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Background: Despite far reaching support for integrated care, conceptualizing and measuring integrated care remains challenging. This knowledge synthesis aimed to identify indicator domains and tools to measure progress towards integrated care. Methods: We used an established framework and a Delphi survey with integration experts to identify relevant measurement domains. For each domain, we searched and reviewed the literature for relevant tools. Findings: From 7,133 abstracts, we retrieved 114 unique tools. We found many quality tools to measure care coordination, patient engagement and team effectiveness/performance. In contrast, there were few tools in the domains of performance measurement and information systems, alignment of organizational goals and resource allocation. The search yielded 12 tools that measure overall integration or three or more indicator domains. Discussion: Our findings highlight a continued gap in tools to measure foundational components that support integrated care. In the absence of such targeted tools, “overall integration” tools may be useful for a broad assessment of the overall state of a system. Conclusions: Continued progress towards integrated care depends on our ability to evaluate the success of strategies across different levels and context. This study has identified 114 tools that measure integrated care across 16 domains, supporting efforts towards a unified measurement framework.

The aim of this scoping review was to examine the utilization of a Health in All Policies (HiAP) approach in municipal government settings. Specific objectives included: to review peer reviewed and grey literature, to identify common themes from the literature, and to highlight gaps in the evidence base for HiAP. An iterative scoping review method was used. Documents were identified through searches of academic databases, reference lists and journal indices, and the World Wide Web. Included documents focused on HiAP in the local or municipal government context, published in English, between 2006 and 2015. Data were extracted and analyzed using descriptive statistics and a narrative thematic method. As of June 2015, 26 documents met the inclusion criteria. A lack of research studies examining HiAP in the municipal government context was identified. Three broad themes were abstracted from analysis of the documents: the conceptualization of HiAP, the adoption of HiAP, and the implementation of HiAP. The focus on a HiAP approach at the municipal level of government is growing. A majority of the existing documents provide narrative evidence and recommendations for implementing a HiAP approach at the municipal level. Research is needed in the areas of conceptualization, implementation, adoption and evaluation of a HiAP approach in municipal settings.

Introduction: Ten key principles have been identified to facilitate successful health systems integration. The principles include: 1) comprehensive services, 2) patient focus, 3) geographic coverage and rostering, 4) standardized care delivery through interprofessional teams, 5) performance management, 6) information technology, 7) organizational culture and leadership, 8) physician integration, 9) governance structure, and 10) financial management. To our knowledge, there is little research on patients/user’ perceptions on the concept of integration. This unique perspective will assist in identifying the relevancy of the principles for patients and users as well as influence recommendations for which indicators should be prioritized for measurement and further research. Methods: As a part of a larger study to identify indicators and tools for measuring health systems integration, three focus groups were conducted with 17 patients/users of the system in three regions (British Columbia and Alberta, Canada, and Rio Grande do Sul, Brazil). Each focus group targeted a different population to capture a variety of perspectives. In British Columbia participants were from rural communities, in Alberta from a large urban setting and in Rio Grande do Sul participants represented the community Health Councils in the City of Porto Alegre. Participants were provided with a list and descriptions of the 10 integration principles. At the end of the session they were asked to prioritize the principles. Both quantitative and qualitative analysis of the data were completed. A virtual meeting was held to discuss similarities and differences in themes. Key sections of data from Brazil was translated into English to be included in our final analysis. Results: The highest priority principles for integration in Canada were patient focus, comprehensive services across the care continuum, and standardized care delivery through interprofessional teams. In Canada, focus groups participants felt the system was still provider and International Journal of Integrated Care – Volume 15, 17 Nov – URN:NBN:NL:UI:10-1-117317 – http://www.ijic.org 3 rd World Congress on Integrated Care, Mexico City, Mexico, 19-21 November, 2015 system focused; while in Brazil the Family Health Strategy was highlighted as a proposal for patient-focused care. Canadian participants considered lack of continuity across the continuum of care was a risk for patients not accessing services in a timely or appropriate manner. In Brazil, integration between health systems was considered