Commentary: academic health centers as accountable care organizations

Linkage between theory-based measurement of organizational readiness for change and lessons learned conducting quality improvement-focused research

Organizations have different levels of readiness to implement change in the patient care process. The Hypertension Telemedicine Nurse Implementation Project for Veterans (HTN-IMPROVE) is an example of an innovation that seeks to enhance delivery of care for patients with hypertension. We describe the link between organizational readiness for change (ORC), assessed as the project began, and barriers and facilitators occurring during the process of implementing a primary care innovation. Each of 3 Veterans Affairs medical centers provided a half-time nurse and implemented a nurse-delivered, telephone-based self-management support program for patients with uncontrolled hypertension. As the program was starting, we assessed the ORC and factors associated with ORC. On the basis of consensus of medical center and research partners, we enumerated implementation process barriers and facilitators. The primary ORC barrier was unclear long-term commitment of nursing to provide continued resources to the program. Three related barriers included the need to address: (1) competing organizational demands, (2) differing mechanisms to integrate new interventions into existing workload, and (3) methods for referring patients to disease and self-management support programs. Prior to full implementation, however, stakeholders identified a high level of commitment to conduct nurse-delivered interventions fully using their skills. There was also a significant commitment from the core implementation team and a desire to improve patient outcomes. These facilitators were observed during the implementation of HTN-IMPROVE. As demonstrated by the link between barriers to and facilitators of implementation anticipated though the evaluation of ORC and what was actually observed during the process of implementation, this project demonstrates the practical utility of assessing ORC prior to embarking on the implementation of significant new clinical innovations.

Challenges of becoming a regional referral system: the University of Kentucky as a case study

The U.S. health care system must change because of unsustainable costs and limited access to care. Health care legislation and the recognition that health care costs must be curbed have accelerated the change process. How should academic medical centers (AMCs) respond? Teaching hospitals are a heterogeneous group, and the leaders of each must understand their institution's goals and the necessary resources to achieve them. Clinical leaders and staff at one AMC, the University of Kentucky (UK), committed to transforming the AMC into a regional referral center. To achieve this goal, UK leaders integrated the clinical enterprise, focused recruitment on advanced subspecialists, and initiated productive relationships with other providers. Attracting adequate numbers of destination patients with complex illnesses required UK to have a "market space" of five to seven million people. The resources required to effect such progress have been daunting. Relationships with providers and payers have been necessary to forge a network. These relationships have been challenging to establish and manage and have evolved over time. Most AMCs are not-for-profit public good entities that nevertheless exist in an industry driven by competition in quality and cost, and therefore scale and access to capital are paramount. AMC leaders must understand their institutions as both part of an industry and as a public good in order to adapt to the changing health care system. Although the experience of any particular AMC is inherently unique, UK's journey provides a useful case study in establishing institutional goals, outlining a strategy, and identifying required resources.

Will accountable care organizations deliver greater quality and lower cost health care?

An Accountable Care Organization (ACO) is a voluntary grouping of health care providers that is envisioned to be able to offer high quality care with lower cost than is typically provided in this country. The cost savings achieved by the ACO would be shared between the ACO and the Centers for Medicare and Medicaid Services (CMS). There are a variety of types of ACO's, and there are certain eligibility requirements. There are both benefits and risks to those participating in these ACOs.

Commentary: Personalized health planning and the Patient Protection and Affordable Care Act: an opportunity for academic medicine to lead health care reform

The Patient Protection and Affordable Care Act of 2010 (PPACA) mandates the exploration of new approaches to coordinated health care delivery--such as patient-centered medical homes, accountable care organizations, and disease management programs--in which reimbursement is aligned with desired outcomes. PPACA does not, however, delineate a standardized approach to improve the delivery process or a specific means to quantify performance for value-based reimbursement; these details are left to administrative agencies to develop and implement. The authors propose that coordinated care can be implemented more effectively and performance quantified more accurately by using personalized health planning, which employs individualized strategic health planning and care relevant to the patient's specific needs. Personalized health plans, developed by providers in collaboration with their patients, quantify patients' health and health risks over time, identify strategies to mitigate risks and/or treat disease, deliver personalized care, engage patients in their care, and measure outcomes. Personalized health planning is a core clinical process that can standardize coordinated care approaches while providing the data needed for performance-based reimbursement. The authors argue that academic health centers have a significant opportunity to lead true health care reform by adopting personalized health planning to coordinate care delivery while conducting the research and education necessary to enable its broad clinical application.