Beyond
y
Coordination:
Integrated Patient Care
Sara Singer, Mark Friedberg, Jako
Burgers, Lucian Leape, Meredith
Rosenthal, Eric Schneider
AcademyHealth Annual Research Meeting
Boston MA ● June 29
Boston,
29, 2010
Financial support was provided by the Health Policy and Management
Department, HSPH, the Lucian Leape Foundation, and
Kaiser Permanente Institute for Health Policy
1
Responding to the need for
greater integration
Condition

More patients with complex
chronic
h i conditions
diti

More specialization of
providers and fragmentation
of patient information

Need to accommodate
patient’s
patient
s needs, social
environments, and
preferences
Response

Organizational
t
transformation
f
ti (e.g.,
(
PCMH/ACOs)

Leadership and
management that
addresses cultural as well
as technical requirements

Feedback about current
models of care delivery
and effect of changes
2
Objectives




Present a conceptual framework for defining
and measuring “integrated
integrated patient care”
care
Describe survey development and pilot
testing
Present preliminary findings
Discuss implications for research and
practice
3
Integration in organizational
theory & health services research

Organizational theory has highlighted:


The need for more integration as organizations
differentiate (Lawrence & Lorsch 1969) and for various
coordinating mechanisms to address different
forms of interdependence (Thompson 1967)
Multiple objects to which integration may refer
(Shortell et al. 1996)

HSR has primarily linked integrated organizational
forms or functions to better performance (Shortell et al.
1994, Tollen 2008, Rodriguez et al. 2009, Solberg et al. 2009, Coleman et
al.l 2009
2009, H
Homer et al.
l 2008)
4
Conceptual model
Integrated
organizations
and activities


?
Integrated
patient care
?
Improved outcomes
and costs for
patients with
complex chronic
conditions
Assumes a distinction between objects of integration
Agnostic to the degree of integration that
characterize the underlying organizational structure
and activities
5
Defining integrated patient
care: not just coordination


“Integration” frequently describes attempts to
achieve better coordination of services
Where patient care is the object of
i t
integration,
ti
its
it definition
d fi iti mustt accountt for
f the
th
role of the patient
Propose that integrated patient care =
coordinated + p
patient-centered care
6
Definition and framework for
measuring IPC

Coordination



Coordinated across professionals, facilities,
facilities and
support systems
Continuous over time and between visits
Patient-centeredness


Tailored
T
il d to patients’
i
’ needs
d and
d preferences
f
Based on shared responsibility between patient
and caregivers
7
Survey development, pilot, and
evaluation

Consulted prior surveys and expert panel and
adapted and added items to fill gaps



Piloted survey Feb-May 2010
 Random
R d
sample
l off up tto 100 patients
ti t iin 13
clinics from one health system


Integration not only by primary doctor and within
primary doctor’s office
Administrative matters that reflect integration
528 respondents (43%)
Psychometric assessment and preliminary results
8
Components of integrated patient
care in the PPIP-C survey
Construct
Alpha Example item
k
Internal coordination and
communication within the primary
care clinic and with the patient
Q22. If you saw other health care providers at your doctor’s
0.81 clinic, how often do you think they knew about all of the medical
services you received from your doctor? (R)
5
External coordination between your
doctor and other doctors outside the
primary care clinic
Q27. If you have received care from a specialist outside your
0.76 doctor’s office, do you think your doctor knows that you have
received care from this specialist?
6
Doctor's efforts to coordinate with
your home and community
Q12. In the last six months
Q12
months, did your doctor or staff in your
0.69 doctor’s office ever ask if you need help at home in managing
your health conditions?
4
y
Coordination and communication by
the specialist and with the patient
0 65
0.65
Q32. After y
your last visit, did you
y leave the specialist
p
confused
about what to do next to manage your health conditions?
4
Patients' perception of
responsiveness of medical system
t own individual
to
i di id l needs
d
0.63
Q15. If you had a question about managing your health
conditions today, would you know how to get answers you trust?
3
Fragmentation problems
Q7. In the last six months, did your doctor ever give you
0.30 instructions for managing a health problem that disagreed with
what another doctor told you to do?
Coordination and communication by
and with the hospital
0.55
Q36. Did you leave the hospital confused about exactly what
medicine to take when you got home?
Note: Derived from PCA with promax rotation; first 6 factors exclude hospital variables.
3
9
4
29
Empirically-derived map to
hypothesized factors
Empirically-derived factors
Hypothesized factors
Coordinated across
Internal coordination and communication within
f
i
l B
Based
d on
professionals;
the primary care clinic and with the patient
shared responsibility
External coordination between your doctor and
other doctors outside the primary care clinic
Coordinated across facilities
Doctor's efforts to coordinate with your home
and community
Coordinated with support
systems
Coordination and communication by the
specialist
p
and with the p
patient
Coordinated across facilities;
Based on shared
responsibility
Patients' perception of responsiveness of
medical system to own individual needs
Tailored to patients’ needs and
preferences
Fragmentation problems
Not coordinated; not patient- 10
centered
Level of integrated patient care
at one health system
Sample Item
Q5. Did you and your doctor talk about the care you received
from other doctors?
Q12. In the last six months,, did your
Q
y
doctor or staff in your
y
doctor’s office ever ask if you need help at home in managing
your health conditions?
Q16 In the last six months
Q16.
months, has your doctor or staff in your
doctor’s office contacted you to ask about your condition?
Q31. At your last visit, do you think this specialist really
understood all of your important medical information?
Q37. Following this hospitalization, did your own doctor or staff
from your doctor’s office contact you to ask about your
condition?
di i ?
n
% Yes
366
74%
512
38%
510
41%
309
89%
108
56%
11
Variation among clinics
Construct
I t
Internal
l coordination
di ti and
d communication
i ti w ithi
ithin th
the primary
i
care
clinic and w ith the patient
External coordination betw een your doctor and other doctors
outside the primary care clinic
Doctor's efforts to coordinate w ith your home and community
Coordination and communication by the specialist and w ith the
patient
Patients' perception of responsiveness of medical system to
ow n individual needs
Fragmentation problems
Coordination and communication by and w ith the hospital
Most
Least
p-value
integrated integrated
for
clinic
clinic
difference
0.34
-0.16
0.42
0 25
0.25
-0.20
0 20
0 25
0.25
0.32
-0.23
0.01
0.16
-0.13
0.69
0 23
0.23
-0
0.23
23
0 36
0.36
0.17
-0.19
0.05
0 10
0.10
-0
0.10
10
0 80
0.80
Notes: Individual responses averaged across 10 imputations. Mean scores standardized to 0;12
most and least integrated refer to highest and low est mean score among 13 participating clinics.
Discussion

PPIP-C survey measures key features of integrated
patient care




Psychometric analysis identified 5-7 factors
Dimensions salient for patients corresponded roughly to
hypothesized factors
Patients experience relatively low levels of
i t
integrated
t d patient
ti t care in
i some respects
t
Variation across clinics was moderate

Variation may be greater and significant among clinics in
different health systems and with larger sample sizes
13
Conclusions


We defined integrated patient care to focus
on the care itself and incorporate patients’
patients
needs and preferences
The PPIP-C
PPIP C survey provides a new measure
of integrated patient care from the patients’
perspective
ti


Examining integration not only within a clinic
Allowing assessment of system-level correlates
and observation of intervention-based
improvement
14
Th k you!!
Thank
15