Just how integrated are integrated delivery systems? Results from a national survey

Horizontal and Vertical Integration of Health Care Providers: A Framework for Understanding Various Provider Organizational Structures

INTRODUCTION

Current U.S. policy and payment initiatives aim to encourage health care provider accountability for population health and higher value care, resulting in efforts to integrate providers along the continuum. Providers work together through diverse organizational structures, yet evidence is limited regarding how to best organize the delivery system to achieve higher value care.

METHODS

In 2016, we conducted a narrative review of 10 years of literature to identify definitional components of key organizational structures in the United States. A clear accounting of common organizational structures is foundational for understanding the system attributes that are associated with higher value care.

RESULTS

We distinguish between structures characterized by the horizontal integration of providers delivering similar services and the vertical integration of providers fulfilling different functions along the care continuum. We characterize these structures in terms of their origins, included providers and services, care management functions, and governance.

CONCLUSIONS AND DISCUSSION

Increasingly, U.S. policymakers seek to promote provider integration and coordination. Emerging evidence suggests that organizational structures, composition, and other characteristics influence cost and quality performance. Given current efforts to reform the U.S. delivery system, future research should seek to systematically examine the role of organizational structure in cost and quality outcomes.

Organizational Capabilities for Integrating Care: A Review of Measurement Tools

The success of integrated care interventions is highly dependent on the internal and collective capabilities of the organizations in which they are implemented. Yet, organizational capabilities are rarely described, understood, or measured with sufficient depth and breadth in empirical studies or in practice. Assessing these capabilities can contribute to understanding why some integrated care interventions are more effective than others. We identified, organized, and assessed survey instruments that measure the internal and collective organizational capabilities required for integrated care delivery. We conducted an expert consultation and searched Medline and Google Scholar databases for survey instruments measuring factors outlined in the Context and Capabilities for Integrating Care Framework. A total of 58 instruments were included in the review and assessed based on their psychometric properties, practical considerations, and applicability to integrated care efforts. This study provides a bank of psychometrically sound instruments for describing and comparing organizational capabilities. Greater use of these instruments across integrated care interventions and studies can enhance standardized comparative analyses and inform change management. Further research is needed to build an evidence base for these instruments and to explore the associations between organizational capabilities and integrated care processes and outcomes.

Organizational Context and Capabilities for Integrating Care: A Framework for Improvement

Background:

Interventions aimed at integrating care have become widespread in healthcare; however, there is significant variability in their success. Differences in organizational contexts and associated capabilities may be responsible for some of this variability.

Purpose:

This study develops and validates a conceptual framework of organizational capabilities for integrating care, identifies which of these capabilities may be most important, and explores the mechanisms by which they influence integrated care efforts.

Methods:

The Context and Capabilities for Integrating Care (CCIC) Framework was developed through a literature review, and revised and validated through interviews with leaders and care providers engaged in integrated care networks in Ontario, Canada. Interviews involved open-ended questions and graphic elicitation. Quantitative content analysis was used to summarize the data.

Results:

The CCIC Framework consists of eighteen organizational factors in three categories: Basic Structures, People and Values, and Key Processes. The three most important capabilities shaping the capacity of organizations to implement integrated care interventions include Leadership Approach, Clinician Engagement and Leadership, and Readiness for Change. The majority of hypothesized relationships among organizational capabilities involved Readiness for Change and Partnering, emphasizing the complexity, interrelatedness and importance of these two factors to integrated care efforts.

Conclusions:

Organizational leaders can use the framework to determine readiness to integrate care, develop targeted change management strategies, and select appropriate partners with overlapping or complementary profiles on key capabilities. Researchers may use the results to test and refine the proposed framework, with a focus on the hypothesized relationships among organizational capabilities and between organizational capabilities and performance outcomes.

