Integrated care models for coordinating services across healthcare settings
Introduction
In today's healthcare system, services remain highly fragmented across different provider settings
like hospitals, primary care offices, behavioral health clinics, long-term care facilities, and social
services organizations. This leads to poor care coordination, unnecessary duplication of services,
and medical errors due to lack of information sharing between providers. Integrated care models
aim to bridge these divides by coordinating services across settings through multidisciplinary
teams, shared data systems, and value-based payment. This paper will explore key features of
integrated care models and their benefits in improving patient outcomes, care quality and costs.
Patient-Centered Medical Home Model
The patient-centered medical home (PCMH) is recognized as an effective model for integrating
care at the primary care level. Its core functions include:
- Comprehensive Care Coordination: Primary care practices assume responsibility for directing
and monitoring all aspects of patient care across various providers and settings. This includes
managing referrals, follow-ups and appointments.
- Care Planning: Physicians work with care teams and patients/families to develop
comprehensive care plans outlining medical/behavioral health goals and treatment timelines.
Plans are shared across the care continuum.
- Enhanced Access: Avenues like same-day appointments, electronic consults and group visits
improve access to care team advice beyond traditional visit-focused model. Telehealth further
supports access.
- Health IT Use: EHRs, registries and e-consults connect the PCMH internally and interface with
external stakeholders like labs, imaging centers and hospitals' EHRs for care coordination.
- Quality and Safety: Process measures ensure standardized protocols for screening/referrals, e-
prescribing, follow-ups and medication reconciliation minimize risks while emphasizing
prevention/wellness.
Payment models like pay-for-performance, medical home supplemental fees and shared savings
initiatives strengthen viability by linking reimbursement to quality and cost-efficiency goals
rather than fee-for-service volume. Studies show PCMHs improve outcomes for chronic illnesses
while lowering costs through reduced ER visits and unnecessary procedures.
Accountable Care Organizations
Accountable care organizations (ACOs) incorporate hospital services and specialists into
coordinated networks accountable for the total cost and quality of care for a defined patient
population. Key ACO features:
- Multidisciplinary Teams: Primary care physicians work closely with mid-level providers,
nurses, social workers, health coaches and specialists in teams to comprehensively manage
populations.
- Data Analytics: Risk-stratification platforms identify high-risk, high-cost patients benefiting
most from intensive care management and home visits using claims and EHR data.
- Care Management: Networked services coordinate transitions of care, medication
reconciliation, treatment adherence and social determinants of health through bridge programs
post-discharge and home visits.
- Payment: Upside-only or two-sided risk sharing links quality performance and total cost of care
benchmark targets. ACOs get bonus payments if savings exceed targets without diminishing
quality.
Studies show ACO-managed patients have better outcomes, fewer inpatient admissions and
readmissions. When combined with medical homes, ACOs demonstrate the strongest results for
improving population health management across care settings. However, success depends on
organizational culture that prioritizes collaboration over competition.
Behavioral Health Integration
Coordinating physical and behavioral healthcare can prove challenging due to their fragmented
financing and delivery systems. Integrated models encompass:
- Colocation of Services: Mental health and substance use services colocated at primary care
offices improve screening, recognition of comorbid conditions and treatment adherence through
"no wrong door" access and stigma reduction.
- Consultation Facilitation: Care coordinators and telepsychiatry help primary care teams consult
specialists and vice versa to address co-occurring conditions with streamlined referrals and
information sharing between EHRs.
- Team-Based Care: Shared caseloads among behavioral health specialists, counselors, nurses,
physicians and care managers ensure holistic evaluation and care planning.
- Measurement-Based Treatment: Screening tools and validated symptom scales guide evidence-
based treatment towards tangible improvement targets rather than open-ended talks therapy.
- Payment Reform: Alternative payment models like integrated bundled payments or population-
based payments provide financial incentives to address both medical and behavioral aspects of
care more seamlessly.
Studies show integrated care improves outcomes for conditions like depression, substance use
disorders, diabetes/obesity and even pediatric and geriatric populations. Coordination also
generates cost savings.
Transition Management
Timely transition management across care settings ensures continuity of care for older adults
with multiple chronic conditions at high risk of hospitalizations and nursing home placements:
- Discharge Planning: Nurses conduct pre-discharge needs assessments and confirm a receiving
provider, follow-up appointments and understood treatment plan before patients leave hospitals.
- Transition Coaching: Home health or community health workers conduct post-discharge home
visits and telephone checks to ensure patients understand self-care, resolve transportation barriers
to follow-ups, and recognize symptoms requiring emergency care.
- Medication Reconciliation: Pharmacists review and reconcile medications with primary care
providers and patients upon discharge and transfer to prevent errors or omissions upon care
handoffs.
- Advance Care Planning: Social workers assist with goals of care conversations,
POLST/MOLST forms and identifying surrogate decision makers to uphold patient preferences
across care settings.
- Electronic Notification: Hospitals automatically notify primary care, skilled nursing and EMS
providers regarding admissions, discharges and transfers alongside consolidated discharge
summaries for seamless coverage.
Studies find transition programs reduce readmissions, nursing home placements and medical
errors during handoffs through close patient monitoring and engagement after leaving inpatient
care. Payment reforms now encourage accountability for successful post-discharge outcomes.
Long-Term Services and Supports
Coordinating acute, primary and long-term care proves particularly vital for older adults and
people with disabilities given their higher needs. Integrated systems encompass:
- Regional Networks: Area agencies on aging, centers for independent living and state Medicaid
programs leverage community-based case management for consistent long-term services across
geographic regions.
- Single Access Points: Aging and disability resource centers serve as centralized "no wrong
door" portals connecting people to home/community-based services and institutional options
through counseling and referrals.
