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Challenges of reforming integrated care in the context of ACO-like organizations: A scoping review


Élizabeth Côté-Boileau ,

Institute of Health Policy, Management and Evaluation, Dalla Lana School of Public Health, University of Toronto, CA
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Jean-Louis Denis,

University of Montreal, CA
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Janine Badr

University of Montreal, CA
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Introduction: Health systems around the world are being redesigned to address issues of poor care coordination, weak information flows, increase in care spending, disparate safety and quality, and inequitable population health outcomes. In the past decade, Accountable Care Organizations (ACO) have risen in the health policy landscape as promising instruments to incentivize both healthcare quality and efficiency through the creation of shared accountability and shared risk delivery systems. ACO-like organizations refer to incentivized entities in the form of legal networks, including hospitals, primary care providers, specialists, community organizations and other system partners, that are financially and clinically accountable to coordinate and deliver continuums of care to attributed populations. ACOs are namely dominant in countries such as the United States, Canada, Australia, the United Kingdom and the Netherlands. More recently, ACOs are growing as potential incubators for large-system care integration. However, to this day, little research has been done on the particular challenges and opportunities arising from reforming integrated in the context of ACO-like organizations.

Aims, Objectives, Theory or Methods: We aim to better understand the particular challenges and opportunities for reforming integrated in ACO-like organizations. We conducted a scoping review (Summer-Fall 2021), systematically investigating six bibliographic databases to search, screen and select relevant literature ACOs and integrated care. We screened 521 papers, then completed a full-text review of 105 identified as relevant based on title and abstract. A total of 36 papers were retained for analysis. Data were extracted and synthesised through descriptive and inductive thematic analysis.

Highlights or Results or Key Findings: We identify four preliminary clusters of challenges and opportunities towards reforming integrated care in ACO-like organizations. First, numerous studies support that ACOs’ shared governance and accountability models raise significant challenges towards care integration. Variability in terms of organizational maturity, institutional logics, and partner engagement strategies namely emerges as factors that would influence the capacity of ACOs to establish shared governance and accountability. Second, the slow development of digital health and data-driven patient navigation functions in ACOs currently hinders population health management capacity building that is crucial to integrated care. Third, collective incentives are still in development within ACOs. An increasing body of research supports that shared risks and rewards might not be sufficient to overcome the various boundaries (clinical, financial, technical, normative, organizational) that keep system partners disintegrated. Finally, patient and community engagement as a strategy for integrated care remains premature and rarely incentivized in ACO-like organizations.

Conclusions: Challenges of reforming and delivering integrated care within ACO-like organizations namely include shared governance and accountability, digital health and patient navigation capacity, collective incentives and patient engagement. Further research should focus on how ACOs may go from offering levers (financial, technical) to support care integration at the organizational level, to conveying true integration at the point of care. 

Implications for applicability/transferability, sustainability, and limitations: With both integrated care systems and ACO-like organizations thriving as health system priorities, we hope to provide timely and actionable knowledge on how to build better capacity and greater accountability for integrated care system-wide.
How to Cite: Côté-Boileau É, Denis J-L, Badr J. Challenges of reforming integrated care in the context of ACO-like organizations: A scoping review. International Journal of Integrated Care. 2022;22(S3):316. DOI:
Published on 04 Nov 2022.


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