Handbook of Integrated Care

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.

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.

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.

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.

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.

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.

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.

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.

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.

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.

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.

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.

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.

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.

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.

In this chapter, we outline the importance and complexity of integrated care governance, by positioning it in the total spectrum of integrated care. Dealing with these complexities is on the one hand daily practice in many countries; on the other hand, we do need more knowledge about what approaches work in what circumstances and why. Integrated care needs suitable governance to sustain and develop further in context. To support leaders, policymakers, and practitioners, we illustrate in this chapter possible approaches and action points, some examples, and we raise new questions for future research and practice.

Countries around the world adjust the way they deliver health and social care services, responding to the changing needs of an aging population and people living with one or more chronic conditions. In many cases, service provider organizations break new ground and start coordinating activities in interorganizational networks. However, despite best intentions, progress has remained limited, not least due to the challenge of governing these networks. This chapter aims at identifying three perspectives on the governance of integrated care networks, describing network governance as structure, process, and practice. To increase the meaning of present experience is to add more conceptual sensors. (Karl Weick)

Governance may not be a top priority when debating healthcare transformation for the twenty-first century, but it is a critical instrument to strengthen public and institutional performance (Van Kersbergen and Van Waarden, European Journal of Political Research 43:143–171, 2004; Chhotray and Stoker, Governance theory and practice: A cross-disciplinary approach. Palgrave-Macmillan, Hampshire, 2009). Governance matters, and never more so than in times of crisis. “For example, since 2008, in the UK approximately one in three NHS foundation trusts have been subject to formal regulatory action on at least one occasion, with poor governance a contributing factor in almost all the cases” (Monitor, Care Quality Commission, & NHS Trust Development Authority, Well-led framework for governance reviews. Government of UK. Retrieved from https://www.gov.uk/government/publications/well-led-nhs-foundation-trusts-a-framework-for-structuring-governance-reviews#history , 2014, p. 4). The first two sections of this chapter cover theoretical aspects, including how governance and accountability are conceptualized and specific considerations of governance and accountability in integrated health systems. The latter two sections focus on the practical aspects of implementing governance and accountability into integrated health systems and the tools needed to support its implementation. We have tried to present a balanced view by drawing on a wide range of published literature; thus, while many of the innovative examples we discuss originate in the UK, we believe that they can easily be applied into types of health system.

Leadership in integrated care does not differ fundamentally from leadership challenges in other network structures and needs to be addressed adequately. Besides the general underestimation of the importance of leadership in healthcare, several aspects have to be considered specifically. This chapter presents general recommendations which highlight the importance of the topic for integrated care.

This chapter argues that the management of change toward integrated care requires the combination of two principle sets of processes: a stepwise progression of managerial tasks that come together to represent the core components of a change management plan (“management”) and the ability to adapt these strategies for change in the context of the complex and multidimensional nature of practical reality (“environment”). Both tasks require key individuals with the managerial skills, and both have a strong relationship-building component and are inherently interrelated.

A business model development process that aims to involve stakeholders is faced with the challenge of communicating a complex subject matter to a nonexpert audience with the aim of empowering them to make informed design suggestions or decisions. This chapter presents an approach to these challenges. It consists of two elements, building on each other. The first element is a method and toolkit for the assessment of socioeconomic impacts in health, care, and ageing, called ASSIST. The second element is a simulation tool based on real-life data that allows building an integrated care service and modeling how it responds to changes in economic factors. This second element we call the ASSIST Service Implementation Simulator. Both elements will be described in the following.When developing and implementing integrated care services, decision-makers need to create complex business models involving many stakeholders across a range of sectors, both for profit and nonprofit, and rely on reimbursement from statutory health and social care bodies as well as on other revenue streams. The needs of these stakeholders have to be identified and duly balanced within the framework of what is possible. This requires the handling of a large amount of economic data, the capacity to anticipate future developments, and creativity in dealing with unintended consequences. Furthermore, the development of a business model is likely to involve stakeholders that are not economic experts. In this chapter, we present a combined approach to business model development that allows stakeholders to get acquainted with economic assessments while carrying out their own assessment and develop their business model.

Integrated care has come into its own in many countries around the world, but sustainable change is still elusive. One of the key problems remains the fact that education and training have not yet caught up with the multifaceted changes in the provision of services. This chapter will explore how education and training must change in order to foster the development of a continuous learning environment which will, in turn, support sustainable change.

Differences in financing sources and mechanisms and in the allocation and flows of financial resources can pose a critical challenge for efforts to better coordinate and integrate across functions, professions, and sectors. This chapter provides an overview of ways in which countries have sought to overcome these challenges. While numerous innovative approaches have been implemented, the evidence of what works best in what contexts and their impacts on outcomes remain elusive.

This chapter emphasizes that integrated care is a means to an end, not an end in itself. It serves merely as a strategy aimed at providing better services for patients and populations. The aim of integrated care is to improve quality, not to reduce costs. As illustrated throughout this book, an integrated care strategy may be implemented on different levels, but in order to be sustainable and effective, it must permeate all tiers of the healthcare value chain—from the system level to the individual level.

