Bridging Autonomy and Integration: How Portuguese Integrated Practice Units Connect with Hospital and Primary Care Services

Background: Integrated Practice Units (Centros de Responsabilidade Integrados - CRI) in Portugal represent autonomous clinical management structures designed to optimize resource allocation while maintaining integration with broader health services. Despite their operational autonomy, understanding how these units coordinate with other services within Local Health Units is fundamental to realizing effective care integration.

 

Objectives: This study aimed to map the relationship patterns between CRIs and other health services, examining: (1) frequency and quality of coordination with hospital departments and primary care, (2) communication mechanisms used for inter-service coordination, (3) existence and nature of care protocols linking autonomous units with other services, and (4) barriers and facilitators to effective integration despite organizational autonomy.

 

Methods: A national survey was conducted across 37 CRIs (Medical=12, Mental Health=11, Surgical=8, Other=5, Emergency=1) focusing on inter-service relationships, coordination mechanisms, and integration challenges within Local Health Units.

 

Results: While CRIs operate with management autonomy, they maintain variable coordination patterns with other services. Most units (31/37) reported consistent or frequent articulation with hospital departments, though coordination occurred primarily through informal channels (ad-hoc communication) and institutional email (n=30). Emergency departments (n=17) and internal medicine (n=14) were the most frequent hospital partners, while primary care coordination appeared limited. Despite autonomy, teams actively developed inter-service protocols, particularly for internal medicine referrals, emergency liaison, and mental health pathways.

 

Communication mechanisms revealed a hybrid model combining formal tools (clinical reports=27, referral letters=24) with informal channels (WhatsApp groups=25, direct phone lines=18). Significantly, 81% of teams participated in developing access/referral criteria, suggesting efforts to standardize interfaces despite autonomous operations. Major integration needs identified included: coordination with primary care (n=21), shared clinical information systems (n=21), and inter-service communication protocols (n=20). Teams requested support primarily through best practice sharing (n=23) and protocol development (n=17), indicating desire for structured integration frameworks.

 

Conclusions: Portuguese CRIs demonstrate a paradox of autonomous operation within interconnected systems. While management autonomy enables resource optimization, integration with hospital services remains largely informal and primary care connections are underdeveloped. The predominance of ad-hoc communication and informal digital tools suggests that formal integration mechanisms have not kept pace with organizational autonomy.

Implications: for Practice: To optimize the CRI model, Local Health Units should develop formal integration protocols that respect unit autonomy while ensuring systematic coordination. Investment in interoperable information systems, structured liaison roles, and regular inter-service meetings could bridge the gap between autonomy and integration. The strong desire for best practice sharing suggests that CRIs seek balanced models that preserve management flexibility while enhancing care coordination.

Keywords: integrated practice units, autonomous clinical management, inter-service coordination, Local Health Units, care integration, Portugal.