Reframing the challenges to integrated care: a complex-adaptive systems perspective

Abstract

IntroductionDespite over two decades of international experience and research on health systems integration, integrated care has not developed widely. We hypothesized that part of the problem may lie in how we conceptualize the integration process and the complex systems within which integrated care is enacted. This study aims to contribute to discourse regarding the relevance and utility of a complex-adaptive systems (CAS) perspective on integrated care.MethodsIn the Canadian province of Ontario, government mandated the development of fourteen Local Health Integration Networks in 2006. Against the backdrop of these efforts to integrate care, we collected focus group data from a diverse sample of healthcare professionals in the Greater Toronto Area using convenience and snowball sampling. A semi-structured interview guide was used to elicit participant views and experiences of health systems integration. We use a CAS framework to describe and analyze the data, and to assess the theoretical fit of a CAS perspective with the dominant themes in participant responses.ResultsOur findings indicate that integration is challenged by system complexity, weak ties and poor alignment among professionals and organizations, a lack of funding incentives to support collaborative work, and a bureaucratic environment based on a command and control approach to management. Using a CAS framework, we identified several characteristics of CAS in our data, including diverse, interdependent and semi-autonomous actors; embedded co-evolutionary systems; emergent behaviours and non-linearity; and self-organizing capacity.Discussion and conclusionOne possible explanation for the lack of systems change towards integration is that we have failed to treat the healthcare system as complex-adaptive. The data suggest that future integration initiatives must be anchored in a CAS perspective, and focus on building the system’s capacity to self-organize. We conclude that integrating care requires policies and management practices that promote system awareness, relationship-building and information-sharing, and that recognize change as an evolving learning process rather than a series of programmatic steps.

Changes in geriatric rehabilitation: a national programme to improve quality of care. The Synergy and Innovation in Geriatric Rehabilitation study

“…However, after implementation of quality improvements, a longer period of evaluation may be needed to reveal changes in service delivery as experienced by patients and informal caregivers [9]. It is a worldwide challenge to initiate, develop and evaluate integrated care on a large scale with multiple health care providers involved in a changing health care economy, also called 'complex adaptive systems' or 'complex interventions' [22][23][24]. These systems are complex because of the dynamics within the different health care providers and the large number of components that interact when developing integrated care delivery [13,22,23,25,26].…”

“…It is a worldwide challenge to initiate, develop and evaluate integrated care on a large scale with multiple health care providers involved in a changing health care economy, also called 'complex adaptive systems' or 'complex interventions' [22][23][24]. These systems are complex because of the dynamics within the different health care providers and the large number of components that interact when developing integrated care delivery [13,22,23,25,26]. Another explanation may be that the national project had too optimistic expectations about the capacity of the organisations to execute a successful change themselves.…”

“…To achieve good adaptation in a real-world setting, an active research design has several advantages [13,22]. Development, implementation and evaluation were combined to develop tailor-made integrated care.…”

Translating the Elements of Health Governance for Integrated Care from Theory to Practice: A Case Study Approach

“…Integrated care is a patient-centred, multi-level, multi-method strategy designed to achieve improved coordination of services across the care continuum of complex health systems [31011]. Integrated care develops within distinct and differing governance structures [12] across three levels of integration – micro, meso and macro [1314].…”

Shaping the midwifery profession in Nepal – Uncovering actors' connections using a Complex Adaptive Systems framework

“…This kind of change would require the involvement of all actors in the studied system. In CAS, change can be difficult to promote, and cannot be forced [34,35]. However, inviting the nursing profession, as an active component of the system, could create an understanding between the two professions and uncover potential threats towards one or the other.…”