December 22, 2020

Five levels of care integration

 The importance of understanding and measuring health system structural, functional, and clinical integration

A helpful framework on integrated care from the Health Services Research article:

The framework focuses on how systems are structured and governed, what people who work in the system believe and how they behave, and activities intended to integrate patient care into a single coordinated process within the system. We chose this model because, while there are many different ways to characterize health systems, we wanted to focus on those characteristics that might prove to be meaningful with regard to performance differences.

Hypothetical relationships are depicted in the model using arrows that move from left to right. The five types of integration depicted in the model (structural, functional, normative, interpersonal and process integration) are hypothesized to effect intermediate and ultimate outcomes. From Singer SJ, Kerrissey M, Friedberg M, Phillips R. A Comprehensive Theory of Integration. Med Care Res Rev. 2020;77(2):204, Sage Publications, Inc. 

  • Structural integration (physical, operational, financial, or legal ties among operating units within a system)
  • Functional integration (formal, written policies, and protocols for activities that coordinate and support accountability and decision making among operating units)
  • Process (or clinical) integration (actions or activities intended to integrate patient care across people, functions, activities, and operating units within the system). In our discussion, we refer to this as clinical integration.

Structural and functional integration are under the direct control of system executives. Our intent was to understand the kinds of strategic decisions they were making, why they made them, and how they saw their decisions affecting their goals for their systems. Understanding the organizations that make up the systems and the extent to which systems are structurally and functionally integrated is a vital starting point for understanding whether process/clinical integration is happening within systems, how it is happening, or indeed whether it is even possible.

Two additional types of integration—normative and interpersonal. 

Normative integration refers to sharing a common culture; interpersonal integration refers to collaboration or teamwork.