Health policy 141 (2024) 104997

Contents lists available at ScienceDirect

Health policy
journal homepage: www.elsevier.com/locate/healthpol

Theories, models and frameworks for health systems integration. A

scoping review
Celia Piquer-Martinez a, *, Amaia Urionagüena b, Shalom I. Benrimoj a, Begoña Calvo b,
Sarah Dineen-Griffin c, Victoria Garcia-Cardenas a, Fernando Fernandez-Llimos d,
Fernando Martinez-Martinez a, Miguel Angel Gastelurrutia a, b
a
Pharmaceutical Care Research Group, Faculty of Pharmacy, University of Granada, Campus de Cartuja s/n, Granada 18071, Spain
b
Pharmacy Practice Research Group, Faculty of Pharmacy, University of the Basque Country, UPV/EHU, Vitoria-Gasteiz, Spain
c
College of Health, Medicine and Wellbeing, School of Biomedical Sciences and Pharmacy, The University of Newcastle, Newcastle, Australia
d
Center for Health Technology and Services Research (CINTESIS), Laboratory of Pharmacology, Department of Drug Sciences, Faculty of Pharmacy, University of Porto,
Porto, Portugal

1. Introduction care [11,12], innovation of new models of care [13], and remuneration
structures [14]. Despite this trend, many of the attempts to integrate
1.1. Current landscape health systems, services, and programs have been challenging, high­
lighting the complexity of integration processes to policy makers, re­
Health systems are facing increasing pressures due to several factors searchers, health managers and practitioners [15,16].
such as the COVID-19 pandemic and rising health and social care de­ This complexity may be due to the lack of a clear and consistent
mands. Policy makers, researchers, health managers, and practitioners definition, and associated implementation strategies for health system
are developing a range of solutions to address these increasing pressures integration, despite the concept of integration gaining popularity since
on health system sustainability, with the aim of avoiding fragmentation the 1990s [17]. The term “integration” has been used interchangeably
or duplication of services, and maintaining a focus on quality, value- with “integrated care” and other terms such as “integrated delivery
based care [1,2]. systems”, “systems integration”, “interdisciplinary communication” and
It has been suggested that health systems must evolve faster and “patient care teams” [18]. While integration is primarily directed to
efficiently to better meet existing and emerging needs [3]. Health sys­ integrating healthcare systems, integrated care predominantly focusses
tems are complex organizations characterized as “...a set of functions on patient care [19,20].
that generally include leadership and governance, financing, planning, Some authors suggest that the lack of agreement on defining inte­
commodities, workforce, service delivery and information systems with gration, combined with a paucity of literature on integrated health
the ultimate goal to improve health outcomes” [4], with “a collection of systems, has made it difficult to make progress in developing integration
interacting parts that function to achieve a shared aim” [5] and science [19,21,22]. However, a common definition of health system
“encompass multiple sectors, organizations, and professionals involved integration is “the coordination of health services and the collaboration
in the delivery of health care services” [6]. amongst provider organizations to establish an effective health system”
[21,23]. As suggested by Shortell et al. [24], integration may not be
1.2. Understanding health system integration: international challenges viewed as an end goal, but rather a process to achieve other outcomes,
such as integrated care or improved market performance of the system
Internationally, health system integration is being utilized as one of and ultimately, a way to enhance health outcomes.
the main strategies to increase health system efficiency [7]. Integration Since 2013, there’s been a noticeable gap in literature regarding
of systems aims to develop common visions, focus resources, services theories, models, and frameworks of health system integration [6].
and avoidance of working in silos [7,8]. Health systems in countries such While the Evans study [6] offered a broad overview of integration
as the United Kingdom [9], United Stated [7] and Australia [10] are strategies, with an emphasis on the evolution from institutional to
increasingly becoming integrated. Interestingly, in these countries, community-focused care, this study not only updates their findings but
particular emphasis is being given to the integration of primary health also analyzes the theories, models and frameworks to identify their

* Corresponding author.
E-mail address: [email protected] (C. Piquer-Martinez).

https://doi.org/10.1016/j.healthpol.2024.104997
Received 29 May 2023; Received in revised form 23 December 2023; Accepted 15 January 2024
Available online 17 January 2024
0168-8510/© 2024 The Author(s). Published by Elsevier B.V. This is an open access article under the CC BY license (http://creativecommons.org/licenses/by/4.0/).
C. Piquer-Martinez et al. Health policy 141 (2024) 104997

