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To examine the evolution of health care integration strategies and associated conceptualization and practice through a review and synthesis of over 25 years of international academic research and literature.

A search of the health sciences literature was conducted using PubMed and EMBASE. A total of 114 articles were identified for inclusion and thematically analyzed using a strategy content model for systems-level integration.

Six major, inter-related shifts in integration strategies were identified: (1) from a focus on horizontal integration to an emphasis on vertical integration; (2) from acute care and institution-centered models of integration to a broader focus on community-based health and social services; (3) from economic arguments for integration to an emphasis on improving quality of care and creating value; (4) from evaluations of integration using an organizational perspective to an emerging interest in patient-centered measures; (5) from a focus on modifying organizational and environmental structures to an emphasis on changing ways of working and influencing underlying cultural attitudes and norms; and (6) from integration for all patients within defined regions to a strategic focus on integrating care for specific populations. We propose that underlying many of these shifts is a growing recognition of the value of understanding health care delivery and integration as processes situated in Complex-Adaptive Systems (CAS).

This review builds a descriptive framework against which to assess, compare, and track integration strategies over time.

To investigate the effects of payor–provider integration on the operational performance of health service provision. The research explores whether integration governs agency problems and tilts the incentives of diverse actors toward more systematic outcomes.

A two stage multimethod case study of occupational health services. A qualitative stage aimed to understand the reasons, mechanisms, and outcomes of payor–provider integration. A quantitative stage evaluated the performance of the integrated hospital against fee-for-service partner hospitals with a sample of 2,726 patients.

Payor–provider integration mitigates agency problems on multiple levels of the service system by complementing formal governance mechanisms with informal mechanisms. Compared to partner hospitals, the integrated hospital yielded 9% lower the total costs of occupational injuries achieved primarily by emphasizing conservative care and faster recovery.

Focuses on occupational health services in Finland. Provides initial evidence of the effects of payor–provider integration on the operational performance.

Vertical integration may provide systematic outcomes but requires mindful implementation of multiple mechanisms. Rigorous change management initiative is advised.

For patients, the research shows payor–provider integration of health services can be implemented in a manner that it reduces care costs while not compromising care quality and customer satisfaction.

This study provides a rare longitudinal analysis of payor–provider integration in health-care operations management. The study adds to the knowledge of operational performance improvement of health services.

This paper aims to report on research undertaken in an National Health Service (NHS) emergency department in the north of England, UK, to identify which patients, with which clinical conditions are returning to the emergency department with an unscheduled return visit (URV) within seven days. This paper analyses the data in relation to the newly introduced Integrated Care Boards (ICBs). The continued upward increase in demand for emergency care services requires a new type of “upstreamist”, health system leader from the emergency department, who can report on URV data to influence the development of integrated care services to reduce further demand on the emergency department.

Patients were identified through the emergency department symphony data base and included patients with at least one return visit to emergency department (ED) within seven days. A sample of 1,000 index visits between 1 January 2019–31 October 2019 was chosen by simple random sampling technique through Excel. Out of 1,000, only 761 entries had complete data in all variables. A statistical analysis was undertaken using Poisson regression using NCSS statistical software. A review of the literature on integrated health care and its relationship with health systems leadership was undertaken to conceptualise a new type of “upstreamist” system leadership to advance the integration of health care.

Out of all 83 variables regressed with statistical analysis, only 12 variables were statistically significant on multi-variable regression. The most statistically important factor were patients presenting with gynaecological disorders, whose relative rate ratio (RR) for early-URV was 43% holding the other variables constant. Eye problems were also statistically highly significant (RR = 41%) however, clinically both accounted for just 1% and 2% of the URV, respectively. The URV data combined with “upstreamist” system leadership from the ED is required as a critical mechanism to identify gaps and inform a rationale for integrated care models to lessen further demand on emergency services in the ED.

At a time of significant pressure for emergency departments, there needs to be a move towards more collaborative health system leadership with support from statistical analyses of the URV rate, which will continue to provide critical information to influence the development of integrated health and care services. This study identifies areas for further research, particularly for mixed methods studies to ascertain why patients with specific complaints return to the emergency department and if alternative pathways could be developed. The success of the Esther model in Sweden gives hope that patient-centred service development could create meaningful integrated health and care services.

