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Among the challenges in delivering integrated health and social care services is the need to attend to the coordination of tasks, roles, activities, and operations, while considering how these efforts are experienced by patients, carers and communities. The literature has noted an important disconnect between how providers and leaders view their efforts to coordinate service delivery, and how patients perceive these efforts on the receiving end. Our team has provided guidance to integrated care efforts in Ontario, Canada by drawing on Goffman's theory of Dramaturgy to help classify the actions of integrated care delivery as linked to the roles individuals play in the delivery of care. Using this framing helps to uncover how "backstage" processes (such as team-functioning, funding models, and digital infrastructures) create a necessary foundation on which "frontstage" actions (or performances) can be effectively delivered. [ABSTRACT FROM AUTHOR]

Over the last three decades, integrated care has emerged as an important health system strategy to improve population health while addressing the unique needs of structurally marginalised communities. However, less attention has been given to the role of integrated care in addressing issues related to inequities in health and health care. In this commentary we introduce the concept of Equity Promoting Integrated Care (EPIC) that situates integrated care in a social justice context to frame the actions necessary to center equity as a priority for integrated care. We suggest that efforts to advance the design and implementation of integrated care should focus on three avenues for future research and practice, namely, the collaborative mobilization of a global network of integrated care stakeholders to advocate for social justice and health equity, investing in equity-focused approaches to implementation science that highlight the importance of social concepts such as colonialism and intersectionality to advance the theory and practice of implementing EPIC models of care, and leveraging innovative approaches to measuring equity-related aspects of integrated care to inform continuous improvement of health systems. [ABSTRACT FROM AUTHOR]

Introduction: In 2019, Ontario's Ministry of Health (the Ministry) introduced Ontario Health Teams (OHTs) to provide population-based integrated healthcare. Primary care was foundational to this approach. We sought to identify factors that impacted primary care engagement during OHT formation from different perspectives. Methods: Interviews with 111 participants (administrators n = 80; primary care providers n = 17; patient family advisors = 14) from 11 OHTs were conducted following a semi-structured guide. Interviews were transcribed, coded, and thematically analyzed. Results: Participants felt that primary care engagement was an ongoing, continuous cycle. Four themes were identified: 1) 'A low rules environment': limited direction from the Ministry (system-level), 2) 'They're at different starting points': impact of local context (initiative-level); 3) 'We want primary care to be actively involved': engagement efforts made by OHTs (initiative-level); 4) 'Waiting to hear a little bit more': primary care concerns about the OHT approach (sector-level). Thirteen factors impacting primary care engagement were identified across the four themes. Discussion and Conclusion: The 13 factors influencing primary care engagement were interconnected and operated at health system, integrated care initiative, and sector levels. Future research should focus on integrated care initiatives as they mature, to address potential gaps in the involvement of primary care physicians. [ABSTRACT FROM AUTHOR]

Introduction: Many studies have investigated the process of healthcare implementation to understand better how to bridge gaps between recommended practice, the needs and demands of healthcare consumers, and what they actually receive. However, in the implementation of integrated communitybased and integrated health care, it is still not well known which approaches work best. Methods: We conducted a systematic review and metanarrative synthesis of literature on implementation frameworks, theories and models in support of a research programme investigating CBPHC for older adults with chronic health problems. Results: Thirty-five reviews met our inclusion criteria and were appraised, summarised, and synthesised. Five metanarratives emerged 1) theoretical constructs; 2) multiple influencing factors; 3) development of new frameworks; 4) application of existing frameworks; and 5) effectiveness of interventions within frameworks/models. Four themes were generated that exposed the contradictions and synergies among the metanarratives. Person-centred care is fundamental to integrated CBPHC at all levels in the health care delivery system, yet many implementation theories and frameworks neglect this cornerstone. Discussion: The research identified perspectives central to integrated CBPHC that were missing in the literature. Context played a key role in determining success and in how consumers and their families, providers, organisations and policy-makers stay connected to implementing the best care possible. Conclusions: All phases of implementation of a new model of CBPHC call for collaborative partnerships with all stakeholders, the most important being the person receiving care in terms of what matters most to them. [ABSTRACT FROM AUTHOR]