In the last two decades, health policy makers in Europe are intensely seeking to integrate health services in order to increase efficiency in the organization and delivery of care and address escalating healthcare budget pressures. This expectation is based on increasing evidence that integrated care (IC) is likely to improve outcomes in terms of health, quality of care, and patient experience at lower cost as it facilitates linkage and coordination of services of different providers along the continuum of care. In the era of personalized medicine and genomics, IC has been characterized as “humanomics” because (i) it incorporates treatment based on personal need, preferences, and capability, (ii) it interacts with the context in which it is implemented, and (iii) its success depends highly on human behavior. As preferences and behavior at individual and organizational level are influenced not only by intrinsic motivation but also by financial motives, financial incentives are one of the main prerequisites for integrating care.

This chapter aims to provide foundational knowledge of how regulation, assessment, and inspection are being designed and implemented across several countries in relation to integrated care. It begins with defining each term, the benefits of each, and roles of various health and social system actors. A common theme throughout regulation, assessment and inspection is the focus on the client journey and how the client experiences and perceives care. Equally important is the value that stakeholders attribute to the regulation, assessment, or inspection process. This forces governments, assessment bodies, and inspectorates to be mindful to monitor outcomes that matter.

Management of complex service innovations, such as integrated health and social care organizations, is known to be demanding. In this chapter, co-leadership will be elaborated as one approach to address the challenges that arise from organizational complexity. This is preceded by a short historical background about how the interpretation of leadership has changed over time, from focusing on the leaders’ personality to envisioning leadership as a function or activity that numerous persons in an organization can have and share at the same time. This chapter is based on literature in the scientific field of integrated care and leadership research and the empirical findings discussed in emanate from a research project.

An essential element of making integrated care successful is an appropriate reimbursement instrument, such as bundled payments. They may differ in the scope of bundling (target population, time, and sectors), as well as in how the price is set (negotiation and fixed). Yet, they always go along with a specific mind set of taking responsibility for the delivered health care and transparency on the own performance.

Accountability within the integrated care movement is increasingly recognized as distinct from traditional models of accountability in health and care organizations. But in what ways is it different, and to what extent have these new accountability features been embraced by organizations and systems advancing toward integrated care? These are the central questions this chapter addresses.The chapter has two primary aims. First, it proposes five working propositions that define the core features of accountability in integrated care, highlighting the added value it brings to conventional accountability frameworks. Second, it presents an empirical analysis of how accountability practices have evolved in four national and regional integrated care systems across Europe. The findings suggest that, despite progress, there is still a long way to go to move from traditional forms of accountability to a distinctive integrated care accountability approach and style.

Safe and effective pharmacological treatment remains one of the greatest challenges in medicine, where models of healthcare delivery lag behind the enormous growth in single disease focused treatment with medicines. The implications for safe, efficient, and effective deployment of healthcare resources and sustainability are significant from both healthcare and societal perspectives. This chapter will highlight the importance of addressing the public health issue of polypharmacy as part of an integrated approach to patient care and its impact on patient safety. It will describe a seven-step process for systematic review of appropriateness of patient’s medication with multiple morbidities, which is patient centered and encourages the patient to be part of the decision-making.

Across the globe, the consequences of Covid-19 and deconditioning as a result of lockdown are driving new approaches to rehabilitation and intermediate care. This chapter describes the continuum of intermediate care services including crisis response pathways; transitional care programs; hospital at home; reablement support and interdisciplinary rehabilitation at home; and step-up and step-down models of bed-based care in community hospitals, care homes, or skilled nursing facilities. The chapter presents an overview of the evidence for these models, drawing on publications from members of the International Foundation for Integrated Care (IFIC) international special interest group on intermediate care.

This chapter on case management starts with a case story about Julia, a person with dementia, and her case manager, John. It introduces a definition of the concept of case management and discusses important terms in it. Two specific competences of case managers are discussed: (1) the assessments of care and social needs and (2) empowering interviewing of clients. The chapter emphasizes that case managers are not only for clients with dementia but are relevant as an approach to support other people with health, educational, and financial problems; clients with developmental disorders; patients with severe mental illness; patients with cancer and metastases; and persons with more than one chronic condition.

Discharge management is an essential—if not the essential—part of providing integrated care in all health systems. However, there is still a long journey towards guaranteeing adequate transitions for patients in most (if not all) health systems. This chapter focus on discharge management as one of the traditional managed care approaches which potentially leads to both—higher quality and reduced costs. The major challenge for its success is the existence of conflicting interests within the different sectors of the health care provision which come together in this process.

This chapter reviews the evidence base on the effectiveness of disease management strategies and programs. We show that, overall, disease management holds promise to improve processes and outcomes of care but evidence that is available tends to be limited to a small set of conditions only.

The implementation of integrated care and essentially every progress in the medical field depends above all on data, that is, health and patient data. Thus, harmonized and high standards of data protection regulations are crucial. The following chapter therefore focuses on the European data protection regime, in particular on health and patient data while also providing insights into the different kinds of data, the lawfulness of processing data, the main data subject rights, and the measures that controllers and processors of personal data have to comply with.In addition, this chapter looks at an aspect of integrated care where data protection considerations and measures are essential to ensure the secure processing of health data.

