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

Aims: This manuscript aims to provide a description of an evidence‐informed Science of Care practice‐based research and innovation framework that may serve as a guiding framework to generate new discoveries and knowledge around fundamental care in a more integrated manner. Background: New ways of thinking about models of care and implementation strategies in transdisciplinary teams are required to accelerate inquiry and embed new knowledge and innovation into practice settings. A new way of thinking starts with an explicit articulation and commitment to the core business of the healthcare industry which is to provide quality fundamental care. Design: This discursive paper delineates an iteratively derived Science of Care research and innovation framework (Science of Care Framework) that draws from a targeted literature review. Method: The Science of Care Framework integrates caring science with safety and symptom sciences with implementation, improvement, innovation and team sciences. Each science dimension is described in terms of seminal and evolving evidence and theoretical explanations, focusing on how these disciplines can support fundamental care. Conclusions: The Science of Care Framework can serve as a catalyst to guide future efforts to propel new knowledge and discoveries around fundamental care and how best to implement it into clinical practice through a transdisciplinary lens. Impact on nursing science, practice, or disciplinary knowledge: The Science of Care Framework can accelerate nursing discipline‐specific knowledge generation alongside inter and transdisciplinary insights. The novel articulation of the Science of Care Framework can be used to guide further inquiries that are co‐designed, and led, by nurses into integrated models of care and innovations in clinical practice. [ABSTRACT FROM AUTHOR]

Background: Although mobile health (mHealth) apps are increasingly being used to support patients with multiple chronic conditions (multimorbidity), most mHealth apps experience low interaction and eventual abandonment. To tackle this engagement issue, when developing an mHealth program, it is important to understand the social-behavioral factors that affect patients' use behavior. Objective: The aim of this study was to explore the social and behavioral factors contributing to patients' use behavior of an mHealth app called the electronic Patient-Reported Outcome (ePRO). The ePRO app supports goal-oriented care delivery in interdisciplinary primary care models. Methods: A descriptive qualitative study was used to analyze interview data collected for a larger mixed methods pragmatic trial. The original 15-month trial was conducted in 6 primary care teams across Ontario, Canada, between 2018 and 2019. The eligibility criteria for patients were being aged ≥60 years with ≥10 visits within the previous 12 months of study enrollment. For this analysis, patients were classified as long-term or short-term users based on their length of use of the ePRO app during the trial. The Social Cognitive Theory by Bandura was used to categorize social-behavioral factors that contributed to patients' decision to continue or discontinue using the app. Results: The patient-provider relationship emerged as a key factor that shaped patients' experiences with the app and subsequent decision to continue using the app. Other factors that contributed to patients' decision to continue using the app were personal and social circumstances, perceived usefulness, patients' previous experience with goal-related behaviors, and confidence in one's capability. There was an overlap of experience between long- and short-term app users but, in general, long-term users perceived the app to be more useful and their goals to be more meaningful than short-term app users. This observation was complicated by the fact that patient health-related goals were dynamic and changed over time. Conclusions: Complex patients' use behavior of a goal-supporting mHealth app is shaped by an array of sociobehavioral factors that can evolve. To tackle this dynamism, there should be an emphasis on creating adaptable health technologies that are easily customizable by patients and able to respond to their changing contexts and needs. [ABSTRACT FROM AUTHOR]

Background: The COVID-19 pandemic has triggered substantial changes to the healthcare context, including the rapid adoption of digital health to facilitate hospital-to-home transitions. This study aimed to: i) explore the experiences of hospital and community providers with delivering transitional care during the COVID-19 pandemic; ii) understand how rapid digitalization in healthcare has helped or hindered hospital-to-home transitions during the COVID-19 pandemic; and, iii) explore expectations of which elements of technology use may be sustained post-pandemic. Methods: Using a pragmatic qualitative descriptive approach, remote interviews with healthcare providers involved in hospital-to-home transitions in Ontario, Canada, were conducted. Interviews were analyzed using a team-based rapid qualitative analysis approach to generate timely results. Visual summary maps displaying key concepts/ideas were created for each interview and revised based on input from multiple team members. Maps that displayed similar concepts were then combined to create a final map, forming the themes and subthemes. Results: Sixteen healthcare providers participated, of which 11 worked in a hospital, and five worked in a community setting. COVID-19 was reported to have profoundly impacted healthcare providers, patients, and their caregivers and influenced the communication processes. There were several noted opportunities for technology to support transitions. Interpretation: Several challenges with technology use were highlighted, which could impact post-pandemic sustainability. However, the perceived opportunities for technology in supporting transitions indicate the need to investigate the optimal role of technology in the transition workflow. [ABSTRACT FROM AUTHOR]

