Do Austrian “INTEGRI (integrated care) projects” comply with international definitions and concepts?
Do Austrian “INTEGRI (integrated care) projects” comply with international definitions and concepts?
Isabel Geiger 0 1 2
Claudia Wild 0 1 2
0 I. Geiger, MA ( ) University of Liverpool , Liverpool , UK
1 C. Wild Ludwig Boltzmann Institute of Health Technology Assessment (LBI-HTA) , Garnisongasse 7/20, 1090 Vienna , Austria
2 I. Geiger, MA MCI/Management Center Innsbruck , Universitätsstraße 15, 6020 Innsbruck , Austria
Summary One of the biggest challenges for European healthcare systems is the fragmentation of care. To overcome this challenge, integrated care (IC) approaches have been recently implemented. To further improve this method, current and past projects must be monitored and evaluated. However, since the definition of IC is very indistinct and varies significantly in literature, key elements have to be defined. The study design selected was a mixed-methods study that includes two approaches: a systematic literature review and qualitative content analysis of the data provided by the Ludwig Boltzmann Institute. Nine key elements of IC projects were identified in the literature review and subsequently compared with the main features coded from previous INTEGRI applications. The results showed that 41 of the applications presented seven or more criteria in their official submission form. The conclusion of the results can be drawn as a justification and validation of the INTEGRI criteria. Although the results are positive on the whole, three recommendations on possible improvements are given.
Integrated care; Key elements; INTEGRI award
Very recently The King’s Fund published a paper on
the effects (challenges and impact) of new or
Do Austrian “INTEGRI (integrated care) projects” comply with international definitions and concepts?
tended roles in delivering integrated care (IC) .
Once again this article highlights the importance
of IC as a possibility to overcome the challenges of
European healthcare systems, which are currently
struggling with the fragmentation of care, disjointed
pathways for patients resulting in a higher rate of
adverse hospitalisation, diagnostic workup,
medical errors and inferior outcomes, in addition to the
changing medical needs of people .
Austria, as one example of a highly fragmented
healthcare system, has made efforts in its “Federal
Targeting-Agreement for Health 2013–2016” to
stimulate IC projects and activities. To give attention to
those efforts the INTEGRI award, as one example, was
launched in 2011 with its main purpose of honouring
professionals and organisations that contribute with
innovative ideas, tender projects tackling the
challenges of a constantly changing health environment
and assist in improving the Austrian healthcare
system through integrated care approaches [3, 4]. When
INTEGRI was awarded for the first time (2012), a total
number of 36 submissions supported the
preliminary assumption that IC was already highly valued in
Austria and many professionals devoted their work
to it. By 2014, an additional 17 applications were
submitted, resulting in a total of 53 different projects.
To further improve IC approaches in the future,
current and past projects must be monitored and
evaluated. However, since the definition of IC is very
indistinct and varies significantly in literature, the
evaluation of such projects appears to be very challenging.
To enable a valid, replicable and transparent
evaluation process, key elements have to be defined.
The purpose of this research was to conduct
accompanying research to the INTEGRI award. The
following paper will give a systematic literature review on
published concepts, guidelines, principles and
recommendations established by the WHO (World Health
Organisation) and the European Union to identify key
elements of IC projects. In addition, this paper will
apply the criteria used for assessing the INTEGRI
applications to contribute to the advancement (and
objectification) of the Austrian award along international
The research is based on a mixed-methods study,
including two approaches: a systematic literature review
and qualitative content analysis of the data (INTEGRI
For the literature review, a comprehensive
literature search in three electronic bibliographic databases
and search engines was performed on the 22 February
2016 using PubMed, Embase and ScienceDirect. The
following combinations of terms were used for
detecting appropriate literature: “integrated care” AND
“evaluation”, “integrated care” AND “principles”,
“delivery of health care, integrated” and “integrated care”
AND “policy”. Additionally, the International Journal
of Integrated Care (IJIC) and the Journal of Integrated
Care (JICA) were handscreened systematically. Also,
hand search for grey literature, especially for those
published by the WHO Regional Office for Europe, the
European Commission and the European Parliament
was carried out.
