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The evaluations of the policy were promising, but the actual practice needs improvement. Future assessment of both policy and practice is recommended. Further research should focus on communication interventions for implementing advance care planning in the daily practice.

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The study hypothesis is that 'we DECide' results in a higher realization of shared decision-making in individual conversations on advance care planning. A better implementation of advance care planning will lead to a higher quality of end-of-life care and more person-centred care. We believe our study will be of interest to researchers and to professional nursing home caregivers and policy-makers.

Introduction: Several measurement instruments have been developed to measure the level of integrated health care delivery. However, no standardized, validated instrument has been found to cover all aspects of integrated care. The purpose of this review is to identify instruments on how to measure the level of integration across health care sectors and to assess and evaluate the organizational elements within the identified instruments.Methods: An extensive, systematic literature review in PubMed, CINAHL, PsycINFO, Cochrane Library, Web of Science for the years 1980-2011.Selected abstracts were independently reviewed by two investigators. Results:We identified 23 measurement instruments. Of these, almost all included well-defined structural and process aspects and 6 included cultural aspects. A theoretical framework was explicitly stated by 14 studies. Within the identified instruments 8 organizational elements were found. No measurement instrument covered all organizational elements. Conclusion and discussion:This review did not identify any measurement instrument covering all aspects of integrated care. In addition, a lack of uniformly use of the eight organizational elements across the studies was prevalent. It is unclear whether development of a single "allinclusive" model for assessing integrated care is desirable. We emphasize the continuing need for validated instruments embedded in theoretical contexts.