Understanding new models of integrated care: a systematic review examining pathways of change, outcomes and impacts

Introduction: The UK National Health Service has been challenged to adopt new, integrated models of service delivery that are tailored to local populations. Learning from the UK and international literature is needed in order to support the development and implementation of these new models of integrated care. Methods: The study carried out a systematic review of available evidence on integrated care since 2006, to enhance understanding of the mechanisms whereby new models of integrated care impact on healthcare outcomes. The study combined rigorous and systematic methods for identification of literature, together with innovative methods for synthesis and presentation of findings. We searched electronic databases to identify studies of relevance. In addition we searched relevant websites, screened reference lists, and carried out citation searching on a previous review. Searches were undertaken in October 2016 to March 2017 in databases including: MEDLINE; Embase; PsycINFO; CINAHL. Evidence identified via these sources was synthesised in a number of ways. Data were used to develop an evidence-based logic model outlining the pathway from interventions to impacts We also examined the strength of evidence for process changes, outcomes and impacts via a comparative four item rating system of stronger, weaker, inconclusive, or insufficient evidence. Results: We included 267 studies in the review. The findings detail the complex pathway from new models to impacts, with evidence outlined regarding elements of integrated care, reported targets for change, changes in process, influencing factors, service-level outcomes, and system-wide impacts. A number of positive process changes were reported such as improved flow of care and better sharing of knowledge, although increased practitioner time was a potential adverse outcome. There was evidence of positive outcomes in terms of increase in: perceived quality of care; patient satisfaction; and access to care, although the evidence regarding wider impacts on the care system was inconclusive.There was an indication that new models have particular potential with patients who have complex needs. Discussion: While some stronger evidence of posiitive effects was apparent, evidence was inconsistent regarding many outcomes, and regarding system-wide impacts. There is evidence that new models of integrated care may have positive effects in terms of improvements in some processes of care delivery, enhanced patient satisfaction and improved access however, the evidence regarding other outcomes is currently inconsistent. Lessons learned: A wide range of factors potentially influencing outcomes are reported which require consideration in planning, implementation, evaluation and sustainability. Limitations: The diverse study populations and interventionsn precluded statistical summary of effectiveness. Defining new models of integrated care is challenging, with potential for our study to have excluded potentially relevant literature due to use of varyng terms and definitions. Suggestions for future research: We identified a need for research to more clearly link particular elements of integrated care to outcomes. Currently much of the research evidence comes from studies in older adults. There is a need for further research to explore the potential for new models of care to impact on the care for other patient groups.