Table 1 Conceptual framework of integrated care from the patient’s perspective

1.Proactive and responsive action

Care-team members reach out to patients before, after, and between visits, and provide 24/7 access to care and information.

2.Coordination within care team

Healthcare providers from different specialties (e.g., general medicine, nursing, pharmacy, etc.) work together to ensure seamless communication and consistent patient care across all team members.

3.Coordination across care teams

Multiple care teams from different levels of healthcare institutions work together to ensure consistent patient care and administrative services.

4.Familiarity with the patient over time

Care-team members are familiar with the patient’s medical history, conditions, and treatments.

5.Guidance on self-management for patients

Care teams help patients set health goals and provide professional guidance on medication, nursing, diet, and lifestyle changes.

6.Patient centeredness

Care teams tailor care to the patient’s needs and preferences.