Integration of health and social care is increasingly central to improving outcomes, experience and sustainability; however, integrated care is not a single construct. This article presents a novel framework to categorize and conceptualize different approaches to integrated care, illustrating variations in attributes, context, complexity and impact. Drawing on international literature, three approaches to integration – condition-based, multi-condition and population-based – are examined along a continuum. Condition-based approaches focus on defined patient groups using standardized clinical pathways requiring limited coordination. Multi-condition integration supports populations with complex chronic conditions, requiring comprehensive, multi-sectoral coordination and interconnected structures. Population-based integration represents the broadest approach, organizing health and social care around community needs and social determinants of health and necessitating system-level governance with aligned policy and funding. While integrated care models can advance without explicitly delivering population health outcomes, population health cannot be advanced without integration as a foundational enabler.

Introduction

Across Canada, health systems are experiencing the same challenges as other health systems worldwide, with persistent struggles related to fragmentation, rising demand and growing complexity of patient needs. In response, integrated health and social care has emerged globally as a policy priority to deliver person-centred, coordinated and efficient care (de Matos et al. 2025; WHO 2016). Strengthening inter-sectoral partnerships and improving coordination across health and social care is recognized as a means to achieve the Quintuple Aim, including improving patient and caregiver experience, reducing costs, improving population health, improving the experience of front-line healthcare teams and addressing health inequities (Nundy et al. 2022). Yet, integration is not a singular concept; it is ideally conceptualized as a continuum of approaches ranging from condition-specific models to system-wide, population-based strategies. As integration models proliferate, there is value in exploring the range of goals, approaches, contexts and key contributing factors for achieving successful integration.

This paper presents a novel framework for categorizing and conceptualizing multiple approaches to integrated care and highlights how the attributes, context, complexity and level of impact change from one approach to another and the connectivity and maturation between each. The authors have developed this framework, supported by literature evidence, to help sensemake what integrated care means and characterize how complexity increases commensurate with the breadth and impact on the population served. The framework is intended to be used as a tool to explain the continuum of approaches to integrated care and help users consider their goals, design principles, implementation steps and enabling elements, as well as evaluation considerations that underpin their chosen approach to integration. Understanding approaches to integration as a continuum enables health system leaders, clinicians, policy makers and researchers, in partnership with people with lived experience and their caregivers, to align strategies with local needs and advance toward a long-term vision for population health and equity.

Defining Condition-Based, Multi-Condition and Population-Based Integration

The integration of health and social care is increasingly recognized as essential for addressing fragmentation, improving patient outcomes and ensuring the sustainability of health systems. Yet the concept of “integration” is highly variable, encompassing diverse strategies from targeted care pathways to whole-system transformation. Seminal works by Kodner and Spreeuwenberg (2002) and Goodwin (2016) highlight that integrated care is best understood as a continuum. At one end, care redesign focuses on discrete patient groups and clinical pathways. At the other end, system-wide approaches to integrated care align health and social care services to improve population health. In between these instances lies integrated care for individuals with multiple complex and chronic conditions. The three different approaches along the continuum of integrated care are explained briefly as follows:

1. Condition-based integrated care

Condition-based integration is the most targeted and structured approach to integrated care, focusing on patients with a single or uncomplicated diagnosis. Common examples include post-acute care pathways for hip and knee replacements, cancer care bundles or stroke rehabilitation (Nolte and McKee 2008). Integrated care delivery generally involves a two-stage care pathway, such as an acute care surgical intervention followed by discharge to a community-based primary and/or homecare provider. In these cases, care shifts from one provider to another, with some level of coordinated care transition and potentially, shared funding arrangements between the two providers.

Evidence-informed treatment protocols enable standardized transitions/clinical pathways across providers that both bridge potential gaps in care and improve efficiency and outcomes (Shortell et al. 2015a). These models ideally align with Wagner's Chronic Care Model (Wagner et al. 2001), which emphasizes structured, evidence-based processes. Outcomes include reduced hospital stays and improved functional recovery. However, their narrow focus makes them less relevant for multimorbid patient populations, who increasingly dominate healthcare demand (Barnett et al. 2012). The overall impact is also limited, given that only a fraction of the total population experiences this type of intervention.

