First Things First: How to Elicit the Initial Program Theory for a Realist Evaluation of Complex Integrated Care Programs

Early View Original Scholarship Integrated care

Policy Points:

  • Realist evaluation (RE) is an emerging and promising research approach for evaluating integrated care, addressing what works, how, for whom, and in what circumstances.
  • The rich philosophical foundation of RE, critical realism, can help to systematically unravel an integrated care program’s initial theory prior to implementation, as a first step within RE.
  • RE can be considered a robust methodological asset in integrated care research by facilitating a deeper level of insight into program functioning than traditional forms of evaluation do and by shaping a realist-informed monitoring and evaluation process.

Context: The complexity of integrated care and the need for transferable evaluation insights ask for a suitable evaluation paradigm. Realist evaluation (RE), underpinned by the philosophy of critical realism, is a theory-driven approach that addresses what works, how, for whom, and in what circumstances. The current study illustrates the process needed for RE’s first step: eliciting the initial program theory (IPT). The TARGET program, a Dutch primary care initiative to facilitate more integrated care for chronically ill patients, i.e., care that is efficient, tailored, and holistic, was taken as a real-world case.

Methods: An RE approach informed the phased IPT elicitation: (1) identifying an abstract theory framework; (2) formulating the preliminary IPT, building on the abstract theory and informed by previous scientific studies that underpin TARGET; and (3) refining the preliminary IPT, informed by RE expert interviews (n = 7). An RE heuristic tool, specifying the interplay between intervention-context-actors-mechanisms-outcomes (ICAMO) and retroductive reasoning, was applied to synthesize the underlying theory of individual TARGET components into TARGET’s IPT.

Findings: Separate but related IPTs were identified for the two main types of actors involved in TARGET: primary care professionals (PCPs) and patients. For both actors, two sorts of mechanisms are assumed to be activated by TARGET, which—via instrumental outcomes—contribute to long-term quadruple aim targets. The first is confidence to enhance PCPs’ person-centered conversational skills and to increase patients’ active engagement in TARGET. The second is mutual trust, between PCPs and patients and between PCPs and their network partners. A supportive context is assumed crucial for activating these mechanisms—for example, sufficient resources to invest in integrated care.

Conclusions: Although the IPT elicitation process is time intensive and requires a mind shift, it facilitates a deeper insight into program functioning than accommodated by the prevailing experimental designs in integrated care. Furthermore, the design of a realist-informed evaluation process can be informed by the IPT.

Keywords: delivery of integrated health care, realist evaluation, program evaluation, primary health care.

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Citation:
Smeets RGM, Hertroijs DFL, Mukumbang FC, Kroese MEAL, Ruwaard D, Elissen AMJ. First Things First: How to Elicit the Initial Program Theory for a Realist Evaluation of Complex Integrated Care Programs. Milbank Q. November 23, 2021. https://doi.org/10.1111/1468-0009.12543