when the parties did not formulate comprehensive data bases
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about one another prior to entering the organizational relationship. 6 The HMO, the hospital, and the nursing home did not have sufficient information about the resources, objectives, finances, responsibilities, or m e m b e r personalities of the other organizations. None of the organizations defined for the other how its individual organizational characteristics would affect its capacity to carry out the obligations of a contractual relationship. Without this information, decision-making processes were hampered. The administrators of the organizations did not consult their respective staff members i n m a k i n g decisions regarding the relationship. This action reflected the weak internal lines of communication existing between administrators and staff in each of the three organizations. The means of communication within each organization became the means of communication between the organizations. Appropriate patterns of communication between administrators and the staffs were not formed; administrators found it difficult to secure the necessary cooperation of their staffs in the organizational relationship. The final problem that inhibited integration was caused by the diverse managerial styles of the three organizations. 7 The health center and hospital were academic, nonprofit organizations. The nursing home was a private proprietary organization. They could not formulate an overall structural design that would accommodate both of these orientations. Integration of the system was not attained because of these problems in the processes of decision making, the patterns of communication, and the styles of management. Professional coordination. In order for the three organizations to attain their c o m m o n goal of comprehensive geriatric health services, they had to achieve not only organizational integration but also professional coordination of three separate staffs. Professional coordination is that aspect of an organizational system which interrelates individual roles, performances, and work activities through reward incentives and supervision in order to form a unified b o d y that performs the functions necessary to attain organizational goals, s At the same time that the three staffs were providing services for the c o m m o n project, they retained their original organizational affiliations, tasks, and responsibilities. In the attempt to coordinate these distinct staffs, four problems emerged: 1. Differences in patterns of care were problematic for the organizations. The staffs at the HMO and hospital were oriented to providing three levels of care--primary, secondary, and t e r t i a r y - w h i c h utilized multiple services (e.g., radiology, laboratories, consultations). In contrast, the staff at the nursing home was oriented toward providing nursing care in a self-contained manner that was not dependent upon outside services. These differences caused tension between the organizations' staffs. The HMO and hospital staff saw their major task as expanding and upgrading medical care. The nursing home staff perceived this medical orientation as an attempt to
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supplant their nursing role. The staffs could not coordinate their different orientations in order to deliver comprehensive geriatric service. 2. Another problem was the divergent nature of the staffs. The health center and hospital staffs were developing innovative concepts such as interdisciplinary teams, expanded roles for health professionals, and new educational programs. They tried to introduce this same innovative approach in their work at the nursing home. At the time of the relationship, however, the nursing home staff was unstable and undergoing constant turnover. This changing staff had to expend its energies learning basic obligations and daily tasks, thus preventing full cooperation or understanding of the innovations. Although the geriatric nurse practitioner worked closely with all three staffs, her role did not catalyze the professional coordination of the divergent staffs, 3. A third problem was the ambiguity of supervisory authority existing in the relationship. None of the staffs knew the answers to the following questions: To whom should they report administratively? To whom should they direct their professional problems? To whom was the main health provider, the geriatric nurse practitioner, responsible? In attempting to resolve these questions, a struggle for supervisory control occurred. 