Integration among health care professionals, health care systems, and public health organizations to improve population health has recently emerged as a policy priority for federal health and public health agencies. A large gap exists, however, between current policy and program implementation efforts and the existing evidence for integration interventions. The challenges of research into integration effectiveness include lack of a standardized definition of integration and lack of a taxonomy to allow grouping of similar interventions that helps to facilitate an understanding of their effectiveness. We address these challenges and advance research into integration. Drawing from prior evidence syntheses of integration interventions, we provide a recommended definition and a classification scheme for describing and grouping like interventions. Our work can benefit researchers engaged in generating evidence for integration interventions and policy makers; it will help to ensure that the integration policy promoted by health and public health agencies is supported by science.

Acknowledgments

This work was supported by internal funding from RTI International.

Introduction

Integration among health care professionals, health care systems, and public health organizations to improve population health has recently emerged as a policy priority for federal health and public health agencies. Beginning in the 1980s, efforts have sought to define, study, and make recommendations on integration (as described by Lasker¹ and Scutchfield et al.²); the most recent example is the work conducted by the Institute of Medicine (IOM) on the integration of primary care and public health.³

These efforts have culminated in a current phase of rapid implementation of integration policy. For example, among state chronic disease programs funded by the Centers for Disease Control and Prevention (CDC), integration is now one of four core areas of program implementation.⁴ Proponents of integration describe the need for “intersectoral partnerships”³ to overcome the siloing of medicine and public health practice and to achieve potential gains in efficiency and effectiveness of health care and public health practice, cost savings, and improved health outcomes.^3,5

A large gap exists, however, between current policy and program implementation efforts and the evidence for integration interventions. Only two formal evidence syntheses for integration interventions have been attempted, and both focused on using integration interventions to deliver preventive services.^6,7 The authors of these studies concluded that the evidence is sparse, and commented on the lack of primary research in this area. The challenges of research into integration effectiveness are many. Four high-priority challenges include: (1) the heterogeneous nature of the interventions that may qualify as “integration,” and the fact that they may not be labeled as an “integration intervention,” in part because of the lack of a standardized integration definition; (2) a lack of standardized metrics for evaluation; (3) the need for a single overarching framework to understand facilitators and barriers to integration; and (4) the need for a taxonomy to allow grouping of similar interventions for facilitating an understanding of their effectiveness. To illustrate the effect of a lack of a standard definition, if we scan the key works in the field, we get the following terms that are used synonymously for the presently favored term “integration”: linkages,⁸ collaborations,⁹ relationships,⁷ partnerships,¹⁰ and synergies.¹

This paper addresses two of these challenges—namely, the need for a standard definition and the need for a taxonomy to describe integration interventions—and will benefit multiple entities. A definition of integration and a taxonomy will benefit researchers engaged in evaluation of integration interventions and those conducting systematic reviews. Policy makers will benefit as researchers attempt to use the taxonomy to close the “evidence gap,” ensuring that science supports the integration policy that health and public health agencies promote. Also, organizations (including federal agencies) disseminating information about integration and practitioners—the direct consumers of information about integration interventions—can also benefit from a standard classification scheme.

The extensive breadth of interventions that can be classified as “integration” is likely bewildering for health and public health practitioners who are being encouraged to integrate. For example, searching for “behavioral health” integration interventions on a current website featuring integration success stories¹¹ revealed three vastly different integration interventions: colocation of a federally qualified community health center and a local health department; a partnership between a local health department and two pediatric practices to incorporate on-site early childhood mental health teams and health navigators; and development of a health information technology system by a nonprofit community health network for Medicaid patients. Health care and public health practitioners need clear guidance demonstrating types and examples of evidence-based integration initiatives, and they need to be able to quickly identify those that are relevant to their settings and their programmatic goals.