The Adoption of Innovations by Provider Organizations in Health Care

Innovations in health care account for some of the most dramatic improvements in population health outcomes in the developed world as well as for a nontrivial proportion of growth in expenditures. Provider organizations are the adopters of many of these innovations, and understanding the factors that inhibit or facilitate their diffusion to and possible disengagement from these organizations is important in addressing cost, quality, and access issues. Given the importance of these issues, the purpose of this article is to (1) create a comprehensive census of studies examining the adoption of and disengagement from innovations in health care provider organizations; (2) organize these studies into an inductively derived classification scheme; (3) assess the studies' strengths and weaknesses; and (4) reflect on the implications of our review for future research.

Do integrated care structures foster processes of integration? A quasi-experimental study in frail elderly care from the professional perspective

OBJECTIVE

This study explores the processes of integration that are assumed to underlie integrated care delivery.

DESIGN

A quasi-experimental design with a control group was used; a new instrument was developed to measure integration from the professional perspective.

SETTING AND PARTICIPANTS

Professionals from primary care practices and home-care organizations delivering care to the frail elderly in the Walcheren region of the Netherlands.

INTERVENTION

An integrated care intervention specifically targeting frail elderly patients was implemented.

MAIN OUTCOME MEASURES

Structural, cultural, social and strategic integration and satisfaction with integration.

RESULTS

The intervention significantly improved structural, cultural and social integration, agreement on goals, interests, power and resources and satisfaction with integration.

CONCLUSIONS

This study confirms that integrated care structures foster processes of integration among professionals.

TRIAL REGISTRATION

Current Controlled Trials ISRCTN05748494.

Indicators and measurement tools for health system integration: a knowledge synthesis protocol

BACKGROUND

Health system integration is a key component of health system reform with the goal of improving outcomes for patients, providers, and the health system. Although health systems continue to strive for better integration, current delivery of health services continues to be fragmented. A key gap in the literature is the lack of information on what successful integration looks like and how to measure achievement towards an integrated system. This multi-site study protocol builds on a prior knowledge synthesis completed by two of the primary investigators which identified 10 key principles that collectively support health system integration. The aim is to answer two research questions: What are appropriate indicators for each of the 10 key integration principles developed in our previous knowledge synthesis and what measurement tools are used to measure these indicators? To enhance generalizability of the findings, a partnership between Canada and Brazil was created as health system integration is a priority in both countries and they share similar contexts.

METHODS/DESIGN

This knowledge synthesis will follow an iterative scoping review process with emerging information from knowledge-user engagement leading to the refinement of research questions and study selection. This paper describes the methods for each phase of the study. Research questions were developed with stakeholder input. Indicator identification and prioritization will utilize a modified Delphi method and patient/user focus groups. Based on priority indicators, a search of the literature will be completed and studies screened for inclusion. Quality appraisal of relevant studies will be completed prior to data extraction. Results will be used to develop recommendations and key messages to be presented through integrated and end-of-grant knowledge translation strategies with researchers and knowledge-users from the three jurisdictions.

DISCUSSION

This project will directly benefit policy and decision-makers by providing an easy accessible set of indicators and tools to measure health system integration across different contexts and cultures. Being able to evaluate the success of integration strategies and initiatives will lead to better health system design and improved health outcomes for patients.

Is the system really the solution? Operating costs in hospital systems

Hospital system formation has recently accelerated. Executives emphasize scale economies that lower operating costs, a claim unsupported in academic research. Do systems achieve lower costs than freestanding facilities, and, if so, which system types? We test hypotheses about the relationship of cost with membership in systems, larger systems, and centralized and local hub-and-spoke systems. We also test whether these relationships have changed over time. Examining 4,000 U.S. hospitals during 1998 to 2010, we find no evidence that system members exhibit lower costs. However, members of smaller systems are lower cost than larger systems, and hospitals in centralized systems are lower cost than everyone else. There is no evidence that the system's spatial configuration is associated with cost, although national system hospitals exhibit higher costs. Finally, these results hold over time. We conclude that while systems in general may not be the solution to lower costs, some types of systems are.

The evolution of integrated health care strategies

PURPOSE

To examine the evolution of health care integration strategies and associated conceptualization and practice through a review and synthesis of over 25 years of international academic research and literature.

METHODS

A search of the health sciences literature was conducted using PubMed and EMBASE. A total of 114 articles were identified for inclusion and thematically analyzed using a strategy content model for systems-level integration.