The aim of this paper is to set the foundation for subsequent empirical studies of the "Implementing models of primary care for older adults with complex needs" project, by introducing and presenting a brief descriptive comparison of the nine case studies in Quebec, Ontario and New Zealand. Each case is described based on key dimensions of Rainbow model of Valentijn and al (2013) with a focus on "meso level" integration. Meso level integration is represented by organizational and professional elements of the Rainbow Model, which are of particular interest in our nine case studies. Each of the three cases in Ontario and three in New Zealand are different and described separately. In Quebec, a local health services network model is presented across the three cases studied with variations in the way it is implemented. The three cases selected in the three jurisdictions under study were not chosen to be representative of wider practice within each country, but rather represent interesting and unique models of communitybased primary healthcare integration. Similarities and variations in the integrated care models, context and dimension of integration offer insights regarding core component of integration of services, offering a foundational understanding of the cases on which future analysis will be based. [ABSTRACT FROM AUTHOR]

Introduction: The variable success of integrated care initiatives has led experts to recommend tailoring design and implementation to the organizational context. Yet, organizational contexts are rarely described, understood, or measured with sufficient depth and breadth in empirical studies or in practice. We thus lack knowledge of when and specifically how organizational contexts matter. To facilitate the accumulation of evidence, we developed a research toolkit for conducting case studies using standardized measures of the (inter-)organizational context for integrating care. Theory and Methods: We used a multi-method approach to develop the research toolkit: (1) development and validation of the Context and Capabilities for Integrating Care (CCIC) Framework, (2) identification, assessment, and selection of survey instruments, (3) development of document review methods, (4) development of interview guide resources, and (5) pilot testing of the document review guidelines, consolidated survey, and interview guide. Results: The toolkit provides a framework and measurement tools that examine 18 organizational and inter-organizational factors that affect the implementation and success of integrated care initiatives. Discussion and Conclusion: The toolkit can be used to characterize and compare organizational contexts across cases and enable comparison of results across studies. This information can enhance our understanding of the influence of organizational contexts, support the transfer of best practices, and help explain why some integrated care initiatives succeed and some fail. [ABSTRACT FROM AUTHOR]

Healthcare system reforms are pushing beyond primary care to more holistic, integrated models of community based primary health care (CBPHC) to better meet the needs of the population. Across the world CBPHC is at varying stages of development and few standard models exist. In order to scale up and spread successful models of care it is important to study what works and why. The first step is to select 'appropriate' cases to study. In this commentary we reflect on our journey in the selection of CBPHC models for older adults, revealing the limited utility of sourcing the empirical literature; the difficulty in identifying "successful" models to study when outcomes of importance differ across stakeholders; the value of drawing on clinical and organisational networks and experts; and the association between policy context and ease of case selection. Such insights have important implications for case study methodology in health services and policy research. [ABSTRACT FROM AUTHOR]

Background: Health systems globally are still struggling to roll out system-wide models of integrated health and social care. While pockets of innovation exist they often remain stuck within single jurisdictions, or, worse yet, never expand beyond the pilot phase. Researchers, providers, managers and health system leaders could learn from the experiences of other countries facing similar challenges, however lack a standardized comparative method to take findings from different contexts and relate them back to their own. Aims and Objectives: This workshop will walk participants through one approach to conducting comparative program summaries originally developed by the Commonwealth Fund in the United States and applied to cases of integrated care across three different countries. The template captures key components of integrate care including client access and eligibility, care coordination and transition processes, information management systems, self-management and caregiver supports, program maturity, measures of success, and evaluation. Audience members will learn about the strengths, weaknesses, opportunities and challenges of adopting this type of comparative work, drawing on the examples presented by a panel of international researchers who have applied the Commonwealth Fund template on integrated care to their original studies SUSTAIN (Netherlands) and iCOACH (Canada, New Zealand). Participants will have the opportunity to go through the exercise of adopting the approach. Participants will be broken up into small groups and given short-form templates that can be applied to their own models of integrated care. Groups will go through the exercise and engage in a facilitated discussion on: 1) whether it can be applied to their contexts; 2) what they can learn from this type of exercise to improve and build on existing or new models; and 3) what is missing and what are the challenges when we try to learn across borders. Target audience: This workshop will be of interest to providers, manager and decision-makers seeking to learn from other examples as they adopt, grow, or spread their own models of care. Researchers will also benefit from this workshop as we tackle the methodological and conceptual challenges of complex comparative case analysis, using a case summary templates as a starting point. Learnings/Take away: Participants of this workshop will learn: How to apply a standardized template to analyze their local contexts. Methods to share knowledge across international borders as a means to further their programs and models of care The values and challenges in engaging in cross-national comparative case analysis. [ABSTRACT FROM AUTHOR]