Our primary purpose is to advance the discussion about integration by promoting a consistent definition of integration and providing a taxonomy for integration interventions. A taxonomy can be defined as “a system for classifying multifaceted, complex phenomena according to common conceptual domains and dimensions.”¹² A taxonomy is critical for evidence synthesis because it allows for grouping of like interventions to understand their effectiveness; it can also facilitate clear communication between policy makers and practitioners about what interventions are supported by the evidence.^12,13 We envision the primary users of a taxonomy to be federal agencies and organizations (e.g., CDC, Health Resources and Services Administration [HRSA], Agency for Healthcare Research and Quality [AHRQ], and Centers for Medicare & Medicaid Services [CMS]), foundations (e.g., Robert Wood Johnson [RWJF] and de Beaumont), and other organizations such as the Patient-Centered Outcomes Research Institute (PCORI) that are funding research on integration. Other major end users will be academic researchers engaged in this work. Secondary users of this taxonomy might be federal agencies and others that are promoting integration policy and disseminating integration interventions.

We are aware of only one taxonomy or classification scheme for integration interventions.¹ Although this work was seminal and is cited in the subsequent generation of integration studies, the classification scheme itself has not been widely used in ensuing work (examples of authors who use this classification include Martin-Misener et al.¹⁴ and Porterfield et al.⁸). Other authors have published models or frameworks for integration that focus on describing the facilitators and barriers to integration interventions rather than classifying the interventions themselves.^15,16 Thus, the heterogeneity of the integration activities and the need for a classification system have not been directly addressed since Lasker’s work in the 1990s.¹ For researchers to evaluate and for federal agencies and other bodies to disseminate integration interventions, defining and classifying these interventions are necessary next steps.

Methods

Figure 1 shows the process of our environmental scan and gray literature review of integration interventions, a scan of the literature for taxonomies of interventions, and information that contributed to our development of an integration definition and the taxonomy. The following text details these steps.

Figure 1

Process for literature review and environmental scan.

As Figure 1 depicts, we first conducted a literature review and environmental scan to identify reviews (systematic or narrative) of the published literature or other descriptive studies of integration interventions. This supported developing a definition of integration and a taxonomy. Because resources are limited, we included only works that identified and synthesized information about a set of integration interventions; thus, we excluded single studies, editorials, or commentaries.

We adapted a search strategy used in 2014 in work conducted for PCORI, by removing search terms specific to the integration type of interest in that work (i.e., preventive services delivery).¹⁷ Table 1 presents the search terms used in the literature review. We limited the search to articles published in English during the past 10 years.

Table 1

Search terms for literature review.

For the environmental scan for reviews of integration studies, we reviewed a set of 11 documents identified in a gray literature scan in summer 2014.¹⁷ We supplemented this body of work with a review of websites from nine organizations and agencies most involved with integration interventions: CDC, HRSA, AHRQ, CMS, American College of Preventive Medicine, American Medical Association, American Public Health Association, Association of State and Territorial Health Officials, and National Association of City and County Health Officials. We searched each of these sites twice, using the terms “linkages” and “integration,” and reviewed at least the first 50 results for each search.

Table 2 presents inclusion/exclusion criteria for the literature review and environmental scan.

Table 2

Inclusion and exclusion criteria for studies.

From these works, we abstracted two types of information: (1) the definition of integration used and (2) any taxonomy or classification of the interventions. Because these works most often did not include a formal taxonomy, we abstracted descriptive information presented by the authors to characterize the interventions. For example, from tables presented in these review articles summarizing the set of interventions, we abstracted the heading and the values in the tables (e.g., “health behavior or condition” and “obesity, physical activity, nutrition, tobacco”).

To develop our definition of integration, we used as our starting point the definition in the 2012 IOM report, which is now widely used (“integration of primary care and public health” is “the linkage of programs and activities to promote overall efficiency and effectiveness and achieve gains in population health”).³ We compared the IOM definition with those definitions abstracted from the included studies. Elements or phrases found in the definitions that differed from the IOM definition were identified and categorized. The authors adapted the IOM definition based on these data.

