A framework approach to enable local leaders integrate care for older persons: moving from the ‘what’ to the ‘how’

Abstract

The aging population is a healthcare 'game changer' (1,2,3) Multi-morbidities increase with age and in turn require more resource (4,5,6). Integrated care is proposed as a key component of addressing this policy challenge, (7,8,9,10). There is growing evidence on 'what works' in integrating and improving care for older persons (11,12,13,1415,16,17), but how best to implement this systemically, beyond local initiatives is less clear (18,19). Large change initiatives are typically centrally defined, 'policy heavy' and overly programmatic, whilst emergent ('bottom up') approach have inherent weaknesses due to problems of fidelity and consistency when deployed systemically. In the messy reality of increasingly pressurised health care environments, the clinical and managerial leaders tasked with delivering these change are doing so as an 'add on' to their normal operational or clinical role. The role and influence of political ideology, professional groups and organisational complexity has challenged contemporary approaches to improvement. A critical starting point is to recognise the context for implementation as that of a complex adaptive system and to ensure the methodology associated with design and implementation of integrated care recognises this (20, 21, 22, 23). In recognition of this dynamic, this paper proposes a rationale for adopting a framework approach to implementing integrated care and in doing so seeks to bridge the 'implementation gap' (24, 25, 26).