necessary, although current initiatives were insufficient and lacked continuity. Discussion: These results provide an in-depth understanding of patient/user perspectives on integration. The principles of patient focus, comprehensive services across the care continuum, and standardized care delivery through interprofessional teams are a priority for this group and provide a foundation for integrated health systems. Conclusion: According to participants the highest priority principles of integration in Canada and Brazil were patient focus and comprehensive services across the care continuum. Team: This collaborative Canadian and Brazilian project includes researchers and knowledgeusers with expertise in health systems policy and planning, systematic reviews, and library ciences. Health systems integration is a priority in both countries. The partnership builds on commonalities such as: publicly funded health systems; comparable funding priorities; and similar geography with large urban centres and rural communities. Conducting collaborative research in these two countries will increase the international applicability of the results. Conference abstract Spanish Introduccion: Diez principios clave han sido identificados para facilitar la exitosa integracion de los sistemas de salud. Los principios son: 1) servicios integrales, 2) enfoque paciente, 3) la cobertura geografica y de turnos, 4) la prestacion de asistencia normalizada a traves de equipos interprofesionales, 5) la gestion del rendimiento, 6) tecnologia de la informacion, 7) la cultura organizacional y liderazgo, 8) medicos en integracion, 9) la estructura de gobierno, y 10) gestion financiera. Hasta donde sabemos, hay poca investigacion sobre las percepciones de los paciente y usuario 'en el concepto de integracion. Esta perspectiva unica ayudara a identificar la relevancia de los principios para los pacientes y usuarios, asi como recomendaciones de influencia para que los indicadores deben ser priorizados para la medicion y una mayor investigacion. Metodos: Como parte de un estudio mas amplio para identificar los indicadores y herramientas para medir la integracion de sistemas de salud, tres grupos focales se llevaron a cabo con 17 pacientes / usuarios del sistema en tres regiones (Columbia Britanica y Alberta, Canada; y Rio Grande do Sul, Brasil). Cada grupo de enfoque dirigido a una poblacion diferente para capturar una variedad de perspectivas. En British Columbia los participantes eran de las comunidades rurales, en Alberta de un entorno urbano grande y en Rio Grande do Sul participantes representaron a la comunidad de los Consejos de Salud de la ciudad de Porto Alegre. Los participantes se les proporciono una lista y descripciones de los 10 principios de integracion. Al final de la sesion se les pidio que dar prioridad a los principios. Se completaron Tanto el analisis cuantitativo y cualitativo de los datos. Un encuentro virtual se llevo a cabo para discutir las similitudes y diferencias en los temas. Secciones clave de los datos procedentes de Brasil fue traducido al Ingles que se incluiran en el analisis final. Resultados: Los principios de mayor prioridad para la integracion en Canada eran enfoque paciente, servicios integrales en todo el continuo de la atencion y la prestacion de atencion estandarizada a traves de equipos interprofesionales. En Canada, los grupos focal de participantes consideraron el sistema seguia siendo proveedor y un sistema centrado; mientras que en Brasil la Estrategia Salud de la Familia se destaco como una propuesta para la atencion centrada en el paciente. Participantes canadienses consideran la falta de continuidad a traves de la continuidad de la atencion era un riesgo para los pacientes no acceden a los servicios en el momento oportuno o conveniente. En Brasil, se considero necesaria la integracion entre los sistemas de salud, a pesar de las iniciativas actuales eran insuficientes y carecen de continuidad. Discusion: Estos resultados proporcionan una comprension en profundidad de las perspectivas del paciente/usuario en la integracion. Los principios de la atencion del paciente, servicios integrales en todo el continuo de la atencion y la prestacion de atencion estandarizada a traves de equipos interprofesionales son una prioridad para este grupo y proporcionan una base para los sistemas de salud integrados. International Journal of Integrated Care – Volume 15, 17 Nov – URN:NBN:NL:UI:10-1-117317 – http://www.ijic.org 3 rd World Congress on Integrated Care, Mexico City, Mexico, 19-21 November, 2015 Conclusion: De acuerdo a los participantes los principios de mayor prioridad de la integracion en Canada y Brasil eran enfocados en pacientes y servicios integrales en todo el continuo cuidado. Equipo: Este proyecto de colaboracion canadiense y brasileno incluye investigadores del conocimiento de los usuarios con experiencia en la politica de los sistemas de salud y la planificacion, revisiones sistematicas, y las ciencias de la biblioteca. Integracion de sistemas de salud es una prioridad en ambos paises. La asociacion se basa en elementos comunes, tales como: sistemas de salud financiados con fondos publicos; prioridades de financiamiento comparables; y la geografia similar con los grandes centros urbanos y comunidades rurales. La realizacion de la investigacion colaborativa en estos dos paises aumentara la aplicabilidad internacional de los resultados.

