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What works for whom, how, in what context and with what outcomes? Integrated care evaluation using the Evidence Integration Triangle: the case of SUSTAIN


Jenny Billings


Background: Sustainable tailored integrated care for older people in Europe (SUSTAIN) is a Horizon 2020 nine country collaborative project that aims to improve existing integrated care initiatives for older people living at home with multiple health and social care needs, ensuring they are patient-centred, prevention-oriented, efficient, and safe. This paper to be presented will describe our approach to evaluation and present some early findings of its application in practice.

In the world of integrated care, health and social care solutions involve complex problems in complex community and healthcare environments, faced by complex patients, settings, and cultures. These challenges demand evaluation approaches that can accommodate this complexity but ensure robust and timely outcomes, creating evidence that is based on the experience of those who know, live, and work with the problem that the evidence needs to solve (Green 2001).

The Evidence Integration Triangle model: With its origins in implementation science, the Evidence Integration Triangle (EIT) (Glasgow 2013) moves away from often unreliable and slow efficacy approaches towards creating a dynamic and transferable flow of high quality evidence to practice, ensuring a rapid and informed response to change and improvement. The EIT is a participative approach, including practitioners, policymakers, and citizens, and fosters robust and high-impact knowledge implementation by practitioners and community partnerships. Such knowledge is created through ‘rapid learning cycles’ and can support sustainability of initiatives.

The EIT depicts in a simple framework the complex multilevel factors affecting the integration of scientifıc knowledge into practical applications. There are three main components to the model, namely the evidence-based intervention; participatory implementation processes; and practical measures of progress and outcome. Bringing evidence and relevant stakeholders together is central. These three components enable stakeholders to use scientific evidence to maximise positive health impact and encourage development and sharing of new knowledge to inform future interactions. The high participation and user involvement levels within this evaluation model enable the research to be relevant and applicable from the onset, and ensure that indicators and measures generated to gather evidence remain sensitive and applicable to the research and practice environment. Qualitative and quantitative evidence is accumulated and used throughout so that the change process remains responsive to improvement.

Context is pivotal to the EIT. The conditions surrounding health problems and intervention opportunities in a particular place with a particular population, is a key starting point. Context also changes over time, and continually informs the other key components. The EIT model promotes a reorientation of the current clinical effectiveness research paradigm toward greater recognition of innovation and practice-based approaches to evidence (Green 2008).

Within this model, a multi-method evaluation encompasses both an outcomes-based and a process evaluation in order to comprehensively identify whether and how improvements in integrated care initiatives came about. Translating the model to SUSTAIN:

• the intervention will focus on existing integrated care sites and the over 65s living at home, and consist of a tailored set of improvements constructed with stakeholders, aimed at the micro, meso, and macro levels within the health and social care system;

• the practical measures will consist of

1) a core set of qualitative and quantitative indicators measured at intervals;

2) multi-method process evaluation focusing on implementation processes and perceptual outcomes;

• the participatory implementation process will consist of key stakeholders attached to the existing integrated care initiatives (e.g. decision-makers, policy makers, senior citizens, health insurers, health and social care providers, commissioners and representatives from the technology industry). They will use the on-going data collection and analysis and their own experiences to give regular feedback informing on progress, identifying problems and creating solutions and modifications to further the intervention improvements to service delivery.

Conclusions: This approach is highly suited to SUSTAIN. Given the integrated care complexities and associated difficulties identifying meaningful outcomes, this methodology will help us to find out what works for whom, how, in what context and with what outcomes. In terms of the wider research agenda, the EIT model can also identify and guide strategic decision-making about research areas to pursue as initiatives are rolled out, so that evidence can inform health promotion and healthcare-quality research.

How to Cite: Billings J. What works for whom, how, in what context and with what outcomes? Integrated care evaluation using the Evidence Integration Triangle: the case of SUSTAIN. International Journal of Integrated Care. 2016;16(6):A125. DOI:
Published on 16 Dec 2016.


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