4. The final problem was inadequacy of the reward-incentive structure. In order to achieve professional coordination, member compliance, facilitated by a reward-incentive structure, is necessary. In the case of the HMO, hospital, and nursing home, the rewards and incentives available to staff members for participating in the relationship were limited. Participants retained full-time positions in their respective organizations and the organizational relationship represented an additional obligation, one in which they had no choice concerning participation. The staffs did not receive monetary or professional reinforcement and their limited inputs into decision-making processes caused a general lack of commitment to the relationship. Without an adequate reward-incentive structure, a critical element of professional coordination could not evolve. Professional coordination was, then, inhibited by problems that developed from differences in patterns of care, divergent nature of staffs, ambiguity of supervisory authority, and inadequacy of the reward-incentive structure. The staffs were unable to coordinate their efforts in order to operate as a unified body performing the tasks necessary to attain their common goal. Adaptation to environmental uncertainty. The health center, hospital, and nursing home existed within the context of a larger environment that surrounded and affected their relationship. The environment for the organizations was continually changing, at increasing rates and toward greater complexity, thereby creating the stress of uncertainty. 8 Specific problems that generated uncertainty were stage of development, economic situation, and the state of the art. The intensity of each organization's effort
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to adapt to an uncertain environment had a cumulative effect on the o u t c o m e of the organizational relationship. Each organization was at an unstable stage of development. The HMO had been fully operational as a health delivery site for only one year when it entered into the relationship. The hospital was undergoing changes in governance and ownership, altering its position from that of a university hospital to that of a c o m m u n i t y hospital. The nursing h o m e was in a period of transition during which time it was upgrading and expanding its services in order to meet certification requirements. None of the organizations could be certain of a long-term existence, financial viability, or maintenance of staff. Because of these uncertainties in individual development, it was a difficult time for the organizations to undertake a relationship with each other. Uncertainty was also produced by the economic situations of the organizations. The HMO experienced uncertainty as a result of the fragm e n t e d and unstable nature of their multi-resource income, which included revenue produced through the prepaid capitation program, grants, fee-forservice patients, and institutional contracts. The hospital had incurred large deficits. Its university owner was contemplating closing or selling the hospital because of the financial difficulties. The nursing h o m e also felt the stress of financial uncertainty, which was rooted in the limited reimbursement provided by certain third party payers. As a result, the nursing h o m e was not certain that it could meet the rising costs of staff salaries, medical suppfies, and building maintenance. The financial uncertainty of the three organizations placed constraints on their ability to participate in the interorganizational relationship. A third uncertainty for the organizations was the state of the art. They were working in new health fields-primary care, comprehensive care, and geriatric care--which were being defined and developed. The problem affecting each organization was to apply and extend new concepts of health care into their specific setting and into the organizational relationship. This process required organizational structuration, the education and socialization of providers and consumers, and the reorientation of values and norms. The organizations were unable to accomplish these goals.
CONCLUSION The formation of relationships with other organizations is a strategy for coping with uncertainty in the environment. Such relationships can produce power, greater control over resources, increased knowledge and information, and linkage into other communication networks. All of these factors might have reduced uncertainty for the HMO, hospital, and nursing home. However, specific stresses emerged for each organization in the areas of organizational integration, professional coordination, and environmental
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adaptation, which prevented their integration into a comprehensive system. As a result, the nursing home, the HMO, and the hospital did not benefit from relationships that could have enabled them to sustain an innovative, comprehensive geriatric health project.
REFERENCES 1. Bums T, Stalker GM: The Management o f Innovatiom London, Associated Book Publishers, 1961. P 22. 2. Dun & Bradstreet Business Information Report on the nursing home, November 28, 1973. 3. Hospital Survey Committee: Directory o f Nursing Convalescent and Rehabilitative Facilities in a Metro Area. March 1974. Philadelphia, Pa. 4. Report of the Field Representative, Standards and Licensure, Southeastern Region, State Department of Public Welfare, November 22, 1974, entitled: " . . . Nursing Center, List the Regulation Violations, from Survey of October 1, 2, 3, 4, 1974." 5. Georgopoulos BS (ed): Organization Research on Health Institutions. Ann Arbor, Mich. Institute for Social Research, 1972. 6. March JG, Simon H: Organizations. New York, John Wiley & Sons, 1958. 7. Lehman EW: Coordinating Health Care: Explorations in Interorganizational Relations. Beverly Hills, Calif. Sage Publications, 1975. 8. Emery F, Tdst E: The causal texture of organizational environments. Human Relations, 18(1):21-32, Feb. 1965.
BUILDING A COMPREHENSIVE GERIATRIC H E A L T H CARE SYSTEM: A CASE STUDY L a u r a Bleiweiss, Ph.D., and S h a r o n S i m s o n , Ph.D.
