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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.

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.

Introduction: Transitions in care between and within healthcare sectors are a major focus across health jurisdictions. It is a time of vulnerability for both patients and their families. Hip fractures are one of the leading causes of hospitalizations among the older population, with patients averaging 3.5 care setting transitions before reaching their final destination. Thus, hip fracture patients are an ideal population to study for understanding transitions of care for older adults. These patients have high rates of readmissions due to medical complications within 6 months of being discharged from acute care. Of those patients who survive one-year post-injury, only 40% can perform activities of daily living independently, leading to potential social vulnerability. Across health regions, there is substantial variation in system performance on care relating to hip fractures, which requires further understanding of the contextual factors influencing care transitions, patient/informal care experiences, and health and well-being outcomes. Methods: A multiple-case study design was chosen to compare transitions in care for hip fractures in two contrasting health jurisdictions. Regions were selected for variation in patient populations, system performance and geography. Qualitative interviews were conducted with patients, their informal care providers (e.g. family/friends), clinicians and decision-makers in both jurisdictions. When possible, patients and caregivers were followed through their care journey by sequential interviews. By interviewing a variety of key stakeholders, the intention was to develop a holistic understanding of care transitions for complex patients and system-level factors contributing to this journey. Results: Data collection is ongoing. We anticipate interviewing 56 individuals (16 patients, 16 family members, 12 clinicians and 12 decision-makers). Preliminary results suggest three main themes: 1) patient, caregiver and healthcare provider uncertainty; 2) urgency to improve transitions; and 3) transitions as a component of the larger care experience. Discussion: Consequences of poor transitions include delays, adverse medication events, dissatisfaction among patients and families as well as high patient readmission rates and emergency department visits following acute care discharge. Findings from this work will identify context specific solutions at the individual, community and system levels to optimize transitions for patients with hip fractures and for those that provide care. Conclusion (w/ key findings): Barriers and enabling factors that influence optimal care transitions are specific to local health system contexts; however, the experiences of key stakeholders across the two jurisdictions were remarkably similar. There remains much room for improvement in care transitions for complex patient populations and their caregivers. Lessons Learned: A community-engagement and integrated knowledge translation approach takes effort and time, but ensures the research is of value to key system users. Limitations: This study compares only two health care jurisdictions in Ontario, with interviewees recruited primarily from one hospital in each jurisdiction, and interviews conducted in English and French alone. It is possible that experiences with transitions may be different across different health regions, in different hospitals in the study regions, and among non-English or French speaking participants. Suggestions for Future Research: Future research can expand to different health regions and include patients and caregivers who speak different languages.

Introduction: Recently, there has been a paradigm shift in healthcare that calls for positioning patients as active partners in healthcare rather than passive recipients. This active partnership is even more evident with patients who live with multiple chronic diseases because with time, these patients become experts in their own bodies, symptoms and management. Two concepts arose as a result of this shift; person-centered care (PCC) and integrated care (IC). Both concepts have been promoted as potential solutions to accommodate the needs of patients with multiple chronic diseases and they become increasingly evident in literature about these patients. However, both concepts have been described by authors as polymorphic and ill-defined. Our study aims at understanding both concepts and revealing the connections between them in the context of patients living with multiple chronic diseases. Methods: We conducted a review of conceptual literature that looked at both PCC and IC, by searching Medline and CINAHL and consulting with experts. We applied a concept analysis approach using a combination of Walker & Avant and simultaneous concept analysis (SCA) to identify the unique characteristics of each concept and their relationships. Results: Through these methods, the antecedents, attributes, consequences and empirical referents of each concept were determined. Additionally, similarities and differences between the two concepts were identified and a definition offered for each concept. Furthermore, the interrelatedness between the key concepts was mapped, and definitions proposed. Our results will promote better understanding and communication about these concepts in practice and in research and policy contexts as well as to theory development by adding to previous research. Discussions: Although both concepts under study stem from the same philosophy of partnering with patients, PCC is a wider concept than IC. Integrated care is one way to achieve PCC but there are other approaches like co-production and redesigning the healthcare with the patients. True integrated care can barely be achieved if not rooted in a culture of PCC. This culture includes systems, organizations, providers, patients as well as their caregivers. In this sense, PCC may be better looked at as a philosophy rather than a quantifiable outcome. Conversely, IC can be measured directly through measurable indices of effectiveness, efficiency and patient experience. Conclusions: We conducted a concept analysis based on a literature review to explore the concepts of PCC and IC. Our comprehensive analysis defined both concepts and added clarity on their areas of interconnectedness and diversion. Lessons learned: PCC and IC are highly intertwined concepts, but they are not similar. Understanding the conceptual basis of both concepts is important for successful implementation of IC and achieving healthcare systems that are person-centered. Limitations: Our results are limited by the databases used. Second, we did not conduct a systematic evaluation of the quality of the included articles. This decision was motivated by the wide variation in literature and the inclusive nature of this concept analysis. Future research: Future work can explore the relationship of PCC and IC with other concepts that stem from the same philosophy as patient experience.

