The goal of integrated care is to deliver coordinated, whole person care – with the aim of improving outcomes for patients and providers. Failing to manage complex conditions and chronically ill patients is often associated with escalating medical concerns, which can lead to increased costs and mortality. Changing the care delivery model in the U.S. is a massive undertaking though, and accounting for the cultural and organizational change required to achieve this can feel overwhelming.
Without understanding where care and skills gaps exist, successful integrated care will not happen. Asking busy providers to heap another task onto their plate without transparency into its necessity or impact is almost guaranteed to fail. Additionally, placing the burden solely on care teams without approaching the necessary structural supports will sputter to a halt.
How to Get There
Integrated care efforts may focus on integration between primary care and behavioral care, or co-locating the delivery of services. With patient health and wellness at the center, whatever mode of delivery enables better outcomes should be promoted.
The following steps are fundamental for integrated care efforts:
1. Identify areas of opportunity
Understanding where to focus efforts and where patients are falling through the cracks, often through the use of a population health management solution, should inform planning for and the delivery of services. Areas of opportunity also include patients who are presenting with chronic or co-existing conditions and experiencing negative outcomes because of a siloed care delivery system.
2. Organize care teams and delivery model
Selecting a delivery model that best serves the population and providers’ capabilities is essential. Considering the needs of both will ensure continued success, as preventing or reducing provider burnout will serve patients and health systems in the long run.
3. Assign team responsibilities and accountability
Identifying who will own the components of care delivery and what processes will support these ensures that each person can own their contribution to better outcomes. Accountability also creates a culture of change by keeping everyone focused on the shared goal.
4. Provide necessary education
New teams and care delivery models will likely stretch providers’ skill sets, and providing them relevant, targeted education ensures they can deliver better outcomes.