Reframing the challenges to integrated care: a complex-adaptive systems perspective
Open accessAbstract
INTRODUCTION: Despite over two decades of international experience and research on health systems integration, integrated care has not developed widely. We hypothesized that part of the problem may lie in how we conceptualize the integration process and the complex systems within which integrated care is enacted. This study aims to contribute to discourse regarding the relevance and utility of a complex-adaptive systems (CAS) perspective on integrated care. METHODS: In the Canadian province of Ontario, government mandated the development of fourteen Local Health Integration Networks in 2006. Against the backdrop of these efforts to integrate care, we collected focus group data from a diverse sample of healthcare professionals in the Greater Toronto Area using convenience and snowball sampling. A semi-structured interview guide was used to elicit participant views and experiences of health systems integration. We use a CAS framework to describe and analyze the data, and to assess the theoretical fit of a CAS perspective with the dominant themes in participant responses. RESULTS: Our findings indicate that integration is challenged by system complexity, weak ties and poor alignment among professionals and organizations, a lack of funding incentives to support collaborative work, and a bureaucratic environment based on a command and control approach to management. Using a CAS framework, we identified several characteristics of CAS in our data, including diverse, interdependent and semi-autonomous actors; embedded co-evolutionary systems; emergent behaviours and non-linearity; and self-organizing capacity. DISCUSSION AND CONCLUSION: One possible explanation for the lack of systems change towards integration is that we have failed to treat the healthcare system as complex-adaptive. The data suggest that future integration initiatives must be anchored in a CAS perspective, and focus on building the system's capacity to self-organize. We conclude that integrating care requires policies and management practices that promote system awareness, relationship-building and information-sharing, and that recognize change as an evolving learning process rather than a series of programmatic steps.
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Common barriers such as absence of healthcare policies and supporting strategies, inadequate interdisciplinary training and workload increase seem to depend on both contextual and individual factors rather than discipline itself.
“Common barriers such as the absence of healthcare policies and supporting strategies, inadequate interdisciplinary training and workload increase seem to depend on both contextual and individual factors rather than the discipline itself.”
From Barriers and facilitators in the integration of oral health into primary care: a scoping review (2017) · cites this paper as [79]
The Results (Diverse, interdependent and semi-autonomous actors) link barriers to limited understanding, lack of time and resources, and environmental factors; the Results (Self-organizing capacity and simple rules) also describe policy and funding barriers. The paper does not identify inadequate interdisciplinary training or increased workload as the stated barriers, nor does it conclude that barriers depend on context and individuals rather than professional discipline. (LLM, conf=0.86)
Experimental — accuracy not yet measuredThe results of the present scoping review are in line with publications on the challenges faced in implementation of integrated care.
“The results of the present scoping review are in line with publications on the challenges faced in the implementation of integrated care.”
From Barriers and facilitators in the integration of oral health into primary care: a scoping review (2017) · cites this paper as [79]
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Ellis, L. A., Churruca, K., & Braithwaite, J. (2017) · International Journal of Mental Health Systems · doi:10.1186/s13033-017-0150-6 · Cited by 52 · see citing works
“This ‘hands-off’ approach is in stark contrast to most modern bureaucracies, including that of the headspace National Office, which has been criticised for imposing change via direct authority rather than supporting bottom-up collaboration [22].”
ResultGrudniewicz, A., Tenbensel, T., Evans, J. M., Gray, C. S., Baker, G. R., & Wodchis, W. P. (2017) · Social Science & Medicine · doi:10.1016/j.socscimed.2017.12.029 · Cited by 52 · see citing works
Self-citationPower and Integrated Health Care: Shifting from Governance to Governmentality
van Rensburg, A. J., Rau, A., Fourie, P., & Bracke, P. (2016) · International Journal of Integrated Care · doi:10.5334/ijic.2480 · Cited by 47 · see citing works
Aantjes, C., Quinlan, T., & Bunders, J. (2014) · Globalization and Health · doi:10.1186/s12992-014-0085-5 · Cited by 47 · see citing works
“Experiences with aligning the health and social welfare sectors in high-income countries have shown variable success [59-62] but a necessary ongoing process in view of changing health care demands as a result of ageing populations and chronic illnesses [63,64].”
