Understanding integrated care: a comprehensive conceptual framework based on the integrative functions of primary care — TEI-tagged view

Pim P. ValentijnpersName, Sanneke M. SchepmanpersName, Wilfrid OpheijpersName, Marc A. BruijnzeelspersName (2013date). “Understanding integrated care: a comprehensive conceptual framework based on the integrative functions of primary care.” International Journal of Integrated Caretitle·j.

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Contribution — a multi-level primary-care framework linking clinical, professional, organisational and system integration

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Abstract. Abstract Introduction Primary careterm has a central role in integrating care within a health system. However, conceptual ambiguity regarding integrated careterm hampers a systematic understanding. This paper proposes a conceptual framework that combines the concepts of primary careterm and integrated careterm, in order to understand the complexity of integrated careterm. Methods The search method involved a combination of electronic database searches, hand searches of reference lists (snowball method) and contacting researchers in the field. The process of synthesizing the literature was iterative, to relate the concepts of primary careterm and integrated careterm. First, we identified the general principles of primary careterm and integrated careterm. Second, we connected the dimensions of integrated careterm and the principles of primary careterm. Finally, to improve content validity we held several meetings with researchers in the field to develop and refine our conceptual framework. Results The conceptual framework combines the functions of primary careterm with the dimensions of integrated careterm. Person-focused and population-based careterm serve as guiding principles for achieving integration across the care continuum. Integration plays complementary roles on the micro (clinical integrationterm·def), meso (professional and organisational integrationterm·def) and macro (system integration) level. Functional and normative integrationterm ensure connectivity between the levels. Discussion The presented conceptual framework is a first step to achieve a better understanding of the inter-relationships among the dimensions of integrated careterm from a primary careterm perspective. Keywords: primary careterm, integrated careterm, collaboration, fragmentation, care coordination Introduction The aging population and the growing prevalence of chronic conditions increases the healthcare costs and utilization of many high income countries [ 1 , 2 ]. Integrated health systems have been promoted as a means to improve access, quality and continuity of services in a more efficient way, especially for people with complex needs (e.g., multiple morbidities) [ 3 – 6 ]. Primary health care (as a set of principles and policies) and primary careterm (as a set of clinical functions) are considered as the corner stones of any health system (throughout this paper both ‘primary careterm’ and ‘primary health care’ are used interchangeably and referred to as ‘primary careterm’) [ 7 – 9 ]. Health systems built on the principles of primary careterm (first contact, continuous, comprehensive, and coordinated care) achieve better health and greater equity in health than systems with a specialty care orientation [ 9 , 10 ]. The philosophy of primary careterm goes beyond the realm of healthcare and requires inter-sectorial linkages between health and social policies [ 7 , 8 ]. Hence, the definition of primary careterm assumes an integrated view with the rest of the health system. However, in many high income countries integration of services is hampered by the fragmented supply of health and social services as a result of specialisation, differentiation, segmentation and decentralisation [ 5 , 8 , 11 ]. Fragmentation results in suboptimal care, higher cost due to duplication and poor quality of care [ 5 ]. In the Netherlands the Primary focus program aims to stimulate integration (both within primary careterm and between primary careterm and other health and social service sectors) by funding 70 collaboration initiatives [ 12 ]. To discover the critical factors that hamper or facilitate integration starting from a primary careterm perspective, the development process of these collaboration initiatives is monitored. A conceptual framework is needed to make systematic and comparable descriptions of these initiatives. However, the concept of integrated careterm is ambiguous, since it is often used as an umbrella term that differs in underlying scope and value [ 4 , 5 , 13 – 15 ]. This lack of conceptual clarity hampers systematic understanding and hence the envision, design, delivering, management and evaluation of integrated careterm. There seems to be a growing need for a conceptual framework to understand the complex phenomenon of integrated careterm and to guide empirical research [ 13 , 16 ]. The aim of this paper is to develop a conceptual framework for integrated careterm from a primary careterm perspective. In this paper we use the definition of integrated careterm of Leutz (1999) [ 17 ] and the definition of primary careterm as stated in the Alma-Ata Declaration [ 7 ], see Table 1 . This paper proposes a conceptual framework that can contribute to a better understanding of the concept of integrated careterm from a