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Introduction: After the era of paper health record, in 2002 standard questionnaires for chronic patients were collected and registered by a hospital nurse. Since then, our electronic health record has been evolving. Nowadays the same electronic health record (eHR) is shared by the whole public health system that attends 2 million people, nursing homes included. The next step forward comes with the creation of standard questionnaires within an “Integral Program Manager”, this meaning that relevant information of the patient will be registered and analyzed giving identical recommendations in any setting (primary care, specialist or hospital) in a given clinical change. This will lead to “message reconciliation” in the system avoiding contradictions and helping educate and empower the patients for self-control. The creation of the personal health record and the new technologies (smartphones) will enable patients to fill the questionnaires by themselves. Description of practice change implemented: Change of paper based fragmented health record to an electronic and integrative one. Aim: Same electronic health record, questionnaires and recommendations in different settings Target population: All patients, but specially: - Pluripathological patients - Home-dependent patients - Nursing home residents - End of life patients Timeline: *Until 1996: health record on paper. *1996-2000: some reports are digitalized and the copy is carried by the patient. *2000-2009: basic electronic health record, different for primary care *Since 2002: assessment questionnaires for heart failure and COPD by phone by a case management nurse *2009-2012: health care based on an electronic health record, but different for hospital and primary care. Beginning of a electronic prescription tool (same for all) *Since 2012: creation of personal health records for patients *2012-2018: integrative electronic health record accessible for all healthcare workers, old paper reports are digitalized, warnings (allergies e.g.), same prescription tool (“Presbide”). *Since 2018: beginning of electronic application forms including those for pluripathological patients. Beginning of the “Integral Program Manager” to suggest recommendations according to clinical changes registered in the application forms. Highlights: -Creation of the electronic health record. -Computer integration: only one electronic health record -Healthcare integration: same questionnaires for all pluripathological patients (generic and specific disease related application forms). Information collected in any setting (call center, primary care physician or hospital) and creation of recommendations accordingly (by the “Integral Program Manager”) leading to remote treatment adjustment, face-to-face assessment in primary care or direct hospital admission. Sustainability: The unification of theelectronic health record reduces maintenance costs and those related to the lack of coordination. Transferability: Transferable for all health services with compatible information systems. Conclusions: Integrative electronic health record and healthcare process with the same questionnaires and recommendations are desirable for a coordinated health care, especially for multipathological patients. Discussion: The new technologies should allow patients to choose the easiest way to fill in control questionnaires by themselves. Lessons learned: This process is not easy because apart from the technical difficulties requires important habit changes, but is the only way to achieve our goals.

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

Aim To implement and evaluate a HF management tool for patients with chronic HF using digital pen and paper for improvement of patient self-management. Methods Developmental and implementation phase: researchers within medical technology and HF care will together with staff from home care and primary care (physicians and nurses) a small group of users (patients) and companies develop a HF management tool based on digital pen and paper and implement it in clinical practice. Evaluation phase The HF management tool will be tested in ten HF patients admitted to hospital-based home care. The technical equipment and clinical follow-up routines will be evaluated (reliability, stability, acceptance, user friendliness, and patient- and staff satisfaction). The patients will monitor and register shortness of breath, intake of medications, weight, blood pressure, pulse and saturation daily. Data will be collected through patient and staff interviews and observations as well as through questionnaires evaluating health-related quality of life, HF self-care and knowledge, quality of care, participation and perceived control. Health care and organisational costs will be estimated from patient and staff records. Innovative aspects and significance of the study: There is a great need for less labour-intensive and more cost-effective innovations that improve care and facilitate follow-up of patients with moderate to severe HF and at high risk for deterioration needing hospitalisation.

Introduction Over the last decade in the United States (US), the burden of chronic disease, health care costs, and fragmented care delivery have increased at alarming rates. To address these challenges, policymakers have prioritized new payment and delivery models to incentivize better integrated health and social services. Policy practice This paper outlines three major national and state policy initiatives to improve integrated health and social care over the last ten years in the US, with a focus on the Medicaid public insurance program for Americans with low incomes. Activities supported by these initiatives include screening patients for social risks in primary care clinics; building new cross-sector collaborations; financing social care with healthcare dollars; and sharing data across health, social and community services. Stakeholders from the private sector, including health systems and insurers, have partnered to advance and scale these initiatives. This paper describes the implementation and effectiveness of such efforts, and lessons learned from translating policy to practice. Discussion and conclusion National policies have catalyzed initiatives to test new integrated health and social care models, with the ultimate goal of improving population health and decreasing costs. Preliminary findings demonstrated the need for validated measures of social risk, engagement across levels of organizational leadership and frontline staff, and greater flexibility from national policymakers in order to align incentives across sectors.

Introduction: Demographic and epidemiological transitions of industralized countries mean health systems have to integrate health and social services to respond to the changing needs of their populations. Efforts to integrate care involve important policy and structural changes. This paper examines whether integration efforts are lost in translation during the bureaucratic appropriation of models, or, in an allegorical way, do they reveal genes of bureaucracy? Description: Since the 1960s, the health system of Quebec has undergone four major structural and progressively integrative transformations, characterized as – modernization, shock of reality, explicit integration, and centralization phases. Discussion: Although integration efforts progressively transformed Quebec’s health and social services system, embedded bureaucracies impeded the realisation of these projects. Notably, inadequate change management strategies and lack of integrated funding models hindered integration efforts. Furthermore, there was variability in government prioritisation and support of different aspects of the model by making some components happen, helping others happen and letting others happen. Conclusion: Drawing insights from bureaucratic obstacles to integration efforts may improve implementation strategies. This paper highlights important policy and administrative challenges that have to be taken into consideration in improving the implementation of integrated care initiatives in a real-life context.

