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Split Decisions

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Consider the organizations—like Cleveland Clinic and Mayo Clinic—that President Barack Obama and other proponents of healthcare reform have held up in the past year as examples of the way healthcare should be. They are large integrated delivery systems. They employ physicians. They own rehabilitation centers and other points along the care continuum. All of this provides centralized control for linking care from the top down.

A patient enters the Cleveland Clinic system through an outpatient office or family health center. If the patient needs to be hospitalized, there's a regional transfer system that allows the organization "to determine through one point of entry what hospital the patient will be best served at, using a Cleveland Clinic critical care transport team," says Harrison. If the patient needs rehab or skilled nursing services, he or she can go to a facility that is either owned by Cleveland Clinic or staffed with its medical directors. The organization even has a distance health initiative that allows for home monitoring and disease management. It owns or operates every step of the continuum.

But how does a community hospital emulate the coordination of an IDS when it doesn't own the other care facilities, or when its medical staff is composed of multiple independent physician groups?

The Institute for Healthcare Improvement is working to answer that question with its State Action on Avoidable Rehospitalizations program, says Amy Boutwell, MD, MPP, director of health policy strategy at IHI.

Most of the hospitals working with the IHI aren't part of integrated systems, but to get in the door they must form "cross-continuum teams" that include the hospital, patients, family representatives, office practices, hospices, nursing homes, and other postacute providers.

"We're looking at transitions between all of those settings in a continuum relationship," Boutwell says. "The goal is improving processes in each setting, but importantly, the focus and the unit of analysis is the continuum, not just the hospital, not just the office. Every part has a piece to play, but what we're really trying to do is create a system across this continuum team."

A lot of the work is based on process changes—improving communication, developing common forms, setting professional norms, educating providers, and tracking and sharing information. But it begins with leadership, most often from the hospital.

When hospitals can't own the continuum, they have to form partnerships. There's really no right answer for how to handle that. They can staff partner facilities with medical directors, sign exclusive contracts, or just reach out to partner and align goals. The key is for senior leaders to make these partnerships a priority.

"Hospital executives have a choice in who they're closely affiliated with," she says. "As we all move toward more public reporting of readmission rates and various payment reforms, it would be important for hospital executives to think about what they would like to see from their postacute providers and vice versa."

Measuring success
The challenge of linking the care continuum is made more difficult by the general lack of true measures of patient health outcomes.

Sure, hospitals are getting better at measuring processes. Current pay-for-performance programs have established some agreed-upon care processes to ensure that providers are taking the right steps to better care. For instance, cardiologists are measured on whether they provide aspirin to patients presenting with heart problems, and oncologists have guidelines for determining when bone scans and other tests are appropriate.

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