Integrated care pathways are increasingly recognized as essential frameworks for improving healthcare delivery, especially in the face of aging populations and complex health needs. The challenge, however, lies in effectively measuring and optimizing these pathways to ensure they truly deliver on their promise of seamless, patient-centered care. This article delves into the critical role of Integrated Care Pathway Assessment Tools, drawing upon a comprehensive review of measurement instruments across key domains of healthcare integration. By understanding and utilizing these tools, healthcare systems can systematically evaluate their progress, identify areas for improvement, and ultimately enhance the effectiveness of integrated care for better patient outcomes.
Despite the widespread advocacy for integrated care as a solution to fragmented and costly healthcare systems, realizing truly integrated systems remains a complex undertaking [1**, 2**, 3]. Integrated care, broadly defined as a coordinated approach to funding, administration, organization, service delivery, and clinical practice across the care spectrum [4], aims to create connectivity and collaboration within and between healthcare sectors. While the benefits of integrated care are well-documented [5**, 6, 7, 8**, 9], the ambiguity surrounding its definition and the lack of standardized measurement tools have hindered progress [2**, 3, 10, 11**, 12]. To advance the field, it is crucial to have robust assessment tools that can effectively measure and evaluate the impact of integrated care strategies across diverse contexts.
The complexity of integrated care, involving intricate interactions of structures, processes, and outcomes, poses significant challenges for evaluation [13**, 14]. The absence of readily available and comprehensive tools to measure various facets of integration further complicates this task [15**, 16]. Consistent and reliable measurement is paramount for driving the effective design and implementation of integrated health systems [10].
This article synthesizes existing knowledge to identify key domains for measuring integrated care and, more importantly, to pinpoint and categorize assessment tools suitable for evaluating these domains, with a specific focus on their application to integrated care pathways. This analysis is grounded in the ten key integration principles previously identified as foundational to successful integrated care initiatives [17]. The central questions guiding this exploration are: (1) What are the most relevant indicator domains for assessing integrated care pathways, aligned with these ten key integration principles? and (2) What assessment tools are available to measure these indicator domains effectively?
This review serves as a valuable resource for healthcare administrators, policymakers, and researchers seeking to implement and evaluate integrated care pathway initiatives. By providing a curated collection of assessment tools, this article aims to empower stakeholders to move beyond conceptual discussions and towards practical, data-driven improvements in healthcare integration.
Foundational Principles for Integrated Care Pathway Assessment
Our approach to identifying and categorizing integrated care pathway assessment tools is rooted in ten key principles that underpin successful integrated care, derived from an extensive synthesis of definitions and models in prior research [17]. These principles provide a comprehensive framework for understanding the multifaceted nature of integrated care and serve as a guide for identifying relevant assessment domains. These ten principles are:
- Comprehensive Services Across the Continuum of Care: Ensuring a full spectrum of services is available and coordinated across all stages of patient care.
- Patient Focus: Placing the patient and their needs at the center of care delivery and decision-making.
- Geographic Coverage and Rostering: Providing equitable access to services across geographic areas and effectively managing patient populations.
- Standardized Care Delivery Through Interprofessional Teams: Utilizing team-based care models and standardized practices to ensure consistent and high-quality care.
- Performance Management: Implementing systems to monitor and improve the quality and efficiency of care delivery.
- Information Technology: Leveraging technology to enhance communication, data sharing, and care coordination.
- Organizational Culture and Leadership: Fostering a supportive organizational environment and leadership that champions integrated care.
- Physician Integration: Engaging and integrating physicians into integrated care models.
- Governance Structure: Establishing effective governance mechanisms to oversee and guide integrated care initiatives.
- Financial Management: Aligning financial incentives and resource allocation to support integrated care goals.
These principles serve as the theoretical backbone for our review, conceptualizing integrated care as a set of interconnected domains that must be addressed to achieve genuine connectivity and collaboration within and across healthcare sectors. This framework aligns with other research that emphasizes the importance of structural and process elements at various levels for successful integrated care implementation [2**, 12, 21, 22**].