Introduction: Team-based care can improve integrated health services by increasing comprehensiveness and continuity of care in primary healthcare (PHC) settings. Collaborative models involving providers from different professions can help to achieve coordinated, high-quality person-centred care. In Canada, there has been variation in both the timing/pace of adoption and approach to interprofessional PHC (IPHC) policy. Provinces are at different stages in the development, implementation, and evaluation of team-based PHC models. This paper describes how different policies, contexts, and innovations across four Canadian provinces (British Columbia, Alberta, Ontario, Quebec) facilitate or limit integrated health services through IPHC teams. Methods: Systematic searches identified 100 policy documents across the four provinces. Analysis was informed by Walt and Gilson’s Policy Triangle (2008) and Suter et al.’s (2009) health system integration principles. Provincial policy case studies were constructed and used to complete a cross-case comparison. Results: Each province implemented variations of an IPHC based model. Five key components were found that influenced IPHC and integrated health services: patient-centred care; team structures; information systems; financial management; and performance measurement. Conclusion: Heterogeneity of the implementation of PHC teams across Canadian provinces provides an opportunity to learn and improve interprofessional care and integrated health services across jurisdictions.

Digital health technologies hold significant promise to advance both functional and normative health and social care integration. The COVID-19 pandemic has created a window of opportunity to rapidly advance the adoption of digital solutions which can improve activities that support integration at clinical, professional, organizational and system levels. Global examples demonstrate how the pandemic has also created opportunities to use technology to address core values of integrated care like person-centredness and coordination. However, rapid and reactive changes could lead to increased fragmentation and exacerbate health inequity. This perspective paper outlines some of the opportunities and threats to advancing integrated care presented by the rapid adoption of digital health tools, suggesting we maintain a long view to ensure the stage we set today will mean greater integration tomorrow.

This paper aims to enhance the current understanding of integrated mental health services in the United States and how they can be better incorporated in perinatal and women's health specialty care from the perspective of a behavioral health provider. While much is known about gender disparities of mental health and low recognition and treatment rates for mental health disorders in women's health and perinatal care, few changes are being implemented to embed mental health specialists where they are needed most to close gaps in care. This paper demonstrates the value creation of integrated behavioral health in a midwife practice in the State of Arizona. Clinical and operational workflows can easily be adapted to include a behavioral health service to address mental and behavioral health needs that, when untreated, lead to long-term adverse outcomes in women and their families. Financial barriers that may hinder success of the integrated model are highlighted and discussed.

Background: Social Prescribing (SP) is an intervention to link users of the primary healthcare services to non-clinical organizations based on the community to tackle social determinants of health. Despite the potential benefits of SP, the effectiveness of this complex intervention remains uncertain. This paper presents the study protocol of the evaluation of the first SP project in Portugal. Methods: A mixed-methods study will be conducted to evaluate the SP project. For the quantitative component, a longitudinal, prospective study with a pre-post design will be performed. Data on patients referred to SP will be collected in four different points in time throughout the intervention, using questionnaires on patients’ health status and sociodemographic characteristics, and scales on patients’ well-being, quality of life and activation. The secondary data will be collected using patients’ medical records and SP’s forms about the referral and social responses elaborated within the intervention. Semi-structured interviews with patients and focus groups with stakeholders will be conducted to assess experiences of participation and improvement suggestions on SP. Conclusion: Comprehensive and complementary evidence will provide insights and learning for the implementation of future SP interventions. This can contribute to inform policy and practice, and to increase investment in social prescribing interventions.

This Perspective Paper explores the challenges of implementing local initiatives guided by the tenets of the Collective Impact (CI) approach. As such, it draws implications of CI for integrated health and social care efforts to improve and sustain health and social outcomes within a community-wide context, based on our efforts to deploy a CI intervention in the regional town of Muswellbrook, New South Wales (NSW) Australia. A program of health and wellbeing activities providing mental health and wellness messages and activities was implemented in the township over 2 years by the Family Action Centre (FAC), University of Newcastle, Australia. A key takeaway was the importance of authentic community engagement and active involvement as opposed to mere consultation.

Introduction: Despite the national and international policy commitment to implement integrated health systems, there is an absence of national standards that support evidence-based design, implementation, and monitoring for improvement. Health Standards Organization (HSO)’s CAN/HSO 76000:2021 – Integrated People-Centred Health Systems (IPCHS) National Standard of Canada (NSC) has been developed to help close this gap. This manuscript outlines the policy context and the process taken to develop the IPCHS standard. Description: The IPCHS standard is built around 10 design principles with detailed, action-oriented criteria and guidance for policy makers and health system partners. The IPCHS standard was co-designed with a technical committee that included balanced representation of policy makers, health system decision-makers, Indigenous leaders, providers, patients, caregivers, and academics. Additional feedback was received from a diverse audience during two public review periods and targeted consultation via interviews. This qualitative feedback, combined with the evidence reviews completed by the technical committee, informed the final content of the IPCHS standard. Discussion: The IPCHS standard was developed through a co-design process and complements existing frameworks by providing 66 detailed, action-oriented criteria, with specific guidance. The co-design process and consultations resulted in increased awareness and capacity among policy makers and health system partners. Supplementary tools are also in development to facilitate implementation and monitoring of progress and outcomes. This manuscript was developed in collaboration with technical committee members and HSO staff who led the targeted consultation and adoption of the IPCHS standard in six integrated care networks. Conclusion: Implementing integration strategies requires that we create and sustain a culture of continuous improvement and learning. Key lessons from the development process focused on the importance of co-design, embedding people-centred practices throughout the standard, formal yet iterative methodology inclusive of broad consultation, clear accountability for both policy makers and system partners, tools that support action and can be adapted to local context and level of integrated system maturity.

