Handbook of Integrated Care

Table of Contents

1. Frontmatter

2. Foundations of Integrated Care

   1. Frontmatter

   2. 1. What Is Integrated Care?

      Nicholas Goodwin, Viktoria Stein, Volker Amelung

      Abstract

      Integrated care is difficult to define and understand since it represents a complex service innovation in the way health and care services should be redesigned around people’s needs. Consequently, integrated care has come to mean different things to different people and the resulting conceptual “soup” has often acted as a barrier when it comes to developing commonly understood strategies to support implementation and change. This chapter attempts to outline that there are three distinct dimensions to what integrated care means in practice.

   3. 2. Refocusing Care: What Does People-Centeredness Mean?

      K. Viktoria Stein, Volker Amelung

      Abstract

      Throughout this chapter, barriers and challenges are mentioned, which still impede the radical cultural and systemic change necessary to implement integrated people-centered systems at scale. Given how long the interplay of body, mind, and social environment has already been recognized as essential for the health and well-being of people, it is at first glance astonishing that so little has changed in our systems thus far. However, upon closer scrutiny, the shift from patho- to salutogenesis represents a profound paradigm shift, which touches at the cultural, financial, and structural core of our systems.

   4. 3. Evidence Supporting Integrated Care

      Ellen Nolte

      Abstract

      This chapter provides an overview of available evidence supporting integrated care. It highlights that evidence of the impacts of integrated care as a whole is difficult to derive, given the complex and polymorphous nature of a concept that has been approached from different disciplinary and professional perspectives. Instead, it may be more instructive for decision-makers and practitioners to draw on evidence of impact of core elements and strategies that can help to achieve integrated care.

   5. 4. Values in Integrated Care

      Nick Zonneveld, Ludo Glimmerveen, Mirella Minkman

      Abstract

      In this chapter, we focus on the values in integrated care. As values often play a role in underlying integrated care processes and mechanisms, they may help us explain why integrated care initiatives work or do not work. However, values are not always tangible or visible and their role is often implicit. This chapter therefore presents a list of 18 frequently appearing values underpinning integrated care, including insight into their relevance on the levels of integration. The list forms an international normative basis for the integrated care concept. Furthermore, it can be used for the identification and explication of values in integrated care practice, while also enabling discussion among stakeholders that appear to prioritize or interpret values differently.

   6. 5. Integrating Health and Social Care Systems

      John G. Eastwood, Robin Miller

      Abstract

      It has long been recognized that social issues have a strong bearing on people’s health and well-being. While medical treatments are essential to address underlying infections and physical malfunctioning, these are insufficient by themselves to maintain and promote the health of a population. Wider social contexts such as poverty, housing, hygiene, employment, and education play a fundamental role in the incidence of disease. These must be considered and connected issues addressed to achieve better health for all. Vaccines can provide important immunity that will help to eradicate a disease, but it is only by societal coordination and development of associated social norms that vaccines are successfully introduced. Health interventions may be able to prolong the life of people with a long-term health condition, but social issues enable life to be of better quality—i.e., a life worth living—and acute care can only successfully operate if people are supported postcrisis to return or access support in the community. In relation to mental health, social networks and access to employment are often the most influential in achieving better well-being.

   7. 6. Integrated Community Care: A Community-Driven, Integrated Approach to Care

      Nieves Ehrenberg, Philippe Vandenbroeck, Monica Sørensen, Tinne Vandensande

      Abstract

      ICC is a resilience-oriented approach that seeks to strengthen communities by tackling the determinants of health. It assumes accountability toward a territorially defined population, creating new cross-sectoral and interdisciplinary partnerships and taking a population health approach with a focus on prevention. In ICC, a new power dynamic and relationship is forged: people and communities co-design and co-produce health and care, the role of government is that of an equalizer (ensuring resources are allocated to those most in need) and investor in public services, and the traditional boundaries between informal and formal care are blurred.