Introduction: Person-centered integrated care (PC-IC) is a concept combining person-centeredness and integrated care to better improve care for people with complex health and social needs. The World Health Organization describes PC-IC as “health services that are managed and delivered in a way so that patients receive both preventive and curative services according to their needs over time that is coordinated across different levels of the health system”. Following this definition, evaluation of PC-IC should include the patients’ experiences with their care. When attempting to assess patient experience (PE) with PC-IC there is a lack of guidance on what to measure, when and how. Our study fills this gap by proposing a roadmap to guide the assessment of PE with PC-IC. Methods: We reviewed peer-reviewed and grey literature that looked at PE with PC-IC by searching Medline and CINAHL and consulting with experts on seminal work in the field. We included theoretical papers and tools that were used to assess PE in an PC-IC setting. We then synthesized this literature to answer: “what”, “when,” and “how” to assess PE with PC-IC. Results: We found that PE with PC-IC depends on two main factors. The first is related to social and demographic characteristics. These characteristics influence PE through two mechanisms; patient goals and expectations. The second factor is related to the organizations that provide PC-IC including culture, norms, resources, type and number of partnering organizations. Organizational factors affect PE by shaping the processes of care which affects PE through various mechanisms as communication, continuity of care, shared-decision making and patient- involvement. We also concluded that PC-IC should be looked at as a process rather than an event in the patient’s trajectory and thus assessment of PE with PC-IC should be process-based not event-based. Additionally, PE with PC-IC is a dynamic outcome that can change over time and measuring it continuously would be the preferred approach. Finally, combining qualitative and quantitative approaches gives the best understanding of PE. Our results will serve as a roadmap for PC-IC designers, implementers, and evaluators on how to assess patient experience. Discussions: Existing tools for measuring PE with PC-IC are often missing the main factors identified in our review. For example, most tools focus on the event of care (e.g. “during your last visit” rather than the process e.g. “organizing your care”. Also, they rarely include patients' social characteristics . Additionally, these tools rarely assess achieving patient goals rather than organizational or system goals. Conclusions: We created a roadmap that can guide building and evaluating tools used to assess PE with PC-IC. Lessons learned: For assessing PE with PC-IC to be successful, the tools used should be built on a comprehensive conceptualization of PC-IC, be conducted at the right time and use the appropriate methods. Limitations: We may have missed important studies or tools that were not identified by our search Future research: Future work can use this roadmap to construct a framework that can be used to create and evaluate tools that assess PE with PC-IC.

