Understanding new models of integrated care in developed countries: a systematic review

Abstract

BackgroundThe NHS has been challenged to adopt new integrated models of service delivery that are tailored to local populations. Evidence from the international literature is needed to support the development and implementation of these new models of care.ObjectivesThe study aimed to carry out a systematic review of international evidence to enhance understanding of the mechanisms whereby new models of service delivery have an impact on health-care outcomes.DesignThe study combined rigorous and systematic methods for identification of literature, together with innovative methods for synthesis and presentation of findings.SettingAny setting.ParticipantsPatients receiving a health-care service and/or staff delivering services.InterventionsChanges to service delivery that increase integration and co-ordination of health and health-related services.Main outcome measuresOutcomes related to the delivery of services, including the views and perceptions of patients/service users and staff.Study designEmpirical work of a quantitative or qualitative design.Data sourcesWe searched electronic databases (between October 2016 and March 2017) for research published from 2006 onwards in databases including MEDLINE, EMBASE, PsycINFO, Cumulative Index to Nursing and Allied Health Literature, Science Citation Index, Social Science Citation Index and The Cochrane Library. We also searched relevant websites, screened reference lists and citation searched on a previous review.Review methodsThe identified evidence was synthesised in three ways. First, data from included studies were used to develop an evidence-based logic model, and a narrative summary reports the elements of the pathway. Second, we examined the strength of evidence underpinning reported outcomes and impacts using a comparative four-item rating system. Third, we developed an applicability framework to further scrutinise and characterise the evidence.ResultsWe included 267 studies in the review. The findings detail the complex pathway from new models to impacts, with evidence regarding elements of new models of integrated care, targets for change, process change, influencing factors, service-level outcomes and system-wide impacts. A number of positive outcomes were reported in the literature, with stronger evidence of perceived increased patient satisfaction and improved quality of care and access to care. There was stronger UK-only evidence of reduced outpatient appointments and waiting times. Evidence was inconsistent regarding other outcomes and system-wide impacts such as levels of activity and costs. There was an indication that new models have particular potential with patients who have complex needs.LimitationsDefining new models of integrated care is challenging, and there is the potential that our study excluded potentially relevant literature. The review was extensive, with diverse study populations and interventions that precluded the statistical summary of effectiveness.ConclusionsThere is stronger evidence that new models of integrated care may enhance patient satisfaction and perceived quality and increase access; however, the evidence regarding other outcomes is unclear. The study recommends factors to be considered during the implementation of new models.Future workLinks between elements of new models and outcomes require further study, together with research in a wider variety of populations.Study registrationThis study is registered as PROSPERO CRD37725.FundingThe National Institute for Health Research Health Services and Delivery Research programme.

More that unites us than divides us? A qualitative study of integration of community health and social care services

“…The opportunity to interview staff at this key point in the process has offered some useful context, insight and recommendations for this ongoing iterative process, with some important learning for others embarking on this transformational change. Integration, while high on the national agenda, has mixed reports of impact in the literature [19]. Integration at any level is widely acknowledged as a hugely challenging and complex undertaking [20] and this paper contributes to our knowledge.…”

“…While other literature has reported mainly on partially integrated care services at team and service level there is a need for further research to continue to explore and report on the complexity involved in implementing fully system level integrated new models of community care services [19]. By interviewing the individuals involved at all levels, we develop an understanding of the multiple and sometimes conflicting perspectives to highlight factors perceived to be supporting or hindering integration.…”

“…Integration is being implemented in various ways across the United Kingdom (UK), and while there has been some evaluation of this [16], there remains a paucity of research particularly around the operational challenges of integrated community health and social care services [17][18][19]. Few studies consider how the multiple experiences and perspectives of those delivering these services may affect this process [20].…”

“…Furthermore, the existing literature mainly reports on clinical integration where the institutions remain separate, with few examples of institutions collaborating or working in partnerships at organisational level [4]. The existing examples of clinical or professional integration have found increased patient satisfaction and a perception of better quality care and access [19]. However, the impact on other outcomes such as reducing costs, readmission to hospital and reduced length of hospital stay are less clear [19,[21][22][23].…”

“…The existing examples of clinical or professional integration have found increased patient satisfaction and a perception of better quality care and access [19]. However, the impact on other outcomes such as reducing costs, readmission to hospital and reduced length of hospital stay are less clear [19,[21][22][23]. Despite this mixed picture in terms of outcomes however, integration continues to be the prime focus in health and social care services organisation across the UK, with a combination of organisational, clinical and service integration considered essential to deliver better outcomes [7,24].…”