ABSTRACT: This case study focuses on the efforts of three urban medical care institutions--a Health Maintenance Organization, a nursing home, and a university hospital--to form an interorganizational relationship. The purpose of the relationship was to utilize the services of the three organizations in order to respond to the comprehensive health needs of an urban geriatric population. Movements in this triadic organizational relationship are described and analyzed in terms of four conceptual stages--exploration, negotiation, interaction and performance, and termination. Problems arising during these stages were not resolved and the relationship was terminated after approximately two years of existence. A sociological discussion of the case focuses on why the relationship failed. The organizational relationship was disrupted by three stresses that occurred during the four stages of the relationship. Stresses emerged for each organization in the areas of organizational integration, professional coordination, and environmental adaptation, making it difficult for the three to become integrated into an organizational system. As a result, th e HMO, the nursing home, and the hospital did not benefit from relationships that could have enabled them to develop the multi-organizational system necessary to sustain an innovative, comprehensive geriatric health project. If, as Whitehead said, the greatest invention of the nineteenth century was the invention of the method of invention, the task of the succeeding century has been to organize inventiveness. The difference is not in the nature of invention or of inventors, but in the manner in which the context of social institutions is organized for their support. 1 T h e p r o b l e m facing the delivery o f h e a l t h care t o d a y is the organization o f inventiveness. F r a g m e n t e d and diffuse discoveries in t h e field o f h e a l t h n e e d to be o r g a n i z e d i n t o a c o m p r e h e n s i v e o p e r a t i o n a l s y s t e m t h a t is responsive to the diverse needs o f varied p o p u l a t i o n s . One o f the p o p u l a t i o n s t h a t e n c o u n t e r s serious difficulties in seeking health care is the u r b a n aged. F r e q u e n t l y afflicted b y a c o n s t e l l a t i o n o f i n t e r r e l a t e d p r o b l e m s t h a t i n c l u d e l o w i n c o m e , social isolation, p o o r n u t r i t i o n , and i n a d e q u a t e housing, the aged find it difficult to secure n e e d e d p r i m a r y care, e m e r g e n c y services, h o s p i t a l i z a t i o n , h o m e care, or e x t e n d e d care. Medical care o r g a n i z a t i o n s p r o v i d i n g these t y p e s o f care have e n c o u n t e r e d obstacles in a t t e m p t i n g to develop, i m p l e m e n t , and m a i n t a i n the services n e e d e d b y the aged. This case s t u d y focuses o n the efforts o f three u r b a n medical care Dr. Bleiweiss is with the University of Pennsylvania, 415 South 19th Street, Philadelphia, Pennsylvania, 19146. Dr. Simson is with the University of Pennsylvania School of Medicine, Philadelphia, Pennsylvania, 19174. This project was partially supported by a Research Fellowship Award, National Institute of Mental Health, No. 5 F22 MH57626-02. 141
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institutions, a university-affiliated Health Maintenance Organization (HMO), a university hospital, and an extended care facility, to form an interorganizational relationship. The purpose of the relationship was to utilize the services of the three organizations in order to respond to the comprehensive health needs of an urban geriatric population.
BACKGROUND
A model comprehensive health care program, a Health Maintenance Organization, was established by a private eastern university in July 1972 as part of a long-range program for improving the delivery of health services to an urban population. The development of the HMO has followed four principles: (1) the facets of a comprehensive health services system include primary care, hospital back-up, emergency services, home care, and extended care; (2) the disciplines needed to provide family-oriented health care are adult medicine, pediatrics, obstetrics-gynecology, mental health, and dental health; (3) the necessary characteristics of a health system are comprehensiveness, accessibility, accountability, and continuity; and (4) the functions of a university health system are to provide a service system as the base upon which education and research operate. In order to develop these principles, the HMO took several steps. It was established as an integral component of the 330-bed hospital of the university, thereby insuring necessary support in emergency services, hospital care, and ancillary services such as radiology and laboratories. As one of seven provider points of a city-wide health plan, the HMO became eligible to deliver care to subscribers drawn from a residential population of 275,000. The HMOs multispecialty, interdisciplinary group practice was designed to accomodate 25,000 consumers by providing comprehensive care directed toward prevention, early treatment, and rehabilitation. To attain its wide range of goals, the HMO formed relationships with numerous medical, philanthropic, educational, social, and governmental organizations. One of these was a center city nursing home. The nursing home was chartered by the state in 1957 as a skilled nursing facility? The home was under a proprietary form of ownership. At the time of the relationship with the HMO it was certified by Medicare but was not accredited by the Joint Commission on Accreditation of Hospitals. 3 The nursing home rendered 24-hour comprehensive nursing care under the direction of licensed practical nurses to patients occupying 138 licensed beds. THE CASE STUDY
The relationship involving the HMO, the university hospital, and the nursing home lasted from July 1975 to March 1975. The formal, contractual