BackgroundCOVID-19 – An Opportunity to Redesign Health Policy Thinking
Sturmberg, J. P., Tsasis, P., & Hoemeke, L. (2020) · International Journal of Health Policy and Management · doi:10.34172/ijhpm.2020.132 · Cited by 46 · see citing works
“Systems as “whole[s] consisting of two or more parts (1) each of which can affect the performance or properties of the whole, (2) none of which can have an independent effect on the whole, and (3) no subgroup of which can have an independent effect on the whole.”
BackgroundSelf-citationFleury, M., Grenier, G., Vallée, C., Aubé, D., & Farand, L. (2017) · International Journal of Integrated Care · doi:10.5334/ijic.2482 · Cited by 46 · see citing works
“These factors are usually underlined in the literature as important barriers to integration [23, 37, 38, 40].”
BackgroundApplication of complexity theory in health and social care research: a scoping review
Carroll, Á. M., Collins, C., McKenzie, J., Stokes, D., & Darley, A. (2023) · BMJ Open · doi:10.1136/bmjopen-2022-069180 · Cited by 46 · see citing works
Evans, J. M., MacKinnon, M., Pereira, J. L., Earle, C. C., Gagnon, B., Arthurs, E., Gradin, S., Buchman, S., & Wright, F. C. (2019) · Psycho-Oncology · doi:10.1002/pon.5076 · Cited by 44 · see citing works
“Weak links between hospitals and community‐based providers exacerbate limited access to and integration of palliative care for patients with cancer.(17-19) The overall goals of INTEGRATE were to (a) enhance provider knowledge and”
BackgroundSelf-citationAllen, E., Elliott, D., & Jackson, D. W. (2017) · Journal of Clinical Nursing · doi:10.1111/jocn.13839 · Cited by 42 · see citing works
Co-Leadership – A Management Solution for Integrated Health and Social Care
Klinga, C., Hansson, J., Hasson, H., & Sachs, M. A. (2016) · International Journal of Integrated Care · doi:10.5334/ijic.2236 · Cited by 38 · see citing works
“Transformation of the current approach to organizing health and social care has been proposed as a way to achieve better continuity in care [1, 18].”
Backgroundvan Rensburg, A. J., & Fourie, P. (2016) · International Journal of Mental Health Systems · doi:10.1186/s13033-016-0081-7 · Cited by 38 · see citing works
“Within this broad categorisation, integrated care has been used to refer to as a patient-centred, demand-driven linking of the health care system with other human service systems on multiple levels to address complex health needs [25, 36, 37]; the consolidation of a range of behavioural, medical and other elements int…”
BackgroundDeconstructing design thinking as a tool for the implementation of a population health initiative
Jarrett, C., Baxter, Y. C., Boch, J., Carrasco, C., Muñoz, D. C., Dib, K. M., Pessoa, L., Saric, J., Silveira, M., & Steinmann, P. (2022) · Health Research Policy and Systems · doi:10.1186/s12961-022-00892-5 · Cited by 40 · see citing works
Valentijn, P., Ruwaard, D., Vrijhoef, H. J., Bont, A. A. D., Arends, R., & Bruijnzeels, M. A. (2015) · BMC Health Services Research · doi:10.1186/s12913-015-1125-4 · Cited by 35 · see citing works
An Instrument to Measure Maturity of Integrated Care: A First Validation Study
Grooten, L., Borgermans, L., & Vrijhoef, H. (2018) · International Journal of Integrated Care · doi:10.5334/ijic.3063 · Cited by 33 · see citing works
“The linkage between changes in services and service outcomes is problematic because most patient or service user outcomes do not emerge from linear cause and effect chains [18].”
BackgroundNicholson, C., Hepworth, J., Burridge, L. H., Marley, J. E., & Jackson, C. L. (2018) · International Journal of Integrated Care · doi:10.5334/ijic.3106 · Cited by 35 · see citing works
“Integrated care is a patient-centred, multi-level, multi-method strategy designed to achieve improved coordination of services across the care continuum of complex health systems [3, 10, 11].”
BackgroundWarm, E. J., Hirsh, D. A., Kinnear, B., & Besche, H. C. (2024) · Academic Medicine · doi:10.1097/acm.0000000000005973 · Cited by 34 · see citing works
“26,27 These systems can spontaneously form patterns without any central authority directing them.”
