Drawing on three decades of experience leading diverse efforts to achieve integrated and higher-value health care, Kenneth W. Kizer, distinguished professor and director of the UC Davis Institute for Population Health Improvement, identified nine key “lessons learned” about health-care integration based on efforts in California and nationally.
Kizer highlighted the lessons during his keynote address to the 14th International Integrated Care Conference in Brussels, Belgium, on April 4, an event that drew health-care leaders and representatives from some 20 countries and four continents.
“Advances in the biomedical sciences and population aging have resulted in the business of health care in developed and many developing nations becoming primarily one of managing chronic health conditions,” Kizer said. “The majority of patients aged 65 and older in the U.S. and many other countries have four or more chronic health conditions and typically need the services of seven or more health-care providers over the course of a year. However, the services that these caregivers provide are too often uncoordinated and not connected in a predictable and consistent manner, resulting in disjointed service delivery, unnecessary redundant testing, medical errors, dissatisfaction with care and substantially increased costs.”
To better integrate health care services, Kizer identified the following nine precepts:
1. Achieving integrated care first and foremost requires changing health-care culture and how clinicians think about care delivery.
“It’s more about sociology than technology,” Kizer said “When care is truly integrated, unplanned hospital admissions or readmissions for many chronic conditions should be viewed as system failures since such events should be largely predictable and preventable. Indeed, we should view hospitals as cost centers instead of revenue centers.” He also noted a number of new competencies that are needed to achieve integrated care, including systems thinking, quality improvement and quality management, big data analytics, population health management, teamwork skills and an understanding of complexity theory.
2. There is no single, universal organizational model that will achieve integrated care, but certain core functionalities are critical regardless of the model.
Using the VA Healthcare System in the early 1990s as an example, Kizer illustrated how an administratively and financially integrated health care system may not be clinically integrated and, despite its structure, not provide integrated patient care.
“Integrated delivery systems come in many forms and sizes, but those that are successful all follow a number of critical guiding principles and demonstrate certain core functionalities. Some of those core functionalities include having a commonly shared vision of health-care service delivery, widely understood clinical objectives and goals, information management tools and other supporting infrastructure, team-based care, a performance management system, and shared financial risks and rewards for clinical outcomes,” he said.
3. Financial payment methods must align with and support the desired outcomes, which can be achieved in multiple ways.
“California has been a robust laboratory for integrated care payment models over the past 20 years,” he said. “And removing financial disincentives to providing integrated care may be as important, or even more important, than providing positive financial incentives.”
4. Strong and respected clinical leadership is essential for achieving clinical integration.
Among the many things that effective clinical leaders do are to promote and maintain focus on the vision of integrated care over the long term, be a bridge between the boardroom and front-line caregivers, build and maintain trust with stakeholders, prioritize goals and objectives, harmonize competing needs, nurture a culture of collaboration and continuous improvement, and create an environment that supports innovation and learning.
5. Achieving integrated care requires an enabling information management and administrative infrastructure, but to be optimally effective these must be embedded in a culture of collaboration and continuous improvement.
Among other things, Kizer believes an enabling integrated care infrastructure must include information management and knowledge transfer tools such as electronic health records, patient registries and clinical decision support systems; clinical guidelines and care management protocols; policies and procedures for coordinating care across conditions, providers, settings and time; a performance management system that includes standardized performance measures, routine care review mechanisms and feedback to frontline caregivers; education and training for new skills development; and patient engagement mechanisms, including shared decision making.
6. Clinical care delivery assets in most health-care organizations will need to be significantly restructured to provide integrated care.
“In most cases this will mean more community-based and less hospital capacity,” he said. He recounted that during the five years he led the VA Healthcare System in the late 1990s, some 29,000 or 55 percent of hospital beds were closed, more than 300 new community-based clinics were opened, the number of hospital admissions dropped by more than 350,000 per year and bed days of care per 1,000 patients dropped by 68 percent.
7. Vigilance for unintended consequences must be designed into the health-care system and its change processes.
Health-care systems operate like complex adaptive systems in that health care is nonlinear and its process changes cannot be specified and controlled with the same precision as can be done with more linear processes like manufacturing. For these and other reasons, there always will be unintended consequences.
"Achieving change in health care requires that critical change levers be identified and then small changes in these critical levers be leveraged to produce the desired outcomes,” Kizer said. “Critical change levers for modern health care include payment methods, performance management and regulation or, often, removal of regulations.”
8. A strategic communications plan is necessary and integral to the change process.
“An essential but often overlooked element in achieving integrated care is a strategic communications plan,” Kizer said. “Such a plan must have a clearly defined message, be health literate and culturally appropriate, use both conventional and unconventional methods of communication and address the challenges of reaching the 24/7/365 health-care workforce. Experience has shown that physicians and nurses are usually viewed as the most credible messengers for communicating the plan’s key messages.”
9. Know that it almost always takes longer and is harder than expected to achieve desired outcomes.
”The role of technology in facilitating change is almost always overestimated, and bringing people along is what takes the most time and involves the most work.”
Currently, Kizer and the UC Davis Institute for Population Health Improvement have a number of projects under way aimed at achieving more integrated care in California. Among other things, Kizer’s past efforts in this regard include pioneering managed care in California’s Medical Assistance Program (Medi-Cal) in the 1980s when he was the state’s health director, engineering the transformation of the Veterans Health Care System in the 1990s, and founding the National Quality Forum to articulate a national strategy and performance measures for higher quality and more integrated health care.
The annual International Integrated Care Conferences are organized by the International Foundation for Integrated Care with financial support from the Kings Fund in the United Kingdom, industry sponsors and other organizations.