primary careterm perspective. Table 1. Definitions of integrated careterm and primary careterm. Methods The framework was developed through an iterative process of: (1) a narrative literature reviewterm·mth, and (2)\xc2\xa0group meetings and expert panels to synthesise the literature. Literature search We conducted a narrative literature reviewterm·mth to identify existing conceptual and theoretical concepts regarding primary careterm and integrated careterm. The literature search involved a combination of electronic database searches, hand searches of reference lists of papers and contacting researchers in the field. We focused on the three concepts of the Primary focus program: (1) primary careterm; (2) integrated careterm; and (3) collaboration. The preliminary search started in the electronic databases Medline/PubMed, Cochrane Library and Google Scholar using the search terms ‘primary careterm’ and/or ‘integrated careterm’ combined with ‘cooperation’ or ‘collaboration’. The following ‘MeSH’ terms were used to broaden the search in Medline/PubMed: ‘Primary Health Care’ and ‘Delivery of Health Care, Integrated’. We included journal articles, books and book chapters written in English that reported conceptual and theoretical concepts related to primary careterm, integrated careterm and collaboration. Potentially relevant references were further obtained from the retrieved publications and by contacting researchers in the field (snowball method). Building the framework The process of synthesising the literature was iterative. The lead author reviewed the literature, and catalogued the different conceptual and theoretical concepts. The research team chose the key features of primary careterm as a base on which to develop a more comprehensive framework. Next, we connected the ambiguous concepts of integrated careterm with the key features of primary careterm into a first draft of the framework. To improve the content validity of the framework we discussed it with seven researchers in the field of integrated careterm and primary careterm. During six meetings of approximately one hour a discussion was held on the synthesis of the essential elements of primary careterm and integrated careterm. Based on these discussions we refined the framework. Results To construct the conceptual framework we used 50 articles obtained by our search. Eighteen were found by direct searches in databases and 25 by using the snowball method. We used 12 articles to identify the key elements of primary careterm and 34 articles to describe the key elements of integrated careterm. Table 2 shows the key elements of primary careterm and integrated careterm that we identified with our literature search. Table 2. Key elements of primary careterm and integrated careterm. In the following sections, we will outline the pillars of our framework: (1) the key elements of primary careterm, (2) the dimensions of integrated careterm, and (3) the combination of the key elements of primary careterm and integrated careterm. Integrative function of primary careterm Primary careterm as stated in the declaration of Alma-Ata in 1978 is a strategy of public health (e.g., a health policy at the macro level) derived from a social model of health, making it possible to distribute health services equitably across populations [ 7 ], see Table 1 . This philosophy contains a number of different concepts, namely: equity on the basis of need, first level of care usually encountered by the population, a political movement, a philosophy underpinning service delivery and a broad inter-sectorial collaboration in dealing with community problems. Taken together, a broad public health policy encompassing a wide range of integration functions and goals. The functions of primary careterm (first-contact, continuous, comprehensive, and coordinated care, see Table 2 ) [ 10 , 18 ] make it possible to accomplish the integrated philosophy that is envisaged in the Alma Ata Declaration. Together these functions make primary careterm the starting point from where to improve and integrate care. The most evident function ‘first contact’ gives primary careterm a central position within the health system. It refers to the directly accessible ambulatory care for each new problem at all times and at close proximity of its users. The second function ‘continuity’ refers to the experienced coherence of care over time that addresses the need and preferences of people. Hereby the personal experience is essential, as continuity is what people experience. The third function ‘comprehensiveness’ refers to an array of services tailored to the needs of the population served. These services comprise curative, rehabilative and supportive care as well as health promotion and disease prevention. The fourth function ‘coordination’ means that people are referred both horizontally and vertically when services from other providers are needed. All together, these functions give primary careterm a central role in coordinating and integrating care. A person and population health-focused view Enclosed in the functional conceptualisation of primary careterm is the person and population health-focused view. This holistic vision is expressed as person-focused and population-based careterm [ 7 , 8 , 10 ]. The first feature, person-focused careterm, reflects a bio-psychosocial perspective of health, as it acknowledges that health problems are not synonymous to