Care integration within and outside health system boundaries

Abstract

Objective Examine care integration—efforts to unify disparate parts of health care organizations to generate synergy across activities occurring within and between them—to understand whether and at which organizational level health systems impact care quality and staff experience. Data Sources Surveys administered to one practice manager (56/59) and up to 26 staff (828/1360) in 59 practice sites within 24 physician organizations within 17 health systems in four states (2017‐2019). Study Design We developed manager and staff surveys to collect data on organizational, social, and clinical process integration, at four organizational levels: practice site, physician organization, health system, and outside health systems. We analyzed data using descriptive statistics and regression. Principal Findings Managers and staff perceived opportunity for improvement across most types of care integration and organizational levels. Managers/staff perceived little variation in care integration across health systems. They perceived better care integration within practice sites than within physician organizations, health systems, and outside health systems—up to 38 percentage points (pp) lower (P < .001) outside health systems compared to within practice sites. Of nine clinical process integration measures, one standard deviation (SD) (7.2‐pp) increase in use of evidence‐based care related to 6.4‐pp and 8.9‐pp increases in perceived quality of care by practice sites and health systems, respectively, and a 4.5‐pp increase in staff job satisfaction; one SD (9.7‐pp) increase in integration of social services and community resources related to a 7.0‐pp increase in perceived quality of care by health systems; one SD (6.9‐pp) increase in patient engagement related to a 6.4‐pp increase in job satisfaction and a 4.6‐pp decrease in burnout; and one SD (10.6‐pp) increase in integration of diabetic eye examinations related to a 5.5‐pp increase in job satisfaction (all P < .05). Conclusions Measures of clinical process integration related to higher staff ratings of quality and experience. Action is needed to improve care integration within and outside health systems.

Social Features of Integration in Health Systems and Their Relationship to Provider Experience, Care Quality and Clinical Integration

“…We used five indexes of functional integration derived from the manager survey for an exploratory moderation analysis. They included functional integration of: colorectal cancer screening and diagnosis, diabetes care management, mental/behavioral health, hospital providers, and patients with complex medical conditions (for index details, see Singer et al, 2020). An example item measuring integration of diabetes care is: "In the last 12 months, has your practice site been engaged in projects to improve quality of diabetes care management?"…”

“…We used five indexes of functional integration derived from the manager survey for an exploratory moderation analysis. They included functional integration of: colorectal cancer screening and diagnosis, diabetes care management, mental/behavioral health, hospital providers, and patients with complex medical conditions (for index details, see Singer et al, 2020). An example item measuring integration of diabetes care is: “In the last 12 months, has your practice site been engaged in projects to improve quality of diabetes care management?” An example item measuring functional integration for patients with complex medical conditions is: “For patients with complex medical or psychosocial conditions, clinicians at your practice all use the same process for collaborating with the patient/family to develop an individual care plan, including treatment goals that are reviewed and updated at each visit.” We calculated the practice average percentage of integrated as the sum of scores for the items comprising each measure divided by the maximum potential score for them.…”

Trade-offs in locational choices for care coordination resources in accountable care organizations

“…All questions used were answered on a 5-point Likert scale where higher score connoted more desirable outcomes. Information sharing across settings was captured using an index applied in past research (Singer et al, 2020), based on the arithmetic mean of five items asking about how difficult it was in the past 12 months for staff in the practice to (a) learn the result of a test your practice site ordered, (b) know that a patient referred by your practice site was seen by the consulting clinician, (c) learn what the consulting clinician recommends for your practice site's patient, (d) transmit relevant information about a patient who your practice site refers to a consulting clinician, and (e) reach the consulting clinician caring for a patient when your staff need to. Knowledge of social service organization referral was based on the item: "When MassHealth members receive referrals to social service organizations, how often is your practice aware that those patients have received support from those organizations?"…”

The dynamics of integration and integrated care

“…Our exploratory research was guided by the work of Singer et al (2020), who define integration "as the making of a unified whole from distinct and interdependent organizational components" characterized by "a set of organizational and social features and courses of action or activities requiring unification that may exist both within and between organizations" (p. 197). We define integrated care as care that is coordinated across professionals, facilities, and support systems and over time and in which patient and family needs, values, and preference are central (Singer et al, 2011).…”

“…Indeed, previous research suggests that structural forms of integration alone do not relate consistently to patient perceptions of integrated care (PPIC; Colla et al, 2020; Kerrissey et al, 2017; Singer et al, 2018). Moreover, scholars have suggested the importance of looking to dynamic factors beyond structural forms of integration as antecedents of integrated care, including organizational behaviors that focus integration efforts (Janse et al, 2016; Ridgely et al, 2020; Singer et al, 2020).…”