Introduction: Community based primary health care (CBPHC) organizations are critical providers of integrated care for complex patients. Exemplar cases exist, but efforts to scale up and spread successful models continue to face major challenges. While scale and spread has become a popular topic, there are still significant gaps in our understanding of what components or activities of integrated care models should and can be spread from one locale or jurisdiction to the next, and to what degree we allow for local adaptation of those activities. Theory/Methods: To address this identified gap we developed a survey for managers and providers in CBPHC organizations that allows respondents to specify which activities require local adaptation for their scale up and spread and which need to be more standardized. The survey builds on learning from the iCOACH project, a study analyzing 9 integrated models of community-based primary health care (CBPHC) in Ontario, Quebec and New Zealand. To develop the survey we carried out 1) a targeted literature review identifying existing reviews of key activities of integrated CBPHC; 2) a workshop session with CBPHC managers and providers to validate the approach and aim of the survey; 3) mapping the findings of the literature review to coded qualitative data from the iCOACH study to validate identified activities; and 4) validation and initial testing of a pilot survey. Results: The literature review yielded 32activities of integrated CBPHC, each of which were found to be present in iCOACH case studies. The workshop session was run in January 2018 with 17 participants. from 3 case study sites. Participants identified all activities as important to models of integrated care; but reported varying needs for standardization or adaptation for specific elements. Discussion from the workshop was used to refine survey wording and structure. The draft survey was tested with managers and providers in CBPHC organizations using cognitive interviewing techniques to refine the instrument. Small scale testing of the survey will be undertaken with staff in 2 CBPHC sites. Discussion: Multiple methods were used to validate the key activities of integrated care; however, the ways in which these activities are implemented in scale and spread efforts are nuanced and context dependent. Conclusions: The survey tool developed will help us to unpack these nuances and contextual influences, with the aim of clarifying core versus peripheral activities of integrated care at different stages of the scale and spread process (e.g., whether early or later stages of adoption). Lessons learned: One critical finding from the symposium was that conceptualizations of fidelity and adaptation are widely varied and needs to be clearly stated in any assessment. Ensuring clarity of these terms was central to the development of this survey. Limitations: While the survey has strong content validity due to our development methodology, additional work will be required to test reliability and other components of validity prior to wider adoption of the survey. Suggestions for future research: Following testing in Canadian settings, we plan to deploy the survey to CBPHC organizations internationally.

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.

Community-based primary health care describes a model of service provision that is oriented to the population health needs and wants of service users and communities, and has particular relevance to supporting the growing proportion of the population with multiple chronic conditions. Internationally, aspirations for community-based primary health care have stimulated local initiatives and influenced the design of policy solutions. However, the ways in which these ideas and influences find their way into policy and practice is strongly mediated by policy settings and institutional legacies of particular jurisdictions. This paper seeks to compare the key institutional and policy features of Ontario, Québec and New Zealand that shape the ‘space available’ for models of community-based primary health care to take root and develop. Our analysis suggests that two key conditions are the integration of relevant health and social sector organisations, and the range of policy levers that are available and used by governments. New Zealand has the most favourable conditions, and Ontario the least favourable. All jurisdictions, however, share a crucial barrier, namely the ‘barbed-wire fence’ that separates funding of medical and ‘non-medical’ primary care services, and the clear interests primary care doctors have in maintaining this fence. Moves in the direction of system-wide community-based primary health care require a gradual dismantling of this fence.

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 community-based 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.

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 aging populations and their carers. Across the world CBPHC is at varying stages of evolution and no standard model exists. In order to scale up and spread successful models of care it is important to study what works well and why to support broader efforts to implement, scale-up and spread promising innovations. The first step in this endevour is to select appropriate cases to study. In this paper we share our adaptation of case study methodology to iteratively select models of CBPHC in three jurisdictions: Ontario, Quebec (Canada) and New Zealand. A combination of literataure searches (of empirical and gray sources) and stakeholder engagement enabled the selection of cases to study, with the latter providing the most fruitful method. We conclude that it is possible to use personal networks and experts exclusively. It is not clear how much value formal searching adds over and above expert advice. However in a situation where there is no existing definitive list of potential cases, and no acknowledged “gold standard” way to create such a list, it seems appropriate to gather cases using multiple methods and to document those methods systematically.

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 community-based 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.

Introduction: While integrated care programs are proliferating around the world, rigorous measurement and evaluation of the intended and unintended effects of these programs are rare outside of the context of specific research programs. There are a number of reasons for the lack of evaluation including implementation without regard to measurement and evaluation, a lack of funding for evaluation activity, and challenges associated with measurement and evaluation in complex interventions. As a result, most research on integrated care is descriptive including case studies that most often summarize what was implemented, in some cases how it was implemented, but far less often what outcomes were achieved. Approach: We describe an evaluation framework for integrated care. It includes multiple components of evaluation (implementation, reporting and feedback, methods and measures) and a host of supplementary tools for measuring successful implementation of integrated care. The broad approach is to use rapid-cycle realist-informed evaluation methodology inclusive of implementation science, person-centred evaluation and comparative-effectiveness methodology. The approach to evaluation adds value and must be adaptable to local variations in models and organizational approaches to integrating care. Evaluation is framed into four components: Implementation: The evaluation of integrated care must first assess the implementation of new models of delivery, including description of the policy and organizational context of providers. Drawing from approaches taken including the Consolidated Framework for Implementation Research, evaluation is best begun parallel with the implementation of new models of integrated care allowing for early successes and challenges or barriers to be identified. Program operational monitoring: Second, programs themselves need to set out key measure of performance. A logic model for program implementation may be a particularly useful way to ensure that the program design will enable desired outcomes and ensure the essential component of the logic model are measured. Patient-centred assessment: The third major component of evaluation is patient-centred measurement including patient reported outcome and patient reported experience measures. Ultimately, patients themselves are the best target for measurement of integrated care. We will address essential domains for measurement of patient and caregiver outcomes and patient and caregiver experience. Outcome evaluation: Finally outcome evaluation is an essential activity. While the most rigorous form of outcome evaluation might involve experimental designs, the focus here is primarily on quasi-experimental approaches. Conclusion: This presentation describes a comprehensive framework for realist-informed rapid-cycle evaluations for integrated care programs. The framework is used to evaluate integrated care. Requirements for Implementation of Evaluation will also be discussed

