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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]

This paper is a response to our recognition that approaches to equity and consumer involvement in research differed in emphasis between our researchers and jurisdictions. Whilst we shared common aspirations we varied in our priorities between equity groups and methods to represent consumer interests. New Zealand has a historical focus on equity for indigenous Maori and shares with Canada concern about enduring inequalities that affect people's lives. [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]

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]

Background: The concept of "mechanism" is central to realist approaches to research, yet research teams struggle to operationalize and apply the concept in empirical research. Our large, interdisciplinary research team has also experienced challenges in making the concept useful in our study of the implementation of models of integrated community-based primary health care (ICBPHC) in three international jurisdictions (Ontario and Quebec in Canada, and in New Zealand).Methods: In this paper we summarize definitions of mechanism found in realist methodological literature, and report an empirical example of a realist analysis of the implementation ICBPHC.Results: We use our empirical example to illustrate two points. First, the distinction between contexts and mechanisms might ultimately be arbitrary, with more distally located mechanisms becoming contexts as research teams focus their analytic attention more proximally to the outcome of interest. Second, the relationships between mechanisms, human reasoning, and human agency need to be considered in greater detail to inform realist-informed analysis; understanding these relationships is fundamental to understanding the ways in which mechanisms operate through individuals and groups to effect the outcomes of complex health interventions.Conclusions: We conclude our paper with reflections on human agency and outline the implications of our analysis for realist research and realist evaluation. [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]