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Background and aim: Many health systems attempt to develop integrated and population health-oriented systems of care, but knowledge of strategies and interventions to support this effort is lacking. We aimed to identify specific redesign strategies and interventions, and to present evidence of their effectiveness. Method: A modified scoping review process was carried out. Fifteen relevant examples of integrated care organizations that incorporated a broad population health approach in countries of the Organization for Economic Cooperation and Development described in 57 articles and reports were included in analysis. Results: Seven key redesign strategies and multiple redesign interventions have been identified and are described. Most commonly used redesign strategies included focusing on health and wellness, embracing intersectoral action and partnerships, addressing health in vulnerable groups, and addressing a wide range of determinants of health, including making improvements in health services. Redesign interventions included creative and innovative ways of addressing clinical and non-clinical issues such as establishing housing surgeries in primary care, establlishing vast social and provider networks to support patients with complex needs and also broadening of the scope of services, workforce redesign and other. Potential reductions in the utilization of care and costs could be derived by the wider adoption of these strategies and interventions. Conclusion: Development of integrated and population health-oriented systems of care requires the redesign of how services are organized and delivered, and how organizations and care systems operate. Combining integration of care with the population health approach can be supported by a set of cohesive strategies and interventions aimed at preventing disease, addressing social determinants of health and improving health equity at both population- and individual-level. [ABSTRACT FROM AUTHOR]

Introduction: Despite the widespread adoption of integrated care initiatives, achieving integrated care goals remains elusive. One continuing challenge is the frequent mismatch between measurement frameworks and goals. Existing literature describes conceptual frameworks or measurement domains without identifying specific measures, or, alternatively, reviews existing measures and measuring tools without explicating how these measures could be used or how they fit together in a performance measurement framework. We sought to develop a performance measurement framework for integrated care initiatives with linked measures that can be adapted to different initiatives and settings and which informs strategy and guides decision-making. Aims Objectives Theory or Methods: We conducted a scoping a review of peer-reviewed studies and grey literature articles to identify performance measurement frameworks, measurement domains and measures for integrated care. Measures were abstracted and categorized based on structure, process and outcomes; outcomes were further classified based on quadruple aim domains. Thematic analysis was conducted based on recommended measurement domains and subdomains in the literature. This was summarized in an overarching performance measurement framework using a logic model format. Further mapping and analysis of measures was conducted onto the proposed measurement framework based on discussion between study authors and feedback from local policy-makers Highlights or Results or Key Findings The initial scoping review search found over 2600 articles; of these, 278 were deemed potentially relevant and screened, resulting in the inclusion of 70 articles. A total of 340 measures of integrated care were found in these 70 articles. Most of these measures were existing outcome measures; and these measures were not directly linked to integrated care initiatives. A performance measurement framework was constructed including process and outcome measurement domains and subdomains. Process measures were divided into 1) measures of key integrated care activities including personalized care, coordinated care, and interprofessional collaboration, and 2) critical outputs including patient empowerment, communication, continuity of care, planned care, and access. Outcomes domains were mapped to the quadruple aim and included user experience (patient, caregiver), provider experience, health outcomes (system-level, person-level), and cost/utilization. Few measures were found that tapped policy environment, context and initiative structure components. Conclusions: Despite the substantial literature on integrated care measurement, many current measures are poorly suited to the task of measuring integrated care. We propose a performance measurement framework for integrated care initiatives that provides a conceptually grounded and useful approach for evaluating integrated care. Implications for applicability/transferability sustainability and limitations: Performance measurement of integrated care initiatives is a complex task. We propose a performance measurement framework and linked performance measures that can be utilized to guide implementation and development, informing practitioners, policy makers, funders and evaluators who seek to assess the performance of integrated care efforts. [ABSTRACT FROM AUTHOR]

Introduction: Discussions of integrated care have ranged in focus from large-scale health system transformations, to discrete interventions intended to enhance local continuity of care. Beyond these variations in scale and focus, literature on integrated care has used a variety of conceptual frameworks to explain various activities and elements necessary to achieve integrated care. Existing frameworks have helped to advance research and practice; yet the complexity of changing practice required to achieve integrated care across the policy, organizational, and clinical levels complicates efforts to represent or implement these innovations in straightforward ways. Aims Objectives Theory or Methods: In this paper, we present a novel strategy for conceptualizing integrated care as developing through a series of milestones observable at the organizational level. Based on analysis of four integrated care organizational case studies in Canada and New Zealand, we outline how this approach to conceptualizing integrated care both resolves the tension of crossing the macro, meso, and micro levels of analysis, and generates new practical insights to guide policy and practice. Methods consist of qualitative interviews, observation, and document analysis across cases, and qualitative data were analyzed temporally to identify milestones as indicated by participants over time. Highlights or Results or Key Findings: We define a milestone as the occurrence of a salient event that is perceived by respondents to facilitate or disrupt efforts towards the development of integrated care. We synthesize these events at the organizational level, suggesting that the organizational level of analysis is the most appropriate level to represent the significance of these milestones. Our analysis identified six categories of milestone: (1) Strategic relational milestones, referring to building relationships between stakeholders. (2) Strategic process change milestones, referring to efforts to improve quality in practice. (3) Structural (intra-organizational) milestones, referring to changes in organizational structure. (4) Structural (inter-organizational) milestones, referring to changes in the legal, operational, or leadership structures that facilitate relationships between organizations. (5) Environmental milestones, referring to changes in the social or natural environment. (6) Political milestones, referring to changes in the control and allocation of resources. Conclusions: Our results generate a new conceptual framework for understanding the achievement of integrated care as occurring through a series of milestones. This approach enhances the focus on achieving integrated care "in the wild", in the actual environments in which leaders, clinicians, policymakers, patients, and caregivers work to implement integrated care. Implications for applicability/transferability sustainability and limitations: Our model emphasizes two practical points. First, that there is no single series of sequential steps that must be taken to achieve integrated care. Second, that policy efforts to support integrated care ought to encourage organizations and their collaborators to work toward milestones that facilitate the development of integrated care. [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]

