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Measuring maturity of integrated care: a first validation study


Liset Grooten ,

Vrije Universiteit Brussel, BE
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Liesbeth Borgermans,

Vrije Universiteit Brussel, BE
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Hubertus Vrijhoef

Vrije Universiteit Brussel, Belgium; Maastricht University Medical Center, the Netherlands; Panaxea B.V., BE
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Introduction: Lessons learned from an observational study and based on unstructured interviews with twelve European health regions are represented in a new instrument, the B3-Maturity Model (B3-MM). B3-MM aims to assess maturity along 12 dimensions (i.e. Breadth of Ambition, Capacity Building, Citizen Empowerment, Evaluation Methods, Finance & Funding, Information & eHealth services, Innovation Management, Population Approach, Readiness to Change, Removal of Inhibitors, Standardisation & Simplification and Structure & Governance) reflecting the various activities that need to be managed in order to deliver integrated care. The current situation of a health care region is assessed by considering a progress or ‘maturity’ measure (on a 0-5 scale) along each dimension thereby revealing areas of strength, further attention and improvement. Usage of these insights and comparing the findings with those of other regions should enable healthcare regions to be matched in order for them to exchange knowledge and experiences to ultimately make faster progress towards maturity. Content validity of B3-MM was tested as part of a larger EU funded project SCIROCCO (Scaling Integrated Care into Context).

Methods: A literature review was conducted to compare the 12 dimensions and their measurement scales of B3-MM with existing measures and instruments focusing on maturity of integrated care. Subsequently, a three survey round international Delphi study with experts in the field of integrated care was performed to test the relevance of 1) the dimensions, 2) the maturity indicators and 3) the rating scale used in B3-MM.

Results: The literature search consisted of two parts. Firstly, 7 out of 300 articles were selected from a recent systematic review on measurement properties of instruments measuring integrated care  of Bautista et al. (2016). Secondly, to broaden the scope of the review, 4 additional articles were retrieved from a narrative search in Google, Google Scholar and IDEAS. The 11 included articles confirmed all dimensions as described by the original version of B3-MM. The Delphi rounds resulted in various phrasing amendments of dimensions and indicators. Full agreement among experts on the relevance of the 12 dimensions and their indicators and rating scale of B3-MM was found after the third Delphi round.

Discussion:  The small number of relevant articles indicates that the maturity measurement in integrated care is not yet strongly developed. Notwithstanding the pragmatic nature of the initial development of the B3-MM, our study provides the first phase of validation of B3-MM. Additional testing is needed to evaluate the robustness of B3-MM as a tool to measure the maturity of integrated care.

Conclusion: The dimensions, maturity indicators and rating scale of B3-MM showed satisfactory content validity. Although there exists no universal agreed indicator set nor best approaches of integrated care development, B3-MM is a unique instrument based that intends to function as a practical and easy to use self-assessment tool for European regions revealing strengths and areas for improvement in the provision of integrated care. The tool needs further validation in supporting the matching of European regions to exchange knowledge and experiences.

Limitations: The different backgrounds and fields of expertise of the experts may have influenced the interpretation of the instrument. To obtain an adequate understanding of the instrument among its future users, a clear manual explaining the meaning and application of the instrument is needed.

Suggestion for further research: To enhance the methodologic quality of B3-MM, further testing is needed to explore its psychometric properties to become a robust instrument in measuring the maturity of integrated care.


1. Bautista, M., Nurjono, M., Lim, Y., Dessers, E., & Vrijhoef, H. Instruments measuring integrated care: a systematic review of measurement properties. The Milbank Quarterly. 2016.

How to Cite: Grooten L, Borgermans L, Vrijhoef H. Measuring maturity of integrated care: a first validation study. International Journal of Integrated Care. 2017;17(5):A412. DOI:
Published on 17 Oct 2017.


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