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relationship extended from mid-July 1974 until early March 1975. Movements in the organizational relationship can be described and analyzed in terms of four conceptual stages-exploration, negotiation, interaction and performance, and termination. The time periods of the stages overlap to some extent and vary in duration. Exploration. During the summer and fall months of 1973, leaders in the three organizations met with each other and with members of their respective organizations to explore the possibility of a triadic liaison. This exploration was initiated when the Director of the HMO and the Director of Social Service at the hospital met with the chief nurse/administrator from the nursing home to discuss the concepts and goals of the HMO. Information from this meeting was relayed to the Director of the nursing home. He expressed interest in securing hospital privileges for his four osteopathic attending physicians but declined any further involvement at that time. However, in the fall of 1973, the Executive Director of the hospital and the Director of the nursing home did establish a linkage; two hospital physicians began attending patients at the nursing home. Communication between the organizations was dormant in spring 1974, while each organization evaluated its reasons for establishing a formal relationship. The nursing home was faced with the necessity of satisfying state certification requirements and improving its financial situation. The nursing home's strategy for solving these problems was to improve the quality of medical care, to upgrade in-service education to staff, and to increase the ratio of private patients to public sector patients. The HMO identified several reasons for entering into a relationship. It hoped to be able to develop and integrate extended care into a comprehensive health services system, to serve a defined geriatric population of the city, and to test its model of the geriatric nurse practitioner. The hospital was seeking a solution to its dilemma of securing transfers and satisfactory placements for aged patients who had exhausted their hospital benefits and no longer required acute care. The hospital had found nursing home beds to be at a premium because of a low turnover rate and resistance to accepting medical assistance patients. Each organization-the HMO, the nursing home, and the h o s p i t a l had determined its set of reasons for forming a triadic relationship. A growing crisis over the licensing of the nursing home propelled the three organizations into the next state of organizational relationship. Negotiation. The nursing home's license from the state to operate a Skilled Nursing Facility expired on March 22, 1974. It was not renewed. Deficiencies at the nursing home were stated to be jeopardizing the health, safety, and welfare of patients in a report by the Field Representative, Standards and Licensure, of the State Department of Public Welfare, Southeastern Region.* The nursing home requested and was granted additional *Data were later recorded in a letter dated November 22, 1974, from the Field Representative to the Administrator of the nursing home.
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time to correct deficiencies. However, visits on May 9, 10, and 15, 1974, and June 3, 4, and 5, 1974, by the State representatives revealed a lack of improvement. Confronted with the loss of license and an insufficient capability to correct deficiencies, the nursing home sought the assistance of the HMO and the hospital. Discussions took place for several weeks between the Director of the nursing home, the Director of the HMO and its main administrators, and the Executive Director of the hospital and several of his top staff members including the Director of Social Service and the Assistant Director for Finances. All the parties approved a relationship between the three organizations, and the terms of the basic agreement were spelled out in two letters of correspondence. In a letter dated July 16, 1974, the Director of the HMO communicated the provisions of the organizational relationship to the Director of the nursing home. The main points were: (1) The Director of the HMO would function as the medical director of the nursing home. The HMO would provide a full-time nurse practitioner and physician services to the nursing home. (2) The HMO would assess the health needs of patients, review clinical data, and arrange it into a health management profile. (3) The HMO would develop written policies of care that would be reviewed by a Utilization Review Committee. Utilization Review would also do a medical audit, thereby creating a Quality Assurance Program. (4) The HMO would develop admission procedures and record information. (5) The HMO would assume an active role in discharge planning. (6) The HMO would be responsible for educational programs to improve the skills of professional staff at the nursing home. (7) The HMO would provide emergency services and physician-on-call coverage. A second letter focusing on the geriatric nurse practitioner was sent by the Director of the HMO to the Director of the nursing home on July 16, 1974. The geriatric nurse practitioner would: (1) be a member of the HMO staff assigned to the nursing home (the HMO would bill the nursing home for her services); (2) be responsible for carrying out the nurse practitioner role in developing patient care programs at the nursing home while working with an HMO physician; (3) develop with other colleagues health care policies for nursing home patients; (4) participate with other personnel in implementation of these policies; and (5) be responsible to the Director of the HMO for her activity. The leaders of the newly related organizations were optimistic. This was apparent in their correspondence with each other during July of 1974. The Director of the nursing home stated: "I consider [this to be] one of the most progressive nursing home]hospital relationships that I have ever encountered. I am confident that all those interested, most importantly the patient, will benefit." The Director of the HMO wrote: "We look forward indeed to working with you and with the nursing s t a f f . . , it should be an exciting project." The Executive Director of the hospital commented: "I