Background: During the COVID-19 pandemic, rapid virtual qualitative methods have gained attention in applied health research to produce timely, actionable results while complying with the pandemic restrictions. However, rigour and analytical depth may be two areas of concern for rapid qualitative methods. Methods: In this paper, we present an overview of a virtual team-based rapid qualitative method within a study that explored health care providers' perspectives of how the COVID-19 pandemic has impacted hospital-to-home transitions, lessons learned in applying this method, and recommendations for changes. Using this method, qualitative data were collected and analyzed using the Zoom Healthcare videoconferencing platform and telephone. Visual summary maps were iteratively created from the audio recordings of each interview through virtual analytic meetings with the team. Maps representing similar settings (e.g. hospital providers and community providers) and Sites were combined to form meta-maps representing that group's experience. The combinations of data that best fit together were used to form the final meta-map through discussion. Results: This case example is used to provide a description of how to apply a virtual team-based rapid qualitative method. This paper also offers a discussion of the opportunities and challenges of applying this method, in particular how the virtual team-based rapid qualitative method could be modified to produce timely results virtually while attending to rigour and depth. Conclusions: We contend that the virtual team-based rapid qualitative data collection and analysis method was useful for generating timely, rigorous, and in-depth knowledge about transitional care during the COVID-19 pandemic. The recommended modifications to this method may enhance its utility for researchers to apply to their qualitative research studies. [ABSTRACT FROM AUTHOR]

Background: Older adults experience a high risk of adverse events during hospital-to-home transitions. Implementation barriers have prevented widespread clinical uptake of the various digital health technologies that aim to support hospital-to-home transitions. Objective: To guide the development of a digital health intervention to support transitions from hospital to home (the Digital Bridge intervention), the specific objectives of this review were to describe the various roles and functions of health care providers supporting hospital-to-home transitions for older adults, allowing future technologies to be more targeted to support their work; describe the types of digital health interventions used to facilitate the transition from hospital to home for older adults and elucidate how these interventions support the roles and functions of providers; describe the lessons learned from the design and implementation of these interventions; and identify opportunities to improve the fit between technology and provider functions within the Digital Bridge intervention and other transition-focused digital health interventions. Methods: This 2-phase rapid review involved a selective review of providers’ roles and their functions during hospital-to-home transitions (phase 1) and a structured literature review on digital health interventions used to support older adults’ hospital-to-home transitions (phase 2). During the analysis, the technology functions identified in phase 2 were linked to the provider roles and functions identified in phase 1. Results: In phase 1, various provider roles were identified that facilitated hospital-to-home transitions, including navigation-specific roles and the roles of nurses and physicians. The key transition functions performed by providers were related to the 3 categories of continuity of care (ie, informational, management, and relational continuity). Phase 2, included articles (n=142) that reported digital health interventions targeting various medical conditions or groups. Most digital health interventions supported management continuity (eg, follow-up, assessment, and monitoring of patients’ status after hospital discharge), whereas informational and relational continuity were the least supported. The lessons learned from the interventions were categorized into technology- and research-related challenges and opportunities and informed several recommendations to guide the design of transition-focused digital health interventions. Conclusions: This review highlights the need for Digital Bridge and other digital health interventions to align the design and delivery of digital health interventions with provider functions, design and test interventions with older adults, and examine multilevel outcomes. [ABSTRACT FROM AUTHOR]

Background: eHealth technologies for self-management can improve quality of life, but little is known about whether the benefits gained outweigh their costs. The electronic patient-reported outcome (ePRO) mobile app and portal system supports patients with multiple chronic conditions to collaborate with primary health care providers to set and monitor health-related goals. Objective: This study aims to estimate the cost of ePRO and the cost utility of the ePRO intervention compared with usual care provided to patients with multiple chronic conditions and complex needs living in the community, from the perspective of the publicly funded health care payer in Ontario, Canada. Methods: We developed a decision tree model to estimate the incremental cost per quality-adjusted life year (QALY) gained for the ePRO tool versus usual care over a time horizon of 15 months. Resource utilization and effectiveness of the ePRO tool were drawn from a randomized clinical trial with 6 family health teams involving 45 participants. Unit costs associated with health care utilization (adjusted to 2020 Canadian dollars) were drawn from literature and publicly available sources. A series of sensitivity analyses were conducted to assess the robustness of the findings. Results: The total cost of the ePRO tool was CAD $79,467 (~US $ 63,581; CAD $1733 [~US $1386] per person). Compared with standard care, the ePRO intervention was associated with higher costs (CAD $1710 [~US $1368]) and fewer QALYs (-0.03). The findings were consistent with the clinical evidence, suggesting no statistical difference in health-related quality of life between ePRO and usual care groups. However, the tool would be considered a cost-effective option if it could improve by at least 0.03 QALYs. The probability that the ePRO is cost-effective was 17.3% at a willingness-to-pay (WTP) threshold of CAD $50,000 (~US $40,000)/QALY. Conclusions: The ePRO tool is not a cost-effective technology at the commonly used WTP value of CAD $50,000 (~US $40,000)/QALY, but long-term and the societal impacts of ePRO were not included in this analysis. Further research is needed to better understand its impact on long-term outcomes and in real-world settings. The present findings add to the growing evidence about eHealth interventions' capacity to respond to complex aging populations within finite-resourced health systems. [ABSTRACT FROM AUTHOR]

