Figure 1 summarizes the conceptual thinking that emerged from the three studies. The construct of ‘Integration Mindsets’ is at the heart of Figure 1 and (Figure Presented) is defined as an individual’s way of thinking about integration that is based on knowledge and beliefs regarding the strategy for achieving integration (i.e., Strategy Mental Model) and the roles and relationships of those involved in the integration process (i.e., Relationships Mental Model) [5]. The similarity of Integration Mindsets is shaped by contextual factors at multiple levels [4]. The similarity of Integration Mindsets, in turn, influences strategic processes and proximal outcomes. The relationships among Integration Mindset similarity, strategic processes, and proximal outcomes are moderated by mental model type (strategy and/or relationships) and mental model content (knowledge and/or beliefs). Both formal and informal feedback from integrative processes and performance continually shape integration strategy content (i.e., what is decided) and the similarity of Integration Mindsets. Thus, shared Integration Mindsets are not a static ‘state’, but rather a dynamic process in which knowledge and beliefs are continuously modified and negotiated.

Introduction: Despite over two decades of international experience and research on health systems integration, integrated care has not developed widely. We hypothesized that part of the problem may lie in how we conceptualize the integration process and the complex systems within which integrated care is enacted. This study aims to contribute to discourse regarding the relevance and utility of a complex- adaptive systems (CAS) perspective on integrated care. Methods: In the Canadian province of Ontario, government mandated the development of fourteen Local Health Integration Networks in 2006. Against the backdrop of these efforts to integrate care, we collected focus group data from a diverse sample of healthcare professionals in the Greater Toronto Area using convenience and snowball sampling. A semi-structured interview guide was used to elicit participant views and experiences of health systems integration. We use a CAS framework to describe and analyze the data, and to assess the theoretical fit of a CAS perspective with the dominant themes in participant responses. Results: Our findings indicate that integration is challenged by system complexity, weak ties and poor alignment among professionals and organizations, a lack of funding incentives to support collaborative work, and a bureaucratic environment based on a command and control approach to management. Using a CAS framework, we identified several characteristics of CAS in our data, including diverse, interdependent and semi-autonomous actors; embedded co-evolutionary systems; emergent behaviours and non-linearity; and selforganizing capacity. Discussion and conclusion: One possible explanation for the lack of systems change towards integration is that we have failed to treat the healthcare system as complex-adaptive. The data suggest that future integration initiatives must be anchored in a CAS perspective, and focus on building the system's capacity to self-organize. We conclude that integrating care requires policies and management practices that promote system awareness, relationship-building and information-sharing, and that recognize change as an evolving learning process rather than a series of programmatic steps.