Scaling up integrated care programs for people with complex needs: a realist synthesis

Context: Adults with multiple chronic diseases, mental health comorbidities, and/or social vulnerabilities, may have complex health and social care needs (hereafter “complex needs”). Appropriate care for people with complex needs calls for integrated care programs that include providers from primary care and other health and social services. Research is needed to identify mechanisms supporting successful scale-up of integrated care programs for this population.

Objective: To explain how, why, and under which circumstances scale-up of integrated care programs for people with complex needs work.

Study Design: Realist synthesis (RS) as first phase of a realist evaluation.

Setting/Population studied/Intervention: Scale-up of integrated care programs for people with complex needs in primary care and other settings.

Methods: A search was conducted in MedLine and Scopus for terms associated with “Integrated care” and “Scale-up”. In addition, cluster searching was used to identify academic and non-academic sources relevant to studies on the scale-up of integrated care programs. In keeping with the realist approach, data were extracted from sources to identify contexts (C) that activate mechanisms (M), leading to specific outcomes (O) (CMO configurations). Analysis of CMO configurations led to the refinement of an initial program theory developed with patient partners, clinicians, decision-makers, and academic researchers based on the Normalization Process Theory and the ExpandNet/WHO framework for scaling up.

Results: The findings suggest that scaling up integrated care programs might be associated with positive outcomes for patients with complex needs (e.g. enhanced experience), health system (e.g. strengthened capacity, capability, and collaboration) and community (e.g. healthier communities). These positive outcomes are produced when mechanisms, such as partner buy in and perceptions of the meaning, uses, and utility of the program, are triggered. The possibility of each mechanism yielding positive outcomes depends on the context related to the target population, care team, intervention setting, social and policy environment, and innovation characteristics.

Conclusions: This study will be helpful to knowledge users, such as decision-makers, practitioners, and patients, interested in scaling-up integrated care for adults with complex needs.