Background: Digital health technologies have been proposed to support hospital-to-home transition for older adults. The COVID-19 pandemic and the associated physical distancing guidelines have propelled a shift toward digital health technologies. However, the characteristics of older adults who participated in digital health research interventions to support hospital-to-home transitions remain unclear. This information is needed to assess whether current digital health interventions are generalizable to the needs of the broader older adult population. Objective: This rapid review of the existing literature aimed to identify the characteristics of the populations targeted by studies testing the implementation of digital health interventions designed to support hospital-to-home transitions, identify the characteristics of the samples included in studies testing digital health interventions used to support hospital-to-home transitions, and create recommendations for enhancing the diversity of samples within future hospital-to-home digital health interventions. Methods: A rapid review methodology based on scoping review guidelines by Arksey and O'Malley was developed. A search for peer-reviewed literature published between 2010 and 2021 on digital health solutions that support hospital-to-home transitions for older adults was conducted using MEDLINE, Embase, and CINAHL databases. The data were analyzed using descriptive statistics and qualitative content analysis. The Sex- and Gender-Based Analysis Plus lens theoretically guided the study design, analysis, and interpretation. Results: A total of 34 studies met the inclusion criteria. Our findings indicate that many groups of older adults were excluded from these interventions and remain understudied. Specifically, the oldest old and those living with cognitive impairments were excluded from the studies included in this review. In addition, very few studies have described the characteristics related to gender diversity, education, race, ethnicity, and culture. None of the studies commented on the sexual orientation of the participants. Conclusions: This is the first review, to our knowledge, that has mapped the literature focusing on the inclusion of older adults in digital hospital-to-home interventions. The findings suggest that the literature on digital health interventions tends to operationalize older adults as a homogenous group, ignoring the heterogeneity in older age definitions. Inconsistency in the literature surrounding the characteristics of the included participants suggests a need for further study to better understand how digital technologies to support hospital-to-home transitions can be inclusive. [ABSTRACT FROM AUTHOR]

Martens and colleagues' paper "Integration or Fragmentation of Health Care? Examining Policies and Politics in a Belgian Case Study," offers an in-depth examination of integrated care policy efforts in Belgium. A key finding in this case study was that political fragmentation proved too great an obstacle for integration efforts. In this commentary, I draw on the organizational behaviour and integrated care literatures to suggest how meso-level mechanisms related to sensemaking, distributive leadership, and evaluation could help overcome policy (or macro) level challenges like those experienced in Belgium. The commentary also suggests we need to consider and address both the process and normative challenges in these transformation efforts. [ABSTRACT FROM AUTHOR]

Introduction: Person-centred integrated care is often at odds with how current health care systems are structured, resulting in slower than expected uptake of the model worldwide. Adopting goal-oriented care, an approach which uses patient priorities, or goals, to drive what kinds of care are appropriate and how care is delivered, may offer a way to improve implementation. Description: This case report presents three international cases of community-based primary health care models in Ottawa (Canada), Vermont (USA) and Flanders (Belgium) that adopted goal-oriented care to stimulate clinical, professional, organizational and system integration. The Rainbow Model of Integrated Care is used to demonstrate how goal-oriented care drove integration at all levels. Discussion: The three cases demonstrate how goal-oriented care has the potential to catalyse integrated care. Exploration of these cases suggests that goal-oriented care can serve to activate formative and normative integration mechanisms; supporting processes that enable integrated care, while providing a framework for a shared philosophy of care. Lessons learned: By establishing a common vision and philosophy to drive shared processes, goal-oriented care can be a powerful tool to enable integrated care delivery. Offering plenty of opportunities for training in goal-oriented care within and across teams is essential to support this shift. [ABSTRACT FROM AUTHOR]

AimThis qualitative study investigates how the Electronic Patient-Reported Outcome (ePRO) mobile application and portal system, designed to capture patient-reported measures to support self-management, affected primary care provider workflows.BackgroundThe Canadian health system is facing an ageing population that is living with chronic disease. Disruptive innovations like mobile health technologies can help to support health system transformation needed to better meet the multifaceted needs of the complex care patient. However, there are challenges with implementing these technologies in primary care settings, in particular the effect on primary care provider workflows.MethodsOver a six-week period interdisciplinary primary care providers (n=6) and their complex care patients (n=12), used the ePRO mobile application and portal to collaboratively goal-set, manage care plans, and support self-management using patient-reported measures. Secondary thematic analysis of focus groups, training sessions, and issue tracker reports captured user experiences at a Toronto area Family Health Team from October 2014 to January 2015.FindingsKey issues raised by providers included: liability concerns associated with remote monitoring, increased documentation activities due to a lack of interoperability between the app and the electronic patient record, increased provider anxiety with regard to the potential for the app to disrupt and infringe upon appointment time, and increased demands for patient engagement. Primary care providers reported the app helped to focus care plans and to begin a collaborative conversation on goal-setting. However, throughout our investigation we found a high level of provider resistance evidenced by consistent attempts to shift the app towards fitting with existing workflows rather than adapting much of their behaviour. As health systems seek innovative and disruptive models to better serve this complex patient population, provider change resistance will need to be addressed. New models and technologies cannot be disruptive in an environment that is resisting change. [ABSTRACT FROM PUBLISHER]

