Guiding research into integrated health and social care in Australia: suitability of three global frameworks for local adoption

Adversity has been defined as all negative experiences and conditions that include childhood maltreatment, parental mental illness, family violence, socio-economic deprivation, bullying and discrimination (Hall et al.,2022). People who experience adversity have higher health and social needs from the community, primary care and hospital and social systems (Øvretveit, 2011). Those who suffer from social isolation and mental illness are even more likely to need additional supports. There is compelling evidence that people who experience severe adversity will have a higher prevalence of health, well-being and legal problems across their lifetime (Felitti, 2009; Loxton et al., 2019; Coumarelos, 2012). Exposure to adverse childhood experiences such as domestic violence is linked to depression, alcohol and drug addiction, early mortality, decreased educational attainment and teen pregnancy (Loxton et al., 2019; Richards, 2011; Herrenkohl et al., 2008). The impact of this early severe adversity relates to later poor physical health and educational attainment, employment, socio-economic status, behavioural and mental health outcomes. Consequently, people who experience adversity have earlier morbidity and mortality compared to the general population (Felitti, 2009).

While the impacts of adversity in local communities have been recognised (Hall et al., 2022; Loxton et al., 2019), the challenge has been for social care systems to fully address the immediate (and life course) health and social needs of these groups in an integrated way. Historically, fragmented care has been characterised by a lack of early-life interventions, poor coordination between different health and social care providers and a lack of continuity of care. At a system level, fragmentation is manifested by the lack of sustainable integrated funding models, poor integrated governance and a lack of policies supporting data sharing across providers (Wodchis et al., 2020; Amelung et al., 2021).

The integrated health and social care approach is one mechanism for system transformation, seeking to improve outcomes of care (including patient-centred care for those facing adversity) by improved linkage of services of providers along the continuum of care (Amelung et al., 2021). Specifically, the approach seeks health equity, improved care experiences, improved health and social outcomes, cost efficiency and improved experience of the workforce involved (Itchhaporia, 2021).

This paper analyses some recent Australian programs that address the needs of families living in disadvantaged geographical areas experiencing high levels of adversity. Integration across health and social services has used a spatial focus, drawing together area-based service providers and user populations to build co-designed initiatives while linking local and more general initiatives (Todd et al., 2021).

Measuring the impact of the integrated health and social care approach remains a crucial aspect. Several integrated care frameworks have been developed to assess innovations in health, covering system change and the evaluation of care for specific populations at a local level (Cash-Gibson et al., 2019; Collins et al., 2023). The bulk of the work conducted involved measuring integrated care for older persons (Harnett et al., 2020; World Health Organization, 2019) and the integration of primary and secondary health care (New South Wales Health, 2018). There is a well-established literature evaluating the relations of integrated health care at micro, meso and macro levels. There is little equivalent research that could guide the development of integrated health and social care initiatives. Most existing work does not go beyond description of clinical care at the local level (Briggs et al. 2018; Thomson and Chatterjee, 2023). There is a pressing need for evaluation of space-based initiatives, assessing their value at multiple levels such as local (referred to here at “inner” setting), system-wide (the “outer” setting) and global enhancements (e.g. through the generation of knowledge exchange networks for those working in integrated care services and research). Unfortunately, there is a lack of locally developed frameworks for evaluating integrated health and social care initiatives. To our best knowledge, a local health-led integrated care framework developed by the New South Wales (NSW) Ministry of Health has been utilised and operationalised to assess their real-time initiatives (NSW Ministry of Health and Government, 2018) using the quadruple aim theoretical underpinning (improving experiences for consumers and service provider as well as improving health and cost efficiency) (Olayiwola and Rastetter, 2020). However, this does not provide a clear local-led framework to go beyond health-based initiatives.

In this paper, we aim to test the usefulness and contribute to the further development of analytical frameworks that guide research into integrated health and social care initiatives. While a unified, comprehensive framework capable of assessing the integrated health and social care agenda and offering a step-by-step guide for evaluation would be gold standard, currently, there is a clear research gap.

Given the lack of local-based integrated health and social care frameworks, we are using three global and widely accepted evaluation frameworks: (1) the Innovative Policy Supports for Integrated Health And Social Care Programs Framework to examine the level of integration of local integrated health and social care interventions (Wodchis et al., 2020); (2) the Consolidated Framework for Implementation Research (CFIR) to determine the specificities, content and taxonomy of context of integrated health and social care in the primary and secondary care network (Damschroder et al., 2009) and (3) the Framework on the Emergence and Effectiveness of Global Health Networks to assess the quality of international policies/strategies and integrated health and social care networks (Shiffman et al., 2016).