Steihaug, S., Paulsen, B., & Melby, L. M. H. (2017) · Scandinavian Journal of Primary Health Care · doi:10.1080/02813432.2017.1397264 · Cited by 34 · see citing works
“The institutional, organizational, and economical contexts constitute important preconditions for collaborative functioning, either as facilitating factors or as barriers [16,21,22].”
BackgroundEvans, J. M., Matheson, G., Buchman, S., MacKinnon, M., Meertens, E., Ross, J., & Johal, H. (2014) · Healthcare Quarterly · doi:10.12927/hcq.2014.24006 · Cited by 33 · see citing works
“Integration strategies are becoming an increasingly timely and common element of health-system redesign and reform efforts as populations age, the burden of chronic disease deepens, financial constraints tighten and new technologies and treatments are developed (Tsasis et al. 2012).”
BackgroundSelf-citationTheories, models and frameworks for health systems integration. A scoping review
Piquer‐Martinez, C., Urionagüena, A., Benrimoj, S. I., Calvo, B., Dineen‐Griffin, S., García‐Cárdenas, V., Fernández-Llimós, F., Martínez‐Martínez, F., & Gastelurrutia, M. Á. (2024) · Health Policy · doi:10.1016/j.healthpol.2024.104997 · Cited by 32 · see citing works
Navigating the Discontinuity Crisis in Medical Education
Warm, E. J., Desai, S. S., & Bowen, J. L. (2025) · New England Journal of Medicine · doi:10.1056/nejmra2408679 · Cited by 32 · see citing works
Complex adaptive systems and their relevance for nursing: An evolutionary concept analysis
Notarnicola, I., Petrucci, C., Barbosa, M. R. D. J., Giorgi, F., Stievano, A., Rocco, G., & Lancia, L. (2017) · International Journal of Nursing Practice · doi:10.1111/ijn.12522 · Cited by 27 · see citing works
Mind the gap: a review of optimisation in mental healthcare service delivery
Noorain, S., Scaparra, M. P., & Kotiadis, K. (2022) · Health Systems · doi:10.1080/20476965.2022.2035260 · Cited by 28 · see citing works
“In essence, integrated care delivery involves coordinating services across multiple healthcare professionals, organisations, and sectors and prioritising patient needs and preferences (Tsasis et al., 2012).”
BackgroundOutcome mapping for health system integration
Tsasis, P., Evans, J. M., Forrest, & Jones (2013) · Journal of Multidisciplinary Healthcare · doi:10.2147/jmdh.s41575 · Cited by 25 · see citing works
Self-citationCare Integration in Primary Dementia Care Networks: A Longitudinal Mixed-Methods Study
Oostra, D. L., Harmsen, A., Nieuwboer, M. S., Rikkert, M. G. M. O., & Perry, M. (2021) · International Journal of Integrated Care · doi:10.5334/ijic.5675 · Cited by 24 · see citing works
Trane, K. A. R., Aasbrenn, K., Rønningen, M., Odden, S., Lexén, A., & Landheim, A. S. (2022) · International Journal of Integrated Care · doi:10.5334/ijic.6011 · Cited by 24 · see citing works
Complexity in programme evaluations and integration studies: what can it tell us?
Kaehne, A. (2016) · Journal of Integrated Care · doi:10.1108/jica-10-2016-0041 · Cited by 23 · see citing works
Bugnon, B., Geissbühler, A., Bischoff, T., Bonnabry, P., & von Plessen, C. (2020) · JMIR Formative Research · doi:10.2196/22319 · Cited by 22 · see citing works
“By definition, a CAS is unpredictable, but some simple rules (ie, guiding principles), can help foster transformation [55,57-59].”
Sharif, Z., Peiravian, F., Salamzadeh, J., Mohammadi, N. K., & Jalalimanesh, A. (2021) · BMC Public Health · doi:10.1186/s12889-021-10619-w · Cited by 20 · see citing works
Feng, C., Zhu, J., & Chen, Y. (2022) · The International Journal of Health Planning and Management · doi:10.1002/hpm.3413 · Cited by 20 · see citing works
Allana, A., Tavares, W., Pinto, A. D., & Kuluski, K. (2022) · International Journal of Integrated Care · doi:10.5334/ijic.6418 · Cited by 20 · see citing works
Leadership in Integrated Care Networks: A Literature Review and Opportunities for Future Research
Mitterlechner, M. (2020) · International Journal of Integrated Care · doi:10.5334/ijic.5420 · Cited by 21 · see citing works
“Anne Wojtak, DrPH, MHSc, Adjunct Faculty, University of Toronto, Canada.”