While these ten principles offer a valuable blueprint for designing integrated care models [23], their broad and abstract nature can make direct measurement challenging. To bridge this gap, this review aims to identify specific, measurable indicator domains and corresponding assessment tools for each principle. Indicator domains are defined as measurable concepts that capture specific aspects of a key principle. For instance, “patient engagement” serves as a measurable indicator domain for the principle of “patient focus.” Assessment tools, in this context, encompass any measurement instruments—such as questionnaires, scales, checklists, and observation forms—used to assess structures, processes, or outcomes associated with these indicator domains.
By using these key principles as a foundation, we provide a structured and research-informed approach to assessing the level of integration within a healthcare system, specifically through the lens of integrated care pathways. This framework allows for a more cohesive and targeted evaluation, moving beyond general assessments to pinpoint specific areas of strength and weakness in pathway design and implementation.
Methodology for Identifying Assessment Tools
This knowledge synthesis followed a rigorous methodology, drawing on established guidelines for systematic reviews [24], to ensure a comprehensive and unbiased identification of relevant assessment tools. The process comprised three key phases: (1) a Delphi process to establish consensus on the most relevant indicator domains from diverse stakeholder perspectives; (2) focus groups with patients to incorporate their insights on crucial integration principles; and (3) a systematic literature review to identify existing assessment tools for each prioritized indicator domain. This article focuses on the Delphi process and the systematic review of assessment tools.
To enhance the global relevance and applicability of this research, a collaborative partnership was established with researchers, decision-makers, and policymakers in both a large urban center in southern Brazil (Rio Grande do Sul) and Canada (Alberta and British Columbia). These regions, with their publicly funded healthcare systems, comparable healthcare priorities, and diverse urban and rural landscapes, provide a valuable cross-cultural context for studying healthcare integration. The active involvement of Brazilian research team members throughout the study, from proposal development to data interpretation, ensured a broader perspective and enriched the findings. Guided by integrated knowledge translation principles [25], knowledge users from each jurisdiction were engaged throughout the research process. Ethical approval for the research protocol was obtained from the ethics boards of all participating jurisdictions.
Delphi Survey for Domain Prioritization
A modified Delphi method [26] was employed to achieve consensus on the most pertinent indicator domains for measuring integrated care pathways. The ten key principles of integrated care [17] served as the starting point for this process. Based on existing literature and expert knowledge, the research team developed an initial list of indicator domains for each of the ten principles. This list was then translated into Portuguese and used in a Delphi survey distributed to 39 experts in integration, including policymakers, decision-makers, and healthcare providers from Canada, Brazil, Europe, and the United States. Participants were identified through research team networks, literature reviews, and healthcare research databases. An extensive search was conducted to identify potential panel experts, ensuring a diverse and knowledgeable group.
The initial survey presented 21 indicator domains across the ten key principles. Participants were asked to rate the relevance and appropriateness of each domain on a scale of 1 to 5 (1 being most relevant/appropriate). In the first round, participants also had the opportunity to suggest additional domains, which were incorporated into the second round of the survey. The goal was to achieve a 75% consensus for either inclusion (ratings of 1 or 2) or exclusion (ratings of 4 or 5) of indicator domains through multiple survey rounds.
Systematic Literature Search for Assessment Tools
Independent and iterative searches were conducted for each indicator domain identified through the Delphi process. These searches spanned across Health Sciences, Education, and Management/Business disciplines, utilizing core bibliographic databases such as Medline (including Cochrane), EMBASE, PsycINFO, CINAHL, ABI Inform, and Business Source Premier. A research librarian assisted in developing search terms specific to each indicator domain. Two additional searches were conducted focusing on “health systems integration” and “instrument/tool development” to broaden the search. Domain-specific searches were then combined with these broader searches to retrieve relevant articles on assessment tools. Grey literature was explored through advanced Google searches, screening the first 50 documents for relevant tools. Websites of relevant government agencies and research organizations (e.g., Institute for Healthcare Improvement), reference lists of included studies, and forward citation searching using Web of Science were also examined. The Brazilian librarian utilized the LILACS database, including abstracts in both English and Portuguese.