- Shared Assessments: Common intake and needs reassessments eliminate duplicative paperwork
between acute, primary and long-term care providers when needs or conditions change over
time.
- Person-Centered Care Planning: Interdisciplinary teams conduct home visits to develop
individualized plans addressing both clinical and social determinants of health needs like
transportation, meals and caregiver supports.
- Financial Alignment: Medicaid managed long-term services and supports (MLTSS) programs
bundle Medicaid funding streams and align incentives across acute and long-term sectors to
reduce institutional bias and cost-shifting.
Studies find integrated community-based long-term services greatly improve quality of life and
cost-efficiency versus fragmented institutional care. However inconsistent data exchange
remains a persistent barrier.
Health Information Exchange
Seamless sharing of electronic health information represents a foundation for success across all
integrated models. Key exchange functions:
- Secure Messaging: Allows providers to request records from other entities and receive direct
responses through standardized formats like C-CDA to spur coordinated care.
- Clinical Data Repository: Regional health information organizations compile records from
multiple data sources into indexed repositories accessible by authorized providers through
encrypted queries for a unified patient view.
- Public Health Reporting: Interfaces connect clinical and administrative systems to
immunization and disease registries for surveillance, reporting mandates, and identifying at-risk
cohorts.
- Patient Portals: Secure personal health record portals empower patients to access own clinical
summaries, test results and care plans to actively participate in their care across organizations.
- Analytic Services: Data aggregation and business intelligence tools transform claims and
clinical data into risk stratification reports, quality metrics and predictive models useful for
population health services.
Studies find areas with achieving universal health information exchange see reductions in
duplicative services, improved medication management and care transitions. However, current
barriers include interoperability, cost and organizational "information blocking." Federal
incentives now promote open exchange standards nationwide.
Sustainable Financing
A sustainable approach requires payment reform strategies incentivizing providers to coordinate
and manage total costs of care across sectors through mechanisms like:
- Bundled Payments: Prospective bundled reimbursements cover all services for an entire
episode of care extending beyond hospital discharge to encourage prevention and reduce
readmissions.
- Shared Savings: Upside-only or two-sided risk models shared between providers, payers and
employers promote quality improvement and cost control initiatives to achieve target budgets
through gainsharing.
- Global Budgets: Population-based budgets hold health systems accountable for total medical
expenses of enrolled patients, not just individual services delivered, by prioritizing prevention
over high-cost interventions.
- Pay-for-Performance: Bonus payments tie portion of reimbursements to comprehensive process
and outcome metrics spanning clinical quality, care transition rates and patient experience of
coordinated care.
- Grant Funding: Initial investments from public and private sources aid multi-stakeholder
collaboratives in implementing care coordination infrastructure with an eye towards self-
sustainability through alternative payment models over time.
Experts agree achieving sustainability requires continued transition from volume-based fee-for-
service reimbursement towards integrated funding mechanisms tying incentives to delivery
reform. Studies show potential for long-term cost-savings.
Conclusion
Fragmented care remains a key driver of poor outcomes and inefficiency in the U.S. healthcare
system. Integrated care models that align providers and settings through coordinated clinical
practices and payment reform hold great promise for managing total costs and population health.
While challenges remain in changing organizational cultures, overcoming data barriers, and
transitioning payment systems, communities demonstrating the strongest multi-stakeholder
collaborations experience the greatest success sustaining high-quality, affordable, patient-
centered care over time. Continued evolution towards comprehensive integration represents a
key strategy for a higher-performing healthcare system.
In today's healthcare system, services remain highly fragmented across different provider settings
like hospitals, primary care offices, behavioral health clinics, long-term care facilities, and social
services organizations. This leads to poor care coordination, unnecessary duplication of services,
and medical errors due to lack of information sharing between providers. Integrated care models
aim to bridge these divides by coordinating services across settings through multidisciplinary
teams, shared data systems, and value-based payment. This paper will explore key features of
integrated care models and their benefits in improving patient outcomes, care quality and costs.
Patient-Centered Medical Home Model
The patient-centered medical home (PCMH) is recognized as an effective model for integrating
care at the primary care level. Its core functions include:
- Comprehensive Care Coordination: Primary care practices assume responsibility for directing
and monitoring all aspects of patient care across various providers and settings. This includes
managing referrals, follow-ups and appointments.
- Care Planning: Physicians work with care teams and patients/families to develop
comprehensive care plans outlining medical/behavioral health goals and treatment timelines.
Plans are shared across the care continuum.
- Enhanced Access: Avenues like same-day appointments, electronic consults and group visits
improve access to care team advice beyond traditional visit-focused model. Telehealth further
supports access.
- Health IT Use: EHRs, registries and e-consults connect the PCMH internally and interface with
external stakeholders like labs, imaging centers and hospitals' EHRs for care coordination.
- Quality and Safety: Process measures ensure standardized protocols for screening/referrals, e-
prescribing, follow-ups and medication reconciliation minimize risks while emphasizing
prevention/wellness.
Payment models like pay-for-performance, medical home supplemental fees and shared savings
initiatives strengthen viability by linking reimbursement to quality and cost-efficiency goals
rather than fee-for-service volume. Studies show PCMHs improve outcomes for chronic illnesses
while lowering costs through reduced ER visits and unnecessary procedures.
Accountable Care Organizations
Accountable care organizations (ACOs) incorporate hospital services and specialists into
coordinated networks accountable for the total cost and quality of care for a defined patient
population. Key ACO features:
- Multidisciplinary Teams: Primary care physicians work closely with mid-level providers,
nurses, social workers, health coaches and specialists in teams to comprehensively manage
populations.
- Data Analytics: Risk-stratification platforms identify high-risk, high-cost patients benefiting
most from intensive care management and home visits using claims and EHR data.
