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The comprehensive framework for integrated healthcare implementation: a realist evaluation of positive parenting in rural primary care in the US

Deborah J. Moon (Social Work, University of Pittsburgh, Pittsburgh, Pennsylvania, USA)
Adrian J. Ballard (Social Work, University of Pittsburgh, Pittsburgh, Pennsylvania, USA)

Journal of Integrated Care

ISSN: 1476-9018

Article publication date: 30 December 2020



This study aimed to develop a comprehensive framework that encompasses contextual determinants of integrated care implementation. The initial framework was developed based on literature and was refined based on contexts and mechanisms that facilitated or interfered with integrating a pilot parenting intervention, Behavior Checker (BC), into the routine service delivery in a rural primary care clinic in the USA.


This study was a single organizational case study informed by the realist evaluation methodology. Data collection methods included key informant interviews, healthcare staff surveys, a focus group and direct observation of meetings. Data analysis focused on identifying the context-mechanism-outcome (CMO) frameworks, a heuristic used in a realist evaluation to map pathways of the interactions between program inputs and contextual conditions leading to intended and/or unintended outcomes.


The identified CMOs and antecedent contexts identified informed the process of revising the initial Comprehensive Framework for Integrated Healthcare Development and Implementation (CF-IHDI). The revised CF-IHDI contained six parent domains of outer setting, basic structures, people and value, intervention characteristics, organizational capabilities for change and key processes.

Research limitations/implications

The CMOs and core characteristics of contextual conditions that activated facilitating mechanisms can inform future studies examining healthcare integration efforts.

Practical implications

The CF-IHDI can guide primary care clinics in identifying factors and strategies to consider when integrating parenting or other psychosocial interventions into primary care routine service delivery.


The CF-IHDI developed in this study contributes to the knowledge of contexts and mechanisms that facilitate and interfere with integrated care implementation.



This study was funded by the Doris Duke Fellowships for the Promotion of Child Well-Being and Social Work Healthcare Education and Leadership Scholars (HEALS) program. The authors thank Dr Michelle Johnson-Motoyama (College of Social Work, Ohio State University) and Dr Eve-Lynn Nelson (Pediatric Behavioral Department, University of Kansas Medical Center) for their support and guidance in completing this study.


Moon, D.J. and Ballard, A.J. (2020), "The comprehensive framework for integrated healthcare implementation: a realist evaluation of positive parenting in rural primary care in the US", Journal of Integrated Care, Vol. ahead-of-print No. ahead-of-print.



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