Our goal in developing a taxonomy was to adapt or build off of an existing taxonomy of public health interventions. Therefore, we conducted a brief scan of the literature and the Internet, and we consulted with public health experts to identify existing classification schemes. We identified only a single example of a comprehensive classification scheme of public health interventions,¹³ which we have used as the starting point for our taxonomy. Jorm et al. reviewed familiar definitions of public health functions, such as the 10 Essential Services,¹⁹ but identified the limitations of these existing frameworks as follows:

However, all are essentially “flat” lists, or at best hierarchical taxonomies, which conflate discrete dimensions such as the purpose of public health activities, the health issues and problems addressed and the settings in which services are delivered, into single “functions.” None presents a well-defined theoretical framework for multiple aspects of effective public health practice.¹³

Using existing definitions and classification schemes, these authors constructed an ontology of public health that formed the basis for their classification scheme, which was subsequently refined by review and feedback by public health experts. In our initial assessment of the Jorm et al. work, we thought that this taxonomy could be used as a basis for a taxonomy of integration interventions. We reviewed numerous other classification schemes, including that developed by the Community Preventive Services Task Force,²⁰ and examples from the fields of health behavior,^21,22 HIV,²³ and implementation science.^24,25 Ultimately, we identified the Jorm et al. work as the most comprehensive (including multiple variables to describe an intervention rather than being a “flat” classification scheme) and, therefore, as the best starting point.

Our next step was to develop an Excel spreadsheet with the six “top-level classes” from this work (functions, health issues, determinants of health, methods, settings, and resources and infrastructure) as columns; we entered each article or document reviewed as a row in the spreadsheet. We abstracted and mapped information from each of the included articles in the following ways:

• Where categories or domains of integration interventions described in the article appeared to match one of the six classes, we included that information in the same column under that heading.
• Where categories did not match one of the six domains, we created a new column.

To develop a taxonomy of integration interventions, we reviewed the mapped data and made decisions about whether to include or revise the Jorm et al. “classes” (or in our terminology, “domains”) and what new domains might be necessary. We also adapted or developed draft definitions of these domains and included or identified new examples of subdomains (“subclasses” in Jorm et al. terminology) for some of the domains.

Results

Our literature search yielded 321 abstracts; we gave six of these publications a full-text review and ended up including two publications. We excluded most of the abstracts because either the organization types did not meet our criteria (e.g., studies excluded integration of health care and behavioral health or social services) or the abstracts described only a single intervention and not a group of interventions. We also included seven documents from our gray literature search (two of which represent the same studies as the two articles initially included) and an additional two peer-reviewed articles from a review of bibliographies of included works. Table 3 describes the 11 included articles or websites, which represent 9 unique studies, presented in chronological order.

Table 3

Summary of included works.

Discussion

Taxonomy of Integration Interventions

Table 4 presents our revised taxonomy, which is a final list of eight domains that we identified by comparing information abstracted from the included works with the Jorm et al.¹³ classes. Overall, Jorm et al. had six classes; we combined two of their classes into one: “Determinants of Health” was combined with “Health Issues” to become “Health Issues and Risk Factors Addressed.” We also added three domains—namely, organizations involved, level of integration, and target population. In Table 4, we identify the domains that Jorm et al. used with BOLD font in the title. Although we changed some of the titles of the Jorm et al. classifications, we adopted many of the definitions from their work.

Table 4

Taxonomy domains for categorization of integration interventions for purposes of research and evidence synthesis.

Table 4 and the following text describe each of the eight domains. We provide a definition and illustrative subdomains (where relevant) and highlight important distinctions from Jorm et al.¹³ We also indicate which of the studies from our review included that domain in its descriptions of integration interventions, informed this domain development, or both.