Predefined selection criteria for inclusion were
(1) published between 2011 and 2016, (2) availability
in English or German and (3) description and
explanation of key elements, features or criteria for evaluating
IC projects. Exclusion criteria were all articles which
(1) mainly focused on reporting clinical
interventions and outcomes, (2) pilot studies or (3) studies
conducted in middle- or low-income countries.
About 3000 studies were identified and after
removing duplicates, 1052 were screened (abstracts only).
Subsequently, 120 full texts were acquired for further
detailed investigation. Finally, after excluding another
101 articles and including studies obtained by hand
search (n = 7), 26 articles met the inclusion criteria
and were therefore used to identify key elements .
The assessment of the quality of the 26 included
publications was conducted in a mixed form: For
assessing the quality of literature reviews, the AMSTAR
checklist  was used. Due to the lack of validated
quality assessment tools for other study types, ranks
between ‘high’, ‘medium’ and ‘low’ were assigned
using a modified version of Harden’s quality assessment
, categorising the publications on three quality
levels. Additionally, all studies included were assigned
to four categories, beginning with the most relevant
studies (1) literature reviews and mixed-study
methods including reviews, (2) policy papers, (3)
framework analysis, rationales and reports and (4) journal
articles, commentaries and declarations. To enable
comparability between different categories, the
AMSTAR scores were also divided into ‘low’ (score 0–3),
‘medium’ (4–7) and ‘high’ sections.
To examine both the literature review and the
analysis of the data (INTEGRI award submissions) in a
systematic way, a qualitative content analysis approach
based on Philipp Mayring was used . As a first step,
the category definition and the level of abstraction
were decided. Once central rules of category
formation were defined, all 26 publications were analysed
carefully and essential phrases were highlighted. Each
important phrase was listed (and clustered if
necessary) and respective categories were formulated. To
check whether the categories fit to the research
question and also to make sure that all central aspects were
noted, a revision of all articles was performed. In an
iterative process of categorisation and revision,
certain categories were combined and others were split
into separate topics. Following the revision, a final
coding of important phrases was carried out,
starting from the beginning of the articles for enhancing
“intra-coder agreement” .
Table 1 Key elements of integrated care as described in recent publications (2011–2016; n = 26) and applied to INTEGRI
submission (2012, 2014; n = 53)
People empowerment and focus on
Change management and governance n = 20
[9, 13, 15–23, 25, 27–34]
Enabling and supportive environment
Clear goals and persistent evaluation
The analysis of the INTEGRI award submissions
was carried out in the same manner, with
identical rules. However, after coding important phrases,
listing and revising them, no new categories were
formulated. Instead, the project characteristics were
matched deductively with the key elements in the
final part of the paper. For clarity and
comprehensibility, project phrases describing similar aspects were
Publication characteristics and quality: Eleven
publications were identified and classified as category one
(n = 11: literature reviews, 42%), representing the
largest group [9–19], of which the scores of the
AMSTAR checklist ranged from two to eight points (low
to medium quality). Three articles were classified as
category two (n = 3: policy papers, 12%) ranging from
‘low’  to ‘medium’ [21, 22] quality. Nine
publications were listed under category three (n = 9:
framework analysis, rationales and reports, 34%) equally
distributed between ‘low’ [23–25], ‘medium’ [26–28]
and ‘high’ quality [29–31]. Category four (n = 3:
journal articles, commentaries and declarations, 12%)
appeared to have the lowest quality with one ‘medium’
quality article  and two publications which both
classified as ‘low’ quality [33, 34]. The majority of the
selected articles (n = 16, 60%) were funded by public
organisations or health institutions such as the WHO
and Ministries of Health. Additionally, about 80% of
the publications were conducted in Europe (n = 21),
specifically in the Netherlands (n = 5), Belgium (n = 4)
and Denmark (n = 3).
Key Elements of Integrated Care: Table 1 provides
an overview of each key characteristic identified in
the literature analysis, its frequency and the relevant
studies. For a better understanding of the elements,
they are briefly described. Importantly, since some of
the categories have been mentioned more often than
others, they are additionally ranked.
