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1.  Structuration theory: open the black box of integrated care 
The health care system is in transition. Integrated cares solutions are prominent and even forced by health care policy. But how can we understand the needs of different stakeholders in this system? Why do they still not act effectively and efficiently together? A closer look, using the structuration theory of Anthony Giddens, may be helpful.
The theory of structuration enables people to explain social interactions. As this is a matter of fact, the health care system was analyzed by the author in her habilitation thesis. The focus of the study laid on the effective and efficient care of the very old people in Germany. The structuration theory was presented, and as an example of practical translation of the theory, the implementation of the ‘Pflegestützpunkte’ (service point for care) was described.
Giddens' structuration theory is on the one hand complex in theory, and simple on the other hand in practice. Choosing the paradigm may be helpful to explain the motivation of the different stakeholders in the health care system. It would be necessary to create a suitable questionnaire, to get deeper insight in how the different actors in the system act and react. Such a questionnaire should be based on Giddens' theory. The following three dimensions are needed: structure (including domination, legitimation, and signification), interaction (including power, sanctioning, and communication) and modality/duality (including instruments of power, norms and interpretation).
PMCID: PMC2807077
structuration theory
2.  Why integrated care? Conclusions from an international expert survey 
Exploring the indicators most crucial for actors in health and social care services and identifying those which lead up to the initiation and implementation of integrated care. By analysing the reasons why integrated care is chosen and initiated, the underlying mechanisms and decision-making processes of integrated care are highlighted.
Even though integrated care projects and programmes are implemented in very different settings and health systems one can find the same main actors everywhere. They share similar goals and principles which are universal and not unique to one specific country or system. Hence, it is likely that the type of actor, i.e. health insurance, is more influential on the decision-making process than the health system and surrounding setting. In other words, it was stipulated that a health insurer in the Netherlands will have similar priorities for integrated care as a health insurer in Singapore and hence will choose similar integrated care approaches.
On the other hand, system administrators can strongly incentivise or discourage innovation and cooperation within the health and social care dominions, i.e. by passing laws or (re)organising the financing system. It is suggested that integrated care is implemented more widely in countries where stakeholders receive targeted incentives and fragmentation within the system is less pronounced.
The hypotheses were tested using an international expert questionnaire, contacting integrated care managers and decision-makers in Europe, North America and Australasia. The results were quantitatively analyzed using SPSS.
Results and conclusions
Integrated care is stipulated to offer solutions to the demographic changes, the concurring increase of chronic disease and the pressures on restricted resources experienced in the modern health systems of today. The survey conducted suggested a more diversified picture regarding the expectations and priorities set into the concept by health care decision-makers. While all of these challenges are perceived by them, their undisputed priority is on the introduction and enhancement of management structures on all levels. They do not value financial restrictions as severely as may have been anticipated and they revealed that neither active patient participation nor the introduction of outcome measurement are high priorities when introducing integrated care. The findings also suggest that the same stakeholders follow similar priorities disregarding the different health systems they act in.
In conclusion, two levels of priority setting have been identified as highly important for integrated care initiation: on the policy level, prioritisation of integrated care along with specific promotion measures influence decision-making; on the organisational level, the need for clear structures and better management tools both in the organisation itself and in the management of the targeted patient population, reflect the highest priorities for the decision-making process.
The response rate was 18% with the majority of responses coming from Germany, The Netherlands, UK and the USA.
Integrated care has come a long way from the first projects implemented by health insurance organisations to a colourful array of projects and permanent programmes, spanning from local to national level and from very targeted to very broad inclusion criteria, initiated, owned and financed by a mix of all stakeholders and agents in the system. Hence, integrated care developed into a ‘Jack-of-all-trades’ approach, stimulating change and confusion at the same time. Still, in most countries, it has not entered mainstream health care organisation and management and continues to struggle in proving its value. Asking why integrated care is initiated and implemented in the first place helps understand the priorities and objectives of decision-makers in health care, and hence can lead to a more targeted development and application of integrated care models.
PMCID: PMC3184810
decision-making; priority setting in integrated care; stakeholder-specific differences
3.  The path dependency theory: analytical framework to study institutional integration. The case of France 
The literature on integration indicates the need for an enhanced theorization of institutional integration. This article proposes path dependence as an analytical framework to study the systems in which integration takes place.
PRISMA proposes a model for integrating health and social care services for older adults. This model was initially tested in Quebec. The PRISMA France study gave us an opportunity to analyze institutional integration in France.
