Integrated health and social care in the community: a critical integrative review of the experiences and well-being needs of service

A need for people-centred health and social support systems is acknowledged as a global priority. Most nations face challenges in providing safe, effective, timely, affordable, coordinated care around the needs and preferences of people who access integrated health and social care (IHSC) services. Much of the current research in the field focuses on describing and evaluating specific models for delivering IHSC. Fewer studies focus on person-centred experiences, needs and preferences of people who use these services. However, current international guidance for integrated care sets a precedence of person-centred integrated care that meets the health and well-being needs of people who access IHSC services. This integrative literature review synthesises empirical literature from six databases (CINAHL; MEDLINE; AMED; TRIP; Web of Science and Science Direct; 2007-2019). This review aims to better understand the experiences and health and well-being needs of people who use IHSC services in a community setting. Twenty studies met the inclusion criteria and results were thematically analysed. Three overarching themes were identified, including relationships, promoting health and well-being and difficulty understanding systems. Findings of this review indicate that relationships hold significance in IHSC. People who access IHSC services felt that they were not always involved in planning their care and that there was a lack of clarity in navigating integrated systems; subsequently, this impacted upon their experiences of those services. However, service user and informal carer voices appear to be underrepresented in current literature and studies that included their views were found to be of low quality overall. Collectively, these findings support the need for further research that explores the person-centred experiences and needs of people who access IHSC.


| INTRODUC TI ON
Over the past decade, an increased focus on the way that integrated health and social care (IHSC) services are delivered and a growing demand for improved service user experience have driven forward improvements in worldwide health and social care (HSC; World Health Organization, 2016a). Person-centred IHSC systems aim to follow principles of participatory care and governance, which are coordinated around service user needs. These systems and strategies offer a balance between population health and wellbeing and ill-health prevention (Marks et al., 2011;World Health Organization, 2016b). Internationally, IHSC interventions aim to include meeting individuals' needs, disease-specific interventions and IHSC that spans across population health (World Health Organization, 2016a).
Across Europe, countries are at different stages of integrating their HSC services, with the common goal of delivering better outcomes of care through collaborative working (Expert Group on Health Systems Performance Assessment, 2017). IHSC services take many different forms to improve population health, with varying levels of coordination across geographical boundaries (Robertson et al., 2014;Wodchis et al., 2015). A lack of understanding of organisational cultures, repeated complex structural changes and ineffective communication are common barriers in IHSC (Burgess, 2012;Mason et al., 2015). These issues can impact upon the experiences of people who use IHSC, their families and professionals involved in their care, resulting in unmet needs (World Health Organization, 2018).
The aim of this integrative literature review was to explore the experiences of people who access IHSC services and their health and well-being needs. The overarching research question for this review asked, 'what are the health and well-being needs and experiences of people who use IHSC?'. For the purpose of this review, key terms and stakeholders in IHSC were defined and agreed by the reviewers (Table 1). Specific exploratory questions of the literature were constructed and iteratively refined to expand upon the overarching research question. Questions of the literature highlighted areas of researcher interest around experiences of IHSC and how people met their health and well-being needs through access to and utility of IHSC, in the context of a home setting (Table 2).

| Review Design
A critical integrative review methodology was used to guide the review process (Murray, 2017;Oliver, 2012). Review methodologies that favour quantitative analysis were considered (e.g. systematic reviews that focus primarily on experimental studies to investigate a specific intervention for a clinical problem; Whittemore & Knafl, 2005).
However, researchers anticipated that evidence that was relevant to the research questions and the phenomenon of interest may be diverse in nature. As integrative review methodology advocates the inclusion and analysis of both experimental and non-experimental studies to explore perspectives of a phenomenon in depth, it was What is known about the topic • Providing health and social care (HSC) that is integrated and person centred can be challenging.
• A range of HSC models are adopted across nations and regions to deliver care.
• Current understanding of service user health and wellbeing priorities within integrated HSC is limited.

What this paper adds
• Current evidence is inconclusive in relation to the benefits of different models of integrated health and social care (IHSC) that meets the needs of people who utilise them.
• Service users expressed a need for collaboration, maintaining and developing roles in their personal life, effective communication and to develop trusting relationships.
• People who use IHSC had mixed experiences; data were limited and further research is recommended.

