Getting to YES. Negotiating Agreement Without Giving In

Section I: Primary Care: Concept and Goals. 1: What is primary care?. 2: A basis for evaluating primary care. Section II: Elements of Primary Care. 3: First contact care and gatekeepers. 4: Longitudinality and managed care. 5: Comprehensiveness and benefit packages. 6: Coordination and the processes of referral. Section III: Primary Care in the United States. 7: Characteristics of practice and practitioners. 8: Organization, financing, and access to services. Section IV: Issues in Primary Care. 9: What type of physicians should provide primary care. 10: Medical records and information systems in primary care. 11: Physician-patient interactionsin primary care. 12: Quality assessment and quality improvement. 13: Community oriented primary care. Section V: Primary Care Systems. 14: Evaluation of primary care programs. 15: Cross-national comparisons of primary care. 16: A research agenda. 17: A policy agenda and epilogue

Primary Care: Concept, Evaluation, and Policy

Primary Care: Concept, Evaluation, and Policy is a comprehensive treatise that should be obligatory reading for all physicians and for legislators planning the future of health care in the United States. Dr Starfield, in this well-written and easily readable book, objectively reviews the concept of primary care in its entirety. She constructs the argument for primary care starting with a historical review. Within the book's first chapter, the need for restructuring from a primary medical to a primary health care model is introduced. Such a change requires new focus (eg, from illness to health), new content (eg, from treatment to health promotion), new organization (eg, from specialists to generalists), and new responsibility (eg, from professional dominance to community participation). To evaluate the rationale and the success of such a change, Dr Starfield reviews the 1978 Institute of Medicine approach to assessing the success of a health care system, noting accessibility,

Integrated care is a key strategy in reforming health systems around the world. Despite its importance, the concept's polymorphous nature and lack of specificity and clarity significantly hamper systematic understanding, successful application and meaningful evaluation. This article explores the many definitions, concepts, logics and methods found in health system and service integration. In addition to framing this evolving, albeit imprecise field, the article summarizes the main elements or building blocks of integrated care and suggests a way to address its various complexities and unknowns in a real-world sense.

All Together Now: A Conceptual Exploration of Integrated Care.

A textbook of family medicine

Introduction: Primary care has a central role in integrating care within a health system. However, conceptual ambiguity regarding integrated care hampers a systematic understanding. This paper proposes a conceptual framework that combines the concepts of primary care and integrated care, in order to understand the complexity of integrated care. Methods: The search method involved a combination of electronic database searches, hand searches of reference lists (snowball method) and contacting researchers in the field. The process of synthesizing the literature was iterative, to relate the concepts of primary care and integrated care. First, we identified the general principles of primary care and integrated care. Second, we connected the dimensions of integrated care and the principles of primary care. Finally, to improve content validity we held several meetings with researchers in the field to develop and refine our conceptual framework. Results: The conceptual framework combines the functions of primary care with the dimensions of integrated care. Person-focused and population-based care serve as guiding principles for achieving integration across the care continuum. Integration plays complementary roles on the micro (clinical integration), meso (professional and organisational integration) and macro (system integration) level. Functional and normative integration ensure connectivity between the levels. Discussion: The presented conceptual framework is a first step to achieve a better understanding of the inter-relationships among the dimensions of integrated care from a primary care perspective.

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Understanding integrated care: a comprehensive conceptual framework based on the integrative functions of primary care.

Introduction: Building integrated services in a primary care setting is considered an essential important strategy for establishing a high-quality and affordable health care system. The theoretical foundations of such integrated service models are described by the Rainbow Model of Integrated Care, which distinguishes six integration dimensions (clinical, professional, organisational, system, functional and normative integration). The aim of the present study is to refine the Rainbow Model of Integrated Care by developing a taxonomy that specifies the underlying key features of the six dimensions. Methods:  First, a literature review was conducted to identify features for achieving integrated service delivery. Second, a thematic analysis method was used to develop a taxonomy of key features organised into the dimensions of the Rainbow Model of Integrated Care. Finally, the appropriateness of the key features was tested in a Delphi study among Dutch experts. Results:  The taxonomy consists of 59 key features distributed across the six integration dimensions of the Rainbow Model of Integrated Care. Key features associated with the clinical, professional, organisational and normative dimensions were considered appropriate by the experts. Key features linked to the functional and system dimensions were considered less appropriate. Discussion:  This study contributes to the ongoing debate of defining the concept and typology of integrated care. This taxonomy provides a development agenda for establishing an accepted scientific framework of integrated care from an end-user, professional, managerial and policy perspective.

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Towards a taxonomy for integrated care: a mixed-methods study

Introduction: The conceptual ambiguity of the integrated care concept precludes a full understanding of what constitutes a well-integrated health system, posing a significant challenge in measuring the level of integrated care. Most available measures have been developed from a disease-specific perspective and only measure certain aspects of integrated care. Based on the Rainbow Model of Integrated Care, which provides a detailed description of the complex concept of integrated care, a measurement tool has been developed to assess integrated care within a care system as a whole gathered from healthcare providers’ and managerial perspectives. This paper describes the methodology of a study seeking to validate the Rainbow Model of Integrated Care measurement tool within and across the Singapore Regional Health System. The Singapore Regional Health System is a recent national strategy developed to provide a better-integrated health system to deliver seamless and person-focused care to patients through a network of providers within a specified geographical region. Methods: The validation process includes the assessment of the content of the measure and its psychometric properties. Conclusion: If the measure is deemed to be valid, the study will provide the first opportunity to measure integrated care within Singapore Regional Health System with the results allowing insights in making recommendations for improving the Regional Health System and supporting international comparison.

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A Prospective Validation Study of a Rainbow Model of Integrated Care Measurement Tool in Singapore

Background
Developing integrated service models in a primary care setting is considered an essential strategy for establishing a sustainable and affordable health care system. The Rainbow Model of Integrated Care (RMIC) describes the theoretical foundations of integrated primary care. The aim of this study is to refine the RMIC by developing a consensus-based taxonomy of key features. 

Methods
First, the appropriateness of previously identified key features was retested by conducting an international Delphi study that was built on the results of a previous national Delphi study. Second, categorisation of the features among the RMIC integrated care domains was assessed in a second international Delphi study. Finally, a taxonomy was constructed by the researchers based on the results of the three Delphi studies. 

Results
The final taxonomy consists of 21 key features distributed over eight integration domains which are organised into three main categories: scope (person-focused vs. population-based), type (clinical, professional, organisational and system) and enablers (functional vs. normative) of an integrated primary care service model. 

Conclusions
The taxonomy provides a crucial differentiation that clarifies and supports implementation, policy formulation and research regarding the organisation of integrated primary care. Further research is needed to develop instruments based on the taxonomy that can reveal the realm of integrated primary care in practice.

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Towards an international taxonomy of integrated primary care: a Delphi consensus approach

This thesis aimed to contribute to a better understanding of what integrated primary care is, and how it can be achieved by focussing on the collaboration processes that underlie the development of integrated primary care. The first part of this thesis operationalized the concept of integrated care from a primary care perspective. The second part of this thesis described the collaboration mechanisms among integrated care projects that were part of a national integrated primary care study in The Netherlands.

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Pim P. Valentijn

Papers

Understanding integrated care: a comprehensive conceptual framework based on the integrative functions of primary care.

Towards a taxonomy for integrated care: a mixed-methods study

A Prospective Validation Study of a Rainbow Model of Integrated Care Measurement Tool in Singapore

Towards an international taxonomy of integrated primary care: a Delphi consensus approach

Rainbow of Chaos: A study into the Theory and Practice of Integrated Primary Care