Abstract
This paper considers an implication of the idea that proposals for integrated care for older people should start
from a focus on the patient, consider co-production solutions to the problems of care fragmentation, and be at a
system-wide, cross-organisational level. It follows that the analysis, design and therefore evaluation of integrated
care projects should be based upon the journeys which older patients with multiple chronic conditions usually
have to make from professional to professional and service to service. A systematic realistic review of recent
research on integrated care projects identified a number of key mechanisms for care integration, including
multidisciplinary care teams, care planning, suitable IT support and changes to organisational culture, besides
other activities and contexts which assist care ‘integration.’ Those findings suggest that bringing the diverse
services that older people with multiple chronic conditions need into a single organisation would remove many
of the inter-organisational boundaries that impede care ‘integration’ and make it easier to address the interprofessional
and inter-service boundaries.