Table 1
TAPIC framework for analysing ‘good’ governance.Source: Adapted from Greer et al. [24].
| DIMENSION | DEFINITION |
|---|---|
| Transparency | Institutions clearly communicate decisions and their rationales to the public and stakeholders. |
| Accountability | Individuals and institutions provide comprehensive accounts of their actions and face consequences when standards are not met. |
| Participation | Stakeholders are meaningfully involved in deliberations, with protections against reprisals. |
| Integrity | Well-defined processes exist for representation, recruitment and enforcement. |
| Policy capacity | Ability to design and implement resource-aligned, strategically focused policies. |
Table 2
Case study selection details.
| PROGRAMME | STUDY SITE | DESCRIPTION | ROLE OF HEALTHCARE PROVIDERS | ROLE OF SOCIAL CARE/COMMUNITY ACTORS |
|---|---|---|---|---|
| EFFICHRONIC Project | Asturias | Funded under the Third EU Health Programme (grant 738127) and delivered June 2018–February 2020 across five countries, with Asturias as the Spanish site. Evaluated the effectiveness and cost-effectiveness of the Chronic Disease Self-Management Programme (CDSMP) for socially vulnerable adults with chronic conditions and their carers, through structured group workshops with standardised outcome and economic evaluation. | Regional health system actors (Health Service of the Principality of Asturias; Public Health Directorate) sit within the consortium; health professionals contribute to recruitment and referral and co-lead workshops alongside lay leaders. | Recruitment targets people missed by routine services, using community-based recruitment sites and vulnerability mapping. |
| Sevilla Contigo, Ciudad Compasiva | Andalusia | Compassionate city initiative launched in November 2015 as a demonstration of the ‘Todos Contigo®/All with You®’ methodology, supporting people with advanced chronic illness, end-of-life needs and bereavement. Combines community awareness and training, mapping of support networks and individualised interventions, operationalised through a community promoter and the RedCuida protocol. | The Andalusian Health Service, health centres and hospitals support and refer people with advanced illness; primary care and palliative care teams act as referrers and partners in the pathway. | Municipal and community actors (City Council, community social services, third-sector organisations, volunteers) activate the support network, led by community promoters who typically hold social work profiles. |
| Integrated Care Process for Complex Pluripathological Chronic Patients | Castile and León | Official regional integrated care process within the chronic care strategy, aiming to improve health and quality of life through integrated care and shared responsibility across levels, including social services. Uses population segmentation based on adjusted morbidity groups (Grupos de Morbilidad Ajustada, GMA) (risk groups G0–G3), positions primary care as the pillar of coordination and specifies interfaces with continuity of care units (unidades de continuidad asistencial, UCA) and health and social care convalescence units (unidades de convalecencia sociosanitaria, UCSS). | Primary care medicine and nursing lead identification, intake, assessment and care planning; coordination involves internal medicine and geriatric interconsultation and a case manager nurse linked to the UCA. | Social work in primary care contributes to integral assessment and care planning; hospital social work manages transitions, including transfer to UCSS. The pathway explicitly frames chronic care as requiring attention to the social and family environment. |
Table 3
How CARE dimensions are expressed in practice: definitions and verbatim examples.
| CARE DIMENSION | SHORT DEFINITION | ILLUSTRATIVE EVIDENCE |
|---|---|---|
| Collaboration | Structured cross-sector working through shared objectives, joint responsibility and regularised relationships across health, social care and community actors | ‘Strong leadership is not just about coordination; it’s about building trust and creating shared goals across sectors. Without this, integration remains a distant goal.’ [R5-SSI-P1] ‘What makes integration work is shared leadership—someone who can align health and social care around one set of priorities, not two parallel agendas.’ [R2-SSI-P1] ‘When we sit at the same table regularly, things move. Without a routine space to meet, coordination depends on whoever has a good personal contact that week.’ [R1-FG-P3] |
| Adaptation | Capacity to revise governance arrangements, roles and practices in response to changing needs, evidence and implementation learning | ‘Systems need to evolve as care needs do. A rigid framework doesn’t work for today’s patients or tomorrow’s challenges.’ [R1-FG-P1] ‘We realised the pathway looked fine on paper but failed in practice, so we redesigned the steps with the team and tested a simpler version the following month.’ [R2-FG-P2] ‘What helped was having a feedback loop—when the coordination process broke down, we reviewed the case, changed the protocol, and everyone knew the new rule.’ [R2-FG-P5] |
| Resource Use | Sustainable alignment and allocation of statutory and enabling resources (workforce roles, time, financing and infrastructure) to support integrated delivery | ‘The biggest resource is time. Coordination is treated like an “extra”, so it happens after hours or not at all.’ [R3-FG-P4] ‘We can’t deliver integrated care on goodwill. If the system wants joint working, it has to fund the roles and the back-office support that make it possible.’ [R3-FG-P2] ‘Digital tools help, but they don’t fix under-resourcing. Without staffing and training, platforms become another task rather than an enabler.’ [R5-SSI-P1] |
| Empowerment | Meaningful influence of patients, carers, communities and frontline professionals on priorities, decisions and accountability | ‘Empowerment isn’t just involvement; it’s influence—having a real say in policies and decisions that directly impact us. We’re invited to consultations, but the decision is already taken. Empowerment would mean seeing what changed because of what we said.’ [R1-FG-P1] ‘If you want meaningful participation, you need decision-tracking: what was proposed, what was accepted, what was rejected, and why.’ [R3-SSI-P1] ‘Frontline staff and service users know where integration fails, but their input isn’t treated as expertise unless there’s a mechanism that turns it into action.’ [R6-SSI-P1] |