Background: Health systems integration continues to be an important mechanism to enhance quality of care and improve health outcomes. In a prior study (Suter et al, 2009), we identified 10 key principles that need to be considered for successful health systems integration. The principles include: 1) comprehensive services, 2) patient focus, 3) geographic coverage and rostering, 4) standardized care delivery through interprofessional teams, 5) performance management, 6) information technology, 7) organizational culture and leadership, 8) physician integration, 9) governance structure, and 10) financial management. There is evidence that organizations that pay attention to these areas achieve a higher level of integration. However, measuring progress towards integration in these areas is not easy because appropriately tested indicators and tools are missing. 3 World Congress on Integrated Care, Mexico City, Mexico, 19-21 November, 2015 International Journal of Integrated Care – Volume 15, 17 Nov – URN:NBN:NL:UI:10-1-117309 – http://www.ijic.org The goal of this study is to identify indicators and tools for measuring health systems integration. Our primary research question is how can we measure health systems integration? More specifically, two sub-questions are addressed: 1) What are appropriate indicators for each of the 10 key integration principles described above? and 2) What measurement tools are used to measure these indicators? The findings from this knowledge synthesis will assist health systems planners and managers to evaluate progress made towards integrating health systems. Approach: We first identified appropriate indicators for each of the 10 key principles for successful integration. Using a modified Delphi approach, a panel of integration experts, knowledge-users and providers (n=39) were invited to provide feedback on the indicators and decide on the most relevant and important indicators. Three rounds of Delphi with 17 participants were used to come to an agreement. For each of the indicators we then conducted a systematic search for tools to measure the indicator. The following databases were searched: Medline, EMBASE, CINAHL, ABI Inform, and Business Source Premier, LILACS and SciELO. For each measurement tool, information on the reliability and validity was extracted (if reported), the context in which the tool was used and potential challenges with using the tool. Findings: Delphi panel members initially received a list of 22 indicators and had the opportunity to propose additional indicators. After three Delphi rounds, the panel reached consensus on 16 indicators across 9 principles. No agreement was reached for indicators for Principle 9 (governance structure). We found a high number of articles for some indicators (e.g., coordinated care transition, intersectoral collaboration). For these indicators we found several measurement tools, mainly in the form of questionnaires; many of them were well tested and validated. For other indicators, the literature was sparse and only a few tools or no tools were found; some of the indicators were best measured by administrative health data or other data sources. We will present a summary of tools and appropriate measures for each of the indicators including recommendations on how to use them. In addition, gaps in measurement tools for indicators will be highlighted and imitations will be discussed. Team: This is a collaborative project between Canadian and Brazilian researchers and knowledge users with expertise in health systems policy and planning, systematic reviews, and library sciences. This partnership was specifically chosen as both countries have: publicly funded health systems; comparable funding priorities; and similar geography of large urban centres and rural communities. Furthermore, health systems integration is a priority in both countries. Having team members from two countries increases the applicability of the tools to different contexts. Conference abstract Spanish Antecedentes: la integracion de sistemas de salud sigue siendo un mecanismo importante para mejorar la calidad de la atencion y mejorar los resultados de salud. En un estudio previo (Suter et al, 2009), se identificaron 10 principios clave que deben tenerse en cuenta para la integracion de los