- Care Management: Networked services coordinate transitions of care, medication
reconciliation, treatment adherence and social determinants of health through bridge programs
post-discharge and home visits.
- Payment: Upside-only or two-sided risk sharing links quality performance and total cost of care
benchmark targets. ACOs get bonus payments if savings exceed targets without diminishing
quality.
Studies show ACO-managed patients have better outcomes, fewer inpatient admissions and
readmissions. When combined with medical homes, ACOs demonstrate the strongest results for
improving population health management across care settings. However, success depends on
organizational culture that prioritizes collaboration over competition.
Behavioral Health Integration
Coordinating physical and behavioral healthcare can prove challenging due to their fragmented
financing and delivery systems. Integrated models encompass:
- Colocation of Services: Mental health and substance use services colocated at primary care
offices improve screening, recognition of comorbid conditions and treatment adherence through
"no wrong door" access and stigma reduction.
- Consultation Facilitation: Care coordinators and telepsychiatry help primary care teams consult
specialists and vice versa to address co-occurring conditions with streamlined referrals and
information sharing between EHRs.
- Team-Based Care: Shared caseloads among behavioral health specialists, counselors, nurses,
physicians and care managers ensure holistic evaluation and care planning.
- Measurement-Based Treatment: Screening tools and validated symptom scales guide evidence-
based treatment towards tangible improvement targets rather than open-ended talks therapy.
- Payment Reform: Alternative payment models like integrated bundled payments or population-
based payments provide financial incentives to address both medical and behavioral aspects of
care more seamlessly.
Studies show integrated care improves outcomes for conditions like depression, substance use
disorders, diabetes/obesity and even pediatric and geriatric populations. Coordination also
generates cost savings.
Transition Management
Timely transition management across care settings ensures continuity of care for older adults
with multiple chronic conditions at high risk of hospitalizations and nursing home placements:
- Discharge Planning: Nurses conduct pre-discharge needs assessments and confirm a receiving
provider, follow-up appointments and understood treatment plan before patients leave hospitals.
- Transition Coaching: Home health or community health workers conduct post-discharge home
visits and telephone checks to ensure patients understand self-care, resolve transportation barriers
to follow-ups, and recognize symptoms requiring emergency care.
- Medication Reconciliation: Pharmacists review and reconcile medications with primary care
providers and patients upon discharge and transfer to prevent errors or omissions upon care
handoffs.
- Advance Care Planning: Social workers assist with goals of care conversations,
POLST/MOLST forms and identifying surrogate decision makers to uphold patient preferences
across care settings.
- Electronic Notification: Hospitals automatically notify primary care, skilled nursing and EMS
providers regarding admissions, discharges and transfers alongside consolidated discharge
summaries for seamless coverage.
Studies find transition programs reduce readmissions, nursing home placements and medical
errors during handoffs through close patient monitoring and engagement after leaving inpatient
care. Payment reforms now encourage accountability for successful post-discharge outcomes.
Long-Term Services and Supports
Coordinating acute, primary and long-term care proves particularly vital for older adults and
people with disabilities given their higher needs. Integrated systems encompass:
- Regional Networks: Area agencies on aging, centers for independent living and state Medicaid
programs leverage community-based case management for consistent long-term services across
geographic regions.
- Single Access Points: Aging and disability resource centers serve as centralized "no wrong
door" portals connecting people to home/community-based services and institutional options
through counseling and referrals.
- Shared Assessments: Common intake and needs reassessments eliminate duplicative paperwork
between acute, primary and long-term care providers when needs or conditions change over
time.
- Person-Centered Care Planning: Interdisciplinary teams conduct home visits to develop
individualized plans addressing both clinical and social determinants of health needs like
transportation, meals and caregiver supports.
- Financial Alignment: Medicaid managed long-term services and supports (MLTSS) programs
bundle Medicaid funding streams and align incentives across acute and long-term sectors to
reduce institutional bias and cost-shifting.
Studies find integrated community-based long-term services greatly improve quality of life and
cost-efficiency versus fragmented institutional care. However inconsistent data exchange
remains a persistent barrier.
Health Information Exchange
Seamless sharing of electronic health information represents a foundation for success across all
integrated models. Key exchange functions:
- Secure Messaging: Allows providers to request records from other entities and receive direct
responses through standardized formats like C-CDA to spur coordinated care.
- Clinical Data Repository: Regional health information organizations compile records from
multiple data sources into indexed repositories accessible by authorized providers through
encrypted queries for a unified patient view.
- Public Health Reporting: Interfaces connect clinical and administrative systems to
immunization and disease registries for surveillance, reporting mandates, and identifying at-risk
cohorts.
- Patient Portals: Secure personal health record portals empower patients to access own clinical
summaries, test results and care plans to actively participate in their care across organizations.
- Analytic Services: Data aggregation and business intelligence tools transform claims and
clinical data into risk stratification reports, quality metrics and predictive models useful for
population health services.
Studies find areas with achieving universal health information exchange see reductions in
duplicative services, improved medication management and care transitions. However, current
barriers include interoperability, cost and organizational "information blocking." Federal
incentives now promote open exchange standards nationwide.
Sustainable Financing
A sustainable approach requires payment reform strategies incentivizing providers to coordinate
and manage total costs of care across sectors through mechanisms like:
- Bundled Payments: Prospective bundled reimbursements cover all services for an entire
episode of care extending beyond hospital discharge to encourage prevention and reduce
readmissions.
- Shared Savings: Upside-only or two-sided risk models shared between providers, payers and
employers promote quality improvement and cost control initiatives to achieve target budgets
through gainsharing.