This research was a large-scale quantitative study drawing upon data from one hospital in the UK to identify risk factors for URV. This quality metric can generate important data to inform the development of integrated health and care services. Further research is required to review URV data for the whole of the NHS and with the new Integrated Health and Care Boards, there is a new impetus to push for this metric to provide robust data to prioritise the need to develop integrated services where there are gaps.

To the best of the authors’ knowledge, this is the first large-scale study of its kind to generate whole hospital data on risk factors for URVs to the emergency department. The URV is an important global quality metric and will continue to generate important data on those patients with specific complaints who return back to the emergency department. This is a critical time for the NHS and at the same time an important opportunity to develop “Esther” patient-centred approaches in the design of integrated health and care services.

The purpose of this paper is to identify and describe the international and New Zealand (NZ) evidence for models of integrated ambulatory care and describe key implementation issues and lessons learnt.

A scoping review was conducted for published and grey literature on integrated care. Publications from 2000 to February 2019 that described integrated ambulatory care were included.

A total of 34 articles were included. Internationally and in NZ, the most common models of integrated care found were: transfer, relocation and joint working. The international literature showed that transferring care from hospitals to community and other integrated models of care between the primary–specialist interface increased access and convenience for patients. However, there was insufficient evidence of clinical and economic outcomes. Very few NZ-based studies reported on effectiveness of models of care. Key implementation issues were: no viable and sustainable funding, lack of infrastructure, lack of confidence, trust and communication between providers, increased workload and time and knowledge and skills gap to perform new roles. The NZ literature highlighted the need for an appropriate location for services, committed leadership, development of a governance group representing different provider groups, strong communication mechanisms, new workforce skills and overall change management.

The review provides an overview of key components of integrated care models in ambulatory settings and identifies some common elements across the models of care. The findings can inform the design and implementation of integrated ambulatory care in health systems.

This paper results from experience gained while developing and delivering the South Devon Integrated Care Network (ICN) and from more recent experience as an Integrated Care Pilot (ICP) organisation. It demonstrates that by taking an integrated approach a hospital can develop and prosper, and that it is possible to reduce the use of beds and manage care in the community within the levels of funding currently available. The paper focuses on integration at organisation level and proposes a model of key system drivers and controls necessary to manage an integrated health and social care system. The next level of integration is at individual customer level, and the paper discusses the enablers for this.

Integrated health care lacks a theoretical concept of the user figure that is appropriate to reflect users’ various claims and multi-dimensional interrelations in the care process. The paper aims to discuss this issue.

Key goals of integrated health care, such as a continuity of care, seamless services and better health outcomes depend strongly on users’ capabilities to engage themselves in the care process. These goals are hardly reachable if integrated health care schemes operate with a one-dimensional understanding of users’ identity.

The suggested concept of users’ identity facets suggests that users draw from different sources while receiving integrated health care. Thus, users are patients, co-producers, citizens, consumers and community members in one person and at the same time. Each facet of the user identity gains or loses relevance depending on health care contexts, health statuses, personal values and the design of service arrangements. As demonstrated by the example of disease management programmes (DMPs), care schemes for chronically ill persons, users have to apply different facets of their identities in order to benefit best from service provision. Moreover, addressing users’ identity may facilitate the extent of integration in DMPs.

Integrated health care schemes are challenged to invent strategies that facilitate and support coherence among users’ diverse identities in the process of service provision. Lessons could be learned from small-scale and localized integrated health care networks.

Objective – Tanzania, Mexico, and the United States are at vastly different points on the economic development scale. Yet, their health systems can be classified as “developing”: they do not live up to their potential, considering the resources available to them. The three, representing many others, share a common structural deficiency: a segregated health care system that cannot achieve its basic goals, the optimal health of its people, and their possible satisfaction with the system. Segregation follows and signifies first and foremost the lack of financial integration in the system that prevents it from serving its goals through the objectives of equity, cost containment and sustainability, efficient production of care and health, and choice.

Method – The chapter contrasts the nature of the developing health care system with the common goals, objectives, and principles of the Emerging Paradigm (EP) in developed, integrated – yet decentralized –systems. In this context, the developing health care system is defined by its structural deficiencies, and reform proposals are outlined.

Findings – In spite of the vast differences amongst the three countries, their health care systems share strikingly similar features. At least 50% of their total funding sources are private. The systems comprise exclusive vertically integrated, yet segregated, “silos” that handle all systemic functions. These reflect and promote wide variations in health insurance coverage and levels of benefits – substantial portions of their populations are without adequate coverage altogether; a considerable lack of income protection from medical spending; an inability to formalize and follow a coherent health policy; a lack of financial discipline that threatens sustainability and overall efficiency; inefficient production of care and health; and an dissatisfied population. These features are often promoted by the state, using tax money, and donors.