BackgroundInfluentialFeddersen, H., Søndergaard, J., Andersen, L., Munksgaard, B., & Primdahl, J. (2022) · BMC Health Services Research · doi:10.1186/s12913-022-08773-x · Cited by 19 · see citing works
Turner, A., Mulla, A., Booth, A., Aldridge, S., Stevens, S., Begum, M., & Malik, A. (2018) · Health Services and Delivery Research · doi:10.3310/hsdr06250 · Cited by 18 · see citing works
Municipal Acute Units as Part of the Clinical Pathway for Older Patients
Johannessen, A., & Steihaug, S. (2019) · International Journal of Integrated Care · doi:10.5334/ijic.4643 · Cited by 18 · see citing works
The reimagination of sustainable integrated care in Ontario, Canada
Embuldeniya, G., Gutberg, J., & Wodchis, W. P. (2020) · Health Policy · doi:10.1016/j.healthpol.2020.11.001 · Cited by 18 · see citing works
Tsasis, P., Evans, J. M., Rush, L., & Diamond, J. (2013) · Administrative Sciences · doi:10.3390/admsci3020009 · Cited by 18 · see citing works
“structures that inhibit the capacity of those within the health care system to self-organize [42].”
BackgroundSelf-citationSharing a vision. Do participants in integrated care programmes have the same goals and objectives?
Kaehne, A. (2019) · Health Services Management Research · doi:10.1177/0951484819871136 · Cited by 17 · see citing works
Eyre, L., George, B., & Marshall, M. (2015) · BMJ Open · doi:10.1136/bmjopen-2015-009567 · Cited by 17 · see citing works
Achieving integrated care through CAS thinking and a collaborative mindset
Edgren, L., & Barnard, K. (2015) · Journal of Integrated Care · doi:10.1108/jica-02-2015-0012 · Cited by 17 · see citing works
Actions to influence the care network of home‐dwelling elderly people: A qualitative study
Kemper‐Koebrugge, W., Adriaansen, M. J. M., Laurant, M. G. H., & Wensing, M. (2019) · Health & Social Care in the Community · doi:10.1111/hsc.12714 · Cited by 16 · see citing works
“Patterns in and between care networks influence cultures of people and organisations within the network and vice versa (Tsasis et al., 2012).”
BackgroundLin, J. L. L., Quartarone, S., Aidarus, N., Chan, C., Hubbert, J., Orkin, J., Fayed, N., Major, N., Soscia, J., Lim, A., et al. (2021) · Healthcare policy · doi:10.12927/hcpol.2021.26574 · Cited by 16 · see citing works
“Healthcare professionals in our study sometimes needed to use ad hoc approaches to bridge cross-sectoral services for CMC. Similar to Tsasis et al. (2012), we observed a disconnect in perspectives and communication difficulties among providers from different care settings.”
MethodSkinner, M. S., Veenstra, M., & Sogstad, M. (2021) · Research in Nursing & Health · doi:10.1002/nur.22144 · Cited by 16 · see citing works
“Nurses in short‐term units may have succeeded in these horizontal and interprofessional collaborations by developing relationships and trust over time (Steihaug et al., 2016; Tsasis et al., 2012).”
BackgroundBogren, M. U., Berg, M., Edgren, L., van Teijlingen, E., & Wigert, H. (2016) · Sexual & Reproductive Healthcare · doi:10.1016/j.srhc.2016.09.008 · Cited by 15 · see citing works
Holstege, M. S., Caljouw, M. A. A., Zekveld, I. G., van Balen, R., de Groot, A. J., van Haastregt, J. C. M., Schols, J. M. G. A., Hertogh, C. M. P. M., Gussekloo, J., & Achterberg, W. P. (2015) · International Journal of Integrated Care · doi:10.5334/ijic.2200 · Cited by 15 · see citing works
“These systems are complex because of the dynamics within the different health care providers and the large number of components that interact when developing integrated care delivery [13,22,23,25,26].”