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]

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]

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. [ABSTRACT FROM AUTHOR]

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, socioecological 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. [ABSTRACT FROM AUTHOR]

Introduction: Varying models of integrated care have been successfully developed in different health systems to deliver value-based care; yet many of these models face challenges in scaleup and spread. One critical theme with limited consensus is the extent to which practices and programs should be standardized for effective spread. Barker 2016 argues that transfers of effective programs and practices into different settings are greatly facilitated by a detailed understanding of the core work and the supportive resources needed for effective programs in order to identify the "scalable unit". Other researchers see healthcare services as "complex adaptive systems"; scaling-up thus requires that the design of interventions be adapted to local contexts, In this view the straightforward replication of effective programs and practices is replaced with local sensemaking, focused experimentation, and participation by local actors in determining what works. This tension between the core elements of an intervention and an adaptable periphery is a key component in Damschroder's Consolidated Framework for Implementation Research. However, there is limited study of providers' and managers' views of standardization and little evaluation of the extent to which views on standardization or local adaptation support or hinder effective implementation. Methods: The iCoach Integrated Care for Older Adults with Complex Health Needs project has carried out a focused program of research exploring different models of integrated care in the Canadian provinces of Ontario and Quebec, and New Zealand. The research team, together with providers and managers engaged in the Ontario case studies are assessing views on where standardization of core activities, such as patient and family engagement, interprofessional team work, case management, leadership and governance are seen as desirable for spread. The team identified key activities and elements of integrated care from the literature. Using a workshop format, individual participants from four different organizations mapped out their views on a continuum of the desirable degree of standardization or adaptation for each activity that will support effective implementation and operations in their settings. [ABSTRACT FROM AUTHOR]

Introduction: The implementation of integrated care involves efforts to engage health care providers in a vision of health care delivery that includes coordination and collaboration for the care of individual clients. The processes by which health care providers engage with an organizational vision for integrated care, and the challenges associated with encouraging health care providers to adopt integrated practices remain under-explored in the research literature. Theory/Method: This paper reports initial findings on health care provider engagement in efforts to implement integrated community-based primary health care from the iCOACH project (Integrated Care for Older Adults with Complex Health Needs). The research project draws on in-depth international case studies of organizations in 3 jurisdictions: Ontario, Canada (n=3), Quebec, Canada (n=3), and New Zealand (n=3). Drawing on the theory of institutional logics, this report will include data from health care provider and organizational management/leadership interviews across all 9 case studies. Results: Preliminary findings suggest that health care providers respond to organizations' visions for integrated care differently depending on whether they feel supported to practice in more integrated ways. Even within a single organization, health care providers may enact or resist the organizational vision (and thus institutional logic) toward integrated care depending on the extent to which they feel engaged. Managerial approaches were found to be of central importance, helping to determine the extent to which health care providers adopted more integrated practices in the provision of everyday care delivery. These findings were illustrated across case studies in each of the 3 study jurisdictions. Discussion: Although these qualitative data only represent preliminary analysis, they point to the importance of managerial engagement strategies to promote health care provider buy-in to an organizational vision of more integrated care. These early findings suggest that managers within health care organizations can act as either barriers or facilitators to implementing integrated care depending on whether and how the interact and work with health care providers. Conclusions: Managerial approaches to the engagement of health care providers are of primary importance for the implementation of integrated care. Further analysis of the iCOACH study data will provide more detailed examination of which managerial approaches promote integrated health care provider practice, and those which act as barriers to integrated primary health care. [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: 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. [ABSTRACT FROM AUTHOR]