People empowerment and focus on patients: One out
of two most frequently (n = 20) mentioned elements is
people or patient empowerment defined by providing
support in self-management, emphasising patient
education, individual skill development and supporting
people to enable deliberate decisions .
Furthermore, healthcare providers should see them not only
as their patients, but rather as partners in attaining
the common goal of better health . To
additionally increase people’s quality of life, the use of
individualised care (also referred to as personalised care
planning ) with a central focus on patient’s health
needs and preventive measures was also emphasised.
Change management and governance (n = 20) is
described as explicit, but flexible management, as well
as integrated governance. Another feature referred to
was the implementation of specific change
management strategies to decrease or handle people’s
potential resistances to change . Also, as Nicholson et al.
 pointed out, a strong commitment to
strengthening clinical leadership and improving accountability
by defining responsibilities and coordinating services
can be seen as additional attributes of IC projects.
Common care strategies (n = 19), as a key feature
of IC that not only focuses on the outcome, but also
concentrates on the care delivery process itself .
Mitchell et al.  stressed the creation and
implementation of care pathways; other authors point to
evidence-based guidelines/protocols  to align
policies as substantial instruments .
Workforce development (n = 17) refers to
professional integration and the development of
multidisciplinary teams. Mitchell et al.  highlight the
importance of the right mixture of interdisciplinary
professionals and clearly defined roles and
responsibilities for facilitating an intra- and extramural
communication and cooperation. Furthermore, a part of
professional development is ongoing education and
training, either in the area of IC, familiarising the
different professionals with common strategies and
values of joint working, or in exchanging knowledge of
different healthcare providers .
Enabling and supportive environment (n = 17):
Having an environment with supportive legislations and
policies enabling the implementation of IC models
was repeatedly mentioned. Specifically,
incentivising the delivery of IC, either by incentives for
performance or by generating commitment, is pointed out
by Lyngso et al. . Other possible approaches
include engaging stakeholders by implementing
roundtables , supporting a paradigm shift and
integrating patients in their communities by, e. g., involving
their families .
Uniform information and communication
technology (n = 16): The need for a universally applicable
clinical information system is mentioned as of
relevance. Lyngso et al.  expressed the importance of
a centralised patient record system for enhanced and
efficient information flow. This, however, requires the
willingness to share information and a high level of
trust of all stakeholders involved . Moreover, to
achieve an end-to-end information exchange, a
standardised, specifically dedicated software was claimed
to be useful .
Innovative financing (n = 14): Like in any other
sector, IC projects also need to have adequate, viable
financing methods to be sustainable .
Communitybased finance models were described as an example
for the cost-efficient use of resources .
MartinezGonzález et al.  stress the potential option for IC
projects to pool funds across several levels of care.
Clear goals and persistent evaluation (n = 14): For
evaluating the effects of IC, clear goals are necessary.
van Houdt et al.  state explicitly the importance
of identifying clear goals and defined target groups.
Additionally, measurement tools for recording
quality improvement and/or performance and health
outcomes should be implemented .
Continuity of care (n = 10): Importantly,
continuity of care has to be seen from a patient’s point of
view and refers to his/her perception of a coherent
and comprehensive care delivery process .
Providing equitable access, preferably by a single point of
entry and smooth transitions between different
careproviders, are also noted frequently . Moreover,
having consistency in health professionals is seen by
the WHO  as a decisive factor for enhancing user
satisfaction and providing patients with a positive
experience which, in turn, should facilitate better health
Project characteristics: 53 INTEGRI award
submissions were analysed: 36 different projects descriptions
submitted in 2012 (68% of all) and a further 17 (32%)
from 2014. The length of the applications was
between 5 and 27 pages. The descriptions included
general information, epidemiology, goals,
methods, integration, patient centeredness, transferability,
cost–benefit relation, quality management,
communication and marketing concept, concept for
evaluation, evaluation results, room for improvements and
attachments for supplementary information. Most
applications were carried out by public institutions
(n = 23) like regional hospitals or social care homes,
which represented 43% of all submissions. A number
of the 49 projects (92.5%) are currently ongoing or
have already been carried out and evaluated. Only
7.5% (or four candidate submissions) were still in the
phase of developing ideas.