Home A permanent residential environment
Health and well-being needs The needs that when met enable people to live healthier lives and feel well Integrated health and social care (IHSC) Where two or more organisations, across two or more sectors, work together to deliver health and social care well-being services; e.g. healthcare sector; social care sector or third sector (including community groups) Service user Individuals who access integrated health and social care services to meet their health and well-being (health and wellbeing) needs Informal carer An individual who provides help and support for a service user that enables the service user to meet their health and well-being needs in a non-professional or non-contractual capacity (e.g. family member; neighbour, friend) IHSC staff member An individual who provides health and well-being support for an IHSC service user, through a contractual obligation (e.g. a nurse; social worker; paid carer; physiotherapist) Note: Agreed definitions of key stakeholders in integrated health and social care.
judged to be the most appropriate methodological approach for this review (Souza et al., 2010;Whittemore & Knafl, 2005). Rigor in the review process was enhanced by monthly meetings of the review team and by following an 'integrative review framework' (Whittemore & Knafl, 2005). This integrative review framework included several steps; namely, identifying the research problem; literature search; data evaluation; data analysis and presentation of the findings. A PROSPERO protocol was published to outline the intentions of the research team in conducting this review and to promote objective reporting of findings (Booth et al., 2012;Sideri et al., 2018). Key stakeholders were offered an opportunity to express their views on the aim, review questions and scope of the review via a focus group (Boote et al., 2011). Additionally, stakeholders were also asked to offer their comments on interpretation of preliminary review findings, via a workshop seminar (Boote et al., 2011). Key search terms, topic focus and contextual settings for this review were iteratively refined as a result of their feedback (Boote et al., 2011;Kreis et al., 2013).

| Search Strategy
To ensure that this literature review would be sensitive to picking up studies pertaining to relevant IHSC services, an initial scoping search was performed in October 2017 using a PICo framework (Moule et al., 2017) (Appendix S1). Subsequently, key terms were revised by researchers and the fields in which they were employed were iteratively refined within the search strategy (Table 3). The search for this review was performed across six digital databases between March 2018 and April 2018. Employing filters by abstract, language, timeframe and field initially generated excessive results that could not be screened meaningfully. These results largely appeared to relate to integration of a specific specialist health service into a wider health care service, which was not concurrent with the aims of this review.
As researchers had iteratively refined the search terms throughout the scoping review process and were satisfied that these terms were appropriate for the purpose of this review, search fields were reconsidered (Hewitt-Taylor, 2017;Oliver, 2012). Filtering field by 'Title' generated more specific results that were relevant to the wider context of IHSC services and the aims of this review.

| Inclusion and exclusion criteria
To ensure that the search was rigorous and transparent, inclusion and exclusion criteria were agreed (

| Quality Appraisal
A triangulated approach was adopted to appraise the quality of each paper and facilitate systematic comparison of included studies. Firstly, papers were subject to screening assessment questions, enabling early identification of those relevant to key areas of interest. Secondly, the quality of evidence was appraised using the Critical Appraisal Skills Programme (CASP) framework (Critical Appraisal Skills Programme, 2018a, 2018b. CASP appraisal frameworks offered rigor to meaningful representation of the quality of each source. Each CASP quality appraisal was tailored to the methodological nature of the evidence, e.g. qualitative data or quantitative data sets (Hopia et al., 2016;Whittemore & Knafl, 2005). For papers using a mixed methodology, both qualitative and quantitative quality appraisal tools were utilised to maximise rigor in quality appraisal (Creswell & Plano Clark, 2018;Miles & Gilbert, 2006). Furthermore, each paper's original contribution to the academic and clinical fields of practice were also deliberated, with a final decision highlighting any intended progression to data extraction.
All quality assessments were carried out by the lead researcher with a selection of assessments also being reviewed by the wider research team.