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truly believe this is a most important relationship that will be valuable and productive for both of our institutions and will repay its cost m a n y times over in better care." With hopes of regaining the nursing home's license, with the terms of the basic agreement established, and with expressed optimism, the three contractually bound organizations entered into another stage of relationship, interaction and performance. Interaction and performance. The contractual relationship began in mid-July 1974 and was terminated in early March 1975. During this time, efforts were made to delineate work schedules, professional duties and responsibilities, financial arrangements, training programs, and other structural details of the organizational relationship. These efforts were punctuated by several problems, which leaders of the organizations identified as the manifest reasons for eventually terminating the relationship. The initial activities of the HMO at the nursing home were directed toward formulating and putting into practice the roles and work schedules of a health team consisting of physicians, medical nurse practitioners, and administrators. In September 1974 a geriatric nurse practitioner was recruited to the HMO staff to work at the nursing home full time. The HMO health team established a routine that included three types of patient visits: monthly visits, admissions work-ups, and treatment for episodic illness. The hours of services rendered were: physicians, 1-1½ hours daily; nurse practitioners, 4 hours daily, increased to 8 hours daily in October; and administrative personnel, 2 hours daily. Further coverage was provided by the hospital's emergency and inpatient services. The involvement of the HMO's primary care center and home care program with the nursing home was under discussion. The next set of activities were a n u m b e r of projects aimed at expanding the range of services offered at the nursing home and improving the quality of patient care. A social worker associated with the HMO and the hospital was asked in August 1974 to evaluate the need for social work input into the proper management and disposition of HMO patients at the nursing home. A report of October 1974 r e c o m m e n d e d that a full-time social worker, with a M.S.W. degree, should be employed at the nursing home. Discussions were underway in September with dentists from the HMO and its affiliated university regarding the provision of dental services to nursing home patients. Research and evaluation projects were in process regarding the various aspects of the organizational relationship. The progress of these efforts to establish an operational program for attaining mutual goals was interrupted on September 30, 1974, when the Director, Division of Long-Term Care Standards Enforcement, United States Department of Health, Education, and Welfare, wrote the nursing home: It is our determination that the provider agreement with the Nursing Center not be renewed at the end of its expiration date [October 31,
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1974] . . . . the Nursing Center has such deficiencies as to place in jeopardy the health and safety of its patients. T h e n o n - r e n e w a l o f the p r o v i d e r a g r e e m e n t at the federal level was f o l l o w e d on O c t o b e r 21, 1974, b y a n o t h e r letter f r o m the state i n d i c a t i n g t h a t the nursing h o m e ' s license was in j e o p a r d y . A licensure s u r v e y h a d b e e n cond u c t e d on O c t o b e r 1, 2, 3, and 4, 1 9 7 4 , and deficiencies were f o u n d in m u l t i p l e areas: o r g a n i z a t i o n , m a n a g e m e n t , nursing services, p h a r m a c e u t i c a l services, h o u s e k e e p i n g , d i e t a r y , a n d disaster p r e p a r e d n e s s . T h e a d m i n i s t r a t i v e leadership at the nursing h o m e was d i s t u r b e d b y these c e r t i f i c a t i o n difficulties a n d c o n s e q u e n t l y also displeased w i t h the p e r f o r m a n c e o f the H M O a n d the hospital, w h i c h it h a d called in to help secure n e c e s s a r y licensure. T h e D i r e c t o r o f the nursing h o m e a s k e d the E x e c u t i v e D i r e c t o r o f the h o s p i t a l to d o c u m e n t the role o f the n u r s i n g h o m e in the long-range plans o f the hospital. T h e h o s p i t a l ' s E x e c u t i v e D i r e c t o r r e p l i e d o n N o v e m b e r 22, 1974: The Hospital serves the oldest patient population of any hospital in the city. Approximately forty-five percent of our inpatient days are accounted for by Medicare-eligible individuals. We are thus extremely concerned about provision of chronic care and extended care. This substantive concern is heightened by the financial reality that we are increasingly being scrutinized by third party payers about the appropriate level of care of our patients. With this background, we entered into discussions with you about developing a closer relationship.., we are quite pleased by the improvement in the ease of transferring patients to your institution. In the long run, we would like to see this improved even more in terms of physician care continuity, which we hope [the HMO] is addressing with the [nursing home] . . . . From the hospital's point of view, then, the relationship with [the nursing home] is working out well . . . . I n a d d i t i o n to this r e s p o n s e , the h o s p i t a l ' s E x e c u t i v e D i r e c t o r a s k e d the D i r e c t o r o f the H M O to set o u t in writing the p r o g r a m m a t i c r e l a t i o n s h i p b e t w e e n the n u r s i n g h o m e a n d the H M O . T h e D i r e c t o r o f the H M O w r o t e o n N o v e m b e r 22, 1974: We accordingly entered into discussions with y o u . . , because we think there is a mutuality of interest around the issues of improved patient care and because of the geographic proximity of our facilities . . . . As we have discussed at a number of meetings, we think we can help you in this upgrading process in areas such as in-service education, exposure to functioning systems at the hospital, and informal quality review analysis. In summary, we think we have established a good working relationship with your organization, have jointly identified a number of areas needing improvement, and have mutually begun the difficult process of bringing about the necessary changes.