sistemas de salud exitosos. Los principios son: 1) servicios integrados, 2) enfoque del paciente, 3) la cobertura geografica y de turnos, 4) la prestacion de asistencia normalizada a traves de equipos interprofesionales, 5) la gestion del rendimiento, 6) tecnologia de la informacion, 7) la cultura organizacional y liderazgo, 8) medico integrado, 9) la estructura de gobierno, y 10) gestion financiera. Existe evidencia de que las organizaciones que prestan atencion a estas areas a alcanzar un mayor nivel de integracion. Sin embargo, medir el progreso hacia la integracion en estas areas no es facil porque faltan los indicadores y herramientas adecuadamente probados. El objetivo de este estudio es identificar los indicadores y herramientas para medir la integracion de sistemas de salud. Nuestra pregunta de investigacion principal es ?como podemos medir la integracion de los sistemas de salud? Mas especificamente, dos sub-preguntas se abordan: 1) ?Cuales son los indicadores apropiados para cada uno de los 10 principios de integracion clave descritos anteriormente? y 2) ?Que herramientas de medicion se utilizan para medir estos indicadores? Los resultados de esta sintesis de conocimientos ayudaran a los planificadores y administradores de los sistemas de salud para evaluar los progresos realizados hacia la integracion de los sistemas de salud. 3 World Congress on Integrated Care, Mexico City, Mexico, 19-21 November, 2015 International Journal of Integrated Care – Volume 15, 17 Nov – URN:NBN:NL:UI:10-1-117309 – http://www.ijic.org Enfoque: En primer lugar, identificamos indicadores apropiados para cada uno de los 10 principios fundamentales para una integracion exitosa. Utilizando un enfoque de Delphi modificado, un panel de expertos en integracion, conocimiento de los usuarios y los proveedores (n = 39) fueron invitados a proporcionar informacion sobre los indicadores y decidir sobre los indicadores mas relevantes e importantes. Tres rondas de Delphi con 17 participantes se utilizaron para llegar a un acuerdo. Para cada uno de los indicadores luego se realizo una busqueda sistematica de herramientas para medir el indicador. Las siguientes bases de datos: Medline, EMBASE, CINAHL, ABI Inform, y Business Source Premier, LILACS y SciELO. Para cada herramienta de medicion, se extrajo informacion sobre la fiabilidad y validez (si informo), el contexto en el que se utilizo la herramienta y desafios potenciales con el uso de las herramientas. Hallazgos: los miembros del panel Delphi recibieron inicialmente una lista de 22 indicadores y tuvo la oportunidad de proponer indicadores adicionales. Despues de tres rondas, el panel Delphi llego a un consenso sobre 16 indicadores en 9 principios. No se llego a un acuerdo para los indicadores de los 9 Principios (estructura de gobierno). Encontramos un gran numero de articulos para algunos indicadores (por ejemplo, la transicion de cuidado coordinado, colaboracion intersectorial). Para estos indicadores encontramos varias herramientas de medicion, sobre todo en forma de cuestionarios; muchos de ellos fueron bien probados y validados. Para otros indicadores, la literatura era escasa y se encuentran solo unas pocas herramientas o sin ninguna; algunos de los indicadores se midieron mejor con los datos de salud administrativas u otras fuentes de datos. Vamos a presentar un resumen de las herramientas y las medidas adecuadas para cada uno de los indicadores que incluyen recomendaciones sobre la forma de utilizarlos. Ademas, las lagunas en los instrumentos de medicion de indicadores seran resaltados y se discutiran las imitaciones. Equipo: Este es un proyecto de colaboracion entre investigadores canadienses, brasilenos y usuarios de conocimiento con experiencia en la politica de los sistemas de salud y la planificacion, revisiones sistematicas, y las ciencias de la biblioteca. Esta asociacion fue elegida especificamente ya que ambos paises tienen: los sistemas de salud financiados con fondos publicos; prioridades de financiamiento comparables; y la geografia similar de los grandes centros urbanos y comunidades rurales. Por otra parte, la integracion de los sistemas de salud son una prioridad en ambos paises. Tener los miembros del equipo de dos paises aumenta la aplicabilidad de las herramientas en diferentes contextos.