biological terms, diagnoses or diseases [ 22 ]. It bridges the gap between medical and social problems as it acknowledges that diseases are simultaneously a medical, psychological and social problem [ 23 ]. Moreover, person-focused careterm is based on personal preferences, needs, and values (i.e., understanding the personal meaning of an illness). In contrast, a disease-focused view reflects a clinical professionals perspective, translating the needs of a person into distinct biological entities that exist alone and apart form a person [ 24 – 26 ]. The second feature, population-based careterm, attempts to address all health-related needs in a defined population. In this view services should be based on the needs and health characteristics of a population (including political, economic, social, and environmental characteristics) to improve an equitable distribution of health (and well-being) in a population [ 10 ]. The need and equity focus of population-based careterm is especially important for socially disadvantaged subpopulations with higher burdens of morbidity [ 8 ]. Population-based careterm entails defining and categorizing populations according to their burden of morbidity. However, Western health systems are dominated by the paradigm of a disease-focused view, that neglects the underlying causes of health and well-being [ 27 ]. This view is dysfunctional in a population, because a growing number of patients suffer from chronic and overlapping health problems (e.g., multi-morbidity) [ 28 ]. Therefore, the person and population health-focused view is essential, as it recognizes that most health and social problems are inter-related. This is especially important in the context of integrated careterm as the person-focused and population-based perspective can link the health and social systems. Dimensions of integrated careterm The second pillar in our conceptual model is the dimensions of integrated careterm. These dimensions are structured around the three levels where integration can take place: the macro (system) level, the meso (organisational) level and the micro (clinical) level [ 29 ]. We start with drawing the contours of an integrated system at the macro level and then continue to the meso and micro level using the integrative guiding principles of primary careterm: person-focused and population-based careterm. The macro level: system integration At the macro level system integration is considered to enhance efficiency, quality of care, quality of life and consumer satisfaction [ 5 , 6 ]. The integration of a health system is an holistic approach that puts the people’s needs at the heart of the system in order to meet the needs of the population served (note the similarity to the definition of primary careterm) [ 4 , 6 , 13 ]. System integration requires a tailor-made combination of structures, processes and techniques to fit the needs of people and populations across the continuum of care [ 4 , 5 ]. However, the current specialisation in health systems (e.g., disease-focused medical interventions) causes fragmentation of services threatening the holistic perspective of primary careterm [ 11 ]. A resultant of the specialisation and fragmentation is vertical integrationterm (see Table 2 ). Vertical integrationterm is related to the idea that diseases are treated at different (vertical) levels of specialisation (i.e., disease-focused view). This involves the integration of care across sectors, e.g., integration of primary careterm services with secondary and tertiary care services. Contrary, horizontal integrationterm is improving the overall health of people and populations (i.e., holistic-focused view) by peer-based and cross-sectorial collaboration [ 30 ]. Primary careterm and public health are characterized by horizontal integrationterm to improve overall health [ 31 ]. The distinction between these integration mechanisms is important, because they require different techniques to be achieved and are based on different theories of change and leadership [ 30 ]. Nevertheless, both vertical and horizontal integrationterm are needed to counteract the fragmentation of services in a health system [ 14 , 16 ]. Incorporating vertical and horizontal integrationterm can improve the provision of continuous, comprehensive, and coordinated services across the entire care continuum. In other words, partnerships across traditional organisational and professional boundaries are needed in order to improve the efficiency and quality of a system [ 32 , 33 ]. In an integrated system these partnerships can pass through the boundaries of the ‘cure’ and ‘care’ sector to provide a real continuum of care to people and populations. Figure 1 shows an integrated health system with the person-focused careterm and population-based careterm perspective as the foundation for system integration. They serve as guiding principles within a system, which requires simultaneously horizontal (x-axis) and vertical integrationterm (y-axis). Figure 1. System integration. Meso level: organisational integrationterm·def One of the most discussed forms of integration is organisational integrationterm·def, conceptualised at the meso level of a health care system [ 21 ]. Organisational integrationterm·def refers to the extent that services are produced and delivered in a linked-up fashion. Inter-organisational relationships can improve quality, market share and efficiency; for