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Before these letters were received the state sent an order to the nursing home to "Cease and desist operation." The deficiencies noted in visits conducted on March 19 and 20, 1974, and on three subsequent occasions were again validated in October 1974. An 18-page report levelled criticisms in m a n y areas. 4 Responding to this report, which threatened its survival, the nursing home marshalled its work activities toward attaining the certification goal and criticized the HMO and the hospital for their efforts in this regard. Although the HMO and the hospital strengthened their involvement at the nursing home, they communicated to each other increasing reservations about the organizational goals and priorities expressed by the nursing home in its intensive drive to gain certification rather than to improve the quality of health care. The certification crisis was accompanied by other problems. In January 1975 the Director of the HMO wrote to the Administrator of the nursing home advising him that the patients on the HMO service at the nursing home had reached 87 in number, 17 b e y o n d the HMO's capacity. A request was made for a reduction to 70 patients, the n u m b e r agreed upon previously. This need to reduce the overload on the HMO service and to place all hospital patients admitted to the nursing home into the HMO service was discussed on January 17, 1975, by the Director of the I-IMO and a top administrator from the nursing home. Although progress was made during the next two weeks to correct these problems, the situation was viewed by the parties in the relationship as symptomatic of a deeper schism that had developed regarding leadership of the triadic relationship. Tensions emerged over the issue of patient transfer on January 29, 1975.** The HMO and hospital officials found it essential that a viable mechanism be established which would guarantee the transfer of their patients from the hospital to the nursing home. They also wanted assurance that nursing home patients who entered the hospital for acute medical care would be readmitted to the nursing home immediately upon hospital discharge. A policy statement aimed at attaining these goals was sent by the Director of the HMO to a top administrator at the nursing home. It consisted of four points: (1) Every patient who is transferred to the hospital will have top priority on coming back to the nursing home. (2) No patient can be discharged from the HMO Service unless an order is written by the HMO. (3) E m p t y beds on the HMO Service must be filled by hospital patients. (4) The HMO makes admission decisions regarding patients onto the HMO Service. To the HMO and hospital officials, this policy was essential for two reasons: one, to build a model health care system linking primary care, extended care, **Information gathered through personal interviews, February to May 1975, with the directors, top administrators, and practitioners of the HMO, university hospital, and nursing home.
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and hospital care; and two, to maintain their financial viability by placing exhausted benefit patients not needing acute hospital care into reimbursable nursing home care. Nursing home administrators did not accept the policy. The nursing home did not want to relinquish control over patient admissions for financial reasons. The nursing home had to maintain a balance between private sector patients, for whom the nursing home was fully reimbursed, and public-welfare sector patients, for whom the nursing home was reimbursed below cost. The nursing home feared that if the HMO and hospital controlled admissions, this balance would be upset and the nursing home would be burdened with non-paying patients who would bring financial difficulties to the proprietary home. These problems were not resolved by the three organizations. The relationship moved into its final stage. Termination. To contractual relationship between the nursing home, the HMO, and the university hospital was dissolved on January 30, 1975, when the Director of the HMO and the Director of the nursing home met and reached the conclusion that the HMO should no longer provide medical service to the patients at the nursing home. A subsequent review of existing issues on February 7, 1975, by the Director of the HMO and the top administrator at the nursing home could not restore the organizational relationship. Medical, financial, and administrative plans were drawn up to terminate the relationship as smoothly as possible. Final termination came on March 7, 1975.
