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Engaging patients is essential to linking the care continuum, and providers are becoming more sophisticated in how they do it. Home monitoring technologies and online tools and communication methods make it a little easier for both patients and physicians. As genetic tests and personalized medicine mature and become more integrated into the delivery process, patient engagement will necessarily be an ongoing and prominent part of the care continuum.

Rethinking care delivery
Prevention and early detection through patient education are only starting points, however. A deeper problem lies with how services are organized, which traditionally has been based on how providers work.

A patient with migraine headaches may jump between a primary care office, an outpatient neurologist, an independent imaging center, a hospital inpatient unit, and several other providers for treatment. Each provider may have lines of communication with multiple other settings, creating a web of information exchange and coordination without a central home. The treatment network for a single condition becomes so complex that fragmentation and miscommunication are almost inevitable.

So what does a better delivery model look like? For one, it's based on the care cycle of the patient rather than the professional designations of providers. Much attention has been paid to the primary care-based medical home model, but comprehensive and continuous care is also needed at the service line level.

A patient going through the Cleveland Clinic Heart and Vascular Institute, for instance, doesn't have to worry about care gaps between hospital departments because the service line brings several specialties together to provide heart care. There is little competition between cardiologists and cardiac surgeons over heart valve procedures, which normally live in a gray area between the two specialties, because the physicians' loyalties are to the heart valve program, not separate departments.

"We have completely reorganized from the traditional departments of medicine and departments of surgery, which often compete with each other internally around patients, around resources, around space, and we've colocated people who work together regardless of whether they come from a medical or surgical background," says Marc Harrison, MD, chief medical operations officer for the nonprofit, multispecialty academic medical center with more than 1,000 beds.

Many service lines are already based on multidisciplinary teams, but the future of the model lies in greater integration and focus. Instead of just organizing around a service, many are becoming disease-specific. Breast cancer centers, diabetes management programs, and other disease lines allow for even greater coordination.

In some ways, it's just a matter of redirecting resources and rebuilding care teams with the right personnel. But it also helps to physically put the multidisciplinary team at one location. To deal with problems of cancer care fragmentation, Decatur Memorial Hospital, a 357-licensed-bed hospital in Illinois, centralized most of the care continuum in 55,000-square-foot comprehensive center that houses medical oncology, radiation, cancer research, diagnostic services, labs, and nuclear medicine.

Care is more coordinated because physician communication is so much easier, says John Ridley, executive director of oncology services for Decatur Memorial Hospital. But perhaps most important, the service line is now organized around all of the patient's needs during the care cycle. In addition to a multidisciplinary physician team, patients also have access to dieticians, social workers, patient navigators, and complementary medicine services.

"My little mantra with the people that enter this facility is, I tell them it's a community center as much as cancer treatment center," Ridley says. "It's important to give people a greater understanding of how easy it is to access care so they don't think there are big barriers or that they will enter this system and get lost in the process."

Locating multiple points of the care continuum together has smoothed transitions and made care more efficient, as well. Previously, if a patient was getting both chemotherapy and radiation, he or she would have to shuffle between medical oncologists and radiation oncologists, and often have to get the treatments on separate days. With both sets of physicians, along with supporting personnel, within a short walk from each other and working in a team environment, both treatments can be knocked out in a single visit.

"Things like that have a direct impact on patient care and throughput and being efficient. Typically when you're more efficient it's both a cost savings and a patient satisfier," Ridley says.

Finding the right model
In theory, linking the care continuum at the service line level sounds simple enough. For hospitals, the meat of the challenge lies in a handful of key changes: aligning with physicians, building multidisciplinary teams, tracking and benchmarking processes and outcomes, and partnering with postacute facilities. But those changes aren't easy to implement for every facility.

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