| Study selection, extraction and analysis
To ensure rigor and transparency in the selection of papers for in- identification of outcomes; reliability and validity, heterogeneity and bias and the reporting and synthesis of findings (Creswell & Plano Clark, 2018;Critical Appraisal Skills Programme, 2018b).
Qualitative data analysis explored justification of study aims; sampling and recruitment strategies; rigor of data analysis strategies and the clarity of discussion to support findings (Critical Appraisal Skills Programme, 2018a). Initial thoughts on key findings were iteratively developed and new concepts derived on the basis of two or more papers reporting on it and mapped in a Thematic Matrix (Creswell & Plano Clark, 2018;Hewitt-Taylor, 2017;Ingram et al., 2006;Microsoft® Corporation, 2016). Themes were iteratively developed as researcher understanding expanded around emerging concepts, in accordance with similarity and perceived meaning (Ingram et al., 2006).

| FINDING S
Search and screening pathways and outcomes are detailed in a PRISMA statement (Moher et al., 2009;Figure 1 Geographical locations and service delivery models of included papers have been summarised in Table 6. Quality appraisal of qualitative data revealed that a description of samples and justification for their selection was not always clear (Brown & Howlett, 2017;Challis et al., 2011;Curry et al., 2013;Petch et al., 2013). Additionally, the researcher-participant relationship was not always considered (Challis et al., 2011;Cook et al., 2017;Curry et al., 2013;Elbourne & Le May, 2015;Hu, 2014;Petch et al., 2013;Spiers et al., 2015). For papers that included quantitative data, quality appraisal, methods of randomisation were not always highlighted ( Table 7).

| Relationships as a cornerstone of IHSC and well-being
This overarching theme focuses on relationships as a cornerstone of IHSC and well-being. Seven papers from the UK and Canada explore the significance of relationships that people who access IHSC have with others (Boudioni et al., 2015;Brown & Howlett, 2017;Craig et al., 2016;Daveson et al., 2012;Hu, 2014;Petch et al., 2013;Spiers et al., 2015). The importance of relationships in IHSC was also considered along with maintenance and promotion of familial relationships and friendships, being a part of the wider community and relationships with IHSC staff (Boudioni et al., 2015;Brown & Howlett, 2017;Craig et al., 2016;Petch et al., 2013;Spiers et al., 2015). Three papers included qualitative service user data (Brown & Howlett, 2017;Petch et al., 2013;Spiers et al., 2015); two included qualitative data from service users and informal carers (Boudioni et al., 2015;Daveson et al., 2014); one included quantitative service user data (Craig et al., 2016) and the last used mixed methodology to collect service user data (Hu, 2014). Quality appraisal indicated that six of these papers were of low quality (Boudioni et al., 2015;Brown & Howlett, 2017;Daveson et al., 2012;Hu, 2014;Petch et al., 2013;Spiers et al., 2015) and one paper was of average quality (Craig et al., 2016; Critical Appraisal Skills pProgramme, 2018a, 2018b). needs (Boudioni et al., 2015;Spiers et al., 2015). However, service users found that the logistics required to maintain and establish relationships were difficult to achieve (e.g. transport and equipment; Boudioni et al., 2015;Petch et al., 2013). Timely access to equipment and environmental adaptations were reported as particular chal-  TA B L E 6 (Continued) (Petch et al., 2013;n = 20). Service users perceived that maintaining and promoting positive and supportive relationships between themselves and IHSC staff was important (Daveson et al., 2014;Hu, 2014;Petch et al., 2013).

| The importance of relationships and their impact on well-being
Multiple sources in the UK provided evidence of the value of staff continuity as a requirement for building trusting relationships (Boudioni et al., 2015;Daveson et al., 2014). These were linked to service users' perceptions of 'good' relationships or 'special bonds' (Boudioni et al., 2015;Hu, 2014;Petch et al., 2013). Where relationships were built on trust and respect, the level of care coordination was enhanced (Boudioni et al., 2015;Daveson et al., 2014).
Furthermore, UK service users living with an advanced progressive illness and their informal carers indicated that 'good' relationship with staff influenced not only their improved experiences of IHSC but also participant outcomes (Daveson et al., 2014;Spiers et al., 2015).
To summarise, findings indicated that maintenance and promo-