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.

Introduction: Currently, there is limited knowledge about operationally feasible strategies that help link the provision of integrated care with the population health approach1,2. The scope of integrated care needs to be expanded to bridge the gaps not only within the health system, but also between public health, health care and social care1,3. This broader focus for integrated health care would enable health systems to address the social determinants of health SDOH of populations4. Using results from an ongoing multi-case study investigating implementation of population health approach in Canada and abroad, we will present an analysis of strategies used by select Canadian primary care and speciality care organizations that have taken on the population health approach and link the provision of integrated care, and successfully tackle issues of inequity and the SDOHs. Methods: In this multi-case study we use field visits, interviews, document analysis and other resources to identify key strategies, barriers and enablers to implementation of the population health approach. Population health experts and health planners nominated potential cases that were then assessed against the criteria that identify population health systems. Integrated knowledge translation has been incorporated to link knowledge users and academic researchers throughout the study. The study draws on the expanded chronic care model, socio-ecological model and equity lenses. Expected results: The study will identify and provide evidence about the effectiveness of specific strategies, including creative approaches and innovations that help routinely screen for the SDOHs and integrate social supports into delivery of care. We will map out strategic partnerships and inter-sectoral collaborations designed to support integrated delivery of health promotion and disease prevention, health care services and social care. Discussion/conclusion: This study will contribute to the knowledge about the planning and implementation of population-based integrated systems of care that successfully address a range of SDOH. Findings may help inform relevant policy and strategy and are directly relevant to ICIC 2018 theme "Population Health Management", sub-themes: Tackling inequalities and the social determinants of health, Improving population health outcomes and Strategy development, partnerships & leadership. Potential suggestions for future research: As the population health approach is adopted across the continuum of care, future research needs to facilitate the spread and scale up of integrated care in the context of population health. References: 1- Struijs JN, Drewes HW, Stein KV. Beyond integrated care: challenges on the way towards population health management. Int J Integr Care. 2015;15December:7-9. 2- Groene O. Kicking off the Special Interest Group Population Health Management – how can the scaling up of innovative success stories be supported ? In: 16th International Conference on Integrated Care, ed. International Journal of Integrated Care IJIC. Vol 16. Barcelona, 23-25 May 2016; 2016:1-8. 3- Trinity M, Dyer MB. Integrating Health Care and Social Services : Moving from Concept to Practice.; 2016. 4- Vaida B. For Super-Utilizers, Integrated Care Offers A New Path. Health Aff. 2017;363:394-397. doi:10.1377/hlthaff.2017.0112.

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.

Despite its theoretical appeal, integrated care remains a new frontier for health and social care systems in many countries. A key motivation for increasing the integration of a range of health care services with socialor community-based services is the imperative to improve the patient experience, particularly for individuals with ongoing multiple and complex health care and functional needs. To meet these needs they receive care from many different providers and often they feel they are bouncing around in an uncoordinated system that requires them to repeatedly tell their stories but that fails to provide a clearly articulated coordinated plan of care to help them manage their conditions. A key to improving the patient experience, care coordination and outcomes, is the need to address failures associated with low-fidelity of information sharing among providers, as patients transition from one provider to another. Failure to share information on treatment goals and therapies almost inevitably results in an incoherent treatment plan that often is duplicative or self-defeating and that in some cases causes more harm than good. Along with improving the patient experience, integrated care can increase the system-level efficiency of treatment and lower costs. Bringing multiple services into a coordinated network where information is centrally held and shared supports coordinated scheduling, shared access to essential information and reduction in duplication of diagnostic tests. In theory integrated care can improve patient experience and outcomes while reducing costs.

