Rethinking Integrated Care: A Systematic Hermeneutic Review of the Literature on Integrated Care Strategies and Concepts

Abstract

Integrated care is best understood as an emergent set of practices intrinsically shaped by contextual factors, and not as a single intervention to achieve predetermined outcomes. Policies to integrate care that facilitate person‐centered, relationship‐based care can potentially contribute to (but not determine) improved patient experiences. There can be an association between improved patient experiences and system benefits, but these outcomes of integrated care are of different orders and do not necessarily align. Policymakers should critically evaluate integrated care programs to identify and manage conflicts and tensions between a program's aims and the context in which it is being introduced. Context Integrated care is a broad concept, used to describe a connected set of clinical, organizational, and policy changes aimed at improving service efficiency, patient experience, and outcomes. Despite examples of successful integrated care systems, evidence for consistent and reproducible benefits remains elusive. We sought to inform policy and practice by conducting a systematic hermeneutic review of literature covering integrated care strategies and concepts. Methods We used an emergent search strategy to identify 71 sources that considered what integrated care means and/or tested models of integrated care. Our analysis entailed (1) comparison of strategies and concepts of integrated care, (2) tracing common story lines across multiple sources, (3) developing a taxonomy of literature, and (4) generating a novel interpretation of the heterogeneous strategies and concepts of integrated care. Findings We identified four perspectives on integrated care: patients’ perspectives, organizational strategies and policies, conceptual models, and theoretical and critical analysis. We subdivided the strategies into four framings of how integrated care manifests and is understood to effect change. Common across empirical and conceptual work was a concern with unity in the face of fragmentation as well as the development and application of similar methods to achieve this unity. However, integrated care programs did not necessarily lead to the changes intended in experiences and outcomes. We attribute this gap between expectations and results, in part, to significant misalignment between the aspiration for unity underpinning conceptual models on the one hand and the multiplicity of practical application of strategies to integrate care on the other. Conclusions Those looking for universal answers to narrow questions about whether integrated care “works” are likely to remain disappointed. Models of integrated care need to be valued for their heuristic rather than predictive powers, and integration understood as emerging from particular as well as common contexts.

Healthcare system maturity for integrated care: results of a Swiss nationwide survey using the SCIROCCO tool

“…However, the federal organisation of healthcare leaves considerable room for the implementation of local initiatives, which may need to be considered since large-scale strategies do not always represent the optimal option. 26 Results of the national integrated care survey conducted in 2015–2016 showed that local integrated care initiatives have been steadily growing in Switzerland over the last 20 years and were characterised by a diversity of types and breadth of initiatives, implemented interventions and targeted population, among others. 11 Therefore, the low maturity results according to the SCIROCCO tool probably reflect a limited maturity for integrated care at the federal level rather than the cantonal one.…”

Are health systems redesigning how health care is delivered?

“…While it may be tempting to look for the entrepreneurial health systems that disrupted care approaches and have high care quality outcomes and expect other systems to be able to follow those models, it has been noted that those efforts may be effective in making systems look more similar, but not actually bring about improvements in efficiency or outcomes when changes are implemented without consideration of each system's unique characteristics and context. 45,46 While labels such as "redesigning" or "transforming" care have intuitive appeal and many health care stakeholders recognize there are numerous opportunities for improving processes that should lead to better outcomes, we are still a long way from being able to systematically measure these changes. System uses quality and analytic teams, IT, and providers to develop care strategies using evidencebased guidelines and standard order sets (in EHR); builds tools for measurement and assessment.…”

“…The tension between the need for models and the strategic selection and adaptation of models to fit local needs points to the importance of informed and skilled health system leaders. While it may be tempting to look for the entrepreneurial health systems that disrupted care approaches and have high care quality outcomes and expect other systems to be able to follow those models, it has been noted that those efforts may be effective in making systems look more similar, but not actually bring about improvements in efficiency or outcomes when changes are implemented without consideration of each system's unique characteristics and context 45,46 …”

Integrated Primary Care and Social Services for Older Adults With Multimorbidity in England: A Scoping Review

“…Whilst previous reviews have been conducted, these have mainly been limited to searches of the published literature, which may not adequately capture efforts in private or voluntary sector care organisations, where most social care is provided. [9,10,11,12] Moreover, few earlier studies have speci cally examined the literature related to England in order to consider the contextual factors of this setting. There is also a relative paucity of evidence that considers integration in relation to primary care, where most care of older adults with multimorbidity occurs.…”