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Introduction: Despite continuing efforts by national and local policy-makers, the French health and social care system still remains fragmented, often resulting in many problems for the users, their family, as well as the local managers and providers of care (Bloch, 2013; Bloch and Henaut, 2014). Most of the recent attempts to overcome fragmentation regarding elderly care took the form of pilot projects. In this paper, based on literature and ethnographic materials, we argue that integration has been difficult to achieve because pilots have been launched, at the national level, by siloed and competing administrations, and circumscribed, on sites, to either health or social care providers. However, new trends in policy piloting seem to be able to change the course of that story. First, some pilot project managers have been able to work with local managers and care providers in order to achieve what we call “integrative piloting”. Second, the rise of a social movement among integrated care pilot project managers is impacting the development of integrated care policies both at the local and national levels. Methods: The paper is based on literature and ethnographic materials. First, complementing the work of Somme and de Stampa (2011), we traced the history of coordination and integration policies for the elderly in France thanks to a systematic literature review of more than 300 documents produced by scholars or policy-makers. Second, we conducted an in-depth analysis of three major coordination schemes that have been implemented across the country after several years of piloting: _CLIC, Reseaux_ and _MAIA_. Interviews and observations have been done in four sites (center of Paris, North East suburb of Paris, Marseille, Ile de la Reunion). Interviews focused on the work of pilot project managers and front-line professionals involved in coordination schemes (N=45), local policy makers (N=15), and leaders of newly created associations or networks related to the different pilots (N=4). Finally, we attended assemblies and training sessions arranged for the managers of the three coordination schemes. Results: At the level of national policy-makers, each administration (social affairs, health care, long term care, and social security) tried to overcome fragmentation by developing its own coordination scheme. The lack of interaction and the on-going competition between administrations, along with the inability to conduct or use public policy evaluations, resulted at the local level in a never-ending struggle against fragmentation. The paper presents the complex web of competing and overlapping coordination schemes in the settings that have been investigated. While most professionals had a limited view of health and social care providers for dependent elderly persons, and of coordination schemes, some project managers succeeded in developing local integration by implementing what we call “integrative piloting”. They got other managers and providers on board thanks to the display of relational and entrepreneurial skills. They also took advantage of calls for applications offered by different administrations to channel new funds and build innovative collaborative schemes. In addition, our study shows the increasing role of the newly created associations and networks of the project managers who are piloting and managing coordination schemes in the development of best practice guides. They are in the process of combining their efforts in order to attract the attention of national policy-makers on several “local success stories”. Discussion: Centrifugal forces take place both at the national and local levels. Because of the lack of learning process, policy-makers have been creating layers of coordination schemes. However, in-depth case studies reveal that it is possible to redesign the different pilots depending on the local context and convert the layers into integrative schemes. The role of the newly created associations of project managers as part of a new centripetal force can be discussed. Conclusion: There is no doubt that national administrations should intervene in a more coordinated way. Moreover, on the face of it, the management of the complexity of the health and social care system can also benefit from local initiatives, and from meso-level organizations such as the association of networks of coordination schemes managers. Only time will tell if these new trends will become perennial. References: 1- Bloch M.-A. La fragmentation du systeme de sante et d’aide pour les personnes âgees, ADSP (Actualite et dossier en sante publique)2013; 85, 30-35. [in french] 2- Bloch M.-A. et Henaut L. Coordination et parcours. La dynamique du monde sanitaire, social et medico-social, Paris, Dunod 2014. 3- Somme D. et Stampa M. de Ten years of integrated care for the older in France, International Journal of Integrated Care, 11, Special 10th Anniversary Edition 2011.