A qualitative approach was used. Analyses were based on semi-structured interviews with actors of all levels of decision-making, observations of advisory board meetings, and administrative documents.
Our analyses revealed the complexity and fragmentation of institutional integration. The path dependency theory, which analyzes the change capacity of institutions by taking into account their historic structures, allows analysis of this situation. The path dependency to the Bismarckian system and the incomplete reforms of gerontological policies generate the coexistence and juxtaposition of institutional systems. In such a context, no institution has sufficient ability to determine gerontology policy and build institutional integration by itself.
Using path dependence as an analytical framework helps to understand the reasons why institutional integration is critical to organizational and clinical integration, and the complex construction of institutional integration in France.
PMCID: PMC2916113  PMID: 20689740
integrated care; institutional integration; path dependence; gerontology
4.  Study of the composition of the various forms of coordination in the case management practice 
In 2004, Quebec’s Health and Social Care Ministry implemented an integrative reform aiming to systematize coordination which employed prescriptive devices. The will to systematize coordination practices is supported by formal coordination devices, such as case management. However, many obstacles lay in the path of these devices’ usage.
This presentation is based on Boltanski and Thévenot’s (1991) theory of conventions. This theory was utilized to analyze the operations that lead to the convened agreements which serve coordination in its formal and emergent aspects.
We utilized a qualitative and exploratory embedded case study design in which we employed three data collection and analysis methods: a documentary analysis of the integrative prescriptions, interviews aiming to make explicit the concrete coordination practices and direct observation of professional practices.
Results and conclusions
We identified different types of coordination systems in case management practices. Notably, the so-called ‘peri-professional’ system that grants the family caregivers the role of intermediate between the frail elder and the health and social care network, as well as the so-called ‘virtual’ system produced by the technological means of the computerized clinical files.
PMCID: PMC3031801
case management; coordination
5.  Health and social services integration in the Veneto Region 
Veneto Region is currently achieving the integration of health and social services by integrating the tele-surveillance (detection of emergencies) already provided to ‘socially frail’ people with tele-monitoring, addressed to patients affected by chronic diseases.
This strategy is guided by the idea that a better integration between the different levels of assistance is capable of improving the quality and continuity of care and generating synergies that benefit the healthcare system both by enhancing coordination of efforts and by reducing costs.
The strategy employs a unique call center at Regional level, that currently performs tele-surveillance services (a social service) originally targeted to ‘socially frail’ people and a more complete tele-monitoring service for chronic patients, thus integrating health and social services. Tele-monitoring consists in the remote measurement of vital parameters (controlled by physicians), and the management of emergencies.
Results and conclusions
This approach to the integration of different assistance levels is being put to the test in the context of the RENEWING HEALTH European Project. The project will assess the services using a multidisciplinary HTA methodology thus providing reliable evidence on the effectiveness and cost-effectiveness on the large-scale implementation of this kind of service.
PMCID: PMC3617744
telemonitoring; chronic diseases; frail people; social and health services integration
6.  Ten years of integrated care: backwards and forwards. The case of the province of Québec, Canada 
International Journal of Integrated Care  2011;11(Special 10th Anniversary Edition):e004.
Québec’s rapidly growing elderly and chronically ill population represents a major challenge to its healthcare delivery system, attributable in part to the system’s focus on acute care and fragmented delivery.
Description of policy practice
Over the past few years, reforms have been implemented at the provincial policy level to integrate hospital-based, nursing home, homecare and social services in 95 catchment areas. Recent organizational changes in primary care have also resulted in the implementation of family medicine groups and network clinics. Several localized initiatives were also developed to improve integration of care for older persons or persons with chronic diseases.
Conclusion and discussion
Québec has a history of integration of health and social services at the structural level. Recent evaluations of the current reform show that the care provided by various institutions in the healthcare system is becoming better integrated. The Québec health care system nevertheless continues to face three important challenges in its management of chronic diseases: implementing the reorganization of primary care, successfully integrating primary and secondary care at the clinical level, and developing effective governance and change management.
Efforts should focus on strengthening primary care by implementing nurse practitioners, developing a shared information system, and achieving better collaboration between primary and secondary care.