FINDINGS

Six major, inter-related shifts in integration strategies were identified: (1) from a focus on horizontal integration to an emphasis on vertical integration; (2) from acute care and institution-centered models of integration to a broader focus on community-based health and social services; (3) from economic arguments for integration to an emphasis on improving quality of care and creating value; (4) from evaluations of integration using an organizational perspective to an emerging interest in patient-centered measures; (5) from a focus on modifying organizational and environmental structures to an emphasis on changing ways of working and influencing underlying cultural attitudes and norms; and (6) from integration for all patients within defined regions to a strategic focus on integrating care for specific populations. We propose that underlying many of these shifts is a growing recognition of the value of understanding health care delivery and integration as processes situated in Complex-Adaptive Systems (CAS).

ORIGINALITY/VALUE

This review builds a descriptive framework against which to assess, compare, and track integration strategies over time.

The changing configuration of hospital systems: centralization, federalization, or fragmentation?

PURPOSE

Research on hospital system organization is dated and cross-sectional. We analyze trends in system structure during 2000-2010 to ascertain whether they have become more centralized or decentralized.

DESIGN/METHODOLOGY/APPROACH

We test hypotheses drawn from organization theory and estimate empirical models to study the structural transitions that systems make between different "clusters" defined by the American Hospital Association.

FINDINGS

There is a clear trend toward system fragmentation during most of this period, with a small recent shift to centralization in some systems. Systems decentralize as they increase their members and geographic dispersion. This is particularly true for systems that span multiple states; it is less true for smaller regional systems and local systems that adopt a hub-and-spoke configuration around a teaching hospital.

RESEARCH LIMITATIONS

Our time series ends in 2010 just as health care reform was implemented. We also rely on a single measure of system centralization.

RESEARCH IMPLICATIONS

Systems that appear to be able to centrally coordinate their services are those that operate in local or regional markets. Larger systems that span several states are likely to decentralize or fragment.

PRACTICAL IMPLICATIONS

System fragmentation may thwart policy aims pursued in health care reform. The potential of Accountable Care Organizations rests on their ability to coordinate multiple providers via centralized governance. Hospitals systems are likely to be central players in many ACOs, but may lack the necessary coherence to effectively play this governance role.

ORIGINALITY/VALUE

Not all hospital systems act in a systemic manner. Those systems that are centralized (and presumably capable of acting in concerted fashion) are in the minority and have declined in prevalence over most of the past decade.

A pilot evaluation of the Family Caregiver Support Program

The purposes of this study were to evaluate a federal and state-funded Family Caregiver Support Program (FCSP) and explore what types of caregiver support service are associated with what caregiver outcomes. Information was obtained on a sample of 164 caregivers' use of eleven different types of support service. Descriptive and comparative analyses were used to detect the differences between users and nonusers of caregiver support services. Six measures included were caregiving appraisal scale, caregiving burden, caregiving mastery, caregiving satisfaction, hour of care, and service satisfaction. Using consulting and education services is associated with lessening of subjective burden; using financial support services is associated with more beneficial caregiver appraisal, such as better caregiver mastery. The findings are practical and helpful for future caregiver service and program development and evaluation and policy making for supporting caregivers. In addition, the evaluation method demonstrated in the study provided a simple and moderately effective method for service agencies which would like to evaluate their family caregiver support services.

Is the Kaiser Permanente model superior in terms of clinical integration?: a comparative study of Kaiser Permanente, Northern California and the Danish healthcare system

BACKGROUND

Integration of medical care across clinicians and settings could enhance the quality of care for patients. To date, there is limited data on the levels of integration in practice. Our objective was to compare primary care clinicians' perceptions of clinical integration and three sub-aspects in two healthcare systems: Kaiser Permanente, Northern California (KPNC) and the Danish healthcare system (DHS). Further, we examined the associations between specific organizational factors and clinical integration within each system.

METHODS

Comparable questionnaires were sent to a random sample of primary care clinicians in KPNC (n = 1103) and general practitioners in DHS (n = 700). Data were analysed using multiple logistic regression models.