In the development process of integrated care many impeding factors occur. Our premise is, that many of these barriers are related to the differences in values or perspectives. This article aims to clarify what an important challenge is for the further development of integrated care and for integrated care research. Professionals and managers in integrated care need to cope with and embrace uncertainty. However, that requires collective reflexivity. Collective reflexivity is a means to investigate the values of the partners interacting to co-create integrated care and to remove the roadblocks on the way.

Transitional care encompasses a range of services designed to promote care integration as patients transfer between different locations or different levels of care. Transitional care programmes have been proven to produce positive outcomes in reducing hospital readmissions and improving patients’ health outcomes. However, little is known about the benefits of the programmes on healthcare cost and the published results have been inconsistent. With increasing healthcare expenditures and limited public healthcare resources, cost-benefit analyses become paramount in informing healthcare resource allocation decisions. This perspective paper describes the approaches used in estimating the total costs of a bundle of transitional care services from an academic medical centre, identifies the key methodological challenges encountered in the process of cost-benefit analysis, and recommends potential solutions to tackle these challenges. By providing a comprehensive perspective on the methodological challenges, this paper encourages program evaluators to take these possible challenges into consideration for future cost-benefit analyses.

Introduction: Ten years ago, progress towards integrated care in Aotearoa New Zealand was characterised as slow. Since then, there has been a patchwork of practices occurring under the broad umbrella of integrated care. These include: collective planning approaches (i.e., alliancing), agreed pathways of care, chronic care management initiatives, shared patient information systems, co-located centres and indigenous models of holistic care (e.g., Whānau Ora). Description: Although integrated care is often mentioned in national policy documents, implementation has been left to regional and local decision making, and very few initiatives have spread beyond their initial locations. Discussion: System incentives that preserve organisational “sovereignty” and path-dependent funding have slowed progress towards more integrated care in some areas. There is some evidence about specific initiatives and their impact, but it is difficult to discern significant trends and commonalities around the country. Conclusion: In the last ten years, the broad range of initiatives designed to achieve integrated care has absorbed regional and local attention and produced some evidence of progress, but the national picture of change is mixed.

Background: Cervical cancer is one of the leading causes of death among Peruvian women. Women seeking screening or treatment services experience delays in receiving screening results provided at community clinics or district hospitals, and lack sufficient resources to pay out-of-pocket to travel to the capital city of Lima for specialized treatment. Continued disparities in health outcomes and systemic barriers to accessing services suggest there are gaps between policy measures and implementation. Objectives: We aim to understand why national policies and clinical pathways that are aligned to global standards have been insufficient in improving cervical cancer screening and treatment in Peru, particularly among women who experience systemic exclusion from health services. Methods: We conducted a policy analysis based on a literature review (2005–2020), in Spanish and English, on PubMed, Global Health, Scopus, EconLit, Lilacs, and Scielo using a value-based care framework. Findings: The main barriers included unequal distribution of health infrastructure and health care workforce, and differences in access to health insurance. Additional barriers, including limited political will and support, limit efforts to prioritize the implementation of cervical cancer policies. We propose policy considerations in redesigning payment models, expanding healthcare workforce, generating costing and policy evidence, and reviewing policies for point-of-care technologies. Conclusions and Recommendations: The barriers identified in this literature review are applicable not only to cervical cancer care, but to primary health care in Peru. Systematic policy changes that address root causes of health inequities and are implemented at scale are needed to advance health reform efforts.

Background: An aging population is one of the key drivers reshaping health care systems. In China, the complex needs of its huge aging population require integration across the health and care sectors. Policies and progress: Over the past decade, the central government of China promulgated a series of policies to promote the establishment of aftercare facilities, specify approaches to integrate health and care service delivery at institutional and community levels, pilot long-term care insurance (LTCI) as a funding mechanism, and reform administrative structures in favor of integration. Progress has been made towards organizational and clinical integration of service delivery both at institutional and community levels. LTCI has been introduced as the financing mechanism covering long term care services. Discussions and Conclusions: The experiences of China in the integration of health and care could be summarized as a top-down approach in policy formulation and implementation, the significant employment of pilots and demonstrations, and the activation of market forces. However, China is still in the initial stage of integrating health and care and is faced with system-level challenges in its financing, management, and workforce, and faces technical challenges, such as a lack of tools, and standards. In the future, these issues need to be addressed.

Introduction: Switzerland’s fragmented healthcare system mirrors its federal structure and mix of cultures and languages. Although the Swiss have a higher life expectancy than most of their neighbours, their healthcare system faces similar challenges that call for more integrated care (IC). Aim/Method: This article aims to provide insight into the specificities of and latest developments in Switzerland’s healthcare system and how they may have influenced the development and implementation of IC there. Description/Discussion: The number of local IC initiatives has been growing steadily for 20 years. With a certain lag, various policies supporting IC have been established. Among them, a recent democratic debate on the federal mandatory health insurance law could either induce a radical move towards centralised support for IC or continue to support scattered local IC initiatives. Conclusion: In the future, Switzerland’s healthcare system will probably navigate between local IC initiatives and centralised, federal support for IC initiatives. This will be the reflection of a very Swiss way forward in a world without clear evidence on whether centralised or decentralised initiatives are more successful at developing IC.