In response to increasing care needs, the development of elderly care systems has become a prominent policy concern across the OECD. Since the beginning of the 1990s, the increasing economic constraints led to the rise of policies that focus on the improvement of “coordination” and “integration” of administrations and services – in other words, policies that aim at reducing the fragmentation of health and social care system. As a result, a growing number of studies focus on innovative integrated care schemes and their transferability from one national context to another. Yet they do not systematically investigate the political, organizational, cultural and societal contexts in which they have emerged neither do they link them to the diverse conceptions of integration or coordination carried by the multiple actors concerned. In this paper, we identified three policy-making mechanisms underpinning integration policies at both national and local levels. Theory/Methods : The POLIA-INLOVE comparative research investigates integration/coordination policies in three European countries – France, Sweden and UK. Its analytical framework borrows from sociology, public policy analysis and management studies. Based on a qualitative and diachronic perspective, not presupposing the existence of any integration/coordination policy in the countries studied, it focuses on the understanding of whether, when and how the need for professional, institutional and organizational integration/coordination came to be formulated. Our approach seeks to deconstruct the meaning of integration and coordination policies led in the three countries, and to understand their institutional, organisational and historical contexts. This paper presents the first results of a literature review and an empirical survey by semi-directive interviews led since 2013 in France (n=27), Sweden (n=22) and the UK (n=28). It covers two levels: interviews with national experts at the macro level of policies developed and implemented nationally and with actors at the micro level concerning specific schemes implemented locally, to take into account the organizational particularities in each of the countries and on chosen territories Results : The analysis of the policies in France, Sweden and UK shows the impact of both the national and the territorial contexts, which varies from one country to the other. It leads us to identify three different policy-making processes towards coordination/integration. We provisionally named them “layers”, “chains” and “lineages”. These logics are unequally shared out between the three countries: the layering process can be identified as a dominant trend in France whereas the chaining logic is dominant in Sweden. The lineage metaphor, finally, looks more appropriate when it comes to analyze the history of attempts for reducing fragmentation in England. Yet, further analysis including concrete solutions experimented on both national and local levels shows that there come to be a mix of logics mobilized in each concrete situation. Thus, the different logics are not directly opposed and they can be expected to work together Discussion : Qualitative comparison raises significant challenges due to the risk of comparing schemes or elements which are not comparable, particularly for locally implemented models developed in specific territorial contexts, unless one focus on the learning and adaptation processes. Secondly, comparison between countries representing different welfare models runs the risk of reducing the observed outcomes to the same variables used for the identification of the welfare models. By putting the accent on identifying the underpinning logics of integration/coordination policies in the three countries rather than running a systematic comparison of their content, we address these challenges in two ways: - The three logics identified articulate both macro and micro analysis since they are based on the identification of the mechanisms underpinning both national policies and locally implemented measures. -The three logics are analyzed in relation to the different welfare state models and to the wider political projects they belong to. Conclusion : The next step of the research consists in identifying common cross-cutting issues in at least two of the three countries studied: -The impact of the political variable on the orientation and the content of integration/coordination policies; -Interactions between local and national levels as opportunities and constraints for integration; -The issue of New Public Management in the integration/coordination process Taken as basis for comparison, these issues can inform aspects of processes of integration/coordination that are often analyzed in one single national/local context.

Introduction: The increasing number of people in chronic conditions requires not only a growing number of diverse care and support services, but also a better articulation between the different providers. To reduce the fragmentation of the health care system, policy makers, professionals, and family and user-led organizations, are engaged in a permanent process of innovation and cooperation. Because the improvement of integrated care relies entirely on that collective dynamics, the latter has to be better understood. Aims: Approach integrated care schemes through their life cycle, offer an interactive model explaining the dynamics of innovation, and identify the success factors that facilitate integration work in France. Results: Comparing seven different integrated care schemes created in France over the past two decades, both for vulnerable elderly and for adults with disabilities, shows that their development follows a similar pattern – what we call the life cycle of integrated care schemes – made of three to four phases: emergence, building up, routine, and eventually disappearance. All along the process, local initiatives, usually conducted by pioneer physicians or family and user-led organizations, face national public policy agenda. Interactions occur through four key processes initiated by national-level policy makers: experimentation, assessment, conceptualization, and generalization. More specifically, these processes are meta-processes because they are fuelling schemes’ life cycles which are themselves organizational processes. Depending on the scheme you consider, the four meta-processes occured neither in the same order nor at the same pace. Hence the comparison helps us understand the factors that may restrict or facilitate the effective implementation of integration work. Finally, the in-depth study we realized on an emergent scheme devoted to the management of people with rare diseases’ care pathways, reveals the reciprocal learning and prescription process between local political entrepreneurs and policy makers working at multiple levels. Conclusions: Innovation is neither the work of a few pioneers nor the one of national policy makers, but a collective and interactive dynamics. The continuity of public funding is crucial in the process, as well as the existence of a resource project team at the national level in order to ensure equal treatment throughout the country.

Introduction: The concept of integration, although dating from the 1990s, has only recently appeared in French public health policy. It must be linked with “coordination”, which is the base of most French public policies applied to geriatrics since the 1960s. Herein, we report the French Society of Geriatrics and Gerontology working group’s findings according to three axes: definition of integration, objectives of this organisational approach and the means needed to achieve them. Discussion: Integration is a process that aims to overcome the fragmentation of services for vulnerable people. This process requires a multilevel approach, particularly concerning how to modify public policies and financing systems. Notably, all relevant levels need to develop shared processes, tools, resources, financing, interventions and action-reports on the latter. Integration must to be accompanied by a local dedicated professional (the “pilot”). Results of recent experiments showed that it is possible to implement integrative dynamics in France.