RESULTS

More clinicians in KPNC perceived to be part of a clinical integrated environment than did general practitioners in the DHS (OR = 3.06, 95% CI: 2.28, 4.12). Further, more KPNC clinicians reported timeliness of information transfer (OR = 2.25, 95% CI: 1.62, 3.13), agreement on roles and responsibilities (OR = 1.79, 95% CI: 1.30, 2.47) and established coordination mechanisms in place to ensure effective handoffs (OR = 6.80, 95% CI: 4.60, 10.06). None of the considered organizational factors in the sub-country analysis explained a substantial proportion of the variation in clinical integration.

CONCLUSIONS

More primary care clinicians in KPNC reported clinical integration than did general practitioners in the DHS. Focused measures of clinical integration are needed to develop the field of clinical integration and to create the scientific foundation to guide managers searching for evidence based approaches.

Ten key principles for successful health systems integration

Integrated health systems are considered part of the solution to the challenge of sustaining Canada's healthcare system. This systematic literature review was undertaken to guide decision-makers and others to plan for and implement integrated health systems. This review identified 10 universal principles of successfully integrated healthcare systems that may be used by decision-makers to assist with integration efforts. These principles define key areas for restructuring and allow organizational flexibility and adaptation to local context. The literature does not contain a one-size-fits-all model or process for successful integration, nor is there a firm empirical foundation for specific integration strategies and processes.

Measurement of integrated healthcare delivery: a systematic review of methods and future research directions

BACKGROUND

Integrated healthcare delivery is a policy goal of healthcare systems. There is no consensus on how to measure the concept, which makes it difficult to monitor progress.

PURPOSE

To identify the different types of methods used to measure integrated healthcare delivery with emphasis on structural, cultural and process aspects.

METHODS

Medline/Pubmed, EMBASE, Web of Science, Cochrane Library, WHOLIS, and conventional internet search engines were systematically searched for methods to measure integrated healthcare delivery (published - April 2008).

RESULTS

Twenty-four published scientific papers and documents met the inclusion criteria. In the 24 references we identified 24 different measurement methods; however, 5 methods shared theoretical framework. The methods can be categorized according to type of data source: a) questionnaire survey data, b) automated register data, or c) mixed data sources. The variety of concepts measured reflects the significant conceptual diversity within the field, and most methods lack information regarding validity and reliability.

CONCLUSION

Several methods have been developed to measure integrated healthcare delivery; 24 methods are available and some are highly developed. The objective governs the method best used. Criteria for sound measures are suggested and further developments should be based on an explicit conceptual framework and focus on simplifying and validating existing methods.

Hospital-physician collaboration: landscape of economic integration and impact on clinical integration

CONTEXT

Hospital-physician relationships (HPRs) are an important area of academic research, given their impact on hospitals' financial success. HPRs also are at the center of several federal policy proposals such as gain sharing, bundled payments, and pay-for-performance (P4P).

METHODS

This article analyzes the HPRs that focus on the economic integration of hospitals and physicians and the goals that HPRs are designed to achieve. It then reviews the literature on the impact of HPRs on cost, quality, and clinical integration.

FINDINGS

The goals of the two parties in HPRs overlap only partly, and their primary aim is not reducing cost or improving quality. The evidence base for the impact of many models of economic integration is either weak or nonexistent, with only a few models of economic integration having robust effects. The relationship between economic and clinical integration also is weak and inconsistent. There are several possible reasons for this weak linkage and many barriers to further integration between hospitals and physicians.

CONCLUSIONS

Successful HPRs may require better financial conditions for physicians, internal changes to clinical operations, application of behavioral skills to the management of HPRs, changes in how providers are paid, and systemic changes encompassing several types of integration simultaneously.

Partnership--success factors of interorganizational relationships

AIM

Key factors of successful interorganizational partnerships are applied to the context of nursing and midwifery education.

BACKGROUND

Reports in nursing education emphasize the need for more collaborative partnerships between the education and healthcare sectors of nursing and midwifery education.