various components. Breaking down healthcare integration into its key • A model is an intentional simplification of a phenomena or a
components may facilitate the development of more effective strategies, particular feature of a phenomenon. Models do not have to be perfect
as well as being able to evaluate the impact of various components of representations of reality to be useful. Models are theories with a
healthcare integration interventions. more narrowly defined scope of explanation; whereas a theory is
both explanatory and descriptive, a model is descriptive.
1.3. Objective • A framework is a structure, overview, outline, or plan made up of
numerous descriptive categories, such as elements, components or
The objective of this scoping review is to provide a summary of variables, and the relationships that are supposed to explain a phe­
literature that identifies theories, models, or frameworks used in health nomenon. Frameworks do not give explanations; they just describe
systems integration. The specific objectives were to: empirical facts by putting them into a predetermined set of
categories.
1. Identify and catalog the theories, models, or frameworks employed
in health system integration. In essence, a theory would be the most developed and complex form
2. Analyze the common and distinguishing components in these the­ to explain how and why certain interactions lead to certain outcomes. A
ories, models, or frameworks. model provides a description less developed but more elaborate than a
framework, which is a straightforward representation of the different
The ultimate objective was to enhance the understanding of the elements or components.
components to facilitate informed selection and adaptation by policy­
makers, practitioners, and researchers to aid the development of effec­ 2.3. Data extraction and analysis
tive strategies and decisions tailored to specific contexts.
One author (CP) reviewed titles and abstracts and was overinclusive.
2. Methods If any doubts arose a second author (SB) was consulted. The selected
articles were reconsidered for inclusion applying the inclusion and
A systematic scoping review of studies reporting theories, models or exclusion criteria in a full-text review. Any uncertainty related to the
frameworks for health systems integration was performed using the JBI paper selection was resolved through discussions between two authors
guidance as recommended by Cochrane [25]. The review is reported (CP and SB) and, when consensus could not be reached a third author
following the PRISMA guideline for scoping reviews [26]. A qualitative (MAG) was consulted. A qualitative content analysis of the included
content analysis of the selected publications was performed using an studies was applied to extract the data using the methodology described
amended methodology described by Levac [27]. by Levac [27] which was based on the Arksey and O’Malley [29]
framework. This research used the methodology [27] consisting of six
stages: Identifying the Research Question, Search Strategy, Study Se­
2.1. Literature search lection, Charting the Data, Collating, Summarizing, and Reporting the
Results and Consultation. These six steps were followed in the research
A comprehensive review by Evans et al. [6] from 1985 to 2013, process for this literature review. Data were coded using a deductive and
reporting the main strategies in health system integration through a descriptive method. The analysis was documented using Microsoft Word
content model analysis, was used as the starting point to identify the­ and Excel 2016.
ories, models or frameworks applied in health. A search was performed
in five databases including Medline, Scopus, PsycInfo, Cochrane library 3. Results
and Web of Science between January 2013 and April 2023. Reference
lists of the included articles were reviewed to identify further relevant 3.1. Characteristics of included studies
articles. The selected search terms were similar to those applied by
Evans et al. [6]. The literature search produced 5584 records with 4094 records
The search strategy in PubMed, which includes Medline and PubMed remaining after removing duplicates. The screening by title and abstract
Central databases, was: (integrated delivery system” OR “organized yielded 424 records for full-text eligibility, of which 36 were finally
delivery system”) AND (“systems integration”) AND (“integrated health included in the data extraction. (See PRISMA diagram (Fig. 1)).
care” OR “integrated services” OR “integrated system OR integrated
delivery”). The search strategies used for other databased are in Ap­ 3.2. Components of the theories, models or frameworks of health system
pendix 1. The terms theories, models and frameworks were not used in integration
the search strategy as in the preliminary work up in developing the
search strategy it was found that these limited the search. Overall, two theories (Table 1), fifteen models (Table 2) and eight
frameworks (Table 3) were identified from the included studies. Details
2.2. Eligibility criteria of the identified theories, models and frameworks are provided in Ap­
pendix 2.
Articles were included if they described a theory, model, or frame­ Through qualitative content analysis aimed at identifying trends,
work for health system integration. Articles were excluded if they patterns, and themes in the literature, eleven components emerged, as
described: (1) integration of specific programs or services for different shown in Fig. 2. They are described in order of frequency, below.
populations groups; (2) case studies (3) models of integrated care; (4) Stakeholders’ Management (n = 22) was the most frequently
different types of health care organizations; and (5) the types of inte­ mentioned component (Fig. 2) and refers to the strategic engagement
gration but not incorporated them into a theory, model or framework. and alignment of all parties involved in health care. It emphasizes the
Nilsen’s classification of theories, models, and frameworks was used importance of strong relationships among health providers, organiza­
as a guide for this review [28] and is summarized as follows: tional members, and decision-makers. This component highlights the
vital role stakeholders have in guiding, supporting, and implementing
• A theory is a system of analytical rules or propositions intended to changes to achieve successful health system integration.
organize our observations, understandings, and world explanations. Adequate Funding (n = 19) speaks to the strategic allocation and
Theories focus on the relationships or connections between management of financial assets to drive health integration. It entails
variables. sourcing funds from varied channels, both public and private, and

2
C. Piquer-Martinez et al. Health policy 141 (2024) 104997

Fig. 1. PRISMA flowchart of study selection process.

Table 1
Integration components targeted by health system integration theories.
Health Stakeholder Adequate Technological Roles Governance Communication Shared Context Culture Community Co-
Systems management funding connectivity vision, engagement location
Integration values
Theory and goals

Complex X ✓ ✓ ✓ ✓ ✓ ✓ ✓ ✓ X X
Adaptive
System
[30–36,15]
Integration ✓ ✓ ✓ X X ✓ ✓ ✓ ✓ ✓ ✓
degree [37,
38]

Summary: (✓) component present; (X) component absent.

leveraging a combination of monetary and non-monetary incentives to strategic course in integrated health environments.
steer health system integration endeavors effectively. Communication (n = 18) entails systematic and strategic interactions
Technological connectivity (n = 19) is about the creation and within the health system framework. With regular engagements, effi­
effective use of shared technological platforms. These platforms ensure cient data transmission, and structured meetings, it aims to promote
consistent and efficient sharing of vital information, ranging from cohesive team-oriented approach.
medical records to clinical data, promoting better communication and a Shared Vision, Values, Goals, and Trust (n = 18) highlights the
streamlined delivery of services. importance of consensus and alignment among all stakeholders. This
Roles (n = 18) emphasizes ensuring that every stakeholder in the involves setting collective goals, upholding agreed-upon ethical values,
health system understands their specific functions and responsibilities. and fostering an environment of trust, which is often enriched by pre­
This clarity ensures a harmonized approach to care, with everyone vious collaborative endeavors and partnerships.
aligned in their roles during the integration journey. Context (n = 16) recognizes the need for adaptability and un­
Governance (n = 18) involves crafting and implementing an orga­ derscores the importance of tailoring health integration strategies to
nizational blueprint that consists of governing boards, leadership as­ local conditions, the market dynamics or specific regional factors, such
semblies, and steering committees. Such structures are imperative to as institutional context, organizational structure, demographic, eco­
guaranteeing smooth coordination, policy updates, and setting the nomic, political, legal, ecological, socio-cultural, and technological