This chapter explores the significant impact of digital devices—such as laptops, tablets, smartphones, and wearables—on the potential for digital health interventions. It focuses on the transformation of healthcare through technology, highlighting the collaborative nature of care delivery between systems and individuals. Despite advancements in digital interventions that have improved design effectiveness, challenges remain, including low engagement, high drop-out rates, and limited efficacy, particularly among older populations facing digital exclusion. To fully harness the benefits of digital transformation in integrated care, a shift toward co-creation and design thinking is essential. This chapter emphasizes the importance of collaboratively designing digital healthcare solutions tailored to the unique needs of patients, caregivers, and providers, thereby enhancing individual welfare and revolutionizing healthcare delivery. Additionally, it showcases best practices for engaging stakeholders in the design process, illustrating how tailored solutions can effectively address the complexities of specific healthcare challenges.

Information communication technologies, ubiquitous across different facets of societies globally, are increasingly central to delivery of health and social care services. The World Health Organization and European Commission have referred to these as eHealth or Digital Health. The growing literature in the space seems to agree of the potential value that Digital Health systems can bring to service delivery in particular its potential to improve quality of care delivery. This chapter focuses on Digital Health systems and the particularly important role it may play in the delivery of integrated health and social care.

The ability to support integrated care to people with health and social care needs living at home has become a preferred policy option in many countries to promote independent living, but also to reduce institutionalization in hospitals and care homes. Healthy at Home is an Australian initiative, led by the University of New South Wales and the NSW Smart Sensing Network, to develop viable sensor-based technologies that support community-dwelling older people to live in their home as safe and well as possible, but which also connects people more effectively to the community and aged care providers that support them. This chapter takes a deep dive into the range of emerging sensor-based technologies created to support this, including attention to measuring people’s vital signs, biomechanics, falls detection, and functional monitoring. It concludes that such new technologies can transform people’s experiences of care and, therefore, should be a major tool in supporting future home-based integrated care programs.

Interoperability plays a crucial role in enabling integrated care by facilitating seamless information exchange among healthcare stakeholders. This chapter explores the significance of interoperability in healthcare, emphasizing its potential to improve care coordination, patient outcomes, and foster innovation. It examines the evolution from Electronic Medical Records to more comprehensive Electronic Health Records, highlighting the challenges in achieving true semantic interoperability. The chapter discusses various technical, legal, and organizational barriers to interoperability, including data standardization issues, privacy concerns, and cultural resistance. It presents strategies to overcome these challenges, such as adopting standardized frameworks, implementing robust data governance, promoting collaboration among stakeholders, and investing in technical infrastructure. The importance of native interoperability is emphasized, along with the need for supportive policies and regulations. Addressing these aspects can drive healthcare systems toward more effective, person-centered integrated care, ultimately improving health outcomes and system efficiency. The chapter concludes that while significant progress has been made, achieving comprehensive interoperability remains an ongoing challenge requiring concerted efforts from all healthcare stakeholders.

Evaluating integrated care innovations poses unique challenges due to their inherent complexity, contextual variability, and the interdependence of healthcare components. This chapter explores how these challenges can be addressed by integrating complexity into the evaluation design from the outset. We provide an overview of the full methodological toolbox of both interventional and observational designs and offer practical guidance on how to navigate the selection of appropriate methods. A structured decision tree supports researchers in aligning study design with the research question, context, and real-world implementation conditions. The chapter advocates for a pluralistic, context-sensitive approach that values methodological diversity over rigid adherence to traditional clinical trial models. Emphasis is placed on the importance of early and participatory evaluation planning, aligning study design with real-world conditions, and involving all relevant stakeholders from the outset. By adopting a flexible, interdisciplinary methodology, evaluations can produce actionable insights that inform policy, enhance implementation, and ultimately improve care delivery in complex healthcare systems.

Integrated care comprises diverse delivery strategies targeting various parts of the healthcare system, while engaging multiple partners in their execution. This poses unique challenges for measuring advances in integrated care. There are many tools that measure individual dimensions of integration with a focus on care coordination and patient-centered care. Fewer tools focus on functional, normative, organization, and system of integrated care despite their importance for successful integration. While useful, current instruments do not capture the complexity and interwoven nature of integrated care as they typically focus on isolated components. Attention in recent years has been on multilevel conceptual integration frameworks covering a range of concepts and target areas. These frameworks are critical to understanding the increasingly complex and multilayered relationships emerging in health systems. However, none of the frameworks offers a unified approach to measurement. We propose that stronger international cooperation needs to occur in the development of the frameworks to promote a coalesced international approach to measurement. Continued progress toward integrated care will depend much on our ability to contrast and compare the impact of strategies across different levels and contexts, using consistent measurement tools.

The rapidly increasing prevalence of chronic diseases reduces population’s health, increases the demand for health and social care, and has macroeconomic consequences for consumption, capital accumulation, labor productivity, and labor supply. Health economic evidence supports healthcare decision-makers with evidence in finding an adequate response to these challenges by investigating the efficiency of healthcare interventions, studying their financing mechanisms, and advocating the efficient allocation of scarce resources. This chapter highlights the need for economic evidence to support the efforts to integrate care and provides an overview of methodological approaches as well as challenges and solutions in generating such evidence.

