Adaptation and standardization of integrated care practices to facilitate scale-up and spread: Insights from Ontario case studies

Abstract

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 scale-up 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. Discussion/Conclusions/Lessons Learned: This presentation outlines the challenges for scale-up and spread, and the methods used in the workshop to assess the desired degree of standardization/adaptation for approximately 50 key activities. The variation in views between roles and between organizations offers an expanded perspective on spread and scale-up. The implication of these findings for implementation strategies is explored using feedback from leaders across established and new sites of integrated care. Clarification of which elements of integrated care should be more standardized and which left open to more local design may contribute to more effective implementation, supporting effective scale-up and spread. Differences in perspectives on standardization may also identify critical implementation challenges. Limitations and suggestions for future research: Our current project is focused on assessing standardization and adaptation in one setting; future workshops will be held in other settings. Comparison of these results will provide insights on the extent to which decisions on standardization are generalizable or context-dependent. Decisions on implementation strategies that reflect results from this research will be tracked as part of our ongoing project.