Search results and review characteristics
Initial searches retrieved 5410 references from electronic databases. After duplicates were removed, 2971 citation records were screened resulting in 71 full text articles for further eligibility assessment. After assessing full text articles, 18 met the inclusion and exclusion criteria (Fig. 1 for PRISMA flow diagram). The main reasons for exclusion among the full text papers included the absence of social care studies in the results or a study design other than a review.
The numbers of articles included in each review article ranged from 9 [29] to 300 [20]. Where reported, reviews reported studies as being conducted in Canada (n = 13), Europe (n = 13), USA (n = 11), Australia and New Zealand (n = 8), Asia (n = 5) and Africa (n = 1). Reviews were described as: umbrella review (n = 1), systematic review (n = 7), realist review (n = 1), narrative review (n = 1), literature review (n = 3), knowledge synthesis (n = 1), meta-analysis (n = 1), scoping review (n = 1) and other/non-systematic review (n = 1). A final article, a development of methodological approaches for evaluating integrated care programmes (n = 1), was included as it encompassed a narrative literature review on existing integrated care programme outcomes. Population groups included adults and older people with long-term conditions in a range of health and social care settings.
Measures used to evaluate health and social care integration
Table 2 provides a summary of the measures identified in the included review articles. The most frequently reported measures were system outcomes and processes, both appearing in 15 articles. Patient- or carer-reported outcomes were identified in 13 articles while health outcomes were reported in 12 articles. The category with the fewest reported measures was structural measures with nine review articles identifying their presence.
Structural measures
A range of measures for evaluating structural and organisational aspects of integrated care were identified in nine review articles (Table 3). Six articles identified studies which measured aspects of the workforce including staff effectiveness, productivity, competency, cohesion, staff communication, task completion, role performance [15, 23, 30, 34], teamwork between providers [21, 30] and physician integration in provider collaboration [15, 33]. Structural measures which evaluated communication across providers and information sharing were also identified in six review articles. Logistics and suitability of information sharing and co-location [22] were identified as important aspects for evaluation. In addition, coordination and communication between services and organisations [15, 21, 30, 33, 34], transition policies, efficiency in assessments, case prioritisation, connections with partner organisations, case and care management [15, 22, 30, 33] were evaluated. IT systems and data management [15, 22, 33] were measures of successful mechanisms of information sharing. Two articles reported the assessment of the workplace ethos towards the integration of care [15, 22], whilst three outlined measures of budget compatibility and resources [15, 22, 31]. Further organisational measures identified are reported in Table 3.
Processes
Process measures were identifed in 15 review articles. The most frequently reported categories included performance measures and the measurement of patient, family or carer perspectives of processes of care. Performance measures were included in seven reviews which predominantly consisted of quality-related measures assessing staff and patient perceived quality, quality standards [13, 15, 21, 28, 31], quality of care transistion [15] and, quality of care planning and performance management [15]. Other measures of performance included waiting times for treatment [13], assessement [22] and timeliness of the transfer of information [15]. Further measures of performance are outlined in Table 3.
Thirteen review articles included measures on patient, family, carer and provider perspectives of processes of care. Patients’ perspectives were evaluated through the measurement of patient satisfaction, experience, preferences met, involvement in decision making and, incidents of complaints [13, 15, 20, 21, 23, 29,30,31,32, 34]. Measurement of levels of empowerment and empathy [15, 30, 32], person centeredness [20, 24], personal respect (dignity, confidentiality, autonomy, comfort) [15, 34], compassionate care and, preferred place of death [24] were also identified. Assessment of patient needs were reported in four review articles [13, 22, 32, 34]. Measures of carer experiences and satisfaction [23, 31] were identified in two reviews whilst measures of provider experience [13, 15, 21, 22, 34] were identified in five reviews.
System outcomes
System outcomes were identified in 15 articles mostly identifying measures of health and social care utilisation which broadly covered admissions, discharge and length of stay [13, 19, 21,22,23,24,25,26,27,28,29,30,31,32]; and measures evaluating the number of services used [13, 21,22,23, 26, 28,29,30,31,32, 34]. Costs were evaluated in 13 articles [13, 19, 21,22,23,24, 26,27,28,29,30,31,32]. Measures of accessibility to resources [13], services [13] and culturally appropriate care, specialty or sub-specialty care [21, 24, 26, 34] were reported in five articles. Further details of system outcome measures, including financial, employment, and health claims [34] and vocational status [23] are presented in Table 3.
Health outcomes
Twelve review articles reported the measurement of health outcomes. The majority of these reported the measurement of clinical health, for example, mortality, blood pressure and various condition specific measures [21, 23,24,25,26,27,28,29, 31, 32, 34]. Clinician rated measures of disability and function were reported within six review articles [22,23,24, 27, 28, 32] whilst five reported the use of proxy (clinician- or caregiver-rated) mental health or behavioural measures [22, 23, 25, 28, 32].
Patient- and carer-reported outcomes
Thirteen review articles reported the use of patient- and carer-reported outcomes. Patient health and well-being measures, for example, quality of life and coping with everyday life, were identified in nine articles [22, 23, 25,26,27, 29,30,31, 34], whilst patient-reported physical health featured in eight [23, 25, 27,28,29,30,31, 34]. Patient-reported psychological and social measures were identified in eight articles, for example, measures of mood, psychological well-being, depression and anxiety [23,24,25,26, 28, 29, 31, 34]. Carer-reported measures featured in eight articles and measured areas of carers’ quality of life, mood, distress and burden, and time spent caring [23,24,25,26, 29,30,31,32, 34]. Family involvement in care was also reported in one article [15]. Further patient-reported outcomes identified (for example, activation and engagement [24]) are reported in Table 3.
Challenges in measuring the integration of care
There was broad consensus among the reviews that findings regarding the outcomes of integrated care should be treated with caution as current evidence is limited, inconsistent or descriptive [13, 25, 26, 28]. Challenges to measuring the effects of the integration of care included the identification, and appropriate measurement of, a wide range of mechanisms and outcomes which may be impacted across conceptually diverse interventions [22, 28, 33]. Comparisons between studies included within the reviews were considered difficult due to the heterogeneity of outcomes and study design [22, 24, 28]. Few studies reported within study comparison, for example, usual care versus integration of care, making it difficult to determine effectiveness [22]. Where studies included a control group, it was possible to demonstrate impacts on the costs of integrated care comparatively across three countries [21]. More recently, the development of a methodological approach which uses a broad evaluation framework and the use of Multi-Criteria Decision Analysis has shown the potential of cross country intervention comparisons [24]. Here the authors identify and define uniform outcomes for use across 17 programmes and further identify additional programme specific outcomes where relevant.
A number of reviews highlighted the need to ensure appropriate, valid and reliable measures to advance the measurement of integrated care and to support the development of clinical guidelines [20, 26, 33]. One extensive review of structure and process measures, reported a need for higher quality measures with better measurement properties [20]. Whilst they report the majority of measures focusing on care integration and patient-centred care, they highlight a need for less studied constructs, such as care continuity/comprehensive care and care-coordination/case management to become integral in new measures that may need to be developed. In contrast, a knowledge synthesis of domains and tools measuring progress towards integrated care reported the existence of many tools measuring care coordination, patient engagement and team effectiveness or performance, yet few tools for performance management and information systems, alignment of organisational goals and allocation of resources [15].