Guiding Principles for transforming towards Integrated Acute Care for Older People close to home: Lessons from 9 Dutch regions

Background: Transforming towards Integrated Acute Care for Older People (IACOP) close to home requires professionals and organisations from different care domains to collaborate. To foster collaboration, nine Dutch regions implement interventions to transform to IACOP. This study provides insight into which implementation strategies are used, why, and when, based on the experiences of these regions. Methods: A Realist Evaluation approach was used to unravel which strategies were undertaken by organisations and regional partnerships, in which contexts, to foster IACOP. The Rainbow Model functioned as theoretical basis for understanding integrated care and its multi-layered nature. We conducted a document analysis, semi-structured interviews and focus groups. Data were clustered into guiding principles, underpinned with strategy-context-mechanism-outcome configurations. Results: The regions were in different phases of transformation and applied a multitude of strategies tailored to their regional context. Nine guiding principles for transforming towards IACOP close to home were formulated. Five focusing on the meso-level: 1. Shared commitment for a regional IACOP-vision; 2. A culture of extensive integral collaboration; 3. Identification of shared bottlenecks and priorities; 4. Systematic implementation of interventions; and 5. Embedding interventions through continuously learning. And four focusing on the macro-level: 6. Coordinated policy by national institutions and health insurers; 7. Financial incentives align with overarching system goals; 8. Regional care coordination and (patient) data exchange; and 9. Legal and quality frameworks for integrated care. Conclusion: Transforming towards IACOP close to home is complex. Its success depends on macro-level integration and on applying strategies that fit the regional context and phase of transformation. Under these conditions, the generative forces for transformation like urgency for change, trust amongst stakeholders, and shared ownership and responsibility are activated.