example, by pooling the skills and expertise of the different organisations [ 3 , 5 , 16 , 21 , 34 ]. To deliver population-based careterm organisational integrationterm·def is needed [ 16 , 35 ]. The needs of a population require collective action of organisations across the entire care continuum (horizontal and vertical integrationterm), as they have a collective responsibility for the health and well-being of a defined population. Especially in socially disadvantaged populations, such as those with large variations in wealth, education, culture and access to health care, the need for integration is high [ 5 , 13 ]. However, the broad spectrum of organisations needed to assure good health in a population makes organisational integrationterm·def complicated [ 5 , 16 ]. For instance, health and social care organisations can differ distinctively in terms of culture, professional roles and responsibilities, and clinical or service approaches [ 13 ]. Furthermore, the differences in bureaucratic structures, levels of expertise, funding mechanisms and regulations can complicate organisational integrationterm·def [ 36 ]. Market, hierarchy and networks Organisational integrationterm·def can be achieved through hierarchical governance structures or through market-based governance structures between organisations [ 37 ]. Markets are more flexible than hierarchies, but the commitment between the organisations is minimal compared to hierarchies. Alternative for hierarchical or market-based governance structures are network-like governance mechanisms, which means a more or less voluntary collaboration between organisations. They depend on relationships, mutual interests, and reputation and are less guided by a formal structure of authority [ 38 ]. Networks are considered as the golden mean which unite flexibility and commitment. Network-like partnerships are prevalent in health and social care [ 5 , 16 , 39 , 40 ], as these arrangements are able to address the opposing demands of state regulation and market competition present in many Western health care systems. The extent of organisational integrationterm·def is often expressed as a continuum, ranging from segregation to full integration [ 17 , 41 ]. In a segregated situation every organisation is autonomous, with organisations functioning as independent entities. On the other hand, full integration contains hierarchical mechanisms of governance such as mergers and acquisitions. The intermediate levels of inter-organisational integration reflect the network-like governance mechanisms; linkage and coordination. The typology of ‘loose’ to ‘tight’ governance agreements is widespread in the literature [ 39 , 42 , 43 ]. Gomes-Casseres (2003) [ 44 ] describes a model that is similar to the continuum of organisational integrationterm·def and ranges from market situations through inter-organisational network arrangements to mergers and acquisitions. His model states that the complexity of inter-organisational networks results from ambiguous shared decision-making and unclear duration of commitment. In Figure 2 , the above-mentioned theories of organisational integrationterm·def and inter-organisational arrangements are combined. Figure 2. Continuum of inter-organisational integration. Source: Adapted from Gomes-Casseres (2003) [ 44 ] and Ahgren and Axelsson (2005) [ 41 ]. The left hand side of Figure 2 shows a segregated situation, where market competition leads to contractual relations between the organisations. In this scenario the duration of commitment and extent of shared decision-making is short-term as a result of the ‘invisible hand’ of market competition [ 37 ]. The right hand side shows a full integrated situation, a top-down coordination of organisations. In this scenario the duration of commitment and extent of shared decision-making is long-term as a result of the ‘visible hand’ of a management hierarchy [ 37 ]. The central part of Figure 2 shows a network mode of integration, and explains the complexity of this type of arrangements due to the continuous tension between flexibility and commitment. Within a network management cannot exercise authority or legitimate power because each organisation retains its autonomy (reflected by shared decision-making) [ 39 ]. This requires the involved organisations to continuously negotiate and assess the outcomes of the collaboration, resulting in an uncertain and changing environment (reflected by duration of commitment) [ 20 ]. Organisational integrationterm·def in the field of primary careterm is often done according to a network mode [ 45 ]. This is, as most primary careterm organisations are not market oriented and many of them are not part of a common hierarchy [ 16 ]. However, these complex network arrangements require effective mechanisms of accountability and governance. Governance structures should align the different independent organisations and coordinate their interdependencies [ 6 , 20 ]. To summarise, organisational integrationterm·def contains several types of inter-organisational relationships on the meso level of a system that provide comprehensive services across the care continuum. Organisational integrationterm·def is defined as follows: Inter-organisational relationships (e.g., contracting, strategic alliances, knowledge networks, mergers), including common governance mechanisms, to deliver comprehensive services to a defined population. Meso level: professional integrationterm·def Professional integrationterm·def refers to partnerships between professionals both within (intra) and between (inter) organisations [ 5 ], and is conceptualised on the meso-level of a health system [ 21 ]. These partnerships can be characterised as forms of vertical and/or horizontal integrationterm. Professionals have a collective responsibility to provide a continuous, comprehensive, and coordinated continuum of care to a population [ 6 , 21 , 32 , 46 , 47 ]. Especially in populations with a growing burden of disease, professionals from a range of disciplines and sectors have to take shared responsibility for the integration of services to assure good health and well-being. Integration led by professionals creates combined responsibilities for commissioning services and promotes shared accountability, problem solving and decision-making to achieve optimal health and well-being in a defined population [ 35 ]. As a consequence of this approach, the professional autonomy is affected and the traditional hierarchy and clear defined roles are blurred [ 48 ]. Professional integrationterm·def can be achieved through a variety of arrangements from virtually integrated professional networks to fully integrated organisations [ 17 , 49 ]. The extent of professional integrationterm·def is expressed as a continuum similar to that of organisational integrationterm·def (with fragmentation, linkage, coordination and full integration) [ 48 ]. Professional integrationterm·def in primary careterm is traditionally characterised by network like arrangements, that create poor conditions for shared accountability [ 45 ]. Appropriate financing and regulation incentives can stimulate this [ 6 , 32 , 45 , 50 ]. Besides the fiscal and clinical dimensions of accountability it is unclear what other types of accountability are required. However, a lack of shared language and divergent healing paradigms can make professional integrationterm·def difficult. Clarity about roles, responsibilities and principles of altruism, ethics, respect and communication seem to be crucial to overcome these difficulties [ 51 ]. The challenge is to stimulate accountable entrepreneurial professionals, while at the same time leaving sufficient freedom for different professional healing paradigms. We define professional integrationterm·def as follows: Inter-professional partnerships based on shared competences, roles, responsibilities and accountability to deliver a comprehensive continuum of care to a defined population. Micro level: clinical integrationterm·def At the micro level of a health system, clinical integrationterm·def refers to the coherence in the primary process of care delivery to individual patients [ 21 ]. Clinical integrationterm·def refers to the extent to which patient care services are coordinated across various professional, institutional and sectorial boundaries in a system [ 32 ]. Kodner [ 5 ] equates clinical integrationterm·def with service integration: “coordination of services and the integration of care in a single process across time, place and discipline” (p. 11). In practice, clinical integrationterm·def tends to be a disease-focused approach rather than a person-focused approach [ 52 ]. For instance, most tools and instruments of clinical integrationterm·def are based on narrow, disease-oriented medical interventions [ 10 , 52 , 53 ]. The limits of clinical guidelines are increasingly recognized, particularly when the broader health context is involved, e.g., by chronic multi-morbidities [ 54 ]. This is particularly relevant for socially disadvantaged people (and populations) whose needs span a number of service areas. In practice, clinical integrationterm·def requires a person-focused perspective to improve someone’s overall well-being and not focus solely on a particular condition. Professionals have to take proper account of the needs of individuals, so that services provided are matched to their needs. This also encloses the important aspect of the patient as a co-creator in the care process; with shared responsibility between the professional and the person to find a common ground on clinical management [ 55 , 56 ]. Emphasis should be placed on a person’s needs, with people coordinating their own care whenever possible [ 14 ]. In other words, clinical integrationterm·def based on a person-focused careterm perspective, can facilitate the continuous, comprehensive, and coordinated delivery of services at an individual level. Our definition of clinical integrationterm·def is as follows: The coordination of person-focused careterm in a single process across time, place and discipline. Linking the micro, meso and macro level: functional integrationterm Functional integrationterm supports clinical, professional, organisational and system integration [ 57 ]. It refers to mechanisms by which financing, information, and management modalities are linked to add the greatest overall value to the system [ 32 ]. Functional integrationterm includes the coordination of key support functions such as financial management, human resources, strategic planning, information management and quality improvement [ 20 , 35 ]. It involves shared policies and practices for support functions across partnerships between different actors within a system. However, functional integrationterm does not mean more centralisation or standardisation [ 35 ]. Functional