Existing theoretical frameworks of integrated healthcare mainly serve a descriptive function, delineating elements, components and processes associated with integrated healthcare. Scholars have pointed to the need to develop frameworks that can prescribe “the making of integration”, which are distinguished from those that describe the “extent of integration”. Such efforts should entail; 1) identifying multidimensional contextual factors that influence the development and implementation of integrated health; 2) advancing the knowledge of the mechanisms through which these contextual factors interact to facilitate or interfere with the effort to develop and implement integrated health. The purpose of this study was to develop and further refine a comprehensive framework of developing and implementing integrated healthcare based on literature and informed by a rural primary care facility’s effort to develop trauma-informed integrated primary care.
An initial framework of integrated care was developed based on a comprehensive literature review. A community-engaged realist evaluation study was conducted to test the initial framework. The study collected multiple forms of data including key informant interviews, focus groups and surveys with healthcare staff, direct observation of various meetings and informal interactions with key stakeholders. Following the realist evaluation protocol, data analysis focused on identifying contexts and mechanisms that influence the development and implementation of integrated care using the convergent parallel mixed method. The results were applied to further revise and refine the initial framework of integrated care.
The initial framework was revised and refined based on the facilitating and interfering contexts and mechanisms identified during the healthcare integration efforts in the rural primary care clinic. The revision process involved; 1) rearranging the hierarchy among multidimensional contextual domains; 2) adding new domains or constructs; and 3) refining definitions of the constructs in the original domains. The initial framework had five domains including the outer setting, basic structure, people and value, key process, and intervention characteristics. A new domain, i.e., Organizational Capabilities for Change, was added to construct a new framework with the total of 6 domains. Other changes included the addition of following new constructs; 1) the awareness of the service gap (or opportunities for service improvement) in the Organizational Capabilities for Change domain; 2) the perception of fit in the intervention characteristics domain; 3) increasing and maintaining staff competency (training and education) and workflow integration in the key process domain; 4) community integration and work environment in the people and value domain; 5) sociocultural context in the outer setting domain; 6) partnering and workflow integration in the key processes domain.
Conclusions and Implications
This study sought to contribute to the effort to further advance the knowledge of contextual factors that influence the “making of integration” by developing the Comprehensive Framework of Integrated Health Implementation (CF-IHM). The refined framework can be used to guide the effort to develop integrated care by highlighting resources and key processes need to be in place for such endeavors.