Key elements in the description of the INTEGRI
submission (projects): Table 1 provides a comparison
between each key characteristic identified in the
literature analysis and applied to the submitted projects
and their frequency in the respective 53 submissions,
described here in their order of giving weight to the
Clear goals and persistent evaluation (n = 52): The
project intentions for evaluating outcome or success
are varying in quantity between one to six concrete
goals, and are omnifarious, including, e. g. the usage
of synergies or improvements in efficiency in
diagnostics and therapy. In all, 35 submissions are intending
to improve the quality of care, comprising aspects like
enhanced survival rates or specialised treatments. For
evaluation purpose, e. g. feedback is acquired through
patient- and relative-questionnaires or through
cooperation with universities or other external analysts.
Innovative financing (n = 52): Efficient re-allocation
of acquired savings implies transparency in costing
and billing. Such savings can be earned—as claimed
in the submissions—with fewer needed transports,
shortened hospital stays and/or fewer (re-)admissions
by decreasing the number of emergencies,
complications and recurrences of diseases (revolving door
effect). Additionally, the relief of other sectors, the
avoidance or delay of early exit of a working life, as
well as the reduction of sick leaves contribute to the
need for innovative ways of resource management,
since optimised financial management contributes to
the sustainable usage of resources by avoiding
redundancies in services. Therefore, the projects suggest
good documentation of costs and avoided costs.
People empowerment and focus on patient (n = 51):
Most projects explicitly declare to be patient-centred
or patient-oriented, including the provision of
individualised services based on patients’ needs, and
offering direct patient–doctor dialogues. Additionally,
enhanced quality of life through, e. g. the
improvement of patients’ satisfaction, improved safety in
treatment and less suffering of patients, as well as
higher survival rates, is expected. Several projects
highlighted the importance of regaining patients’
autonomy and maintaining their self-responsibility. The
provision of detailed information and issuing clear
instructions to enable self-management is
implemented. In addition, a few applications claimed to
emphasise patient empowerment through enhanced
education and training.
Workforce development (n = 49): Most projects
include components of communication, professional
integration and multidisciplinary teamwork. The
enhancement of intra- and extramural cooperation by
fostering the communication between the different
sectors is stressed. The improvement of
multiprofessional teamwork includes the integration of social
services, care nurses and general practitioners (GP) and
the offering of multidisciplinary support. Advanced
educational programmes comprising new learning
techniques and methods, knowledge exchange in
multiprofessional workshops and meetings,
problembased learning as well as cross-sector training to
improve the level of knowledge in all services are offered
in the projects.
Common care strategies (n = 48): Most submissions
not only incorporate standardised assessments of the
patients, including predefined parameters, indicators
and measures, but also standardise the processes of
service delivery by implementing treatment pathways
or care plans and by developing clear guidance on
different levels of care. The compliance with
evidencebased guidelines or with best practices models is
Enabling and supportive environment (n = 38): The
cooperation between all stakeholders and their
involvement in the process of developing common goals
is mentioned as a major enabler and organised in
most projects. Furthermore, the integration of
relatives, e. g. by offering educational programmes or
psychological support to ease their burden, as well as
other surrounding factors like the destigmatisation of
mental diseases and the sensitisation of the
environment, as well as the inclusion of the communities and
the social environment by offering public relations
(PR) activities to avoid future conflicts, are
emphasised. Financial incentives to enhance the compliance
of GPs are mentioned for facilitating cooperation.