This study uses case studies based in decentralised administrative areas within the NSW state health system. Local hospital districts (LHDs) cover a network of public hospitals, linked to state-run community health and social services. Primary Health Networks coordinate nationally funded primary health services, especially general practice. The case studies all centre on integrated care initiatives addressing early life and life course adversity as well as knowledge translation.

We undertook a critical appraisal for choosing suitable frameworks to explore our case studies. Table 1 outlines essential context and characteristics for placing each framework against the studies.

Integrated care interventions were next assessed regarding how far they facilitate and advance integrated health and social care knowledge, practice and models of care at local levels by using the Innovative Policy Supports for Integrated Health and Social Care Programs Framework devised by Wodchis et al. (2020), which is based on substantial integrated care policy research undertaken by several teams in high-income countries (National Academy of Medicine, 2017; Leijten et al., 2018; World Health Organization, 2016; Verma and Bhatia, 2016).

The core components of this framework and descriptions are presented in Table 2.

The LHDs and/or primary care networks (health system components) and social care providers (including community-based organisations) that form the integrated care interventions are assessed utilising the widely used (Kirk et al., 2016; Skolarus et al., 2017) CFIR (Damschroder et al., 2009). The CFIR framework is used to identify and explore how the elements of each case study are addressed under the context of integrated care.

The domains of this framework and its description are presented in Table 3.

The Framework on the Emergence and Effectiveness of Global Health Networks (Shiffman et al., 2016) is used to assess the quality of the international initiatives and/or activities (including the International Foundation of Integrated Care (IFIC)) denominated “global policy learning”. This tool is fundamental for analysing the factors regarding why networks are formed more easily surrounding some issues than others and why some are more able to shape policy and public health outcomes (Shiffman et al., 2016). The domains of this framework and its description are presented in Table 4.

Using the framework devised by Wodchis et al. (2020), two initiatives, the Healthy Homes and Neighbourhood Initiative (HHAN) and the Camperdown Common Ground (CCG), were reviewed ( Supplementary File 1).

HHAN is an NSW Health-funded inter-sectoral initiative developed by the Sydney Local Health District (SLHD) in 2015. HHAN aims to break the persistent and troubling cycles of inequity within our society by working with families in SLHD who experience adverse social determinants of health to address their complex needs (Wodchis et al., 2020). CCG is an affordable housing complex in Camperdown that follows a housing-first model, a social mix of formerly homeless and low-income people managed by Mission Australia, funded by the Department of Communities and Justice that works in partnership with the SLHD. Thus, this initiative is designed to assist vulnerable people and those experiencing long-term homelessness. The model also aims to improve their quality of life, health, social and economic outcomes, increase access to mainstream services, reduce utilisation of acute and emergency services and deliver broad community development (Mission Australia Housing, 2016).

These two initiatives are assessed on how they are integrated beyond the point of pilots or time-limited programs and to what extent the initiatives are fostering joint governance and decision-making, integrated workforce and staffing, integrated financing systems and data sharing and use. HHAN is funded by state government health agencies (Ministry of Health) only, while CCG is funded by the social system (Social Services departments) (Category 3, Table 2). HHAN incorporates integrated health and social care staff (Category 2, Table 2). Both initiatives have established integrated health and social care governance and partnerships (Category 1, Table 2). None of the initiatives have established standardised and formal integrated health and social care report pathways using shared data (Category 4, Table 2).

Using the framework developed by Damschroder et al. (2009), two research studies ( Supplementary File 2) were assessed for their components’ salience against the CFIR constructs and measured to the extent to which these constructs are used practically, explored or researched. This body of work aims to advance knowledge of integrated health and social care within a broader system-level approach.

The first study aims to examine the interface between place-based health services and virtual service delivery in health and social services and how these two trends interact and potentially complement each other, focusing on service provision over the life course in disadvantaged communities. The second study seeks to understand how integrated health and social care agendas are implemented in health and social care settings and how, if any, these are further tailored to minority groups, to culturally and linguistically diverse (CALD) groups and considering their specific social and health needs.

Both studies are exploring domains related to the characteristics of the intervention and/or service (Domain 1, Table 3) (Damschroder et al., 2009). Specifically, adaptability of core components (the essential and indispensable elements) within the services (especially during COVID-19 pandemic) and how services were delivered to mainstream populations (face-to-face vs virtual) and what efforts were in place to support priority populations (CALD groups) are to be explored.

