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

Complex adaptive systems (CAS) theory views healthcare as numerous sub-systems characterized by diverse agents that interact, self-organize, and continuously adapt. We apply this complexity science perspective to examine the extent to which CAS theory is a useful lens for designing and implementing health policies. We present the case of Health Links, a “low rules” policy intervention in Ontario, Canada aimed at stimulating the development of voluntary networks of health and social organizations to improve care coordination for the most frequent users of the healthcare system. Our sample consisted of stakeholders from regional governance bodies and organizations partnering in Health Links. Qualitative interview data were coded using the key complexity concepts of sensemaking, self-organization, interconnections, coevolution, and emergence. We found that the complexity-compatible policy design successfully stimulated local dynamics of flexibility, experimentation, and learning and that important mediating factors include leadership, readiness, relationship-building, role clarity, communication, and resources. However, we saw tensions between preferences for flexibility and standardization. Desirable developments occurred only in some settings and failed to flow upward to higher levels, resulting in a piecemeal and patchy landscape. Attention needs to be paid not only to local dynamics and processes, but also to regional and provincial levels to ensure that learning flows to the top and informs decision-making. We conclude that implementation of complexity-compatible policies needs a balance between flexibility and consistency and the right leadership to coordinate the two. Complexity-compatible policy for integrated healthcare is more than simply ‘letting a thousand flowers bloom’. [ABSTRACT FROM AUTHOR]

Introduction: This study explores the implementation of "Health Links", a provincial integrated care initiative aimed at transforming care systems for high needs patients in Ontario, Canada. Launched in 2012 with 19 early adopters, there are currently 54 operational Health Links in Ontario. Each Health Link consists of multiple providers and is led by a coordinating partner such as a hospital, primary care group, or community support agency. We explored the implementation of Health Links from the perspective of Local Health Integration Networks (LHINs). LHINs are regional planning and funding bodies that have played an active role in overseeing the implementation process. In this study, we aimed to understand how environmental and organizational contexts influence the implementation and success of Health Links. Theory/Methods: We conducted semi-structured telephone interviews with LHIN leaders directly engaged in overseeing and managing the Health Links within their boundaries. The interviews focused on the LHIN role in implementing and supporting the Health Links, achievements to date, key challenges, and perceived similarities, differences, and degrees of success and innovation among the Health Links in their region. Probing questions were used to clarify the nature and extent of influence of organizational or environmental factors on the participants' experiences and perceptions. The Context for Integrated Care (CIC) Framework (recently developed by the authors) was used as an analytical framework for data analysis. Interview transcripts were qualitatively analyzed in two successive rounds. In the first round, an open-ended, iterative approach was used to identify recurrent themes. In the second round, the dimensions of the CIC Framework were used to code the transcripts. Results: Fourteen interviews were conducted with 26 participants between August and September 2014, representing a 100% participation rate from all fourteen of Ontario's LHINs. Significant differences across Health Links were noted in target patient populations, primary care versus hospital leadership, perceived success in rural versus urban areas, and a flexible versus standardized approach to structuring and implementing the network. The response to the "lowrules", grass-roots style of implementation by the Ontario Ministry of Health and Long-Term Care was also varied, with some LHINs choosing to impose a prescriptive standardized approach across their Health Links and others embracing the flexibility and opportunity for local adaptation. Despite significant diversity across the LHINs, several common environmental challenges were identified including loss of momentum during the Health Link application and approval process, a lack of clarity regarding the role and accountability of LHINs, measurement limitations impacting evaluation, and sustainability of funding. When mapped on to the CIC Framework, which has an explicit focus on the organizational and network levels, the following factors were evoked most frequently: resources, leadership, primary care engagement, readiness to change, a strategic focus on improvement, and historical inter-organizational relationships. Discussion: Results of the qualitative analysis show that LHIN experiences implementing Health Links varied on a continuum that ranged from positive and eager to demonstrate impact to frustrated and change-fatigued. Despite differences in network structure, implementation approach and geography and demography, recurring themes were identified that reflect the potency of environmental and organizational factors on efforts to integrate services. The CIC Framework enabled a comprehensive analysis of organizational context. The results suggest that factors such as organizational culture, internal design, and work environment are less important to the implementation of integrated care initiatives than leadership, resources, and readiness for change. Although multiple perspectives are required before drawing firm conclusions about the relative importance of various factors, these results can be used to help prioritize key areas for discussion, measurement and/or change management. Conclusions: The results of this study have implications for policymakers, organizational leaders, and researchers. Policymakers should consider how best to balance flexibility and standardization in the implementation of new programs to support a diverse range of needs and capabilities. Rapid feedback and approval turn-around during the implementation process is crucial to maintain momentum, as is clarity of roles between levels of governance, a shared evaluation framework, and sustainability plans. Leaders must be attuned to the context of their organization, and partnering organizations, to enhance synergy and build on respective strengths. Finally, additional research is required to understand when and how specific contextual factors matter. Although generalizability is limited by the focus on one jurisdiction in Canada, given the diversity of the Health Links in terms of geography, target patient population, organizational partners, and integrated care model/intervention design, we expect that the results have some transferability to other settings. The research team is currently engaged in interviews with clinicians and leaders working directly within the Health Links. [ABSTRACT FROM AUTHOR]

Healthcare system reforms are pushing beyond primary care to more holistic, integrated models of community based primary health care (CBPHC) to better meet the needs of the population. Across the world CBPHC is at varying stages of development and few standard models exist. In order to scale up and spread successful models of care it is important to study what works and why. The first step is to select 'appropriate' cases to study. In this commentary we reflect on our journey in the selection of CBPHC models for older adults, revealing the limited utility of sourcing the empirical literature; the difficulty in identifying "successful" models to study when outcomes of importance differ across stakeholders; the value of drawing on clinical and organisational networks and experts; and the association between policy context and ease of case selection. Such insights have important implications for case study methodology in health services and policy research. [ABSTRACT FROM AUTHOR]

Frameworks for understanding integrated care risk underemphasizing the complexities of the development of integrated care in a local context. The objectives of this article are to (1) present a novel strategy for conceptualizing integrated care as developing through a series of milestones at the organizational level, and (2) present a typology of milestones empirically generated through the analysis of four cases of integrated community-based primary health care (ICBPHC) in Canada and New Zealand. Our paper reports on an analysis of 4 specific organizational case studies within a large dataset generated for an international multiple case study project of exemplar models of ICBPHC. Drawing on earlier analyses of 359 qualitative interviews with patients, caregivers, health care providers, managers, and policymakers, in this article we present a detailed analysis of 28 interviews with managers and leaders of local models of integrated care. We generated a detailed timeline of the development of integrated care as expressed by each participant, and synthesized themes across timelines within each case to identify specific milestone events. We then synthesized across cases to generate the broader milestone categories to which each event belongs. We generated 5 milestone categories containing 12 more specific milestone events. The milestone categories include (1) strategic relational, (2) strategic process change, (3) internal structural, (4) inter-organizational structural, and (5) external milestones. We propose a comprehensive framework of developmental milestones for integrated care. Milestones represent a compelling strategy for conceptualizing the development of integrated care. Practically, policymakers and health care leaders can support the implementation of integrated care by examining the history and context of a given model of care and identifying strategies to achieve milestones that will accelerate integrated care. Further research should document additional milestone events and advance the development of dynamic frameworks for integrated care. • Developmental milestones accelerate or decelerate achievement of integrated care. • 5 categories of milestones are identified. • A comprehensive framework for milestones of integrated care is proposed. • Implementation strategies should be based on past milestones achieved. [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]