Inclusion and exclusion criteria were developed, tested, and refined by the research team to ensure consistent study selection. Key inclusion criteria were: (1) articles describing instruments to measure structures, processes, or outcomes related to the Delphi-identified integration domains; (2) instruments relevant to healthcare contexts; (3) articles in English or Portuguese; and (4) publication dates between 1995 and 2014. A decision was made to exclude studies focusing solely on administrative data, as these data can be influenced by factors outside of integration efforts. Instruments measuring integration aspects outside the identified domains or primarily focusing on clinical outcomes were also excluded. Training sessions were conducted to ensure consistency in abstract rating, with multiple rounds of rating and discussion until a desired level of agreement was reached. Two researchers were assigned to screen abstracts for each indicator domain, with a third resolving disagreements. A data extraction template, adapted from existing tools [27], was used to guide information extraction and assess article relevance and quality. Data extraction focused on the original instrument development article, even if published before 1995. Audits were conducted at both the relevancy and extraction stages to maintain consistency.
The Brazilian research team followed the same procedures for screening and selecting articles from the LILACS database. Their findings were then integrated into the overall synthesis.
Figure 1 visually summarizes the flow of abstracts screened, assessed for relevance, and included for full review using a PRISMA flow chart.
Figure 1 Prisma flow chart.
Findings: Assessment Tools for Integrated Care Pathways
Delphi Survey Outcomes: Prioritized Indicator Domains
The Delphi survey involved 17 experts across three rounds to identify priority indicator domains for measuring integrated care pathways. In the first round, consensus was achieved on 15 indicator domains (≥ 75% agreement on relevance and appropriateness). Participants suggested 36 additional domains, which were thematically grouped and merged to create 38 domains for the second round. In the second round, consensus was reached on 29 domains, with 16 deemed relevant/appropriate, 13 irrelevant/inappropriate, and no consensus on nine. These nine domains proceeded to a third round, resulting in a final consensus on 37 indicator domains. Of these, 16 were considered highly relevant and used for the systematic literature search for assessment tools. Twenty-one domains were deemed less relevant and excluded. Notably, no consensus was reached on indicator domains for Principle 9, focusing on governance, highlighting the complexity of measuring this aspect of integration.
Systematic Review Results: Identified Assessment Tools
The systematic review of the 16 prioritized indicator domains yielded a total of 7,133 abstracts. After rigorous screening and selection, 114 unique assessment tools were identified as relevant for measuring the state of integrated care pathways.
Table 1 presents a summary of the review results for each of the 16 domains, detailing the number of abstracts screened, full-text articles reviewed, and tools identified. Some domains with overlapping characteristics and search terms were reviewed together. Two tools were found to be applicable to two different domains. An “Overall Integration” domain was added to capture tools assessing three or more domains, providing a holistic measure of integration.
Table 1
Number of abstracts screened and tools identified by domain.
