LEADERSHIP ASSIGNMENT PART 2

SUPPORT

C L IN IC A L IN T E G R A T IO N By Laura Ramos Hegwer In an era of increased partnership and affiliation, health­ care leaders are leveraging their collective strengths on the path toward clinical integration. The success of these efforts depends on healthcare executives’ commitment to investing in the infrastructure needed while allowing physicians to take the lead.

Healthcare leaders cite the need to achieve clinical integra­ tion as one factor spurring the wave of innovative af filiations and established partnerships among providers across the country. The degree to which geographically separate hospi­ tals, physicians and other healthcare entities or personnel are clinically integrated— coordinating their activities for the benefit of patients— is key to success in an era of value-based business models and increased consumerism in healthcare, according to Rob Schreiner, MD, FACP, FCCP, managing director, Huron Healthcare Consulting, Dunwoody, Ga., and an ACHE Member.

But in spite of the importance of clinical integration, healthcare leaders often are hard-pressed to articulate what clinical integration looks like, Schreiner says.

To a patient, clinical integration might be viewed as the ability to be seen by a physician more quickly, gain improved access to specialty care and encounter a more seamless care experience across the continuum. To a CEO, clinical integration might take the form of increased mar­ ket share. To a health system or facility CFO, it might equal higher margins by service line and lower supply chain costs. To a quality officer, it might mean higher Health Effectiveness Data and Information Set scores. To the marketing officer, it might look like an opportunity to leverage the organization’s branding power.

Even with its potential advantages, clinical integration presents a prioritization challenge for healthcare CEOs, Schreiner says. “It’s the C E O ’s conundrum: How much should I invest to build the infrastructure for value-based payment today versus next year or the following year?” he says. “Healthcare leaders recognize they need to build their capabilities before payers insist on this transition.”

How can healthcare leaders effectively support— but not control— clinical integration from the C-suite? Healthcare

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leaders for three organizations that have demonstrated suc­ cess in integrating care across the continuum share five les­ sons for success.

L e ss o n No. 1: C o m m it th e R e s o u rc e s f o r a L o n g -T e rm A p p ro a c h

networks, which permit legally separate healthcare provid­ ers to form a combined entity that allows single-source contracting without running afoul of antitrust laws, Schreiner says. They also enable providers to jointly invest in the infrastructure needed to support clinical integration.

In 2013, C H I St. Vincent, a 447-bed hospital in Little Rock, Ark., formed a CIN that has become the backbone of its accountable care and population health manage­ ment strategy. Called the Arkansas Health Network, this C IN received a $1.9 million bonus payment through the Medicare Shared Savings Program during its first perfor­ mance year in 2014. Leaders at C H I St. Vincent say their success is based on aligning with committed physician partners and investing in the resources needed for clinical integration— including care managers, population health coaches and new technologies.

The capabilities needed to support clinical integration include IT and analytics tools, although Schreiner believes their role in driving clinical integration is often overstated. “Analytics and IT are enablers of clinical inte­ gration, but they do not create it,” he says. “Clinical inte­ gration is really about changing operations and opening up access to the right level of care. Changing workflows and the organization’s culture is more im portant than having the right analytics and reporting platforms.”

Schreiner believes increased data transparency— specifi­ cally around physician performance— can help drive the cultural changes that need to occur at the physician- practice level to improve individual and group performance. “Physicians behave differently when they believe they are accountable to one another,” he says. “That account­ ability is an important cultural leap for a practice, and it is more impor­ tant than the tactical issues such as bolstering an organization’s IT capa­ bilities around business intelligence or care management.”

Today, many healthcare organiza­ tions are facilitating clinical inte­ gration through the development of

“Clinical integration is not a short-term commitment,” says Polly Davenport, DSc, FACHE, president, C H I St. Vincent. “You have to dedicate the resources and commit for the long haul.”

Although leaders at C H I St. Vincent are still searching for the right mix of technology, they have found value in a risk stratification tool that identifies the physician practices whose patients are most likely to use the health system’s services at a higher-than-average rate in the coming year.

“We have been very intentional about placing our care managers and population health coaches in clinics where they are likely to have the greatest impact,” says Rachel Kahn, manager, strategy and governance. “As a result, we’ve seen a lot of improvement, particu­ larly in our chronic obstructive pulm onary disease and end-stage renal populations. At the same time, we’ve seen an overall decline of inpatient costs and utilization and a shift toward care delivered in prim ary care settings.”