Continuity of care (n = 37): Particularly the
provision of equitable access, as well as a coherent and
comprehensive care delivery process with consistent
personnel by granting gapless documentation and an
end-to-end cooperation, are planned and organised
in most submissions. Securing the access to care by
removing barriers like waiting times and thereby
easing the admission process, or by offering additional
treatment and prompt diagnosis are activities within
Change management and governance (n = 36):
Clearly defined and agreed upon responsibilities,
definitions of work-flow and tasks as well as explicit
(disease- and discharge-) management or integrated
governance (case management) and interface
management between different sectors are stated in the
applications. The service coordination throughout
different levels of care and specific change
management activities in implementation is also stressed by
Uniform information and communication
technology (n = 23): Universally applicable information and
communication technologies (ICT) with uniform
medical records are mentioned in about half of the
submission. Solutions are, e. g. a central database,
telemedicine, common electronic documentation or
specific software connecting different sectors.
Comparison of INTEGRI award submissions with
literature key elements
After the analysis of the 53 INTEGRI submissions,
grouped characteristics (features) were created whilst
comparing the coded phrases with the literature (see
Table 1). The results illustrate that a minimum of
four out of nine elements were met by each INTEGRI
project. Furthermore, 41 of all INTEGRI
submissions presented seven or more key criteria in their
application. One-third of the submissions (n = 18,
34%) included eight key elements. Five of the
elements were mentioned by 90% and more. In specific,
those most frequently mentioned were “innovative
financing” as well as “common goals and persistent
evaluation”; each was only missing in one project.
In more detail, the majority mentioned the feature
of “specific goals” also in the context of cost savings,
re-allocation of resources and efficiency and
therefore showed an overlap with “innovative financing”.
“Patient empowerment and focus on patient” was
mentioned in 51 submissions, most often described
as patient-centred. “Enabling and supportive
environment”, “continuity of care” and “change management
and governance” were incorporated by 60–80% of all
Summary and discussion of findings
IC is a very complex and multifaceted area which tries
to connect different stakeholders throughout all
sectors of health. Although efforts on enhancing the
taxonomy have already been made, e. g. by Valentijn et al.
, there is still no uniform definition available.
Consequently, identifying key elements out of an
indefinable subject is challenging and requires certain
delimitation. For that reason, the literature review was
restricted in time, language and type of study.
Nevertheless, the elements identified are still relatively
widespread and give an ample scope of interpretation.
This limiting factor might have negatively impacted
the results presented in this paper.
In this respect, it has to be further mentioned that
all analysed documents, including the articles from
literature and the project submission forms, were
carefully read, reread and revised to enhance the
“intracoder agreement”, also referred to as intratester
reliability. But, to comply with the guidelines based on
Mayring , it would have been valuable if a second
analyst had been involved to improve the interrater
reliability. Another possible approach in this regard
would have been including a computer-based
programme to analyse all documents. However, due to
time restrictions and the scope of this paper, neither
a computer-based system nor a second examiner was
included in this research.
The results of this paper contribute to the
understanding of IC by contrasting the theoretical concepts,
approaches, guidelines, principles and
recommendations with real-life examples. Those projects include
the implementation and organisation of IC for chronic
diseases and/or a successful integration of social care
with the healthcare sector. More specifically, the
results show that almost all key characteristics were
mentioned by about 70% and more of the projects
(n ≥ 36). This can most probably be attributed to the
submission form, which already requires several key
elements itself (patient-centeredness, clear goals and
an evaluation concept, including cost–benefit
assessment and quality management, costing and billing
Although having a template aided many applicants
in submitting a comprehensive report, the analysis
also showed that it was not only beneficial. Uniform
information and communication technology (ICT),
for instance, was found in less than 50% of the project
descriptions. The fact that ICT is not separately
mentioned as a specific area in the official submission
form could be suspected as one of the reasons. Other
explanations for the low quantity of projects
describing ICT, however, could also be the novelty of this
approach. Also, if no information technology (IT)
system has ever been established, implementing a new
one would be an expensive investment. Furthermore,
as Mitchell et al.  highlighted, having a uniform
IT platform needs a high level of trust and
willingness of all stakeholders to share information. This
constitutes a big issue in Austria exemplified during
the implementation phase of the electronic medical
health record (ELGA), where medical doctors,
especially GPs, launched a campaign asking patients to
refrain from ELGA for data protection reasons .
