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.

One of the biggest challenges when it comes to patients with chronic conditions is making sure they actually receive the tests and follow-up care recommended by their primary care physicians. That basically defines the concept of integration across the continuum.

"In California, we've been on this clinical integration model for a long time," says Vivien Tran, director of strategic programs for Coast Healthcare Management, a company based in Lakewood, Calif., that works with independent physician groups in the southern part of the state. "The health care landscape in California moved many years ago from fee for service. Now everything is all about value-based care."

Supporting Articles

Tran says that value-based care requires independent organizations such as unaffiliated medical groups to be clinically integrated, "because you can't do population health management to deliver value-based care if you're not clinically integrated."

Getting there requires analytics programs, Tran says. As an example, Coast Healthcare Management uses a cloud-based platform called ZirMed that provides data to identify patients who experience gaps in required preventive tests and screenings. "If I'm the physician in the office and Mrs. Smith is coming in for an appointment today, I can go into the point-of-care system, pull up Mrs. Smith's profile and look at what preventive tests and screenings she's needing," Tran says. "if she's due for a mammogram, she's due for her HbAB1C test and so forth. It clearly identifies all the care gaps the patient has. So, at a snapshot, the physician knows exactly what's been done and what's needed for the patient, and can get those addressed at that point of care."

Tran says physicians can view such information by individual patient, disease category and by the types of tests and screenings needed.

Besides improving the patient care experience, utilizing the data has proven beneficial to Coast Healthcare Management's quality ratings. "We consistently improve in our quality scores every year from 3 to 5 percent," Tran says.

Holly Taylor, a ZirMed area vice president for population health, says "it's very easy to get lost in the complexity" of all the health data that's out there. "We can imbed into the EMR and have a single sign-on so [physicians] can get in and see snapshots in our system, or the nurse can access our system. We can serve up to the point of care data that helps the doctor understand the broader context of that patient's health. And that's what we mean when we talk about population health management."

Tran says the accelerating drive toward clinical integration and value-based care likely will lead to the extinction of the more traditional health care model. "It's going to change to an accountable care organization or some sort of hybrid ACO-HMO environment. Fee for service won't exist in its current form. The national health care budget can't sustain the rate that our health care costs are going up." •