- Global Budgets: Population-based budgets hold health systems accountable for total medical
expenses of enrolled patients, not just individual services delivered, by prioritizing prevention
over high-cost interventions.
- Pay-for-Performance: Bonus payments tie portion of reimbursements to comprehensive process
and outcome metrics spanning clinical quality, care transition rates and patient experience of
coordinated care.
- Grant Funding: Initial investments from public and private sources aid multi-stakeholder
collaboratives in implementing care coordination infrastructure with an eye towards self-
sustainability through alternative payment models over time.
Experts agree achieving sustainability requires continued transition from volume-based fee-for-
service reimbursement towards integrated funding mechanisms tying incentives to delivery
reform. Studies show potential for long-term cost-savings.
Conclusion
Fragmented care remains a key driver of poor outcomes and inefficiency in the U.S. healthcare
system. Integrated care models that align providers and settings through coordinated clinical
practices and payment reform hold great promise for managing total costs and population health.
While challenges remain in changing organizational cultures, overcoming data barriers, and
transitioning payment systems, communities demonstrating the strongest multi-stakeholder
collaborations experience the greatest success sustaining high-quality, affordable, patient-
centered care over time. Continued evolution towards comprehensive integration represents a
key strategy for a higher-performing healthcare system.
In today's healthcare system, services remain highly fragmented across different provider settings
like hospitals, primary care offices, behavioral health clinics, long-term care facilities, and social
services organizations. This leads to poor care coordination, unnecessary duplication of services,
and medical errors due to lack of information sharing between providers. Integrated care models
aim to bridge these divides by coordinating services across settings through multidisciplinary
teams, shared data systems, and value-based payment. This paper will explore key features of
integrated care models and their benefits in improving patient outcomes, care quality and costs.
Patient-Centered Medical Home Model
The patient-centered medical home (PCMH) is recognized as an effective model for integrating
care at the primary care level. Its core functions include:
- Comprehensive Care Coordination: Primary care practices assume responsibility for directing
and monitoring all aspects of patient care across various providers and settings. This includes
managing referrals, follow-ups and appointments.
- Care Planning: Physicians work with care teams and patients/families to develop
comprehensive care plans outlining medical/behavioral health goals and treatment timelines.
Plans are shared across the care continuum.
- Enhanced Access: Avenues like same-day appointments, electronic consults and group visits
improve access to care team advice beyond traditional visit-focused model. Telehealth further
supports access.
- Health IT Use: EHRs, registries and e-consults connect the PCMH internally and interface with
external stakeholders like labs, imaging centers and hospitals' EHRs for care coordination.
- Quality and Safety: Process measures ensure standardized protocols for screening/referrals, e-
prescribing, follow-ups and medication reconciliation minimize risks while emphasizing
prevention/wellness.
Payment models like pay-for-performance, medical home supplemental fees and shared savings
initiatives strengthen viability by linking reimbursement to quality and cost-efficiency goals
rather than fee-for-service volume. Studies show PCMHs improve outcomes for chronic illnesses
while lowering costs through reduced ER visits and unnecessary procedures.
Accountable Care Organizations
Accountable care organizations (ACOs) incorporate hospital services and specialists into
coordinated networks accountable for the total cost and quality of care for a defined patient
population. Key ACO features:
- Multidisciplinary Teams: Primary care physicians work closely with mid-level providers,
nurses, social workers, health coaches and specialists in teams to comprehensively manage
populations.
- Data Analytics: Risk-stratification platforms identify high-risk, high-cost patients benefiting
most from intensive care management and home visits using claims and EHR data.
- Care Management: Networked services coordinate transitions of care, medication
reconciliation, treatment adherence and social determinants of health through bridge programs
post-discharge and home visits.
- Payment: Upside-only or two-sided risk sharing links quality performance and total cost of care
benchmark targets. ACOs get bonus payments if savings exceed targets without diminishing
quality.
Studies show ACO-managed patients have better outcomes, fewer inpatient admissions and
readmissions. When combined with medical homes, ACOs demonstrate the strongest results for
improving population health management across care settings. However, success depends on
organizational culture that prioritizes collaboration over competition.
Behavioral Health Integration
Coordinating physical and behavioral healthcare can prove challenging due to their fragmented
financing and delivery systems. Integrated models encompass:
- Colocation of Services: Mental health and substance use services colocated at primary care
offices improve screening, recognition of comorbid conditions and treatment adherence through
"no wrong door" access and stigma reduction.
- Consultation Facilitation: Care coordinators and telepsychiatry help primary care teams consult
specialists and vice versa to address co-occurring conditions with streamlined referrals and
information sharing between EHRs.
- Team-Based Care: Shared caseloads among behavioral health specialists, counselors, nurses,
physicians and care managers ensure holistic evaluation and care planning.
- Measurement-Based Treatment: Screening tools and validated symptom scales guide evidence-
based treatment towards tangible improvement targets rather than open-ended talks therapy.
- Payment Reform: Alternative payment models like integrated bundled payments or population-
based payments provide financial incentives to address both medical and behavioral aspects of
care more seamlessly.
Studies show integrated care improves outcomes for conditions like depression, substance use
disorders, diabetes/obesity and even pediatric and geriatric populations. Coordination also
generates cost savings.
Transition Management
Timely transition management across care settings ensures continuity of care for older adults
with multiple chronic conditions at high risk of hospitalizations and nursing home placements:
- Discharge Planning: Nurses conduct pre-discharge needs assessments and confirm a receiving
provider, follow-up appointments and understood treatment plan before patients leave hospitals.
- Transition Coaching: Home health or community health workers conduct post-discharge home
visits and telephone checks to ensure patients understand self-care, resolve transportation barriers
to follow-ups, and recognize symptoms requiring emergency care.
