Parkview Health, in Fort Wayne, Ind., is investing in developing a clinically integrated network for the organization's own physicians group as well as independent physicians in its community. John Meister, senior vice president of delivery system integration at Parkview, sees this network as a "vehicle to support our physician alignment and bring about shared goal-setting and joint contracting."

The health care organization has put together a comprehensive care registry with a risk-stratification engine that identifies high-risk or fragile patients who may need care management, patients who have their conditions well-managed and patients who need preventive care. This tool is "a homegrown care registry," Meister explains. The registry is updated regularly and refreshed weekly so providers have current data to provide high-quality, timely care. "The progress reports that physicians receive on demand have been of great value," Meister says. "They provide opportunities for collaboration and improvement, which are supported by strong physician leadership." 

Guidance from an AHA Fellowship

As Meister has worked on this clinical integration project, he has received guidance and feedback from other health care leaders participating in the AHA's Health Care Transformation Fellowship. Meister and 15 other fellows first met in July 2013 at the Health Forum and AHA Leadership Summit. Topics for their three in-person learning retreats were clinical integration, financial risk and population health management. All fellows work on a project that addresses the needs of their own organizations. The fellowship provides them with feedback and guidance from fellowship faculty, AHA staff and their learning cohort.

"The learning atmosphere is unique," observes Meister. "Very credible, high-profile organizations were willing to share their experiences." The fellowship class included many physicians, and Meister says "their candidness and insights were greatly appreciated." According to Meister, Parkview is continuing to build a solid infrastructure for clinical integration, recognizing that no two markets are alike. "As our market continues to evolve toward more pay-for-performance and value-based contracts, we want to be ready for that," he adds.

Actionable Tools for Transformation

Besides the collaboration with thought leaders on topics related to transformation of care, the fellowship provides early exposure to different kinds of tools, according to Sylvia Getman, president and CEO of The Aroostook Medical Center and senior vice president of Eastern Maine Healthcare Systems, where she co-chairs the transformation steering committee. EMHS was designated as a pioneer ACO. A recent fellow, Getman valued the access to road maps and tools on the second curve and transformation competency work. "All are helpful in gauging where the industry is and where it is going."

Maine is a rural state, and Getman's hospital serves a rural population in northern Maine. As a member of EMHS, Aroostook is part of a statewide organization that serves Maine's rural areas as well as more populated cities, such as Portland and Bangor. "Since all of the fellows were working toward transformation, we had more in common than dissimilar … . Size does not really dictate how fast an organization is transforming." 

Getman's fellowship project focused on clinical integration and building a foundation for physician leadership. "We used this project as a catalyst in our system to advance conversations that are a little more challenging, like physician leadership and integration," Getman explains.

The fellowship allows participants to bring different sets of colleagues to each learning retreat. Like other fellows, Getman brought physician leader colleagues, finance colleagues and population health leaders, based on the retreat's topic, which she says was a "huge benefit … it gave us a different type of access to those thought."

Reduced Readmissions in a Rural Setting

Julie Cann-Taylor, COO of Wyoming Medical Center in Casper, is working with a state collaborative to improve care transition throughout Wyoming. Through grant funding, 26 transition coaches were dispersed throughout the state, and five were allotted to Wyoming Medical Center. "During an episode of illness, patients may receive care in multiple settings, often resulting in fragmented or poorly executed transitions," Cann-Taylor says. The transition project's objective is "to move patients and their families through these transitions with a transition coach at their sides … to prevent readmission to the hospital," she explains. The initiative focuses on 10 diagnoses and has contributed to reduced readmissions for acute myocardial infarction, congestive heart failure and pneumonia.

Wyoming Medical Center is focusing on primary care and building more primary care practices, bringing them in to work with the transition coaches. "After these practices are built, the coaches not only will see patients on discharge and take them to their first doctor's appointment but also be able to do care planning with these patients in the community," Cann-Taylor emphasizes. "I plan on expanding this work to see if transition coaches can be the glue between hospital visits and primary care."

As part of the fellowship program, Cann-Taylor says she learned much from other projects, including ideas about population health management, that will inform her work in a rural hospital setting. "I have 30 more people I can call if anything comes up. The fellowship was a great way to expand our horizons," Cann-Taylor says. In turn, she was able to share information that other fellows had not tried yet.

Blazing the New Frontier

According to James Jones, M.D., a critical care nephrologist and physician adviser who works on clinical documentation improvement at Mount Sinai Health System, "Everyone is at the frontier when it comes to health care transformation. There is no playbook saying ‘Do this, do this, do this, and you'll get to this.' Everyone is trying different types of project planning to get to the same mission, which is population health."

A recent fellow, Jones is working on clinically integrating an independent physician association, using quality dashboards and integrating service lines. He predicts that true clinical integration is three to five years away; quality measures, a year away; long-term integration, five or more years away. "The strength of the fellowship program is seeing what other health systems, small and large, are doing and learning from their experience. This is an excellent networking opportunity for leaders in the field."

Author's note: Applications are now being accepted for a new class of fellows, which will convene in July at the Health Forum and AHA Leadership Summit. For information about the Health Care Transformation Fellowship and video and audio interviews with recent fellows, visit www.hpoe.org/hctfellowship.

Cynthia Hedges Greising is a communications specialist for the Health Research & Educational Trust.