2. Multi-condition integrated care

At the next stage of the continuum, integrated care extends to populations of patients with multiple, complex chronic conditions such as older adults with multiple ambulatory care sensitive conditions such as diabetes, heart failure, chronic obstructive pulmonary disorder (COPD), people experiencing addiction and/or mental health challenges, children with medical complexity who may or may not be technology dependent, and people requiring palliative care. These individuals are often high users of healthcare yet experience poor outcomes due to fragmented services (Goodwin et al. 2014). Multi-condition integration seeks to address these challenges through comprehensive care management, interdisciplinary teams, shared care planning and coordinated support across sectors (Nolte and McKee 2008).

Integrated care delivery may involve multiple health and social care providers providing care simultaneously, requiring a coordinated team-based approach across providers and organizations to achieve maximum effectiveness and optimal patient experience and outcomes. Models of care may include primary health homes and integrated case management, which rely on inter-organizational, interdisciplinary teams at the point of care, shared care plans and proactive team-based support (Boult et al. 2009). Evaluations show reductions in avoidable hospitalizations, improved patient experience and better management of chronic diseases (Bodenheimer and Berry-Millett 2009).

Key enablers include interoperable health information systems, aligned funding (e.g., capitated payments) and relational integration across professional boundaries (Valentijn et al. 2013). Barriers include high resource requirements and challenges to sustaining multidisciplinary collaboration.

Compared to condition-specific models, these models of integrated care encompass a larger proportion of the overall population, given that approximately one in 12 Canadians have multimorbidity, defined as having three or more chronic health conditions (Statistics Canada 2023). Multi-condition approaches demand greater system-level coordination, flexible funding arrangements and strong relational collaboration among providers. As complexity increases, these realities heighten the need for adaptive leadership capable of navigating uncertainty, aligning diverse actors and unlocking greater opportunities for system-level impact. In practice, this growing complexity calls for adaptive front-line teams that can respond in real time, support cross-sector problem-solving and translate system-level ambition into tangible improvements in care delivery and outcomes. A high-performing approach would expand beyond disease management toward whole-person well-being.

3. Population-based integrated care

At the broadest and most mature level, population-based integration organizes health and social care around entire communities rather than specific conditions or patient groups. This model shifts the focus from illness treatment to holistic well-being, explicitly engaging social determinants such as housing, education, food security, social connection and employment within a population health approach (Marmot et al. 2010). Population-based integration typically involves networks of providers such as hospitals, primary care, social services, community organizations, public health, municipalities and other community assets working under collective governance and financing arrangements. Examples include Accountable Care Organizations (US), Integrated Care Systems (England) and regional partnerships in Scandinavia (Ham and Alderwick 2015; Shortell et al. 2015b). Specific strategies may include community health hubs and neighbourhood care teams. These models emphasize collective governance, pooled budgets, shared accountability for population outcomes and whole system transformation.

Emerging evidence suggests population-based integration can reduce inequities and improve system sustainability (Goodwin et al. 2022). However, challenges include governance complexity, complex team dynamics, skills to create the enabling conditions, long implementation timelines and the need for aligned and sustained political and funding support.

Introducing the Continuum Framework for Integrated Care

The Continuum Framework for Integrated Care contrasts the three different approaches to integration, showing variations in scope, complexity and system requirements, and is intended to support healthcare leaders and policy makers to make strategic choices about how to leverage integrated care to transform care delivery. Aligning the chosen approach(es) to integrated care with the intended goals ensures that collective efforts are fit for purpose.

It is important to stress that the three approaches to integration are not mutually exclusive, and the framework is not intended to frame implementation of integrated care models as sequential. In fact, using a layered strategy that encompasses multiple approaches may help systems realize shorter-term gains while creating the necessary conditions to advance improvements in population health over the longer term.

To explain the details of the continuum framework, the authors have created a series of diagrams where each figure (Figures 1–5) successively builds the elements of the framework in stages, with Figure 5 representing the expression of the framework in its entirety. Each stage (Figures 1–5) represents an expansion in purpose, partnership and relational depth.

The continuum framework positions the three approaches to integration: (1) condition-based, (2) multi-condition and (3) population-based, as distinct but interconnected on a continuum of integration. Each approach is described separately and then plotted on the continuum framework. The framework outlines the conceptual underpinnings, evidence base, and implications for practice and policy in moving from one integrated care approach to another.

The development of the Continuum Framework for Integrated Care starts with Figure 1, which provides a basic explanation of the three different approaches to integrated care delivery and serves as the foundation for the framework.

