The Multiple Meanings of Integration

Integration is not a new topic and yet the term is not universally understood or defined among the health care community. According to the World Health Organization, integrated service delivery is “the organization and management of health services so that people get the care they need, when they need it, in ways that are user-friendly, achieve the desired results and provide value for money.”(1)

In their report “Integrated Health Services: What and Why?” they identify five considerations regarding integrated services. The first, rather than thinking of integration as either good or bad, consider how to deliver services to those who need them. Secondly, integrated services fall along a continuum based on that which is needed to provide quality health services – there are many possible permutations of services. Third, not everything has to be integrated into one package. The aim according to the report “is to provide services which are not disjointed for the user and which the user can easily navigate..” (2) Fourth, changing how services are provided might require “political, technical and/or administrative action. It may require action at several levels, including sustained commitment from the top. It is useful to look for good ‘entry points’ for enhancing integration and to consider what incentives there are for health workers and their managers to change their behavior.” (3) And lastly, integration should not be a response to inadequate resources. Integration may provide saving but inadequate funds will not keep it going indefinitely.

The term integration in the health, field can mean many things. For primary care and public health entities, integration means taking both a population-based and patient-based approach so that both settings can provide for the health and well-being of individuals, communities and populations across the nation. Both approaches relate to and inform each other in ways that could yield substantial and lasting improvements in the nation’s health. (4) Integration can also mean coordinating physical and mental health care. In support of integrated case, The Substance Abuse and Mental Health Services Administration states “integrating mental health, substance abuse, and primary care services produces the best outcomes and proves the most effective approach to caring for people with multiple healthcare needs.” (5)

When considering integration of health services it might be useful to consider the following questions developed by the U.S. Agency for International Development for integration of products and delivery systems. (6) The questions have been adapted slightly to look at integration of health care delivery.

Vision/Goals/Objectives: What is the goal of the integration efforts? Do participants understand and endorse the concepts of integration? Are client (internal and external) requirements/needs known? What client service and performance improvements does the program want to achieve through integration? What characteristics define a well-performing integration in services? Is there a clear vision for what integration will look like? How will the success of integration be measured?

Leadership/Coordination: Is there consensus among leaders within the system about the integration efforts? Can expectations be aligned? Is there a champion to lead the integration effort? Do mechanisms for coordination and communication between sectors exist or can they be created?

Policy: Do clear policies support integration as the intervention for system improvement? If not, how can policies be adapted or created to support integration?

Organizational Development: Do current organizational structures support integration? If not, how can they be adapted? Is there sufficient human resource capacity to implement the integrated system? Are roles and responsibilities clearly defined? What are the organizational-/program-specific ownership and territory issues and do they present obstacles to the integration process? Does the organization have the ability to learn during the integration process and adapt as needed? Is there a change management plan in place or in the planning stage?

Resources/Financing: What are the cost savings the organization hopes to achieve through integration? How will these be measured/assessed? Is there funding for the integration process (including implementation)? Is the funding flexible across products/programs?

In Change Matrix’s work around systems change, we extend this concept of integration into much of our multi-disciplinary systems work. Specifically, in children’s mental health we support the integration of all dimensions of health, using a public health approach to mental health that includes promoting positive health, preventing problems and concerns from escalating, treating identified problems, and re/claiming health. In our work to build and maintain collaborative systems, we support and sustain the integration of various organizations and agencies from different sectors to provide a comprehensive array of services.

(1) Integrated Health Services: What and Why?http://www.who.int/healthsystems/technical_brief_final.pdf
(2) ibid
(3) ibid
(4) Primary Care and Public Health: Exploring Integration to Improve Population Health. http://www.nationalacademies.org/hmd/Reports/2012/Primary-Care-and-Public-Health.aspx
(5) What is integrated care? http://www.integration.samhsa.gov/about-us/what-is-integrated-care
(6) Putting Integration into Perspective: Proven Practices to Strengthen Public Health Supply Chains. http://deliver.jsi.com/dlvr_content/resources/allpubs/logisticsbriefs/InteProvPrac.pdf