integrationterm should be a flexible approach in order to enable partnerships to adapt to the constantly changing environment (e.g., population needs). One of the most important aspects of functional integrationterm is the linking of the financial, management, and information systems around the primary process of service delivery (clinical integrationterm·def) [ 35 , 58 ]. These linked systems can support and coordinate policy-makers (system integration), managers (organisational integrationterm·def), professionals (professional integrationterm·def) and patients (clinical integrationterm·def) in their accountability and shared decision-making in (inter-sectorial) partnerships. To sum, functional integrationterm supports and links the clinical (micro-level), professional and the organisational integrationterm·def (meso-level) dimensions within a system (macro-level). Functional integrationterm is defined as follows: Key support functions and activities (i.e., financial, management and information systems) structured around the primary process of service delivery, to coordinate and support accountability and decision-making between organisations and professionals to add overall value to the system. Linking the micro, meso and macro level: normative integrationterm Another integration dimension that achieves connectivity and also spans the micro, meso and macro level in a system is known as normative integrationterm [ 5 , 19 , 20 ]. It is a less tangible but essential feature to facilitate inter-sectorial collaboration and ensure consistency between all the levels of an integrated system. Veil and Hébert [ 58 ] define normative integrationterm as: “ensuring coherency between the actors’ systems of value, service-organization methods, and the clinical system” (p. 76). Integration is to a large extent shaped by and based on professional behaviour and attitudes [ 34 , 41 , 59 ]. Informal coordination mechanisms based on shared values, culture, and goals across individuals, professionals and organisations are considered as essential. Person-focused and population-based careterm are important social norms, that should guide behaviour within a health system. In the involvement of various actors different frames of reference need to be combined to improve the health of a population. The clashing of cultures (e.g., between medical and non-medical professionals) is one of the reasons why many integration efforts fail [ 6 , 45 ]. A clear mission and vision that reflects the needs of the local population is considered a critical success factor for population-based careterm [ 32 , 60 ]. Mutual shared goals and an integrative culture are necessary at all levels of an integrated system, and can be created by leadership [ 6 ]. Particularly at the professional and management level, leadership plays an important role in propagating an integrated approach [ 6 , 20 , 58 ]. Normative integrationterm can provide a common frame of reference that binds together all the levels of an integrated system. Normative integrationterm is defined as follows: The development and maintenance of a common frame of reference (i.e., shared mission, vision, values and culture) between organisations, professional groups and individuals. Combining primary careterm and integrated careterm Figure 3 shows our conceptual framework that combines the primary careterm and integrated careterm literature into a holistic picture. The core value of primary careterm is the integration of the biomedical, psychological and social dimensions of health and well-being, expressed in our conceptual framework as person-focused and population-based careterm. The person-focused and population-based careterm perspectives provide a foundation upon which the entire conceptual framework rests. They serve as guiding principles for achieving better coordination of services across the entire care continuum. The integrative functions of primary careterm (first contact, continuous, comprehensive, and coordinated care) are incorporated implicit in the dimensions of integrated careterm. We make a distinction between the levels of care when focusing on integration. At the macro level system integration puts the individual needs at the heart of the system in order to meet the needs of the population. That is because system integration incorporates the notion that what is best for individuals within a population is best for the population. This holistic view requires simultaneous horizontal and vertical integrationterm to improve the overall health and well-being of individuals and the population. Our framework is therefore visualised as a concentric circle, with the person-focused perspective at the centre. Integration at the meso level emphasises a population-based approach, requiring professional and organisational integrationterm·def to facilitate the continuous, comprehensive, and coordinated delivery of services to a defined population. At the micro level clinical integrationterm·def highlights the person-focused perspective, ensuring that service users experience continuous care. Health professionals have to take proper account of the needs of individuals, so that the services provided are matched (both horizontally and vertically) to their needs. This may mean that integration may be pursued at the meso and macro level, when services from other providers or organisations are needed. Finally, functional and normative integrationterm