The Generation of Integration: The Early Experience of Implementing Bundled Care in Ontario, Canada

• Published in: The Milbank quarterly Vol. 96; no. 4; pp. 782 - 813
• Main Authors: EMBULDENIYA, GAYATHRI, KIRST, MARITT, WALKER, KEVIN, WODCHIS, WALTER P.
• Format: Journal Article
• Language: English
• Published: United States Wiley Subscription Services, Inc 01.12.2018; Blackwell Publishing Ltd; John Wiley and Sons Inc
• Subjects: Biomedical technology; bundled care; Bundling; Care coordinators; Collaboration; Communities; Content analysis; Coordinators; Early experience; Funding; Group facilitation; Health care; Health care delivery; Health care expenditures; Health care organizations; Health care payments; Health care policy; Home care services; Implementation; Information sharing; Integrated care; integrated funding models; Integration; Integrative medicine; Interagency collaboration; Interdisciplinary aspects; Interest groups; Interorganizational relations; Interorganizational relationships; mechanisms of health care integration; Original Scholarship; Partnerships; Patients; Physicians; Policy making; Production; Qualitative research; Stakeholders; Trustworthiness; Canada; Ontario Canada; bundled care; integrated funding models; mechanisms of health care integration
• ISSN: 0887-378X; 1468-0009; 1468-0009
• DOI: 10.1111/1468-0009.12357

Context: By bundling services and encouraging interprofessional and interorganizational collaboration, integrated health care models counter fragmented health care delivery and rising system costs. Building on a policy impetus toward integration, the Ministry of Health and Long-Term Care in the Canadian province of Ontario chose 6 programs, each comprising multiple hospital and community partners, to implement bundled care, also referred to as integrated-funding models. While research has been conducted on the facilitators and challenges of integration, there is less known about how integration is generated. This article explores the generation of integration through the dynamic interplay of contexts and mechanisms and of structures and subjects. Methods: For this qualitative study, we conducted 48 interviews with program stakeholders, from organization leaders and managers to physicians and integrated care coordinators, across the hospital-community spectrum. We then used content analysis to explore the extent to which themes were shared across programs and to identify idiosyncrasies, followed by a realist evaluation approach to understand how integration was produced in structural and everyday ways in local program contexts. Findings: Integration was generated through the successful production of connectivity and consensus—the coming together of people, practice, and things, as perceived and experienced by stakeholders. When able, the programs harnessed existing cultures of clinician engagement, and leveraged established partnerships. However, integration could be achieved even without these histories, by building trust, developing thoughtful models, using clinicians' existing engagement strategies, and implementing shared systems and technologies. The programs' structures (from their scale to their chosen patient population) also contextualized and mediated integration. Conclusions: This article has both practical and theoretical implications. It provides transferable insights into the strategies by which integration is generated. It also contributes conceptually to realist approaches to evaluation by advancing an understanding of mechanisms as contextually and temporally contingent, with the capacity to produce new contexts, which in turn generate new sets of mechanisms.