Understanding Rehabilitation as a Health Strategy - Evaluation Report

Summary

From September 13 to October 24, 2021, Learning, Acting, and Building for Rehabilitation in Health Systems (ReLAB-HS), led by Physiopedia, successfully delivered a Massive Open Online Course (MOOC) entitled “Understanding Rehabilitation as a Health Strategy” via the Physioplus online learning platform. The program consisted of four independent courses, which included:

1. Introduction to Rehabilitation
2. Rehabilitation in Health Systems
3. Rehabilitation Infrastructures and the Rehabilitation Team
4. Competent Delivery of Rehabilitation Teams

In each course, the learner completed required learning activities and a final quiz that tested knowledge gained from the course. To complete the overall Understanding Rehabilitation as a Health Strategy program, the learner had the option to submit and pass a written assignment.

Course Type: Free, Open, Online

Institution: ReLAB-HS via Physiopedia

About this Course: This MOOC aimed to equip health and social care professionals with a comprehensive knowledge of rehabilitation within the current global context, so they can play an effective and proactive role in local and global efforts to increase access to high-     quality rehabilitation.

Target Audience: These courses were designed and written for health and social care professionals, clinicians, students, assistants, and other rehabilitation-related health systems stakeholders.

Time Commitment: 16 hours over four weeks (with an optional extra eight hours)

Date: September 13 to October 24, 2021, (remains available on Physioplus platform to members)

Requirements: Participants were required to complete online learning activities, engage with additional resources, and complete the course evaluations and quizzes.

Assessment: There was a quiz at the end of each course, and participants could complete an optional final written assignment to demonstrate knowledge gained from the four courses.

Awards: Four course completion certificates awarding a total of 15.5 Physioplus (P+) points with an additional four Physioplus (P+) points available for the optional assignment.

Accreditation: Each individual course was accredited for continuing education and professional development (CE/CPD) by Texas Board of Physical Therapy Examiners and South African Society of Physiotherapy

Registrations: 10,703

Countries Represented: 107

Professions Represented: 25   

Acknowledgements

The Understanding Rehabilitation as a Health Strategy MOOC was developed and delivered by ReLAB-HS and Physiopedia.

Course Coordinators: Rachael Lowe, Naomi O’Reilly

Content Contributors: Naomi O’Reilly, Cindy John-Chu, Habibu Salisu Badamasi, Khloud Shreif, Neha Duhan, Safiya Naz, Shreya Pavaskar, Tunde Aderonmu, Vidya Acharya, Liliane Kirenga

Course Facilitators: Rachael Lowe, Naomi O’Reilly, Jess Bell, Tarina van der Stockt, Lucy Aird, Lucinda Hampton, Kate-Lynn Downey

For information regarding this report, please contact: Rachael Lowe ([email protected])

Introduction

During September and October 2021, ReLAB-HS,  led by Physiopedia, delivered a Massive Open Online Course (MOOC) entitled, “Understanding Rehabilitation as a Health Strategy.”      This USAID-funded program built on Physiopedia’s ten-year track record of developing and delivering MOOCs, being its tenth annual release of a customized learning program. The MOOC was delivered as four courses with an optional written final assignment to complete the program.

The Understanding Rehabilitation as a Health Strategy program aimed to equip health and social care professionals with a comprehensive knowledge of rehabilitation within the current global context, so that they can play an effective and proactive role in local and global efforts to increase access to high-quality rehabilitation services.

The four week-long courses presented different topics through a variety of learning activities to suit all learning styles. The required learning activities within each course were developed to take between four to six hours depending on the participant's learning style, and optional activities were provided should the participant wish to take part in additional learning. A short orientation period before the course provided participants with an opportunity to become familiar with the delivery platform and the topic via the provided pre-course resources.

The course was delivered through the Physioplus online learning platform, an innovative platform specifically developed to provide online education and support learners with a personalized learning dashboard. For each course, the related learning activities were released on a specific course page. Participants engaged with each course and the respective learning activities, and their activity was recorded and displayed in their personal learning dashboard.

A course was considered complete once the learner finished all required learning activities and successfully passed the final quiz that tested knowledge gained each week. There was also an optional written assignment designed for participants to apply the knowledge gained from all four courses.  On completion of each course the participants had the option to download a completion certificate and export a record of their learning from their activity log.

This report evaluates the experiences and engagement of the participants on the Understanding Rehabilitation as a Health Strategy MOOC.