Another element that was not separately required
on the application form, but could be found within
other sections was “change management and
governance”, which was described rather implicitly by less
than 70% applicants with defining responsibilities,
etc. Nonetheless, not only due to the fact that change
management and governance was most frequently
mentioned in literature, but also because of the high
number of aspects it includes, it might be focused
on more extensively in future award applications (as
much as in setting-up the projects).
The economic impact of IC projects was not
included, neither within the key elements nor in the
project analysis, although terms like cost efficiency
and cost savings as aspects of innovative financing
were repeatedly found. The underlying reasons for
that consist of the complexity of an impact evaluation
and the lack of appropriate data. However, obtaining
profound evidence/data on the estimated amount
in savings and cost efficiency would be desirable for
future analysis. It would especially be of essence
because the effects of IC approaches and their
economic impact are still unclear. Having data on
reallife projects in this area could support researchers like
Nolte and Pitchforth , who already made significant
efforts in gathering information on utilisation, cost
effectiveness and costs/expenditures.
The literature review aimed at identifying key
elements of IC projects through a systematic literature
research. Although the electronic database search
was supplemented with a hand search for grey
literature, publication bias cannot be ruled out. As
noted earlier, the lack of international taxonomy of
IC constitutes another limitation, which in turn may
reduce the validity of the search terms used.
Moreover, although scientific articles are usually published
in English, some relevant literature could have been
missed because of language restrictions. All articles
included highlighted certain aspects of IC projects,
which have later been coded to identify the key
elements. However, only a small number of studies
had their primary focus on the evaluation of IC. The
assessment of the INTEGRI submissions was based
on a qualitative content analysis approach. However,
biases due to potential, unwitting personal
selectivity cannot be completely ruled out. Furthermore,
the analysis performed was based on theoretical and
qualitative elements only. There was no quantitative
The main contribution of this paper is the
determination of the criteria used for assessing the INTEGRI
applications. The underlying aim was to validate these
criteria and to contribute to the advancement and
objectification of the Austrian award along international
concepts and definitions. To fulfil this purpose, key
elements from literature were compared with the
information provided by the 2012 and 2014 INTEGRI
participants. Special focus in analysing the projects
was put on the official submission forms, primarily
to see if the information which had to be provided
corresponds to the aspects identified in the literature.
As the results show, all applications include at least
four out of nine key elements. Most elements, in turn,
were mentioned by 70% of the projects and more.
Additionally, having a mean of seven incorporated
elements can also be seen as an achievement. Therefore,
the conclusion of the results can be drawn as a
justification and validation of the INTEGRI criteria.
It is not only an acknowledgement for the INTEGRI
award itself, but also for Austrian policy makers in
healthcare. Their previous efforts to implement IC as
a response to the current challenges of the health
system have shown to be successful. Although the results
are positive on the whole, three recommendations on
possible improvements are given:
One aspect found to be lagging behind others and
which should be considered for future developments
of the official submission form was uniform
information and communication technologies. It would be
advisable to include this in the template as a separate
area, like patient centeredness.
Another suggestion concerning the adaptation of
the submission form is to enclose additional parts
of the element change management and governance.
A new version could also include questions about
defining responsibilities within the project and how
change management will be/was implemented.
It is also recommended that if future INTEGRI
awarding wants to honour not only innovative
approaches in the field but also contribute to the
advancement of the research in this area, the economic
impact of IC projects should be outlined as well.
A possible suggestion for modifying the cost–benefit
requirements would be to add specific questions on
innovative ways of financing.
In general, further research on the definition of IC
should be carried out to facilitate international
comparison. Importantly, search terms used should then
also include “stepped care” and other synonyms of
IC. Moreover, and also regarding the
recommendation above, additional research on the real economic
impact of IC and propositions on how to measure it
accurately is recommended.
Acknowledgements INTEGRI supported the research by
providing access to the 2012 and 2014 applications; LBI-HTA
supported the research with a small grant.
Open access funding provided by University of Liverpool.
Conflict of interest I. Geiger and C. Wild declare that they
have no competing interests.
Open Access This article is distributed under the terms of
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Commons license, and indicate if changes were made.
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