spans the micro, meso and macro level and ensures connectivity within a system. Figure 3. Conceptual framework for integrated careterm based on the integrative functions of primary careterm. Discussion This paper contributes to the conceptualisation of integrated careterm from a primary careterm perspective. We constructed a framework to understand the complex phenomenon of integrated careterm. This means a simplification of reality which helps to better understand the complex interactions of integrated careterm [ 16 ]. We suggest that integration has to be pursued at different levels within a system to facilitate the continuous, comprehensive, and coordinated delivery of services to individuals and populations. How these integration levels interact will vary according to the specific context in which they develop. There are several directions for further research grounded in our new framework. First, the model provides further guidance to study the preferred directions of integration: Is it for instance a ‘bottom-up’ (clinical), ‘top-down’ (system) or two-sided (bottom-up and top-down) approach as specified by Kodner and Spreeuwenberg [ 13 ]. Second, the framework provides directions to identify the optimal scenario for integration and the contribution of the different integration mechanisms. For instance, our model in combination with the work of Leutz [ 17 ] and Ahgren and colleagues [ 41 ] can be used to discover the extent of integration at all integration levels in conjunction. However, there are some methodological challenges that arise from our conceptualisation. First, evidence-based knowledge about integration is hampered by the lack of standardised, validated tools and indicators to measure integration [ 61 , 62 ]. For instance, most available evidence is based on small pilots, what makes it difficult to generalise these findings [ 63 ]. Second, there is often a lack of information regarding the validity and reliability of measurement tools [ 61 , 62 ]. The inter-sectorial nature of integrated careterm and primary careterm requires a comprehensive mixed method approach that can be applied across multiple settings [ 64 , 65 ]. However, most literature on the measurement of integrated careterm contains a wide variety of concepts, methods and measurements [ 61 ]. More research is needed to build up evidence with validated measurement tools to evaluate integrated careterm initiatives in a more synergetic and analytic way. The conceptual framework presented in its current form is intended for further testing, refinement and development. As the conceptual framework is built on the theoretical concept of primary careterm, we invite further discussion on whether and how far the framework may apply in other integrated careterm settings (for example in specialty care or intramural settings). Ultimately, we hope to develop our framework as a tool for conducting analysis of integrated careterm initiatives to be used to test for causal relationships among the different integration levels. Thereafter the framework will be validated in the Primary focus program. We hope that our framework provides a comprehensive base for policy-makers, managers, professionals and other stakeholders to better understand the synergetic nature of integrated careterm. Conclusion We conclude that to deliver integrated, person-focused, and population-based careterm, vertical- and horizontal integrationterm through inter-sectorial partnerships across the health and social service system is needed. Our conceptualization includes multiple dimensions of integration that play complementary roles on the micro (clinical integrationterm·def), meso (professional- and organisational integrationterm·def) and macro (system integration) level to deliver comprehensive services that address the needs of people and populations. Functional and normative integrationterm can ensure connectivity of all the levels of an system. Acknowledgments The Primary focus program and the evaluation research were commissioned by the Ministry of Health, Welfare and Sport (VWS) and organized by ZonMw, The Netherlands Organization for Health Research and Development. The authors are grateful to ZonMw for funding this research. The authors would like to thank Nick Goodwin, Bert Vrijhoef, Dirk Ruwaard, Wienke Boerma, Willemijn Ruizendaal and Roos Arends who contributed helpful comments on earlier versions of this work. We would like to especially thank the reviewers for their valuable remarks. Contributor Information Pim P. ValentijnpersName, Jan van Es Institute, Netherlands Expert Centre Integrated Primary Careterm, The Netherlands. Sanneke M. SchepmanpersName, NIVEL, Netherlands Institute for Health Services Research, The Netherlands. Wilfrid OpheijpersName, Twynstra Gudde, Consultants and Managers, The Netherlands. Marc A. BruijnzeelspersName, Jan van Es Institute, Netherlands Expert Centre Integrated Primary Careterm, The Netherlands. Reviewers Mario Cruz Peñate , MD, MPH, Regional Advisor on Primary Health Care, Pan American Health Organization, Regional Office of the World Health Organization, Washington, D.C., USA Reynaldo Holder , MD, MSc, Regional Advisor on Hospitals and Integrated Health Care Delivery, Pan American Health Organization, Washington, D.C., USA Margaret MacAdam , PhD, Associate Professor (Adjunct), factor-Inwentash Faculty of Social Work, University of Toronto One anonymous reviewer.