Introduction: In a world where the prevalence of chronic conditions is increasing, the importance of a strong primary care system cannot be underestimated. One of the suggested strategies for person-centered integration of care is to explicitly focus on the patients' goals; or in other words a focus on goal-oriented care (GOC). To make GOC more applicable, it is important to build an understanding on how it should be provided in practice. Therefore, it is vital to not only learn from literature, but foremost of primary healthcare professionals themselves on how they operationalize GOC. Aims, objectives, theory or methods: This study explored how primary healthcare professionals operationalize GOC in their practice. Therefore, professionals were recruited in different primary care settings in Ottawa (Canada), Vermont (USA), and Flanders (Belgium). A two-step approach of a deductive and inductive analysis was used to analyze the in-depth interviews. Firstly - with the aim to validate the literature - the theoretical framework that emerged from the concept analysis on GOC, was used as a lens for the deductive analysis. Secondly, an inductive thematic analyses following Sundler was performed to expand the theoretical knowledge with insights from practice. All interviews were audio taped and transcribed verbatim. Highlights or results or key findings: When looking at the data trough a deductive lens, the theoretical framework - presenting a stepwise approach of GOC with the phases of goal-elicitation, goal-setting, and goal-evaluation and the patients' needs and preferences as a common thread - could be confirmed. However such a linear approach in one-on-one interactions, as emerged from the literature, could not be determined. The dynamic and iterative character of GOC should be more emphasized. The inductive analysis revealed three main themes that were not described in the concept analysis: 1) involving the patients, 2) interprofessional collaboration, and 3) the use of tools or guidance. The participants involved their patients by communicating in a constructive dialogue and informing them about their health status. Interprofessional collaboration allowed the participants to bring all different expertise - who could support the patients to work towards their goals - together. Finally, participants used tools to support the process of eliciting and setting patients' personal goals. Conclusions:The findings validated the theoretical framework emerged from the literature. Besides this validation, we learn from practice that professionals made use of tools to support goalelicitation, goal-setting, and to prepare interprofessional meetings. All this with the overall aim to encourage patients to actively take part in their care. Implications for applicability/transferability, sustainability, and limitations: This study allowed us to go beyond the theoretical knowledge of GOC and build on experiences of primary healthcare professionals from different disciplines, settings, and countries. This is needed to gain a full understanding on GOC and explore the elements that go along with providing GOC. [ABSTRACT FROM AUTHOR]

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

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

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: Information and communication technologies (ICTs) are recognized as a critical enablers of integrated primary care to support patients living with multiple chronic conditions. Although ICTenabled integrated primary care hold promises to support complex patients through team-based and continued care, critical implementation factors regarding what ICTs are available and how they enable the integrated model are yet to be mapped in the literature. This scoping review addresses this current knowledge gap in order to identify opportunities and gaps to help guide future implementation of the ICT-enabled integrated primary care model. Aims Objectives Theory or Methods: Objective: This study systematically scoped the literature on ICT-enabled integrated healthcare delivery models for patients with complex care needs to identify which technologies have been used in integrated primary care settings. Method: The Arksey and O'Malley method was used to guide this scoping review. Four electronic medical databases were accessed: MEDLINE, EMBASE, CINAHL, PsycINFO, collecting studies published between January 2000 - December 2020. Identified peer-reviewed articles were screened in two stages: 1) title and abstract screening; and 2) full-text review. Relevant studies were charted and analyzed using the Rainbow Model of Integrated Care and the eHealth enhanced Chronic Care model. Highlights or Results or Key Findings: A total of 46,736 articles were screened at the title and abstract level of which 37 met the eligibility criteria of the review. A large number of the studies originated from North America (62.5%) and used a quantitative method as a study design (51%). 70% of the studies used technology to enable professional and clinical level integration through clinical information sharing among a multidisciplinary team or across multiple organizations. There were fewer studies focused on the organization or system-level integration of care through technologies. A range of technologies was used in these models including web-based platforms, mobile applications, and telemonitoring being the most frequently used. Multiple implementation factors were identified that could enable or hinder the successful implementation of technologies including patient health/digital literacy and training; provider workload, attitudes, and beliefs; usability and interoperability of technologies; and system factors such as incentives, technical and human resource support. Conclusions: To maximize technological benefits in primary care, the literature suggests system-level support and favourable implementation climate are required. Future research is needed to explore how to integrate technologies at an organization and system level to create a health system that is wellprepared to optimize technologies to support patients. Implications for applicability/transferability sustainability and limitations: The study findings benefit system leaders in showing the implementation factors and the types of technologies they need to consider when applying technology to optimize their integrated care models. Due to time constraints, gray literature was excluded in the review which may limit the findings of the study. [ABSTRACT FROM AUTHOR]