| Domain | Total # abstracts screened | Total # full-text articles | Total # of tools2 |
|---|---|---|---|
| Principle 1 | |||
| Coordinated transitions in care across the continuum of care1 (transferring care from one area to another) | 298 | 195 | 17 |
| Client care is coordinated between sectors and providers within the health system and with supporting services such as education and social services | 610 | 97 | 14 |
| Principle 2 | |||
| Patient and/or family involvement in care planning for all patients | 569 | 128 | 34 |
| Principle 3 | |||
| Primary care network structures in place (e.g., family health teams, primary care networks, GP Divisions, inner city PHCs) | 118 | 23 | 8 |
| Principle 4 | |||
| Team effectiveness | 198 | 83 | 12 |
| Use of shared clinical pathways across the continuum of health care (e.g., diabetes, asthma care) and geography1 | 957 | 229 | 7 |
| Individualization of care pathways for patients with co-morbidities | |||
| Principle 5 | |||
| Performance measurement domains and tools in place1 | 1657 | 99 | 2 |
| Clinical outcomes being measured | |||
| Data tracked and shared | 410 | 47 | 0 |
| Principle 6 | |||
| Data (e.g., administrative, performance, clinical) tracked and shared with stakeholders1 | 315 | 107 | 1 |
| Shared patient electronic charts across continuum of care accessible to patients | |||
| Data collected is used for service planning | 554 | 68 | 1 |
| Principle 7 | |||
| Organizational goals and objectives aligned across sectors | 483 | 50 | 1 |
| Principle 8 | |||
| Physician integration within care teams and across sectors | 560 | 53 | 6 |
| Principle 10 | |||
| Attainment of goals and objectives are supported by funding and human resource allocation | 404 | 39 | 1 |
| Overall integration | |||
| Tools that measure several constructs of integration | 0 | 87 | 12 |
| Total | 7133 | 1305 | 116 |
1 Overlap in domains; screened together.
2 Total number is higher as two tools were appropriate for two domains.
Overview of Assessment Tool Types
Appendix 1 provides detailed information on each identified assessment tool, including the concepts measured, the setting and sample populations in which they were tested, and available psychometric properties. Questionnaires were the predominant instrument type (94 tools), followed by checklists, toolkits, observational tools, and indicators. The majority of instruments (92) relied on self-report data, while 22 utilized external observation or data from multiple sources (e.g., patient and provider reports). Providers were the primary respondents for 56 instruments, patients for 42, administrators for 10, and a combination of respondents for the remaining tools.
The vast majority of tools (all but eight) were derived from peer-reviewed literature, with 110 developed within healthcare settings. Some tools were designed and validated for specific populations (e.g., mental health, pediatrics) but hold potential for adaptation to broader populations. Psychometric properties varied significantly across tools, with some demonstrating robust validation and others requiring further testing. The number of citations for each instrument is also included in Appendix 1, providing an indication of their usage and impact in the field.
The following sections provide a more detailed overview of the assessment tools identified within each principle-based domain, highlighting those particularly relevant for evaluating integrated care pathways.
Principle 1: Comprehensive Services Across the Care Continuum – Tools for Pathway Assessment
Coordinated Transitions Across the Continuum of Care
This indicator domain, focusing on the effectiveness of care transitions within and between different care settings, is crucial for evaluating the seamlessness of integrated care pathways. Seventeen instruments were identified that measure continuity of transitional care. Most of these tools (n=14) were designed for community or primary care settings [28**, 29, 30, 31, 32, 33, 34, 35, 36, 37, 38, 39, 40, 41], with fewer developed for acute care [42] or combined primary and acute care settings [43**, 44]. The Care Transitions Measure (CTM, [43]), and its various adaptations [45**, 46**], stands out as a widely used tool in this domain.
Many of these tools assess process-related aspects of care transitions within integrated care pathways, measuring factors such as the timeliness of information transfer, provider continuity, provider-patient interaction during transitions, and the quality of transition planning from the patient’s perspective. Some tools also evaluate structural components, such as the presence of transition policies or care plans within pathways. These instruments are directly applicable to evaluating the effectiveness of transition points within integrated care pathways, a key element of pathway success.
Client Care Coordination Across Sectors
The second indicator domain under Principle 1 addresses the coordination of client services across different sectors, such as health and social services, vital for holistic integrated care pathways. The search yielded 14 instruments measuring intersectoral coordination, ranging from loose linkages to close collaboration. Predominantly questionnaires, these tools were developed and tested in healthcare settings or with health-related outcomes. They capture intersectoral coordination through variables like connections between organizations [47**, 48, 49, 50], social networks [51**, 52], interagency linkages [53**, 54, 55, 56], depth of integration [57**, 58], and system integration level [59]. Notably, Morrissey et al. 1994 [51] developed two instruments specifically relevant to this domain. These tools offer valuable means to assess the strength and quality of connections between health and social care sectors within integrated care pathways, essential for addressing the broader needs of patients.
