The Need for Leadership, Information, Incentives, Patient Engagement, Primary Care and Proactive Care: Perspectives on Integrated Care

  

    
DOMAINS 
    
Subdomain    (Interview Discussions) 
    
Example    Quotes from Interview Participants 
  
  

    
Coordination within care team 
    
Care plans shared via medication lists, portable    medical histories, and with other providers and staff
    
“ I think the    teams should include everyone who participates in the care of the patient.    And that’s not always feasible. And it’s not like you’re necessarily all    going to be in the same place at the same time kind of team. It may be a    little more virtual than physical, depending on the setting and    circumstances. And this is what we haven’t done a good job in, is maximizing    the participation of every person on the team.”[Male, Family Physician,    Hospital Executive]
  
  

    
 
    
Information clearly communicated without duplicated, conflicting, or repeated sources
    
 
  
  

    
Coordination across care team 
    
Entire team assist with follow-up appointments,    tests, and referrals at the primary clinic and with other sites of care
    
“Coordinators    that can help make sure, they’ll keep track of the referred patients and make    sure that their referrals are getting back, the reports are getting back.”    [Male, Family Physician, Private Practice]
  
  

    
 
    
Dialogue across care providers to provide a    consistent message about care plans, medications, and test results without duplication and conflicting information
    
“ It was that    mindset that we did our things and then sent them out at the other end…but    that’s not there.”[Male, Physician, Private Hospital CEO]
  
  

    
Coordination between care teams and community    resources 
    
Communication between providers and other    community caregivers adds to the patient’s care plan and support systems
      
Ongoing feedback from community provides greater    health information to health teams and vice versa
    
“The intervention is all about coaching patients    so that they understand their health problems, their medication list and red    flags for their conditions. And the idea    is that a coach visits the patient while they’re in the hospital, enrolls    them, talks to them about this stuff. And then within 48 hours after they’re discharged they visit the    patient at home. And then there’s two    follow-up calls within the first month. And that’s the intervention...[someone] whose job entirely is making    sure that we’re seeing the right patient, in the right place, in the right    time, with the right treatment¨So the    job is literally to go across the silos and bring people together. [Female, Physician, Public Hospital CEO] 
  
  

    
Continuous familiarity with patient over time 
    
Information available throughout site of usual source of care, with other    specialists, pharmacy, emergency department, inpatient teams about medical    history, care plan and medication history
    
“You can share    information but if the information is not iterative,…or accurate, or if its    not relevant, then just the sharing of information is not sufficient.”[Male, Specialist, Physician Executive, County    Hospital System] 
  
  

    
Continuous proactive and responsive action    between visits 
    
Appointments, follow-up, tests, and insurance questions without significant barriers or delay over email, phone or health    portals
    
“a combination of    being available for access to services when you’re sick, having prevention    services available, but also doing outreach to find people.”[Male, Internist,    Clinic Medical Director]
  
  

    
 
    
Address all patients perceived needs for their    health or health education 
    
“What we fall    down on is the ability to identify the unmet need, that doesn’t express    itself, so the diabetic who hasn’t been in in six months, who’s not complying    with medications and hasn’t had a hemoglobin A1C tested.” [Male, Internist,    Private Practice]
  
  

    
Patient-centered care 
    
Focus on the patient experience of care that    extends beyond regular doctor’s office hours and setting 
    
“What is the    patient’s problem, what is the patient’s needs, what needs to happen, what    are the recommendations, who’s going to carry it out, who’s going to provide    the optimal care for a patient at the right time.“[Male, Family physician,    Integrated delivery system]
  
  

    
Shared responsibility 
    
Aligned incentives 
    
”A set of rules    for engagement and accountability that sits on top of a set of processes of    care, that are defined, so that everybody sees what they are and they’re well    developed... there’s a greater degree of upfront communication to patients    about how this episode of healthcare or this path of healthcare is going to    happen, so that, one, both their expectations can be realistic, and then it’s    an additional incentive for us to hold ourselves to those    expectations.”[Male, Internist, Private Hospital Medical Director]
  
  

    
 
    
Accountability and oversight resides with the healthcare    providers, financial fiduciary and the patient
    
 
  

Table 3:  Domains and Subdomains with Sample Quotes from Semi-structured Interviews.

Theme 1: Coordination within care team: Most participants felt that care teams functioned best when centered on primary care and when incentives were aligned to foster a culture of shared responsibility within the care team. Some stated that it was important that coordination within a care team involved appropriate stratification of patient needs and ensuring that the full scope of care was not just contingent upon one physician. Some used examples of utilizing nurses and nurse practitioners to triage basic complaints, health coaches to educate patients, and case managers to assist a few high-utilizing patients avoid the emergency department. Nearly all participants felt strongly that an important means to improving coordination within the care team was through the use of an electronic medical record to reduce errors, track population health performance metrics such as blood pressure or vaccinations, and standardize care.

