Systems Integration

Delivering the right care at the right location in a multi-site care delivery system is a key element of a value-based health care system. To integrate care effectively, providers need to re-define the scope of services at each facility and rationalize the benefit of each site as a component of the whole organization. For instance, high-cost and highly resourced downtown medical campuses may be better suited for complex medical conditions, while regional care centers may be better suited for lower acuity, more routine, and higher volume services. This strategy will allow concentration of volume by medical condition to fewer locations. Numerous studies have shown that technically difficult procedures, such as surgery, radiation therapy, and chemotherapy administration, have been associated with higher morbidity and in some cases mortality in lower volume settings as compared with care received at higher volume facilities. Although volume is not the immediate goal, volume for complex therapies can be a proxy for value and needs to be considered when integrating and rationalizing service lines. Additionally cost needs to be considered since many times regional suburban sites are less expensive than providing the same care in an urban tertiary care facility.

The strategy for regional expansion needs to be based on the essential value principles of achieving the best outcomes at the lowest cost. The best examples of effective regional expansion involves the expansion of the main center’s IPU to the regional facility utilizing teams who work in both locations and who are connected to the IPU through regular meetings and electronically. Use of the same EMR is essential for data sharing and electronically facilitated consultations. A frequently overlooked critical component of an effective regional expansion program is centralized scheduling of patients and clinicians by individuals who know the various IPUs and the system. 

The bottom line of transparency is essential and patients and clinicians must be assured that the outcomes of care are the same no matter where the care is being provided. Care for chronic conditions may be delivered in both types of settings depending on the needs of the patient. For example, in cancer care, initial assessments and initiation of treatment may best be done in the main center and follow up assessment and treatment can be done in a regional facility closer to a patient’s home.

The financial relationships in regional expansion programs has been trending toward increasing use of affiliation agreements and away from full mergers and acquisition of regional facilities by main centers. Regional centers maintain some degree of autonomy yet gain the power of affiliation with a major high volume provider bringing expertise and brand recognition. The key in this type of affiliation is outcome measurement across the system as the ultimate measure of quality of care in the system.

The integration of specialty care IPUs with primary care IPUs in a regional expansion strategy is essential for the success of the expansion program. The most successful expansions effectively and seamlessly integrate primary care with specialty care with a common EMR, shared scheduling, and timely communication of primary care providers and specialists.  The ultimate bottom line of a successful regional expansion is that the right care is provided in the right location with the right group of providers. When that happens, value is achieved and patient satisfaction with the care process is optimized. 

A powerful example of a highly effective value oriented expansion is the Children’s Hospital of Philadelphia system.  They expanded outside of Philadelphia beginning at the turn of the 21st century with the aim to improve the care for all children in the area by providing the right care in the right location. They effectively expanded their main center IPUs to regional care centers and to community hospitals and pediatric practices through affiliations, acquisitions, and building CHOP facilities. They effectively integrated specialty care with specialty IPUs using CHOP personnel, a common EMR, and a common integrated scheduling system. They also provided CHOP care for all children in the region at all times of the day, night and weekends through urgent care centers and a nurse run telephone triage system. They linked the network with their own patient transport system and provided home care services throughout the system.

The Rothman Institute in Philadelphia, a regional orthopedic practice, represents a different type of a value oriented regional expansion. They found that they could provide the same outcomes and significantly reduce cost to selected low risk patients operated on in an ambulatory surgery facility and avoiding the academic medical center downtown.

When the University of Texas MD Anderson Cancer Center expanded regionally, they affiliated with respected providers in the region and leased nearby office space for their outpatient activities. They integrated their care through their robust IPU structure and was able to perform more complex procedures at the main center and permit patients to undergo less intense evaluation and treatment closer to home in the expansive greater Houston area.

In all successful examples of regional expansion of care, the most common elements were an IPU structure that spans the sites, a common EHR, unified scheduling, standardized measurement of outcomes and cost, physician alignment through either employment or affiliation, integrated communication and education, and a common culture.