Introduction: As part of major policy reforms begun in 2010, England introduced a wave of initiatives to encourage more integrated care between health and social care. These built on previous attempts which sought to achieve similar objectives through a focus on better partnership working. This article provides an overview and critical commentary on integrated care policy in England from 2010–2020 based on reviews by regulators, parliamentary committees and the national audit office. Overview of Policy: Integrated care became a priority through the work of the Future Forum, a group of leading stakeholders established due to concerns about greater competition in public health care. This led to a public statement of shared commitment to integrated care by national health and social care bodies. Early mechanisms included a pooled fund to achieve nationally set objectives, the creation of local authority led partnership boards, and high profile innovation programmes. Later in the 2010’s, new health led partnerships became more dominant vehicles to achieve integrated care at regional level. Impact of Policy: Despite progress within a few local areas, and reduction in delayed discharges from hospital the overall picture from national reviews was that expected improvements were not achieved. Emergency admissions to hospital continued to grow, patients within primary care reported being less involved in their care, and health inequalities worsened. The initial response to COVID-19 was health-centric contributing to outbreaks in care homes and inadequate supplies of protective personal equipment. The ability of leaders to look beyond their organisations’ interests was reported as vital for local progress. National government performance frameworks discouraged system based working and chronic underfunding of social care led to major capacity and workforce challenges. Conclusion: The experience of England suggests that greatest progress is made when integrated care focusses on tangible issues and when there is a clear understanding of how success will be measured. Even with considerable investment and intent progress should be expected to be slow and difficult. Layering of numerous policy initiatives provides confusion and can distract from the important work of relationship building. And ultimately, integrated care cannot by itself address major inadequacies in the underlying resources and structural inequalities.

Introduction: For more than a decade the English NHS has pursued integrated care through three national pilot programmes. The independent evaluators of these programmes here identify several common themes that inform the development of integrated care. Description: The three pilot programmes shared the aim of better coordination between hospital and community-based health services and between health and social care. Each programme recruited local pilot sites that designed specific interventions to support inter-professional and inter-organisational collaboration. The pilots were highly heterogenous and results varied both within and between the three programmes. While staff were generally positive about their achievements, pilots had mixed success especially in reducing unplanned hospital admissions. Common facilitators to achieving pilots’ objectives included effective senior leadership and shared values, simple interventions and additional funding. Barriers included short timescales, poor professional engagement, information and data sharing problems, and conflicts with changing national policy. Discussion: There was little stable or shared understanding of what ‘integrated care’ meant resulting in different practices and priorities. An increasing focus on reducing unplanned hospital use among national sponsors created a mismatch in expectations between local and national actors. Conclusion: Pilots in all three national programmes made some headway against their objectives but were limited in their impact on unplanned hospital admissions.

Introduction: Japan’s health policies to address the most advanced-aged society have been the target of focus in Asia, but no studies have investigated this issue using tools for cross-country comparisons. Theory and methods: A cross-country study design was used to compare healthcare reform policies with a framework in Japan, Korea, Thailand, China, Indonesia, and the Philippines. Data were collected via document reviews and key informant interviews. Results: Three distinctions were identified. First, all countries except for the Philippines have policy decisions regarding reforms for the existing service delivery systems for healthcare, long-term care and welfare. Second, the most extensive service delivery reform is currently being implemented in Japan, whose system is shifting to primary health care. Third, the direction of the transformation of service delivery system is different between Thailand and China despite a similar level of ageing society. China has made progress on facility-based care integration between health and social care, whereas Thailand is focusing on home-based care. Conclusions and discussion: Doctor and hospital-based healthcare delivery system requires more drastic reform for an aged society. This fact implies that strengthening primary health care is not only useful for current health issues but also an investment for the aged society near future in low- and middle-income countries.

Introduction: Much of the evidence for integrated care is based on small scale studies or specific care groups. Landmark legislation to integrate health and social care for adults in Scotland was introduced in 2014 based on a shared vision and narrative about improving outcomes for people and communities. This case study reflects on the experience of implementing reform at scale in Scotland, reports outcomes observed from 2015 to date and considers lessons for recovery post pandemic.Methods: A documentary review of published data and reports was conducted in 2019 by a cross sector team of experts from IFIC Scotland’s Reference Network. The enablers and barriers of country-wide implementation of integrated health and social care were identified and framed according to IFICs nine conceptual pillars. The impacts of system change were based on analyses of key trends over time in publicly available health and care data using data linkage systems to reflect outcomes for population health, resource use, quality and experience of care.Highlights: Published reports noted positive progress in collaborative working and encouraging evidence of impacts, albeit with significant local variation. Relational and citizen led approaches were considered critical for success, but system leaders and managers reported it takes time to build trusting relationships, influence organisational and professional cultures and cede power. A constraint noted was significant turnover in key personnel in Ministerial, policy and senior management posts. Despite some frustration at the pace and scale of progress, five years on there are many examples of innovation and positive outcomes despite increasing demographic, workforce, and financial challenges. In particular, there has been a significant shift in the balance of care for older people towards care at home, avoiding institutional care costs and releasing resource for investment in community health and care support and services. However serial patient and carer experience surveys highlight a continuing need for greater continuity and coordination of care. Relative inequalities have widened over the last decade prompting a commitment to improve community wellbeing, particularly for vulnerable populations who have experienced greater health and economic impacts from Covid-19. Conclusion: Implementing major reform after a prolonged period of austerity required considerable agility in coordinating multiple interdependent policies and interventions for different care groups, care settings and local context. Assessing and attributing impacts was challenging and progress at a national level seemed slower than local experience suggests, due in part to the relative immaturity of linkable national datasets for community and primary care interventions. Realising and evidencing the true value from integration will require a stronger focus on implementing place-based prevention and early intervention supported by data linkage systems for community and citizen level data. Implications: The pandemic has accelerated local collaboration and enhanced capability to facilitate system changes at unprecedented speed. Careful reflection and analysis of this recent experience is required to fully understand the respective contributions of people, communities, organisational structures, processes and enabling technologies. This case study offers insights for those seeking to reflect on integrated care policy implementation at this pivotal time for integrated systems.