Principle 2: Patient Focus – Tools for Pathway Assessment
Patient and Family Involvement in Care Planning
This indicator domain, the sole focus under Principle 2, emphasizes patient-centeredness within integrated care pathways by assessing the extent of patient and family involvement in care planning and decision-making. This domain yielded the largest number of assessment tools (34) among all 16 indicator domains, highlighting the strong emphasis on patient-centeredness in contemporary healthcare.
All 34 instruments were developed and tested in healthcare settings. The majority (25) are designed for completion by patients and/or families [31**, 60, 61, 62, 63, 64, 65, 66, 67, 68, 69, 70, 71, 72, 73, 74, 75, 76, 77, 78, 79, 80, 81, 82, 83, 84], while others are completed by healthcare professionals [85, 86, 87, 88, 89] or both [90, 91, 92]. The Kim Alliance Scale (KAS) [72] and its revised, shorter version (KAS-R) [93**] are prominent examples in this domain.
These instruments assess a wide range of structure, process, and outcome aspects from the patient and family perspective, directly relevant to evaluating the patient-centeredness of integrated care pathways. These aspects include: (1) patient experiences with care, such as administrative processes and customer service; (2) patient satisfaction with various care aspects, including doctor-patient consultation; (3) perceived quality of care, particularly in relation to patient education and respect; (4) family involvement in care, such as information sharing; (5) shared decision-making and patient participation in care decisions; (6) satisfaction with decisions made; (7) communication effectiveness, including style and preferences; and (8) patient empowerment and perceived empathy. Most instruments cover multiple areas, providing a comprehensive assessment of patient and family perspectives within integrated care pathways.
Principle 3: Geographic Coverage and Rostering – Tools for Pathway Assessment
Primary Care Network Structures in Place
This domain, the only indicator domain under Principle 3, recognizes the foundational role of well-developed primary care structures in achieving healthcare system integration and effective integrated care pathways. Eight questionnaires were identified that measure general structural components [94**, 95, 96, 97] or specific aspects of primary care, such as the medical home model [98, 99, 100], palliative care [101], and child services [102]. The Medical Home Index (MHI [100]) and its shorter versions [103**, 104] are notable tools in this area.
The Instrumento de Avaliação da Coordenação das RAS pela APS (COPAS) [97], originally developed in Portuguese, is a unique and valuable instrument for assessing the coordination of integrated health service delivery networks in primary health care. This 78-item questionnaire covers five dimensions: (1) population focus, (2) primary health care services, (3) support systems, (4) logistic systems, and (5) management systems. The COPAS has been translated into English as the Tool for Assessment of the Coordination of Integrated Health Service Delivery Networks by the Primary Health Care and validated in primary care settings [105]. These tools are useful for evaluating the structural foundation of primary care networks that support integrated care pathways, ensuring adequate geographic coverage and effective rostering.
Principle 4: Standardized Care Delivery Through Interprofessional Teams – Tools for Pathway Assessment
Team Effectiveness
Team effectiveness is a critical indicator domain under Principle 4, representing the performance of interprofessional teams essential for standardized care delivery within integrated care pathways. Twelve instruments were identified as relevant to the integration context, drawn from the broader literature on team performance. Nine of these instruments are from the healthcare sector [106**, 107, 108, 109, 110, 111, 112, 113**, 114], two assess virtual team effectiveness [115**, 116], and one is from grey literature [117]. Most are questionnaires, with one observational tool for teamwork in surgical settings [113]. Five instruments are embedded within larger questionnaires [106, 108, 110, 111, 115**].
