Characteristics of a Fully Integrated Delivery System

After our talking to describe forms of integration of medical system; would like to review main and acceptable integration characteristics(Domains) have put by America’s Essential Hospitals as follow:

Component of fully integration health system;

Domain 1: Value-Driven Governance & Leadership:

Ø  The board is very focused on integration and reflects all relevant stakeholders.

Ø  Administrative leadership is very committed to promoting and implementing integration.

Ø  Physician leaders are very committed to promoting and implementing integration.

Ø  The organizational structure is very favorable to integrated care.

Ø  Strategic, financial and operational planning toward integration is very clear and convincing.

Ø  A culture of safety and teamwork is continuously taught and reinforced.

Ø  Financial, quality and community benefit data are transparent throughout the organization and to the community.

Domain 2: Hospital/Physician Alignment:

Ø  The system has a clear and convincing approach to aligning and integrating clinicians with hospital administration.

Ø  Physician leaders frequently represent the interests of all system physicians.

Ø  Physicians and administrators frequently participate in joint decision making.

Domain 3: Financial Integration:

Ø  The system is well-prepared for assuming risk-based payment and has conducted considerable analysis of the implications.

Ø  The system has a very good ability to manage contractual relationships with payers with sufficient staff/resources and compatible information systems.

Domain 4: Clinical Integration/Care Coordination:

Ø  The system provides or contracts for the full range of services and sites of care needed to meet patient demand for preventive, ambulatory, acute, post-acute and behavioral health care.

Ø  Strong evidence exists of accountability, peer review and teamwork among providers.

Ø  Care is frequently delivered at the most cost-effective and appropriate setting.

Ø  Transitions and handoffs between settings are effectively managed and need little improvement.

Ø  Strong collaboration exists between the hospital system and social services.

Ø  The system has almost fully integrated behavioral health programs into primary care.

Domain 5: Information Continuity:

Ø  Electronic Health Records (EHRs) for each patient are accessible to all providers within the system and most community providers outside of the system.

Ø  The EHR system can track all patient encounters and combine all data to system wide level for evaluation and benchmarking.

Ø  EHRs can track health outcomes of patients with specific conditions within all physicians’ panels.

Domain 6: Patient-Centered & Population Health Focused:

Ø  The system has very good, complete data on sociodemographic, utilization, cost and health status characteristics of the populations it serves.

Ø  The system’s resources and services are well-matched to the needs of the populations served.

Ø  The system provides significant social services to assist patients in accessing needed care.

Ø  The system provides almost full or full, 24/7 access to care via phone, email or in-person visits.

Ø  The system has trained all or nearly all staff in cultural competency skills.

Ø  All providers have been trained in encouraging expanded patient/family/caregiver roles in decision making and self-management.

Domain 7: Continuous Quality Improvement & Innovation:

Ø  The system frequently trains/develops employees to be future leaders.

Ø  The system frequently tests strategic activities through pilot projects

Ø  Staff feel very empowered to innovate.

Ø  Providers frequently employ evidence-based practices.