Figure 2 builds on Figure 1, demonstrating that complexity increases when moving from left to right along the continuum – from a focus on patients¹ with a discrete condition to a focus on patient groups with multiple complex health conditions. As the scope of integration increases, there is a complementary increase in complexity, with increasingly higher levels of collaboration, intersectoral partnerships across health and social care and the need for more intensive care coordination. There is also a much greater shift in focus toward wellness, disease prevention/health promotion and the broader social determinants of health. Furthermore, there is a need for greater mobilization of community assets, including citizen engagement and co-design with people with lived experience, to achieve system transformation.

Figure 3 adds the dimensions of complexity and degree of impact as the x- and y-axes, demonstrating that both complexity and impact increase when moving from left to right along the continuum. When more people are receiving integrated care, the more complex the structures, partnerships and factors underpinning the system, and the higher the impact on the overall health of the population. In general, single condition-based integrated care models can involve as few as two partner organizations, such as an acute care hospital and a home care team, whereas patients with multiple chronic health conditions may need to access support from several intersectoral health and social care services to provide them with the full range of care they need, including an increasing emphasis on health promotion and self-management. In the full realization of an integrated system of care, all health and social care sectors serving that community are part of the network, thus requiring more complex models of integrated governance and processes to enable shared accountability.

Figure 4 adds the need for realignment of funding models supported by enabling policy. Single condition-based models of integration can be supported with bundled or shared funding arrangements between two or more partners. These arrangements are intended to achieve better coordination of cross-continuum care and enable more flexibility in care delivery (Wojtak and Purbhoo 2015). As more organizations and sectors become engaged in population-based systems of care, care delivery requires more complex funding arrangements, such as capitation and pooled funding, to align care and enable integration functions that bridge across different provider organizations and sectors.

Finally, Figure 5 represents the full expression of the Continuum Framework for Integrated Care, including the addition of systems governance and adaptive leadership.

As health systems progress along the continuum toward population-based transformation, leadership and governance must evolve to match increasing complexity and the demands of collective accountability. Distributed leadership and shared governance function as critical system conditions that enable this evolution. Distributed leadership models are non-hierarchical in nature, with decision-making and accountability shared among team members and a strong focus on collaboration (Seed et al. 2018). Distributed leadership transcends positional authority, emphasizing collective capability – the shared capacity of organizations, sectors and communities to lead, learn and adapt in pursuit of common goals. It enhances a system's adaptive capacity by fostering relational trust, collective sensemaking and coherence across boundaries, thereby enabling progress on challenges that no single entity can address alone.

Shared governance provides the institutional architecture through which distributed leadership operates. Traditional hierarchical and compliance-driven models must give way to relational, transparent, and participatory forms of governance anchored in shared accountability for outcomes. As integration deepens, governance extends from ensuring quality within discrete pathways to orchestrating cross-sector collaboration and embedding community participation in decision making. When leadership and governance advance in concert along this continuum, integrated care goes beyond its origins as a coordination mechanism to become an enabling architecture for population health that organizes systems around collective stewardship, equity, and resilience.

Leading across complex independent sectors and settings of care requires a different set of leadership competencies than more traditional organizational settings (Evans et al. 2016). The most commonly used theory for examining leadership in integrated care is complex adaptive systems (CASs) Theory (Edgren and Barnard 2012; Fillingham and Weir 2014; Tsasis et al. 2012). CASs involve systems that are self-organizing through relationships and interactions among diverse agents. These systems require leadership styles that support facilitative, distributed leadership focused on relationships, trust and shared power (Evans et al. 2016). Moving from left to right on the continuum framework demonstrates that a shift in leadership competencies, with increasing focus on leadership styles that align with complex adaptive systems, including greater adaptability to ambiguous and unpredictable environments, is required to guide the development of more complex and integrated systems of care.

Notably, Figure 5 also demonstrates that as the degree of complexity increases along the x-axis, the time required to implement more complex levels of integration also increases, in some cases taking years or decades to reach maturity.

Discussion

The Continuum Framework for Integrated Care illustrates how different approaches to integration evolve when shifting from targeted, condition-specific models to comprehensive, population-based systems that improve the health and well-being of entire communities. Each progression along the continuum represents a step-change in complexity, collaboration, and impact – moving from simple linear coordination to complex adaptive systems that learn and transform over time.