Introduction: Faced with rising healthcare costs and systemic inefficiencies, the Ministry of Health and Long-Term Care (MOHLTC) selected six programs, each a collection of acute/post-acute care organizations, to implement bundled care across the province of Ontario, Canada in 2015. A single team provided patient care from hospital to home over 60 days while program partners shared funds, hoping that shorter hospital stays would lead to better patient outcomes and cost savings. Focusing on three Chronic Obstructive Pulmonary Disease and Congestive Heart Failure programs, we examine a) how unique challenges encountered within programs changed over time, and generated ideas and practices and that may help when spreading and scaling similar models and b) how stakeholder visions of sustainability spatially and temporally reimagine integrated care. Methods/Theory: We conducted 36 interviews, 12 with each program; with the first 18 completed in 2016, and the rest in 2018. Interviews were conducted with program leaders and practitioners across the hospital-community spectrum. Anonymized transcripts were coded and a cultural constructivist framework informed analysis. We were interested in how stakeholders' location within specific contexts shaped their experience of integration, as well as how these contexts were in turn shaped by stakeholders over time. Results: Stakeholder experiences were informed by program contexts, from program scale to existing cultures of collaboration. Program A experienced the challenges of being the largest in scale differently as the program matured, eventually advocating a local approach to clinician engagement and funding. Program B, facing early financial planning challenges due to uncertain patient volumes, developed a new financial reconciliation process. Program C, faced with the need to overcome early misgivings and work with a specific community partner, suggested developing standardized pathways for community services that mirrored those in acute care. Stakeholders across programs suggested that sustainability could be encouraged by moving the model upstream to preventative primary care, addressing comorbidities and social complexity, eliminating disincentives to integration by rethinking volume-based hospital funding, linking programs to existing health and social resources, and increasing program length to foster continuity. Discussion: Stakeholders' reconceptualization of integrated models of care emphasized the local and familiar, from relationships to funding models. Stakeholders advocated systemic transformation that wrapped care around the patient both spatially and temporally- by expanding the hospital-community partnership to include primary care and other community-based health and social services, while providing longer-term, ongoing care. It was a reconceptualization of the original focus on seamless transitions from hospital to home in holistic, far-reaching ways. Conclusion/Lessons Learnt: Spreading and scaling bundled care may be best accomplished by reclaiming the local, allowing individual jurisdictions some autonomy over integrated care implementation. Nevertheless, system-wide transformation is needed to support these myriad forms of integration; from transforming funding structures, enabling comorbidity tracking, and facilitating links to existing health and social resources. Limitations: Sample size is a practical limitation, given that the scale of some bundled care initiatives challenged the incorporation of all partner perspectives. Suggestions for future research: Future research might examine whether perspectives on sustainability differ among stakeholders in non-chronic programs. [ABSTRACT FROM AUTHOR]

Background: Studying implementation of integrated models of community-based primary health care takes a "whole systems" multidisciplinary approach to capture micro (patient/carer and provider), meso (organization) and macro (system/policy) factors. In new research studying the implementation of these integrated models intended to improve care for older adults with complex care needs, our project team adopted four theoretical perspectives to capture micro, meso and macro factors influencing implementation. Problem Statement: Four theoretical and disciplinary perspectives were adopted to guide data collection and analysis. These perspectives were guided by 1) Wagner's Chronic Care Model as related to Ham's 10 Dimensions of High Performing Chronic Care Systems addressing patient/caregiver and provider level perspectives; 2) the Organizational Context and Capabilities for Integrating Care framework capturing organizational and provider level perspectives; and 3) the Health Policy Monitor survey methodology covering system and policy level perspectives. The different perspectives capture a wide breadth of concepts; however there is also significant conceptual overlap across those frameworks. The nature of this overlap requires clarification in order to: 1) ensure efficient data collection at the case sites; and 2) guide inter-disciplinary data analysis. Theory/Methods: Concept mapping was used to identify connections between the concepts across perspectives. Novak and Canas (2007)'s methods and software CmapTools were used to first generate a descriptive map. We explored the conceptual links of the map using data from 1 case studies in Ontario collected as part of the iCOACH project. Results: The concept map reveals many links across policy/system, organizational, provider and patient/carer theoretical perspectives. Examination of the overlap between concepts related to care coordination reveals different meanings, approaches, and implementations, depending on from which perspective you start. For instance, from a policy perspective care coordination is related to how services are delivered and delivery arrangements, the organizational perspective highlights inter-organizational linkages and collaboration, the provider perspective focuses on teamwork and community linkages, and the patient and carer perspective emphasizes the experience of coordinated care. Conclusions: Our analysis reveals that while concepts from different theoretical perspectives and disciplines may be similar in definition, each perspective offers a different meaning, value and driver associated with similar concepts. This analysis highlights the importance of developing a "whole system" perspective, and how concept mapping can be used to guide this approach to data collection and analysis. [ABSTRACT FROM AUTHOR]