These instruments are specifically designed to assess interprofessional teams in healthcare or virtual teams, relevant to integrated care pathways where services may be geographically dispersed and rely on virtual collaboration. They measure team effectiveness through team perceptions of performance, overall productivity, efficiency, and the ability of team members to complete assignments. Some tools also assess factors contributing to team effectiveness, such as team cohesion, individual well-being, and resource utilization. These instruments are crucial for evaluating the functioning of interprofessional teams delivering care within integrated care pathways.
Shared and Individualized Clinical Pathways
The domains of “shared clinical pathways” and “individualized care pathways” were analyzed together due to their conceptual overlap. These domains assess the existence and utilization of shared clinical pathways across care settings and the degree of individualization within pathways for patients with comorbidities – core components of integrated care pathway design.
Five instruments were identified for shared clinical pathways [118**, 119, 120, 121**, 122] and three for individualized care pathways [123**, 124**, 125]. Four are designed for healthcare management or physicians [118**, 119, 121, 122], while two evaluate pathways from the patient perspective [120**, 123].
These instruments can assist in developing integrated care pathways [125] and evaluating their quality and impact on patient experience [119**, 124**, 126]. Shared care pathways are essential for ensuring consistency and continuity of care across team members [127]. These assessment tools become increasingly important as care pathways span multiple organizations and care sectors, facilitating the evaluation of pathway standardization and individualization.
Principle 5: Performance Management – Limited Tools for Pathway Assessment
Performance Measurement and Clinical Outcomes
These two indicator domains, related to Principle 5, focus on the structures and processes in place for ongoing quality monitoring and performance measurement within integrated care pathways. Despite the recognized importance of performance measurement systems, only two instruments were identified: the Medical Home Index (MHI [100]), which includes themes related to data management and quality improvement, and the Índice de Responsividade do Serviço (IRS) (Health Services Responsiveness Index – SRI) [131], a Portuguese-language questionnaire measuring health system responsiveness to user expectations.
The limited number of tools in this domain highlights a significant gap in the availability of instruments specifically designed to assess performance measurement systems within integrated care pathways. This gap underscores the need for further development of tools that can effectively evaluate the performance management aspect of integrated care.
Data Tracking and Sharing with Stakeholders
This indicator domain, also under Principle 5, assesses the extent to which data is tracked and shared with relevant stakeholders within healthcare systems. However, no instruments were found that specifically measure this crucial aspect of performance management and transparency in integrated care pathway implementation. This lack of measurement tools represents another significant gap, as data sharing is essential for effective performance monitoring and continuous improvement of integrated care pathways.
Principle 6: Information Systems – Limited Tools for Pathway Assessment
Shared Information Systems and Data Utilization
The indicator domains under Principle 6 focus on information systems that support integration, including shared systems across sectors, electronic health records accessible to patients, and the use of data for service planning – all vital for effective integrated care pathways. For the domains of shared information systems and electronic health records, only one instrument was found: a survey by Chou et al. 2010 [132] evaluating an internet-based wellness portal in primary care.
For the domain of data utilization for service planning, a single instrument was identified: a semi-structured telephone interview guide [133] exploring the types of data used, their purpose, and barriers to data utilization.
The scarcity of tools in these information systems-related domains highlights a significant need for developing more comprehensive assessment instruments to evaluate the role of information technology in supporting integrated care pathways. Effective information systems are foundational for seamless data exchange, care coordination, and pathway optimization.
Principle 7: Organizational Culture and Leadership – Limited Tools for Pathway Assessment
Alignment of Organizational Goals Across Sectors
This indicator domain, under Principle 7, assesses the alignment of organizational goals and objectives across healthcare and other relevant sectors. Only one instrument was found: the Organizational Culture Assessment Instrument (OCAI) [134]. Based on the Competing Values Framework, the OCAI uses six items to assess organizational culture types (hierarchy, market, clan, adhocracy) and determine cultural alignment, including leadership styles across sectors.