Background: Goal-oriented care is being adopted to deliver person-centered primary care to older adults with multimorbidity and complex care needs. Although this model holds promise, its implementation remains a challenge. Digital health solutions may enable processes to improve adoption; however, they require evaluation to determine feasibility and impact.Objective: This study aims to evaluate the implementation and effectiveness of the electronic Patient-Reported Outcome (ePRO) mobile app and portal system, designed to enable goal-oriented care delivery in interprofessional primary care practices. The research questions driving this study are as follows: Does ePRO improve quality of life and self-management in older adults with complex needs? What mechanisms are likely driving observed outcomes?Methods: A multimethod, pragmatic randomized controlled trial using a stepped-wedge design and ethnographic case studies was conducted over a 15-month period in 6 comprehensive primary care practices across Ontario with a target enrollment of 176 patients. The 6 practices were randomized into either early (3-month control period; 12-month intervention) or late (6-month control period; 9-month intervention) groups. The primary outcome measure of interest was the Assessment of Quality of Life-4D (AQoL-4D). Data were collected at baseline and at 3 monthly intervals for the duration of the trial. Ethnographic data included observations and interviews with patients and providers at the midpoint and end of the intervention. Outcome data were analyzed using linear models conducted at the individual level, accounting for cluster effects at the practice level, and ethnographic data were analyzed using qualitative description and framework analysis methods.Results: Recruitment challenges resulted in fewer sites and participants than expected; of the 176 target, only 142 (80.6%) patients were identified as eligible to participate because of lower-than-expected provider participation and fewer-than-expected patients willing to participate or perceived as ready to engage in goal-setting. Of the 142 patients approached, 45 (32%) participated. Patients set a variety of goals related to self-management, mental health, social health, and overall well-being. Owing to underpowering, the impact of ePRO on quality of life could not be definitively assessed; however, the intervention group, ePRO plus usual care (mean 15.28, SD 18.60) demonstrated a nonsignificant decrease in quality of life (t24=-1.20; P=.24) when compared with usual care only (mean 21.76, SD 2.17). The ethnographic data reveal a complex implementation process in which the meaningfulness (or coherence) of the technology to individuals' lives and work acted as a key driver of adoption and tool appraisal.Conclusions: This trial experienced many unexpected and significant implementation challenges related to recruitment and engagement. Future studies could be improved through better alignment of the research methods and intervention to the complex and diverse clinical settings, dynamic goal-oriented care process, and readiness of provider and patient participants.Trial Registration: ClinicalTrials.gov NCT02917954; https://clinicaltrials.gov/ct2/show/NCT02917954. [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: Digital solutions are increasingly central in the delivery of integrated care models. Adopting co-design methods is one means to ensure usability of solutions. Although user-centered co-design is routinely embraced during software design, the challenges of eliciting needs from users with complex continuing health conditions is not well addressed by existing methodologies. We develop an approach to user-engagement for patients with complex care needs resulting in the creation of the electronic Patient-Reported Outcomes (ePRO) tool to support interprofessional primary care delivery. Theory/Methods: User-centered co-design principles were integrated with interpretive descriptive qualitative research methods to capture user priorities, experiences, feedback and expectations. Phase 1 involved a needs assessment conducted through user focus groups and interviews. Phase 2 engaged user groups to iteratively design a prototype, and Phase 3 undertook a usability study prior to evaluation (currently underway). Iterative analysis consistent with qualitative interpretive description were used to generate findings at each phase. Results: In Phase 1, 14 patients and caregivers participated in focus groups, followed by interviews with primary care providers, and experts in the field of primary care, complex care, and digital health solutions. Findings analyzed through interpretive descriptive methods linked user needs to technology solutions, generating a prototype with four key features (symptom monitoring, medication management, educational materials, hospital access notification). Modified cognitive walk-throughs with patients, caregivers and providers were used in Phase 2 to refined the prototype, resulting in the removal of education and medication management features, and revisions to the symptom monitoring and hospital access notification features. The Phase 3 usability assessment included in-depth focus groups and interviews with 11 patients and 6 providers who used the tool for four weeks. Qualitative data yielded surprising results regarding the feasibility and usefulness of ePRO resulting in a significant pivot in functionality from a tool that monitored symptoms, to one that supported personalized goal-setting and monitoring. Discussion: Adopting rigorous qualitative methods alongside iterative technology development resulted in a tool that was very different than initially anticipated, but more useful and meaningful to end-users. While many critique user-centered co-design for resulting in status quo solutions, our application of qualitative analysis techniques with a team of multi-disciplinary researchers and developers allowed us to be purposively disruptive and innovative, while still ensuring meaningfulness to users. Conclusions: End users adopt technology that is perceived as valuable and meaningful. Working with unique populations required adoption of rigorous qualitative methods alongside designthinking approaches as a means to effectively elicit user needs. Lessons learned: True user-centred co-design means setting aside pre-conceived notions about what a technology solution should look like so we can really hear the challenges of users and innovate meaningful solutions. Limitations: Each phase of the study had its own set of limitations. Small user groups and participants were engaged in each phase which may limit generalizability. Adoption of theoretical frameworks at each phase helps address this gap. Suggestions for future research: Bringing forth foundational theoretical frameworks like interactionism can help inform design through better understand how users derive meaning from interacting with technology. [ABSTRACT FROM AUTHOR]

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

Introduction: 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 rapidcycle evaluations for integrated care programs. The framework is used to evaluate integrated care. Requirements for Implementation of Evaluation will also be discussed. [ABSTRACT FROM AUTHOR]