1.1 Aim

Through this MOOC, ReLAB-HS aimed to build on recent work to strengthen the advocacy case for better recognition of rehabilitation in health systems by increasing knowledge among global stakeholders and build on Physiopedia’s global community of professional learners to amplify the growing voice of professional identity and challenges for integrating rehabilitation into health systems.

In order to achieve this, a program of four courses was created with the aim of developing            a comprehensive knowledge of rehabilitation within the current global context among health and social care professionals so that they can play an effective and proactive role in local and global efforts to increase access to high-quality rehabilitation services. The program included an introduction to rehabilitation, overview of rehabilitation with health systems, rehabilitation infrastructure and the rehabilitation teams, and competent delivery of rehabilitation interventions.

1.2 Learning Objectives

At the end of this program of courses, participants were able to:

1. Explain what is meant by the term rehabilitation
2. Describe conceptual models related to rehabilitation based on a case study
3. Discuss the demographic trends triggering the growing need for rehabilitation
4. Describe five benefits of rehabilitation
5. Discuss Rehabilitation 2030 and three recommendations
6. Describe health equity through a disability and intersectionality lens
7. Identify three factors leading to exclusion and inequities in health care
8. Explain the key components of inclusion
9. Correctly describe the concept of Universal Health Coverage
10. Describe the scope of rehabilitation in a health system
11. Explain the role of the interdisciplinary team in rehabilitation services
12. Describe the roles of five common team members within the rehabilitation team
13. Describe the actions rehabilitation providers can take to manage and improve services
14. Discuss the general impact of the Covid-19 pandemic on rehabilitation services
15. Describe the different ways rehabilitation frameworks are used and the design features associated with different framework applications
16. Justify the use of different therapeutic interventions depending on treatment goal for a patient
17. Choose an appropriate set of interventions that could be included in a rehabilitation management plan of a patient

1.3 Intended Audience

This course is suitable for all rehabilitation professionals, students, and assistants, including but not limited to: physiotherapists, occupational therapists, speech and language      therapists, rehabilitation doctors, rehabilitation nurses, prosthetists, orthotists, psychologists, audiologists, dietetics, social workers, and community-based health workers. Other health, social, and rehabilitation professionals interested in this subject are also invited to participate.

1.4 Cost to Participants

The course was free to all participants who completed the course within the 6-week timeframe and remains free to all Physioplus members and residents of low-income countries outside of this timeframe.

1.5 Course Availability

The program of four courses and optional assignment were made available on September 13, 2021. Participants had until October 24, 2021 to complete the courses under their free access to Physioplus. The course remains available on the Physioplus platform to members; membership is free to individuals from low-income countries and available at a discounted rate to individuals in middle-income countries.

1.6 Courses, Course Awards, and Accreditation

Four individual courses were created for the Understanding Rehabilitation as a Health Strategy Program, which can each be completed individually or can be completed as a program of courses with an additional assignment.

Course 1:  Introduction to Rehabilitation (3.8 P+ Points)

Course 2: Rehabilitation in Health Systems (3.4 P+ Points)

Course 3: Rehabilitation Infrastructures and the Rehabilitation Team (4.2 P+ Points)

Course 4: Competent Delivery of Rehabilitation Teams (3.1 P+ Points)

Course Program: Understanding Rehabilitation as a Health Strategy (5.0 P+ Points)

Physiopedia provided individual course completion certificates to all participants that passed each of the four individual courses. For individuals who completed all four courses and completed the assignment were also provided with a program certificate for recognition of completing the full program.

2.0 Demographics of the Participants

2.1 Country

Of the 10,703 registered participants, individuals started the Understanding Rehabilitation as Health Strategy program before the end date of October 24, 2021, representing 107 countries. The tables below show a breakdown by country and country income classification. A full list of the countries and number of participants from each country can be found in Appendix 1. In total, 335 individuals completed the fourth MOOC course, which is used as the definition of MOOC completion in the data below.