BackgroundEvans, J. M., Grudniewicz, A., & Tsasis, P. (2018) · International Review of Administrative Sciences · doi:10.1177/0020852318783063 · Cited by 14 · see citing works
“The development of hybrid integrated care networks is a prime example of such a change, and previous work by the authors applies SMM theory to such integrated care efforts (Evans and Baker, 2012; Evans et al., 2014a; Evans et al., 2014b; Tsasis et al., 2012).”
MethodSelf-citationAllana, A., Kuluski, K., Tavares, W., & Pinto, A. D. (2022) · BMC Health Services Research · doi:10.1186/s12913-022-07856-z · Cited by 13 · see citing works
“Setting system rules and structures A key role of health system governance is to create the social and structural conditions for integration and adaptation to emerge amongst networks of actors throughout the system [2, 6].”
BackgroundResultInfluentialLocal networks of community and healthcare organisations: a mixed methods study
Kemper‐Koebrugge, W., Koetsenruijter, J., Rogers, A. E., Laurant, M. G. H., & Wensing, M. (2016) · BMC Research Notes · doi:10.1186/s13104-016-2135-y · Cited by 13 · see citing works
“It is an intentional act of an individual to activate social capital [15, 18].”
BackgroundReview of complex adaptive systems in nursing practice
Kiviliene, J., & Blaževičienė, A. (2019) · Journal of Complexity in Health Sciences · doi:10.21595/chs.2019.21169 · Cited by 12 · see citing works
“Researchers conclude that integrating care requires policies and management practices that encourage system understanding, relationship building, and information sharing and consider change as an ongoing learning process rather than a sequence of programmatic steps [12].”
BackgroundGoldhar, J., Daub, S., Dhalla, I. A., Ellison, P., Purbhoo, D., & Sinha, S. K. (2014) · Healthcare Quarterly · doi:10.12927/hcq.2014.24022 · Cited by 12 · see citing works
People-centred integration in a refugee primary care service
Phillips, C. B., Dykgraaf, S. H., Elmitt, N., Bookallil, M., & Douglas, K. A. (2017) · Journal of Integrated Care · doi:10.1108/jica-10-2016-0040 · Cited by 12 · see citing works
Johannessen, A., & Steihaug, S. (2020) · Scandinavian Journal of Primary Health Care · doi:10.1080/02813432.2020.1717085 · Cited by 11 · see citing works
“The significance of good relationships between providers, knowledge about and mutual respect for each other’s work and competence, and sufficient time and resources for ongoing relationship building has been emphasised in the literature [16,17].”
BackgroundBuse, C. G., Allison, S., Cole, D. C., Fumerton, R., Parkes, M. W., & Woollard, R. F. (2022) · Frontiers in Public Health · doi:10.3389/fpubh.2022.867397 · Cited by 11 · see citing works
“First, the complexity of grappling with both health systems aiming toward greater integration (90) and linkages with other sectors relevant to eco-social concerns, creates challenges for most practitioners and organizations involved (22).”
BackgroundTherapeutic Communication Experiences of Nurses Caring for Patients with Hematology
Lee, H., Park, B.-M., Shin, M. J., & Kim, D.-Y. (2022) · Healthcare · doi:10.3390/healthcare10122403 · Cited by 11 · see citing works
“Moreover, sufficient knowledge of each other’s work, a culture of mutual respect, the recognition of each other’s expertise and capabilities, and free and open information exchange are necessary, in addition to sufficient time and resources for establishing effective and continuous relationships between care providers…”
BackgroundCao, H., Yin, G., Bao, X., & Tao, H. (2025) · International Journal for Equity in Health · doi:10.1186/s12939-025-02468-5 · Cited by 11 · see citing works
“These factors are consistent with earlier studies in Canada that highlighted similar barriers to integration [38].”
Myers, A., Quirk, H., Lowe, A. C., Crank, H., Broom, D. R., Jones, N., Reid, H. A. B., Speers, C., & Copeland, R. J. (2021) · PLoS ONE · doi:10.1371/journal.pone.0257802 · Cited by 11 · see citing works
“Being embedded within the higher levels of the system meant that the Consultant understood how the system behaved [32].”