   8. 7. Path Dependence and Integrated Care

      Carolin Auschra, Jörg Sydow

      Abstract

      Using the theory of path dependence, this chapter increases our understanding of the hyper-stability of certain practices in healthcare as well as of the whole health system. Technological, institutional, and organizational path dependences are based on self-reinforcing mechanisms that create such stability, making deviations from existing paths extremely difficult. If coordination and complementarity or learning and adaptive expectation effects are at work, transformation toward more integrated care will be difficult, if not impossible. Policy-makers, health professionals, and healthcare managers should be aware of these difficulties when aiming for technological, institutional, or organizational change.

   9. 8. Values and Culture for Integrated Care: Different Ways of Seeing, Being, Knowing, and Doing

      Robin Miller, Marisa de Andrade

      Abstract

      In this chapter, we will begin with a consideration of what is meant by “culture” and “values” and how they have been connected in relation to the field of integration. We will then focus on two key approaches to developing them positively—teamwork and interprofessional learning—while critically reflecting on some of the challenges. Creative-relational inquiry is then introduced as an alternative framework to exploring cultures and values. Finally, we conclude with a reflection on what this means for those leading and working in integrated settings.

   10. 9. The Importance of Scale in Integrated Care

       Sander Merkus, Mirella Minkman

       Abstract

       This chapter explores the critical yet often ambiguous concept of scale in integrated care networks. While integrated care is increasingly recognized as essential for delivering high-quality, person-centered care, the question of what constitutes a “suitable scale” remains underexplored in empirical research. Drawing on interviews with Dutch healthcare CEOs and network coordinators, the study identifies seven key factors influencing decisions about suitable scales, clustered into three overarching perspectives: the needs of the target population, systemic-organizational principles, and social-relational dynamics. The findings reveal that scale is not a fixed or purely rational construct but is shaped by contextual, normative, and historical factors. The need for dynamic, reflective scaling processes that evolve with changing contexts and demands is also an insightful recommendation. Moreover, CEOs often approach scale from the perspective of their own organization’s survival, conditions, attractiveness, and influence—while network coordinators adopt a perspective in which the network collaboration takes center stage, emphasizing collective goals and systemic coherence. The chapter highlights the importance of aligning these perspectives to avoid inefficiencies and missed opportunities in care delivery. Rather than relying on traditional macro-meso-micro frameworks, the chapter proposes a more nuanced, practice-based understanding of scale that can guide integrated care initiatives. The study offers a heuristic framework to support discussions and decisions about scale in integrated care, emphasizing that suitable scaling needs more attention and is a continuous, negotiated process rather than a one-time decision. In times of permanent resource scarcity, rethinking scale becomes increasingly relevant for sustainable and effective care collaboration in health and social care systems.

3. People-Centeredness

   1. Frontmatter

   2. 10. Patient and Public Involvement in the Design and Implementation of Integrated Care

      Wilma van der Vlegel-Brouwer

      Abstract

      Efforts to integrate patient and public involvement (PPI) in health and social services, including efforts to improve, redesign, or shape services, are growing. By using the unique experiences of patients and public, the role of people changes from just being the receiver of services to producers and participants. This has a beneficial effect on quality. By tailoring the support to the patients’ level of activations, voice, choice, and coproduction, as ideal types of patient and public involvement, can be developed. More co-creative practices at the individual level, community level, organizational level, and at the system level need development professionals’ skills, attitude, and values at all levels of care. Incorporating patients’ expertise, perspectives, and stories as a legitimate source of knowledge in practice, education, and research will enhance the quality and relevance of what we strive for in integrated care. Frameworks and strategies are provided that put the patient and the public at its’ heart.

   3. 11. Patients’ Preferences

      A. Mühlbacher, Susanne Bethge

      Abstract

      The presented studies reviewed in this chapter support efforts for increased consideration of patient benefit as an essential quality criterion in the assessment of integrated care. Especially where it is difficult to clearly differentiate between services in terms of medical and financial aspects, comprehensive information on patient benefits (and to that of communities as well) can be very useful in prioritizing approaches to care and treatment. Studies of this type can thus help to stimulate fresh discussion and lead to the formulation of increasingly person-centered care concepts in the long term.