Table 1: Top Ten Represented Countries

Country	n (Participants Who Started)	n (% completed from country)
Australia	163	39 (24%)
Nigeria	160	36 (23%)
India	149	12 (8%)
United Kingdom	137	27 (20%)
Philippines	84	11 (13%)
Egypt	65	6 (9%)
United States	62	14 (23%)
Pakistan	62	15 (24%)
South Africa	51	13 (25%)
Uganda	39	11 (28%)

Data are numbers (n) and percentage of country participants (%)

Table 2: Country Income Classification

Classification	n (Participants Who Started)	n (Participants Who Completed)
High	608	145 (24%)
High-middle	206	51 (25%)
Low-middle	702	114 (16%)
Low	121	27 (22%)

Data are numbers (n) and percentage of country participants (%)

Table 3: ReLAB-HS Countries

Country	n (Participants Who Started)	n (Participants Who Completed)
Myanmar	8	1 (13%)
Pakistan	62	15 (24%)
Uganda	39	11 (28%)
Ukraine	10	3 (30%)

Data are numbers (n) and percentage of country participants (%)

2.2 Professions

Twenty-five different professions including carers and patients started the Understanding Rehabilitation as Health Strategy program before the end date of October 24. The top ten represented professions can be found in Table 4. A full list of participants' professional backgrounds is in Appendix 1.

Table 4: Participants’ Professional Backgrounds (top ten)

Profession	n (%)
Physiotherapist / Physical Therapist	882 (73.9%)
Student (all professions combined)	82 (6.9%)
Occupational Therapist	57 (4.8%)
Physical Rehabilitation Physician / Physiatrist	21 (1.8%)
Nurse	18 (1.5%)
Physiotherapy / Physical Therapy Assistant	30 (2.5%)
Doctor of Medicine (not Rehabilitation / Physiatry specialist)	16 (1.3%)
Personal Trainer	11 (0.9%)
Massage Therapist	10 (0.8%)
Prosthetist / Orthotist	8 (0.7%)
Speech Therapist	8 (0.7%)

Data are numbers who completed the competency rating tool (n) and percentage of all respondents (%)

2.3 Work-Based Setting

Course participants come from a wide range of work-based settings. Work-based settings are outlined in Table 5.

Table 5: Current Workplace of Participants

Professional Role	n (%)
Governmental Organization	311 (31.7%)
Private Sector Business	250 (25.4%)
Academic Institutions	172 (17.5%)
Nongovernmental Organization	113 (11.5%)
Other	75 (7.6%)
Community-Based Organization	28 (2.8%)
Organization of Persons with Disabilities	23 (2.3%)
Faith-Based Organization	10 (1.0%)

Data are numbers who completed the competency rating tool (n)and percentage of all respondents (%)

2.4 Age and Gender

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3.0 Engagement of the Participants

3.1 Platform

The Understanding Rehabilitation as a Health Strategy program and associated four courses were delivered on Physioplus. Thirty-eight knowledge-sharing topic summary articles on Physiopedia were either created or updated for the learners to use during these courses; these articles received 91,221 unique views before the final date of the supported course on October 24, 2021.

3.2 Learning Activities

The program included a total of 51 required learning activities, such as watching videos, directed reading, and discussions (the full list of learning activities can be found in Appendix 2). To complete each course, participants were required to fully engage with the required learning activities and pass a quiz. Once successfully completed, Physioplus Points (equivalent to hours of learning) and a completion certificate were awarded. A breakdown of the number of required learning activities and the number of learning activities that were completed in each course can be found in Table 6.

Table 6: Learning activities logged and total Physioplus Points awarded for each course

	Course 1: Introduction to rehabilitation	Course 2: Rehabilitation in health systems	Course 3: Rehabilitation infrastructure and the rehabilitation team	Course 4: Competent delivery of rehabilitation interventions	Program     completion	Total
Required Learning Activities	10	14	12	11	6	53
Learning Activities Logged	18,411	7,374	5,284	5,280	832	37,181
Physioplus Points Awarded	4,686	2,119	1,860	1,702	209	10,576

3.3 Discussion Forum

Each course contained four to five optional open forum discussions. Learners were encouraged to engage with international course participants on a wide range of different topics associated with the course. These discussions were intended to provide a rich learning experience to the learner through self-reflection and community engagement. Participants submitted thousands of forum comments and questions, an impressive level of engagement given all Physioplus discussions throughout this course were optional.

In total there were 4,815 discussion posts over the course of the program. There were 596 comments on the most active discussion, which considered the individual context participants were working in, what rehabilitation means within those contexts, and the challenges they were facing in providing rehabilitation services both within those contexts and within the constraints of the COVID-19 pandemic. Table 7 presents an outline of the number of discussion posts for each discussion forum in each of the four courses.