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 International Journal of Integrated Care – Volume 15, 27 May– URN:NBN:NL:UI:10-1-116989 – http://www.ijic.org/ 15th International Conference on Integrated Care, Edinburgh, UK, March 25-27, 2015 2 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.

Introduction: Faced with rising healthcare costs and inefficiencies in the healthcare system, the Ministry of Health and Long-Term Care invited proposals for integrated funding models (IFMs) across the province of Ontario, Canada. Six pilot programs were selected, each of which included hospital and community partners. While they were diverse in scale (from two to fourteen partners) and chosen clinical condition (from COPD to cardiac surgery), all were based on the bundling of care and the integration of funding. A single team provided patients seamless care from hospital to home, while program partners transferred funds that correlated with expected use of a service to each other or a commonly held bundle, in the hope that shorter hospital stays would lead to better patient outcomes and cost savings. Methods/ Theory: Researchers at the University of Toronto conducted a mixed-methods provincial evaluation, the qualitative component of which sought to identify how integration was generated and implementation challenges faced. Forty-eight stakeholder interviews were conducted, six with each program, including interviews with funders, regional authorities, program leaders and practitioners. Anonymized transcripts were coded using NVivo. A realist framework informed analysis. Results: Content analysis revealed that seamless integration was enabled by decisions about IFM structure, existing partnerships, trust-building, thoughtful model development, clinician engagement, and information-sharing. These mechanisms, themselves informed by unique contexts, were enabled by a range of micro-mechanisms that transformed clinical practice, information sharing systems, and organizational cultures into what was typically a more closely connected version of what existed before implementation. While there were typically noted challenges in this process (e.g., difficulties securing physician buy-in and integrating IT systems), we also identified unanticipated disincentives and stakeholder tension relating to the very purpose of integration. Discussion/ Lessons learnt: Behind the goal of integrated care lay the generation of connectivity and consensus - the coming together not just of resources, but also of organizational leaders, clinicians, and systems from heterogeneous organizations representing acute and post-acute aspects of healthcare. This work contributes to scholarship by a) identifying the micro-mechanisms, both strategic and accidental, that produced and complicated systemic integration, b) identifying tensions that complicated implementation, ranging from the new funding model being at odds with existing ones to different albeit overlapping stakeholder expectations of healthcare integration, and c) advancing an understanding of mechanisms as contextually and temporally contingent, with the capacity to inform and produces new contexts, which in turn generate a new set of mechanisms. Limitations: Sample size may be a practical limitation, given that the scale of some IFMs challenged the incorporation of all IFM partner perspectives. Suggestions for future research: While this research explored the contexts, mechanisms and challenges of integrated funding models, there is scope to further investigate their implications for the sustainability of IFMs. While being contextually circumscribed, this could nevertheless provide tentative guidance on spread.