3
C. Piquer-Martinez et al. Health policy 141 (2024) 104997

Table 2
Integration components targeted by health system integration models.
Health Systems Stakeholder Adequate Technological Roles Governance Communication Shared Context Culture Community Co-
Integration Model management funding connectivity vision, engagement location
values
and
goals

Model for an ✓ ✓ X ✓ ✓ X X ✓ X X X
Integrated Health
System [21]
Network Integration X X X ✓ X X ✓ X X X X
[39]
The Landscape of ✓ ✓ ✓ ✓ ✓ ✓ ✓ ✓ ✓ ✓ ✓
Physician–System
Integration Model
[40]
Integration of ✓ ✓ ✓ ✓ ✓ ✓ ✓ X ✓ ✓ X
Community
Health and
Prevention into
Community-
based Primary
Care [41]
The McKinsey 7S ✓ X ✓ ✓ ✓ ✓ ✓ X ✓ ✓ ✓
Model [42,43]
Conceptual Model ✓ X ✓ ✓ ✓ ✓ ✓ ✓ ✓ ✓ ✓
of Integration
Types [44]
Integrated Primary ✓ ✓ X ✓ X ✓ X X ✓ X ✓
Care [16]
Provider-based ✓ X X X X X X X X X ✓
Conceptual Model
[45]
Continuum of X ✓ ✓ ✓ ✓ ✓ ✓ ✓ X X X
Integration [18]
Outcome Map [46] ✓ ✓ ✓ ✓ ✓ ✓ ✓ ✓ ✓ ✓ ✓
Model of Integrated ✓ X ✓ ✓ ✓ ✓ ✓ ✓ X X X
Service Delivery
[47]
The 3C’s Model ✓ ✓ ✓ ✓ ✓ ✓ ✓ X ✓ ✓ X
[40]
The integration ✓ ✓ ✓ ✓ ✓ ✓ X X X ✓ X
toolkit and the
Building Blocks of
Integration [24]
The Embedded CAS ✓ X ✓ X ✓ ✓ X ✓ ✓ X X
Conceptual Model
[48]
An integrative ✓ ✓ ✓ ✓ X X X X X X X
model of
physician hospital
alignment [49]

Summary: (✓) component present; (X) component absent.

factors, in the environment where integration will take place. It’s about and frameworks available for health systems integration. Key compo­
ensuring relevance and responsiveness. nents are identified to assist policy makers, researchers, and other
Culture (n = 15) focuses on cultivating a shared understanding of stakeholders in selecting the most suitable or mix of theories, models or
group dynamics, stories, and values. Leaders and managers play a frameworks to meet their specific objectives.
pivotal role, ensuring that the environment champions collaboration The literature revealed differences in the number of theories
and places emphasis on normative unity. (Table 1), models (Table 2), and frameworks (Table 3). In addition to the
Community Engagement (n = 14) is about proactively drawing the two integration theories identified in this review, some integration
broader community into the integration process. By aligning with the models applied theories derived from other disciplines such as economic
needs, preferences, and values of patients and families, this component or organizational theories i.e.: Open systems theory (LOPSI model) [2],
ensures the integration echoes the principles of people-centric care. collaborative capital (Outcome Map) [46] and Institutional economic theory
Co-location (n = 10) was the least mentioned component and it (Continuum of integration) [18]. These theories were not included in this
emphasizes the importance of placing health service providers in shared scoping review since they were not specific to integration.
or nearby locations. Additional terminologies, including network, mapping or toolkit,
were used by several authors to describe theories, models and frame­
4. Discussion works of health systems integration [24,39,46]. For consistency of
analysis, these were recategorized as theories, models or frameworks
4.1. Summary of findings and contribution to the literature according to the definitions by Nilsen [28] previously described. As
Nilsen P. states, there is a significant degree of overlap between these
This review provides an up to-date mapping of the theories, models categories.

4
C. Piquer-Martinez et al. Health policy 141 (2024) 104997

Table 3
Integration components targeted by health system integration frameworks.
Health Systems Stakeholder Adequate Technological Roles Governance Communication Shared Context Culture Community Co-
Integration management funding connectivity vision, engagement location
Framework values
and
goals

Analytical ✓ ✓ ✓ ✓ ✓ ✓ ✓ ✓ ✓ ✓ X
Framework for
Integration [50]
Conceptual ✓ ✓ X X X X ✓ ✓ X ✓ X
Framework:
Five Health
Care Activities
that Facilitates
Integration [51]
The Four Domain ✓ ✓ X X X X X ✓ X ✓ X
Integrated
Health
Framework
[52]
Theoretical ✓ ✓ ✓ ✓ ✓ ✓ ✓ X X X ✓
Framework of
Different Forms
of Integration
[53,54]
Monitoring and ✓ ✓ ✓ ✓ ✓ ✓ ✓ ✓ ✓ ✓ X
Evaluation
Framework of
Integration [55]
Conceptual ✓ ✓ ✓ X ✓ X ✓ ✓ ✓ ✓ X
Framework for
Analysing
Integration of
Targeted Health
Interventions
into Health
Systems [4]
Framework for an ✓ ✓ ✓ ✓ ✓ ✓ ✓ ✓ ✓ X ✓
Integrated
System
Scorecard [56]
Framework for ✓ ✓ ✓ X ✓ ✓ ✓ ✓ ✓ ✓ ✓
examining
integration [17]

Summary: (✓) component present; (X) component absent.