This chapter explores the evolving landscape of evaluating complex interventions in healthcare, driven by the increasing need for evidence-based resource allocation and improved patient outcomes. It discusses the defining characteristics of complex interventions, such as multiple interacting components, contextual adaptability, and non-linear causal pathways, and contrasts them with simpler technologies. Drawing from frameworks like the MRC guidance and RE-AIM, it outlines the rationale, challenges, and methodological approaches for their evaluation, including formative and summative assessment, process evaluation, and both experimental and quasi-experimental study designs. Special attention is given to integrated care as a paradigmatic example of complexity in healthcare. The chapter emphasizes the importance of context, fidelity, and stakeholder perspectives in designing and reporting evaluations that are robust, transferable, and policy-relevant.

Realist research and evaluation methods, including integrated care endeavors, are increasingly used in health and social care research settings. The realist view of how the world is and how we can explain it seeks to look ‘beneath the hood’ and to ask the questions of how and why. Health and social policy and service settings, within which integrated care strives to make a difference, are complex ‘open’ systems that can only partially be understood using empirical methods alone. Abductive and retroductive modes of reasoning, as used by realist researchers, are commonly used by physicians, detectives, and lawyers to postulate hidden explanations based on available experienced evidence. The approach is, therefore, not foreign to many readers of this chapter, and realist scientific methodology gives validity to this common but scientifically neglected mode of analysis.

This chapter examines if claims data generated in standard medical care is suitable for evaluating integrated care. To do so, we describe the structure and contents of relevant data and explain its advantages as well as the methodological challenges of using such data for evaluation research. Selected short examples will illustrate how to use the data and the conclusions drawn from the results for practical application. This chapter ends with a description of the potential of the data in addition to approaches pursued in clinical research. In order to do so, we will examine to what extent the conclusions drawn for Germany can be applied to other countries based on a number of examples.

Complexity theory has the potential to be an inspiring and invigorating contribution to the study of integrated care. In this chapter, I propose that using Preiser’s six organizing principles of a CAS provides a general typology around which we can design, evaluate, and research integrated care interventions to develop a deeper, richer understanding of integrated care systems and interventions. We have already acknowledged that integrated care is complex and surely that behoves us to embrace complexity theory like many other disciplines have to unpack the black box of integrated care.

In this chapter we focus on evaluation in the context of integrated care practice. Well-structured and rigorous evaluation of integrated care policy and practice contributes to our evidence and knowledge about what works in different contexts. Integrated care can be challenging to evaluate and this chapter explores why this is. It presents the types of evaluation we see commonly in integrated care and different methodologies that can be employed in design and execution by program teams in collaboration with independent research teams or embedded within the program. The steps that evaluators need to take to address these challenges and ensure that evaluation results are reliable in context and potentially generalizable to other contexts are also explored.

Complementing the previous contributions, this chapter argues that the evaluation of integrated care services and programs, as any evaluation of a complex intervention, requires the skillful use of research techniques as well a great dosage of resourcefulness and inventiveness. However, it has some distinctive characteristics that derive from the object of the evaluation. Drawing from the authors’ experience conducting evaluations of international health and care programs and services, the chapter explores those aspects that evaluators need to consider when crafting their evaluations in the context of integrated care.

It has been well established that evidence-informed health and social care during pregnancy, childbirth, and the early years play a significant role in lowering maternal and infant mortality, improving the health and well-being of women, and promoting long-term physical, psychological, and social well-being for the child. Despite decades of research into biomedical, psychological, health education, and organizational and policy interventions, there remains substantial evidence that those efforts are not achieving their full potential in either resource-poor or wealthy healthcare settings. While some of the challenges are related to the equitable distribution of resources, many of the other difficulties relate to organizational and system issues. The important role played by individuals, families, and communities is acknowledged but often not fully elaborated. Similarly, the importance of the mental health and social protection of women, infants, and their families is frequently overlooked. It is here that integrated perinatal and infant health and social care can make a significant impact on mortality, long-term chronic disease, and the psychosocial and mental health and well-being of children, adults, families, and communities more generally.

This chapter draws on the work of the European Joint Action on Prevention and Management of Frailty (2017–2019) that frames frailty as a public health challenge. It describes the consequences of frailty for older people and for health and care systems, outlining the evidence for adopting an integrated model of care for the prevention and management of frailty.

Integrated care for children is in early stages in most countries, highlighting promising signs that children’s distinctive health needs are beginning to be recognized. Building evidence and policy translation are the next goals in realizing integrated care for children, and it is helpful to look again at the ultimate goals.

Care for frail older people with dementia and multimorbidity presents a growing challenge, driven by increased life expectancy, and a shortage of care professionals. The main challenge is to support people with dementia to live a meaningful life in dignity. Further, it calls for innovative approaches of health and social care services across domains to facilitate service users, their families, and society in achieving this high ambition. This complex issue calls for new care paradigms and organizational frameworks. Key to this transformation is the development of personalized and person-centered care models within networks (on the level of the person and interorganizational), grounded in shared normative and functional frameworks. This shift requires the dedicated attention of policymakers and care-providing services, as well as communities.

Integrated care models for older adults are key to addressing their complex, often coexisting, health, and social needs. In this chapter, we explore their main characteristics and the challenges associated with geriatric care, such as multimorbidity, declining intrinsic capacity, frailty, geriatric syndromes, fragmentation of care, and the role of place of living and informal caregiving.Through examples of successful models, we present strategies that have been shown to reduce service use, improve well-being, and increase older adults and caregiver satisfaction. In addition, evidence is provided on supportive resources and strategies, such as care transitions, intermediate care, home hospitalization, preventive care, and social prescribing. The need to evaluate the impact of these models through patient-reported outcome measures (PROMs) and patient-reported experience measures (PREMs) is emphasized, and qualitative research is presented.Technology has an essential role in facilitating integrated care, although there are still challenges to its adoption. The importance of user-centered design and human factors is highlighted. Finally, the need to improve in training professionals to provide sustainable and effective integrated care for the older person is emphasized.