Table 7: Number of Discussion Forum Posts

	Course 1: Introduction to rehabilitation	Course 2: Rehabilitation in health systems	Course 3: Rehabilitation infrastructure and the rehabilitation team	Course 4: Competent delivery of rehabilitation interventions	Total
Discussion 1	596	272	209	168	1,245
Discussion 2	449	218	205	160	1,032
Discussion 3	358	204	171	172	905
Discussion 4	326	212	179	107	824
Discussion 5	361	N/A	N/A	148	509
Reflections	176	52	39	33	300
Total	2,266	958	803	788	4,815

Data are Number (n) of Individual Posts

The discussion forums have provided an overview of barriers and challenges that rehabilitation workers currently face when providing rehabilitation services, particularly in the context of the COVID-19 pandemic. Many creative solutions to increase access to services have been highlighted in these discussion forums across a broad range of settings and contexts worldwide.

The most thought-provoking discussion forum was the one that looked at the global needs for rehabilitation, where course participants were asked to explore the WHO Rehabilitation Needs Estimator Tool and share the rehabilitation needs of their community based on this tool. They also were asked to consider the impact this might have on their service provision over the next five years. Common conditions highlighted were low back pain, neurological conditions, and hearing loss. This forum highlighted just how important the role of rehabilitation professionals is and will be in helping to maintain and improve quality of life. These forum discussion posts provide great insight into the state of rehabilitation across the world and ReLAB-HS recommends anyone interested in rehabilitation to look at these in more detail. The forums will stay active, and Physioplus members can continue to read and contribute to the discussion points as they complete the courses.

3.4 Final Assignment

An optional final assignment was designed to give participants an opportunity to reflect on their learning and use the knowledge gained throughout the courses. Participants were asked to follow the assignment guidelines or video assignment guidelines on Physiopedia, and the Physiopedia team assessed the submitted assignments. To successfully pass the final assignment, learners needed to demonstrate: evidence of learning from the course, academic skill with evidence-based writing, and proper referencing. Assignments had to be written in English. A total of 23 assignments were submitted of which nine have currently met the assignment requirements and were rewarded with a passing grade and program certificate.

3.5 Engagement versus Completion

1,753 learners began Course 1 (Introduction to Rehabilitation) of the Understanding Rehabilitation as Health Strategy program, with 37.1% completion rate. The number of learners who began and completed each of the four individual courses can be found in Table 8.

Table 8: Course Initiation and Completion

	Course 1	Course 2	Course 3	Course 4	Program
Learners who Started	1,753	689	490	515	233
Learners who Completed	635	434	360	335	6
Percentage Completion	36.2%	63.0%	73.4%	65.0%	2.6%

Data are Numbers (n) of Learners

Of the 10,703 learners who registered to take part in Understanding Rehabilitation as a Health Strategy program, 1,753 (16.8% of registered learners) began the first course before October 24, 2021. Table 9 displays the number of learners who began and completed the first and final course and the optional final assignment.

High numbers of dropouts are a common challenge for MOOC’s, suggested to be related to limited participant interactions (Fricton et al., 2015) and lack of face-to-face sessions, which generate a sense of isolation and disconnection (Jessica et al., 2021). While smaller numbers completed each consecutive course in the Understanding Rehabilitation as a Health Strategy program, the completion rates for the later courses were much higher than for the initial course, suggesting a good connection with the content. Overall, these completion rates are well above those seen for both health-related MOOC’s, with completion rates reported to range between 4.3% and 11% (Maxwell et al., 2018), and technology-related MOOC’s that are generally below 13% (Onah et al., 2014).

4.0 Thematic Analysis of Discussion Forums

Given the role and the importance of the discussion forums as a means for rehabilitation professionals to interact and share their expertise and knowledge with others across the world it was determined that a further thematic analysis be conducted on the discussion forums across each of the four courses to understand the overriding themes and sub-themes evident when examining rehabilitation.

First, all discussion forums from each course were reviewed in detail. Following this, forum discussions were further analysed to gain an understanding of the overall themes expressed across the four courses of the MOOC. Next, initial codes were generated utilising the WHO Rehabilitation Competency Framework as a guide to explore in greater detail the content of the selected discussion forums. Common emerging codes were then grouped to form themes and sub-themes. After themes and sub-themes were found, a second review was conducted to look for keywords to ensure that no common themes or sub-themes were missed. Overlapping themes were then identified. Themes and sub-themes were then searched for across each of these discussion forums (Nowell et al., 2017). The thematic analysis was performed on the selected discussion forums using NVivo 12 Software (NVivo Version 12.6.1).