Introduction: In the Netherlands multiple single, cross sector and cross governance level policy reforms were introduced to improve health and social care and decrease fragmentation. In addition to legislative and funding measures, the governmental strategy was to set up long-lasting improvement programs and supported by applied research. Description: Five national improvement programs on chronic disease management, maternity care, youth care, care for older people and dementia care were analysed. The Laws of integration of Leutz were used as an analytical framework. The programs demonstrated a mixture of employing policy, quality and financial measures to stimulate coherence and integration. Discussion: The Laws that Leutz formulated are to a large extent applicable in the Dutch context. However, the characteristics of the system of governance being corporatist in its structure and its culture imply that it is hard to distinguish single actors being in the lead. Integration is a more complex process and requires more dynamics, than the law ‘keep it simple, stupid’ suggests. Conclusions: In the Dutch context integration implies a permanent pursuit of aligning mechanisms for integration. Sustainable integration requires long-standing efforts of all relevant stakeholders and cannot be achieved quickly. It may take a decade of consistently applying a mix of policy instruments.

Introduction: In recent years many knowledge about integrated health services has been developed. So far research has focused on operational themes and interventions on the one side, which help decision makers in practice. On the other hand, a number of studies about generic elements of person-centered and integrated care have been published, resulting in valuable conceptual models and frameworks [1-9]. A third area of research is how to measure integrated care. However, if we want to further develop the person-centered integrated approach to improve the quality of services for civilians, a better understanding of the essence of integrated care and it’s underlying values is necessary. Shared values and principles can help to concretely identify what integrated care really is about and what integrated care thinking stands for [10,11]. Therefore, IFIC and Vilans have initiated a Special Interest Group (SIG) on values and principles of integrated care. The aim of the SIG is to develop a valuable and workable set of values and principles for person-centered integrated care. Within this context, a systematic literature review on value and principles of person-centered integrated care is carried out as a starting point. We propose a session with two objectives: A SIG-meeting with exchange of experiences A presentation and discussion about the first deliverable: the systematic literature review Theory/Methods: A systematic literature review of scientific and grey literature was conducted. Two researchers independently screened the initial results by title and abstract. Differences in interpretation were resolved by consensus. Each full text paper was independently assessed by two researchers on the criteria for inclusion. In each included article, values and principles of person-centered integrated care were identified and coded independently by two researchers. The codes were discussed in the research team. 3) Preliminary results 732 records were identified through the systematic search. After removing duplicates 396 articles remained, of which 48 were assessed for eligibility after the screening of titles and abstracts. 23 articles (48%) contained values and principles of person-centered integrated care and were coded. Currently (Dec 2016) an expert panel, mostly members of IFIC and Vilans’ SIG on Values of Integrated Care, is reflecting on the search results. Additional articles suggested by experts, are being added to the database the coming months (before ICIC2017). The experts have a range of backgrounds, including health and social care, and practice and academia. Conclusion & Discussion: A large amount of literature about integrated care is available, but less about the underlying values and principles. Preliminary results show that in the selected articles values and principles are present, which partly support the set of Ferrer and Goodwin [12]. At this moment the international expert panel is reviewing the search results, more definite results can be discussed in spring nest year. Lessons learned: Only limited literature has a focus on this level of abstraction (values and principles). The perspective appears to be quite new which is interesting a SIG topic. Limitations: Because the limited amount of literature, available conceptual models were analysed to derive values and principles. The quality of this process asks for skilled researchers; to enhance quality, all articles were independently assessed by two researchers. Suggestions for future research: To further develop the set of values and principles, a multi-perspective Delphi Study will be carried out. Multiple (SIG) experts with different backgrounds (clients, caregivers, developers, researchers) will be involved. The results of the Delphi Study will also be shared in the SIG. References: 1- Boshuizen D, Engels J, Versleijen M, Vlek H, Rebel M, Driessen S. White paper: Hoe maak je een succes van persoonsgerichte zorg?Vilans: Utrecht. 2014. 2- Cash-Gibson L, Rosenmoller M. Project INTEGRATE - a common methodological approach to understand integrated health care in Europe. International Journal of Integrated Care. 2014;14(4). DOI: http://doi.org/10.5334/ijic.1980 3- Kodner D, Spreeuwenberg C. Integrated care: meaning, logic, applications, and implications a dis¬cussion paper. International Journal of Integrated care. 2002;E12:2. 4- McCormack B, McCance T. Person-centred Nursing: Theory and Practice. Oxford: Wiley Blackwell. 2002. 5- Minkman M. Developing integrated care. Towards a development model for integrated care. PhD report. Deventer: Kluwer, ISBN 9789013100266801300; 2012. 6- Schlette S, Frohlich A, Marti T. The Bellagio Model - Population-oriented Primary Care: A diagnostic grid to assess, improve and enhance primary care. Vortrag BMJ International Forum, Session B5. 2009;Berlin: 18.03.2009. 7- Valentijn P. Rainbow of Chaos. A study into the the¬ory and practice of integrated primary care. Phd report;2015. 8- Wagner E. Chronic disease management: What will it take to improve care for chronic illness? Effective Clinical Practice. 1998;1(1):2-4. 9- World Health Organization. Innovative care for chronic conditions: building blocks for action: global report. Geneva: World Health Organization Library Cataloging-in-Publication Data; 2002. 10- Minkman M. Values and Principles of Integrated Care. International Journal of Integrated Care. 2016;16(1):2. DOI: http://doi.org/10.5334/ijic.2458 11- Goodwin N. Taking integrated care forward: the need for shared values. International Journal of Integrated Care. 2013;13(2). DOI: http://doi.org/10.5334/ijic.1180 12- Ferrer L, Goodwin N. What are the principles that underpin integrated care? International Journal of Integrated Care 2014; Oct–Dec; URN:NBN:NL:UI:10-1-114804. 13-World Health Organization. WHO global strategy on people-centred and integrated health services. Interim report. WHO Press, World Health Organization, 20 Avenue Appia, 1211 Geneva 27, Switzerland; 2015.