PMCID: PMC3111887  PMID: 21677842
integrated care; health care system; chronic disease; health policy; Quebec/Canada
7.  Developing integrated health and social care services for older persons in Europe 
This paper is to distribute first results of the EU Fifth Framework Project ‘Providing integrated health and social care for older persons—issues, problems and solutions’ (PROCARE— The project's first phase was to identify different approaches to integration as well as structural, organisational, economic and social-cultural factors and actors that constitute integrated and sustainable care systems. It also served to retrieve a number of experiences, model ways of working and demonstration projects in the participating countries which are currently being analysed in order to learn from success—or failure—and to develop policy recommendations for the local, national and European level.
The paper draws on existing definitions of integrated care in various countries and by various scholars. Given the context of an international comparative study it tries to avoid providing a single, ready-made definition but underlines the role of social care as part and parcel of this type of integrated care in the participating countries.
The paper is based on national reports from researchers representing ten organisations (university institutes, consultancy firms, research institutes, the public and the NGO sector) from 9 European countries: Austria, Denmark, Finland, France, Germany, Greece, Italy, the Netherlands, and the UK. Literature reviews made intensive use of grey literature and evaluation studies in the context of at least five model ways of working in each country.
As a result of the cross-national overview an attempt to classify different approaches and definitions is made and indicators of relative importance of the different instruments used in integrating health and social care services are provided.
The cross-national overview shows that issues concerning co-ordination and integration of services are high on the agenda in most countries. Depending on the state of service development, various approaches and instruments can be observed. Different national frameworks, in particular with respect to financing and organisation, systemic development, professionalisation and professional cultures, basic societal values (family ethics), and political approaches have to be taken into account during the second phase of PROCARE during which transversal and transnational analysis will be undertaken based on an in-depth analysis of two model ways of working in each country.
Far from a European vision concerning integrated care, national health and social care systems remain—at best—loosely coupled systems that are facing increasing difficulties, given the current challenges, in particular in long-term care for older persons: increasing marketisation, lack of managerial knowledge (co-operation, co-ordination), shortage of care workers and a general trend towards down-sizing of social care services continue to hamper the first tentative pathways towards integrated care systems.
PMCID: PMC1393267  PMID: 16773149
health and social care; integrated service delivery; older persons in need of care; European overview
8.  From organizational integration to clinical integration: analysis of the path between one level of integration to another using official documents 
Services’ integration comprises organizational, normative, economic, informational and clinical dimensions. Since 2004, the province of Quebec has devoted significant efforts to unify the governance of the main health and social care organizations of its various territories. Notwithstanding the uniformity of the national plan’s prescription, the territorial integration modalities greatly vary across the province.
This research is based upon a conceptual model of integration that comprises six components: inter-organizational partnership, case management, standardized assessment, a single entry point, a standardized service planning tool and a shared clinical file.
We conducted an embedded case study in six contrasted sites in terms of their level of integration. All documents prescribing the implementation of integration were retrieved and analyzed.
Results and conclusions
The analyzed documents demonstrate a growing local appropriation of the current integrative reform. Interestingly however, no link seems to exist between the quality of local prescriptions and the level of integration achieved in each site. This finding leads us to hypothesize that the variable quality of the operational accompaniment offered to implement these prescriptions is a variable in play.
PMCID: PMC3031828
clinical integration; innovation
9.  The Chronic Care Model as vehicle for the development of disease management in Europe 
The Chronic Care Model (Wagner, WHO) aims to improve the functioning and clinical situation of chronic patients by focussing on the patient, the practice team and the conditions that determine the functioning of the team.
The patient is the most important actor who must be stimulated proactively by a competent, integrated practice team. Six interdependent conditional components are essential: health care organisation, delivery system design, community resources and policies, self-management support systems, decision support and clinical information systems.
While the Chronic Care Model focuses on quality and effectiveness of care, disease management programmes underline more the efficiency of care. These programmes apply industrial management principles in health care. Information about process, structure and outcome is gathered and used systematically and human and material sources are used efficiently.
There is evidence that the approaches of the Chronic Care Model and disease management can be integrated. Both approaches underline the need of information and focus on the patient as the main actor to improve and that a balance can be found between effectiveness and efficiency. Ideas will be given how the Chronic Care Model can be used as a framework for the development of a European way of disease management for people with a chronic condition.
PMCID: PMC2430288
chronic care model; disease management programme
10.  Forty years of integration of health and social services in the province of Québec (Canada) 
Québec is the only province in Canada to have integrated health and social services since 1971. A single ministry is responsible for health and social services and this integration is also effective at regional and local agencies. The Local Community Services Centres (Centre locaux de services communautaires—CLSC) were created to provide preventive and primary care and services for a borough in large cities, a medium-size town or many villages in a rural area. In 2003, a major reform created the Health and Social Service Centres (Centre de santé et de services sociaux—CSSS) by merging hospitals, nursing homes and CLSC in 95 areas over the province.