Four main themes were identified that appeared across all discussion forums, with a further 12 sub-themes also identified. Table 10 and Figure 3 display the themes and associated sub-themes.

Table 10: Themes and Sub-Themes of Understanding Rehabilitation Discussion Forums

Themes		Sub-Themes
1	Access to Rehabilitation	Challenges Barriers Facilitators
2	Communication and Collaboration	Person-Centred Care Advocacy - Rehabilitation, Person, Family Cultural Competence
3	Interdisciplinary Teamwork	Facilitate Sharing of Knowledge Interpersonal Skills Sense of Purpose
4	Leadership	Leading by Example Positive Attitude to Change Sharing Culture

4.1 Access to Rehabilitation

Contemporary models and practice in rehabilitation recognize the right of individuals to have choices about their care, and the capability of people to do so as experts in their own lives and individual goals. It is a highly person-centered health care strategy by which treatment caters to the underlying health conditions, as well as to the goals and preferences of the user (Mauk, 2012). Throughout all four courses of the MOOC, access to rehabilitation was a key point of discussion, both within high- and low-resource settings, with concerns around disparity being very prominent within much of the discussion. Repeatedly, participants across all contexts identified and examined the challenges and barriers they faced to providing the right access to rehabilitation at the right time.

In many places distance and cultural values have a huge impact on access to rehabilitation services.

“In Australia, a large country with a relatively small population, the main barriers to rehabilitation services I see are 1. People in rural areas have to travel hundreds of KMs to access services (relying on the flying doctors for emergencies). 2. The indigenous population have different cultural attitudes and are often misunderstood and or remote populations.”

While in other contexts it is very evident that rehabilitation professionals have very limited input towards health policy, often resulting in disjointed services with poor care pathways.

“In Nigeria rehabilitation professionals are not involved in making health policies, rehabilitation services are not properly integrated into and between Primary, secondary and tertiary healthcare systems.”

A key issue highlighted by huge numbers across both low- and high-resource settings was the shortage of rehabilitation professionals to meet the current rehabilitation needs. In some settings this results in long waiting times to access services, but in other situations it can result in no access to services at all.

“Similar to friends in Nigeria, we in Cambodia have very few rehab professionals like PTs, P&O and social work. We almost do not have a rehab medical doctor, and have no training in OT, or Speech Therapy, We do not have rehab nurses. In addition to limited workforce, other resources are also poor such as ATs, rehab settings, and most importantly fund allocation, from government, developmental partner and private. The political will is not aligning with the 2030 goals of health for all, primarily the conflict of interests of officials and institutions that try to keep most of rehabilitation service under its not-prioritised agenda.”

The following discussion highlights many of the challenges and barriers that continue to impact access to rehabilitation services:    

“…policy is not sufficient to support, less resources, less available human resources, unused available human resources, infrastructure not sufficient where it is available, geographical context of Nepal, unavailability of equally distributed services, too costly to get services, long travelling to reach service areas, lack of sufficient budget, peoples motivation and lack of awareness, undervalued by government officials, unavailable sufficient education opportunity for rehab courses and employment after that… .”

Despite these challenges and barriers, it was also evident that participants of the MOOC were able to identify facilitators across all contexts to try and bridge the gaps. Innovation was a key part of this, and a passionate workforce with an overriding recognition of the benefits of rehabilitation. Changes in policy, particularly around provision of services for individuals with a disability are some of the key changes that many feel have helped support better access to rehabilitation, as have the implementation of community-based rehabilitation programs.

“Implemented government policies to facilitate people with disabilities and rehabilitation programs (eg. National policy for persons with disabilities and National action plan for disabilities)”

“Implementation of CBR programs in some areas by government and private sector with the help of NGOs”

Finally, there was a lot of recognition of the role of knowledge sharing as a key facilitator both for access to rehabilitation, and more importantly support for change, with many individuals recognising that higher-income countries often have increased access to funding to support service development.

“Opportunities for knowledge sharing and change management within organisation; opportunities for better representation of rehab professionals in decision making processes and service development. Some families do appreciate and value the role of rehab professionals in their children's recovery and participation; developed, higher income countries therefore have easier access to funding for service development”.