| Maintaining and promoting health and wellbeing through IHSC
This overarching theme focuses on maintaining and promoting health and well-being through IHSC. It encompasses 'feeling able and learning to cope with changing HSC needs' and 'promotion of well-being through improved quality of life, inclusion, feeling safe and functionality', for service users and informal carers. Of the 11 papers relating to this theme, five papers present quantitative service user-derived data in Canada, Finland, Ireland and the UK (Craig et al., 2016;Hammar et al., 2007;Lewis et al., 2017;Murphy et al., 2017;Peters et al., 2013). Three papers present qualitative UK service user-derived data (Brown & Howlett, 2017;Petch et al., 2013;Spiers et al., 2015). One paper presents mixed-methods service user data (UK; Hu, 2014). One paper presents qualitative service user and informal carer data (UK; Boudioni et al., 2015) and the final paper offers UK service user and IHSC staff data (Elbourne & Le May, 2015). Quality appraisal indicated that 10 of these papers were of low quality (Boudioni et al., 2015;Brown & Howlett, 2017;Elbourne & Le May, 2015;Hammar et al., 2007;Hu, 2014;Lewis et al., 2017;Murphy et al., 2017;Petch et al., 2013;Peters et al., 2013;Spiers et al., 2015) and one paper was of average quality (Craig et al., 2016) (Critical Appraisal Skills Programme, 2018a, 2018b).

| Feeling able and learning to cope with changing HSC needs
This sub-theme focuses on feeling able to cope and learning to cope with changing HSC needs. Findings across Europe indicate that service users wanted to feel able to cope with their changing HSC needs and strengthen their own sense of well-being (Boudioni et al., 2015;Brown & Howlett, 2017;Craig et al., 2016;Elbourne & Le May, 2015;Hammar et al., 2007;Hu, 2014;Lewis et al., 2017;Murphy et al., 2017;Petch et al., 2013;Peters et al., 2013;Spiers et al., 2015). They cited autonomy and control as important in achieving this (Brown & Howlett, 2017;Craig et al., 2016;Spiers et al., 2015). Service users and informal carers in the UK and Canada also reported concerns about coping with their changing HSC needs and subsequent decisions about their care. This caused them to experience uncertainty, Connecting with services and providers to achieve health and social well-being

TA B L E 7 Overview of themes
Note: Overview of thematic findings of this review.
Furthermore, UK service users and informal carers appeared to hold a 'sense-of-self', confidence building, decision-making and independence as important to their emotional well-being (Boudioni et al., 2015;Petch et al., 2013;Spiers et al., 2015). Service users linked confidence to resilience and they associated the ability to 'get out of the house' with maintaining independence (Petch et al., 2013;Spiers et al., 2015). Some service users felt a loss of dignity and respect when accessing IHSC (Boudioni et al., 2015;Hu, 2014).
However, some service user and informal carer participants in qualitative interviews felt that these feelings changed over a 6-month 'emotional journey'; as time progressed they felt more content and relaxed about their changing healthcare needs (Boudioni et al., 2015; n = 10). Arguably, this could signify that participants who are new to accessing IHSC may have a different experience to those participants who have received IHSC for a longer period.
Overall, service users felt anxiety and stress about their changing HSC needs and they wanted to be able to cope with these changes. Dignity, respect, autonomy and control over their own services were identified as important to service users. Both service users and informal carers valued joint decision-making with IHSC professionals.