This structural integration has taken place at the same time that the PRISMA model of coordination-type integration for frail older people was being implemented. Integration improves efficiency of the system, but underfunding of long-term care still hampers the provision of adequate home care services. It is now time for moving the beveridge-type funding system to a long-term care public insurance covering the needs of community-dwelling older people with disabilities.
PMCID: PMC3617756
PRISMA; integrated health and social services; Canada; public insurance; long-term care; structural integration
11.  Institutional integration, health and social care policy and social welfare: an application of the ‘path dependence’ theory in France 
The PRISMA integration model is a promising method to implement integration in health and social services for elderly people. The PRISMA France study aims to investigate the implementation of this model, which relies on the establishment of advisory boards at institutional, organisational and professional levels of decision-making, in France. These boards are guided by whole systems thinking and function in a joined-up, co-ordinated manner.
A qualitative approach was adopted to study the model's implementation. Analyses were based on semi-structured interviews with actors of all levels of decision-making, observations of advisory board meetings and administrative documentations. Validity was insured by triangulation methods and content saturation.
Our analyses revealed the complexity, instability and fragmentation of the institutional governance of publics policies for elderly people. The ‘path dependence’ to the Bismarckian system and the incomplete reforms of gerontological policies generate a cohabitation of three concurrent policies (national, regional and local) and a juxtaposition of two institutional systems (health and social care policy and social welfare). In such a context, no institution possesses sufficient authority to determine gerontological policy.
In the light of these analyse, the particularly complex and time-consuming implementation of the PRISMA model in France can be better understood.
PMCID: PMC2807065
path dependency; public policies; integrated health care networks; France
12.  Mergers and integrated care: the Quebec experience 
As a researcher, I have studied the efforts to increase the integration of health and social services in Quebec, as well as the mergers in the Quebec healthcare system. These mergers have often been presented as a necessary transition to break down the silos that compartmentalize the services dispensed by various organisations. A review of the studies about mergers and integrated care projects in the Quebec healthcare system, since its inception, show that mergers cannot facilitate integrated care unless they are desired and represent for all of the actors involved an appropriate way to deal with service organisation problems. Otherwise, mergers impede integrated care by creating increased bureaucratisation and standardisation and by triggering conflicts and mistrust among the staff of the merged organisations. It is then preferable to let local actors select the most appropriate organisational integration model for their specific context and offer them resources and incentives to cooperate.
PMCID: PMC3653283  PMID: 23687474
integration; merger; health and social services; integrated care; Canada
13.  Integrated care in Eindhoven, a challenge for healthcare providers, provider organizations and patients/clients 
To share experiences by discussing the necessity, the challenges and the used (implementation) strategies on integrated care.
Integrated care and chronic care by SGE will be described. SGE delivers with 260 professionals integrated primary healthcare, based on protocols, standards and disease programs for 80,000 people. There is a formalized and structural cooperation with hospitals, their specialists, social services and other organizations.
Because half of all the people with chronic illness have multiple conditions, SGE has taken interest in changing the management of diseases, such as heart failure, COPD, diabetes, depression. Deficiencies in current management and the transformation of health care from reactive to proactive are discussed. Approaches, methods and tools used by SGE are focused on. For example: the transition with the Chronic Care Model. This model summarizes the basic elements for improving health care in health systems at the community, organizations, practice and patient levels. Issues like implementation of chronic care programs and how SGE cooperates with the Maastricht University for evaluating outcomes of effectiveness of integrated care by SGE come up for discussion.
Data source
1. Kodner DL, Spreeuwenberg C. Integrated care: meaning, logic applications and implications, a discussion paper. Int J Integr Care 2002 Oct–Dec;2:e12.
2. Glasgow RE, Davis C, Bonomi AE, Provost L, McCulloch D, Carver P, Sixta C. Quality improvement in chronic illness care: a collaborative approach. Jt Comm J Qual Improv 2001;27:63–80.
3. Pater L, Dubbeldam S, Verweijen M. Implementeren, het speelveld in de praktijk. Lemma 2005.
4. Grol R, Wensing M, Eccles M. Improving patient care, the implementation of change in clinical practice. Butterworth-Heinemann 2004.
