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Faced with rising healthcare costs and inefficiencies in the healthcare system, the Ministry of Health and Long-Term Care invited proposals for integrated funding models (IFMs) across the province of Ontario, Canada. Six pilot programs were selected, each of which included hospital and community partners. While they were diverse in scale (from two to fourteen partners) and chosen clinical condition (from COPD to cardiac surgery), all were based on the bundling of care and the integration of funding. A single team provided patients seamless care from hospital to home, while program partners transferred funds that correlated with expected use of a service to each other or a commonly held bundle, in the hope that shorter hospital stays would lead to better patient outcomes and cost savings. Methods/ Theory: Researchers at the University of Toronto conducted a mixed-methods provincial evaluation, the qualitative component of which sought to identify how integration was generated and implementation challenges faced. Forty-eight stakeholder interviews were conducted, six with each program, including interviews with funders, regional authorities, program leaders and practitioners. Anonymized transcripts were coded using NVivo. A realist framework informed analysis. Results: Content analysis revealed that seamless integration was enabled by decisions about IFM structure, existing partnerships, trust-building, thoughtful model development, clinician engagement, and information-sharing. These mechanisms, themselves informed by unique contexts, were enabled by a range of micro-mechanisms that transformed clinical practice, information sharing systems, and organizational cultures into what was typically a more closely connected version of what existed before implementation. While there were typically noted challenges in this process (e.g., difficulties securing physician buy-in and integrating IT systems), we also identified unanticipated disincentives and stakeholder tension relating to the very purpose of integration. Discussion/ Lessons learnt: Behind the goal of integrated care lay the generation of connectivity and consensus - the coming together not just of resources, but also of organizational leaders, clinicians, and systems from heterogeneous organizations representing acute and post-acute aspects of healthcare. This work contributes to scholarship by a) identifying the micro-mechanisms, both strategic and accidental, that produced and complicated systemic integration, b) identifying tensions that complicated implementation, ranging from the new funding model being at odds with existing ones to different albeit overlapping stakeholder expectations of healthcare integration, and c) advancing an understanding of mechanisms as contextually and temporally contingent, with the capacity to inform and produces new contexts, which in turn generate a new set of mechanisms. Limitations: Sample size may be a practical limitation, given that the scale of some IFMs challenged the incorporation of all IFM partner perspectives. Suggestions for future research: While this research explored the contexts, mechanisms and challenges of integrated funding models, there is scope to further investigate their implications for the sustainability of IFMs. While being contextually circumscribed, this could nevertheless provide tentative guidance on spread.

The Generation of Integration: The mechanisms and challenges of implementing healthcare integration across Ontario, Canada