Background: Health system integration is a key component of health system reform with the goal of improving outcomes for patients, providers, and the health system. Although health systems continue to strive for better integration, current delivery of health services continues to be fragmented. A key gap in the literature is the lack of information on what successful integration looks like and how to measure achievement towards an integrated system. This multi-site study protocol builds on a prior knowledge synthesis completed by two of the primary investigators which identified 10 key principles that collectively support health system integration. The aim is to answer two research questions: What are appropriate indicators for each of the 10 key integration principles developed in our previous knowledge synthesis and what measurement tools are used to measure these indicators? To enhance generalizability of the findings, a partnership between Canada and Brazil was created as health system integration is a priority in both countries and they share similar contexts. Methods/design: This knowledge synthesis will follow an iterative scoping review process with emerging information from knowledge-user engagement leading to the refinement of research questions and study selection. This paper describes the methods for each phase of the study. Research questions were developed with stakeholder input. Indicator identification and prioritization will utilize a modified Delphi method and patient/user focus groups. Based on priority indicators, a search of the literature will be completed and studies screened for inclusion. Quality appraisal of relevant studies will be completed prior to data extraction. Results will be used to develop recommendations and key messages to be presented through integrated and end-of-grant knowledge translation strategies with researchers and knowledge-users from the three jurisdictions. Discussion: This project will directly benefit policy and decision-makers by providing an easy accessible set of indicators and tools to measure health system integration across different contexts and cultures. Being able to evaluate the success of integration strategies and initiatives will lead to better health system design and improved health outcomes for patients.

Introduction: The importance of integration across the continuum of care is not limited to the health care sector. Coordinating client care between sectors and including supportive services such as education and social services is considered an essential part of building a fully integrated health system. Building on previous integration research, this study is a part of a comprehensive systematic review focused on identifying indicator and measures of the key principles of integration. We identified 16 indicator domains through a modified Delphi process using an expert panel of policy-makers, decision-makers, providers, and researchers. Intersectoral collaboration was identified as one of two indicator domains for the first principle of successful health systems integration, Comprehensive Services across the Continuum of Care. Methods: Search terms were generated for intersectoral collaboration to identify tools in the peer-reviewed and targeted gray literature. Tools were identified through a rigorous review process including abstract review, relevancy ratings, identifying additional articles in reference lists, quality ratings, and extraction. To avoid duplication of tools, only “tool development” articles were included in data extraction. If an article was found which used but did not develop an appropriate tool, the original article reporting the development and testing of the tool was identified and data was extracted from this source only. Notable exceptions included articles where the original tool was modified to measure intersectoral collaboration. Results: A review of 650 abstracts identified 14 tools which measure intersectoral collaboration. Most of the tools were questionnaires or checklists and were created or tested in a health care setting or with health related outcomes. The tools collected information from organizations in different sectors in a number of differed ways. Distributing a questionnaire or checklist to multiple organizations to measure the perceived level of mutual collaboration was the most common way. Network analysis was also used and one tool measured intersectoral collaboration as a quadrant using a balanced scorecard approach. The variables identified to measure intersectoral collaboration include identifying “high and low structure” between partnering organizations; a low level of connectivity represented “cooperation and coordination” and a high level of connectivity represented “collaboration and consolidation”. Other variables included looking at social networks, assessing interagency linkages, measuring the depth of integration in a model of human services integration, and system integration and change. All the tools came from medium-high to high quality empirical papers where in most cases the tools were tested and the psychometric properties were reported. Only one tool came from the gray literature. Discussion: Only a small number of tools have been identified, but the diversity among these tools was substantial. Ranging from simple questionnaires to complicated network analyses a number of options were found to capture ways to measure these intersectoral relationships. Some tools not only measured intersectoral collaboration but also provided a blueprint for how to use and build collaborative relationships across health care sectors and the community. For instance, Browne’s Human Services Network Integration model and measure highlights the model and how integration between sectors can be facilitated and measured. This study has a number of strengths and limitations. The review is strengthened by its thorough methodological approach. The fact that intersectoral collaboration is one indicator domain which is a part of the larger, comprehensive knowledge synthesis allows the results to contribute to the greater picture of healthcare integration. The size of the knowledge synthesis is a strength and a limitation. Given the size of the knowledge synthesis and the breadth of the topic areas, it is possible that articles and tools may have been missed despite extensive search and review strategies. Conclusion: A lot of emphasis has been put on the importance of integrated health care systems; however, there are few ways to identify and measure indicators and outcomes related to health services integration. It is not only important to identify key dimensions or principles of integrated care but also to be able to measure progress towards these integrated systems. Intersectoral collaboration is an important indicator domain contributing to building and sustaining health care integration. Valid and reliable tools to measure collaboration are essential. As such, this knowledge synthesis provides a number of appropriate tools for users including researchers, policy- and decision-makers, and providers across a wide range of health care systems. In this study we focused on measuring the presence but not the impact of intersectoral collaboration; this is an area we hope to investigate in future research.