Preliminary conclusion
The multi-problem patients do need a change in health systems. Despite everything already done, there is still a long way to go. Local, national and international collaborations and networks therefore are a must.
Is the Chronic Care Model the model to make integrated care for frail elderly, patients with chronic care or long term care needs possible? The do's and the dont's in implementing integrated care.
PMCID: PMC2807094
chronic care model; multiple conditions
14.  Prioritising integrated care initiatives on a national level. Experiences from Austria 
Introduction and background
Based on a policy initiative and the foundation of the Competence Centre for Integrated Care by the Austrian Social Security Institutions in 2006, the aim of the project was to identify and prioritise potential diseases and target groups for which integrated care models should be developed and implemented within the Austrian health system. The project was conducted as a cooperation between the Competence Centre for Integrated Care of the Viennese Health Insurance Fund and the Institute of Social Medicine of the Medical University Vienna to ensure the involvement of both, theory and practice.
Project report
The focus of the project was to develop an evidence-based process for the identification and prioritisation of diseases and target groups for integrated care measures. As there was no evidence of similar projects elsewhere, the team set out to design the prioritisation process and formulate the selection criteria based on the work in a focus group, literature reviews and a scientific council of national and international experts. The method and criteria were evaluated by an expert workshop.
The active involvement of all stakeholders from the beginning was crucial for the success. The time constraint proved also beneficial since it allowed the project team to demand focus and cooperation from all experts and stakeholders included.
Our experience demonstrates that, with a clear concept and model, an evidence-based prioritisation including all stakeholders can be achieved. Ultimately however, the prioritisation is a political discussion and decision. Our model can only help base these decisions on sound and reasonable assumptions.
PMCID: PMC2748184  PMID: 19777115
integrated care priorities; national priority setting; project management; process design; decision making
15.  Implementing a continuum of care model for older people—results from a Swedish case study 
There is a need for integrated care and smooth collaboration between care-providing organisations and professions to create a continuum of care for frail older people. However, collaboration between organisations and professions is often problematic. The aim of this study was to examine the process of implementing a new continuum of care model in a complex organisational context, and illuminate some of the challenges involved. The introduced model strived to connect three organisations responsible for delivering health and social care to older people: the regional hospital, primary health care and municipal eldercare.
The actions of the actors involved in the process of implementing the model were understood to be shaped by the actors' understanding, commitment and ability. This article is based on 44 qualitative interviews performed on four occasions with 26 key actors at three organisational levels within these three organisations.
Results and conclusions
The results point to the importance of paying regard to the different cultures of the organisations when implementing a new model. The role of upper management emerged as very important. Furthermore, to be accepted, the model has to be experienced as effectively dealing with real problems in the everyday practice of the actors in the organisations, from the bottom to the top.
PMCID: PMC3225243  PMID: 22128279
older people; continuum of care; integrated care; implementation; qualitative methods; Sweden
16.  Understanding managerial behaviour during initial steps of a clinical information system adoption 
While the study of the information technology (IT) implementation process and its outcomes has received considerable attention, the examination of pre-adoption and pre-implementation stages of configurable IT uptake appear largely under-investigated. This paper explores managerial behaviour during the periods prior the effective implementation of a clinical information system (CIS) by two Canadian university multi-hospital centers.
Adopting a structurationist theoretical stance and a case study research design, the processes by which CIS managers' patterns of discourse contribute to the configuration of the new technology in their respective organizational contexts were longitudinally examined over 33 months.
Although managers seemed to be aware of the risks and organizational impact of the adoption of a new clinical information system, their decisions and actions over the periods examined appeared rather to be driven by financial constraints and power struggles between different groups involved in the process. Furthermore, they largely emphasized technological aspects of the implementation, with organizational dimensions being put aside. In view of these results, the notion of 'rhetorical ambivalence' is proposed. Results are further discussed in relation to the significance of initial decisions and actions for the subsequent implementation phases of the technology being configured.
Theoretical and empirically grounded, the paper contributes to the underdeveloped body of literature on information system pre-implementation processes by revealing the crucial role played by managers during the initial phases of a CIS adoption.
PMCID: PMC3132703  PMID: 21682885
17.  Evaluating the successful implementation of evidence into practice using the PARiHS framework: theoretical and practical challenges 
The PARiHS framework (Promoting Action on Research Implementation in Health Services) has proved to be a useful practical and conceptual heuristic for many researchers and practitioners in framing their research or knowledge translation endeavours. However, as a conceptual framework it still remains untested and therefore its contribution to the overall development and testing of theory in the field of implementation science is largely unquantified.