Introduction: change towards patients/citizens who have more information, are educated and active regarding their health process is an important part of the evolution that all health systems need to integrate in all aspects of their activities, management and design. In Europe, the White Paper reiterates the importance of participation in any individual or collective health process whether in local or regional contexts. In our country, the Basic Law on Patient Autonomy Regulation and Rights and Obligations Regarding Clinical information and Documentation recognizes the patients ‘capacity to choose and influence the organisations that represent them. The active participation of patients represents a new way of understanding therapeutic relationships, one that is respectful of patients‘ rights and potentially beneficial for the therapeutic process. The main objective of this project is to promote patient involvement in order to help improve/design healthcare strategies; to achieve this goal, we will be implementing a patient group dynamic that is currently used in the Dutch health system. Short description: this project comprises the setting up of patient focus groups (named “mirror meetings" in The Netherlands) where patients’ contacts with the health system will be discussed so health professionals can learn and improve from the experiences of these patients. This dynamic allows patients/citizens that have been in contact with health services/units/procedures… (COPD, surgical or Hospital at Homepatients…) to communicate their experiences, satisfaction, positive outcomes, to improve aspects… It´s a patient focus group attended also by professionals so they can learn from patients ‘ opinions. These steps will be followed throughout the process: first the topic of debate will be chosen. Later, patients who have been in contact with that area/service will be contacted and consent obtained if they wish to take part. The next step will be group formation and debate; information from these debates will be gathered by witnessing professionals in situ; this information will be double checked with the patients that took part. Finally, the organisation will aim to implement, whenever suitable, those suggestions that are considered viable. For evaluation purposes, the utility of these groups will be measured based on patient/professional satisfaction and implemented suggestions. Targeted population and stakeholders: citizens from whom we, as health professionals, can learn after listening to their experiences as patients. We believe that society as a whole will be our stakeholder since this is a topic that will hopefully improve health provision. Timeline: this is a project aimed to be started in October of 2018 and that will run through the first semester of 2019 Transferability: the strategies will first be tested on a couple of units/health centers and the aim is to reach the whole OSI or even the whole of the Basque Health Service- Osakidetza once the pilot study is finished and its usefulness is confirmed.

The annual amount spent on healthcare per capita is higher and expected to grow in the U.S. compared to healthier level 4 countries (e.g., United Kingdom, Canada, Germany, Australia, Japan, Sweden, Netherlands), while health outcomes continue to be suboptimal [1, 2, 3]. Therefore, healthcare is slowly shifting from a fee-for-service to value-based care, which addresses social determinants of health, promotes outcome-based contracting and employs more Population Health Management (PHM) activities. The root cause for this shift has been the increase in patients’ out-of-pocket costs and the pervasiveness of poorer outcomes. PHM has been defined by many as a mindset and activities that support the Triple Aim Initiative (i.e., improving population health, experience of care, reducing costs) [4]. This article outlines the value of pharmacists on health outcomes in the U.S., Germany, and Scotland and innovative PHM approaches through pharmacist collaborative networks, polypharmacy management and pharmacists’ integration in care models [1, 5].

Air pollution is a major, preventable and manageable threat to people’s health, well-being and the fulfillment of sustainable development. Air pollution is estimated to contribute to at least 5 million premature deaths each year across the world. No one remains unaffected by dirty air, but the adverse impacts of air pollution fall most heavily upon vulnerable populations, such as children, women, and people living in poverty — groups to whom States have special obligations under international human rights law. The National Academies of Sciences and Medicine of South Africa, Brazil, Germany and the United States of America are calling upon government leaders, business and citizens to take urgent action on reducing air pollution throughout the world — to the benefit of human health and well-being, to the benefit of the environment and as a condition towards sustainable development. Air pollution is a cross-cutting aspect of many UN Sustainable Development Goals.

