Clinical integration across providers and care settings historically has been a sought-after, yet rarely achieved, goal. It recently became a hot topic as a number of major organizations make investments to increase clinical integration to improve the patient experience, clinical outcomes and clinical cost-effectiveness, and to position for health care reform. Among them are Advocate Health Care, Oak Brook, Ill., Geisinger Health System, Danville, Pa., Dean Health, Madison, Wis., and Dartmouth-Hitchcock Medical Center, Lebanon, N.H.
There are four factors driving these initiatives:
- The cost of health care is under scrutiny, with the value of care being perceived as compromised by an excessively fragmented delivery system.
- Technologies like electronic health records, and emerging organizations, such as health information exchanges, regional health information organizations and regional extension centers, are taking hold, largely due to government funding and incentives.
- Physicians are migrating to large group practices or hospital employment because of anxiety over reform, reimbursement pressure and frustration with the complexity of a small practice.
- The prospect of health care reform, which requires accountable care-capable delivery.
Very few organizations are lining up to participate in accountable care organizations, mostly because of the nature of the proposed regulations. However, many hospitals, systems and their boards increasingly are focused on becoming more accountable care-capable because of the profound implications for market strategy in areas such as population vs. care management and the move to ambulatory care.
Organizations are reinventing the medical staff model to address the need for more physician involvement, virtual medical groups and the role of the primary care physician. They also are redesigning how they deliver services to coordinate more effectively across the continuum of care: acute, ambulatory, skilled nursing and home care. Institutions also are considering the financial implications of moving from encounter-based reimbursement to a bundled, performance- or capitation-based payment system. Finally, there will be many issues requiring board involvement, such as antitrust implications of these changes, impact on state licensure and governance of new delivery models.
While ACOs and health reform are in flux, the goal of clinical integration is at the forefront, with tangible targets to decrease costs and improve coordination of care between hospitals and physicians. Clinical integration is a physician-centric set of processes that support continuity of care, and population and complex patient management. Key components include:
- An integrated technology platform that supports continuity of care and enables access to medical history and critical patient data for all stakeholders
- Collaborative communication among primary care physicians, specialty physicians and hospitalists regarding where care is delivered (emergency department, urgent care facility, hospital, physician's office, patient's home or another setting), specialist assessments and treatments, and care planning
- Case managers who are responsible for discharge planning starting at admission or when the patient enters the ED
- Medical management coordination, including management of complex cases, coordination with disease-management programs, and outreach to chronic, high-cost frequent fliers
- Data on populations, utilization, program participation, clinical outcomes and costs
With integrated clinical care, evidence suggests that spending can be reduced without rationing services for patients with chronic diseases. Readmissions are a perfect example. Studies have shown that between 15 and 25 percent of patients who are discharged from the hospital will be readmitted within 30 days. Integration of clinical care among the primary care provider, specialists and the hospital requires coordination to create a cohesive plan to avoid and prevent unnecessary readmissions.
In the longer term, the goal of clinical integration is to increase clinical value by moving up the value curve. Most organizations are in the earlier stages of data display and retrieval. However, the opportunity to truly impact clinical quality and cost requires integration that will eliminate unnecessary testing, procedures and time; facilitate moving from reactive care management to managing the patient as a person by integrating all care needs into a single view of his or her care requirements and experiences; and use available technical and professional resources better.
Experience dictates that it is a very tough journey that demands committed leadership from the board, administrators and physicians. The challenges require cultural, system, process and practice changes. But with a commitment to this delivery model and the necessary systems, processes, disease-management programs and incentives, clinical integration can be implemented successfully, with a significant impact on clinical cost and quality.
Trustees often ask where they should start. After recognizing that moving to effective clinical integration is not a single event but rather a well-managed process over time, there are three specific actions the board can take to put the appropriate emphasis on the organization's approach to clinical integration. Boards should:
- Require a thorough gap analysis that clearly depicts problems to be addressed for each of the major components of clinical integration outlined previously.
- Ask for alternative strategy options, the business case for taking action and the organization's preferred strategy.
- Require a step-by-step plan of action for moving to clinical integration.
- The journey to clinical integration will not happen overnight, but with the direction that health care reform is heading, it is a journey that marketplace winners will be taking.
John H. "Hank" Duffy (firstname.lastname@example.org) is founder of JHD Group, Addison, Texas.