- Medication Reconciliation: Pharmacists review and reconcile medications with primary care
providers and patients upon discharge and transfer to prevent errors or omissions upon care
handoffs.
- Advance Care Planning: Social workers assist with goals of care conversations,
POLST/MOLST forms and identifying surrogate decision makers to uphold patient preferences
across care settings.
- Electronic Notification: Hospitals automatically notify primary care, skilled nursing and EMS
providers regarding admissions, discharges and transfers alongside consolidated discharge
summaries for seamless coverage.
Studies find transition programs reduce readmissions, nursing home placements and medical
errors during handoffs through close patient monitoring and engagement after leaving inpatient
care. Payment reforms now encourage accountability for successful post-discharge outcomes.
Long-Term Services and Supports
Coordinating acute, primary and long-term care proves particularly vital for older adults and
people with disabilities given their higher needs. Integrated systems encompass:
- Regional Networks: Area agencies on aging, centers for independent living and state Medicaid
programs leverage community-based case management for consistent long-term services across
geographic regions.
- Single Access Points: Aging and disability resource centers serve as centralized "no wrong
door" portals connecting people to home/community-based services and institutional options
through counseling and referrals.
- Shared Assessments: Common intake and needs reassessments eliminate duplicative paperwork
between acute, primary and long-term care providers when needs or conditions change over
time.
- Person-Centered Care Planning: Interdisciplinary teams conduct home visits to develop
individualized plans addressing both clinical and social determinants of health needs like
transportation, meals and caregiver supports.
- Financial Alignment: Medicaid managed long-term services and supports (MLTSS) programs
bundle Medicaid funding streams and align incentives across acute and long-term sectors to
reduce institutional bias and cost-shifting.
Studies find integrated community-based long-term services greatly improve quality of life and
cost-efficiency versus fragmented institutional care. However inconsistent data exchange
remains a persistent barrier.
Health Information Exchange
Seamless sharing of electronic health information represents a foundation for success across all
integrated models. Key exchange functions:
- Secure Messaging: Allows providers to request records from other entities and receive direct
responses through standardized formats like C-CDA to spur coordinated care.
- Clinical Data Repository: Regional health information organizations compile records from
multiple data sources into indexed repositories accessible by authorized providers through
encrypted queries for a unified patient view.
- Public Health Reporting: Interfaces connect clinical and administrative systems to
immunization and disease registries for surveillance, reporting mandates, and identifying at-risk
cohorts.
- Patient Portals: Secure personal health record portals empower patients to access own clinical
summaries, test results and care plans to actively participate in their care across organizations.
- Analytic Services: Data aggregation and business intelligence tools transform claims and
clinical data into risk stratification reports, quality metrics and predictive models useful for
population health services.
Studies find areas with achieving universal health information exchange see reductions in
duplicative services, improved medication management and care transitions. However, current
barriers include interoperability, cost and organizational "information blocking." Federal
incentives now promote open exchange standards nationwide.
Sustainable Financing
A sustainable approach requires payment reform strategies incentivizing providers to coordinate
and manage total costs of care across sectors through mechanisms like:
- Bundled Payments: Prospective bundled reimbursements cover all services for an entire
episode of care extending beyond hospital discharge to encourage prevention and reduce
readmissions.
- Shared Savings: Upside-only or two-sided risk models shared between providers, payers and
employers promote quality improvement and cost control initiatives to achieve target budgets
through gainsharing.
- Global Budgets: Population-based budgets hold health systems accountable for total medical
expenses of enrolled patients, not just individual services delivered, by prioritizing prevention
over high-cost interventions.
- Pay-for-Performance: Bonus payments tie portion of reimbursements to comprehensive process
and outcome metrics spanning clinical quality, care transition rates and patient experience of
coordinated care.
- Grant Funding: Initial investments from public and private sources aid multi-stakeholder
collaboratives in implementing care coordination infrastructure with an eye towards self-
sustainability through alternative payment models over time.
Experts agree achieving sustainability requires continued transition from volume-based fee-for-
service reimbursement towards integrated funding mechanisms tying incentives to delivery
reform. Studies show potential for long-term cost-savings.
Conclusion
Fragmented care remains a key driver of poor outcomes and inefficiency in the U.S. healthcare
system. Integrated care models that align providers and settings through coordinated clinical
practices and payment reform hold great promise for managing total costs and population health.
While challenges remain in changing organizational cultures, overcoming data barriers, and
transitioning payment systems, communities demonstrating the strongest multi-stakeholder
collaborations experience the greatest success sustaining high-quality, affordable, patient-
centered care over time. Continued evolution towards comprehensive integration represents a
key strategy for a higher-performing healthcare system.
In today's healthcare system, services remain highly fragmented across different provider settings
like hospitals, primary care offices, behavioral health clinics, long-term care facilities, and social
services organizations. This leads to poor care coordination, unnecessary duplication of services,
and medical errors due to lack of information sharing between providers. Integrated care models
aim to bridge these divides by coordinating services across settings through multidisciplinary
teams, shared data systems, and value-based payment. This paper will explore key features of
integrated care models and their benefits in improving patient outcomes, care quality and costs.
Patient-Centered Medical Home Model
The patient-centered medical home (PCMH) is recognized as an effective model for integrating
care at the primary care level. Its core functions include:
- Comprehensive Care Coordination: Primary care practices assume responsibility for directing
and monitoring all aspects of patient care across various providers and settings. This includes
managing referrals, follow-ups and appointments.
- Care Planning: Physicians work with care teams and patients/families to develop
comprehensive care plans outlining medical/behavioral health goals and treatment timelines.
Plans are shared across the care continuum.
- Enhanced Access: Avenues like same-day appointments, electronic consults and group visits
improve access to care team advice beyond traditional visit-focused model. Telehealth further
supports access.