Introduction: Information and communication technology (ICT) is a promising enabler to support delivery of integrated care by inter-disciplinary teams by supporting information sharing across professional and organizational boundaries; arguably a crucial aspect of successful models of integrated care. The literature suggests that there are core components of ICT functionality such as interoperability between systems, supported chronic disease management functions and patient and caregiver access to ICT, are required to support the delivery of integrated models of care. While suggestions on what ICT for integrated care should look like abound in the literature, few studies have explored how ICT is used in practice in the implementation of integrated community-based primary health care. Theory and Methods: We draw on data from interviews with front-line staff and management collected from 2 cases in Canada (one in Ontario and one in Quebec) and 3 case studies in New Zealand collected as part of the iCOACH project. Interview data was thematically coded around three core themes: 1) types of ICT systems adopted; 2) the role ICT plays in the model of care with regard to central activities of integrated care, and 3) perceived value of systems from the perspective of health care providers and organizational managers and leaders. Results: All case sites had some form of ICT system in place (most often electronic medical records), however variation occurs within and across jurisdictions in terms of which integrated care activities were supported by ICT, the level of adoption, and the sophistication of systems. Most models faced significant challenges with regard to between-system interoperability to allow for effective information sharing. There was additional diversity in terms of healthcare provider use and acceptance of available technology. Where systems were lacking, sites would use workarounds, for example co-locating providers who could access multiple systems at a single site. Discussion: Preliminary analyses of case study data suggest that ICT was used to support a range of integrated care activities. Interoperability remains an important, and often elusive, requirement. Front-line providers and organizations showed the ability to creatively work around limitations of ICT, but did not see these as sustainable solutions. Conclusion: ICT systems across the cases varied in terms of maturity and functionality. There was a consensus across sites regarding the importance of ICT to support integrated care, however many cases did without robust systems. Providers and leaders identified the need to adopt ICT systems that supported information sharing across teams to sustain and grow programs. Lessons Learned: Adoption of ICT systems into models of integrated care can occur at different stages of implementation, with many models reaching a point at which integrated ICT systems are required to support effective sustainable growth. Limitations: Case study findings offer unique and in-depth perspective on the adoption of ICT in 9 different models of integrated care. Findings may not be generalizable to all of models of integrated care. Suggestions for future research: Further exploration is required to determine at exactly which point in the implementation process (early vs. sustained adoption) ICT is required. [ABSTRACT FROM AUTHOR]