Introduction: Current investments in integrated care have predominantly focused on downstream strategies designed to reduce the fragmentation of healthcare services. Yet, there is a growing recognition that integrated care strategies must also move upstream and focus on health and wellness at the population level. Progress in this area has been slow, but a number of early adopters of the population health approach in integrated care provide insights into key approaches. This research identifies early initiatives, identifies common design components, and analyzes the lessonslearned. Theory/Methods: We undertook a scoping review of the international literature to define and describe the broad range of initiatives underway using Arskey & O'Malley's five stage scoping review methodology. Literature included academic and grey literature amongst developed OECD countries between the years 2000 and 2015. These papers were abstracted by two reviewers, thematic elements were identified by the team and the evidence synthesized. Results: Thirty-three papers were identified, describing 14 different initiatives taking place in eight different countries around the world. Most of the initiatives were initiated and lead by healthcare system providers (largely within primary care) who interfaced with local social services in order to meet the health needs of a target population. In some cases integrated care strategies were initiated and lead by public health or some other sector that then linked with healthcare. Target populations most often included seniors but also included other subpopulations including families living in high deprivation neighbourhoods, and mothers and children. Beyond healthcare, these initiatives often focused on such determinants of health as physical and social environments, personal health practices, education and literacy, and income. Discussion: There is a growing need to attend to population health within the context of healthcare delivery, rather than as a set of initiatives divorced from front-line practitioners. Several population health oriented integrated care strategies are underway around the world. These initiatives often face implementation challenges in creating robust partnerships across organizations and the alignment of vision, mandates, roles & responsibilities among partners. In addition, governance challenges and funding incentives must be addressed to support program success. Leadership, use of technology and community engagement are major enablers for success. Conclusions: Health systems in the industrialized world face increasing concerns about aging populations and the growing burden of chronic disease. Population health-oriented integrated care strategies have become an important part of sustainable health system reform. By studying early population health oriented integrated care initiatives, lessons learned from implementation can inform the broader thinking in reorienting models of care. Lessons learned: In the context of daily pressures to deliver care, it can be challenging to integrate population health based approaches, but these may be critical for managing chronic conditions. Limitations: This scoping review is limited to those initiatives reported in the literature. The literature is heterogeneous in terms of focus and methods so detailed comparisons between programs is limited. Suggestions for future research: Additional comparative case study research would help to elaborate on the strategies and mechanism for integrating population health approaches into integrated care. [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]

Background: Integrated care systems coordinate services for individuals and populations, linking health and community care providers and engaging patients and families to improve outcomes. Many jurisdictions have identified better integration as a key strategy for improving healthcare system performance. But these policies supporting integration are often inconsistent and require local adaptation and alignment to support implementation. This paper reports the experience of 9 community-based primary care organizations in three jurisdictions (the provinces of Ontario and Quebec in Canada, and New Zealand). Detailed case studies of these organizations identify the challenges of integration, the leadership and organizational strategies to foster integrated care, and the unintended consequences of policy frameworks, regulation, funding and program design. Theory and Methods: Results are pulled from the 9 case studies and include document analysis and key informant interviews with providers and organizational managers/leaders from each of the case sites, as well as interviews with policy-makers from each of the three jurisdictions. Qualitative thematic analysis was used to code interview transcripts and documents using both a deductive approach, based on the Context for Integrating Care theoretical framework developed to guide this study, as well as an inductive, data-driven approach. After coding, single case analysis methods will be used to understand tensions at each of the 9 cases, and cross-case analysis methods will be used to compare across the 9 cases. As we are still completing data collection, results presented below are based on preliminary analysis of findings generated from coding a sub-sample of available data. Results: Preliminary data analysis identified common challenges faced by leaders trying to integrate care across programs and organizations. These challenges include inadequate information sharing, often due to limited IT infrastructure and connectivity, inadequate time and human resources to launch new programs, high rates of HR turnover (in some cases), and confusion over "who owns the patient" with regard to integrated practice across multiple organizations. Beyond these organizational level challenges, leaders face a host of funding and policy issues. While funders and regulators in each jurisdiction have provided resources and supports for integration, these supports often take the form of one-time project funding that may not be sustainable over the longer term. Regulatory requirements often vary between programs in different sectors, raising local conflicts about integrating programs. As a result policy frameworks may be inconsistent and not conducive to integrating care, leading organizations to integrate in spite of policy rather than because of it. Policy and regulation thus have unintended consequences, creating tensions for leaders, undermining efforts to integrate care that require managing separate funding streams, conflicting regulatory regimes, and other complexities. Early analysis suggests that lack of sustained funding results in organizations behaving opportunistically rather than strategically, leading to potentially inefficient program designs. Discussion: Preliminary analysis suggests that in the face of these tensions, leaders often rely on past and present inter-organizational partnerships and the opportunities offered by fragmented funding programs to develop more integrated models of care for their patients. Leaders seek to present a coherent image to both funders and patients despite substantial organizational complexity that may create inefficiencies and frustrations for clients and staff. Developing a shared vision and sharing scarce resources have been key strategies in some of these cases to enable partners to secure funding for more integrated programs and provide a more coordinated care experience for patients and their families. Further analysis will illustrate how leaders brought individuals with differing perspectives and goals together from across the spectrum of health and social care to develop more integrated approaches to service. Conclusions: Our findings suggest that strong leadership is needed to navigate the tensions of integrating care. At the organizational level, leaders need to be able to identify and manage these tensions early to avoid inefficient and ineffective program design. Policy makers, in turn, need to assess the unintended consequences of fragmented funding and overlapping program designs, acknowledging the challenges these present for organizational leaders in health care. Finally, investment is needed in strategies to more systematically support and develop leadership capabilities for building collaboration and integration throughout the health system. [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]