In response to growing populations of citizens with multiple chronic conditions, integrated care models are being implemented in many countries. Based on our experiences from three EU co-funded actions (ICARE4EU, SUSTAIN, JA-CHRODIS), we notice that users’ experiences are not always taken into account when assessing the quality of integrated care, whereas research shows that it is in this particular domain that quality improvement is most evident. The greatest value of integrated care for people with multiple chronic conditions may not lie in its potential to improve their health or reduce their use of services, but in its potential to improve their care experience, by strengthening person-centred decision-making and delivering care and support accordingly. Collaborations of care providers, (representatives of) people with multiple chronic conditions and researchers need to develop appropriate methods and measures to include users’ experiences in qualityassessment of integrated care.

Introduction The Scottish Parliament recently passed legislation on integrating health and social care in Scotland. In this perspective paper, the clinical lead who supported the development and implementation of national policy on older people, long term conditions and integrated care in Scotland describes how political, policy and professional leaders have together created the right conditions to enable this ambitious change. The author reflects on the respective contributions from innovation, improvement, co-production, financial incentives, and through a clear focus on outcomes for people – whether patients, clients, carers, staff or citizens. The paper discusses how Scotland adapted Kotter’s eight steps for managing change and explores the transferable learning for other regions embarking on system transformation for integrated care.

Shared electronic health and social care records in some service systems are already showing some of the benefits of digital technology and digital data for integrating health and social care. These records are one example of the beginning “digitalisation” of services that gives a glimpse of the potential of digital technology and systems for building coordinated and individualized integrated care. Yet the promise has been greater than the benefits, and progress has been slow compared to other industries. This paper describes for non-technical readers how information technology was used to support integrated care schemes in six EU services, and suggests practical ways forward to use the new opportunities to build person-centered integrated care.

Many survey studies in health care adjust for demographic characteristics such as age, gender, educational attainment and general health when performing statistical analyses. Whether the effects of these demographic characteristics are consistent between patient groups remains to be determined. This is important as the rationale for adjustment is often that demographic sub-groups differ in their so-called 'response tendency'. This rationale may be less convincing if the effects of response tendencies vary across patient groups. The present paper examines whether the impact of these characteristics on patients' global rating of care varies across patient groups.Secondary analyses using multi-level regression models were performed on a dataset including 32 different patient groups and 145,578 observations. For each demographic variable, the 95% expected range of case-mix coefficients across patient groups is presented. In addition, we report whether the variance of coefficients for demographic variables across patient groups is significant.Overall, men, elderly, lower educated people and people in good health tend to give higher global ratings. However, these effects varied significantly across patient groups and included the possibility of no effect or an opposite effect in some patient groups.The response tendency attributed to demographic characteristics - such as older respondents being milder, or higher educated respondents being more critical - is not general or universal. As such, the mechanism linking demographic characteristics to survey results on patient experiences with quality of care is more complicated than a general response tendency. It is possible that the response tendency interacts with patient group, but it is also possible that other mechanisms are at play.

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

Introduction: Japan has the largest percentage of elderly people in the world. In 2012 the government implemented a community-based integrated care system which provides seamless community healthcare resources for elderly people with chronic diseases and disabilities. Methods: This paper describes the challenges of establishing a community-based integrated care system in 1974 in Mitsugi, a rural town of Japan. This system has influenced the government and become the model for the nationwide system. Results: In the 1970s, Mitsugi’s aging population was growing faster than Japan’s, but elder care was fragmented among a variety of service sections. A community-based integrated care system evolved because of the small but aging population size and the initiative of some local leaders of medical care and politics. After the system took effect, the proportion of bedridden people and medical care costs for the elderly dropped in Mitsugi while it continued to rise everywhere else in Japan. Mitsugi’s community-based integrated care system is now shaping national policy. Conclusion: Mitsugi is in the vanguard of Japan’s community-based integrated care system. The case showed the community-based integrated care system can diffuse from rural to urban areas.

While trying to represent patients in the design of integrated care, I have heard the words 'system', 'systemic' and 'holism' used frequently. Few of those using the words seem to be aware of the history of systems thinking, or its principles. Health interventions are instead designed using logic modelling, which is aholistic and disintegrative. This concern is illustrated in relation to the UK’s Better Care Fund, which was an attempt to reduce hospital admissions by co-ordinating care. Systems thinking is then used to provide a possible distinction between three operating systems for the UK’s National Health Service (NHS). The first, an ideal market operating system, is inherently fantastic, and doubly so when it is impossible to determine who has contributed what to which outcomes. The accountable professional operating system may re-emerge as the rational option. However, weak analysis can lead to the emergence of a quasi-market operating system, which lacks the capacity to integrate the essential elements of a viable system. The fault lies not with systems thinking, but with the failure to study how viable systems are constructed.

Introduction: In response to increase of patients with complex conditions, policies prescribe measures for improving continuity of care. This study investigates policies introducing coordinator roles in Norwegian hospitals that have proven challenging to implement. Methods: This qualitative study of policy documents employed a discourse analysis inspired by Carol Bacchi’s ‘What‘s the problem represented to be?’. We analysed six legal documents (2011–2016) and selected parts of four whitepapers presenting the statutory patient care coordinator and contact physician roles in hospitals. Results: The ‘problem’ represented in the policies is lack of coherent pathways and lack of stable responsible professionals. Extended personal responsibility for clinical personnel as coordinators is the prescribed solution. Their duties are described in terms of ideals for coherent pathways across conditions and contexts. System measures to support and orchestrate the individual patient’s pathway (e.g. resources, infrastructure) are scarcely addressed. Conclusions and Discussion: We suggest that the policies’ construction of the ‘problem’ as a responsibility issue, result in that neither diversity of patients’ coordination needs, nor heterogeneity of hospital contexts regarding necessary system support for coordinators, is set on the agenda. Adoption of rhetoric from diagnosis-specific standardized pathways obscures unique challenges in creating coherent pathways for patients with complex needs. © 2018 The Author(s). This is an open-access article distributed under the terms of the Creative Commons Attribution 4.0 International License (CC-BY 4.0), which permits unrestricted use, distribution, and reproduction in any medium, provided the original author and source are credited. See http://creativecommons.org/licenses/by/4.0/.