| Promoting well-being through improved quality of life: inclusion, feeling safe and functionality
This sub-theme explores some of the strategies used by service users as they accessed IHSC services to promote their well-being through improved quality of life. Studies relating to this theme were based in Canada, Finland, Ireland and the UK (Brown & Howlett, 2017;Craig et al., 2016;Elbourne & Le May, 2015;Hammar et al., 2007;Hu, 2014;Lewis et al., 2017;Murphy et al., 2017;Petch et al., 2013;Peters et al., 2013;Spiers et al., 2015). Factors that helped service users to promote their well-being included: continuing in previous roles and preserving personal safety. Additionally, avoiding isolation through the maintenance of social roles and contacts, maintaining functional abilities and preserving quality of life also helped them to promote their well-being. The UK literature relating to service users indicates that they also sought to maintain their psychological wellbeing through continuing to fulfil previously held occupational roles both within their community and on a more personal level (Boudioni et al., 2015;Brown & Howlett, 2017;Hu, 2014;Petch et al., 2013;Peters et al., 2013;Spiers et al., 2015).
The ability to maintain housework routines within the home environment was important to UK service users. They cited feelings of helplessness and self-resentment when they were no longer able to fulfil these roles due to functional decline (Brown & Howlett, 2017;Hu, 2014). UK service users felt that appropriate housing environments, allowing access to all areas of the house with necessary adaptations, were important (Brown & Howlett, 2017;Hu, 2014;Spiers et al., 2015). Participants experienced frustration at the inaccessibility of every-day items such as washing machines and work-top spaces when they were awaiting further equipment and adaptation. These frustrations provoked negative perceptions of reduced levels of confidence, social inclusion and self-esteem, emphasising the multifactorial nature of psychosocial well-being (Boudioni et al., 2015;Petch et al., 2013;Spiers et al., 2015).
Environmental adaptations were seen by service users as crucial in maintaining social contacts and previous roles, affording an opportunity to be able to get 'out and about' independently (Hu, 2014;Spiers et al., 2015). Service users from the UK and Canada acknowledged the importance of maintaining social contacts with others while using IHSC (Boudioni et al., 2015;Brown & Howlett, 2017;Craig et al., 2016). They highlighted that environmental adaptations, personal safety and routines (such as showering) are linked to independence, self-confidence and well-being (Petch et al., 2013;Spiers et al., 2015;n = 35;n = 20). Additionally, service users and their informal carers highlighted the importance of financial and emotional security and the knowledge that help was available (Craig et al., 2016;Petch et al., 2013).
Research data present a mixed picture of service users' func- Largely, functionality for service users who used IHSC was inconclusive. International studies reported little or no improvement in participant functionality while accessing IHSC services, in comparison to those who were not accessing IHSC (Hammar et al., 2007;Hu, 2014;Lewis et al., 2017;Murphy et al., 2017). For example, a cluster randomised trial in Finland showed a reduction in participants' activities of daily living which corresponded to a service user-perceived reduction in their quality of life in comparison to those in a control group (Hammar et al., 2007;n = 669). Furthermore, service user participants who were accessing an IHSC Day Unit once weekly showed no improvement in functionality in comparison to the control group who accessed weekly care from community nurses (Murphy et al., 2017). However, when some UK service users accessed IHSC and suitable housing and environmental aids were put in place, their functionality was enhanced (Hu, 2014;Spiers et al., 2015).
Overall, research findings here suggested that the benefits of IHSC in relation to service users' functionality were mixed. Where appropriate environmental adaptations and aids were provided, some activities of daily living were maintained or restored and potentially resulted in enhanced social inclusion and psychosocial well-being.
These adjustments were essential for service users to maintain their own personal safety. Hence security, safety, functionality and social inclusion appeared to be intrinsically linked and their absence had a negative impact upon service users' experiences of IHSC.