Over recent decades, the care of individuals with intellectual disability (IDD) and autism spectrum disorder (ASD) has gained increasing attention due to their rising prevalence rates, the mental and physical vulnerability, and the shift toward community-based care. Despite advancements in healthcare, individuals with these neurodevelopmental conditions still face significant barriers to accessing quality care, including systemic inadequacies, lack of trained professionals, and fragmented services. Holistic care approaches, incorporating physical, behavioral, and mental health perspectives, are critical for enhancing the quality of life for individuals with IDD and ASD as well as interdisciplinary training, and policy reforms to improve outcomes and enhance the quality of life for individuals with IDD and ASD. The crucial role of families and caregivers is also discussed, along with the impact of transitions between different life stages and care systems.

The integrated palliative care model proposed in this chapter involves a set of professional health and social care services, which envelop the support and assistance of family and volunteers from an empowered community capable of caring for their families and neighbors. In the context of the growing chronic care challenge to contemporary health systems, palliative care provides better quality, more cost-efficient ways of treating people at the later stages of their chronic diseases, and end of life than treating them in acute hospitals. Thus, as a key element in any chronic care strategy, palliative care shows the way forward in the design of a service delivery model truly embedded in the emerging integrated care paradigm.

Mental HealthThis chapter emphasizes that innovation at the interface between physical and mental health has often been driven by individual clinical champions working, at least initially, in relative isolation from the rest of the system. To be sustainable, the work of these clinical innovators needs to receive support from senior leaders within local organizations and must be reinforced by consistent messages from this leadership. A powerful catalyst for cultural change is direct contact between professionals working in different parts of the system—specifically, those traditionally responsible for physical health and those specializing in mental health. Given this, service models that create opportunities for skills transfer between mental and physical healthcare professionals have particular potential.Physical and mental health are closely dependent on each other. Evidence reviewed in this chapter demonstrates that having a physical health condition significantly increases the risk of developing a mental health problem and vice versa. More broadly, mental health is a vital component of health and well-being and is influenced by the activities of all parts of the healthcare system. It is for this reason that the World Health Organization has long argued that there is “no health without mental health” (Herrman H, Saxena S, Moodie R. Promoting mental health. Concepts, emerging evidence, practice. World Health Organisation, 2005).Despite this interdependency, it often remains the case that the institutional architecture of health systems, the design of reimbursement systems, and the training and education of professionals all tend to reinforce structural and cultural barriers between mental and physical health care. As described below, these barriers mean that mental and physical health is often treated as if existing in isolation of each other.When thinking about this dimension of integrated care, there are three separate but closely related issues that require consideration: 1. Comorbidity between long-term physical health conditions and mental health problems is highly common and has a significant effect on outcomes. 2. Psychological distress is frequently expressed in the form of physical symptoms—so-called medically unexplained symptoms that lack an organic cause and are often challenging to manage. 3. All physical illness can have an important psychological or emotional component, regardless of whether or not a diagnosable mental health problem is present. The first two of these issues relate to defined client groups, whereas the third is a cross-cutting issue applicable to any form of health care. All three have profound implications for integrated care. In this chapter, we will focus largely on the specific needs of people with comorbid conditions and/or medically unexplained symptoms. However, many of the principles discussed are also relevant to the wider issue of the psychological and emotional aspects of health.

Rare diseases (RDs) are serious, often chronic, progressive, degenerative, and associated with comorbidities, substantially affecting quality of life.Integrated care is essential to ensure the transfer of scarce expertise on RDs, the needed coordination between care providers, and to ultimately improve care pathways, guaranteeing the continuous and holistic care delivery that people with RDs need.Studies and pilots conducted so far have shown that integrated and holistic care provision leads to important quality of life improvements for those living with RDs and their families, while being cost-effective and improving the coordination among care providers.Despite this growing evidence, much remains to be done to achieve integrated care for people living with RDs in Europe. In 2016, the Commission Expert Group on Rare Diseases recommended that European Member States should implement measures to facilitate multidisciplinary, holistic, continuous, and person-centered care to people living with RDs.In 2019, EURORDIS-Rare Diseases Europe published an important set of recommendations to support the implementation of integrated care for RDs in Europe. These refer measures to create a supporting environment at national level, specific mechanisms to ensure integrated care, and concrete actions to support the dissemination of essential knowledge and good practices.Various methods can and should be used simultaneously to promote integrated care for RDs, including the following: Centers of Expertise and resource centers for RDs; case managers; care pathways and standards of care; individual care plans; networking and training programs for service providers; eHealth; European Reference Networks; and the integration of RDs into national functionality/disability assessment systems.