Overall, this leads into the next theme of communication and collaboration, which has the capacity to be a huge facilitator for change in all aspects of the health care systems.                

4.2 Communication and Collaboration

Just as communication and collaboration is prominent throughout each individual rehabilitation profession’s guidelines and standards, and a key element of the WHO Rehabilitation Competency Framework, it is no surprise that it has emerged as a key theme within our discussion forums, with the discussion forums identified as a community of practice that allow sharing of knowledge and expertise at a remote level. Across the board there was recognition of the importance of understanding the patient’s perspective when developing and adapting plans of care as vital to the rehabilitation process and the clinical decisions being made. All professions recognized that cultural competence was necessary when responding to the patient’s unique needs and the needs of the populations that the professional works with.

“Having the patient as a key team member in decision making and involving the multidisciplinary approach for a successful intervention to achieve the best results.”

“While interacting with patients first it provides information about their psychological status. Along with understanding of diseases and the manifestation as a result of that disease it gives an idea about rehabilitation. But a person's needs, beliefs, family support, surroundings, education, job, activity level, employment, persons interest and the outcome of disease should be considered. Without understanding these aspects it can have a great impact on rehabilitation needs.”

All professions also agreed that being an advocate for their patients, their patient’s family, and their rehabilitation profession was key. But it also became more apparent within the discussion forums as to the role rehabilitation professionals play in advocating for rehabilitation services, and more importantly, for services suitable for the specific culture and context.

“I think I learnt quite a lot from this course, and I feel my behavior and thinking now have changed. For example, I think about how to promote the introduction of a competency framework not only for ensuring competency of personnel in my current setting but for all rehabilitation centers in Cambodia. Beyond this is lobbying for introducing to training institutions to improve their training curriculum to produce graduates with sets of competencies for rehabilitation workforce”

“Everybody should be conscious about the importance of rehabilitation. We need to inform people about these different stages of rehabilitation. If more people promoted rehabilitation to be a part of our health systems at all levels then our patients and the people in our communities will reap the benefits.”

4.3 Interdisciplinary Teamwork

Working efficiently and effectively on an interdisciplinary team was identified by many as an important aspect of the rehabilitation process, regardless of the phase, setting, and context.

Knowledge sharing within this team allowed members to gain a better appreciation and understanding of the roles of other rehabilitation professionals and each profession’s unique contribution to patient care. It also provided an opportunity to develop a common sense of purpose, provided a mechanism to work together towards common goals, with a focus on participation to improve quality of life.

“The MDT approach is most effective here in the refugee setting where I work due to comprehensive goal setting and comprehensive service provision. Communication, practical knowledge & keeping client centered are the key qualities.”

“I work in an interdisciplinary team and we often overlap in tasks, especially the nurses. We have regular MDT meetings to discuss the patients goals etc. This style of rehab is focused on the patient to enable them to achieve their goals and have the best outcome. We all work together with the patient.”

4.4 Leadership

Effective leaders in health services emphasize safe, high-quality, compassionate care as the top priority. They promote continuous development of knowledge, skills, and abilities in order to improve quality of patient care, safety, compassion, and the patient experience. They ensure the voice of patients is consistently heard at every level: patients’ experience, concerns, needs and feedback (positive and negative). They offer supportive, available, empathic, fair, respectful, compassionate, and empowering leadership, employing participation and involvement as core leadership strategies. They consistently encourage, motivate, reward innovation, and introduce new/improved ways of working (West et al., 2015).

“Qualities of a team should be effective leadership and communication; clinical weekly meetings are part of it, a good team spirit; collaborating effectively, Respect for each discipline; knowing one’s limits, as well as team support; builds each one’s strength.”

Leadership was highlighted as a key factor in capacity to develop successful rehabilitation services. Leaders influence the culture – both positively and negatively. Good leaders      lead by example while providing an open and safe environment for team members to share their thoughts and generate opportunities for innovation (HSE Quality Improvement Division, 2018).

There must be direction, alignment, and commitment to a shared, holistic view of care that includes commitment to improving linkages with other providers and to achieving system goals, such as continuity of care. This in turn implies alignment across different parts of organizations, different providers, other relevant groups, and different levels of care. Ensuring key cultural elements are in place also requires leadership that creates direction, alignment, and commitment in relation to these cultural elements (West et al., 2015).

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