Table 1 Sample indicators for each key principle

1. Comprehensive services across the care continuum

• Cooperation between health and social care organizations

• Access to care continuum with multiple points of access

• Emphasis on wellness, health promotion, and primary care

• Coordinated transitions in care across services [23]

• Shared programs across sectors/services [24]

• Third next available appointment [25]

• Emergency department average LOS registration to discharge; registration to admission (QPSD 23) [26]

• Measure wait time for referral to treatment by provider type (QPSD 20) [26]

• Proportion of patients with health outcomes which are avoidable given the current state of medical knowledge and access to appropriate care [27]

• Tobacco screening [28]

2. Patient focus

• Patient-centred philosophy; focusing on patients’ needs

• Patient engagement and participation

• Population-based needs for assessment; focus on defined population

• Involvement in care planning for chronic disease/complex care [29]

• Evidence of a population-based needs assessment [30, 31]

3. Geographic coverage and rostering

• Maximize patient accessibility and minimize duplication of services

• Roster: responsibility for identified population; right of patient to choose and exit

• Existence of primary care network structures (e.g. family health teams, primary care networks, GP Divisions, inner city primary health care clinics) [30]

4. Standardized care delivery through interprofessional teams

• Interprofessional teams across the continuum of care

• Provider-developed, evidence-based care guidelines and protocols to enforce one standard of care, regardless of where patients are treated

• Team effectiveness [32]

• Using a shared clinical pathway across care sectors (e.g. diabetes care, asthma care) [33]

5. Performance management

• Committed to quality of services, evaluation, and continuous care

• Diagnosis, treatment, and care interventions linked to clinical outcomes

• Performance measurement indicators and tools are in place and being used regularly [34]

• Clinical outcomes being measured [35]

6. Information systems

• State-of-the-art information systems to collect, track, and report activities

• Efficient information systems that enhance communication and information flow across the continuum of care

• Shared information systems across care sectors [36, 37]

7. Organizational culture and leadership

• Organizational support with demonstration of commitment

• Leaders with vision who are able to instil a strong, cohesive culture

• Extent to which organizational goals and objectives are aligned across care sectors [36]

8. Physician integration

• Physicians are the gateway to integrated health care delivery systems

• Pivotal in the creation and maintenance of a single-point-of-entry or universal electronic patient record

• Engage physicians in leading role, participation on Board to promote buy-in

• Physician integration within care teams and across care sectors [10, 36, 38]

• Practitioner payment models that support integration [37]

9. Governance structure

• Strong, focused, diverse governance represented by a comprehensive membership from all stakeholder groups

• Organizational structure that promotes coordination across settings and levels of care

• Existence of interagency agreements, service delivery team coalitions [39]

• Governance model that includes representation of communities served [30]

• Evidence of governance in monitoring and evaluation of health system [40]

10. Financial management

• Aligning service funding to ensure equitable funding distribution for different services or levels of services

• Funding mechanisms must promote interprofessional teamwork and health promotion

• Sufficient funding to ensure adequate resources for sustainable change

• Extent to which financial management is coordinated across care units and sectors [36]

11. Overall integration

• Degree of integration within the health system and across sectors [41, 42]