- Health IT Use: EHRs, registries and e-consults connect the PCMH internally and interface with
external stakeholders like labs, imaging centers and hospitals' EHRs for care coordination.
- Quality and Safety: Process measures ensure standardized protocols for screening/referrals, e-
prescribing, follow-ups and medication reconciliation minimize risks while emphasizing
prevention/wellness.
Payment models like pay-for-performance, medical home supplemental fees and shared savings
initiatives strengthen viability by linking reimbursement to quality and cost-efficiency goals
rather than fee-for-service volume. Studies show PCMHs improve outcomes for chronic illnesses
while lowering costs through reduced ER visits and unnecessary procedures.
Accountable Care Organizations
Accountable care organizations (ACOs) incorporate hospital services and specialists into
coordinated networks accountable for the total cost and quality of care for a defined patient
population. Key ACO features:
- Multidisciplinary Teams: Primary care physicians work closely with mid-level providers,
nurses, social workers, health coaches and specialists in teams to comprehensively manage
populations.
- Data Analytics: Risk-stratification platforms identify high-risk, high-cost patients benefiting
most from intensive care management and home visits using claims and EHR data.
- Care Management: Networked services coordinate transitions of care, medication
reconciliation, treatment adherence and social determinants of health through bridge programs
post-discharge and home visits.
- Payment: Upside-only or two-sided risk sharing links quality performance and total cost of care
benchmark targets. ACOs get bonus payments if savings exceed targets without diminishing
quality.
Studies show ACO-managed patients have better outcomes, fewer inpatient admissions and
readmissions. When combined with medical homes, ACOs demonstrate the strongest results for
improving population health management across care settings. However, success depends on
organizational culture that prioritizes collaboration over competition.
Behavioral Health Integration
Coordinating physical and behavioral healthcare can prove challenging due to their fragmented
financing and delivery systems. Integrated models encompass:
- Colocation of Services: Mental health and substance use services colocated at primary care
offices improve screening, recognition of comorbid conditions and treatment adherence through
"no wrong door" access and stigma reduction.
- Consultation Facilitation: Care coordinators and telepsychiatry help primary care teams consult
specialists and vice versa to address co-occurring conditions with streamlined referrals and
information sharing between EHRs.
- Team-Based Care: Shared caseloads among behavioral health specialists, counselors, nurses,
physicians and care managers ensure holistic evaluation and care planning.
- Measurement-Based Treatment: Screening tools and validated symptom scales guide evidence-
based treatment towards tangible improvement targets rather than open-ended talks therapy.
- Payment Reform: Alternative payment models like integrated bundled payments or population-
based payments provide financial incentives to address both medical and behavioral aspects of
care more seamlessly.
Studies show integrated care improves outcomes for conditions like depression, substance use
disorders, diabetes/obesity and even pediatric and geriatric populations. Coordination also
generates cost savings.
Transition Management
Timely transition management across care settings ensures continuity of care for older adults
with multiple chronic conditions at high risk of hospitalizations and nursing home placements:
- Discharge Planning: Nurses conduct pre-discharge needs assessments and confirm a receiving
provider, follow-up appointments and understood treatment plan before patients leave hospitals.
- Transition Coaching: Home health or community health workers conduct post-discharge home
visits and telephone checks to ensure patients understand self-care, resolve transportation barriers
to follow-ups, and recognize symptoms requiring emergency care.
- Medication Reconciliation: Pharmacists review and reconcile medications with primary care
providers and patients upon discharge and transfer to prevent errors or omissions upon care
handoffs.
- Advance Care Planning: Social workers assist with goals of care conversations,
POLST/MOLST forms and identifying surrogate decision makers to uphold patient preferences
across care settings.
- Electronic Notification: Hospitals automatically notify primary care, skilled nursing and EMS
providers regarding admissions, discharges and transfers alongside consolidated discharge
summaries for seamless coverage.
Studies find transition programs reduce readmissions, nursing home placements and medical
errors during handoffs through close patient monitoring and engagement after leaving inpatient
care. Payment reforms now encourage accountability for successful post-discharge outcomes.
Long-Term Services and Supports
Coordinating acute, primary and long-term care proves particularly vital for older adults and
people with disabilities given their higher needs. Integrated systems encompass:
- Regional Networks: Area agencies on aging, centers for independent living and state Medicaid
programs leverage community-based case management for consistent long-term services across
geographic regions.
- Single Access Points: Aging and disability resource centers serve as centralized "no wrong
door" portals connecting people to home/community-based services and institutional options
through counseling and referrals.
- Shared Assessments: Common intake and needs reassessments eliminate duplicative paperwork
between acute, primary and long-term care providers when needs or conditions change over
time.
- Person-Centered Care Planning: Interdisciplinary teams conduct home visits to develop
individualized plans addressing both clinical and social determinants of health needs like
transportation, meals and caregiver supports.
- Financial Alignment: Medicaid managed long-term services and supports (MLTSS) programs
bundle Medicaid funding streams and align incentives across acute and long-term sectors to
reduce institutional bias and cost-shifting.
Studies find integrated community-based long-term services greatly improve quality of life and
cost-efficiency versus fragmented institutional care. However inconsistent data exchange
remains a persistent barrier.
Health Information Exchange
Seamless sharing of electronic health information represents a foundation for success across all
integrated models. Key exchange functions:
- Secure Messaging: Allows providers to request records from other entities and receive direct
responses through standardized formats like C-CDA to spur coordinated care.
- Clinical Data Repository: Regional health information organizations compile records from
multiple data sources into indexed repositories accessible by authorized providers through
encrypted queries for a unified patient view.
- Public Health Reporting: Interfaces connect clinical and administrative systems to
immunization and disease registries for surveillance, reporting mandates, and identifying at-risk
cohorts.
