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A framework approach to enable local leaders integrate care for older persons: moving from the ‘what’ to the ‘how’

Authors:Patrick John Harnett

Abstract The aging population is a healthcare ‘game changer’ (1,2,3) Multi-morbidities increase with age and in turn require more resource (4,5,6). Integrated care is proposed as a key component of addressing this policy challenge, (7,8,9,10). There is growing evidence on ‘what works’ in integrating and improving care for older persons (11,12,13,1415,16,17), but how best to implement this systemically, beyond local initiatives is less clear (18,19).Large change initiatives are typically centrally defined, ‘policy heavy’ and overly programmatic, whilst emergent (‘bottom up’) approach have inherent weaknesses due to problems of fidelity and consistency when deployed systemically. In the messy reality of increasingly pressurised health care environments, the clinical and managerial leaders tasked with delivering these change are doing so as an ‘add on’ to their normal operational or clinical role. The role and influence of political ideology, professional groups and organisational complexity has challenged contemporary approaches to improvement. A critical starting point is to recognise the context for implementation as that of a complex adaptive system and to ensure the methodology associated with design and implementation of integrated care recognises this (20, 21, 22, 23). In recognition of this dynamic, this paper proposes a rationale for adopting a framework approach to implementing integrated care and in doing so seeks to bridge the ‘implementation gap’ (24, 25, 26).References:1- Bloom, D., Chatterji, S., Kowal, P., Lloyd-Sherlock, P., McKee, M., Rechel, B. Rosenberg, L.Smith ,J., Macroeconomic implications of population ageing and selected policy responses, The Lancet, 2014;385(9968):577-662.2- Prince,M., Wu, F., Guo, Y., Gutierrez Robledo, L., O’Donnell, M., Sullivan, R., Yusuf, S., The burden of disease in older people and implications for health policy and practice, The Lancet, 2014;385(9968):549-562.3- Oliver D, Foot C, Humphries R. Making our health and care systems fit for an ageing population. London, UK: King’s Fund. 2014.4- arnett, K. Mercer, SW. Norbury,M. Watt, G. Wyke, S. Guthrie, B. Epidemiology of multi-morbidity and implications for health care, research, and medical education: a cross-sectional study. Lancet , jul 7. 2012;380(9836):37-435- HSE. National Service Plan, 2015. available from: (accessed 4.6.15)6- Blumenthal, D. Chernof, B. Fulmer, T. Lumpkin, J. Selberg, J. (2016) Caring for High-Need, High-Cost Patients An Urgent Priority, N Engl J Med 2016;375:909-911.7- Minkman, M. Integrated care in the Netherlands, (EU Observatory on Health Systems summer school). 20158- Hendry, A. (2013) Reshaping care pathways for older people, JIT Scotland, Conference presentation, May 2013.9- Wodchis, W. Dixon, A. Anderson, G. Goodwin, G. Integrating care for older people with complex needs: key insights and lessons from a seven-country cross-case analysis, International Journal of Integrated Care, 15,6,10- Kodner, D. All together now. A conceptual Exploration of integated care. Healthcare Quarterly. Special issue, Volume 13. 2009.11- Parker SG, Peet SM, McPherson A, Cannaby AM, Abrams K, Baker R, Wilson A, Lindesay J, Parker G, Jones DR. A systematic review of discharge arrangements for older people. Health Technology Assessment. 2002;6(4):1–183.12- Stewart MJ, Georgiou A, Westbrook JI. Successfully integrating aged care services: a review of the evidence and tools emerging from a long-term care program. Int J Integr Care. 2013. Feb 22;13: Jan-Mar.13- Bodenheimer, T Berry-Millet, R, Care Management of Patients with Complex Health Care Needs, Research Synthesis Report No. 19 (Princeton, N.J.: Robert Wood Johnson Foundation, Dec. 200914- C. Boult, A. F. Green, L. B. Boult et al, “Successful Models of Comprehensive Care for Older Adults with Chronic Conditions: Evidence for the Institute of Medicine’s ‘Retooling for an Aging America’ Report,” Journal of the American Geriatrics Society, Dec. 2009;57(12):2328–37.15- RAND Europe. Evaluation of Integrated Care Pilots. Available at: (accessed on 8 November 2010). 201016- Shepperd S, McClaran J, Phillips CO, Lannin NA, Clemson LM, McCluskey A,Cameron ID, Barras SL. ‘Discharge planning from hospital to home (Cochrane Review)’. Cochrane Database of Systematic Reviews, issue 1. 2010.17- Philip, A. Mills, K. Long, J. Thanvi, B. Ghosh, K. Reducing hospital bed use by frail older people: results from a systematic review of the literature, International journal of integrated care, 13,4, 2013.18- Best, A., Greenhalgh, T., Lewis, S., Saul, J.E., Carroll, S. and Bitz, J., ‘Large-System Transformation in Health Care: A Realist Review’, Milbank Quarterly, 2012:90(3):421–456.19- Greenhalgh, T., MacFarlane, F., Barton-Sweeney, C. and Woodard, F. If We Build It, Will It Stay?’ A Case Study of the Sustainability of Whole-System Change in London’, Milbank Quarterly, 2012;90:516–547.20- Benson, H., ‘Chaos and complexity: applications for healthcare quality and patient safety’, Journal of Healthcare Quality, 2005;27(5):4–10.21- Booth, B.J., Zwar, N. and Harris, M.F., ‘Healthcare improvement as planned system change or complex responsive processes? A longitudinal case study in general practice’, BMC Family Practice, 2013;14:51–62.22- Benson, H., ‘Chaos and complexity: applications for healthcare quality and patient safety’, Journal of Healthcare Quality, 2005;27(5);4–10.23- Dixon-Woods, M. Bosk, C.L., Aveling, E.L. Goeschel, C.A. and Pronovost , P.J., ‘Explaining Michigan: Developing an Ex Post Theory of a Quality Improvement Program’, Milbank Quarterly, 2011b;89(2):167–205.24- Valentijn, P. Biermann, C. Bruijnzeels, M. Value based integrated (renal) care: Setting a development agenda for research and implementation strategies. BMC Health Services Research, 2016;16:330.25- Ovretveit, J., ‘Understanding the conditions for improvement: research to discover which context influences affect improvement success’, BMJ Qual Saf.; 2011. p. 20.26- Massoud, R. Barry, D. Murphy, A. Albrecht, Y. Sax, S. Parchman, M. How do we learn about improving healthcare, the call for a new epistemological paradigm. International Joural for Quality In Healthcare, April, 2016. p. 1-5.


aging population, policy challenge, complex adaptive system, implementation gap

How to Cite:

Harnett PJ. A framework approach to enable local leaders integrate care for older persons: moving from the ‘what’ to the ‘how’. International Journal of Integrated Care. 2017;17(5):A104.

DOI: on 17th October 2017