Background: Care coordination is central in models of integrated care. Goal-oriented care is one approach that supports care coordination for multimorbid and complex patients by tailoring shared care plans to patient-identified goals rather than disease-specific targets. However, providers struggle with the adoption of goal-oriented care. Personal values have been found to influence provider behaviour in care delivery. It is possible that personal values may be a mechanism to drive the adoption of goal-oriented care. This work aims to understand the personal values of providers in the adoption of goal-oriented care. Methods: This is a sub-study of an international comparative case study of three primary healthcare sites that have implemented goal-oriented care in Ghent (Belgium), Ottawa, (Canada), and Vermont, (United States). A secondary analysis of 17 semi-structured interviews from the Vermont case site was conducted using inductive thematic analysis. The Vermont case study is situated within an integrated care setting. At this site, providers come from various disciplines and work in collaboration across organizations. Findings: Preliminary findings demonstrated that providers delivering goal-oriented care valued 'putting the patient at the centre', providing care in a holistic manner to understand the 'whole person', which could best be supported through team-based care. These values were often linked to beliefs around the importance of addressing the social determinants of health to improve health outcomes of patients. While most providers shared these values, they told different stories regarding how they came to these beliefs, which related to their education and training experiences. Community-based providers including social workers and mental health providers were introduced to the concepts of social determinants early in their professional training and reported personcentredness to be a core value of their profession. Alternatively, physicians and providers trained in medical models reported a shift in their values from problem-oriented towards personcentredness. Specific team-based training supported the adoption of core values like personcentredness. Discussion: Despite differences in disciplines and organizations, participants demonstrated similar values. These perceived difference in values appear to trace back to the model of training in postsecondary education that providers were trained under. However, with additional training on goal oriented care, shifts in values appear to be possible as participants were aligned in the values they held that support goal-oriented care. Another value that supported the adoption was a belief in team-based care for their patients. In practice, this was reinforced by working with interdisciplinary teams and an increasing presence of integration in their work environment. Conclusion: Across different disciplines and organizations, participants strongly valued personcenteredness, understanding the whole person, and team-based care. There is an opportunity to utilize structured training in goal-oriented care for providers to have aligned values to support its adoption. Lessons learned: Common values among interdisciplinary teams seem to support the adoption of goal-oriented care. Structured training in goal-oriented care appears to lead to providers having common values. Future research: The analysis will expand to other case study sites to compare and contrast the provider values working in other primary healthcare settings in different contexts. [ABSTRACT FROM AUTHOR]

Digital health solutions, in particular information communication technologies, often experience implementation failures leading to slower adoption than expected. This implementation challenge has spurred the development of frameworks to help navigate this uncertain and messy process. These frameworks point to environmental, organizational, individual, and technological factors that can drive or hinder implementation, with some in the field suggesting that perceived value may play a pivotal role. However, the concept of value can have varying meanings and be challenging to operationalize as a means to support implementation. Attending to philosophical and psychological meaningfulness for users and organizations in which technologies are adopted may offer a useful lens, by linking perceived value to individual behavior changes often required as part of implementing digital health technologies. Lessons learned from developing, evaluating, and implementing the electronic Patient-Reported Outcome (ePRO) tool demonstrate how qualitative methods can be used to uncover meaningfulness. By drawing from this example and other similar studies, this viewpoint offers suggestions on how future inquiry could deepen an understanding of meaningful innovation to help drive the implementation of digital health technologies. [ABSTRACT FROM AUTHOR]

Introduction: There are currently multiple integrated care IC models and pilots developed to enhance collaborative care delivery for older adults living with complex health and social needs. Technology innovations are increasingly embedded in the delivery of IC for this population. These include, electronically-delivered: information communication, shared-care planning, early risk identification, decision support, self-management support and remote monitoring. However, at various stages of implementation, there are common setbacks that influence the adoption and spread of these technologies and overall IC delivery. The objective of this systematic review is to examine the following questions: 1 Across different implementation stages of IC for older adults with complex needs, what are the key enablers of technology adoption; 2 how do these factors interact to influence successful technology adoption across various levels of IC including at the: individual, provider, team, organizational and across care settings. Theory/Methods: A detailed search strategy was developed, and conducted in following databases: Medline/PubMed, EMBASE, PsychINFO, CINAHL and Scopus. When articles described barriers or challenges that emerged from the implementation of technology in IC, they were systematically recorded. Following a multilevel thematic analysis, these statements were mapped against a combination of two frameworks: 1- the Consolidating Framework for Research Implementation CFIR; 2- the Fit between Individuals Task and Technology framework FITT Results: Preliminary results of this systematic review found that technologies were predominantly implemented to enhance integration at the provider-teams level, followed by at the organizational level. The most frequently reported influencers of adoption were related to the providers' knowledge and perceptions of the technology, and how it impacted their ability to perform their responsibilities. This was followed by the technology characteristics; particularly its seamlessness or disruptiveness to the existing systems of work. As well as how adaptive and responsive the technology was to the goals and needs of the: older adults, providers, organization and the system. Factors such as organizational and system leadership, environmental culture and the ability to engage key players in the co-design and implementation of technologies were also key influencers. Conclusions key findings: These early findings highlight the need to tailor technological innovations to the IC setting, as well as the importance of considering change management strategies to enhance the system readiness and responsiveness to change. Supporting stakeholders before and during the processes of implementing IC technologies will increase their effectiveness in being flexible and adaptive to system changes. Limitations: The results presented are based on preliminary findings, however, an extensive systematic review is underway. A significant limitation is that the review did not deeply examine older adult and caregiver factors that could influence the implementation of technology in IC. A comprehensive systematic review and qualitative analysis will further examine this necessary dimension of technology implementation. Suggestions for future research: Results of the review will be used to inform the development of a tool that assesses the cross-sectoral capability of adopting technologies that support IC for older adults living with complex needs. [ABSTRACT FROM AUTHOR]