- Patient Portals: Secure personal health record portals empower patients to access own clinical
summaries, test results and care plans to actively participate in their care across organizations.
- Analytic Services: Data aggregation and business intelligence tools transform claims and
clinical data into risk stratification reports, quality metrics and predictive models useful for
population health services.
Studies find areas with achieving universal health information exchange see reductions in
duplicative services, improved medication management and care transitions. However, current
barriers include interoperability, cost and organizational "information blocking." Federal
incentives now promote open exchange standards nationwide.
Sustainable Financing
A sustainable approach requires payment reform strategies incentivizing providers to coordinate
and manage total costs of care across sectors through mechanisms like:
- Bundled Payments: Prospective bundled reimbursements cover all services for an entire
episode of care extending beyond hospital discharge to encourage prevention and reduce
readmissions.
- Shared Savings: Upside-only or two-sided risk models shared between providers, payers and
employers promote quality improvement and cost control initiatives to achieve target budgets
through gainsharing.
- Global Budgets: Population-based budgets hold health systems accountable for total medical
expenses of enrolled patients, not just individual services delivered, by prioritizing prevention
over high-cost interventions.
- Pay-for-Performance: Bonus payments tie portion of reimbursements to comprehensive process
and outcome metrics spanning clinical quality, care transition rates and patient experience of
coordinated care.
- Grant Funding: Initial investments from public and private sources aid multi-stakeholder
collaboratives in implementing care coordination infrastructure with an eye towards self-
sustainability through alternative payment models over time.
Experts agree achieving sustainability requires continued transition from volume-based fee-for-
service reimbursement towards integrated funding mechanisms tying incentives to delivery
reform. Studies show potential for long-term cost-savings.
Conclusion
Fragmented care remains a key driver of poor outcomes and inefficiency in the U.S. healthcare
system. Integrated care models that align providers and settings through coordinated clinical
practices and payment reform hold great promise for managing total costs and population health.
While challenges remain in changing organizational cultures, overcoming data barriers, and
transitioning payment systems, communities demonstrating the strongest multi-stakeholder
collaborations experience the greatest success sustaining high-quality, affordable, patient-
centered care over time. Continued evolution towards comprehensive integration represents a
key strategy for a higher-performing healthcare system.
In today's healthcare system, services remain highly fragmented across different provider settings
like hospitals, primary care offices, behavioral health clinics, long-term care facilities, and social
services organizations. This leads to poor care coordination, unnecessary duplication of services,
and medical errors due to lack of information sharing between providers. Integrated care models
aim to bridge these divides by coordinating services across settings through multidisciplinary
teams, shared data systems, and value-based payment. This paper will explore key features of
integrated care models and their benefits in improving patient outcomes, care quality and costs.
Patient-Centered Medical Home Model
The patient-centered medical home (PCMH) is recognized as an effective model for integrating
care at the primary care level. Its core functions include:
- Comprehensive Care Coordination: Primary care practices assume responsibility for directing
and monitoring all aspects of patient care across various providers and settings. This includes
managing referrals, follow-ups and appointments.
- Care Planning: Physicians work with care teams and patients/families to develop
comprehensive care plans outlining medical/behavioral health goals and treatment timelines.
Plans are shared across the care continuum.
- Enhanced Access: Avenues like same-day appointments, electronic consults and group visits
improve access to care team advice beyond traditional visit-focused model. Telehealth further
supports access.
- Health IT Use: EHRs, registries and e-consults connect the PCMH internally and interface with
external stakeholders like labs, imaging centers and hospitals' EHRs for care coordination.
- Quality and Safety: Process measures ensure standardized protocols for screening/referrals, e-
prescribing, follow-ups and medication reconciliation minimize risks while emphasizing
prevention/wellness.
Payment models like pay-for-performance, medical home supplemental fees and shared savings
initiatives strengthen viability by linking reimbursement to quality and cost-efficiency goals
rather than fee-for-service volume. Studies show PCMHs improve outcomes for chronic illnesses
while lowering costs through reduced ER visits and unnecessary procedures.
Accountable Care Organizations
Accountable care organizations (ACOs) incorporate hospital services and specialists into
coordinated networks accountable for the total cost and quality of care for a defined patient
population. Key ACO features:
- Multidisciplinary Teams: Primary care physicians work closely with mid-level providers,
nurses, social workers, health coaches and specialists in teams to comprehensively manage
populations.
- Data Analytics: Risk-stratification platforms identify high-risk, high-cost patients benefiting
most from intensive care management and home visits using claims and EHR data.
- Care Management: Networked services coordinate transitions of care, medication
reconciliation, treatment adherence and social determinants of health through bridge programs
post-discharge and home visits.
- Payment: Upside-only or two-sided risk sharing links quality performance and total cost of care
benchmark targets. ACOs get bonus payments if savings exceed targets without diminishing
quality.
Studies show ACO-managed patients have better outcomes, fewer inpatient admissions and
readmissions. When combined with medical homes, ACOs demonstrate the strongest results for
improving population health management across care settings. However, success depends on
organizational culture that prioritizes collaboration over competition.
Behavioral Health Integration
Coordinating physical and behavioral healthcare can prove challenging due to their fragmented
financing and delivery systems. Integrated models encompass:
- Colocation of Services: Mental health and substance use services colocated at primary care
offices improve screening, recognition of comorbid conditions and treatment adherence through
"no wrong door" access and stigma reduction.
- Consultation Facilitation: Care coordinators and telepsychiatry help primary care teams consult
specialists and vice versa to address co-occurring conditions with streamlined referrals and
information sharing between EHRs.
