What Works in Integrated Care Programs for Older Adults with Complex Needs? A Realist Review

Abstract

Introduction: Integrated healthcare models are increasingly being implemented to reduce health system fragmentation and costs related to high service utilization through increased community intervention (e.g., home care) for populations with complex care needs like older adults. These models are intended to increase coordination of the healthcare system, and improve the patient and caregiver experience. However, these models have returned mixed results and the context and mechanisms of integrated care programs have not yet been established. We conducted a realist review of the evaluative evidence on integrated care programs for older adults to identify key processes that lead to the success or failure of these programs in achieving outcomes such as reduced healthcare utilization, improved patient health, and improved patient and caregiver experience. Theory and Methods: The realist review method sought to identify the relationship between program mechanism, context and outcomes, through processes of initial theory-building, literature search, extraction, quality appraisal and synthesis. Initial theories guiding the review included trust in multidisciplinary team relationships, organizational readiness, and the role of leadership to establish an organizational culture receptive to integrated care programs. We searched for international academic literature in 12 indexed, electronic databases and grey literature through internet searches, to identify evaluative studies on integrated care programs for older adults, published between January 1980 and July 2015, in English. Results: A total of 65 articles, representing 28 integrated care programs, were included in the review. We identified two context-mechanism-outcome configurations (CMOcs): 1) trusting multidisciplinary team relationships, and 2) provider commitment to and understanding of the model. Discussion and Lessons Learned: The review emphasizes the importance of trusting multi-disciplinary team relationships for processes of effective communication and knowledge sharing, and for program success. Contextual factors such as strong leadership that sets clear goals and establishes an organizational culture in support of the program, along with joint governance structures, supported team collaboration and subsequent successful implementation. Furthermore, provider commitment to and understanding of the model (organizational readiness), as fostered by strong leadership, clear governance, time to build an infrastructure to implement and flexibility in implementation, emerged as key processes instrumental to success of these programs. Limitations: In general, published evaluations do not provide detailed information on mechanisms and contextual factors that drive program success or failures, which limits reviewers’ ability to fully identify these processes. Suggestions for future research: This review included a wide range of international evidence, and identified key processes for successful implementation of integrated care programs that should be considered by program planners, leaders and evaluators.