4.2. Similarities and differences in health system integration theories

Interestingly, only two theories were identified in this review

(Table 1). The Integration Degree theory [37,38], suggests that health
integration is a gradual process that involves different levels of inte­
gration, with each level building on the previous one. The theory pro­
poses that health integration can be measured by the degree of
integration, which is determined by the extent of interdependence and
cooperation among organizations. It also suggests that there are
different types of integration, such as functional, structural, and oper­
ational, each of which serves a specific purpose.
Comparatively, the Complex Adaptive System (CAS) theory [35],
views health integration as a complex and adaptive process that is
influenced by various factors such as the characteristics of the organi­
zations involved, the external environment, and the interactions among
organizations. The theory suggests that health integration is nonlinear
and is subject to constant change, as new structures and patterns of
behaviour emerge.
Both theories suggest that health integration is complex and influ­
enced by various factors, such as the characteristics of the organizations
Fig. 2. Bubble plots showing the distribution of components of the theories, involved and the external environment. Both theories suggest that
models or frameworks of health system integration. Foot note: Each bubble in health integration involves cooperation and interdependence among
the figure represents a key component of theories, models or frameworks of organizations. Additionally, both emphasize communication and tech­
health system integration. The size of the bubble is proportional to the number nological connectivity among organizations for successful health inte­
of times the component was identified in studies.
gration. However, in the Integration Degree theory, communication and

5
C. Piquer-Martinez et al. Health policy 141 (2024) 104997

technological connectivity is suggested to be important for achieving ‘governance’, ‘community engagement’ and ‘technological connectivity’
different levels of integration, while in the Complex Adaptive System might be more relevant due to organisational reasons.
(CAS) theory [36], communication and technological connectivity are
important for facilitating the adaptive process, to create more rapid 4.5.1. Stakeholder management
responses for new situations and challenges and the emergence of new Building relationships and finding ways to bring together various
structures and patterns of behaviour [32,35]. and different perspectives to create a shared understanding among all
Integration degree theory may be easier to adapt to each health system parties is of major significance [46,51]. Several experts [31,37] argue
integration context or specific programs, as suggested by McVicar [37]. that changes to the organizational structure and management culture
However, CAS theory emphasizes the importance of all stakeholders in may be necessary to promote stakeholder participation. For example,
the process, the analysis of the preestablished hierarchy and the rele­ Shortell et al. [47] suggests a shift towards a “new management culture”
vance of adaptability for future events. which could involve creating more decentralized and participatory
decision-making processes, in addition to establishing clear lines of
4.3. Similarities and differences in health system integration models communication and accountability between different stakeholders.
Other strategies for promoting stakeholder participation in health
Most of the models identified (n = 15) (Table 2) emphasized the integration systems may include incentivizing collaboration through
importance of cooperation and interdependence among organizations to financial or non-financial rewards, providing training and support for
achieve effective health integration. Some differences between models effective teamwork and communication, and fostering a shared sense of
included the specific focus or goal of the model, the intensity of inte­ mission and purpose among stakeholders. Ultimately, success of health
gration it aims to achieve [40], the type of integration it emphasizes system integration appears to depend on active engagement and
(such as functional, structural, or operational) [57], the specific com­ participation of all stakeholders, and ongoing efforts are needed to
ponents or elements it includes, the type of organizations or stake­ promote this collaboration and cooperation.
holders it targets, the level of adaptability or flexibility it allows for, the
data or metrics used to measure successful integration, the underpinning 4.5.2. Adequate funding
theoretical or conceptual framework, and the level of complexity or Effective integration of health systems requires changes in organi­
simplicity of the model. For example, Network integration [39] empha­ zational structures and processes and sufficient financial resources for
sizes the role of networks in facilitating communication and cooperation sustainability. Inadequate funding limits the success of integration ef­
among organizations. In contrast, The Landscape of Physician–System forts, as organizations may not have the necessary resources to support
Integration (LOPSI) model [2] covers all components but was highly new activities and roles. Several studies emphasize the need for identi­
focused on the integration of physicians into the healthcare system, fying the optimal regulation and budgetary support to fully realize the
which may not be appropriate for all organizations or goals. The 3C’s value of health system integration [31]. Various types and sources of
Model [40] emphasizes the integration, coordination, and continuity of funding were identified in this review, including global hospital bud­
care, providing a comprehensive approach to health system integration. gets, pay-for-performance, medical offsets or even a combination of
monetary and non-monetary incentives [32].
4.4. Similarities and differences in health system integration frameworks
4.5.3. Technological connectivity
Eight frameworks were identified in this review which appear to Technological connectivity plays a crucial role in the success of
have similarities (Table 3). All the identified frameworks focus on health system integration. Different solutions to resolve technological
analyzing and evaluating different aspects of integration in health sys­ connectivity were found, particularly a common platform, technology or
tems, facilitating integration within health systems, assessing perfor­ system [32,42,43] to share data and information. This was identified to
mance, and understanding the different forms of integration in health improve clinical decision-making, reduce errors, improve patient out­
systems. However, they differ in their specific elements, activities, do­ comes, achieve certainty in interprofessional teamwork, facilitate
mains, and approaches used to evaluate and analyze integration. For communication [32], improve service delivery systematization and
example, The Analytical Framework for Integration [50] focuses on predictability [56], prevent delays in care, avoid duplication of efforts,
governance, financing, service delivery, human resources, and infor­ and ensure patients receive the most appropriate and timely care.
mation systems. Comparatively, the 5As framework focuses on five ac­
tivities (Awareness, adjustment, assistance, alignment, and advocacy) 4.5.4. Roles
[51] while the 4DIH framework [52] focuses on four domains of inte­ Health system integration required clarity of roles [44,46] in the
gration, such as the nature of the problem, the structure of the health majority of the theories, models and frameworks found in the literature
system, systems of care and global priorities. The Theoretical Framework (n = 18). Health providers require role delineation [15,42] and an un­
of Different Forms of Integration [53] provides a theoretical understand­ derstanding of the role of each provider, i.e., the establishment of clear
ing, based on Axelsson and Bihari Axelsson [54], outlining different responsibilities for providers responsible for the same patient’s care.
strategies to be used in integration processes. The M&E framework [55] Singer et al. [44] suggest that defining of roles and duties may shift from
provides a structure for monitoring and evaluating the progress and “little appreciation of other’s role” to “in-depth understanding of others
impact of integration in health systems. This includes defining health roles” [16]. However, the CAS theory [32] suggests that roles should not
challenges specific to the country, identifying crucial points of contact be strictly defined because the competencies required for a task belong
for care, creating logic models to outline possible causal pathways, and not to an individual agent but to the cooperation of the different agents
enhancing the health information system and data utilization. and the focus should be more on agreed actions.