Introduction: Adults with multiple chronic illnesses account for more than 75% of health care spending. Many are considered complex due to multimorbidity, high service use, and psychosocial vulnerability. Practice Change Implemented: The Health Links (HLs) are networks of multiple health and social service organizations that voluntarily partner to deliver integrated care to complex, high-cost patients in Ontario, Canada. Aim and Theory of Change: We explored how organizational and network factors (e.g., resources, culture) influenced the implementation of the HLs. We conducted case studies of three HLs within one regional health authority. Data was analyzed using The Context and Capabilities for Integrating Care (CCIC) Framework, which stipulates that organizational and network factors (within the Basic Structures, People & Values, and Key Processes domains) influence an organization/network's readiness and capacity to integrate. Targeted Population and Stakeholders: The HLs initiative is targeted at patients with four or more chronic or "high-cost" conditions, including a focus on individuals living with mental health and addictions, palliative care patients, and the frail elderly. The organizations involved vary by HL and often include hospitals, primary care practices, community support agencies, social services organizations, and emergency response. Timeline: The HLs were implemented in 2012 with 19 early adopters; there are now 82 HLs in various stages of implementation in the province. In the spring/summer of 2016, we conducted semistructured interviews with leaders and providers working within three HLs. Interviews were supplemented with surveys and document review. Highlights: (Innovation, Impact and Outcomes) Preliminary results show that successful implementation was linked to the key organizational facilitators of leadership, patient-centredness, and team-based delivery of care. Leaders that prioritized the initiative were able to facilitate interorganizational collaboration. Similarly, partnerships were facilitated by an explicit focus on patientcentredness and patient outcomes, rather than on formal governance and accountability structures. Comments on Sustainability: Partnering organizations will have to address several barriers going forward, including: poor awareness of HLs in the community, inefficient identification of patients, dwindling clinician engagement due to low perceived value of the initiative over and above regular care, and limitations to patient data sharing within the network. Comments on Transferability: Using the CCIC Framework, we identified organizational and network factors that supported integration of care in HLs networks. The findings are limited to three HLs networks in Ontario, however, the framework can be used across cases to support the measure of factors and the transfer of best practices to other integrated care initiatives. Conclusions: (Comprising Key Findings) Preliminary results suggest that there are common factors that most influence the implementation of integrated care initiatives, including leadership, clinician engagement, patient-centeredness, and delivery of care. Discussions: The CCIC Framework enabled a comprehensive analysis of organizational and network context. These results can be used to help prioritize key areas for discussion, measurement, and change management. Lessons Learned: Despite continued interest in partnering, we found a loss of clinician engagement and buy-in over time in HLs that did not meaningfully involve clinicians and did not demonstrate value to the patient. [ABSTRACT FROM AUTHOR]

Introduction: Interventions aimed at integrating care have become widespread in healthcare; however, there is significant variability in their success. Differences in organizational contexts and associated capabilities may be responsible for some of this variability. This study develops and validates a conceptual framework of organizational capabilities for integrating care, identifies which of these capabilities may be most important, and explores the mechanisms by which they influence integrated care efforts. Theory/Methods: The Context and Capabilities for Integrating Care (CCIC) Framework was developed through a literature review, and revised and validated through interviews with leaders and care providers engaged in integrated care networks in Ontario, Canada. Interviews involved openended questions and graphic elicitation. Quantitative content analysis was used to summarize the data. Results: The CCIC Framework consists of eighteen organizational factors in three categories: Basic Structures, People and Values, and Key Processes. The three most important capabilities shaping the capacity of organizations to implement integrated care interventions include Leadership Approach, Clinician Engagement and Leadership, and Readiness for Change. The majority of hypothesized relationships among organizational capabilities involved Readiness for Change and Partnering, emphasizing the complexity, interrelatedness and importance of these two factors to integrated care efforts. Discussion: The quantitative content analysis of participant interviews suggests that the social and psychological context for integrating care should not be neglected in research and practice. Five of the nine organizational capabilities deemed most important to integrating care are from the "People and Values" domain of the framework. An understanding of the subjective context, and associated organizational capabilities such as leadership approach, clinician engagement, organizational culture, and readiness for change, may be of equal, if not greater, importance to study as the objective contextual factors such as physical features, resources, and organizational/network design. Organizational leaders can use the framework to determine readiness to integrate care, develop targeted change management strategies, and select appropriate partners with overlapping or complementary profiles on key capabilities. Conclusions: We developed a consolidated research- and practice-informed framework to guide the implementation of integrated care interventions and to help focus measurement of organizational context and capabilities. We also prioritized the most important organizational capabilities and explored their inter-relationships via interviews with key informants. Lessons Learned: Participants' views and experiences did not always align with the initial framework's structure and wording. Based on the results, we made modifications to terminology. Participants also identified complex, often non-linear relationships among capabilities that require additional study in future research. Limitations: The validation results presented are based on a sample of 29 participants in one Canadian province. Although participants came from diverse organizations and differed in approaches to integrating care, the limited scope of the sample indicates that the results may not be widely generalizable. Suggestions for Future Research: Additional research is needed to empirically test the proposed framework, with a focus on the hypothesized relationships. Research needs to move beyond general statements about variations in the performance of integrated care interventions being due, for example, to "culture" or "leadership", to more specific assessments of these capabilities. [ABSTRACT FROM AUTHOR]

