To deliver more value, providers need to focus on deepening their expertise, and expanding their ability to serve the complex and interrelated needs of each patient over the full cycle of care. The greatest improvements in health care outcomes and efficiency will come from sustained, team-based focus on a carefully defined set of medically integrated services and practices. Care must be organized around medical conditions over the full cycle of care and delivered in integrated practice units (IPUs). Integrated practice units will achieve scope and scale by growing locally and geographically in their areas of strength.
PRIMARY CARE: In primary and preventative care, the unit of organization are segments of the population with clearly defined needs such as healthy adults, patients with acute illnesses, elderly, women, and patients with chronic diseases.
SPECIALTY CARE: In specialty and subspecialty care, a medical condition is best defined from the patient’s perspective and represents either an acute or chronic disease process that may require management by multiple clinicians representing different specialties and types of providers and support personnel. Care for a medical condition involves management of that patient for the entire cycle of care for that condition and often includes management of common co-morbid conditions and complications of treatment. Typical medical conditions are diabetes, hypertension, coronary artery disease, osteoarthritis, pregnancy, breast cancer, etc.
INTEGRATED PRACTICE UNITS: Teams working in integrated practice units or IPUs provide care in both primary care and specialty care. Care delivery in the IPU model is organized around the medical condition or around groups of related conditions. For example, for patients with breast cancer, care is best delivered in an integrated practice unit that brings together clinicians and support teams and services that all manage aspects of breast cancer over the full cycle of care. This would be surgical oncologists, medical oncologists, radiation oncologists, reconstructive surgeons, pathologists, and radiologists. Specialized nurses, pharmacists, social workers, and nutritionists all who focus on the care of the patient with breast cancer, would support them. Ideally, they would be co-located in a single breast cancer center with unified scheduling and coordinated after hours care.
Some conditions occur infrequently but represent patients with similar needs who are also best treated in the IPU model. An example would be children born with heart defects. While these children have differing anatomical defects resulting in differing physiology and different treatments, what they have in common are that they have congenital heart disease and are best managed in an IPU that focuses on the care of all of these children with cardiac surgeons, cardiologists, anesthesiologists, intensivists all of whom are supported by specialized nurses, perfusionists, respiratory therapists, social workers and others who have accumulated vast experience caring for children with these problems.
For each condition, there is a cycle of care that generally progresses from prevention through early detection, diagnosis, treatment, recovery and rehabilitation through long-term sustainability of health. While that cycle of care differs from condition to condition, there are some common themes such as who engages with the patients in the various stages, what is measured to assess success, and the other resources needed by the patient throughout the care cycle.
In organizing care in integrated practice units there are 10 essential elements that lead to the best results:
- 1. Care is organized around a medical condition or group of closely related conditions over the full cycle of care. In primary care delivery is organized around well-defined patient segments
- 2. Care includes common co-occurring conditions and complications
- 3. A dedicated, multidisciplinary team devoting a significant portion of their time to the condition delivers care. IPUs can involve affiliated staff and integration with partner services
- 4. Care is ideally co-located in dedicated facilities. A hub and spoke structure connecting multiple or affiliated sites, incorporating telemedicine where appropriate
- 5. Optimize the location of care across services
- 6. Patient education, engagement, adherence, follow-up, and prevention are integrated into the care process
- 7. A physician team captain, clinical care manager, or both oversees each patient’s care
- 8. IPUs have a clear clinical leader, a common scheduling and intake process, and unified financial structure which ideally is a unified profit and loss statement
- 9. IPUs routinely measure outcomes, costs, care processes, and patient experience using a common platform, and accept joint accountability for results
- 10. The team regularly meets formally and informally to discuss individual patient care plans, and process improvements aimed to improve results and control cost
In designing an IPU there are a number of additional essential elements that represent the software of IPUs. From a design perspective, there needs to be co-location of essential people and services with a dedicated IPU leadership team. Patient and clinician scheduling is critical to success. The processes of care need to be well defined and mapped accurately. Whenever possible standard care processes need to be followed. It is especially important to have standardized handoffs and other communication rituals with clear timelines and measures of progress.
One of the most important aspects of an effective IPU are regular multidisciplinary case reviews of patients to determine treatment plans and care coordination. Effective communication and collaboration with individuals outside the IPU are also essential. Integrating the primary care team and other outside specialists will lead to further success of the IPU. In addition to these treatment-planning meetings, other meetings are essential. Reviews of difficult patients should be a regular event in addition to morbidity and mortality conferences for the most serious of cases. Outcomes of care should be reviewed on a regular basis with transparent information about team performance and individual performance in multidimensional outcomes. Lastly, educational sessions need to be held regularly with new findings from the literature and reports of scientific meetings. These sessions insure that all team members remain current with new science as well as providing an opportunity to innovate care based on new developments in the management of the condition treated in a particular IPU.
In addition to a focus on outcomes and ways to improve outcomes, the IPU needs to have a focus on costs of care delivery and needs to regularly review the costs of the processes of care being utilized. This is best accomplished by regularly reporting care delivery costs to the team and thinking of ways to control cost. Each IPU should have its own profit and loss statement whose results are owned by the team. Team compensation should also be based on value and not volume of services provided.
One of the benefits of the IPU model is that it allows teams to develop deep expertise in treating a single condition or group of conditions. There is a well-recognized relationship between volume of cases treated and the health outcomes achieved. While early studies of the volume outcome relationship suggested that it was the volume of a single provider, like a surgeon, who had large volume and better outcomes, more recent research has found that the volume outcome relationship results from specialized teams who see higher volumes of specific conditions that leads to better outcomes. A well run integrated practice unit accululates more and more experience leading to better teams, more efficient care, sub-specialization, faster innovation, better outcomes, enhanced reputation and ultimately more volume of patients to effectively create more value over time.
Sources: Harvard Business School, Institute for Strategy and Competitiveness, https://www.isc.hbs.edu/health-care/value-based-health-care/key-concepts/Pages/organize-care-around-condition.aspx#:~:text=Care%20is%20organized%20around%20a,co%2Doccurring%20conditions%20and%20complications