This being the case, the paper provides an integrated summary of our conceptual and theoretical thinking so far and introduces a typology (derived from social policy analysis) used to distinguish between the terms conceptual framework, theory and model – important definitional and conceptual issues in trying to refine theoretical and methodological approaches to knowledge translation.
Secondly, the paper describes the next phase of our work, in particular concentrating on the conceptual thinking and mapping that has led to the generation of the hypothesis that the PARiHS framework is best utilised as a two-stage process: as a preliminary (diagnostic and evaluative) measure of the elements and sub-elements of evidence (E) and context (C), and then using the aggregated data from these measures to determine the most appropriate facilitation method. The exact nature of the intervention is thus determined by the specific actors in the specific context at a specific time and place.
In the process of refining this next phase of our work, we have had to consider the wider issues around the use of theories to inform and shape our research activity; the ongoing challenges of developing robust and sensitive measures; facilitation as an intervention for getting research into practice; and finally to note how the current debates around evidence into practice are adopting wider notions that fit innovations more generally.
The paper concludes by suggesting that the future direction of the work on the PARiHS framework is to develop a two-stage diagnostic and evaluative approach, where the intervention is shaped and moulded by the information gathered about the specific situation and from participating stakeholders. In order to expedite the generation of new evidence and testing of emerging theories, we suggest the formation of an international research implementation science collaborative that can systematically collect and analyse experiences of using and testing the PARiHS framework and similar conceptual and theoretical approaches.
We also recommend further refinement of the definitions around conceptual framework, theory, and model, suggesting a wider discussion that embraces multiple epistemological and ontological perspectives.
PMCID: PMC2235887  PMID: 18179688
18.  Grounded Theory of Barriers and Facilitators to Mandated Implementation of Mental Health Care in the Primary Care Setting 
Objective. There is limited theory regarding the real-world implementation of mental health care in the primary care setting: a type of organizational coordination intervention. The purpose of this study was to develop a theory to conceptualize the potential causes of barriers and facilitators to how local sites responded to this mandated intervention to achieve coordinated mental health care. Methods. Data from 65 primary care and mental health staff interviews across 16 sites were analyzed to identify how coordination was perceived one year after an organizational mandate to provide integrated mental health care in the primary care setting. Results. Standardized referral procedures and communication practices between primary care and mental health were influenced by the organizational factors of resources, training, and work design, as well as provider-experienced organizational boundaries between primary care and mental health, time pressures, and staff participation. Organizational factors and provider experiences were in turn influenced by leadership. Conclusions. Our emergent theory describes how leadership, organizational factors, and provider experiences affect the implementation of a mandated mental health coordination intervention. This framework provides a nuanced understanding of the potential barriers and facilitators to implementing interventions designed to improve coordination between professional groups.
PMCID: PMC3414007  PMID: 22900158
19.  Defining and Measuring the Patient-Centered Medical Home 
The patient-centered medical home (PCMH) is four things: 1) the fundamental tenets of primary care: first contact access, comprehensiveness, integration/coordination, and relationships involving sustained partnership; 2) new ways of organizing practice; 3) development of practices’ internal capabilities, and 4) related health care system and reimbursement changes. All of these are focused on improving the health of whole people, families, communities and populations, and on increasing the value of healthcare.
The value of the fundamental tenets of primary care is well established. This value includes higher health care quality, better whole-person and population health, lower cost and reduced inequalities compared to healthcare systems not based on primary care.
The needed practice organizational and health care system change aspects of the PCMH are still evolving in highly related ways. The PCMH will continue to evolve as evidence comes in from hundreds of demonstrations and experiments ongoing around the country, and as the local and larger healthcare systems change. Measuring the PCMH involves the following:Giving primacy to the core tenets of primary careAssessing practice and system changes that are hypothesized to provide added valueAssessing development of practices’ core processes and adaptive reserveAssessing integration with more functional healthcare system and community resourcesEvaluating the potential for unintended negative consequences from valuing the more easily measured instrumental features of the PCMH over the fundamental relationship and whole system aspectsRecognizing that since a fundamental benefit of primary care is its adaptability to diverse people, populations and systems, functional PCMHs will look different in different settings.Efforts to transform practice to patient-centered medical homes must recognize, assess and value the fundamental features of primary care that provide personalized, equitable health care and foster individual and population health.