   4. 12. People-Driven Care: From Rhetoric to Reality

      Nieves Ehrenberg, Tinne Vandensande, Anita Reboldi, Sanja Simic

      Abstract

      This chapter advocates for a deliberate shift beyond “people-centered” care toward “people-driven” care, where people have true agency in participating in their health and greater power in decision-making. People and communities can no longer be excluded from designing the very solutions that impact their health and well-being.

   5. 13. Learning from Worldwide Community Health Worker Programs: Exploring Their Potential for Integrated Care in Belgium

      Caroline Masquillier

      Abstract

      Community health workers (CHWs) support people living in socio-economically vulnerable situations to navigate the health system. CHWs are trusted members of local communities, who share the lived experience of the people they support. Inspired by examples of CHW programs worldwide, the Belgian Federal government gave the National Institute for Sickness and Disability Insurance and the National InterMutualist College the task to develop the first nationwide CHW program to improve access to care. This chapter provides insights into the Belgian Federal CHW program within the global CHW landscape. Community health workers play an important and unique but complex role situated between the health system and the community. We argue that CHWs have the potential to support a shift from vertical and disease-oriented services for people living in socio-economically vulnerable circumstances—which results in fragmentation that fosters duplication of services, weak coordination between levels of care and the inefficient use of human and financial resources—to a more horizontal and integrated approach. In exploring the potential of CHWs in integrated care, it is important to ensure that their “community-based identity” is safeguarded so that they can support people on the basis of mutual understanding and trust.

   6. 14. The Important Role of Health Literacy in Integrated Care

      Anna-Sophia Beese, Saskia Maria De Gani

      Abstract

      This chapter explores the vital role of health literacy in the implementation of integrated care, especially in the face of growing complexity and interconnected global crises. It argues that strengthening health literacy at individual, professional, organizational, and systemic levels is essential to empower people to find, understand, appraise, and apply health-related information effectively.

      Health literacy is conceptualized as a dynamic set of competencies that enables people to manage their and others health and well-being. The chapter presents theoretical foundations and best practice examples and offers recommendations for policy and practice to support health literacy development. It emphasizes that integrated care cannot be sustainably achieved without robust health literacy—and conversely, integrated care can foster health literacy across various levels.

   7. 15. The Circle of Care: A Proposed Multichannel Approach to Integrated Community-Based Primary Care

      Nachiket Mor, Rubayat Khan, Anne Stake, Shirley Du Yan, Shahed Alam

      Abstract

      Introduction: While definitions of community-based primary care include the community health worker (CHW) as a representative of the formal system in its remit, they tend to ignore three other critical providers of healthcare and public health services: the family, the community pharmacy or medicine shop, and faith-based healers. Even the Alma Ata Declaration of 1978 failed to recognize the essentially plural nature of health systems at the primary care level when the reality is that even when well-equipped and free primary care clinics are made available, they receive fewer than half the patient’s visits. And, even for these visits, the clinics and CHWs are unable to fully address the challenges of poor health-seeking and adherence to treatment recommendations. In this chapter we explore what an updated CBPHC approach might look like if it gave due consideration to people’s preferences and constraints.

      Methods: The chapter, benefitting from the authors’ experience, carries out a rapid evidence synthesis and then examines conceptual frameworks which can help develop an approach toward integrating multiple primary care providers at the community level.

      Results: We find that people use all four categories of healthcare providers to meet their healthcare needs. These include community health workers, pharmacists, family members, and faith-based healers, each of whom provides a distinct set of services with its own unique mechanism of impact. Many health systems have used one or more of these providers. We also find four frameworks from which insights can be drawn to integrate the services offered by these providers.

      Discussion: While each channel adds value, no one channel can provide all the services needed to deliver comprehensive primary care, and there are also risks of harm associated with some of the approaches taken by these providers. It is important to preserve the unique contribution of each channel and to resist the temptation of training them all to provide the same set of biomedical services and to find a way to integrate their services so that the patient can have the best possible experience of primary care. We suggest that making the community health worker the point of integration, supported by a digital layer, which is also linked to payments, may offer the best way to ensure this.