Introduction: Designing appropriate studies for evaluating complex interventions, like eHealth solutions to support integrated care, remains a methodological challenge. Although randomized control trials RCTs persist as the gold standard, they may not always be appropriate. Identification of contexts and mechanisms that can influence outcomes of an intervention typical in realist evaluations can help to identify appropriate methods for subsequent evaluation studies. Exploratory trials can be used to uncover these determinants, occurring at macro policy/system, meso organizational/team and micro person/provider levels in complex interventions prior to designing a full evaluation plan. Methods: An exploratory trial of the electronic Patient Reported Outcome ePRO tool was conducted to uncover contexts, mechanisms and relevant outcomes prior to full-scale evaluation. ePRO is a mobile application and portal designed to support goal-oriented care in inter-disciplinary primary health care practices. The four month trial was conducted in two practices in Toronto, Canada. Patients were randomized into control and intervention groups and compared pre and post on outcome measures quality of life and activation. Semistructured interviews were conducted with providers and patients in the intervention group to capture relevant contexts, mechanisms and outcomes. Results: Eight providers and 16 patients 7-control, 9-intervention participated in the study. Outcomes were captured using the AQoL-4D and PAM surveys; analyzed using descriptive statistics. Interview transcripts were analyzed using interpretive descriptive methods. There was little change in outcome measures, with a high baseline, suggesting patients were higherfunctioning than anticipated. Qualitative data highlighted factors for study consideration. Micro level factors included: participant characteristics, comfort with technology, training, and patient-provider relationship. Meso level factors included: provider workflows and norms, and organizational resources and culture. Macro level factors included: the technology policy environment, and system structure. Notably the research context and processes themselves were also influential. Enabling mechanisms occurred mainly at the micro level around motivation and readiness to set goals, and feelings regarding technology. Discussion: Multiple contextual variables and mechanisms were found to be potentially influential on study outcomes. Identifying relevant theories has been suggested as a way to address context and mechanisms in large scale control studies. In the ePRO example, we see the potential for dozens of potentially relevant theories ranging from individual level behaviour change theories, to organizational level innovation adoption theories. Conclusion: The number of complex, overlapping influencing variables suggests that complex interventions like ePRO may not be well suited to controlled evaluation designs. Realist, mixedmethods, and case studies which adopt ethnographic and narratives approaches may be more appropriate. Lessons Learned: Context variables and mechanisms can occur at multiple levels and may change over time of the intervention. Limitations: Although our analysis methods were informed by realist approaches, the study was not set up as a realist evaluation. Opportunities for observation and follow-up that would have allowed for more in-depth exploration may have been missed. Suggestions for future research: Studies of complex interventions, liked eHealth enabled models of integrated care, should consider alternatives to RCT approaches when "controlling" all relevant variables is unlikely. A case-study ethnographic approach will be taken as part of the next phase of ePRO evaluation. [ABSTRACT FROM AUTHOR]

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

Introduction: Information technology in health care, also referred to as eHealth technology, may offer a promising solution to the provision of better care and support for people who have multiple conditions and complex care needs and their caregivers. In particular eHealth technologies such as electronic medical records, telemonitoring systems, web-based portals and mobile health (mHealth) can enable information sharing between providers, clients and their families to improve integration of care across health and social care systems. Description of policy context and objective: eHealth technology often acts as an enabler of improved care delivery, rather than being an intervention per se. But how are different countries seeking to leverage adoption of these technologies to support people who have chronic conditions and complex care needs? Through a comparative cross-case analysis of Ontario, Canada, Scotland and Kaiser Permanente Colorado in the United States the strengths, weaknesses, opportunities, threats (SWOT) with regard to adoption of technology to address the challenge of multi-morbidity and increasing complexity is explored. Targeted Population: The focus on this presentation is on adoption of technologies that can best support care delivery across health and social care systems for persons with complex chronic disease and disability. This population can be characterized as having multiple chronic conditions (multimorbidity) as well as social/contextual challenges which make management of their health difficult. Highlights: (innovation, impact and outcomes) While each jurisdiction presents a unique policy context and health and social care system environment, there are a number of key similarities. Common strengths include: increasing governmental and organizational commitment and investment in technology, new innovations and system capabilities being adopted and explored, and a general increased awareness of the challenge of complexity and the need for personcentred solutions. This final strength also marks an important opportunity across jurisdictions for new investment in technologies to support this population. Although each jurisdiction is poised to leverage eHealth technologies, lack of integration and interoperability between systems used across health and social care systems, as well as a general fragmentation within and between health and social care systems marks a significant shared weakness. Furthermore, lack of sustainable resources, issues with demonstrating value for money, and data privacy and security challenges pose ongoing threats to adoption of new technologies across all three jurisdictions. Comments on transferability: The comparative analysis presented demonstrates how very different jurisdictions can face similar challenges when seeking to adopt eHealth solutions, suggesting that findings may be transferable to other countries. Conclusions: The cross-case analysis suggests a series of recommendations for organizational and governmental decision-makers with regard to adopting eHealth technologies to support persons with complex care needs. Supporting interoperability, adopting user-centred design and development approaches, and adoption of national-level strategies are identified as important enablers to wide adoption of solutions that can improve care delivery for persons with complex care needs and multimorbidity. [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: 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]