| Collaborative services and communication in IHSC
This sub-theme focuses on the factors that enhance collaborative services and interprofessional communication systems in order to deliver IHSC across Europe. It considers a diverse landscape of models of IHSC that promote collaboration and communication between service users, informal carers and IHSC staff. It also explores the importance of clarity and information giving and the influence that these can have upon the experiences of people who use and deliver IHSC (Baumann et al., 2007;Bien et al., 2013;Bonciani et al., 2017;Challis et al., 2011;Cook et al., 2017;Curry et al., 2013;Murphy et al., 2017;Petch et al., 2013).
In comparison with those accessing non-integrated HSC models of care, service user satisfaction was improved for people living in Italy when they frequently accessed an IHSC 'Primary Care Centre (PCC)' model (Bonciani et al., 2017; n = 2,025; p < 001). Furthermore, psychosocial well-being was thought to be improved for service user participants who accessed an IHSC Day Unit model of care, in comparison to those who accessed community nurse care alone (Murphy et al., 2017;n = 63). Geographical and regional comparisons between services and models of IHSC that were included in this review, presented a mixed picture of IHSC models (Baumann et al., 2007;Bien et al., 2013;Bjerkan et al., 2011;Challis et al., 2011;Kehusmaa et al., 2012). Some researchers explored utility and access to models of IHSC, identifying organisational arrangements, strategic priorities and the location of staff as instrumental in the provision of IHSC (Baumann et al., 2007;Challis et al., 2011).
Models of IHSC varied across different regions and nations (categorised in Table 6). In a randomised-control trial across Finland, the experiences of frail elderly service users highlighted the relationship between the effective use of social services and an improvement in their health status, in comparison to those who accessed non-integrated services (Kehusmaa et al., 2012;n = 732). However, informal carer participants in a multi-European nations cross-sectional survey highlighted fragmented and uncoordinated services (Bien et al., 2013;n = 2,629). They found that involvement of multiple social services did not invariably result in less unmet needs.
Intermediate IHSC services (that look to facilitate discharge from or prevent admission to hospital) were found to go some way to addressing the fragmentation of IHSC.
In the UK and Ireland, intermediate service models offered a 'whole-system' approach that supported collaborative communication across organisational and professional boundaries (Cook et al., 2017;Lewis et al., 2017). UK service users indicated that fragmentation was reduced when practitioners who specialised in a particular condition became involved. This was indicated even though these specialist practitioners were not regular members of the IHSC team (Petch et al., 2013;n = 20). This suggests that the most effective way to ensure that service users' needs are met could be to involve a subsection of the IHSC team, along with specialist input for a particular condition as required (e.g. a long-term condition specialist practitioner). From a survey of service users in Italy, co-location was believed to reduce fragmentation for people with complex care needs who frequently access IHSC, in comparison to those who did not have access co-located services (n = 2,025; Bonciani et al., 2017).
Transparency was found to be important in facilitating the coordination and delivery of IHSC services (Baumann et al., 2007;Curry et al., 2013;Daveson et al., 2014;Elbourne & Le May, 2015). Lack of clarity could lead to increased feelings of powerlessness and difficulties for service users when attempting to navigate the systems that had been set up to coordinate and provide their care. This had a negative impact on their experience (Boudioni et al., 2015;Daveson et al., 2014).
Overall, the quality of service users' experiences of IHSC is influenced by several organisational factors. IHSC services can be fragmented but intermediate services and co-location of professionals appeared to reduce this. Collaborative interprofessional communication was perceived as beneficial by service users and staff alike, whether the latter were based in one or several locations.
Collaborative services should be organised in a way that can be easily grasped so that clear information can be given about them.
Transparent communication channels must exist between professionals. Equally, communication about IHSC systems must be clear between informal carers, service users and IHSC professionals.

