Drivers of successful implementation of integrated care for multi-morbidity: Mechanisms identified in 17 case studies from 8 European countries

Willemijn Looman,Verena Struckmann,Mirjana Huic,Roland Bal,Janos Pitter,Jonathan Stokes,Julia Köppen,Maureen Rutten-Van Mölken,Sabine Ruths,Erik Baltaxe,Thomas Czypionka

doi:10.1016/j.socscimed.2021.113728

Abstract

This paper provides a deeper understanding of the mechanisms underlying implementation strategies for integrated care. As part of the SELFIE project, 17 integrated care programmes addressing multi-morbidity from eight European countries were selected and studied. Data was extracted from ‘thick descriptions’ of the 17 programmes and analysed both inductively and deductively using implementation theory. The following ten mechanisms for successful implementation of integrated care were identified. With regards to service delivery, successful implementers (1) commonly adopted an incremental growth model rather than a disruptive innovation approach, and found (2) a balance between flexibility and formal structures of integration. For leadership & governance, they (3) applied collaborative governance by engaging all stakeholders, and (4) distributed leadership throughout all levels of the system. For the workforce, these implementers (5) were able to build a multidisciplinary team culture with mutual recognition of each other's roles, and (6) stimulated the development of new roles and competencies for integrated care. With respect to financing, (7) secured long-term funding and innovative payments were applied as means to overcome fragmented financing of health and social care. Implementers emphasised (8) the implementation of ICT that was specifically developed to support collaboration and communication rather than administrative procedures (technology & medical devices), and (9) created feedback loops and a continuous monitoring system (information & research). The overarching mechanism was that implementers (10) engaged in alignment work across the different components and levels of the health and social care system. These evidence-based mechanisms for implementation are applicable in different local, regional and national contexts.

Highlights

The WHO has reinforced the importance of integrated care in its worldwide call for people-centred and integrated health services (WHO, 2015)
It remains largely unclear which implementation strategies contribute to successful upscaling and sustainable integrated care programmes that are structurally embedded in the health and social care system
We identified ten mechanisms of implementation, nine of which were primarily linked to the six components of the SELFIE framework and one of which was an overarching strategy

Summary

Introduction

The WHO has reinforced the importance of integrated care in its worldwide call for people-centred and integrated health services (WHO, 2015). Integrated care is the structured effort to provide coordinated, pro-active, person-centred, multidisciplinary care by two or more communicating and collaborating care providers that may work at the same organisation or different organisations, either within the healthcare or across the health, social, or community care sectors (including informal care) (Leijten et al, 2018) Even though it is increasingly perceived as a promising solution for addressing the complex care needs of people with multi-morbidity, integrated care is complex and involves overcoming many barriers in the fragmented health and social care systems (Valentijn et al, 2013). More insight is required into the working mechanisms of integrated care and the actual strategies that contribute to successful implementation, preferably substantiated by implementa tion theory (Goodwin, 2017; WHO, 2015)

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