Building Blocks of Success for Two-Sided Risk Models: Clinical Integration

As part of an on-going blog series on building successful two-sided risk models, Premier experts are sharing insights and tips on how to prepare for a successful transition. Let’s explore the role of clinical integration along the pathway to success.

What is Clinical Integration?
In an integrated network, with value-based payment contracts, providers share accountability for patients’ health and outcomes. And in order to do this, they must achieve clinical integration. This term refers to the coordination of care among and between various providers across the care continuum, including primary care physicians, specialists, and post-acute care and behavioral health providers.

Supportive Capabilities
First and foremost, clinical integration requires true physician engagement, which can be greatly enhanced by intentionally designed, supportive systems and process infrastructure. Health system leaders must be committed to investing time and resources in the training, technology and new care models required for effective and sustainable integration. Providers across the network need to be engaged as leaders in the development and implementation of standardized care models that optimize clinical integration. Technology platforms must enable front-line providers to access and maintain patient information, communicate and share information rapidly and with ease, and keep track of the care patients receive outside their network. And actionable analytics should be used to identify specific patients to target care management and interventions accordingly.

Care Management as a Core Strategy
One key strategy for achieving effective clinical integration is the use of care management. A strong care management program can support physicians and is an integral part of the design of a highly reliable system of care that provides seamless coordination across sites. Care managers, working in tandem with a patient’s primary clinic team, can serve as a “home base” to contact as patients navigate their care journey. Care managers also play a liaison role between providers, supporting longitudinal coordination of care between primary care and various specialists. This approach promotes whole-person, patient-centered care, while helping streamline and coordinate care to avoid duplicative or unnecessary, high-cost services.

A care management system is particularly valuable in the context of caring for patients with complex or multiple chronic conditions and needs. During a single hospitalization or emergency room visit, to truly integrate care, many steps are required—each provider needs to be notified of the admission and communicate associated changes in treatment, several follow-up appointments often need to be scheduled to address different health concerns, and care teams must ensure the patient actually receives post-discharge services. A care manager can be the most effective means to unify these efforts by acting as a central conduit for communicating and orchestrating care for patients post-discharge.

Mrs. Smith is a 90 year-old woman who lives alone and has a primary diagnosis of congestive heart failure. In less than 3 months, she had a series of visits to her primary care physician, cardiologist and the emergency department, and was also hospitalized. The cost of care during this period was $56,800. A care manager and social worker met with Mrs. Smith to educate her on managing her illness and helped Mrs. Smith stay independent as long as possible –her primary goal. Mrs. Smith learned how to avoid fluid overload and what to do if she sees an increase in her weight. She started reporting her daily weight and blood pressure. After a month, it was clear Mrs. Smith had a better understanding of how to monitor and control her condition, and she was able to transition to a different level of care and monitoring.

“The most amazing thing about following Mrs. Smith is remembering our first introduction in the primary care doc’s office. Mrs. Smith looked tired, worried, and seemed to really struggle with shortness of breath during our first conversation. Now Mrs. Smith is happy, always smiling and eager to talk about her improved health and what she is doing to manage her care. I truly believe that the increased calls by the care manager, and the change in the care plan to make it more patient centered, made all the difference in her outcome!”– Care Manager

The role of social determinants of health (SDOH)

To improve health outcomes of the populations they serve, networks should consider the influence of social and environmental factors (e.g., transportation, social support, food insecurities). Even providing an air conditioning unit for a patient with chronic obstructive pulmonary disease could prevent unwanted exacerbations and hospitalizations in the summertime. In fact, addressing these needs is essential to delivering high-quality care at lower costs. Robust IT systems should support providers with access to SDOH information to inform interventions that improve care. And care managers can partner with social workers and community organizations as needed. Alongside a strong infrastructure and engaged physician community, understanding this comprehensive picture of patient well-being can be the most essential piece to coordinating effective care.

As healthcare organizations take on more risk, effective clinical integration is vital to a successful model. To learn more about transitioning to a risk-based arrangement, download our white paper “Ready, Risk, Reward: Building Successful Two-Sided Risk Models.” For more information visit www.premierinc.com/vbc.