By Hubertus J.M. Vrijhoef,
National University Singapore & National University Health System, Singapore; Maastricht University Medical Center, the Netherlands; Vrije Universiteit Brussels, Belgium; Panaxea B.V., Amsterdam, the Netherlands

Mystery is not a word that we often connect with health and care as these are worlds in which we like to deal with the practical and the real. However it often seems that working out how best to successfully co-ordinate the contribution of different professionals, services and agencies is clouded in uncertainty and doubt.

One contributory issue is that integrated care is not a simple intervention. It can perhaps best be classified as a complex, multi-component programme to improve the quality of healthcare. Moreover, integrated care is foremost known for its polymorphous nature. Underlying integrated care is a wide range of very varied interventions and care approaches. Not surprisingly, recent literature reviews of integrated care, trying to draw conclusions on the differential impacts of approaches evaluated in individual studies, collectively reveal that the evidence base is inconsistent. It gets troublesome when studies recommend that more research is needed referring to the classic format of experimental design. Similar to the notice that ‘doing more of the same,’ when redesigning healthcare, is not going to bring improvement, researchers need to rethink how to evaluate integrated care for research to improve decision making.

Being a researcher in the field of integrated care myself, I took inspiration from Simon Sinek’s golden circle. In brief, Sinek says that every person knows what they do, most people know how they do it, whereas very few people know why they do what they do. In studying a linear, mechanical or natural, tightly coupled causal relationship most efficiently, an experimental study design may be exactly correct. However, in case of complex, multi-component interventions (often instable and non-linear) other, richer, ways to learn are needed. Where the experimental design removes most of the local details about how something works and about the what of contexts, alternative designs may be more helpful to understand what works, for whom, in what respects, to what extent, in what contexts, and how. Hence, if those involved in the research of integrated care want to support informed decision making, a reorientation of how to perform research and what steps to take in doing so is urgently needed.

As part of the EU supported Project INTEGRATE, I co-developed the COMIC model. This model aims to provide guidance to the study of Contexts, Outcomes, Mechanisms of Integrated Care interventions. The COMIC model is based on the principles of Realist Evaluation which suggest an alternative evaluation model for the evaluation of a social programme. In short, realist evaluation specifies what mechanisms will generate the outcomes and what features of the context will affect whether or not those mechanisms operate. These elements (i.e. mechanisms, outcomes, context) are made explicit at the evaluation design stage to enable data collection and test the different elements of a programme like integrated care. Further, in realist evaluation both quantitative and qualitative data are collected, often with quantitative data being focused on context and outcomes and qualitative data on mechanisms.

The COMIC model (Figure) assumes that integrated care is introduced using certain mechanisms, which are met with particular context factors, which combined, contribute to specific outcomes. The mechanisms are defined in terms of the interrelated components of the Chronic Care Model: health system, self-management support, delivery system design, decision support, clinical information system, and community. Context is operationalised using the Implementation Model, which specifies different levels of healthcare at which barriers and facilitators to change can occur: innovation, individual professional, patient, social context, organisational context, and economical and political context. Outcomes of integrated care are defined according to the dimensions of quality of care, as defined by the Institute of Medicine: effectiveness, efficiency, accessibility, patient-centeredness, equity and safety. For its development, we applied a literature review, two case studies, and an expert survey.


The COMIC model is believed to add value in the understanding of integrated care is in the examination of the interplay between the mechanisms, contexts, and outcomes. However, the validation and testing of the COMIC model is work in progress. Given the multiple initiatives in different countries regarding the development, testing, evaluation and implementation of integrated care programmes, the COMIC model may help decision makers to learn from their own and similar experiences in different contexts.

I believe that programmes, including the Integrated Care Pioneers in England, Regional Health Systems in Singapore, Pilot projects Integrated Care in Belgium, and the State Innovation Models in the US, can all benefit by using the COMIC model in conducting evaluations. Those involved in such evaluation initiatives are hereby kindly invited to contribute to the further validation and development of the COMIC model. I welcome those interested and/or involved in the evaluation of integrated care to contact me directly hoping this helps me to learn why you do what you do and perhaps to coordinate common activities in this field. And perhaps together we can unlock the mysteries of integration.

*The above Blog is based on my talks at a Research Seminar and a Workshop organized by Birmingham University and the London School of Hygiene and Tropical Medicine, 14 & 15 September 2016.

Author:  Hubertus J.M. Vrijhoef, PhD MSc

Affiliations: National University Singapore & National University Health System, Singapore; Maastricht University Medical Center, the Netherlands; Vrije Universiteit Brussels, Belgium; Panaxea B.V., Amsterdam, the Netherlands.

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