Introduction: Complex patients have multiple chronic conditions, often compounded by psychosocial challenges They require a mix of services delivered by multiple providers across settings, which are optimally coordinated through integrated care models. A key success factor of these models is patient-centeredness and engagement. In 2012, Ontario, Canada launched Health Links (HL), a patient-centered initiative that aims to better coordinate care for patients with complex needs. This is achieved via individualized, coordinated care plans (CCPs) that are tailored to the needs and preferences of every patient. HL documents had a clear vision about how to put patients front and center and engage them in every step of the intervention, including co-designing the program, engaging in implementation and evaluation of the patients’ experience with HL. This study aimed to explore if the vision of patient-centeredness and engagement was operationalized in the same way it was planned. Theory/Methods: We conducted evaluative case studies of three HLs within one regional health authority in the spring/summer of 2016. Data was collected through semi-structured interviews with leaders and providers working within the three HLs and an in-depth document analysis of business plans, pre-implementation documents, meeting minutes and all publicly available electronic materials. We compared documentation to interview data, conceptualizing documents as the source of the planned view and draw the operationalizing view from the interviews. Results: Our preliminary results show that leaders and providers agree with the HLs’ planned view that patient-centeredness and engagement is the key philosophy behind HL as a program. However, in terms of operationalization participants identified a lack of clarity about the mechanisms of execution especially when working with such complex patients. Although the documents emphasized the importance of the role of patients in managing their own care, leaders and providers found many barriers to this for example the low buy-in from some patients and the lack of access to medical records. While having the voice of the patients on HL committees was acknowledged in all HL documents, leaders and providers highlighted that most of the time the patients do not have a voice and even when they do, a single patient will never represent all patients. Conclusions: (Comprising Key Findings) Patient-centeredness is a primary goal of HLs. However, in practice, participants struggled to clearly incorporate and execute patient-centeredness in the design, implementation, and evaluation of HL. Discussion: Our case studies provide analysis on how operationalization of patient-centeredness and engagement can be a challenge to integrated care models. The results can help inform decision-makers on how to better deliver patient-centered integrated care. Lessons Learned: Successful implementation of complex interventions like HL requires detailed clarity on the operational level alongside the policy level. Limitations: Our findings are limited to three HLs in Ontario, however, the results highlight an important discrepancy between discourse and action that may be relevant for other patient-centered integrated care initiatives. Suggestions for Future Research: Future work can examine the challenges in operationalizing a patient-centered approach to integrated care and test interventions that support the engagement of complex, high-needs patients.

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.

Introduction: Coordinated health services are required for complex patients with comorbid mental and physical health conditions. Health Links (HL) is an initiative in Ontario, Canada promoting integration across the mental and physical health sectors. Collaborative structures in HLs were determined by local partnering organizations, resulting in various integration approaches. Therefore, HLs offers a unique opportunity to examine different approaches to mental and physical health service coordination under the umbrella of a common initiative. Our aim was to contrast two approaches to coordinating mental and physical health services, and to explore the sustainability of each approach. Methods: This analysis was undertaken as part of an overall case study evaluation of HLs. Qualitative data collected through semi-structured interviews with HLs leaders and frontline practitioners in two HLs cases were analyzed. We conducted a descriptive content analysis of interview data to understand and contrast care coordination in each HL, and linked these to theory to explore sustainability considerations. Results: In case 1, a multi-organizational coordination approach was used; care coordination was assigned to the most appropriate organization, which was added staff members’ caseloads. Other partnering organizations were involved in care as required. Multi-organizational involvement expanded the service pool, which is vital for resource-constrained sectors. Shared organizational agendas facilitated continued commitment to integration despite staff turnover. One drawback is that processes may be too slow for timely intervention. In case 2, a primary health care coordinator was stationed at an addictions clinic to develop care plans, coordinate services and provide point-of-care physical health assessments. The coordinator diversified the scope of services at the clinic, was more likely to develop trusting relationship-based ties with other health workers, and was able to reach traditionally hard-to-access addictions patients by establishing transitive relationships. However, case 2 is difficult to scale up and sustainability is threatened by staff turnover. Discussion: Different coordination approaches may impact the sustainability of cross-sectoral coordination; however, the “most sustainable” approach is unclear and may be dependent on the needs of patients and the goals of integration. Sustainable collaboration has not been empirically well-explored, but institutional and social capital theories lend insight on this. Multi-organizational coordination might be sustained when resources are low and normative system drivers are pushing different sectors towards similar philosophies of patient care. Cross-sectoral point-of-care coordination may be sustained when dealing with vulnerable or marginalized patient populations, where trust is the foundation for maintaining ties. Conclusions: We examined two approaches to cross-sectoral coordination; each approach has its strengths and limitations regarding sustainability of integration. Lessons Learned: Policymakers and practice leaders should foster care coordination approaches that best address the needs of complex patients in local care settings, while considering sustainability. Limitations: The current analysis only examined two approaches to coordinating care across physical and mental health sectors, and does not consider whether outcomes differ across integrated care models. Suggestions for future research: Researchers should continue exploring sustainability considerations amongst various forms of cross-sectoral coordinated care. Moreover, understanding how the sustainment of outcomes is achieved through these various forms is valuable.

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 self-organizing 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 self-organization. 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.