| Connecting with services and providers to achieve health and social well-being
This sub-theme explores' how individuals connected with services and providers to achieve health and social well-being. It encompasses three elements; firstly, the need for effective communication for collaboration between people who use and deliver IHSC (UK and Norway; Baumann et al., 2007;Bjerkan et al., 2011;Boudioni et al., 2015;Challis et al., 2011;Cook et al., 2017;Curry et al., 2013;Daveson et al., 2014;Elbourne & Le May, 2015;Hu, 2014;Petch et al., 2013). Secondly, it considers the value of promoting trust and enhancing the quality of care for service users through professional knowledge (UK; Baumann et al., 2007;Boudioni et al., 2015;Challis et al., 2011;Cook et al., 2017;Daveson et al., 2014;Peters et al., 2013). Finally, it considers the importance of service users being able to access the right professional at the right time (multi-national; Bien et al., 2013;Cook et al., 2017;Kehusmaa et al., 2012;Lewis et al., 2017;Petch et al., 2013;Peters et al., 2013;Spiers et al., 2015).
Data from service users and informal carers also suggested that wherever communication was ineffective and decision-making was not shared, the service users felt a sense of powerlessness (Boudioni et al., 2015; n = 10). Care planning for IHSC provided a way to facilitate cross-organisational communication and was found to follow diverse forms. Some researchers investigated 'individualised care plans' led by local authorities in Norway (Bjerkan et al., 2011;n = 59). Some areas of the UK adopted a 'case management' approach to care planning (Challis et al., 2011;n = 56). However, the effectiveness of these approaches in relation to meeting service users' needs was not explored.
Nevertheless, a single-shared assessment process, as part of a 'partnership working' approach to IHSC, was found to positively influence service user-identified and valued outcomes (Petch et al., 2013;n = 20).
Service users and IHSC staff in the UK & Ireland emphasised the importance of gaining access to the right professional at the right time via a coordinated team (Cook et al., 2017;Lewis et al., 2017;Petch et al., 2013;Peters et al., 2013;Spiers et al., 2015). Several factors enhanced communication in collaborative care. The use of inter-disciplinary meetings (including the housing department) enabled services to meet and communicate simultaneously (Challis et al., 2011;Cook et al., 2017). Service users and IHSC staff highlighted reduced duplication when service users held their own records or when a single-assessment process was adopted (Brown & Howlett, 2017;Challis et al., 2011;Craig et al., 2016). In addition, service users and IHSC staff also indicated that specialist practitioners played a key role in coordinating inter-disciplinary communication and care that was tailored to an individual's specialist needs (e.g. practitioners that focus on one specialist area of practice ;Cook et al., 2017;Petch et al., 2013;n = 35;n = 20). However, even when specialists were not involved, service users wanted the professionals providing their care to have a good level of expertise in their condition and needs. Regular multi-organisation meetings provided valuable opportunities for enhancing knowledge (Baumann et al., 2007;Boudioni et al., 2015;Peters et al., 2013).
Overall, models for delivering IHSC services were diverse. No consensus could be found regarding which of the many models for delivery of IHSC best met service users' needs. Early communication and accessing the right professional at the right time was important to service users who accessed IHSC. Professionals were expected to have a high standard of knowledge about the service user's condition and a lack of knowledge had a negative influence on the experiences of some service users.
There are clear links to service users' need for environmental adaptations and aids to meet their functionality and personal safety needs, which can also be linked to emotional well-being. Review findings are inconclusive about the relationship of IHSC and improved functionality for service users. It cannot be assumed that the provision and utility of IHSC invariably results in improved service user functionality.
Fulfilling previous roles (such as completing housework and gardening tasks) and remaining independent can result in significant improvements in emotional well-being, facilitating maintenance of social contacts (Brown & Howlett, 2017;Hu, 2014;Petch et al., 2013;Peters et al., 2013;Spiers et al., 2015). Equally, people who utilise IHSC at home expressed a need to have their voices heard and be involved in making decisions about their own care (Boudioni et al., 2015;Brown & Howlett, 2017;Hu, 2014;Petch et al., 2013;Peters et al., 2013;Spiers et al., 2015). Feeling empowered and prepared when dealing with the uncertainty of changing health and care needs is important to service users and informal carers. It could be argued that this is an integral role of professionals who deliver IHSC (UK; Boudioni et al., 2015;Brown & Howlett, 2017;Spiers et al., 2015).
Helping stakeholders meet their needs through a collaborative approach to IHSC is challenging for many IHSC providers, with a diverse range of strategies evident in the wider literature (Expert Group on Health Systems Performance Assessment, 2017;Marks et al., 2011;World Health Organization, 2016a. A lack of papers that explored the benefits of IHSC models of delivery, through comparison to non-integrated HSC, was noted. However, many papers considered different models of IHSC. IHSC providers must pay careful attention to levels of continuity of staff and the degree of coordination within their services (Baumann et al., 2007;Bien et al., 2013;Boudioni et al., 2015;Curry et al., 2013;Daveson et al., 2014;Elbourne & Le May, 2015;Hu, 2014;Petch et al., 2013;Peters et al., 2013;Spiers et al., 2015). Fragmentation of systems and services should be avoided since this has a negative impact on the experiences of users of IHSC. The use of intermediate IHSC services along with more effective coordination can potentially go some way to address this issue (Cook et al., 2017;Lewis et al., 2017).
Service users and informal carers experienced reduced levels of autonomy, self-worth and confidence and a lack of dignity and respect when utilising IHSC services, resulting in unmet health and well-being needs (Boudioni et al., 2015;Hu, 2014;Petch et al., 2013;Peters et al., 2013;Spiers et al., 2015). Maintaining and promoting existing and new relationships can be seen as a fundamental cornerstone of IHSC that influences the experiences of people who use IHSC and should be considered when planning IHSC services (Boudioni et al., 2015;Eastwood et al., 2019;Petch et al., 2013;Spiers et al., 2015). Relationships are closely linked to promotion of well-being, reducing social isolation and a foundation of trust among service users, informal carers and professional staff (Boudioni et al., 2015;Brown & Howlett, 2017;Cameron et al., 2014;Craig et al., 2016;Daveson et al., 2014;Glasby, 2014;Hu, 2014;Petch et al., 2013). It could be argued that a gap exists in the current body of knowledge with further scope to explore the significance of these supportive relationships in IHSC.
Overall, the quality of papers included was generally low. Some studies that employed mixed-method data collection focused upon quantitative data under-reported important qualitative elements; others were unclear regarding sampling methodology. Seven papers consider qualitative data, two of which included staff data (Baumann et al., 2007;Cook et al., 2017). Three of these qualitative papers included service user data (Brown & Howlett, 2017;Petch et al., 2013;Spiers et al., 2015) and two offered service user and informal carer data (Boudioni et al., 2015;Daveson et al., 2014). It could be argued that there is a pressing need to further explore needs and experiences of IHSC that combines all three stakeholders. Two papers in this review explore service user health and well-being needs as defined and perceived by the service user (Petch et al., 2013;Spiers et al., 2015).
Further research that explores service user-derived health and well-being needs would add to the current body of evidence.

