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Structural integration is increasingly explored as a means of achieving efficiency gains alongside improved health outcomes. In 2015, three boroughs in London, England began working together to develop an Accountable Care Organisation for the 750,000 population they serve. The purpose of this paper is to understand the experiences of working across organisational and sectoral boundaries for the benefit of the population, including enablers and barriers encountered, the role of financial incentives and perspectives on Accountable Care Organisations.

A single site instrumental case study involving 35 semi-structured interviews using a topic guide, with key leaders and decision makers from the site and nationally, between April 2016 and August 2016.

There are differences in levels of autonomy and operational priorities between councils and the NHS. Existing financial mechanisms can be used to overcome sectoral boundaries, but require strong leadership to implement. There are challenges associated with primary care participating in integration, including reluctance for small organisations to adopt the risk associated with large scale programmes. Interviewees were aligned on espoused ambitions for the Accountable Care Organisation but not on whether one organisation was needed to deliver these in practice.

Progressing the integration agenda requires consideration of the context of primary care and the core differences between health and government. Further, research into ACOs is required as they may not be required to deliver the anticipated integration and system outcomes. Understanding if there are specific population groups for whom cross-organisation and cross-sector working could have particular benefits would help to target efforts.

This paper highlights some of the challenges associated with cross-sector collaboration.

The implementation of the Patient Protection and Affordable Care Act has facilitated the development of an innovative and integrated delivery care system, Accountable Care Organizations (ACOs). It is timely, to identify how health care managers in rural health clinics (RHCs) are responding to the ACO model. This research examines RHC managers’ perceived benefits and barriers for implementing ACOs from an organizational ecology perspective.

A survey was conducted in spring of 2012 covering the present RHC network working infrastructures – (1) Organizational social network; (2) organizational care delivery structure; (3) ACO knowledge, perceived benefits, and perceived barriers; (4) quality and disease management programs; and (5) health information technology (HIT) infrastructure. One thousand one hundred sixty clinics were surveyed in the United States. They cover eight southeastern states (Alabama, Florida, Georgia, Kentucky, Mississippi, North Carolina, South Carolina, and Tennessee) and California. A total of 91 responses were received.

RHC managers’ personal perceptions on ACO’s benefits and knowledge level explained the most variance in their willingness to join ACOs. Individual perceptions appear to be more influential than organizational and context factors in the predictive analysis.

The study is primarily focused in the Southeastern region of the United States. The generalizability is limited to this region. The predictors of RHCs’ participation in ACOs are germane to guide the development of organizational strategies for enhancing the general knowledge about the innovativeness of delivering coordinated care and containing health care costs inspired by the Affordable Care Act.

RHCs are lagged behind the growth curve of ACO adoption. The diffusion of new knowledge about pros and cons of ACO is essential to reinforce the health care reform in the United States.

The paper seeks to move the integrated care debate forward by exploring what contributes to improved quality and efficiency, and to consider the practical consequences of translating a model exemplifying that success into the English context.

The authors contend that a key driver is to unite the whole system in a single purpose, incentivising all parts to align with that single shared purpose. Although designed for a very different healthcare system, the Accountable Care Organisation (ACO) model exemplifies this principle – aligning incentives across a variety of providers to achieve practical integration driven by outcomes.

The authors explore what an ACO model would comprise if transposed, demonstrating that it offers the short term gains claimed for integrated care whilst also providing a structured framework setting out a clear long term roadmap for both commissioner and provider evolution, hitherto not addressed by policy. Drawing analogies from other industries it is suggested that potential conflict between integration, competition and choice is exaggerated. The discussions with leaders and whole community groups has consistently been found to provide fresh and helpful insight.

In this paper, the authors bring fresh insight to what aspects of integrated care contribute to future success and then explore why and how that insight can be applied by translating growing experience from elsewhere into the English NHS setting.

The purpose of this paper is to identify the primary executive leadership skills required to promote the effectiveness of Medicare Shared Savings Program Accountable Care Organizations (MSSP ACOs) and to create a new substantive theory describing these skills. The author identifies that MSSP ACO is a relatively new value-based care delivery (VBCD) structure in the USA that links clinicians’ compensation to their clinical outcomes. The research question concerns what primary executive leadership skills are essential in the VBCD era.

This single, embedded, exploratory case study is based on interviews, a focus group discussion and archival record data of MSSP ACO executives in the Northeast, Midwest, South and West of the USA.

The findings represented seven major categories or the primary executive leadership skills required to succeed in the VBCD environment. Each category or skill included five subcategories or concepts supporting the leadership skills essential for reaching VBCD goals. The categories and subcategories gave rise to a new substantive theory – the Accountable Healthcare Leadership Theory of Five Ps: promoting partnership between providers, patients and payers.

The empirical generalizability of the results was limited by its essence as a single, embedded, exploratory case study of 18 MSSP ACO executives in 4 regions of the USA. The strength of this study, however, lies in its potential for making analytic generalizations for identifying theoretically meaningful leadership skills essential for success in the VBCD era.

The author has developed and validated a new theory describing the primary executive leadership skills required to succeed in the VBCD environment.

This chapter integrates organization design and sustainability concepts to describe an accelerated transformational change at the Fairview Medical Group (United States).

A case study of the transformation at Fairview Medical Group’s primary care clinics was developed from interviews and first-person accounts of the change. Objective data regarding outcomes was used to evaluate the effectiveness of the redesign process.

The Fairview Medical Group developed an innovation and change capability to transform 35 primary care clinics in six months. All of the clinics were certified by the state of Minnesota as complying with their healthcare standards. Clinical outcomes, costs, and employee and physician engagement also increased. All of the improved measures are sustained.

