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

Research Article

J Fam Med. 2016; 3(8): 1085.

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

Walker KO*

Deputy Chief Science Officer, Patient-Centered Outcomes Research Institute, 1919 M Street, NW 2nd Floor, Washington, DC 20036, USA

*Corresponding author: Kara Odom Walker, Deputy Chief Science Officer, Patient-Centered Outcomes Research Institute, 1919 M Street, NW 2nd Floor, Washington, DC 20036, USA

Received: September 09, 2016; Accepted: October 03, 2016; Published: October 05, 2016


Purpose: As healthcare providers in the U.S. merge into integrated systems with the goal of providing more coordinated and cost-effective care, the question arises of how to define and evaluate integrated patient care. As efforts of various organizational models are underway to improve value-based care, this study investigates the following questions: what do health care providers and health system leaders identify as the most important elements of integration and coordinated care, and what are some facilitators and barriers to achieving them?

Theory and Methods: Nineteen providers and health system leaders participated in interviews and written surveys during which they were questioned about coordinated and integrated patient care. Interviews were transcribed and analyzed for thematic content, and such concepts were correlated with a recently proposed conceptual model of integrated care. Brief survey data was analyzed to further describe and triangulate the findings.

Results: Providers and health care leaders had varied but often overlapping definitions about integrated care. Recurring themes drawn from the interviews were often reflected within a proposed framework of integrated care with lessons that may call for further elaborations of the existing constructs. To move toward improved integrated care, participants particularly emphasized proper alignment of financial incentives and accountability, a robust primary care system, and infrastructure to promote seamless communication and manage populations.

Conclusion: The informed experiences of providers and health administrators may provide valuable lessons that help guide the development of improved and validated metrics for evaluating coordinated and integrated care, and ensure that such organizational and policy changes translate to sustainable and high-quality patient care.

Keywords: Patient care; Health care; Primary care; Proactive care; Integrated care


A 2011 survey by the Commonwealth Fund showed that more than 7 of 10 adults believe the U.S. health care system needs “fundamental change or complete rebuilding [1]”. Poor patient and provider satisfaction, problems of redundancy, avoidable complications, and high costs have led to a movement to reform US health care, including the enactment of the Patient Protection and Affordable Care Act (PPACA) in 2010. While expansion of health care coverage is one important goal, health reform is also demanding sweeping changes in how health care is organized and delivered. One key objective of system reform is achieving greater health care integration. Integration of health services is viewed as an important strategy for achieving patient-centered care and ameliorating patients’ chaotic experience of their health care journey [2], and for achieving more effective and efficient health care delivery [3]. Several policy strategies have been advanced in the US to promote health care integration. Accountable Care Organizations (ACOs) align physicians with hospitals and other components of the health care system and provide incentives for improving quality and controlling costs [4-6]. Advocates of ACOs believe that this approach may achieving some of the organizational advantages of group-model HMOs such as Kaiser Permanente, without the complete degree of structural, vertical integration that characterizes traditional HMOs. Health reform has also emphasized patient-centered medical homes (PCMH) as a hub of quality primary care to enhance care coordination and communication [7,8]. This notion of a medical home has expanded to the concept of a medical neighborhood, a term coined by Fisher to describe a constellation of well-coordinated services, providers, and organizations in a health system that in addition to primary care medical homes, consists of specialists, emergency facilities, inpatient services, home care, pharmacies, and other components [9]. Nations other than the US are also contending with the need for better care integration and implementing strategies such as colocation of services and bridging of ambulatory and hospital sectors [10].

A key question for the field is whether these organizational reforms will truly achieve the functional performance necessary to accomplish the triple aim of better patient experience, better health outcomes, and more affordable care [11]. Designing care models that will function well in practice requires an understanding of the perspectives and experiences of patients and clinicians about the elements that make for successful care integration and the facilitators and barriers to integration. In a previous qualitative study, we investigated patients’ experiences of integrated care. That study validated a conceptual framework of the functional domains of care integration and affirmed the importance that patients place on all members of the care team “being on the same page [10]”. In this article, we extend that work by exploring the perspectives of practicing physicians and health care administrators. The study’s aims were to explore physicians’ and administrators’ definitions of integrated and coordinated care and their perspectives on the facilitators and barriers to achieving functional integration in a qualitative study.

Theory and Methods

Using domains proposed in the conceptual framework of integrated care by Singer et al (Table 1), we conducted a qualitative study through semi-structured interview to explore each of these domains. To further explore the thematic findings, we supplemented our qualitative data collection with a brief written survey. The semistructured interviews were conducted with a series of open-ended questions, facilitated by interviewers trained in the use of qualitative interview techniques. The semi-structured interviews asked participants about their definitions of integrated and coordinated care and examples of when the system seemed to be working well or not working well for patients, how information should be shared, and how providers should work together, adapted from published surveys of providers about coordinated care (Table 2) [12-15]. The written survey involved 20-questions based on the same survey items to reflect provider experiences with different aspects of patient care. The survey questions were selected as a subset most relevant to providers’ views of integrated care.