Introduction: Policy makers in many countries are encouraging the development of integrated care strategies and the development of new models of integrated care. These new models require changes at a clinical or service level, organizational level and system level with strong leadership necessary at all three levels. Despite the key role of leadership in these efforts, there has been only limited study of what organizational leadership approach is successful in different contexts for integrated care. Theory/Methods: This paper analyses the organizational leadership behaviors and strategies in the iCOACH project (Integrated Care for Older Adults with Complex Health Needs) for 9 integrated care projects in 3 jurisdictions: New Zealand, and the Canadian provinces of Ontario and Quebec. Data are derived from interviews with leaders, policy makers and providers in these cases. We draw on institutional logics and institutional entrepreneurship theories to explore how leaders engaged external stakeholders and developed strategies to optimize the effectiveness of integrated care within and between their organizations in these different contexts. Results: There are concerted efforts to develop integrated care models of community based primary health care in all three jurisdictions. However, the policy environments vary in the latitude and resources provided to organizational leaders to develop organizational forms and networks. In Ontario and New Zealand there have been considerable variations in the nature of integrated care organizations and networks, while in Quebec the government has mandated new organizational forms and specified their relationships with other providers. Preliminary analysis of our data suggests that institutional entrepreneurship takes different forms in response to these environments, and other policy issues, such as the development of health care resources for Maori have also influenced the support and direction of integrated care. There is also variation in the entrepreneurial styles within and across these organizations, balancing the need for external stakeholder management and developing local capability for more integrated care based on the vision for the organization. Discussion: Leadership is a critical resource in the development of new organizational forms and in carrying out the negotiations needed to garner the resources and legitimacy necessary for effective organizations. However, leadership strategies can vary in different contexts, and the types of institutional entrepreneurship necessary for building these organizations varies as well. Conclusions: Understanding successful leadership strategies and entrepreneurial behaviors in different contexts helps to illuminate the similarities and differences across different policy and organizational environments. Lessons learned: While leadership is essential for integrated care, there is no single model that has been successful across the contexts we have studied. Limitations: The analysis of the data described here is still underway. Our data is derived from cases in three jurisdictions and these are likely not fully representative of the range of policy and organizational environments. Suggestions for future research: Further research on the leadership strategies that are successful in different environments is needed to confirm and extend the analysis from the 9 cases we have studied.

It is well known in the literature how the modern health and care systems are being oriented to launch and develop national strategies to construct and build a more comprehensive system for the people with "complex health and social care needs". Most of Chronic Care programs have been introduced proactive care management for this vulnerable population who are causing high utilization of high cost services. However a new Integrated health and social care approach have been introduced in some countries and regions and there is a need of identifying these populations at risk with new and well accepted criteria and new care approaches in the field. This workshop will combine both the "policy and implementation in practice" related to proactive management of people with complex care needs from a joint health and social care perspective. 2 or 3 countries will be invited to explain main strategies and real implementation examples which could be easily escalated. An additional overview of Walter Wodchis as international expert and reviewer of different international national or regional best practices will be incorporated. We will introduce different issues related to complexity: - Earlier work of complex chronic health needs during implementation of Chronic Care programs. Some part of this work has started some time ago and experience of some yers could be - Evolution from the “complex health needs” toward a “complex health and social care needs” approach. New approaches to identify criteria related to complex social care needs will be explored especially related to the social care area. ·International overview of the most recognized innovative experience related to care for people with complex health and social care needs - "Terminology" required to talk properly about "complexity": complexity, complex care needs, multimorbidity, complex health and social care needs,...? - Complex care in practice approach explaining which strategy is being developed to take care of people with complex health and social care needs from an “individual, team and territorial (county)” perspective - ICT developments to support work with different organizations and professionals who work collaboratively to manage people under a "person centred model": introduction of Key Information Summary or Individual Intervention Plans to be shared by all organizations and professionals under a 24/7 scheme and other strategies - Evaluation approach of complex care strategy It would be introduced 2 or maybe 3 experiences and an additional international overview: - Catalonia and Scotland will talk about both policy and implementation in practice models which have priorised "complex care approach" - Walter Wodchis from Intitit oof Healt Policy, Management and Evaluation at University of Toronto speak about the most promising and innovative world experiences related to complex care (Walter Wodchis is co-author of the June issue of IJIC publishing 7 study cases related to complexity), showing lessons about these experiences and reccommendations for countries and regions developing and implementing Integrated Care for people with complex health and social care needs. This workshop will offer a combination of policy and implementation in practice issues and additionally an overview of the best practices in the world related to complex care