While the OCAI provides a valuable tool for assessing organizational culture and alignment, the limited number of instruments in this domain underscores the need for further development of tools to evaluate the cultural and leadership aspects of integrated care pathway implementation. Organizational culture and leadership play a crucial role in fostering a supportive environment for successful pathway adoption and sustainability.
Principle 8: Physician Integration – Tools for Pathway Assessment
Physician Integration Within Care Teams
This indicator domain, the sole focus of Principle 8, addresses the integration of physicians within care teams and across healthcare sectors, recognizing the critical role of physician engagement in successful integrated care pathways. Six relevant instruments were identified [111 (2 instruments), 136**, 137, 138, 139**]. Newer instruments primarily focus on physician integration in the context of interprofessional collaboration, rather than broader system integration.
These tools primarily measure physician integration through collaboration with other healthcare providers (e.g., pharmacists, nurses), crucial for effective team-based care within integrated care pathways. Given the central role of physicians in primary care, assessing and enhancing collaboration between physicians and other providers is essential for continuous quality improvement, patient safety, and positive patient-provider experiences within these pathways. Physician integration is vital for improving care delivery and service planning in the evolving healthcare landscape.
Principle 10: Financial Management – Limited Tools for Pathway Assessment
Resource Allocation Alignment with Goals
This indicator domain, under Principle 10, examines the alignment of financial and human resource allocation with organizational goals and objectives within integrated care systems. Only one instrument was identified: a questionnaire by Bradford et al. 2000 [140] assessing resource allocation processes and effectiveness.
This tool measures resource allocation practices, including priority-setting methods, grant-making processes, service monitoring, and outcome assessment. The limited availability of tools in this domain highlights the need for further development of instruments to evaluate the financial and resource management aspects of integrated care pathway implementation. Financial alignment is crucial for supporting the sustainability and effectiveness of integrated care initiatives.
Overall Integration Assessment Tools
The “Overall Integration” domain includes instruments that measure health systems integration more broadly or assess multiple indicator domains, providing a holistic view of integration. Twelve instruments were identified, including ten questionnaires targeting various stakeholders [14**, 141, 142, 143, 144, 145, 146, 147, 148, 149] and two indicator-based tools [1**, 150].
These tools often capture multiple indicator domains for which specific instruments are lacking. For example, the questionnaire by Gillies et al. 1993 [145], further developed into the integration scorecard [143], measures perceived system integration across dimensions like support services, organizational culture, strategic planning, information systems, financial management, and physician integration. The Clinical Microsystem Assessment Tool [146] and the Whole System Measures (WSM [150]) also offer comprehensive assessments across multiple integration domains. These overall integration tools are particularly valuable for gaining a broad understanding of system-level integration and can complement domain-specific tools for a more complete evaluation of integrated care pathways.
Discussion: Advancing the Measurement of Integrated Care Pathways
This knowledge synthesis aimed to identify relevant indicator domains and assessment tools for measuring integrated care pathways, utilizing ten key integration principles as a guiding framework. Building upon prior research [17], this study provides a comprehensive overview of available measurement instruments and highlights critical gaps in current assessment capabilities.
The Delphi process successfully prioritized 16 indicator domains across nine of the ten key integration principles, confirming the enduring relevance of these principles for guiding integrated care pathway development and evaluation. The lack of consensus on governance indicator domains underscores the inherent complexity of measuring this aspect of integration, suggesting a need for further conceptual and methodological work in this area.
The systematic literature review identified 114 unique instruments relevant to the 16 prioritized domains. A significant proportion of these tools focused on care coordination and patient and family involvement, aligning with the emphasis on these areas in healthcare reform and integrated care initiatives [152]. However, a notable scarcity of tools was found for domains related to primary care network structures, performance monitoring, information systems, data utilization, and organizational alignment. This finding echoes previous reviews [10**, 2**] and underscores a critical evidence gap in the measurement of these functional, system-level dimensions of integrated care pathways. These dimensions are crucial for the overall success of integration efforts, yet remain poorly measured, hindering comprehensive pathway evaluation and improvement.