Introduction: Attempts to understand the emergence of integrated care using traditional approaches provide limited insights. Increasingly, scholars are applying complex adaptive systems (CAS) theory to explain the implementation of integrated care policies and interventions. A CAS perspective suggests that integrated care efforts designed to support sensemaking, which allows staff to give meaning to their experience and efforts, self-organizing, and adaptive approaches are more likely to be successful than efforts which are more 'mechanistic' and 'linear'. We examined the implementation of the 'Health Links' (HLs), a provincial integrated care initiative in Ontario, Canada. Launched in 2012, there are currently 82 operational HLs, consisting of voluntary partnerships among organizations aimed at improving care for the top 5% of health system users in terms of costs. The HLs were introduced in a 'low rules' policy framework to stimulate grass-roots networks and approaches. In this study, we explored the extent to which this approach has generated interconnections, sensemaking, self-organization, emergence and coevolution, key aspects of CAS. Theory/Methods: We used key terms from CAS theory to deductively code transcripts from 37 interviews conducted in 2014/2015 with managers and clinicians from 24 HLs in all 14 regional health authorities in Ontario. Two reviewers coded a subset of interview data, in duplicate, that had been coded as addressing CAS themes in an earlier study. Results: Health Links generated novel interconnections between organizations and professionals across health and social services. These interconnections stimulated sensemaking, as individuals came together to understand, interpret, and adapt the initiative within their own contexts. Several selforganizing processes were identified as staff designed, tested and refined their structures and processes, and at the regional level where some regions standardized HLs within their borders. Despite enthusiasm for the 'low-rules' environment, some participants struggled with the lack of guidance or consistency from the province, and all agreed that some standardization was necessary. Early signs of emergence and co-evolution were identified, however, many HLs were still in early stages of implementation. Discussions: Our results show that a flexible policy environment encouraged interconnections, sensemaking, and self-organization among actors in the system. However, there were different capacities and preferences for self-organizing, and limits to what could be achieved through selforganization. Successful implementation required leadership and some operational consistency across HLs. Barriers to self-organization persisted in the form of pre-existing organizational and regional regulations. Conclusions: A 'low-rules' integrated care policy can generate novel interconnections, adaptive sensemaking, and productive self-organization among actors. Lessons learned: Operationalizing CAS theory domains is challenging and requires clarification of definitions and the level of analysis. Limitations: As a qualitative study, the results are limited in their generalizability. Interviews were conducted within three years of HLs launch and are limited to the initial implementation. Suggestions for future research: Future research should develop clear and applied definitions of CAS domains to support empirical studies of complexity dynamics in integrated care. [ABSTRACT FROM AUTHOR]