“ C lin ic a l in te g r a tio n is n o t a s h o r t - t e r m c o m m itm e n t. You h a v e to d e d ic a te th e

r e s o u r c e s an d c o m m it f o r th e lo n g h a u l.”

P o lly D av e n p o rt, DSc, FACHE CHI S t. V in c e n t

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Leaders at C H I St. Vincent structured the governance of the C IN so that it reflects the appropriate mix of com m unity and employed physicians (less than half of Arkansas Health N etw ork’s 1,200 providers are employed). An 11-member board composed of five inde­ pendent physicians, three employed physicians, adm in­ istrators and com m unity members leads Arkansas Health Network.

Driving C H I St. Vincent’s clinical integration efforts is a commitment to becoming better partners with physicians and other providers in the community, Davenport says. Increased partnership is the premise behind C H I St. Vincent’s five-year agreement with Conway Regional Hospital, a 154-bed community hospital in Little Rock. Under the deal, C H I St. Vincent will manage the opera­ tions of the hospital while Conway Regional maintains its local governance and autonomy, Davenport says.

Lesson No. 2: Have a S trate g y for Onboarding Physicians The healthcare CEO should be the key executive sponsor of any effort to make the organization more clinically inte­ grated, Schreiner says. Too often, though, CEOs and other healthcare leaders get caught up in trying to get physicians “on board” with clinical integration, as if it were a top-down strategy. The best approach: Use mutual patient-centered goals in seeking physician buy-in, Schreiner says.

“Tell physicians you need their help with clinical integra­ tion because patients deserve highly reliable, humanistic, empathetic and easily accessible care, and clinical integra­ tion will enable the health system to achieve that desired state for the good of the communities you serve,” he says. “Doctors will sign up for that.”

O nboarding physician practices is critical to the suc­ cess of clinical integration initiatives. To do so success­ fully, healthcare leaders should consider hiring practice facilitators, says Patrick W right, M D , senior vice presi­ dent, quality and patient safety, Cone H ealth, Greensboro, N .C . Practice facilitators support the 1,200 physicians (60 percent independent, 40 percent employed) who make up Cone H e a lth ’s C IN and accountable care organization, Triad H ealthC are N etwork. “O u r practice facilitators work behind the scenes with physicians and office staff to further our clinical integration initiatives,” W right says.

“We believe there is going to be continued consolidation across the state,” says Tadd Richert, C H I St. Vincent’s CFO. “We also understand there are community-based providers across the state that are looking for some type of support. Through the alliance, we can develop relationships and support each other in different ways, through purchasing supplies or providing physician support where needed. Together, we can create a network that works not only as a clinically integrated model, but also as an operating model that will be more sustainable in the future.”

Specifically, practice facilitators— who are typically regis­ tered nurses— are responsible for helping physicians achieve various clinical and financial benchmarks that are

part of T H N ’s payer agreements. As of January 2016, T H N will be managing 77,000 lives through the Centers for Medicare & Medicaid Services’ Next Generation ACO Model, several commercial Medicare Advantage plans and its own MA plan.

W hen a new physician practice joins T H N , a practice facilitator educates the physicians and office

“Clinical integration can’t come from the C -s u ite — it has to be

physician driven.” P a tr ic k W rig h t, MD

Cone Health

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staff on resources provided by the CIN such as a list of the practice’s patients who have exhibited high utilization and who are at risk for inpatient admission or readmis­ sion. The practice facilitator will help office staff close care gaps for these patients and keep physicians informed on treatment protocols in high-priority areas, such as chronic obstructive pulmonary dissease and heart failure. The practice facilitator also may recommend pro­ cess changes in the practice to improve access or effi­ ciency. They may even help office staff implement new software or tools, such as a point-of-care dashboard. This dashboard displays a patient’s most recent diagno­ ses, medication list, upcoming screenings and other inter­ ventions needed so physicians can refer to it during the office visit. It also includes a utilization section that shows per-member-per-month cost data.