As systems advance, six interacting dimensions deepen simultaneously:

1. Intensity of coordination and collaborative partnerships;
2. Focus on wellness, prevention and social determinants;
3. Partnership with people with lived experience and community mobilization;
4. Payment systems and funding alignment;
5. Degree of adaptability, complexity and impact;
6. System governance and adaptive leadership.

Together, these dimensions are reflected in the significant level of complexity, impact and time required in moving from left to right along the continuum:

• Complexity and adaptive capacity increase. Integration becomes less about control and more about coherence and aligning diverse actors around shared purpose.
• Impact expands from individual to collective. The system evolves from improving outcomes for some to enabling well-being for all.
• Time and trust are non-negotiable. Building the relational and adaptive infrastructure for population-based integration requires patience, persistence and partnership.

The authors' Continuum Framework for Integrated Care is strongly aligned with the Nine Pillars of Integrated Care developed by the International Foundation for Integrated Care,¹ which are positioned as the critical elements required to design, implement and sustain integrated care in practice. Across all three approaches along the continuum, the pillars are present, but the depth, sophistication and intentionality with which they must be enacted vary. For example, shared values and vision may begin with agreement among a small number of providers in condition-based models but evolve into community-wide purpose at the population level. Likewise, “people as partners in care” grows from shared decision making at the point of clinical encounter to community co-ownership in governance and priority setting. Workforce capability progresses from standardized protocols to interprofessional team-based practice and, ultimately, to collaborative leadership and stewardship across organizational, sector and industry boundaries. Governance, digital solutions, funding alignment, and transparency similarly intensify as integration broadens, requiring greater coherence, trust and shared accountability. In this way, the nine pillars function not as static elements but as dynamic drivers that scale in scope and relational depth as systems advance along the continuum toward population health and well-being.

At the condition-based integrated care part of the continuum, there can be meaningful improvements in coordination, value and experience for individuals who receive care through integrated clinical pathways. At the other end of the continuum, leveraging large-scale population-based interventions can generate widespread and sustained improvements in health outcomes across a whole community. Progression along the continuum depends on the ability to build relationships, align intent, and collaboratively embrace adaptive complexity in pursuit of collective impact. Ultimately, not all integrated care leads directly to population health improvement, but population health cannot be advanced without integration.

Conclusion

The Continuum Framework for Integrated Care offers a conceptual and practical tool for understanding how systems can progress from condition-specific care coordination to population-based transformation. It underscores that integration is not a singular intervention but a developmental process requiring alignment of purpose, leadership, governance and enabling conditions. As systems evolve, integration becomes less about structural redesign and more about cultivating relational, adaptive and learning capacities across sectors. The framework illustrates that achieving population health and equity depends on an ecosystem approach that integrates health, social and community systems through shared purpose, distributed leadership and collective accountability.

Advancing along the continuum demands both strategic intent and sustained investment in the social architecture of collaboration. Trust, co-design and continuous learning are as essential as policy alignment or funding reform. By embedding these relational and adaptive capacities, health systems can transcend transactional coordination and instead organize around collective well-being and resilience. The Continuum Framework for Integrated Care thus serves as both a sensemaking model and a guide for action to help leaders, practitioners and communities navigate complexity and co-create the conditions for integrated, equitable and sustainable population health.

While the Integrated Care Continuum Framework and the Nine Pillars of Integrated Care describe what is required for integrated care, how these elements are enacted in practice depends on the development of core competencies that enable large-scale change. Advancing along the continuum is not solely a structural or programmatic task; it requires a set of strategic, relational and adaptive capabilities that allow systems to work in interdependent ways. Depending on contextual considerations, these capabilities may include the ability to build and sustain trust, share power across organizational boundaries, lead strategically and collectively rather than hierarchically, create safety for learning and unlearning to enable growth and impact together and steward complexity through reflection and adaptation. These are the impact-at-scale skills that enable the shift along the continuum and facilitate the realization of the nine pillars within real-world contexts. Without these competencies, efforts to integrate care may align in form but fail in function, remaining transactional rather than transformational.

In an upcoming issue of Healthcare Quarterly, the authors will focus explicitly on the how by articulating the core capabilities and enabling conditions that allow integrated care to move from intent to enduring practice, and advance the strategic, operational, relational and adaptive work required for system transformation and population health impact at scale.

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