Theme 2: Coordination across care teams: The need for improved communication across care teams was a prominent theme. Participants emphasized the importance of two-way communication between hospitalists and primary care providers – a system in which hospitalists can access outpatient records as fluidly as PCPs can access hospitalist records. The importance of communication between the emergency department and the PCP was also highlighted, such as through real-time notices to the PCP, a discharge note, and the ability to book appointments directly to the patient’s primary physician. Finally, the need for mental health integration with primary care was mentioned often; since in most cases, behavioral health notes are not available to primary care providers due to HIPPAA regulations, this is a common barrier to coordination of services. One provider proposed the “visible behavioral medicine note” to improve mental health care communication to the patient’s PCP.

More than 50% of participants spoke of the need for a robust integrated electronic health record to improve communication between providers across care teams. At the same time, many emphasized the need to consider that EHR was just a means to an end: “You can share information but if the information is not iterative or accurate, or if it’s not relevant, then just sharing of information is not sufficient” (Male, Specialist, Physician Executive, and County Hospital System). Many promoted electronic communication between the primary care provider and specialist through informal means such as e-mail (“curbside consults”) and a formal e-referral system for back and forth communication between primary and specialty provider. Some also suggested feedback from the physical or occupational therapist back to the PCP, and even a chat room where all providers can interact dynamically in a way that is transparent to all members of the care team.

Involvement of the pharmacy was another potential area of integration discussed within this domain. Many providers felt that pharmacists could help manage and support chronic care and that problems arose out of this deficiency e.g., the lack of a “feedback loop” or difficulty of getting information back to the provider on whether or not a prescription is filled or a patient is adherent with medications.

Theme 3: Coordination between care teams and community resources: Some providers discussed that coordinated care also meant connecting patients to community resources, such as needs around transportation, care management, language services, etc. One provider suggested comprehensive language services integrated directly into patient care for patients with limited English proficiency, such as through language-specific modules where everyone on a team including physicians, nurses, medical assistants, health educators, and diabetic educators were all equipped with bilingual capabilities. Others suggested interpreter services, translated materials, and fully translated prescription bottles.

Theme 4: Continuous familiarity with patient over time: Most providers emphasized that successful integrated and coordinated care is unlikely without a well-organized system of primary care because a primary care provider is necessary for continued familiarity with a patient over time. This enables a provider to be responsible for care transitions, to provide lifelong care and to cross disciplines or silos of specialization. One participant described the challenges and frustrations for some patients that must navigate the health care system without a primary care provider: “[Patients] have just been to a gazillion specialists and no one’s looked at the big picture” (Female, Integrative Medicine, Private Practice). Another emphasized the importance of creating a culture and system in which primary care was recognized by all members, including specialists, as the medical home for patients.

Theme 5: Continuous proactive and responsive action between visits: Patient outreach and education were brought up as important elements of proactive and responsive between patient visits. One participant lauded a system that could be “a combination of being available for access to services when you’re sick, having prevention services available, but also doing outreach to find people” (Female, Public Health, Hospital CEO). Some suggested ways to achieve this through active preventive health reminders, e.g., phone calls to remind patients to get a mammogram, a PAP smear, blood test, etc. One identified this lack as a weakness of some systems: “What we fall down on is the ability to identify the unmet need that doesn’t express itself, [such as] the diabetic who hasn’t been in in six months, who’s not complying with medications and hasn’t had a hemoglobin A1C tested” (Male, Internist, Private Practice). Others felt that one way of being proactive was by focusing on the highest needs groups, even if they made up a small minority. Finally, patient portals were suggested as ways to interact with patients between clinic visits – e.g., a built-in patient portal that allowed for patient education by linking directly to vetted medical education sites.

One provider worked in a system that sought to improve closer follow-up after discharge from the hospital: “We have an agreement with our hospital that if any of our patients leave the hospital, within 48 hours they get a telephone visit with us, so that we have fairly rapid contact with the patient” (Male, Internist, Integrated Delivery System). Another lamented the inappropriate use of emergency rooms due to the lack of extending clinic hours while someone else shared a successful example of open-access scheduling dropping their emergency room utilization by 50% among their patients. Teambased care such as utilizing committed case managers to keep track of referred patients to ensure that referrals were getting back was considered one way to improve proactive action. Finally, home visits were also suggested as ways to work with families to prevent hospital admissions.

Theme 6: Patient centeredness: Participants spoke often of the need for patient-centeredness. A commonly suggested tool was patient advisory boards. One provider stated: “We’ve aggressively pursued the strategy of including patients and family members in our improvement work, which has helped us with a lot of sense-making in terms of what the priority should be” (Female, Public Health, Hospital CEO). This provider suggested a two-prong approach to achieving true patient-centered care: “One is involving the patients in everything that includes executive decisions. And the other is a relentless pursuit of quality. And I think that if you keep two things there, that then sort of dictates the way you use all the grand tools that you have available too” (Female, Nurse, Hospital CEO).

