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Int J Qual Health Care. 2017 Oct 1;29(5):612-624. doi: 10.1093/intqhc/mzx095.

What works in implementation of integrated care programs for older adults with complex needs? A realist review.

Author information

Institute of Health Policy, Management and Evaluation, Dalla Lana School of Public Health, University of Toronto, 155 College St., Toronto, Canada M5T 3M6.
Department of Psychology, Wilfrid Laurier University, 75 University Ave. West, Waterloo, ON, Canada N2L 3C5.
Dalla Lana School of Public Health, University of Toronto, 155 College St., Toronto, Canada M5T 3M6.
The Change Foundation, 200 Front Street West, Toronto, Canada M5V 3M1.
Centre for Urban Health Solutions, Li Ka Shing Knowledge Institute, St. Michael's Hospital, 30 Bond St., Toronto, Canada M5B 1W8.
Toronto Central Local Health Integration Network, 250 Dundas St. West, Toronto, Canada M5T 2Z5.
Toronto Rehabilitation Institute, 550 University Ave., Toronto, Canada M5G 2A2.
Institute for Clinical Evaluative Sciences, 2075 Bayview Ave., Toronto, Canada M4N 3M5.



A realist review of the evaluative evidence was conducted on integrated care (IC) programs for older adults to identify key processes that lead to the success or failure of these programs in achieving outcomes such as reduced healthcare utilization, improved patient health, and improved patient and caregiver experience.

Data sources:

International academic literature was searched in 12 indexed, electronic databases and gray literature through internet searches, to identify evaluative studies.

Study selection:

Inclusion criteria included evaluative literature on integrated, long-stay health and social care programs, published between January 1980 and July 2015, in English.

Data extraction:

Data were extracted on the study purpose, period, setting, design, population, sample size, outcomes, and study results, as well as explanations of mechanisms and contextual factors influencing outcomes.

Results of data synthesis:

A total of 65 articles, representing 28 IC programs, were included in the review. Two context-mechanism-outcome configurations (CMOcs) were identified: (i) trusting multidisciplinary team relationships and (ii) provider commitment to and understanding of the model. Contextual factors such as strong leadership that sets clear goals and establishes an organizational culture in support of the program, along with joint governance structures, supported team collaboration and subsequent successful implementation. Furthermore, time to build an infrastructure to implement and flexibility in implementation, emerged as key processes instrumental to success of these programs.


This review included a wide range of international evidence, and identified key processes for successful implementation of IC programs that should be considered by program planners, leaders and evaluators.


care coordination; health and social care services; integrated care; older adults

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