Integrating care across provider types is a key strategy for improving care for populations with complex needs. This is particularly the case in primary care, which is often people’s entry point into the health system and is frequently responsible for coordinating care for individuals with complex health and social needs. For example, primary care providers may seek to coordinate with other entities or develop multidisciplinary teams to support patient access to physical health specialists, behavioral health services, and even social services.
Care integration is also a common focus of care delivery and payment reform initiatives, such as accountable care organizations (ACOs). ACOs are groups of health care providers that come together to provide high-quality, coordinated care for their patients.
To better understand primary care practices' experiences with care integration and how Medicaid policy can influence integration, the Playbook recently spoke with Michaela Kerrissey, Associate Professor of Management, Health Policy and Management, Harvard T.H. Chan School of Public Health. Dr. Kerrissey’s research focuses on innovation in health care organizations, including how health systems and care teams can better integrate care and help overcome organizational silos. Her recent co-authored paper analyzes the level of care integration within primary care sites in Medicaid ACOs in Massachusetts, based on a survey conducted 18 months after initial program implementation.
Q. How do you define integrated care and care integration?
A. Integrated care is the outcome we are trying to produce. I use the definition of integrated care developed by Sarah Singer and colleagues, which is: “patient care that is coordinated across professionals, facilities, and support systems; continuous over time and between visits; tailored to the patients’ needs and preferences; and based on shared responsibility between patient and caregivers for optimizing health.” I define care integration as the structures, processes, activities, and social relationships that can be put into place by health care organizations to generate the experience of integrated care.
Q. Why is integrated care important for people with complex health and social needs?
A. Everyone should feel that their care is continuous, coordinated, and inclusive of their needs and preferences. That said, integrated care is particularly important for people with complex health and social needs because this group faces greater risk of receiving fragmented care. For example, if someone only receives one health care service a year, the potential for fragmentation is low. However, in contrast, for patients who receive multiple services across multiple health care settings on a regular basis, coordination and continuity of care becomes particularly relevant. When people have many touchpoints with the health system, there’s more opportunity for their preferences or other pieces of information about their care to get lost in communications between providers. The health system often relies on patients to coordinate between providers, but that’s hard work given the complexities of the health system.
Q. What are key barriers to care integration at the primary care level?
A. I’m happy to say it’s not a lack of desire on the part of providers! Fragmented care is a source of frustration for providers just as much as it is for patients. The barriers to integrated care are much more practical and embedded in how the health system has been historically designed. Achieving integrated care requires organizational change, such as changing workflows and policies, building infrastructure, and developing new relationships, to overcome traditional health care silos and that is challenging.
For example, one finding from my work on primary care integration in Massachusetts’ Medicaid ACOs was that the level of integration around behavioral and social services was much lower on average than it was in clinical integration. My hypothesis is that this is in part because the former requires broader changes, both within and across organizations, which are thornier to pursue. Implementing clinical integration, such as by implementing new clinical protocols, organizing new types of heath care teams, or tracking certain quality measures, is largely within the bounds of one healthcare organization.
When we start to think about behavioral and social service integration, that generally goes beyond the boundaries of individual health systems and requires new ways of working across organizations. This brings challenges for integrating both processes and structures. For example, are referral systems at different organizations able to share data back and forth? How do providers know how a referral to a social service organization got resolved? If not in place, these systems and protocols are challenging to construct. The social and relational elements of integration are just as important. How do you build the relationships that are needed to have the trust and joint problem solving required to support integrated care? Getting novel cross-organization efforts off the ground requires intensive problem solving and learning in the early days.
Q. How can Medicaid ACOs support better care integration?
A. Medicaid ACOs are making care integration a core goal of delivery system reform and changing the payment system to support that. Being explicit about the goal of providing integrated care creates the opportunity for organizations to make explicit connections between integration and other priorities like advancing health equity. Additionally, we have historically seen that one of the main barriers to integrated care is that the predominant fee-for-service payment system does not enable it. Even the most well-intentioned primary care practices will have a hard time integrating care if they are working against their payment environment. Changing payment incentives so that provider organizations don’t harm themselves financially is important. Moving toward care integration is challenging, even when appropriate financial incentives are in place, but payment reform is an important starting point.
An optimistic finding from my research on Massachusetts’ Medicaid ACOs is that, while integration is hard work, primary care providers and administrators in practices that were able to do it reported better perceived ability to improve quality of care and address health equity issues. So far, our work has only looked at outcomes from the first 18 months of the Massachusetts Medicaid ACO implementation but it shows trends in the right direction.
Q. What considerations would you highlight for policymakers seeking to support integrated care for Medicaid members with complex needs?
A. A key policy strategy is providing supports for practice transformation. Without that, the primary care practices that have the farthest to go toward achieving care integration will be left behind. One finding in our study of Massachusetts ACOs is that prior experiences of a practice site, such as prior experience with value-based contracts or collaborations with other organizations, was associated with their ability to make short-term changes toward more care integration. This signals that there are different resource needs across practices to do this work. There is opportunity for states to design implementation supports tailored to where different practices are starting from. States can also consider how to better support cross-practice learning. For example, with behavioral health integration, we saw both a huge need for greater integration and wide variation in how integrated practices were. While there are a lot of practices that have a long way to go to support behavioral health integration, there are also some practices doing it in sophisticated ways. There is opportunity for primary care practice learning communities within and across states to share practical strategies for success.
States should also think holistically about how to evaluate changes at the front line of care. There is opportunity to collect more intermediate measures related to integration of services so that they can be compared across practices and across ACOs. If we can do that with precision and standardization across settings, measures of integration can inform us about where there are gaps in care integration and what operational tweaks are needed to make it easier and faster for organizations to change.
Q. Are there other lessons related to how health care organization can work toward care integration that you would like to highlight?
A. I would emphasize the importance of the social aspects of care integration (e.g., teamwork, interpersonal relationships, norms that care integration is valued). In the policy literature, function and process factors tend to get more attention, but research shows that social features are strong predictors of an organization’s ability to integrate services and deliver high quality care. Social factors related to care integration deserve attention too and are something that leaders are well-equipped to instill deliberately within their organization. In some of my research, I’ve seen substantial variation across practice sites in how people talk about norms and values related to care integration and how much it is prioritized. This suggests that the role of leadership in supporting those social aspects is huge and deserves thoughtful attention.