Many spoke of improving convenience and customer service as a key component to patient-centeredness. One provider stated that a patient-centered practice is “built around patient convenience, patient need, and informed decision-making from the patient’s perspective” (Male, Family Physician, Private Practice). One example of improving convenience was the improvement of easing appointment scheduling through open-access scheduling, also referred to as same-day scheduling.

Finally, one provider stated it was important to remember to make room for customizing to patient needs and preferences even while developing more automated, integrated care processes: Patientcenteredness is “putting the patient in the center, where they may not represent the average patient – understanding that care is not algorithmic, that a patient may require, for example, a much smaller dose of medication than the average person, and that may be what works for them” (Male, Family Physician, Hospital Executive).

Theme 7: Shared responsibility: The theme of shared responsibility involves both the patient and his or her family and care team as responsible members of promoting health and managing financial resources. One provider explained how one major barrier to this end was the lack of transparency to patients in the cost of care. As one provider stated, “You can’t expect people to willingly participate in something if they have no idea what the cost is…I’m not going to consider buying some flat screen TV if I have no idea what the cost is relatively to the cost of another flat screen TV. And so what happens with people in the absence of information, people either making the wrong assumptions, and in making the wrong assumptions about cost would in fact delay care” (Female, Public Health, County health executive). Many suggested more active patient outreach, education, and the use of patient portals as important ways to achieve shared responsibility (Table 3).

Facilitators and barriers to integration

The participants described many facilitators and barriers to integration, which are summarized in Table 4. They suggested many key facilitators that cut across several domains to achieve integration: 1) importance of seamless EHR and other information technology to promote information flow, 2) alignment of incentives to achieve patient-centered care, 3) robust primary care to act as a medical home, 4) genuine patient engagement, 5) a culture of teamwork fostered by strong leadership, and 6) proactive care that improves patient access and fosters a preventive care model. Some of the hindrances to achieving such key facilitators related to the systematic lack of infrastructure in place. A few specific barriers mentioned included 1) a financial model that did not reward teamwork and patient outcomes, 2) a shortage of a primary care workforce which poses a challenge for primary care to act as highly functioning medical homes, 3) the lack of a customer service model, which hinders access and transparency in cost for patients to make decisions about their care, and 4) difficulty accessing specialty care and ancillary services (Table 4).

  

    
Construct
    
Facilitator
    
Barrier
  
  

    
Coordination within care team
    
Electronic Systems: Medical Record
      
Specialists understand the role of the PCP
      
Medical Homes centered around primary care
      
Increased supply of primary care physicians
      
Working with case managers, coordinators and    health coaches
    
Shortage and lack of primary care workforce
      
Communication gaps between providers
      
 
  
  

    
Coordination across care teams
    
Electronic Systems: Medical Record, e-prescribing, robust IT
      
PCPs understand the role of the specialists
      
Increased face-to-face and electronic    communication between primary care physician and other providers,    specialists, hospitalists, emergency departments, mental health
    
Lack of access to specialty care
      
Communication gaps between providers
      
Poorly integrated Pharmacy data
      
Fragmentation in the emergency care setting
      
Inadequate ancillary services, such as PT, OT,    rehab
  
  

    
Coordination between care teams and community resources
    
Electronic Systems: Registries for population management
      
Community Oriented Primary Care
    
Gaps in healthcare delivery
  
  

    
Continuous familiarity with patient over time
    
Electronic Systems: EMR
      
Patients linked with a primary care medical home
    
Duplication, overuse, wasted time with documents and    approvals
      
Lack of patient “ownership” of their health data
  
  

    
Continuous proactive and responsive action between    visits
    
Systems to reach out to those due for preventive and chronic    disease management
      
Providing timely access to care
      
Reaching out for post-discharge time windows
      
Providing home visits
      
Care team members respond to patients between visits
    
 
  
  

    
Patient centered
    
Electronic Systems: patient portals, portable medical    record, Care team members create care to meet patients needs and preferences    and promote self-management
      
Working with patient advisory boards
      
Using patient surveys
      
Improving convenience according to patient needs    and preferences
    
Lack of customer service model
  
  

    
Shared responsibility
    
Electronic Systems: performance improvement,
      
Care team and patient both are responsible for promoting health    and managing financial resources
      
Strong organizational leadership, management and    adequate resources
      
Aligning incentives (financial, quality and    accountability)
    
Poor payment and incentive structures, based on “sick care    model”
      
Lack of transparency in cost of care to patients
      
Lack of leadership and management experience    among clinicians
  

Table 4:  Barriers and Facilitators to Integrated Care.