As healthcare organizations are looking for strategic initiatives to transport them into the future, clinical integration is often the plan. Clinical integration is the answer for provider practices and/or systems that are ready to move into the “new normal.” However, clinical integration requires more than organizational realignment and a commitment to the Triple Aim. Developing an effective clinically integrated network demands commitment and investment in a complete clinical care model redesign focused on team-based, patient-centric care along with the necessary infrastructure to enable this change. Clinical integration requires several key components for success. When is an organization ready to take this next step toward clinical integration? Below are ten key indicators that an organization’s efforts are poised for success.
1. Primary Care Geographic Coverage of the Target Market
When considering a clinically integrated network, the expansiveness of the primary care network is a critical component. In a clinical integration model, primary care is a pivotal access point to the system, and the primary care physician works alongside the patient to drive the care plan. Geographic coverage not only refers to an adequate number of primary care physicians, but also to the presence of extended hours sites, urgent care clinics, or telephonic triage services. All of these access sites can assist in directing patients, who may otherwise access the emergency room inappropriately or not access care at all, to the right care at the right place at the right time.
2. Affiliation or Ownership of Services Along the Continuum
A fully integrated care model with services across the continuum is a central tenet for success. Gaps in coverage along the continuum can lead to insufficient knowledge transfer among physicians, poor hand-offs, and a high risk for complications during transitions in care. The delivery network must include ambulatory, acute care, and post-acute services through ownership or affiliation. Additionally, the network should be linked with community agencies that can provide psychosocial supports, preventive care, and education, as well as integrating these services into the care planning when necessary.
3. Scalable Care Models and Information Technology (“IT”) Systems
A clinically integrated network must maintain an infrastructure that can adapt as the network grows. Patient workflows, care models, and staffing models must be developed such that they are scalable as the network continues to grow. Similarly, the IT systems in place to enable these work flows should be able to mirror the growth of the delivery network. Interoperability, cost, and ease of implementation should all be considered. The IT should support the needed care models across the continuum.
4. Established Quality Improvement and Process Improvement
Clinical outcomes, patient satisfaction, and patient safety are critical to the success of the clinically integrated network. Value-based payment models utilize process and outcomes-based metrics to determine reimbursement. To continuously improve in these areas, a clinically integrated network relies on ongoing quality improvement initiatives with an established framework for process improvement.
5. Population-Based Reporting On Clinical Quality and Financial Outcomes
In order to educate members of the network on their performance, the network should have the capability to conduct analytics and reporting for both patient and population management. Clinical integration relies on clinical model transformation; clinical transformation can only occur with enough data to produce information that will drive this change. Physicians need information on their clinical outcomes, adherence to protocols, and value-based metrics. Transparency in these reports (including the financial results) is critical to physician behavior change.
6. Providers and Facilities Across the Continuum With Aligned Incentives and the Same Strategic Goal
In the past, physician and hospital incentives have not always aligned. Clinical integration requires a re-wiring of these incentives. Trust must exist between providers and facilities. In a clinically integrated network, all providers are working towards the same organizational goals. Providers must work together towards the Triple Aim and develop mutual respect – and rewards – for everyone’s involvement and input in this effort.
7. Established Evidence-Based Guidelines
Evidence-based guidelines are key to reducing variability among physician practice patterns. Established guidelines and protocols ensure that providers are following standards that result in the high-quality care – consistently across the network. Additionally, these guidelines eliminate unnecessary utilization of healthcare services. Evidence-based guidelines should be embedded in the technology tools that physicians utilize. Physicians must lead the charge in developing, utilizing, and monitoring adherence for the use of guidelines and protocols. Reports of non-adherence should be made available to the clinically integrated network’s leadership, and processes for remedial action need to be established for providers who routinely vary from the established protocols.
8. Regular Education for Providers and Staff
The healthcare environment is changing at a rapid pace. Clinically integrated networks must continually educate their physicians and staff on these changes. Rigorous training programs focused on standards of practice should occur regularly. Changes in reimbursement, care models, coding requirements, IT systems and capabilities, and organization-wide goals should be regularly distributed with timely education sessions. Care management staffs need significant training to ensure they are providing adequate support to providers and are working to the top of their license.
9. Interdisciplinary Care Teams
To continuously improve quality and patient satisfaction, clinically integrated networks require interdisciplinary teams to provide care to their highest risk patients. The use of an interdisciplinary team could include the involvement of primary care physicians, specialists, care managers, social workers, pharmacists, dieticians, or any other ancillary provider. The team works together towards a single care plan for the patient.
10. Aligned Vision that Focuses On the “We” Not the “Me”
Clinical integration requires significant cultural change. It is a mindset based on accountable care, where the entire care team is responsible for providing high-quality care. The vision for clinical integration must be ingrained in all physicians and staff as they work to achieve a common goal. No longer can physicians be worried only about their individual performance but rather the care of their patients across the continuum. The clinically integrated network needs to concern itself with its population of patients and how appropriate interventions and utilization of care can improve the health of the population.
Ms. Calhoun is a senior consultant with The Camden Group and specializes in the areas of care management strategy and design, strategic and business planning analysis, accountable care organization applications, development and implementation, and the development of clinically integrated organizations. Ms. Calhoun has supported numerous clients with the completion of Medicare Shared Savings Program (“MSSP”) applications and implementation strategy and planning. Her experience includes care model design and implementation that spans the continuum. She may be reached at firstname.lastname@example.org or 310-320-3990.