The Safe Communities Opportunity and Resource Centre (SORCe) is an innovative, multi-agency collaborative designed to address the complex health and social needs of homeless citizens in Calgary, Canada. The model is driven by a “Housing First” and inclusivity philosophy. The Calgary Police Service historically has been the backbone agency that supports SORCe. Complemented by 13 health care, justice, and social service agencies, SORCe offers a wide range of integrated services to Calgary’s most vulnerable population. In operation since 2013, the center sees increasing numbers of client visits per year. Positive outcomes for the homeless population as well as the justice and health systems have emerged. The model continues to evolve and grow, with the Cross Roads Centre as a recent example of connected initiatives. Collectively, these initiatives create an opportunity for real impact and successful reintegration of homeless people into the community.

Stroke remains a leading cause of death and disability. Effective treatment and management require seamless integration across the healthcare and social care interface. Cooperation and collaboration between professionals, patients, and caregivers are needed. This chapter elaborates on the Dutch Knowledge Network of Stroke Services (KNCN). The network supports the stroke services through several activities focused on quality measurement and quality improvement of integrated stroke care, i.e., benchmark of quality indicators, healthcare standard stroke care, knowledge broker network, self-evaluation tool, audit instrument, screening for impairment at home, and shared decision-making.

There are more than 600 neurological conditions, variable in style, progression, and complexity. Living with a neurological condition can affect people at individual, family, neighborhood, and/or societal level(s). This chapter explores the needs of people living with a neurological disorder and how integrated care can meet them. From the current state of integrated care in neurology, moving to exemplar cases, this chapter illustrates different models of care and how people and services can benefit from care integration. Described below are integrated care goals and challenges to consider in the field of neurology when developing and implementing interventions and care initiatives.

At a global level, the World Health Organization (WHO) and the United Nations Children’s Fund (UNICEF) have jointly led a redesign of the child and adolescent health and well-being agenda to better respond to the needs of children and adolescents in the first two decades of life. The agenda encompasses several strategic shifts, including toward life-course interventions, integrated family-, child-, and adolescent-centered services, and quality and coverage of care with equity through whole-of-government and whole-of-society approaches.This chapter will review recent advances in public health, from a survival agenda for children under five toward a “thrive” agenda focusing on child and adolescent health and well-being. A comprehensive agenda informing the redesign of child and adolescent health and development services will be summarized. This will be followed by a focus on the important role a proposed schedule of child and adolescent well-care visits can play as a platform for delivering integrated child and adolescent health interventions and making connections between essential services in health and other sectors.

This chapter describes integrated care in the context of mental health service provision in rural and remote Australia. Australia is a large continent with a small population; there are both geographical and systemic barriers to delivering person-centered integrated care. This chapter highlights the context and how the nine pillars of integrated care align to the Orange Declaration on rural and remote mental health. Aligning to the nine pillars, challenges are highlighted, along with integrated care case examples that better meet the needs of rural and remote Australians, from place-based solutions to centrally enabled digitally supported cases. While there are great case examples, much remains to overcome structural, financial, workforce, and geographical challenges to deliver equitable and integrated mental healthcare to rural and remote Australians.

This chapter elaborates on the Swiss Survey of Integrated Care (SSIC), which highlights the existence of a number of integrated care initiatives. These results are encouraging and consistent with those obtained by other similar European projects.

When you seek medical care in the Netherlands, you expect to receive high-quality healthcare. The Netherlands ranks among the top 10 countries globally for healthcare quality, ensuring that care is both affordable and accessible to everyone. However, these important aspects are under significant pressure due to upcoming demographic changes, which are expected to lead to an increased demand and shortage of healthcare professionals among other challenges. In this chapter, the design and implementation of the PLOTmodel is discussed. This model consists of three main parts in order to organize differently, monitor differently, and finance differently. It was developed to initiate change towards regional collaboration for a healthier region.

This chapter argues that striving for universal health coverage alone is insufficient in inequitable societies.Integrated care models that take into account social determinants are necessary. It discusses the Pan American Health Organization proposal of Integrated Health Services Networks (IHSNs) as a response to fragmented health systems in the Americas, advocating for community-centered primary care services integrated with specialized care. The importance of citizen empowerment and state accountability in securing the right to health is emphasized. Different approaches to integrated care are presented as case studies from Latin America, including Chile’s pilot program for universalizing primary care, Bolivia’s community-oriented health initiatives during the COVID-19 pandemic, Costa Rica’s culturally sensitive maternity care models, and Buenos Aires’ social dialogue initiative for community-based mental health.

Uonuma City, Japan, has a population of about 35,000 and faces many issues, such as a declining population and an increase in older adults seeking medical services. Uonuma School for Community Health and Social Care was established in 2011 to educate health and social care multiprofessionals for interprofessional collaboration and enlighten community residents. The school curriculum includes three major themes: (1) medical students and trainees, (2) a daytime lecture-based “open school” and night school for community residents, and (3) health and social care professionals addressing various issues. In the past 16 years, the school’s outcomes have included reducing the number of patients with HbA1c greater than 8%, controlling the introduction of dialysis, and reducing ambulance calls for mild cases. Despite having few medical doctors, Uonuma had the lowest medical expenditure nationwide in 2015. A cluster of COVID-19 occurred in the hospital in April 2021, managed collaboratively by multiprofessionals and community residents. However, a sound community-based integrated care system could be built with interprofessional education, collaborative practice, and the participation of community residents, resulting in a life expectancy nearly the same as the national average and low medical expenditures in Uonuma City.