Introduction: This study explores the implementation of "Health Links", a provincial integrated care initiative aimed at transforming care systems for high needs patients in Ontario, Canada. Launched in 2012 with 19 early adopters, there are currently 54 operational Health Links in Ontario. Each Health Link consists of multiple providers and is led by a coordinating partner such as a hospital, primary care group, or community support agency. We explored the implementation of Health Links from the perspective of Local Health Integration Networks (LHINs). LHINs are regional planning and funding bodies that have played an active role in overseeing the implementation process. In this study, we aimed to understand how environmental and organizational contexts influence the implementation and success of Health Links. Theory/Methods: We conducted semi-structured telephone interviews with LHIN leaders directly engaged in overseeing and managing the Health Links within their boundaries. The interviews focused on the LHIN role in implementing and supporting the Health Links, achievements to date, key challenges, and perceived similarities, differences, and degrees of success and innovation among the Health Links in their region. Probing questions were used to clarify the nature and extent of influence of organizational or environmental factors on the participants' experiences and perceptions. The Context for Integrated Care (CIC) Framework (recently developed by the authors) was used as an analytical framework for data analysis. Interview transcripts were qualitatively analyzed in two successive rounds. In the first round, an open-ended, iterative approach was used to identify recurrent themes. In the second round, the dimensions of the CIC Framework were used to code the transcripts. Results: Fourteen interviews were conducted with 26 participants between August and September 2014, representing a 100% participation rate from all fourteen of Ontario's LHINs. Significant differences across Health Links were noted in target patient populations, primary care versus hospital leadership, perceived success in rural versus urban areas, and a flexible versus standardized approach to structuring and implementing the network. The response to the "lowrules", grass-roots style of implementation by the Ontario Ministry of Health and Long-Term Care was also varied, with some LHINs choosing to impose a prescriptive standardized approach across their Health Links and others embracing the flexibility and opportunity for local adaptation. Despite significant diversity across the LHINs, several common environmental challenges were identified including loss of momentum during the Health Link application and approval process, a lack of clarity regarding the role and accountability of LHINs, measurement limitations impacting evaluation, and sustainability of funding. When mapped on to the CIC Framework, which has an explicit focus on the organizational and network levels, the following factors were evoked most frequently: resources, leadership, primary care engagement, readiness to change, a strategic focus on improvement, and historical inter-organizational relationships. Discussion: Results of the qualitative analysis show that LHIN experiences implementing Health Links varied on a continuum that ranged from positive and eager to demonstrate impact to frustrated and change-fatigued. Despite differences in network structure, implementation approach and geography and demography, recurring themes were identified that reflect the potency of environmental and organizational factors on efforts to integrate services. The CIC Framework enabled a comprehensive analysis of organizational context. The results suggest that factors such as organizational culture, internal design, and work environment are less important to the implementation of integrated care initiatives than leadership, resources, and readiness for change. Although multiple perspectives are required before drawing firm conclusions about the relative importance of various factors, these results can be used to help prioritize key areas for discussion, measurement and/or change management. Conclusions: The results of this study have implications for policymakers, organizational leaders, and researchers. Policymakers should consider how best to balance flexibility and standardization in the implementation of new programs to support a diverse range of needs and capabilities. Rapid feedback and approval turn-around during the implementation process is crucial to maintain momentum, as is clarity of roles between levels of governance, a shared evaluation framework, and sustainability plans. Leaders must be attuned to the context of their organization, and partnering organizations, to enhance synergy and build on respective strengths. Finally, additional research is required to understand when and how specific contextual factors matter. Although generalizability is limited by the focus on one jurisdiction in Canada, given the diversity of the Health Links in terms of geography, target patient population, organizational partners, and integrated care model/intervention design, we expect that the results have some transferability to other settings. The research team is currently engaged in interviews with clinicians and leaders working directly within the Health Links. [ABSTRACT FROM AUTHOR]

Introduction: Providers, managers, health system leaders, and researchers could learn across countries implementing system-wide models of integrated care, but require accessible methods to do so. This study assesses if a common framework could describe and compare key components of international models of integrated care., Theory and Methods: A framework developed for an international study of programs that address high needs high cost patients was used to describe and compare 11 case studies analyzed in two international research projects; the Implementing Integrated Care for Older Adults with Complex Health Needs (iCOACH) study in Canada and New Zealand, and the Vilans research group exploring models in the Netherlands. Comparative summaries were generated, with findings discussed at a 2019 International Conference on Integrated Care workshop., Results: The template was found to be useful to compare integrated case analyses in different contexts, and stands apart from other case comparison approaches as it is easily applied and can provide practical guidance for frontline staff and managers. Areas of improvement for the template are identified and two updated versions are presented., Conclusions and Discussion: There is value to using a common template to provide guidance in international comparison of models of integrated care. We discuss the applicability of the approach to support scale and spread of integrated care internationally., Competing Interests: WPW is a facilitator of the IFIC Canada hub site, and leads the Scientific Committee for the North American Conference on Integrated Care (NACIC) planned for October 2020. CSG is also on the Scientific Committee for NACIC. WPW and CSG’s roles are on a voluntary basis. All other authors have no competing interests., (Copyright: © 2020 The Author(s).)

Health and social care systems across western developed nations are being challenged to meet the needs of an increasing number of people aging with multiple complex health and social needs. Community based primary health care (CBPHC) has been associated with more equitable access to services, better population level outcomes and lower system level costs. Itmay be well suited to the increasingly complex needs of populations; however the implementation of CBPHC models of care faces many challenges. This paper describes a program of research by an international, multi-university, multidisciplinary research team who are seeking to understand how to scale up and spread models of Integrated CBPHC (ICBPHC). The key question being addressed is "What are the steps to implementing innovative integrated community-based primary health care models that address the health and social needs of older adults with complex care needs?" and will be answered in three phases. In the first phase we identify and describe exemplar models of ICBPHC and their context in relation to relevant policies and performance across the three jurisdictions (New Zealand, Ontario and Québec, Canada). The second phase involves a series of theory-informed, mixed methods case studies from which we shall develop a conceptual framework that captures not only the attributes of successful innovative ICBPHC models, but also how these models are being implemented. In the third phase, we aim to translate our research into practice by identifying emerging models of ICBPHC in advance, and working alongside policymakers to inform the development and implementation of these models in each jurisdiction. The final output of the program will be a comprehensive guide to the design, implementation and scaling-up of innovative models of ICBPHC.