Introduction: Health systems integration is a cornerstone for health system reform enhancing quality of care and health outcomes. Health systems planners invest significant resources to create fully integrated health systems. However, impacts of these efforts are difficult to determine due to the lack of well-defined indicators and tools to measure progress towards integration. The goal of this study was to identify indicator domains and measurements tools to evaluate health system integration. Methods: This international knowledge synthesis utilized a modified seven-stage scoping review approach across three sites: Rio Grande do Sul, Brazil, and Alberta and British Columbia, Canada. The knowledge synthesis built on previous work of two principle investigators (NO, ES) identifying 10 key principles for integration. A group of knowledge-users were included in discussions to validate the research questions. A panel of experts, policy and decision-makers, and providers participated in a modified Delphi process to identify relevant and important indicator domains for each principle. Three rounds of Delphi surveys were completed in English and Portuguese. Potential tools and measures for each indicator domain were identified using inclusion/exclusion criteria applied to peer-reviewed and targeted grey literature sources. Relevancy and quality were assessed using standardized tools. Data are being extracted, collated, and summarized with a final report to be completed summarizing all significant tools and measures. Results: The Delphi process identified 16 indicator domains for nine of the ten principles. Domains included: coordinated transitions across the continuum of care; coordinated care across sectors; patient/family involvement in care planning; primary care network structures in place; team effectiveness; shared clinical pathways across the continuum of care; individualization of care pathways for patients with co-morbidities; performance measurement indicators and tools in place; clinical outcomes measured; data (e.g., administrative, performance, clinical) tracked and shared with stakeholders; shared information systems across sectors; shared patient electronic charts accessible to patients; data used for service planning; organizational goals and objectives aligned across sectors; physician integration within care teams; and goals and objectives supported by funding and human resources. No agreement was achieved by the Delphi participants on indicator domains for principle 9, governance structure. To capture tools or measures related to two or more domains an eleventh principle, overall integration, was added. To date we have reviewed over 5500 abstracts across the 16 indicator domains. Over 115 tools have been identified for such domains as transitions in care, patient focus, intersectoral collaboration, and the use of shared clinical pathways. Where tools were not appropriate, measurement approaches and gaps in evaluation strategies have been identified. Once the literature review has been completed in its entirety we anticipate a comprehensive set of tools and measures for the indicator domains of the principles of health systems integration. Discussion: Availability of high quality tools and measurement approaches for indicator domains varies. Some domains are more developed, such as coordinated transitions, where a large number of high quality tools have been identified. For other domains, there is a need to develop high quality tools. Tools of medium or low quality require refinement through further validity and reliability testing to assess their potential to measure domains of integration. For domains where tools were not located approaches to measure these domains require further development. For Principle 9, governance structure, the relevance of the principle to health system integration needs to be examined. Strengths of the study include the use of the Delphi process to identify indicator domains for each of the principles by stakeholders and the thorough systematic review process conducted for each domain. Several challenges were also experienced. The Delphi process used an online survey approach; synchronous or asynchronous discussion between participants was not completed. The identification of appropriate search terms for some domains was challenging due to the variation of terms and conceptualizations used in the integration literature. Multiple searches were required to ensure the focus of the search terms were appropriate for each domain. Conclusion: This knowledge synthesis is the first of its kind to provide a comprehensive set of tools and measures to evaluate health systems integration. The tools to measure indicator domains of integration and overall integration will provide beneficial information to policy-makers, decision-makers, and providers across a variety of health care systems internationally. Key areas for future research include: testing of tools and measures to ensure high quality tools to measure all aspects of integration; the development of further tools to measure less developed aspects of integration; and translation and validity testing of tools in different languages.