Healthcare reform in the United States struggles because the organization design challenges are great and the change difficulties even greater. Fairview’s experience provides important evidence and lessons that can help advance our understanding of effective healthcare and create more sustainable healthcare systems. This chapter provides healthcare system administrators evidence and alternatives in the pursuit of implementation.

The purpose of this paper is to describe the current landscape of health information technology (HIT) in early accountable care organizations (ACOs), the different strategies ACOs are using to develop HIT-based capabilities, and how ACOs are using these capabilities within their care management processes to advance health outcomes for their patient population.

Mixed methods study pairing data from a cross-sectional National Survey of ACOs with in-depth, semi-structured interviews with leaders from 11 ACOs (both completed in 2013).

Early ACOs vary widely in their electronic health record, data integration, and analytic capabilities. The most common HIT capability was drug-drug and drug-allergy interaction checks, with 53.2 percent of respondents reporting that the ACO possessed the capability to a high degree. Outpatient and inpatient data integration was the least common HIT capability (8.1 percent). In the interviews, ACO leaders commented on different HIT development strategies to gain a more comprehensive picture of patient needs and service utilization. ACOs realize the necessity for robust data analytics, and are exploring a variety of approaches to achieve it.

Data are self-reported. The qualitative portion was based on interviews with 11 ACOs, limiting generalizability to the universe of ACOs but allowing for a range of responses.

ACOs are challenged with the development of sophisticated HIT infrastructure. They may benefit from targeted assistance and incentives to implement health information exchanges with other providers to promote more coordinated care management for their patient population.

Using new empirical data, this study increases understanding of the extent of ACOs’ current and developing HIT capabilities to support ongoing care management.

Service transformation of health and social care is currently requiring commissioners to assess the suitability of their contracting mechanisms to ensure goodness of fit with the integration agenda. The purpose of this paper is to provide a description and critical account of four models of contracting, namely Accountable Care Organisations, the Alliance Model, the Lead Provider/Prime Contractor Model, and Outcomes-based Commissioning and Contracting.

The approach taken to the literature review was narrative and the results were organised under an analytical framework consisting of six themes: definition and purpose; characteristics; application; benefits/success factors; use of incentives; and critique.

The review highlighted that while the models have relevance, there are a number of uncertainties regarding their direct applicability and utility for the health and social care agenda, and limited evidence of effectiveness.

Due to the relative newness of the models and their emerging application, much of the commentary was limited to a narrow range of contributors and a broader discussion is needed. It is clear that further research is required to determine the most effective approach for integrated care contracting. It is suggested that instead of looking at individual models and assessing their transferable worth, there may be a place for examining principles that underpin the models to reshape current contracting processes.

What appears to be happening in practice is an organic development. With the growing number of examples emerging in health and social care, these may act as “trailblazers” and support further development.

There is emerging debate surrounding the best way to contract for health and social care services, but no literature review to date that takes these current models and examines their value in such critical detail. Given the pursuit for “answers” by commissioners, this review will raise awareness and provide knowledge for decision making.

The purpose of this paper is to introduce the new US health organizations called accountable care organizations (ACOs) which are expected to improve the quality and reduce the cost of healthcare for Medicare enrolees. It assesses the importance of ACOs, defining and articulating the values that will underpin their strategic and clinical decision making.

This paper uses a social values framework developed by Clark and Weale to consider the values relevant to ACOs.

It is likely that social values could be made more explicit in a US setting than they have ever been before, via the new ACOs. Social values could start to form part of a local health economy's marketing strategy.

ACOs are very new. This paper identifies that they will need to be very explicit about the values relevant to them. The development of ACOs and the articulation of social values therein may even form the basis of a meaningful dialogue on the importance of assessing value for money or cost‐effectiveness in the wider US health policy environment.

The purpose of this article is to share emerging evidence about the qualitative and economic benefits of integrating care, based on an innovative population‐based approach across a small region of Germany. The article aims to discuss the features that have similarities to the international discussion around managed care and accountable care, e.g. the use of a “gain share” model to incentivise all the main partners, and the quite unique approaches derived from a public health background. The operation of Gesundes Kinzigtal could be considered as a benchmark for the “Clinical commissioning groups” that are in development as a result of the Health and Social Care Act 2012 in the UK.

A regional health management company in cooperation with the physicians' network in the region and two health insurance providers has reorganized the delivery of care across all sectors towards improving the health of the population. The key features of the approach are summarised in the paper. Administrative and medical data obtained from the health insurance providers and from routine management monitoring are used to evaluate the benefits of the approach compared to control groups.

The project is beginning to demonstrate that this model of integrated care can be effective, with cost benefits and savings for the partners, and improved health outcomes for the population.

The project started in 2006, and only early results of the first three to four years are reported here because of the use of claims data of health insurers.

The approach is an innovative model of integration in its combination of logistical re‐engineering of care processes, IT integration, public health and prevention measures. Its evaluation through an ambitious series of studies may have long‐term relevance for the organisation and management of care services internationally.

This case study aims to introduce a novel home care service integrator model called “Kotitori”. In the model the City contracts with a private provider, which, in turn, works with public, private, and third sector providers in order to meet the customer needs in a personalised way.

The case study draws from key policy documents and stakeholder interviews.

The study introduces a unique form of public‐private partnership in Finland, and describes the basic elements of Kotitori, the development process of the model, and the model's distinctive features compared to more traditional ways of home care service delivery.

The Kotitori model is still in its early stages of implementation and reliable data on performance are limited.

The transferability potential of the Kotitori model is good both nationally and internationally. The model is potentially beneficial for countries with an interest in developing integrated care in general, as it reflects a form of “accountable care organisation”.

This is the first study describing the Kotitori model for an international audience.