4.5. Exploring the key components of theories, models or frameworks 4.5.5. Governance
used in health systems integration Several of the theories, models and frameworks for health systems
integration presented a governance or leadership structure with all
All the components identified may be applicable at varying intensity stakeholders represented [50] to sustain the progress of the integration
to all actors in the integration process. For example, from a politician’s process [42]. Furthermore, shared accountability [46], and managing
perspective when developing a policy, policy makers might prioritize “competing interests” were also highlighted as important for strong
‘stakeholder management’ and ‘adequate funding’ due to the need for governance [50]. Sims et al. [58] highlighted that a shared mis­
political support and fiscal purposes. Meanwhile, for an administrator, sion/vision, supportive relationships, trust and effective communication

6
C. Piquer-Martinez et al. Health policy 141 (2024) 104997

are required for effective governance. Management, governance, and understand the specific needs and priorities of the communities they
clinical practice elements should be developed and aligned to fully serve [44,60]. Sharing information at the local level fosters integration
support integration efforts [17,24]. and engagement [36].

4.5.6. Communication 4.5.11. Co-location

Communication was a central component among theories, models Co-location was the least mentioned component for health system
and frameworks of this review. It was suggested that effective commu­ integration and rather identified as a “collaboration facilitator” [37] for
nication may transform into less bureaucracy and administrative work improved communication and information exchange among team
[24,47,48], increase efficiency [33,34], and interprofessional enhanced members. When individuals work in proximity, they are more likely to
trust, to arrive to a shared concept of team-based care [16]. Many engage in face-to-face communication and build relationships based on
different ways to promote communication were suggested, such as trust, shared purpose, and mutual understanding. This can help to break
regular meetings, joint planning and decision-making, face-to-face in­ down silos and improve coordination and integration between different
teractions, implementing shared patient electronic health records, health providers and organizations [42]. Co-location is also suggested to
formal communication protocols and practices or informal conversa­ facilitate the sharing of resources and expertise, allowing for more
tions [35,49,53]. efficient and effective delivery of care [44]. However, other authors [56]
argue that there is no empirical evidence to support the effectiveness of
4.5.7. Shared vision, values and goals co-location in the integration process and that the services could be
Overall, the identified theories, models and frameworks highlighted functioning normally in individual facilities, without any focus on
the value of a shared vision among health providers are required to align coordinating with other locations. Face-to-face contact, regular meet­
values, goals and reasons such as an improvement in health outcomes ings and use of technology may help to overcome this barrier of sharing
[16], a reduction in costs [15], address health disparities, enhance space or physical proximity.
quality of life, decrease wait time, and improve access to care [41]. It
was suggested that consensus may be reached through care-planning 4.6. Implications for future practice, policy, and research
meetings [50,53,54], and programs for policy decision makers [55] to
ensure a clear understanding on the objectives of the system [56]. This scoping review provides insights for researchers, decision-
makers and political leaders in designing integration strategies that
4.5.8. Context suit the specific characteristics of their health systems. Integration of
Individual countries have different economic, political and business health organizations and professional groups such as physicians [2],
[59] contexts or legal conditions that impact health system integration nurses [4,42], pharmacists [61], social workers [51], administrative
[21]. For instance, the economic landscape, political priorities, and legal staff [16] and patients [41,60], can lead to better use of resources,
frameworks can shape the strategies and outcomes of integration efforts improved health outcomes, and reduced administrative workload [17,
Singer et al. [44] suggest that context can be understood as internal and 40]. While organizational and process-focused strategies such as
external organizational characteristics, whereas internal context is governance, information technology, and data are important, they alone
related to the size of the health system, number of practice sites or seem insufficient [30].
specialty mix, whereas external context is related to the structure of the This review found that there is no dominant health system integra­
health market, which also has an influence on the integration process tion theory, model or framework suggesting that a one-size-fits-all so­
[45]. lution may be ineffective [62]. The eleven components identified in
theories, models and frameworks have different applicability and in­
4.5.9. Culture tensity for the three levels (i.e. micro at a local practice level, meso at a
A need for including a component on cultural transformation in state level, macro at a national level) of health system. ‘Adequate
health system integration was identified in the theories, models and funding’, ‘stakeholder management’ and ‘governance’ may apply to all
frameworks through the adoption of norms and with an understanding levels. ‘Roles’ and ‘co-location’ are particularly more relevant to the
of the environment of work is advocated [46]. It is shown that the micro level. However, what is clear is that it is crucial to consider the
adoption of new ideas and technologies are impacted by dominant social and political dimensions of health systems and involve healthcare
cultural norms and principles held by organizations in the integration providers in the process to promote a grass-roots professional move­
process [4]. It is suggested that organizations should cultivate a learning ment, foster a commitment to a common purpose, and build a trusted
culture that considers both individual and group needs. Organizational network. The findings of this review highlight the need for further
narratives play a role in shaping culture, and personal stories are research into health system integration, particularly in terms of devel­
important in building group solidarity and creating a shared vision. oping and evaluating effective theories, models and frameworks.
Stories can be used to bring together the multiple professional identities
within an organization into a shared cultural identity that can drive 4.7. Limitations
improvement [30].
There are several limitations to this review. First, there is no agree­
4.5.10. Community engagement ment on a definition of the term "integration" in the literature, and as
Community engagement is a crucial aspect of health system inte­ such not all studies may have been identified because of the search
gration as it involves the involvement of the population and patients in strategy applied. Secondly, as the focus of this review is on the published
the integration process and the assessment of their health needs [4,55]. scientific literature, relevant information in the grey literature may have
Different strategies to promote community engagement have been been omitted. Additionally, although only one author (CP) reviewed
identified, such as community outreach, community meetings, part­ titles and abstracts, and this acknowledged as a limitation, there were
nerships, advisory groups, health literacy and education [41,54]. These many general discussions with other authors (SB). Furthermore, while
strategies provide feedback and guidance for quality improvement, the review identified key components for integration, it did not delve
communication between providers and patients, and alignment of local into specific barriers and facilitators influencing the effectiveness of
solutions to local problems [40]. The involvement of the community, as integration across different settings. The identified theories, models, and
a whole, is significant because it helps to overcome limited awareness frameworks were not thoroughly categorized based on the particular
and understanding across organizations and professionals [52]. Through health professionals involved in the integration process. Finally, this
community engagement, it is suggested that health providers can better study did not explore methods for quantifying the intensity or degree of