Introduction: Studying implementation of integrated models of community-based primary health care requires a "whole systems" multidisciplinary approach to capture micro, meso and macro factors. However, there is, as yet, no clear operationalization of a "whole systems" approach to guide multidisciplinary research programs. Theoretical frameworks and approaches from diverse academic traditions specify different aspects of the health system in more depth. Enabling analysis across the system, when data and ideas are captured using different taxonomies, requires that we map terms and constructs across the models., Theory and Methods: This paper uses concept mapping techniques to compare and contrast the theoretical frameworks and approaches used in the iCOACH project including: Ham's Ten Characteristics of the High-Performing Chronic Care System (capturing patient/carer and provider perspectives), the Organizational Context and Capabilities for Integrating Care framework (capturing the organizational perspective), and the Health Policy Monitor framework (capturing the policy system perspective). The aim of the paper is to link concepts across different theoretical framework to guide the iCOACH study., Results: A concept map was developed that identifies 8 overarching concepts across the heuristic models. A preliminary analysis of one of these overarching concepts, care coordination, demonstrates how different perspectives will assign different meanings, values, and drivers of seemingly similar ideas. For patients and carers care coordination is about having a responsive team of health care providers. Building relationships in teams that exist within and across different organizations is essential for providers to achieve care coordination, where managers and policy makers see care coordination as being more about creating linkages and addressing systems gaps., Discussion and Conclusion: This work represents a first step towards development of a fully formed conceptual framework that includes key domains, concepts, and mechanisms of implementing integrated community-based primary health care.

Background: Interventions aimed at integrating care have become widespread in healthcare; however, there is significant variability in their success. Differences in organizational contexts and associated capabilities may be responsible for some of this variability., Purpose: This study develops and validates a conceptual framework of organizational capabilities for integrating care, identifies which of these capabilities may be most important, and explores the mechanisms by which they influence integrated care efforts., Methods: The Context and Capabilities for Integrating Care (CCIC) Framework was developed through a literature review, and revised and validated through interviews with leaders and care providers engaged in integrated care networks in Ontario, Canada. Interviews involved open-ended questions and graphic elicitation. Quantitative content analysis was used to summarize the data., Results: The CCIC Framework consists of eighteen organizational factors in three categories: Basic Structures, People and Values, and Key Processes. The three most important capabilities shaping the capacity of organizations to implement integrated care interventions include Leadership Approach, Clinician Engagement and Leadership, and Readiness for Change. The majority of hypothesized relationships among organizational capabilities involved Readiness for Change and Partnering, emphasizing the complexity, interrelatedness and importance of these two factors to integrated care efforts., Conclusions: Organizational leaders can use the framework to determine readiness to integrate care, develop targeted change management strategies, and select appropriate partners with overlapping or complementary profiles on key capabilities. Researchers may use the results to test and refine the proposed framework, with a focus on the hypothesized relationships among organizational capabilities and between organizational capabilities and performance outcomes.

Background: To address the challenges of caring for a growing number of older people with a mix of both health problems and functional impairment, programmes in different countries have different approaches to integrating health and social service supports., Objective: The goal of this analysis is to identify important lessons for policy makers and service providers to enable better design, implementation and spread of successful integrated care models., Methods: This paper provides a structured cross-case synthesis of seven integrated care programmes in Australia, Canada, the Netherlands, New Zealand, Sweden, the UK and the USA., Key Findings: All seven programmes involved bottom-up innovation driven by local needs and included: (1) a single point of entry, (2) holistic care assessments, (3) comprehensive care planning, (4) care co-ordination and (5) a well-connected provider network. The process of achieving successful integration involves collaboration and, although the specific types of collaboration varied considerably across the seven case studies, all involved a care coordinator or case manager. Most programmes were not systematically evaluated but the two with formal external evaluations showed benefit and have been expanded., Conclusions: Case managers or care coordinators who support patient-centred collaborative care are key to successful integration in all our cases as are policies that provide funds and support for local initiatives that allow for bottom-up innovation. However, more robust and systematic evaluation of these initiatives is needed to clarify the 'business case' for integrated health and social care and to ensure successful generalization of local successes.