Much is changing in health care organization today. A perspective or paradigm that is gaining ever increasing momentum is that of translational, extramural and integrated care. Current research suggests many potential benefits for integrated care and health care networks but the ethical issues are less frequently emphasized. Showing that integrated care can be beneficial, does not mean it is automatically 'ethically' justified. We will argue for three ethical requirements such health care networks should meet. Subsequently we will look at the mechanisms driving the formation of networks and examine how these can cause networks to meet or fail to meet these ethical requirements or obligations. The three mechanisms we will examine are government, civil society and market mechanisms, which, we argue, should be balanced properly. Each mechanism is able to provide a relevant ethical perspective to health care networks. However, when the balance is skewed towards a single mechanism, health care networks might fail to promote one or more of the ethical requirements.

The iCOACH study involved key health care system decision-makers from Ontario, Quebec and New Zealand. This article is written by the key decision-makers involved in the iCOACH study and discusses their motivations to engage in the research project, the value of participation and key recommendations for best practices to engage decision-makers in research projects. Suggestions for knowledge translation are identified including practical tools for decision-makers and providers to use to assess readiness to implement integrated community-based primary health care. Case study briefs with key enablers and ‘talking-points’ and infographics are similarly recommended as approaches to transfer knowledge gained from this research study.

Integrated care requires joined up information for effective planning, delivery and management. Different countries are experimenting with a range policy approaches to designing integrated information systems with varying levels of success. Information systems to support integrated care that start with the needs of the user of information (individual, health and care professional, service manager, payer, policy maker), are most likely to succeed in being adopted. We suggest that using the MINDSPACE behavioural framework alongside technology tools to engage users in a process of co-design for integrated information systems will help deliver on the promise of better population health and better value healthcare sooner rather than later by producing information systems that support real time coordinated person- and community-centred decision-making.

Objectives: This paper discusses the increasing incidence of mental health problems in Pakistan, and specifically in the Swat valley, in relation to the growing insurgency and current violence in Pakistani society. The paper argues that the health care system's response in Pakistan is not adequate to meet the current challenges and that changes in policy are needed to build mental health care services as an important component of the basic health package at primary care level in the public sector.Method: This paper reviews the existing mental health situation in Pakistan with reference to the findings of a case study in the Swat valley in Khyber Pukhtoonkhwa Pakistan. The figures presented in the case study are used to support the need for an integrated national mental health policy.Conclusion: Mental health care needs to be incorporated as a core service in primary care and supported by specialist services. There is a strong need to provide adequate training for general practitioners and postgraduate training for mental health professionals to meet the current demands. A collaborative network between stakeholders in the public and private sector, as well as non-governmental organisations are required that promotes mental health care and advocates for changes in mental health policy.

In North West London, health and social care leaders decided to design a system of integrated care with the aim of improving the quality of care and supporting people to maintain independence and participation in their community. Patients and carers, known as ‘lay partners,’ were to be equal partners in co-production of the system. Lay partners were recruited by sending a role profile to health, social care and voluntary organisations and requesting nominations. They formed a Lay Partners Advisory Group from which pairs were allocated to system design workstreams, such as which population to focus on, financial flow, information technology and governance. A larger and more diverse Lay Partners Forum provided feedback on the emerging plans. A key outcome of this approach was the development of an integration toolkit co-designed with lay partners. Lay partners provided challenge, encouraged innovation, improved communication, and held the actions of other partners to account to ensure the vision and aims of the emerging integrated care system were met. Key lessons from the North West London experience for effective co-production include: recruiting patients and carers with experience of strategic work; commitment to the vision; willingness to challenge and to listen; strong connections within the community being served; and enough time to do the work. Including lay partners in co-design from the start, and at every level, was important. Agreeing the principles of working together, providing support and continuously recruiting lay representatives to represent their communities are keys to effective co-production.

The Solomon Islands Government is pursuing integrated care with the goal of improving the quality of health service delivery to rural populations. Under the auspices of Universal Health Coverage, integrated service delivery packages were developed which defined the clinical and public health services that should be provided at different levels of the health system. The process of developing integrated service delivery packages helped to identify key policy decisions the government needed to make in order to improve service quality and efficiency. The integrated service delivery packages have instigated the revision of job descriptions and are feeding into the development of a human resource plan for health. They are also being used to guide infrastructure development and health system planning and should lead to better management of resources. The integrated service delivery packages have become a key tool to operationalise the government’s policy to move towards a more efficient, equitable, quality and sustainable health system.

Reports of how different countries are responding to the need to develop more integrated health and social care services for older adults can provide useful lessons for other health systems. However an understanding of how the wider structural, political, economic and cultural context affects implementation of these models of care is essential when considering the potential for models to be scaled up or transferred to other jurisdictions.