Policy implications – The situation can be rectified by (a) “centralizing” – at any level of development and resource availability – health system finance around a set package of core medical benefits that is made available to the entire population and (b) “decentralizing” consumption and provision of care. The first serves equity and cost containment and sustainability. The second supports efficiency and client satisfaction.

Originality/value of chapter – The chapter views commonly discussed problems of the health care system – a lack of insurance coverage and income protection – as symptoms of a large problem: health system segregation.

Policies on integrated care have waxed and waned over time in the English health and care sectors, culminating in the creation of 42 integrated care systems (ICSs) which were confirmed in law in July 2022. One of the four fundamental purposes of ICSs is to tackle health inequalities. This paper reports on the content of the overarching ICS plans in order to explore how they focus on health inequalities and the strategies they intend to employ to make progress. It explores how the integrated approach of ICSs may help to facilitate progress on equity.

The analysis is based on a sample of 23 ICS strategic plans using a framework to extract relevant information on health inequalities.

The place-based nature of ICSs and the focus on working across traditional health and care boundaries with non-health partners gives the potential for them to tackle not only the inequalities in access to healthcare services, but also to address health behaviours and the wider social determinants of health inequalities. The plans reveal a commitment to addressing all three of these issues, although there is variation in their approach to tackling the wider social determinants of health and inequalities.

This study adds to our knowledge of the strategic importance assigned by the new ICSs to tackling health inequalities and illustrates the ways in which features of integrated care can facilitate progress in an area of prime importance to society.

Although a large amount of literature about the levels, aims, and relevance of integrated care is present, to realise change in practice knowledge about the implementation and development process of integrated care is also crucial. Instruments such as quality management models can facilitate improvement, but are not frequently used in integrated care practice. The purpose of this paper, therefore, is to present further insight into these models and into the related literature about network and organisational development.

An overview of the recent literature is presented.

The improvement of integrated care is complex and there is no consensus about a set of relevant elements for integrated care. Available quality management models vary in their underlying evidence and do not have integrated care as their central focus or are aimed at specific patient groups such as the chronically ill. The lack of a consistent set of elements and the need for a generic, evidence‐based quality management model for integrated care is important for integrated care improvement. It can be assumed that, as described in the literature about networks and organisations, dynamic stages or phases could be relevant for integrated care. These issues raise important next questions for further research and for facilitating organisational change.

The paper presents a current overview of the available literature about the concept of integrated care, with a special focus on integrated care improvement and its dynamics. It raises the relevant questions and challenges for the further expansion of knowledge about these topics, which will be addressed in a second article in a later issue of Journal of Integrated Care.

Given the complex nature of integrated care systems (ICSs), the geographical spread and the large number of organisations involved in partnership delivery, the importance of leadership cannot be overstated. This paper aims to present novel findings from a rapid realist review of ICS leadership in England. The overall review question was: how does leadership in ICSs work, for whom and in what circumstances?

Development of initial programme theories and associated context–mechanism–outcome configurations (CMOCs) were supported by the theory-gleaning activities of a review of ICS strategies and guidance documents, a scoping review of the literature and interviews with key informants. A refined programme theory was then developed by testing these CMOCs against empirical data published in academic literature. Following screening and testing, six CMOCs were extracted from 18 documents. The study design, conduct and reporting were informed by the Realist And Metanarrative Evidence Syntheses: Evolving Standards (RAMESES) training materials (Wong et al., 2013).

The review informed four programme theories explaining that leadership in ICSs works when ICS leaders hold themselves and others to account for improving population health, a sense of purpose is fostered through a clear vision, partners across the system are engaged in problem ownership and relationships are built at all levels of the system.

Despite being a rigorous and comprehensive investigation, stakeholder input was limited to one ICS, potentially restricting insights from varied geographical contexts. In addition, the recent establishment of ICSs meant limited literature availability, with few empirical studies conducted. Although this emphasises the importance and originality of the research, this scarcity posed challenges in extracting and applying certain programme theory elements, particularly context.

This review will be of relevance to academics and health-care leaders within ICSs in England, offering critical insights into ICS leadership, integrating diverse evidence to develop new evidence-based recommendations, filling a gap in the current literature and informing leadership practice and health-care systems.