BackgroundReno, R., Beaujolais, B., & Davis, T. S. (2018) · Social Work in Health Care · doi:10.1080/00981389.2018.1531105 · Cited by 11 · see citing works
Concept analysis of patient journey disruptions: the obstacle of integrated care
Vesinurm, M., Sylgren, I., Bengts, A., Torkki, P. M., & Lillrank, P. M. (2024) · Journal of Integrated Care · doi:10.1108/jica-08-2023-0060 · Cited by 10 · see citing works
Seniors’ campus continuums: local solutions for broad spectrum seniors care
Morton-Chang, F. M., Majumder, S., & Berta, W. B. (2021) · BMC Geriatrics · doi:10.1186/s12877-020-01781-8 · Cited by 10 · see citing works
“These structural and operational practices align with critical success factors for integrated systems of care outlined in a growing body of literature on the complexity of intra/inter-organizational, inter-professional, intergovernmental, and inter-sectoral collaborations and coordination (3,53,39,15,40,22,30,41).”
BackgroundBillings, J. R., de Bruin, S. R., Baan, C. A., & Nijpels, G. (2020) · BMC Health Services Research · doi:10.1186/s12913-020-05775-5 · Cited by 10 · see citing works
“Authors have highlighted a range of evaluation challenges that include the stability and sustainability of initiatives; data collection and the suitability of measures [1, 2]; and a lack of appreciation of the complexity [3].”
BackgroundStrengthening collaboration through collective impact: A rural Australian case study
Williams, T. M., Lakhani, A., & Spelten, E. R. (2021) · Community Development · doi:10.1080/15575330.2021.1903061 · Cited by 10 · see citing works
Quartarone, S., Lin, J. L. L., Orkin, J., Fayed, N., French, S., Major, N., Soscia, J., Lim, A., Diaz, S., Moretti, M. E., et al. (2022) · International Journal of Integrated Care · doi:10.5334/ijic.6073 · Cited by 9 · see citing works
Steenkamer, B. M., Baan, C. A., Putters, K., OERS, H. A. M. V., & Drewes, H. W.-T. (2018) · Journal of Health Organization and Management · doi:10.1108/jhom-06-2017-0146 · Cited by 9 · see citing works
“Both types of guiding principles are interdependent as is in line with previous work (Tsasis et al., 2012; D’amour et al., 2008).”
ResultKumar, V., & Cheng, S. Y. C. (2023) · Social Development Issues · doi:10.3998/sdi.5294 · Cited by 10 · see citing works
“These ideas and the theoretical framework surrounding CAS allowed scholars to understand the challenges and opportunities for managing new or existing integration efforts in healthcare organizations (Dattée & Barlow, 2010; Edgren & Barnard, 2012; Tsasis, Evans, & Owen, 2012).”
BackgroundExploring the Quality Paradigms in Integrated Care: The Need for Emergence and Reflection
KEMENADE, E. V., van der Vlegel-Brouwer, W., & van der Vlegel, M. (2021) · International Journal of Integrated Care · doi:10.5334/ijic.5594 · Cited by 8 · see citing works
“There is still a tendency to reduce messy realworld situations into parts that can be investigated, disregarding the context of complex interventions and the relationships and interactions shaping the outcomes [1, 6, 7, 8, 9, 10].”
BackgroundMohammadi, N. K., Rezaei, Z., Burggraf, L., & Pype, P. F. (2024) · Health Promotion International · doi:10.1093/heapro/daae001 · Cited by 8 · see citing works
Surveying work-as-done in post-operative delirium risk factors collection and diagnosis monitoring
Falegnami, A., Patriarca, R., Costantino, F., Gravio, G. D., & Bilotta, F. (2020) · Applied Ergonomics · doi:10.1016/j.apergo.2020.103347 · Cited by 8 · see citing works
KEMENADE, E. V., Kuiper, M. D., Booij, M., & Minkman, M. M. N. (2022) · International Journal of Integrated Care · doi:10.5334/ijic.5935 · Cited by 8 · see citing works
Parker, S., Conghail, L. M., Siersbaek, R., & Burke, S. (2023) · Frontiers in Public Health · doi:10.3389/fpubh.2023.1088728 · Cited by 8 · see citing works
“Thus, health reform efforts to improve access to universal integrated care in the COVID-19 context should not only focus on integrating structures or improving individual components but should equally consider strengthening relationships among those working together across all system levels (17, 22).”