Wright believes leadership education for physicians can make or break the success of clinical integration efforts. “Clinical integration can’t come from the C-suite— it has to be physician driven,” Wright says. To that end, Cone Health provides courses on leadership designed specifi­ cally for physicians. The health system also has developed an effective infrastructure of physician-led committees. T H N ’s operating committee, which includes nine inde­ pendent physicians and eight employed physicians as well as Cone Health administrators and a patient representa­ tive, oversees the C IN ’s day-to-day operations. Under the operating committee, there are five subcommittees: cre- dentialing, quality, contracting and finance, health infor­ mation exchange and medical management, which review cost information and provide dashboard data to physi­ cians on their performance.

Improving quality is often the central rallying call for physicians involved in clinical integration, but finding the right way to engage providers may take time. For example, T H N has moved away from its early attempts to improve quality by service line. “That worked well for about a year, but what we found was that the approach was a bit too siloed, and we were producing a number of process-based metrics that weren’t moving the needle on population health,” Wright says. Instead, leaders at T H N redesigned the health system’s quality subcommittees around key outcomes for population

R a c h e l K a h n , m a n a g e r, s t r a t e g y a n d g o v e r n a n c e : Tadd R ic h e r t, CFO; a n d P o lly D a v e n p o rt, D S c , FA C H E. p r e s i d e n t , C H I S t . V in c e n t , w o r k c o l l a b o r a t i v e l y o n c l i n i c a l i n t e g r a t io n .

D a v id (C lin t) M a t t h e w s , p r e s i d e n t a n d CEO, R e a d in g H e a lt h S y s t e m , b e lie v e s p h y s ic ia n e d u c a t io n is v i t a l f o r c l i n i c a l in t e g r a t io n .

F lo S p y r o w , R N , J D , FA C H E , in t e r i m CEO, H a m m o n d - H e n r y H o s p it a l ( p i c t u r e d a t r i g h t ) , s h a r e s p la n s w i t h P e n n y P a r k , R N .

P a t r i c k W r ig h t , M D . s e n io r v i c e p r e s i d e n t , q u a l i t y a n d p a t i e n t s a f e t y . C o n e H e a lth , s a y s h ir in g p r a c t i c e f a c i l i t a t o r s c a n h e lp s u p p o r t c l i n i c a l i n t e g r a t i o n e f f o r t s .

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health. They also have formed teams around readmis­ sions, sepsis, surgical-site infections, C O PD and heart failure, to name a few.

W right recommends engaging physicians in just six to eight major quality initiatives at a time. “Sometimes, you can get so overwhelmed w ith data th at it paralyzes you,” he says. “Clinical integration is really about con­ necting with people who can improve care across the continuum .”

care, home care and nursing home care, in their commu­ nities, so they have to reach out and develop more part­ nerships. The challenge for rural and critical access hospitals that wish to maintain their independence is find­ ing the right balance between clinical integration and pro­ viding patients with a seamless experience across the continuum of care without getting de facto aligned or becoming part of another system.”

Spyrow believes the best strategy for healthcare leaders in rural and critical access hospitals is building multiple part­ nerships, rather than working with one large health sys­ tem, to gain access to the services or resources they do not have under their own roof. That has been the strategy at Hammond-Henry, which has partnered with two health systems: UnityPoint Health-Trinity, a regional integrated delivery system that operates four hospitals in Illinois and Iowa, and Genesis Health System, a five-hospital system that serves a 10-county, bistate region and is part of the University of Iowa Health Alliance.

L e s s o n No. 3: D e v e lo p M u ltip le P a r tn e r s h ip s to F ill G aps W h e n N e e d e d In an environment of increased competition and consolidation, m aintaining independence can be difficult for rural and critical access hospitals, particularly as leaders consider their clinical integration options, says Flo Spyrow, RN, JD, FACHE, interim CEO, Hammond- Henry Hospital, a 25-bed commu­ nity hospital managed by HealthTech Management Services in Geneseo, 111., part of the Quad Cities area.

“R u ra l and c ritic a l a c c e s s hospitals h ave n e ith e r th e p a tie n t base nor the re ve n u e n e c e s s a ry to m a k e

m an ag in g population health fe a s ib le on th e ir ow n. They also m a y not have a c c e s s to a ll le v e ls o f c a re ,

including s p e c ia lty c a re , hom e c a re and nursing hom e c a re , in th e ir

co m m u n itie s , so th e y have to re ac h out and develop m o re p a rtn e rs h ip s .”