Goals. Our top-level domain is “goals” rather than “functions,” because the former term is more familiar to U.S. public health practitioners than the latter. For goals, we have not used the Jorm et al.¹³ subclasses; rather, we created a draft list that builds on the goal of integration stated in the draft definition. The four illustrative subdomains reflect broadly the goals of the health care system and public health; they also emphasize data infrastructure and information exchange; finally, they include a fourth category comprising multiple drivers of health, including policy, education, and research.³²

Health Issues and Risk Factors Addressed. Our second domain, “health issues and risk factors addressed,” represents the diseases and risk factors that integration interventions may address. Our draft list of health-related subdomains (e.g., chronic disease, maternal and child health) is based on the reviews cited in the table. Grouping interventions by health issue or risk factor addressed is critical to understanding effectiveness and providing clear and relevant guidance to practitioners. We may eventually learn that certain integration intervention types are effective across health conditions (e.g., linking data among public health and health care to establish an immunization registry and a cardiovascular disease surveillance system). We would argue, however, that disease- or risk-factor–specific studies are a priority to establish effectiveness, guide policy, and inform actionable guidance to practitioners.

Organizations Involved. For this domain, we developed a list of subdomains based on studies in our review. As in our draft definition, the two categories of involved parties in an integration intervention are (1) health care organizations, which can vary in size from a single private practice to a health system or coalition of health systems, and (2) public health entities. We argue that the “public health” category should include a wide variety of non–health care organizations and not be restricted to governmental public health agencies. In our judgment, the question of whether to include for-profit organizations, such as businesses, in both this category and in the definition of integration interventions warrants broader discussion.

Type of Intervention. “Type of intervention” is equivalent to the Jorm et al. “methods” class.¹³ The original “methods” class included a list of 35 categories. Some of these categories are common among integration interventions and are relevant for this work (e.g., “monitoring and surveillance”); others, although valid public health activities (e.g., “radiation safety methods”), do not appear to be relevant to integration interventions, based on our findings. This domain illustrates what activities the organizations involved in the integration are pursuing to achieve stated goals. This domain corresponds to many of the more familiar categorizations of public health activity, is perhaps the most important domain in terms of guiding research and practice, and has proved the most challenging to detail. In addition to reviewing Jorm et al.¹³ subdomains, we reviewed several frameworks or classification schemes for types of intervention from the literature (e.g., health impact pyramid,³³ behavior change wheel,²² intervention wheel,³⁴ and the classification scheme used by the Community Preventive Services Task Force²⁰). We also attempted to generate a list of subdomains from four of our included works, which provided the most detail and offered a categorization of the methods of the interventions (see Table A1 in Appendix A).^1,8,9,26 Types of interventions in these four studies did not overlap much; each study identified types of interventions not described in other studies. Our conclusion is that developing subdomains for this domain will require a comprehensive review of the intervention literature (rather than a review of literature reviews, as we have done), synthesis with existing frameworks for interventions, and more formal processes, including expert feedback, to articulate a definitive set.

Table A1

Subdomains within “Types of Interventions” from included studies.

Resources and Infrastructure. This domain represents the means available for the operation of health systems which, broadly speaking, includes human resources, facilities, equipment and supplies, financial funds, and knowledge. At this point, we do not propose subdomains; rather, we suggest the need for further efforts to elucidate these. Early work describes the “spanning infrastructures”^16,35 found in integration interventions to facilitate preventive services delivery, such as information systems for patient referral. Identifying and establishing the evidence for spanning infrastructures and other, organization-based resources and infrastructure that support the implementation and effectiveness of integration intervention are rich areas for future research. A first step is to synthesize literature from existing work in integration and from implementation science frameworks^24,36 to develop a working list of subdomains for future research.

Level of Integration. The IOM has proposed levels of integration (isolation, mutual awareness, cooperation, collaboration, partnership, and merger) for this domain; although the IOM does not give detailed definitions, these may prove useful as part of a taxonomy.³ A standardized set of terms to describe the level of integration has intrinsic appeal in terms of utility, but when using such terms, “more is not always better.” Different levels of intervention are commonly understood to be appropriate and effective in different situations; we need to work to document this contention. As part of defining levels of integration, specific characteristics of integration interventions may be included; alternatively, these characteristics may be useful as stand-alone elements within this domain (or even included in the resources and infrastructure domain). For example, descriptive work needs to detail whether a contract or a memorandum of understanding (MOU) formalizes the integration²⁶ or whether a coordinating committee or a coalition guides the integration intervention. Such examples may provide a useful starting point for grouping in an evidence synthesis (e.g., does the presence of an MOU facilitate implementation of an integration intervention and outcomes?). Thus, we need to expand work in this domain, as in the resources and infrastructure domain, to develop detailed definitions of each of the levels of integration and to apply them moving forward in descriptive and research studies.