7
C. Piquer-Martinez et al. Health policy 141 (2024) 104997

integration and its various components. reforms. Health Aff 2020;39:413–20. https://doi.org/10.1377/
hlthaff.2019.01410.
[2] Nguyen AM, Johnson CE, Wood SJ, Dowling WL. Organizational factors affecting
5. Conclusions successful physician-system integration: a qualitative study of Washington State
health executives. Health Care Manag Rev 2021;46:35–43. https://doi.org/
10.1097/HMR.0000000000000238.
This review suggests that health system integration is a complex and
[3] Minderhout RN, Baksteen MC, Numans ME, Bruijnzeels MA, Vos HMM. Effect of
multifaceted process that requires the management and participation of COVID-19 on health system integration in the Netherlands: a mixed-methods study.
multiple stakeholders. The theories, models and frameworks identified J Am Coll Emerg Physicians Open 2021;2:1–10. https://doi.org/10.1002/
in this review may be used to develop integrated health systems that emp2.12433.
[4] Atun R, de Jongh T, Secci F, Ohiri K, Adeyi O. Integration of targeted health
provide, amongst other outputs, seamless care across different providers interventions into health systems: a conceptual framework for analysis. Health
and settings, such as specialist care and primary care. Policy Plan 2010;25:104–11. https://doi.org/10.1093/heapol/czp055.
The identification of 11 key components provides a useful starting [5] Bo T., Williams S., Childerhouse P., Deakins E., Zealand N., Towill D. Squaring the
circle of healthcare supplies supplies 2014;28:247–65. 10.1108/JHOM-01-201
point for policymakers and practitioners to understand the factors that 3-0014.
are essential for successful integration. These components have a broad [6] Evans JM, Baker RG, Berta W. The evolution of integrated health care strategies. In:
range of potential applications, which can span the various levels Goes J., Savage G.T., Friedman L., editors. Advances in health care management,
15. Emerald Group Publishing Limited; 2013. p. 125–61. https://doi.org/10.1108/
(micro, meso, and macro), geographic scopes (local, regional, and na­ s1474-8231(2013)0000015011.
tional), and organizational boundaries (within or across organizations). [7] Sandhu S, Sharma A, Cholera R, Bettger JP. Integrated health and social care in the
In addition, the maturity of health care systems may be an important United States: a decade of policy progress. Int J Integr Care 2021;21:9. https://doi.
org/10.5334/ijic.5687.
contextual issue to consider. They offer flexibility and applicability to [8] Timmins N, Ham C. The quest for integrated health and social care: a case study in
diverse contexts and settings, enabling their use across a wide spectrum Canterbury, New Zealand. Kings Fund; 2013. p. 64.
of healthcare integration initiatives. [9] C. Fuller. Next steps for integrating primary care: Fuller Stocktake report. NHS UK
2022:38. https://www.england.nhs.uk/wp-content/uploads/2022/05/next-steps
These components help understand, select models, initiate integra­
-for-integrating-primary-care-fuller-stocktake-report.pdf (accessed April 4, 2023).
tion, and implement integrative approaches effectively. They apply at [10] Trankle SA, Usherwood T, Abbott P, Roberts M, Crampton M, Girgis CM, et al.
different stages of integration, from planning to ongoing improvement. Integrating health care in Australia: a qualitative evaluation. BMC Health Serv Res
However, they may have some application in other forms outside inte­ 2019;19:954. https://doi.org/10.1186/s12913-019-4780-z.
[11] Khan AI, Harris JK, Barnsley J, Wodchis W. Exploring intra and interorganizational
gration of health systems. integration efforts involving the primary care sector–a case study from Ontario. Int
Further research into the application of these findings have the po­ J Integr Care 2022;22:1–17. https://doi.org/10.5334/ijic.5541.
tential for health system integration which subsequently may lead to [12] Sullivan EE, Breton M, McKinstry D, Phillips RS. COVID-19’s perceived impact on
primary care in New England: a qualitative study. J Am Board Fam Med 2022;35:
improving the overall quality of care and outcomes for patients. 265–73. https://doi.org/10.3122/jabfm.2022.02.210317.
[13] Burns LR, Goldsmith JC, Sen A. Horizontal and vertical integration of physicians: a
Funding tale of two tails. In: Goes J., Savage G.T., Friedman L., editors. Advances in health
care management, 15. Emerald Group Publishing Limited; 2013. p. 39–117.