BackgroundInfluentialIdentification of Key Components in Health System Using System Thinking Approach: A Scoping Review
Emami, M., Haghdoost, A. A., Yazdi‐Feyzabadi, V., & Mehrolhassani, M. H. (2023) · Medical Journal of the Islamic Republic of Iran · doi:10.47176/mjiri.37.47 · Cited by 8 · see citing works
“Quality of manpower training Strengthening knowledge management and training of employees (40, 66, 67) Deep understanding and knowledge of various components of the system (23)”
BackgroundInfluentialMoloi, H., Daniels, K. L., Brooke-Sumner, C., Cooper, S., Odendaal, W., Thorne, M., Akama, E., & Leon, N. (2023) · Cochrane Database of Systematic Reviews · doi:10.1002/14651858.cd013603.pub3 · Cited by 2 · see citing works
Community treatment orders and social factors: complex journeys in the mental health system
Haynes, P., & Stroud, J. (2019) · Journal of Social Welfare and Family Law · doi:10.1080/09649069.2019.1663017 · Cited by 8 · see citing works
McCarville, E. E., Martin, M. A., Pratap, P., Pinsker, E. C., Seweryn, S. M., & Peters, K. (2023) · Journal of Interprofessional Care · doi:10.1080/13561820.2023.2183183 · Cited by 7 · see citing works
“Tsasis et al. (2012, p. 4) highlight this point, noting that integration is a process, which is situated within complex adaptive systems.”
BackgroundGutberg, J., Evans, J. M., Khan, S., Abdelhalim, R., Wodchis, W. P., & Grudniewicz, A. (2021) · Medical Care Research and Review · doi:10.1177/10775587211064671 · Cited by 7 · see citing works
Self-citationSupporting critically conscious integrated care: A toolbox for the health professions
Brown, M. E. L., & George, R. (2023) · The Clinical Teacher · doi:10.1111/tct.13569 · Cited by 7 · see citing works
“patient experiences across health care settings by enhancing service coordination.(7) Although addressing health inequalities is one of the core purposes of integrated care and its systems,(8) educators have lit-”
BackgroundMoloi, H., Daniels, K. L., Brooke-Sumner, C., Cooper, S., Odendaal, W., Thorne, M., Akama, E., & Leon, N. (2023) · Cochrane Database of Systematic Reviews · doi:10.1002/14651858.cd013603.pub2 · Cited by 17 · see citing works
Lüdecke, D. (2014) · International Journal of Integrated Care · doi:10.5334/ijic.1361 · Cited by 7 · see citing works
Pless, S., Hootegem, G. V., & Dessers, E. (2018) · International Journal of Integrated Care · doi:10.5334/ijic.3745 · Cited by 7 · see citing works
Big Data and what it means for evaluating integrated care programmes
Kaehne, A. (2019) · Journal of Integrated Care · doi:10.1108/jica-05-2019-0017 · Cited by 7 · see citing works
Huber, C., Montreuil, C., Christie, D. P., & Forbes, A. (2022) · Frontiers in Clinical Diabetes and Healthcare · doi:10.3389/fcdhc.2022.845547 · Cited by 6 · see citing works
Kaehne, A. (2020) · Journal of Integrated Care · doi:10.1108/jica-07-2020-078 · Cited by 6 · see citing works
MacLeod, K. K., Flores, K. N., & Chandra, K. (2023) · International Journal for Equity in Health · doi:10.1186/s12939-023-01900-y · Cited by 5 · see citing works
“Fragmentation refers to components of care systems that “function in silos” [19], such as the separation of health care from social care in organizations, service delivery, and funding mechanisms.”
BackgroundLim, Z. Z. B., Kadir, M. M., Ginting, M. L., Vrijhoef, H. J., Yoong, J., & Wong, C. H. (2021) · International Journal of Environmental Research and Public Health · doi:10.3390/ijerph182111160 · Cited by 6 · see citing works
“These findings point to the realities of working in complex systems, which comprise many “diverse, interdependent and semi-autonomous actors” whose self-organization and interaction with each other may produce non-linear trajectories in the system [72].”