D I S C U S S I O N OF T H E C A S E : W H Y T-HE R E L A T I O N S H I P F A I L E D
The attempt by the HMO, university hospital, and nursing home to form an organizational relationship that would enable them to provide comprehensive health services to an urban geriatric population was disrupted by three stresses, which occurred during the four stages of the relationship. The stresses were: organizational integration, professional coordination, and adaptation to environmental uncertainty. Organizational integration. The HMO, hospital, and nursing home were three distinct organizational entities that joined together to form a system through which they could exchange resources for their common purpose. To attain this end, organizational integration of the three parties in the system was critical. This could be accomplished by the development of shared values, norms, and attitudes that would integrate them into a viable system, s However, integration was inhibited by problems in three areas: processes of decision making, patterns of communication, and managerial styles of the organizations in the relationship. Problems in the processes of decision making emerged at the very beginning when the parties did not formulate comprehensive data bases
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about one another prior to entering the organizational relationship. 6 The HMO, the hospital, and the nursing home did not have sufficient information about the resources, objectives, finances, responsibilities, or m e m b e r personalities of the other organizations. None of the organizations defined for the other how its individual organizational characteristics would affect its capacity to carry out the obligations of a contractual relationship. Without this information, decision-making processes were hampered. The administrators of the organizations did not consult their respective staff members i n m a k i n g decisions regarding the relationship. This action reflected the weak internal lines of communication existing between administrators and staff in each of the three organizations. The means of communication within each organization became the means of communication between the organizations. Appropriate patterns of communication between administrators and the staffs were not formed; administrators found it difficult to secure the necessary cooperation of their staffs in the organizational relationship. The final problem that inhibited integration was caused by the diverse managerial styles of the three organizations. 7 The health center and hospital were academic, nonprofit organizations. The nursing home was a private proprietary organization. They could not formulate an overall structural design that would accommodate both of these orientations. Integration of the system was not attained because of these problems in the processes of decision making, the patterns of communication, and the styles of management. Professional coordination. In order for the three organizations to attain their c o m m o n goal of comprehensive geriatric health services, they had to achieve not only organizational integration but also professional coordination of three separate staffs. Professional coordination is that aspect of an organizational system which interrelates individual roles, performances, and work activities through reward incentives and supervision in order to form a unified b o d y that performs the functions necessary to attain organizational goals, s At the same time that the three staffs were providing services for the c o m m o n project, they retained their original organizational affiliations, tasks, and responsibilities. In the attempt to coordinate these distinct staffs, four problems emerged: 1. Differences in patterns of care were problematic for the organizations. The staffs at the HMO and hospital were oriented to providing three levels of care--primary, secondary, and t e r t i a r y - w h i c h utilized multiple services (e.g., radiology, laboratories, consultations). In contrast, the staff at the nursing home was oriented toward providing nursing care in a self-contained manner that was not dependent upon outside services. These differences caused tension between the organizations' staffs. The HMO and hospital staff saw their major task as expanding and upgrading medical care. The nursing home staff perceived this medical orientation as an attempt to
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supplant their nursing role. The staffs could not coordinate their different orientations in order to deliver comprehensive geriatric service. 2. Another problem was the divergent nature of the staffs. The health center and hospital staffs were developing innovative concepts such as interdisciplinary teams, expanded roles for health professionals, and new educational programs. They tried to introduce this same innovative approach in their work at the nursing home. At the time of the relationship, however, the nursing home staff was unstable and undergoing constant turnover. This changing staff had to expend its energies learning basic obligations and daily tasks, thus preventing full cooperation or understanding of the innovations. Although the geriatric nurse practitioner worked closely with all three staffs, her role did not catalyze the professional coordination of the divergent staffs, 3. A third problem was the ambiguity of supervisory authority existing in the relationship. None of the staffs knew the answers to the following questions: To whom should they report administratively? To whom should they direct their professional problems? To whom was the main health provider, the geriatric nurse practitioner, responsible? In attempting to resolve these questions, a struggle for supervisory control occurred. 