This chapter provides an overview and a broad, forward-looking reflection on the evolution of integrated care in the Basque health system. It discusses how the existing challenges resulting from changes in the demographic, social, and epidemiological profiles have been addressed so far.

The PRISMA model presented in this chapter shows that it is feasible and efficacious to improve integration functionally without—or in spite of—structural integration and merging of organizations. Implementation of the innovation should be closely monitored and adequate resources should be allocated to support the implementation and training for professionals and managers. Funding is a key issue in integration, and budget incentives and mechanisms should be adapted to the integration model. The most difficult challenge is to institutionalize the innovation, given the complexity of health care systems.

Significant heterogeneity exists in the implementation of bundled care. This chapter outlines the different typologies of bundled care programs and, as a case study, highlights the implementation of bundled care in Ontario. There are several lessons for those considering adopting bundled care in their local context. In particular, great consideration should be given to the duration of treatment, the type of condition, the event triggering the beginning of the bundle and the care context, and providers included in the bundle. More particularly, physician payment should be included in a bundle, as physicians make most of the decisions about care provided to patients. Finally, for health systems considering the implementation of bundled care programs, there must be widespread commitment and adoption from both payers and providers.

Portugal’s healthcare system, influenced by the Beveridge model, has undergone significant reforms to enhance integration, efficiency, and quality of care. A key initiative in this transformation has been the establishment of Local Health Units (LHUs), which integrate primary and secondary healthcare services within a geographical region. This chapter explores the evolution of LHUs in Portugal, highlighting their role in advancing integrated care through innovative models, including case management, clinical pathways, complex chronic patient support teams, and mental health integration.The chapter presents four case studies demonstrating how LHUs have facilitated multidisciplinary collaboration, improved care coordination, and optimized healthcare resources. The first case study examines a case management program for individuals with complex chronic conditions, which has led to reductions in emergency visits and hospitalizations. The second focuses on clinical pathways for heart failure and multimorbid patients incorporating digital tools for proactive care management. The third discusses a dedicated support team for complex chronic patients, emphasizing personalized care plans and intersectoral collaboration. Lastly, the integration of mental health services within primary and secondary care structures is analyzed, showcasing a shift toward community-based and person-centered mental healthcare. Results indicate that LHUs have contributed to better health outcomes, reduced hospital dependence, and increased patient empowerment. However, challenges such as resistance to change, workforce limitations, and structural barriers remain. The chapter highlights the need for policy alignment, sustainable financing models, and broader replication of successful integration practices to strengthen Portugal’s healthcare system further.

The US healthcare system has a history of continuous organizational change. The result is by no means a perfect healthcare system. However, a by-product of this history is a large number of experiments, making the USA probably the largest laboratory for healthcare delivery reform in the world. Both quality and costs are pressing issues for US healthcare reform. Efforts to address these issues by means of integrated care delivery and innovative payment models are mostly driven by the Centers for Medicare and Medicaid Services (CMS) and specifically the Center for Medicare and Medicaid Innovation (CMMI). Many of CMS’s reform efforts can be linked to goals now known as the Quadruple Aim: improving the experience of care and the health of populations, providers attaining joy in work, while reducing per-capita costs. These aims conflict with traditional, fragmented delivery structures, and fee-for-service (FFS) payments, which are still the underlying structures or circumstances for reimbursing providers and delivering care for patients. One of the most discussed alternative payment models is the accountable care organization (ACO). This chapter illustrates the concept of ACOs and discusses some preliminary findings on the impact of this model of integrated care delivery.

Concerning vertical care integration, the prioritized disease approach will give the Turkish health system the chance to take it as pilot and reflect the implementation lessons to upcoming steps.

“Gesundes Kinzigtal” is the flagship model of an Integrated Health Care System and the only fully population-based system in Germany that has been subject to rigorous external evaluation. It is based on the IHI Triple-Aim model, simultaneously pursuing to improve patient experience of care and population health and reducing per capita cost of health care. At its core is a value-oriented population-based shared savings contract. Two central evaluation studies demonstrate the success of “Gesundes Kinzigtal,” (i) a survey among the insured regarding their perceived health, satisfaction, and health behavior and (ii) an analysis of the over-, under-, and misutilization of health services, based on the analysis of routinely available health claims data from the Social Health Insurance. Based on these experiences, OptiMedis (the management company behind “Gesundes Kinzigtal”) initiated similar integrated care networks in three further areas. Recent modeling of the OECD on the OptiMedis networks suggests that substantial improvements in outcomes and efficiency can be gained from further scaling up the model.

Norway has one of the highest per capita health expenditures in the world. As life expectancy increases and more people lives with long-term conditions, recent health policy development seeks to improve care coordination between primary and specialist care, shift healthcare toward more preventive and person-centered interventions, and enhance user involvement in clinical decisions.

In Spain, the more advanced Autonomous Communities have been pursuing integrated care, chronic care management, and promoting an overall culture of health care for their population, but with different strategies and a different package of policies, tools, and innovations in each region. In this subchapter, we describe some of the innovative strategies and projects that have been implemented in the Autonomous Community of Madrid describing their main elements and results that have been achieved.