EVALUATION

There is little research examining the implementation of interorganizational relationships particularly in nursing.

KEY ISSUES

Key success factors are grouped into seven areas of trust and valuing the partner, leadership and managing change, a partnership framework, communication and interaction, equity and involvement in decision making, power and the role of partnership coordinator.

CONCLUSION

There is a need for contextual research in relation to implementing partnership in nursing and midwifery.

IMPLICATIONS FOR NURSING MANAGEMENT

Partnership arrangements are essential for quality nursing and midwifery education. This article adds knowledge by way of application of these factors to organizations that provide nursing and midwifery education. Nurse managers have an important role in determining the quality of learning experience within the health service. It is essential, therefore that both nurse managers and nurse educationalist know the key factors which promote successful interoganizational relationships to ensure these factors are manifest in practice.

Learning to cross boundaries: The integration of a health network to deliver seamless care

We analysed the development of an integrated network from a learning perspective to see how care givers from different organisations were able to cross the professional and organisational boundaries that existed between them to make sure patients receive the right care, at the right moment, in the right place. We show how through a process of collective learning social contacts between health professionals increased and improved. These professionals learned to speak each other's language, learned how other professionals and organisations work and learned to look at the care process from a network perspective instead of only from a professional or organisational perspective. Through this learning process, they also experienced the limitations of standardizing knowledge in criteria, protocols and rules, and the value of direct contact for sharing information and knowledge, to ensure continuity in care.

Physician involvement in setting priorities for health regions

Although many authors have emphasized the importance of including physicians in organizational activities, especially in integrated delivery systems, much of the literature has focused on physician involvement in governance or as managers. In this paper, program budgeting and marginal analysis (PBMA) is suggested as a mechanism to link physicians into organizational decision-making processes. This research included a wide range of examples that demonstrate the versatility of PBMA, and many ways to involve physicians.

Hospital-physician affiliations and patient treatments, expenditures, and outcomes

OBJECTIVE

To determine the relationship between hospital-physician affiliations and the treatments, expenditures, and outcomes of patients.

DATA SOURCES

Sources include the Medicare Provider Analysis and Review dataset, the American Hospital Association (AHA) Annual Survey, and the Area Resource File (ARF).

STUDY DESIGN

A multivariate regression analysis of the relationship between hospital-physician affiliations (such as physician-hospital organizations [PHOs] or salaried employment) and the treatment of Medicare patients with a diagnosis of acute myocardial infarction admitted to general medical-surgical hospitals between 1994 and 1998. Dependent variables include whether the patient received a catheterization or angioplasty or bypass surgery; whether a patient was readmitted, or died within 90 days of initial admission; and expenditures. Independent variables include patient, admission hospital, and market characteristics, as well as hospital and year fixed effects.

PRINCIPAL FINDINGS

The integrated salary model form of hospital-physician affiliation is associated with slightly higher procedure rates, and higher patient expenditures. At the same time, there is little evidence that hospital-physician affiliations in the aggregate have had any measurable impact on patient treatment or outcomes.

CONCLUSIONS

The limited effect of hospital-physician affiliations on patient outcomes is consistent with previous research showing that affiliations have not much changed the nature of health care delivery. However, the finding that the integrated salary model is associated with higher treatment intensity suggests that affiliations may have had some impact on patients, and could have more in the future.

Integrated delivery networks: a detour on the road to integrated health care?

This paper reviews the rationales and evidence for horizontal and vertical integration involving hospitals. We find a disjunction between the integration rationales espoused by providers and those cited in the academic literature. We also generally find that integration fails to improve hospitals' economic performance. We offer seven lessons from hospitals' efforts to integrate and then suggest four alternative models for achieving integrated delivery of health care services.

Integrated health systems: success or failure?

There continues to be an increasing number of healthcare delivery systems as a result of marketplace changes that include declining reimbursement and increasing costs for healthcare. However, the majority of these systems fail. Failures are a consequence of poor management, lack of a common mission and business rationale, individual's interests that outweigh the entity's interests, and the conflict of cultures. Incremental changes will continue, but the healthcare environment will remain unstable for the foreseeable future.