The dominance of self-report questionnaires among identified tools, while offering ease of implementation, highlights the need for a broader range of assessment methods. Self-report measures are susceptible to biases and may not capture the full complexity of integrated care processes and outcomes [151]. A more balanced approach, incorporating observational measures, administrative data, and qualitative methods, is needed for a more robust and multi-faceted assessment of integrated care pathways.
The “overall integration” instruments identified in this review offer a valuable starting point for holistic pathway assessment, particularly in domains where specific tools are lacking. These instruments provide a broader system-level perspective and can be used to complement domain-specific tools for a more comprehensive evaluation. However, further development of targeted, high-quality assessment tools is crucial for advancing the field of integrated care pathway measurement. This includes a focus on psychometric testing and validation of existing instruments across diverse contexts [2], as well as the development of new tools to address the identified measurement gaps. Improving the reporting quality of survey research [155] is also essential to enhance the usability and interpretability of assessment tool findings.
The collaboration with Brazilian researchers enriched this project, adding valuable perspectives and identifying unique Portuguese-language instruments. This highlights the importance of cross-cultural collaborations in advancing the field of integrated care measurement and ensuring the global applicability of assessment tools.
This review contributes to the growing body of literature focused on measuring progress towards integrated care [2**, 3, 10, 18, 19, 20**, 22]. The challenge now lies in translating these inventories of tools into practical application. Selecting the most appropriate instrument from a vast collection requires careful consideration of the specific context, the goals of the assessment, and the psychometric properties of the tools. A unified measurement framework, with clear recommendations on indicators and measurement instruments [13], is essential for facilitating consistent evaluation and comparison of integrated care pathway initiatives across different settings. Standardized and effective assessment tools are crucial for driving continuous improvement in integrated care pathway design and ultimately achieving better health outcomes for patients.
Strengths and Limitations of the Study
This review benefits from several strengths. The use of a previously established framework of ten key principles, combined with a Delphi consensus approach, ensured a robust and expert-informed selection of relevant measurement domains. The inclusion of grey literature broadened the search beyond traditional academic sources, identifying practical tools often accompanied by user manuals, enhancing their usability. However, grey literature searches are inherently limited by indexing and accessibility challenges, potentially leading to omissions. The iterative search strategy and ongoing refinement of search terms aimed to address the complexity of the literature, but the sheer volume of publications remained a challenge. The search was limited to literature up to 2014, potentially missing more recent instruments. The involvement of multiple researchers across different domains introduced potential for process variations, mitigated through checks and balances, audits, and frequent team discussions.
Conclusion: Towards Enhanced Assessment of Integrated Care Pathways
This study has identified over 100 unique assessment tools relevant to measuring 16 indicator domains for integrated care. While questionnaires are prevalent, measuring care coordination, patient involvement, and team effectiveness, significant gaps exist in tools for performance measurement, information systems, organizational alignment, and financial management. These gaps represent critical areas for future research and tool development, as these domains are vital for the success of integrated care pathways. Overall integration tools offer a valuable alternative in the absence of targeted measures for specific domains.
Moving forward, there is a clear need to develop a broader range of assessment instruments beyond questionnaires, incorporating diverse data sources such as administrative databases [18**, 19**]. Existing tools would benefit from rigorous psychometric testing and validation across various contexts to enhance their applicability and reliability. By addressing these measurement gaps and promoting the use of robust assessment tools, the field of integrated care can move towards more data-driven evaluation and continuous improvement of integrated care pathways, ultimately leading to more effective and patient-centered healthcare systems.
Additional File
The additional file for this article can be found as follows:
AppendixDetails of Instruments. DOI: https://doi.org/10.5334/ijic.3931.s1