- Team-Based Care: Shared caseloads among behavioral health specialists, counselors, nurses,
physicians and care managers ensure holistic evaluation and care planning.
- Measurement-Based Treatment: Screening tools and validated symptom scales guide evidence-
based treatment towards tangible improvement targets rather than open-ended talks therapy.
- Payment Reform: Alternative payment models like integrated bundled payments or population-
based payments provide financial incentives to address both medical and behavioral aspects of
care more seamlessly.
Studies show integrated care improves outcomes for conditions like depression, substance use
disorders, diabetes/obesity and even pediatric and geriatric populations. Coordination also
generates cost savings.
Transition Management
Timely transition management across care settings ensures continuity of care for older adults
with multiple chronic conditions at high risk of hospitalizations and nursing home placements:
- Discharge Planning: Nurses conduct pre-discharge needs assessments and confirm a receiving
provider, follow-up appointments and understood treatment plan before patients leave hospitals.
- Transition Coaching: Home health or community health workers conduct post-discharge home
visits and telephone checks to ensure patients understand self-care, resolve transportation barriers
to follow-ups, and recognize symptoms requiring emergency care.
- Medication Reconciliation: Pharmacists review and reconcile medications with primary care
providers and patients upon discharge and transfer to prevent errors or omissions upon care
handoffs.
- Advance Care Planning: Social workers assist with goals of care conversations,
POLST/MOLST forms and identifying surrogate decision makers to uphold patient preferences
across care settings.
- Electronic Notification: Hospitals automatically notify primary care, skilled nursing and EMS
providers regarding admissions, discharges and transfers alongside consolidated discharge
summaries for seamless coverage.
Studies find transition programs reduce readmissions, nursing home placements and medical
errors during handoffs through close patient monitoring and engagement after leaving inpatient
care. Payment reforms now encourage accountability for successful post-discharge outcomes.
Long-Term Services and Supports
Coordinating acute, primary and long-term care proves particularly vital for older adults and
people with disabilities given their higher needs. Integrated systems encompass:
- Regional Networks: Area agencies on aging, centers for independent living and state Medicaid
programs leverage community-based case management for consistent long-term services across
geographic regions.
- Single Access Points: Aging and disability resource centers serve as centralized "no wrong
door" portals connecting people to home/community-based services and institutional options
through counseling and referrals.
- Shared Assessments: Common intake and needs reassessments eliminate duplicative paperwork
between acute, primary and long-term care providers when needs or conditions change over
time.
- Person-Centered Care Planning: Interdisciplinary teams conduct home visits to develop
individualized plans addressing both clinical and social determinants of health needs like
transportation, meals and caregiver supports.
- Financial Alignment: Medicaid managed long-term services and supports (MLTSS) programs
bundle Medicaid funding streams and align incentives across acute and long-term sectors to
reduce institutional bias and cost-shifting.
Studies find integrated community-based long-term services greatly improve quality of life and
cost-efficiency versus fragmented institutional care. However inconsistent data exchange
remains a persistent barrier.
Health Information Exchange
Seamless sharing of electronic health information represents a foundation for success across all
integrated models. Key exchange functions:
- Secure Messaging: Allows providers to request records from other entities and receive direct
responses through standardized formats like C-CDA to spur coordinated care.
- Clinical Data Repository: Regional health information organizations compile records from
multiple data sources into indexed repositories accessible by authorized providers through
encrypted queries for a unified patient view.
- Public Health Reporting: Interfaces connect clinical and administrative systems to
immunization and disease registries for surveillance, reporting mandates, and identifying at-risk
cohorts.
- Patient Portals: Secure personal health record portals empower patients to access own clinical
summaries, test results and care plans to actively participate in their care across organizations.
- Analytic Services: Data aggregation and business intelligence tools transform claims and
clinical data into risk stratification reports, quality metrics and predictive models useful for
population health services.
Studies find areas with achieving universal health information exchange see reductions in
duplicative services, improved medication management and care transitions. However, current
barriers include interoperability, cost and organizational "information blocking." Federal
incentives now promote open exchange standards nationwide.
Sustainable Financing
A sustainable approach requires payment reform strategies incentivizing providers to coordinate
and manage total costs of care across sectors through mechanisms like:
- Bundled Payments: Prospective bundled reimbursements cover all services for an entire
episode of care extending beyond hospital discharge to encourage prevention and reduce
readmissions.
- Shared Savings: Upside-only or two-sided risk models shared between providers, payers and
employers promote quality improvement and cost control initiatives to achieve target budgets
through gainsharing.
- Global Budgets: Population-based budgets hold health systems accountable for total medical
expenses of enrolled patients, not just individual services delivered, by prioritizing prevention
over high-cost interventions.
- Pay-for-Performance: Bonus payments tie portion of reimbursements to comprehensive process
and outcome metrics spanning clinical quality, care transition rates and patient experience of
coordinated care.
- Grant Funding: Initial investments from public and private sources aid multi-stakeholder
collaboratives in implementing care coordination infrastructure with an eye towards self-
sustainability through alternative payment models over time.
Experts agree achieving sustainability requires continued transition from volume-based fee-for-
service reimbursement towards integrated funding mechanisms tying incentives to delivery
reform. Studies show potential for long-term cost-savings.
Conclusion
Fragmented care remains a key driver of poor outcomes and inefficiency in the U.S. healthcare
system. Integrated care models that align providers and settings through coordinated clinical
practices and payment reform hold great promise for managing total costs and population health.
While challenges remain in changing organizational cultures, overcoming data barriers, and
transitioning payment systems, communities demonstrating the strongest multi-stakeholder
collaborations experience the greatest success sustaining high-quality, affordable, patient-
centered care over time. Continued evolution towards comprehensive integration represents a
key strategy for a higher-performing healthcare system.