BackgroundWalker, R. L., Hastings, S., Cook, C., Cunningham, C., Cook, L. L., Cullum, J., Seidel, J. E., Hagens, J., & Oddie, S. (2022) · International Journal of Integrated Care · doi:10.5334/ijic.5674 · Cited by 6 · see citing works
Sprauer, W., Blackburn, T. D., Blessner, P., & Olson, B. A. (2015) · Journal of Management in Engineering · doi:10.1061/(asce)me.1943-5479.0000405 · Cited by 6 · see citing works
Relational coordination in value-based health care
van Staalduinen, D. J., van den Bekerom, P., Groeneveld, S. M., Stiggelbout, A. M., & Marle, M. E. V. D. A. (2023) · Health Care Management Review · doi:10.1097/hmr.0000000000000381 · Cited by 5 · see citing works
Vo, M. T. H., Nakamura, K., Seino, K., Moncatar, T. R. T., Han, T. D. T., Siongco, K. L. L., Tashiro, Y., & Vo, T. V. (2023) · International Health · doi:10.1093/inthealth/ihad082 · Cited by 5 · see citing works
“…in professional identities, roles and responsibilities are key barriers to successful collaboration among healthcare professionals, 57 , 58 our findings indicate that effective collaboration can take place in Vietnam by using available resources and established connections across the…”
BackgroundUsing More Equitable Integrated Care Programs to Reduce Fragmentation in Home Care
MacLeod, K. K. (2022) · International Journal of Integrated Care · doi:10.5334/ijic.6553 · Cited by 5 · see citing works
- Authors
- Tsasis, P., Evans, J. M., & Owen, S.
- Affiliations
- York University (CA)
- University of Toronto (CA)
- Venue
- International Journal of Integrated Care
- Publisher
- Ubiquity Press, Ltd.
- Published
- 2012-09-18
- Volume
- 12
- Issue
- 5
- Pages
- e190-e190
- ISSN
- 1568-4156 (ISSN-L)
- PMC
- PMC3601537
- OpenAlex
- W1619559784
- Cited by
- 172
- References
- 59
- Citations by year
- 2026: 7 · 2025: 15 · 2024: 13 · 2023: 16 · 2022: 21 · 2021: 17 · 2020: 15 · 2019: 8 · 2018: 14 · 2017: 15 · 2016: 13 · 2015: 7 · 2014: 8 · 2013: 3
- FWCI
- 10.24
- Type
- journal article
- Language
- en
- Open access
- gold
- doi.org
- Licence
- Locations
- International Journal of Integrated Care (publishedVersion, cc-by)
- Europe PMC (PubMed Central) (publishedVersion, cc-by)
- PubMed Central (publishedVersion, cc-by)
- PubMed (publishedVersion)
- International Journal of Integrated Care (IJIC) (acceptedVersion, cc-by)
- DOAJ (DOAJ: Directory of Open Access Journals) (submittedVersion, cc-by-sa)
- Utrecht University Repository (Utrecht University) (submittedVersion, cc-by)
- Topics
- Health Sciences › Health Professions › General Health Professions › Health Services Management and Policy
- Health Sciences › Health Professions › Health Information Management › Healthcare Quality and Management
- Social Sciences › Business, Management and Accounting › Organizational Behavior and Human Resource Management › Healthcare Systems and Technology
- Keywords
- integrated care, health systems integration, complex adaptive systems, Local Health Integration Networks, Ontario, healthcare professionals' perspectives, self-organization, bureaucratic management, weak ties, system complexity, emergent behavior, health policy
About these checks
Registry, retraction, Cites and statistics results are computed, not judged, with one exception: a printed reference that no index lists is read once by a model before it counts as a citation error. Claims are extracted by a model and kept only when their quote appears verbatim in the text; each cited source is then checked, with a model’s help, for whether it says what the claim relies on. Those verdicts can be wrong — read the claim’s quote and the cited source before relying on one.
Statistics and arithmetic are recomputed, not judged.
Confidence bands are shown only for fields calibrated on our annotated test set. None is calibrated yet, so no band is shown.
What counts as a claim ›How we measure confidence ›How we check this ›
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