This chapter shows typical entry points and a toolbox for the introduction of integrated people-centered health services (IPCHS) as part of a population health management (PHM) strategy at district and community levels. It needs to be kept in mind, however, that there is no “one-size-fits-all” for these types of services. The same tools may be used in different settings, but tool selection must be guided by local needs as well as priorities and resources, which may differ considerably between territories and contexts. Integrated community care (ICC) is a living instrument, which can and should develop alongside people’s changing needs, by applying evidence-based solutions and building new tools and people-centered services to create positive change and added value as defined by the triple/quadruple aims of accountable care organizations (ACO) despite the various challenges.

As with many other health and care systems, healthcare in Ireland is a complex adaptive system and mechanistic linear reductionist thinking is insufficient for systemic change. Creating the conditions for change, an adaptive space and some simple rules or enabling constraints have been successful in our experience. At the end of the day, all integration is local and attending to relationships and local context which understanding system context is important to be successful. Cultivating highly networked connections is vital for success. Improvement is iterative, dynamic, and organic, and it takes time to build trust and confidence so that policymakers and executive decision-makers are on board. While restructuring within the Irish healthcare system has made implementation challenging, the introduction of Regional Health Areas (and associated integrated healthcare) under the Sláintecare policy provides a strategic opportunity to enable adaptation of integrated care at scale and pace.

The Canterbury Health System, considered to be among to the most integrated in the world, places significant emphasis on valuing patients’ time, trusting clinicians, fostering curiosity among its staff, and applying improvement science to further enhance organizational performance. While no system can be transferred wholesale elsewhere, there are numerous lessons that can be applied for others’ learning to “Make it Better” for their citizens.

From the central policymaking and the local implementation perspectives, Turkish health system has strong aspects including a robust and flexible IT system, local efforts on care coordination, and multidisciplinary work. These aspects will help take the care integration efforts forward effectively. Good and increasing coverage of primary care structures together with increasing utilization figures imply public awareness and acceptance for the primary level services. These initial results present a good indication of success in the efforts to shift ambulatory care load towards the primary care.

Singapore’s health system has evolved from a tax-funded colonial model to a complex mixed-ownership ecosystem of public, private, and people-sector providers. This chapter traces major transitions across five phases since Singapore’s independence in 1965, culminating in Healthier SG, a national initiative aimed at integrated, preventive, and person-centered care. It explores healthcare financing, governance, community and virtual care, and the integration of social and health services. The pandemic served as a catalyst for integration, highlighting both strengths and systemic fragmentation. Challenges remain in data interoperability, financing alignment, and public engagement, but ongoing reforms offer promise for sustainable and inclusive population health.

Integrated care is a prioritized public policy in Catalonia. Since 2011 clear policy and action has been established with great progress in Integrated Care for people with chronic conditions. New updated action has been introduced to design and implement Integrated Care between both health and social care services, creating a new model of person centered care, especially for both people living in the community included in home care programs and residential care. Additionally new potential instruments could be introduced in the process of creation of a new Agency for Integrated Care to facilitate tools in terms of governance, financing and commissioning, and digital solutions and transformation.

This chapter describes the experience of integrating health and social care across the whole of Scotland. The opening section outlines the first horizon—the political and policy landscape, financial and demographic context, stakeholder engagement, and the introduction of new organizational arrangements. The second section covers important enablers for implementing integrated care. It signposts to local examples of change and considers the challenge of measuring impacts and outcomes. The journey to improve population health and reduce inequalities is the subject of the third section. The chapter concludes with some lessons learned and a case study that illustrates the adoption of new ways of working.

Wales has come a long way in its journey towards a more integrated health and care system for its people. It has integrated health boards with a one to one or one to many relationships with local authorities, and together, they have responsibility for population health, established legislation, developed policy, and provided funding mechanisms to support such change. Yet what has become clear is that change will not necessarily happen by top-down directives but is dependent upon people making change happen, or not. Integrated care in Wales will happen when people can see it as the right thing to do and because they are encouraged, motivated, and supported to do so.

Like other member countries of the Organization for Economic Co-operation and Development (OECD), the French healthcare system faces a shortage of general practitioners (GPs), resulting in medically underserved areas and increasing disparities in access to health care. For a long time, solo practice remained the norm among French GPs—who are mainly self-employed—in a poorly structured outpatient sector. However, since 2007, new private coordinated care facilities—known as “Multidisciplinary Primary Care Groups” (Maisons de Santé Pluriprofessionnelles, MSPs, in French)—have emerged. These structures, led by self-employed GPs and supported by the public authorities, have catalyzed significant changes in the organization and financing of outpatient care. Alongside GPs, MSPs integrate nurses and allied healthcare professionals, with the aim of fostering coordinated and preventive care through formal contracts signed with local public authorities. The number of MSPs gradually increased, reaching 2251 by the end of 2022. Studies indicate MSPs have positive impacts on the distribution of primary healthcare providers, the evolution of professional practice with an expansion of the range of public health services offered to patients, the quality of care, and GPs working conditions. However, the dissemination of this model, which involves only 17% of GPs and remains heterogeneous, faces a number of obstacles and competes with other forms of integration.

This chapter argues how integrated care has found its way into the German healthcare system and how it has developed since its introduction. To shed light on the process of integrated care in Germany, the chapter starts with an overview of the general developments in the German healthcare system. This is followed by an excursion on the innovation fund, which can be seen as a motive for promoting integrated care, and a discussion of the new introduction of health regions.