Introduction: An abundance of studies have investigated the many influences on the implementation of healthcare aimed at bridging the gap between recommended practice, what healthcare consumers want and need, and what they actually receive. Yet it is still not well known which implementation approaches work best in the use of knowledge, and the adoption and perpetuation of new ways of providing care in community-based settings. The metanarrative review will purposively inform implementation in the third phase of a programme of research, implementing integrated care for older adults with complex health needs (iCOACH) in New Zealand and Canada. Methods: This work reviewed what is known about implementation that may be suitable to guide the scaling up and evaluation phase of iCOACH. Metanarrative review methods were applied to systematic and narrative reviews of literature on implementation frameworks, theories and strategies. We synthesised heterogenous findings in a way that informs the practice of implementation. Results: Thirty-five systematic and narrative reviews met our inclusion criteria and were appraised, summarised, and qualitatively analysed. The various assumptions, worldviews and findings represented in the literature were subjected to high level analysis and interpretation that identified five metanarratives concerning the constructs, influencing factors, frameworks, and the effectiveness of interventions and strategies employed in implementation. Discussion: A wide range of people have a stake in how to implement what works best and matters most for older adults with chronic health care problems in various community-based settings, not least consumers themselves. We call for collaborative adaptation with stakeholders, most importantly the person receiving care and their family in the implementation of a new model. Conclusions and lessons learned: There is still no 'silver bullet' in implementation science in spite of abundant primary and secondary studies. People- and relationship-centred care is fundamental to integrated, community-based care at all levels in the broader health care delivery system. Yet many implementation theories and frameworks neglect these important considerations. All phases of implementation of a new model of care call for collaborative adaptation with stakeholders, the most important being the person receiving care in terms of what matters most to them. Limitations: While our search strategies were extensive we cannot guarantee that we located every systematic or narrative review on this topic. Suggestions for future research: Participatory research methods and realist evaluation approaches informed by this metanarrative review is required of the implementation of a new model of integrated, community-based care for older adults with chronic health problems to establish what has worked best, for whom and how. [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]

Background: Given the complex and evolving needs of individuals with multimorbidity, the adoption of mHealth tools to support self-management efforts is increasingly being explored, particularly in primary care settings. The electronic patient-reported outcomes (ePRO) tool was codeveloped with patients and providers in an interdisciplinary primary care team in Toronto, Canada, to help facilitate self-management in community-dwelling adults with multiple chronic conditions. Objective: The objective of study is to explore the experience and expectations of patients with multimorbidity and their providers around the use of the ePRO tool in supporting self-management efforts. Methods: We conducted a 4-week pilot study of the ePRO tool. Patients' and providers' experiences and expectations were explored through focus groups that were conducted at the end of the study. In addition, thematic analyses were used to assess the shared and contrasting perspectives of patients and providers on the role of the ePRO tool in facilitating self-management. Coded data were then mapped onto the Individual and Family Self-Management Theory using the framework method. Results: In this pilot study, 12 patients and 6 providers participated. Both patients and providers emphasized the need for a more explicit recognition of self-management context, including greater customizability of content to better adapt to the complexity and fluidity of self-management in this particular patient population. Patients and providers highlighted gaps in the extent to which the tool enables self-management processes, including how limited progress toward self-management goals and the absence of direct provider engagement through the ePRO tool inhibited patients from meeting their self-management goals. Providers highlighted proximal outcomes based on their experience of the tool and specifically, they indicated that the tool offered valuable insights into the broader patient context, which helps to inform the self-management approach and activities they recommend to patients, whereas patients recognized the tool's potential in helping to improve access to different providers in a team-based primary care setting. Conclusions: This study identifies a more explicit recognition of the contextual factors that influence patients' ability to self-manage and greater adaptability to accommodate patient complexity and provider workflow as next steps in refining the ePRO tool to better support self-management efforts in primary care ahead of its application in a full-scale randomized pragmatic trial. [ABSTRACT FROM AUTHOR]

Digital health and virtual care (DH/VC) interventions have been rapidly transforming healthcare systems, offering enormous potential to bridge gaps in healthcare access and deliver person-centred interventions to equity-deserving populations. Working in partnership with patients, caregivers and communities to meaningfully integrate lived experience perspectives into DH/VC interventions can help ensure that diverse needs are met. In this commentary, we propose a consolidated set of principles for co-designing equity-informed DH/VC interventions. We also identify how these principles can be leveraged through resources and opportunities offered by Healthcare Excellence Canada and others., (Copyright © 2024 Longwoods Publishing.)