(Part one of a three-part story)

Everything is connected.

That, in a nutshell, sums up the current state of health care as we strive to promote wellness, improve outcomes and tame costs. Traditional boundaries are vanishing. There’s renewed recognition that an individual’s well-being involves both medical and social factors and that caring for him or her takes place across a continuum — a continuum of time and people. As we strive to promote community health and ensure that we deliver the most effective care possible, we must recognize that a provider’s responsibility no longer starts when patients walk in the door and it certainly doesn’t end when they walk out.

In this special report, we offer case studies of hospitals and a physician network that explore different ways to enhance clinical integration to improve the quality of patient care and, in the process, reduce unnecessary costs. We hope the lessons they learned and the insights they provide guide other hospital leaders as you move your own integration efforts to the next level.

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A key driver of the clinical integration movement is the need to improve the management and prevention of chronic disease. A 2016 white paper from the Partnership to Fight Chronic Disease says the "growing burden of chronic disease is unsustainable" and it advocates increased coordination, continuity of care and care management.

For patients with chronic conditions, medications pose a particularly dicey concern. Providers must make sure various medications do not interfere with one another, that the dosages are correct, that patients obtain their meds, use them properly once they are out of the hospital and that no adverse reactions occur.

"One of our major concerns, like most health organizations in the U.S., is medication reconciliation," says Shawn Parekh, pharmacy director for Abington Jefferson Health in Pennsylvania. "There were high error rates that we discovered — up to 30 percent — that our physicians were making. There were drugs being omitted or there were incorrect doses, things of that nature."

Parekh is also on-site director and consultant for Comprehensive Pharmacy Services, a company headquartered in Memphis, Tenn., that works with hospitals to improve pharmacy operations across the continuum of care.

Compounding those problems was the problem of patients not taking their medications when they went home, and a resulting series of medication problems led to high readmission rates. "That's the problem we set out to fix," Parekh says.

"Medications have become increasingly complex and patients are on more medications than they ever have been," says Jeff Lackman, a CPS divisional vice president in Naperville, Ill. "Over 20 percent of prescriptions go unfilled, for a lot of reasons. We know that medications are not reconciled. We don't have systems in place that effectively make sure patients don't have medications duplicated or missed or not added to their care plan appropriately. Sixty-six percent of emergency readmissions for patients over 65 are due to adverse medication events."

Hospitals that work with CPS to reduce unnecessary readmissions notify the company when a patient is about to be discharged. CPS checks the patient's record to determine what medications the patient is supposed to be taking, and then one of its pharmacists calls the patient, or the patient's caregivers, at bedside in the hospital or at home.

The pharmacist asks the patient how he or she is feeling and then asks questions specific to medications, such as, 'You went to the hospital for pneumonia. You were prescribed an antibiotic and something to help you with your breathing. Did you get your prescriptions filled?' "

Lackman said the patient may tell the pharmacist she got the prescription filled and took it for a day, but then got so sick to her stomach that she quit taking it. "At that point we're getting information we're going to take back to a primary care physician or the hospital. If the patient sounds like they're getting worse, we're going to ask them to stay on the phone while we contact whomever the hospital wants us to contact — the emergency room, the primary care physician. Sometimes if it's a very serious issue, we would call an ambulance and get help to them immediately."

If a discharged patient tells the CPS pharmacist he didn't get his prescription filled, the pharmacist will ask why. The reason might be that the patient can't afford the medication or doesn't live near a drug store.

"We build these conversation trees or cascades based on the diagnosis the patient went home with," Lackman says. "Obviously, one for congestive heart failure is going to flow differently than one for pneumonia, which is going to flow differently than one for after a heart attack. We come in with ideas and suggestions, but we build this in partnership with the hospital. We don't have a one-size-fits-all answer to this, because every hospital's needs are going to be different."

Abington Memorial Hospital teamed up with CPS on a pilot program that ran from October 2014 to March 2015 involving two units of the hospital that showed particularly high readmission rates. Physicians and nurses participated in the program.

Once a physician created a patient's discharge medication list, a nurse would call a CPS office in Naperville. The CPS pharmacist would dial via VPN into the hospital's electronic health record and pull up the patient's medication list. The pharmacist also would glean pertinent information about the patient's medications from an electronic prescribing database.

"That gave a very clear picture of what the patient should have been taking and, at that point, they could make interventions," Parekh says.

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For instance, if the CPS pharmacist saw that the discharge list omitted medications the patient was supposed to be taking, the pharmacist could call the physician and ask for an explanation. Then the physician could acknowledge the discrepancy and authorize CPS to correct those errors in the database and inform the nurse.

The CPS pharmacist also had the ability to call patients in their rooms to seek clarifications about the medications they were on. "We were able to prevent a lot of patients from going home with an inaccurate list," Parekh says.

A second pilot program, which began early this year, targets heart failure patients who are discharged from Abington's heart failure unit. First, a nurse navigator contacts CPS to identify the patient. Then the company’s pharmacist accesses the patient's health record and searches for medication issues that require reconciliation. If changes are needed, the CPS pharmacist calls the patient's physician.

If the patient is discharged to a nursing home or other long-term care facility, CPS will call that facility within 24 hours and verify the accuracy of the patient's medication list. When the patient goes homes, CPS calls the patient and makes sure she gets her prescriptions filled. If a prescription hasn't been filled, the CPS pharmacist finds out why and notifies the patient's transition nurse.

"Otherwise they're going to be back in the hospital," Parekh says.

How to adopt clinical integration to achieve value-based care

There is broad consensus among health care experts that providers must adopt clinical integration to succeed in a value-based care environment. Moving from more traditional models to clinical care requires a comprehensive strategy that includes systemic collaboration, robust information technology and consistent outreach to patients.

Here are comments from three industry experts on this topic:

John R. Combes, M.D., chief medical officer and senior vice president of the American Hospital Association: "First you have to create a vision of what you're trying to achieve. The vision that is appropriate will appeal to the professional values of the clinical staff as well as the organization. The second step is to create a place for this work to be done. Is there an organization or a clinical improvement network or a clinically integrated network that is working on particular issues to improve care? Is there infrastructure in IT that can support this work?"

Dani Hackner, M.D., vice president and chief medical officer for care management at Memorial Hermann Health System in Houston:  "One of the most important first steps is what our medical network, MHMD, did in terms of making some important cuts. This group of doctors is in because they're willing to share quality and share risk, and [this other group is] not in because they're unwilling to adhere to certain standards. A subsequent step, which is much more challenging, is integration of operations: taking your ambulatory and inpatient resources and marrying them, having them deeply, collaboratively working together."

Jeff Lackman, divisional vice president for Comprehensive Pharmacy Services: "When the hospital triggers us, it allows us to come into contact with a patient. We'll talk to patients at admission. We can check their medications against a national database of adjudicated pharmacy claims. We can provide the physician with a gap analysis of what the patient thinks they're taking and what they should be taking. If it's my mom and she says she takes a green pill and a blue pill, we can find out what those green pills and blue pills are."