Electronic supplementary material
The online version of this article (doi:10.1007/s11606-010-1291-3) contains supplementary material, which is available to authorized users.
PMCID: PMC2869425  PMID: 20467909
primary care; patient-centered medical home; measurement; quality improvement
20.  Fostering participation of general practitioners in integrated health services networks: incentives, barriers, and guidelines 
While the active participation of general practitioners (GPs) in integrated health services networks (IHSNs) plays a critical role in their success, little is known about the incentives and barriers to their actual participation.
Data were gathered through semi-structured interviews and a mail survey with GPs enrolled in SIPA (system of integrated care for older persons) at 2 sites in Montreal. A total of 61 GPs completed the questionnaire, from which 22 were randomly selected for the qualitative study, with active and non-active participation in the IHSN.
The key themes associated with GP participation were clinician characteristics, consequences perceived at the outset, the SIPA implementation process, relationships with the SIPA team and professional consequences. The incentive factors reported were collaborative practices, high rates of elderly and SIPA patients in their clienteles, concerns about SIPA, the selection of frail elderly patients, close relationships with the case manager, the perceived efficacy of SIPA, and improved professional practices. Barriers to GP participation included high expectations, GP recruitment, lack of information on SIPA, difficult relationships with SIPA geriatricians and deterioration of physician-patient relationships. Four profiles of participation were identified: 2 groups of participants active in SIPA and 2 groups of participants not active in SIPA. The active GPs were familiar with collaborative practices, had higher IHSN patient rates, expressed more concerns than expectations, reported satisfactory relationships with case managers and perceived the efficacy of SIPA. Both active and non-active GPs reported quality care in the IHSN and improved professional practice.
Throughout the implementation process, the participation of GPs in an IHSN depends on numerous professional (clinician characteristics) and organizational factors (GP recruitment, relationships with case managers). Our study provides guiding principles for establishing future integrated models of care. It suggests practical guidelines to support the active participation of GPs in these networks such as physicians with collaborative practices, recruitment of significant number of patients per physicians, the information provided and the accompaniment by geriatricians.
PMCID: PMC2664801  PMID: 19292905
21.  Translating Research into Practice: Organizational Issues in Implementing Automated Decision Support for Hypertension in Three Medical Centers 
Information technology can support the implementation of clinical research findings in practice settings. Technology can address the quality gap in health care by providing automated decision support to clinicians that integrates guideline knowledge with electronic patient data to present real-time, patient-specific recommendations. However, technical success in implementing decision support systems may not translate directly into system use by clinicians. Successful technology integration into clinical work settings requires explicit attention to the organizational context. We describe the application of a “sociotechnical” approach to integration of ATHENA DSS, a decision support system for the treatment of hypertension, into geographically dispersed primary care clinics. We applied an iterative technical design in response to organizational input and obtained ongoing endorsements of the project by the organization's administrative and clinical leadership. Conscious attention to organizational context at the time of development, deployment, and maintenance of the system was associated with extensive clinician use of the system.
PMCID: PMC516243  PMID: 15187064
22.  The Population Health Approach: health GIS as a bridge from theory to practice 
The Population Health Approach, proposed by Health Canada, is the articulation of a long advocated model of human health. This approach strives to ensure that the health system is appropriately oriented to improve health status by applying evidence based practices across the continuum from health determinants to service interventions. Although conceptually appealing, it has been difficult to implement widely in the existing program-based health care system. The Population Health Surveillance Unit (PHSU) of the Vancouver Island Health Authority (VIHA) has developed a health geographical information system (HGIS), where GIS is used as both platform for information integration and as an analytical tool supporting comprehensive data analysis. With the assistance of the HGIS, the theory of the population health approach can be transformed into a practical, stepwise process supporting health services and program planning.
Three important components of a health service planning and evaluation framework grounded in population health theory are described in this article. In particular, a stepwise methodological process to enable the incorporation of the principles of a population health into practical applications is presented; the technical functionality to integrate multiple sources of information, with different levels and scales is discussed; and sources of information about the health of the population at the appropriate level to populate this frame are proposed. An application of the methodology in the planning of health services for a high needs neighbourhood is presented as an illustrative example.
The population health approach incorporates the consideration of health determinants and the context within which the health conditions arise in communities. The complexity of these relationships requires the application of innovative methodologies such as Health GIS to frame the issues practically. A population health based foundation for the planning and evaluation of health services can now move from theory to practice.