| Strengths and limitations
The strength of this study lies in its underpinning integrative methodology. While a systematic review methodology may have produced differing results, integrative review methodology and rigorous data analysis represent the complexity of the research questions and the diversity of data that are key to developing evidence-based practice in this field (Hopia et al., 2016;Whittemore & Knafl, 2005). Rigorous adherence to the underpinning integrative framework of this review and transparency were promoted among researchers through monthly meetings for the duration of the review, thus, reducing the potential for bias. The results of this review present a level of understanding around experiences of IHSC services and highlight gaps in current IHSC practice.
A further strength of this study lies in the involvement of stakeholders in identifying the review topic and the interpretation of results (Boote et al., 2011;Kreis et al., 2013). However, time constraints meant that stakeholder involvement was not possible throughout the whole review process and is acknowledged as a limitation of this review. While researchers strove to ensure that results could be meaningfully screened by filtering of 'Title' field, they recognise that the scope of this review may have been limited by their decision. Identifying relevant studies from abstract, rather than the title alone, may have highlighted further studies for inclusion. In addition, researchers also acknowledge that papers that have been published since the literature search was performed in 2018 are not included in this review. The scope of this review is also limited by the exclusion of papers that related solely to inpatient setting as they were more likely to represent integration of a specialist healthcare service to another acute healthcare service (e.g. the integration of a singular specialist health service into another pre-existing health service

| CON CLUS ION
Overall, findings from this review outline that the potential impact of relationships between professionals and service users must not be underestimated; these grow stronger when providers approach care planning with involvement and collaboration.
Difficulties in navigating the integrated systems can be overcome by ensuring that new and existing structures are clear. More evidence is needed on the effectiveness of IHSC as an intervention that promotes health and well-being and its impact on the experiences of those who receive it. Further research that focuses upon the needs of people who use IHSC services, as defined by those people themselves is also warranted. Research that explores supportive relationships and involves participation of all three IHSC key stakeholders would provide valuable insights to enhance knowledge in the field and support future developments in IHSC practice.

ACK N OWLED G EM ENTS
This review has been conducted by Louise Henderson (PhD student) and supervisors Professor Catriona Kennedy, Dr Heather Bain and Dr Elaine Allan as part of a funded PhD studentship. The studentship is sponsored by Robert Gordon University and funded by NHS Grampian.

CO N FLI C T O F I NTE R E S T
Authors have no conflict of interest to declare.