Exploring components of the outer setting (Domain 2, Table 3) is also undertaken for both studies (Damschroder et al., 2009). For example, priority is given to describe how integrated care at a system level meets patient needs and to what extent the integrated care approach is supported by external policies and incentives.

The inner setting (Domain 3, Table 3) component of networks and communications is sought in detail (Damschroder et al., 2009). Vertical and horizontal integration communications (including data sharing procedures) occurring between providers at the same level of care, as well as the various levels of care, are to be mapped. The establishment of formal and informal integrated care networks and governance, as well as the barriers and facilitators of these, are to be reported. Both initiatives will be reflecting on the implementation process (Domain 5, Table 3) and drawing lessons on “what worked”, for whom and under what circumstances at a system level (Damschroder et al., 2009).

A country-level network has been invigorated with the aim of advancing international policy to address fragmentation of both care and health and social care systems, with the view of accelerating knowledge translation ( Supplementary File 3).

The vision is achieved through the support of IFIC Australia. IFIC Australia was founded in 2015 as a country hub to promote and support integrated care in the Asia Pacific Region. Currently, knowledge translation is achieved by engaging with key stakeholders to shape policy, service models and integrated care while supporting educationally targeted initiatives including conferences, workshops and training.

Meaningful knowledge transfer is associated with the effectiveness of networks and their characteristics (Shiffman et al., 2016). IFIC Australia is characterised by effective leadership (Category 1, Table 4) (Shiffman et al., 2016), a clear governance (Category 1, Table 4) and a formal Partnership Committee composed by a sustainable and heterogeneous group of health and social care stakeholders (Category 1, Table 4) (Shiffman et al., 2016). Efforts in this space are significant because it is a pathway for local and global system learning, which is necessary for reducing system fragmentation.

In this paper, we tested the usefulness and contributed to the further development of three analytical frameworks that can guide research into integrated health and social care initiatives (Wodchis et al., 2020; Damschroder et al., 2009; Shiffman et al., 2016). We examined the level of integration of local space-based health and social care interventions based on Wodchis et al.'s work (Wodchis et al., 2020), developed a taxonomy of LHD and/or primary care network integrated care initiatives to locate the “local” within a broader policy context using Damschroder et al.'s study (Damschroder et al., 2009) and evaluated the quality of international policies and/or strategies and integrated health and social care networks based on Shiffman et al.'s work (Shiffman et al., 2016).

Several research studies are currently being undertaken, comprising the evaluation of initiatives targeting health and social disadvantage including child and family disadvantage, homelessness and youth and family mental health.

Understanding the facilitators and barriers to integrated care at a local and system level and focussing on the enhancement of integrated care globally, including establishing higher-level system capacity, is crucial for system change and program sustainability. This study facilitates and advances integrated health and social care knowledge, moving from the study of local initiatives to a higher-level taxonomy of integrated care initiatives and exploring the emergence and effectiveness of global integrated care knowledge exchange networks.

This paper does not propose a step-by-step guide on how to evaluate integrated health and social care initiatives in different settings; instead, it proposes the usability of three different suitable frameworks to assess the enhancement of the integrated health and social care using an array of multi-level innovation efforts as local case studies.

While this was an attempt to analyse these multi-level initiatives using the most appropriate framework for each level, this paper highlights the need for further research and additional supports for formulating a single unified integrated health and social care framework that can assess innovations at multiple levels beyond local settings (Collins et al., 2023).

It is important to note that the authors strongly encourage local researchers in the health and social care space to conduct a theory-led approach combined with an in-depth empirical investigation at the local level to determine whether there are potential hidden instances of integrated health and social care approach emerging from the ground up, middle out or/and policy-led. Context knowledge and a sound understanding of local-based initiatives prior defining research and suitability of frameworks are crucial (including the alignment with specific goals of inquiry).

Previous evidence has demonstrated the value of investment into research that enables the generation of a more suitable framework that can be used for initiatives covering broader settings (Cunningham et al., 2019; Committee on Educating Health Professionals to Address the Social Determinants of Health et al., 2016). The generation of an expert advisory group or committee conducting brainstorming and mind-mapping sessions to assess existing or novel frameworks and to consider how they might be applied to study health and social care initiatives and identify any gaps can be a way forward.

Consultation can be garnered from clinician and consumer experiences, service managers, policymakers and network knowledge partners to determine a unified framework that better reflects the large multi-level agenda for integrated health and social care system change.

We recognised the contribution made by CIs, AIs and partners to the National Health Medical Research Centre Integrated Health and Social Health Centre for Research Excellence (CREHSCI) (No: APP1198477) grant and their support for this work.

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