Integrating Health Care for the Most Vulnerable: Bridging the Differences in Organizational Cultures Between US Hospitals and Community Health Centers

Abstract

Policymakers have increasingly promoted health services integration to improve quality and efficiency. The US health care safety net, which comprises providers of health care to uninsured, Medicaid, and other vulnerable patients, remains a largely fragmented collection of providers. We interviewed leadership from safety net hospitals and community health centers in 5 US cities (Boston, MA; Denver, CO; Los Angeles, CA; Minneapolis, MN; and San Francisco, CA) throughout 2013 on their experiences with service integration. We identify conflicts in organizational mission, identity, and consumer orientation that have fostered reluctance to enter into collaborative arrangements. We describe how smaller scale initiatives, such as capitated model for targeted populations, health information exchange, and quality improvements led by health plans, can help bridge cultural differences to lay the groundwork for developing integrated care programs.

Referral to an Acute Child and Adolescent Inpatient Unit: The Experiences and Views of Community Mental Health Referrers

“…There is evidence supporting aspects of this picture as an ideal to be strived for, particularly with respect to communication and collaboration (Ko et al, 2015;Leonard & Frankel, 2011;Weller et al, 2014). The finding that participants varied widely in how much they valued the different genres of communication is consistent with studies of communication within hospitals (Conn et al, 2009).…”

Federally Qualified Health Center Strategies for Integrating Care with Hospitals and Their Association with Measures of Communication

“…Prior case studies of health center/hospital collaborations note that the involvement of a health plan, an ACO contract, or a capitated payment model was a key driver of greater collaboration between health centers and hospitals. 17 The spread of ACO models in state Medicaid programs provides new incentives for health centers to work with partners to improve the health and reduce excess spending for their attributed populations. States have implemented ACO models in which health plans or even entire regions are the primary unit of accountability, which may be more compatible with health center governance requirements.…”

“…Second, while health centers are focused on providing comprehensive primary care for primarily indigent populations, hospitals generally serve a more economically diverse population. 17 These distinct patient populations may cause hospitals and health centers to prioritize different goals. 10,16 In addition, their orientation toward preventive care and acute care, respectively, may result in misaligned financial incentives between health centers and hospitals when both participate together in risk-based payment arrangements.…”

“…Finally, health centers and hospitals may not have the infrastructure or resources to participate in costly initiatives designed to improve care such as health information exchange (HIE) or hiring care coordination staff. 16,17 Although health centers were early adopters of EHRs, the lack of a shared EHR platform or the limited ability to exchange clinical data can pose a barrier to coordination between health centers and hospitals given the importance of timely data for post-discharge care planning. [18][19][20] In the face of these potential barriers, little is known about the prevalence of different care integration strategies used by health centers and how these strategies are affecting the delivery of care.…”

Possible consequences of regionally based bundled payments for diabetic amputations for safety net hospitals in Texas

“…Solutions to this disparity have ranged from improvements in risk adjustment to calls for better care coordination at safety net hospitals, and the debate to these challenges continues at present. 13,[30][31][32][33] A recent Cochrane review noted that despite flaws in the trials themselves, complex care interventions can markedly reduce amputation rates in diabetic patients. 34 Because of the goal to shift 85% of CMS reimbursements to quality-based payments, we would suggest not including uncommon, high-risk procedures in bundled payment models without well-established risk-modification strategies.…”