[14] Dombrowski SK, Bacci JL, Klatt PM, Osborne M, Castelli G, Burns A, et al. Key
This research did not receive any specific grants or funding from factors for sustainable integration of pharmacists in team-based primary care
agencies in the public, commercial, or not-for-profit sectors. physician practices. J Am Pharm Assoc 2019;59:439–48. https://doi.org/10.1016/
j.japh.2019.02.005. e1.
[15] Begun J.W., Zimmerman B., Dooley K. Health care organizations as complex
CRediT authorship contribution statement adaptive systems n.d. Adv. Health Care Manag., 2003; 253–88.
[16] Vogel M, Malcore S, Illes R, Kirkpatrick H. Integrated primary care: why you
should care and how to get started. J Ment Health Couns 2014;36:130–44.
Celia Piquer-Martinez: Conceptualization, Formal analysis, Writing [17] Gillies RR, Shortell SM, Anderson DA, Mitchell JB, Morgan KL. Conceptualizing
– original draft, Writing – review & editing. Amaia Urionagüena: and measuring integration: findings from the health systems integration study.
Conceptualization, Writing – review & editing. Shalom I. Benrimoj: Hosp Health Serv Adm 1993;38:467–90.
[18] Ahgren B, Axelsson R. Evaluating integrated health care: a model for measurement.
Formal analysis, Supervision, Writing – original draft, Writing – review Int J Integr Care 2005;5:1–9. https://doi.org/10.5334/ijic.134.
& editing, Conceptualization. Begoña Calvo: Writing – review & edit­ [19] Sun X, Tang W, Ye T, Zhang Y, Wen B, Zhang L. Integrated care: a comprehensive
ing. Sarah Dineen-Griffin: Writing – review & editing. Victoria Gar­ bibliometric analysis and literature review. Int J Integr Care 2014;14:e017.
[20] Goodwin N. Understanding integrated care. Int J Integr Care 2016;16:6. https://
cia-Cardenas: Writing – review & editing. Fernando Fernandez-
doi.org/10.5334/ijic.2530.
Llimos: Writing – review & editing. Fernando Martinez-Martinez: [21] Martin L, Knowles EE. Model for an integrated health system. J Integr Care 2020;
Supervision, Writing – review & editing. Miguel Angel Gastelurrutia: 28:161–70. https://doi.org/10.1108/JICA-08-2019-0034.
[22] Shigayeva A, Atun R, McKee M, Coker R. Health systems, communicable diseases
Supervision, Writing – review & editing.
and integration. Health Policy Plan 2010;25:i4–20. https://doi.org/10.1093/
heapol/czq060.
Declaration of competing interest [23] Leatt P, Pink GH, Guerriere M. Towards a Canadian model of integrated healthcare.
Healthc Pap 2000;1:13–35.
[24] Shortell SM, Gillies RR, Anderson DA, Mitchell JB, Morgan KL. Creating organized
The authors report no conflict of interest. delivery systems: the barriers and facilitators. Hosp Health Serv Adm 1993;38:
447–66.
[25] Pollock D, Davies EL, Peters MDJ, Tricco AC, Alexander L, McInerney P, et al.
Acknowledgements Undertaking a scoping review: a practical guide for nursing and midwifery
students, clinicians, researchers, and academics. J Adv Nurs 2021;77:2102–13.
We acknowledge the University of Granada, Spain (UGR) for their https://doi.org/10.1111/jan.14743.
[26] Tricco AC, Lillie E, Zarin W, O’Brien KK, Colquhoun H, Levac D, et al. PRISMA
support. This work is part of Celia Piquer-Martinez’s PhD in Social extension for scoping reviews (PRISMA-ScR): checklist and explanation. Ann Intern
Pharmacy. Med 2018;169:467–73. https://doi.org/10.7326/M18-0850.
[27] Levac D, Colquhoun H, O’Brien KK. Scoping studies: advancing the methodology.
Implement Sci 2010;5:69. https://doi.org/10.1186/1748-5908-5-69.
Supplementary materials [28] Nilsen P. Making sense of implementation theories, models and frameworks.
Implement Sci 2015;10:53. https://doi.org/10.1186/s13012-015-0242-0.
Supplementary material associated with this article can be found, in [29] Arksey H, O’Malley L. Scoping studies: towards a methodological framework. Int J
Soc Res Methodol 2005;8:19–32. https://doi.org/10.1080/
the online version, at doi:10.1016/j.healthpol.2024.104997. 1364557032000119616.
[30] Harnett PJ. Improvement attributes in healthcare: implications for integrated care.
References Int J Health Care Qual Assur 2018;31:214–27. https://doi.org/10.1108/IJHCQA-
07-2016-0097.
[31] Burrows KE, Abelson J, Miller PA, Levine M, Vanstone M. Understanding health
[1] Chernew ME, Conway PH, Frakt AB. Transforming medicare’s payment systems:
professional role integration in complex adaptive systems: a multiple-case study of
progress shaped by the ACA: a narrative review of Affordable Care Act payment