PMCID: PMC1274340  PMID: 16209717
Community Health Planning; Needs Assessment; Public Health Informatics; Medical Geography; Geographic Information Systems
23.  Institutionalization of evidence-informed practices in healthcare settings 
The effective and timely integration of the best available research evidence into healthcare practice has considerable potential to improve the quality of provided care. Knowledge translation (KT) approaches aim to develop, implement, and evaluate strategies to address the research-practice gap. However, most KT research has been directed toward implementation strategies that apply cognitive, behavioral, and, to a lesser extent, organizational theories. In this paper, we discuss the potential of institutional theory to inform KT-related research.
Despite significant research, there is still much to learn about how to achieve KT within healthcare systems and practices. Institutional theory, focusing on the processes by which new ideas and concepts become accepted within their institutional environments, holds promise for advancing KT efforts and research. To propose new directions for future KT research, we present some of the main concepts of institutional theory and discuss their application to KT research by outlining how institutionalization of new practices can lead to their ongoing use in organizations. In addition, we discuss the circumstances under which institutionalized practices dissipate and give way to new insights and ideas that can lead to new, more effective practices.
KT research informed by institutional theory can provide important insights into how knowledge becomes implemented, routinized, and accepted as institutionalized practices. Future KT research should employ both quantitative and qualitative research designs to examine the specifics of sustainability, institutionalization, and deinstitutionalization of practices to enhance our understanding of these complex constructs.
PMCID: PMC3520843  PMID: 23171660
24.  Chiropractic physicians: toward a select conceptual understanding of bureaucratic structures and functions in the health care institution 
The purpose of this article is to present select concepts and theories of bureaucratic structures and functions so that chiropractic physicians and other health care professionals can use them in their respective practices. The society-culture-personality model can be applied as an organizational instrument for assisting chiropractors in the diagnosis and treatment of their patients irrespective of locality.
Society-culture-personality and social meaningful interaction are examined in relationship to the structural and functional aspects of bureaucracy within the health care institution of a society. Implicit in the examination of the health care bureaucratic structures and functions of a society is the focus that chiropractic physicians and chiropractic students learn how to integrate, synthesize, and actualize values and virtues such as empathy, integrity, excellence, diversity, compassion, caring, and understanding with a deep commitment to self-reflection.
It is essential that future and current chiropractic physicians be aware of the structural and functional aspects of an organization so that chiropractic and other health care professionals are able to deliver care that involves the ingredients of quality, affordability, availability, accessibility, and continuity for their patients.
PMCID: PMC3342833  PMID: 22693481
Chiropractic; Sociology
25.  A Complex, Nonlinear Dynamic Systems Perspective on Ayurveda and Ayurvedic Research 
The fields of complexity theory and nonlinear dynamic systems (NDS) are relevant for analyzing the theory and practice of Ayurvedic medicine from a Western scientific perspective. Ayurvedic definitions of health map clearly onto the tenets of both systems and complexity theory and focus primarily on the preservation of organismic equanimity. Health care research informed by NDS and complexity theory would prioritize (1) ascertaining patterns reflected in whole systems as opposed to isolating components; (2) relationships and dynamic interaction rather than static end-points; (3) transitions, change and cumulative effects, consistent with delivery of therapeutic packages in the reality of the clinical setting; and (4) simultaneously exploring both local and global levels of healing phenomena. NDS and complexity theory are useful in examining nonlinear transitions between states of health and illness; the qualitative nature of shifts in health status; and looking at emergent properties and behaviors stemming from interactions between organismic and environmental systems. Complexity and NDS theory also demonstrate promise for enhancing the suitability of research strategies applied to Ayurvedic medicine through utilizing core concepts such as initial conditions, emergent properties, fractal patterns, and critical fluctuations. In the Ayurvedic paradigm, multiple scales and their interactions are addressed simultaneously, necessitating data collection on change patterns that occur on continuums of both time and space, and are viewed as complementary rather than isolated and discrete. Serious consideration of Ayurvedic clinical understandings will necessitate new measurement options that can account for the relevance of both context and environmental factors, in terms of local biology and the processual features of the clinical encounter. Relevant research design issues will need to address clinical tailoring strategies and provide mechanisms for mapping patterns of change that account for the contiguous, self-replicating, cumulative, and synergistic theories associated with successful Ayurvedic treatment approaches.
PMCID: PMC3405450  PMID: 22830972

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