For instance, Hammond-Henry joined UnityPoint Health- Trinity’s ACO last year. “We have fewer than 20 Medicare and commercial patients who are attributed to us, and these

patients would be difficult to manage on our own,” Spyrow says. By joining the ACO, Hammond-Henry has been able to leverage UnityPoint’s care pathways and other resources to help care for these patients across the continuum and better manage costs across an episode of care. Hammond- Henry also recently entered into an agreement to participate in Genesis’ ACO. “This will help us broaden our patient base and increase our learning in the future,” Spyrow says.

“Rural and critical access hospitals have neither the patient base nor the revenue necessary to make managing population health feasi­ ble on their own,” Spyrow says. “They also may not have access to all levels of care, including specialty

Flo S p y ro w , RN. JD, FACHE H a m m o n d -H e n ry H osp ital

L e s s o n No. 4 : K e e p P h y s ic ia n R e c r u itm e n t S tro n g One way in which leaders at Ham m ond-Henry have supported clinical integration is by honing the hospital’s long-range physician recruitment strategy. “You have to

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be able to recruit and retain high-quality physicians to become more clinically integrated,” Spyrow says.

The hospital has partnered with UnityPoint Health- Trinity to identify medical students and physicians early in their careers who are interested in rural healthcare. Leaders at the system are building relationships with medi­ cal students who grew up in the area and others who are interested in completing a six-month medical rotation in a rural community. They also collaborated with the health system and various residency programs to identify and attract residents who are interested in rural care but desire to be part of a larger system of coordinated care.

H ealthcare executives and physician leaders also are investigating ways to provide financial support to resi­ dents in exchange for a com m itm ent to work in the area later on. For instance, physicians at H am m ond- H enry have raised more th an $50,000 from their own pockets to improve recruitm ent efforts.

Lesson No. 5: Consider a Collaborative Some healthcare leaders are taking

evolved at Reading Health System, which includes a 647- bed acute care hospital and a rehabilitation hospital. In 2012, Matthews and his team decided to implement a CIN . For the first year, they focused on educating the board and medical staff on why the health system needed such a network. “Rather than jumping immediately into shared savings, we needed to develop the infrastructure,” Matthews says. Healthcare executives also wanted to make sure they were following the 1996 rules governing CINs from the Federal Trade Commission and the U.S. Departm ent of Justice. “We actually went to the FTC and presented our network to them to make sure we were meeting all of the requirements,” Matthews says.

After scaling the legal hurdles, the health system named its network Reading H ealth Partners, which today includes 650 physicians in 50 specialties. The C IN has played a pivotal role in the health system’s risk-sharing agreement with a local self-insured employer, East Penn M anufacturing. Based on its suc­ cess with the East Penn population, the C IN is in talks with other employers as well as payers to enter into

risk-sharing agreements. clinical integration to the next level by form ing large-scale regional collaboratives. O ne exam­ ple is AllSpire Health Partners, which includes seven healthcare systems covering New Jersey, New York, M aryland and Pennsylvania.

“O ur seven systems have common goals in working with our physicians as we all move into risk sharing and value-based payment,” says David (Clint) Matthews, president and CEO, Reading (Pa.) Health System, and an ACHE Member. Specifically, the collaborative is focused on shar­ ing best practices to improve clinical outcomes and developing shared ser­ vices to reduce costs.

A regional focus on population health management has gradually

"W hether physicians are em ployed or independent, they

are thre a te n e d by the changes in our industry. Som etim es, the

health system can seem like the common enem y. That's w h y it is im portant to educate physicians on how clinical integration can help them w o rk tog e th er fo r the

purpose of im proving quality and access as w e ll as m anaging the

cost of c a re .” David (Clint) M atthew s Reading Health System

Matthews says the most challenging aspect of working on clinical inte­ gration has been overcoming physi­ cian skepticism and distrust, which leaders achieved through regular communication.

“W hether physicians are employed or independent, they are threatened by the changes in our industry,” Matthews says. “Sometimes, the health system can seem like the common enemy. T h a t’s why it is important to educate physicians on how clinical integration can help them work together for the purpose of improving quality and access as well as managing the cost of care.”

Laura Ramos H egwer is a freelance

writer a n d editor based in L ake Bluff, III.

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