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November 23, 2021
Early View Original Scholarship Integrated care
Rowan G. M. Smeets
Dorijn F. L. Hertroijs
Ferdinand C. Mukumbang
Mariëlle E. A. L. Kroese
Arianne M. J. Elissen
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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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