8
C. Piquer-Martinez et al. Health policy 141 (2024) 104997

physician assistants in Ontario, Canada. BMC Health Serv Res 2020;20:365. [48] Benham-Hutchins M, Clancy TR. Social networks as embedded complex adaptive
https://doi.org/10.1186/s12913-020-05087-8. systems. JONA J Nurs Adm 2010;40:352–6. https://doi.org/10.1097/
[32] Edgren L. The meaning of integrated care: a systems approach. Int J Integr Care NNA.0b013e3181ee42bc.
2008;8. https://doi.org/10.5334/ijic.256. [49] Trybou J, Gemmel P, Annemans L. The ties that bind: an integrative framework of
[33] Edgren L, Barnard K. Complex adaptive systems for management of integrated physician-hospital alignment. BMC Health Serv Res 2011;11:36. https://doi.org/
care. Leadersh Health Serv 2012;25:39–51. https://doi.org/10.1108/ 10.1186/1472-6963-11-36.
17511871211198061. [50] Calciolari S, Ilinca S. Comparing (and learning from) integrated care initiatives: an
[34] McDaniel RR, Driebe DJ, Lanham HJ. Health care organizations as complex analytical framework. J Integr Care 2011;19:4–13. https://doi.org/10.1108/
systems: new perspectives on design and management. In: Goes J., Savage G.T., 14769011111191412.
Friedman L., editors. Advances in health care management, 15. Emerald Group [51] Reed S, Evans EJ, Hooyman N. Social work: leading the move upstream to improve
Publishing Limited; 2013. p. 3–26. the Nation’s Health. Health Soc Work 2021;45:77–9. https://doi.org/10.1093/
[35] Jordon M, Lanham HJ, Anderson RA, McDaniel RR, McDaniel Jr RR. Implications HSW/HLAA006.
of complex adaptive systems theory for interpreting research about health care [52] Sarkar NDPP, Baingana F, Criel B. Integration of perinatal mental health care into
organizations. J Eval Clin Pract 2010;16:228–31. https://doi.org/10.1111/j.1365- district health services in Uganda: why is it not happening? The Four Domain
2753.2009.01359.x. Integrated Health (4DIH) explanatory framework. Soc Sci Med 2022;296:113464.
[36] Tsasis P, Evans JM, Owen S. Reframing the challenges to integrated care: a https://doi.org/10.1016/j.socscimed.2020.113464.
complex-adaptive systems perspective. Int J Integr Care 2012;12. https://doi.org/ [53] Berglund H, Blomberg S, Dunér A, Kjellgren K. Organizing integrated care for older
10.5334/ijic.843. persons: strategies in Sweden during the past decade. J Health Organ Manag 2015;
[37] McVicar KL, Ivanitskaya LV, Bradley DW, Montero JT. Primary care and public 29:128–51. https://doi.org/10.1108/JHOM-04-2013-0082.
health collaboration reports: a qualitative review of integration aims, participants, [54] Axelsson R, Axelsson SB. Integration and collaboration in public health–a
and success determinants. Popul Health Manag 2019;22:422–32. https://doi.org/ conceptual framework. Int J Health Plan Manag 2006;21:75–88. https://doi.org/
10.1089/pop.2018.0160. 10.1002/hpm.826.
[38] Tschudy MM, Toomey SL, Cheng TL. Merging systems: integrating home visitation [55] Reynolds HW, Sutherland EG. A systematic approach to the planning,
and the family-centered medical home. Pediatrics 2013;132:S74–81. https://doi. implementation, monitoring, and evaluation of integrated health services. BMC
org/10.1542/peds.2013-1021E. Health Serv Res 2013;13:168. https://doi.org/10.1186/1472-6963-13-168.
[39] Blanken M, Mathijssen J, van Nieuwenhuizen C, Raab J, van Oers H. Cross-sectoral [56] VanDeusen Lukas C, Meterko M, Lowcock S, Donaldson-Parlier R, Blakely M,
collaboration: comparing complex child service delivery systems. J Health Organ Davies M, et al. Monitoring the progress of system integration. Qual Manag Health
Manag 2022;36:79–94. https://doi.org/10.1108/JHOM-07-2021-0281. Care 2002;10:1–11. https://doi.org/10.1097/00019514-200210020-00004.
[40] De Jong I, Jackson C. An evaluation approach for a new paradigm–health care [57] Urionagüena A, Piquer-Martinez C, Gastelurrutia MÁ, Benrimoj SI, Garcia-
integration. J Eval Clin Pract 2001;7:71–9. https://doi.org/10.1046/j.1365- Cardenas V, Fernandez-Llimos F, et al. Community pharmacy and primary health
2753.2001.00285.x. care–types of integration and their applicability: a narrative review. Res Soc Adm
[41] Lachance LL, Friedman Milanovich AR, Garrity AN. Clinic and community: the Pharm 2023;19:414–31. https://doi.org/10.1016/j.sapharm.2022.10.007.
road to integration. Am J Prev Med 2016;51:1072–8. https://doi.org/10.1016/j. [58] Sims S, Fletcher S, Brearley S, Ross F, Manthorpe J, Harris R. What does success
amepre.2016.09.006. look like for leaders of integrated health and social care systems? A realist review.
[42] Swartz CH, Bentley S. Developing governance structures in health care system Int J Integr Care 2021;21:26. https://doi.org/10.5334/ijic.5936.
consolidation: a framework for nurse leaders. Nurs Adm Q 2016;40:292–8. https:// [59] Nguyen AM, Wood SJ, Johnson CE, Dowling WL. A conceptual model for
doi.org/10.1097/NAQ.0000000000000181. physician-system integration: a scoping review. J Hosp Adm 2019;8:34. https://
[43] Waterman RH, Peters TJ, Phillips JR. Structure is not organization. Bus Horiz 1980; doi.org/10.5430/jha.v8n5p34.
23:14–26. https://doi.org/10.1016/0007-6813(80)90027-0. [60] Singer SJ, Burgers J, Friedberg M, Rosenthal MB, Leape L, Schneider E. Defining
[44] Singer SJ, Kerrissey M, Friedberg M, Phillips R. A comprehensive theory of and measuring integrated patient care: promoting the next frontier in health care
integration. Med Care Res Rev 2020;77:196–207. https://doi.org/10.1177/ delivery. Med Care Res Rev 2011;68:112–27. https://doi.org/10.1177/
1077558718767000. 1077558710371485.
[45] Kaasa S, Loge JH, Aapro M, Albreht T, Anderson R, Bruera E, et al. Integration of [61] Ryan K, Patel N, Lau WM, Abu-Elmagd H, Stretch G, Pinney H. Pharmacists in
oncology and palliative care: a Lancet Oncology Commission. Lancet Oncol 2018; general practice: a qualitative interview case study of stakeholders’ experiences in
19:e588–653. https://doi.org/10.1016/S1470-2045(18)30415-7. a West London GP federation. BMC Health Serv Res 2018;18:234. https://doi.org/
[46] Tsasis P, Evans JM, Forrest D, Jones RK. Outcome mapping for health system 10.1186/s12913-018-3056-3.
integration. J Multidiscip Healthc 2013:99. https://doi.org/10.2147/JMDH. [62] Armitage GD, Systems H, Health A, Calgary S, Suter E, Oelke ND, et al. Health
S41575. systems integration: state of the evidence. Int J Integr Care 2009;9. https://doi.
[47] Shortell SM, Gillies RR, Anderson DA. The new world of managed care: creating org/10.5334/ijic.316.
organized delivery systems. Health Aff 1994;13:46–64. https://doi.org/10.1377/
hlthaff.13.5.46.