Settings. Settings can describe a type of physical location in which an intervention takes place, such as a school or worksite; a geographic area (e.g., the scope of the intervention, whether local, statewide, or national); or a categorization of that geographic area (e.g., rural or urban).

Target Populations. This new domain is informed by our review of the included studies. If the target population of the intervention consists of individuals, then important information about the intervention would include characteristics of that population (e.g., age, sex, race and ethnicity). Targets for integration interventions, however, could also include organizations (e.g., if a health plan and a health department work together to change screening algorithms in primary care clinics). In terms of synthesizing our framework with other frameworks of interventions, we suggest that the levels of the social-ecological model²¹ may best fit within this domain; one can think of the targets of the integration intervention being policy-making bodies, the community, organizations, families, or individuals.

Conclusion

We present an initial step in developing a new taxonomy of integration interventions between health care professionals and systems and public health organizations. We also offer a new definition of integration (building on that from the 2012 IOM report³), which can be used to promote research and evidence synthesis. The very small number of evidence syntheses (even within a specific content area, preventive services delivery) have struggled with heterogeneity of studies and an insufficient number of studies to provide definitive findings on effectiveness. To allow grouping of like interventions to describe them in a standardized way, synthesize findings, and disseminate evidence of intervention effectiveness, researchers, practitioners, and policy makers need a sensible classification scheme that can be applied across integration interventions.

The next step in the development process will be sharing the taxonomy with a broad set of experts for feedback and refinement. To develop the taxonomy further, we will delineate subdomains for the priority domains of intervention types and resources and infrastructure. Also, we plan to develop an abstraction worksheet that other authors could use in conducting systematic reviews (similar to that published by the Community Guide²⁰) to facilitate use of the taxonomy.

The research team will disseminate this taxonomy widely to researchers, funders, and policy makers working in integration. We suggest that researchers use the domains in our taxonomy in descriptive studies and evidence syntheses. RTI authors will lead by using the taxonomy in our future work in integration—particularly in systematic reviews of integration interventions. Even with the taxonomy in this draft stage, we believe that taxonomy will be immediately useful to policy makers for providing specificity in guidance to grantees promoting integration interventions.

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Appendix A

Deborah S. Porterfield is a senior public health research analyst at RTI International and an Associate Professor at the University of North Carolina at Chapel Hill School of Medicine.

Lucia Rojas-Smith, DrPH, is a director of the Social, Health, and Organizational Research and Evaluation program at RTI International.

Megan Lewis, PhD, is a senior research scientist and leader of the Health Care Communication Team, Health Communication Program, at RTI International.

Lauren A. McCormack, PhD, is the senior director of the Health Communication Program at RTI International.

Thomas J. Hoerger, PhD, is a senior fellow in the Public Health Economics Program at RTI International.

Debra J. Holden, PhD, is the senior director of the Community Health Promotion Research Program at RTI International.

RTI International is an independent, nonprofit research organization dedicated to improving the human condition. The RTI Press mission is to disseminate information about RTI research, analytic tools, and technical expertise to a national and international audience. RTI Press publications are peer-reviewed by at least two independent substantive experts and one or more Press editors.

Suggested Citation

Porterfield, D.S., Rojas-Smith, L., Lewis, M., McCormack, L.A., Hoerger, T.J., Holden, D.J. (2015). A Taxonomy of Integration Interventions Between Health Care and Public Health. RTI Press Publication No. OP-0023-1507. Research Triangle Park, NC: RTI Press. http://doi.org/10.3768/rtipress.2015.op.0023.1507

RTI International is an independent, nonprofit research institute dedicated to improving the human condition. We combine scientific rigor and technical expertise in social and laboratory sciences, engineering, and international development to deliver solutions to the critical needs of clients worldwide.