4. The final problem was inadequacy of the reward-incentive structure. In order to achieve professional coordination, member compliance, facilitated by a reward-incentive structure, is necessary. In the case of the HMO, hospital, and nursing home, the rewards and incentives available to staff members for participating in the relationship were limited. Participants retained full-time positions in their respective organizations and the organizational relationship represented an additional obligation, one in which they had no choice concerning participation. The staffs did not receive monetary or professional reinforcement and their limited inputs into decision-making processes caused a general lack of commitment to the relationship. Without an adequate reward-incentive structure, a critical element of professional coordination could not evolve. Professional coordination was, then, inhibited by problems that developed from differences in patterns of care, divergent nature of staffs, ambiguity of supervisory authority, and inadequacy of the reward-incentive structure. The staffs were unable to coordinate their efforts in order to operate as a unified body performing the tasks necessary to attain their common goal. Adaptation to environmental uncertainty. The health center, hospital, and nursing home existed within the context of a larger environment that surrounded and affected their relationship. The environment for the organizations was continually changing, at increasing rates and toward greater complexity, thereby creating the stress of uncertainty. 8 Specific problems that generated uncertainty were stage of development, economic situation, and the state of the art. The intensity of each organization's effort
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to adapt to an uncertain environment had a cumulative effect on the o u t c o m e of the organizational relationship. Each organization was at an unstable stage of development. The HMO had been fully operational as a health delivery site for only one year when it entered into the relationship. The hospital was undergoing changes in governance and ownership, altering its position from that of a university hospital to that of a c o m m u n i t y hospital. The nursing h o m e was in a period of transition during which time it was upgrading and expanding its services in order to meet certification requirements. None of the organizations could be certain of a long-term existence, financial viability, or maintenance of staff. Because of these uncertainties in individual development, it was a difficult time for the organizations to undertake a relationship with each other. Uncertainty was also produced by the economic situations of the organizations. The HMO experienced uncertainty as a result of the fragm e n t e d and unstable nature of their multi-resource income, which included revenue produced through the prepaid capitation program, grants, fee-forservice patients, and institutional contracts. The hospital had incurred large deficits. Its university owner was contemplating closing or selling the hospital because of the financial difficulties. The nursing h o m e also felt the stress of financial uncertainty, which was rooted in the limited reimbursement provided by certain third party payers. As a result, the nursing h o m e was not certain that it could meet the rising costs of staff salaries, medical suppfies, and building maintenance. The financial uncertainty of the three organizations placed constraints on their ability to participate in the interorganizational relationship. A third uncertainty for the organizations was the state of the art. They were working in new health fields-primary care, comprehensive care, and geriatric care--which were being defined and developed. The problem affecting each organization was to apply and extend new concepts of health care into their specific setting and into the organizational relationship. This process required organizational structuration, the education and socialization of providers and consumers, and the reorientation of values and norms. The organizations were unable to accomplish these goals.
CONCLUSION The formation of relationships with other organizations is a strategy for coping with uncertainty in the environment. Such relationships can produce power, greater control over resources, increased knowledge and information, and linkage into other communication networks. All of these factors might have reduced uncertainty for the HMO, hospital, and nursing home. However, specific stresses emerged for each organization in the areas of organizational integration, professional coordination, and environmental
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adaptation, which prevented their integration into a comprehensive system. As a result, the nursing home, the HMO, and the hospital did not benefit from relationships that could have enabled them to sustain an innovative, comprehensive geriatric health project.
REFERENCES 1. Bums T, Stalker GM: The Management o f Innovatiom London, Associated Book Publishers, 1961. P 22. 2. Dun & Bradstreet Business Information Report on the nursing home, November 28, 1973. 3. Hospital Survey Committee: Directory o f Nursing Convalescent and Rehabilitative Facilities in a Metro Area. March 1974. Philadelphia, Pa. 4. Report of the Field Representative, Standards and Licensure, Southeastern Region, State Department of Public Welfare, November 22, 1974, entitled: " . . . Nursing Center, List the Regulation Violations, from Survey of October 1, 2, 3, 4, 1974." 5. Georgopoulos BS (ed): Organization Research on Health Institutions. Ann Arbor, Mich. Institute for Social Research, 1972. 6. March JG, Simon H: Organizations. New York, John Wiley & Sons, 1958. 7. Lehman EW: Coordinating Health Care: Explorations in Interorganizational Relations. Beverly Hills, Calif. Sage Publications, 1975. 8. Emery F, Tdst E: The causal texture of organizational environments. Human Relations, 18(1):21-32, Feb. 1965.
