The document defines various types of integrated delivery systems. An integrated delivery system is a network of organizations that provides coordinated care for a defined population and is responsible for their health status. Integrated systems vary in their breadth of services, depth of operating units, and degree of integration. Clinical integration coordinates care across functions to provide cost-effective, quality care. Structural integration brings organizations together under one structure while functional integration coordinates support functions. The Kaiser Permanente model exemplifies vertical integration through ownership of facilities and contracting with physician groups. Independent practice associations also integrate physicians virtually through contractual relationships without common ownership.

1. Definitions of
Integrated Delivery
System

2. Integrated care
Well-planned and well-organized set of
services and care processes, targeted at
the multidimensional needs of an
individual client, or a category of
persons with similar needs … built up by
elements of acute health care, long-term
care, social care, housing and services
such as transport and meals.

3. Integrated Delivery System
 Is a network of organizations (e.g., ambulatory
care clinics, physician groups, diagnostic
centers, hospitals, nursing homes, home health
care agencies) which provides, or arranges to
provide, a coordinated continuum of services to
a defined population and is willing to be held
clinically and fiscally responsible for the health
status of that population. These systems often
own, or are closely aligned with, an insurance
service.”

4. Integrated Delivery System
 Integrated health systems vary according to
their breadth (number of different functions
and services provided along the continuum of
care), depth (number of different operating
units within a system that provide a given
function or service) and degree of integration
(proportion of health services integrated)

5. Different Names for The Same Concept
 Integrated Delivery Networks
 Integrated Delivery System (IDS)
 Integrated Health Care System
 Integrated Health Delivery System
 Integrated Health Networks
 Integrated Healthcare Delivery Systems
 Integrated Healthcare Network (IHN)
 Organized Delivery Systems

6. Clinical integration
 “The extent to which patient care services are
coordinated across various functions, activities,
and operating units of a system.
 It is viewed as the most important form of
integration because it is the primary means by
which organized delivery systems are able to
provide cost effective, quality care in a
managed care environment, particularly under
capitated payment structures.”

7. Integration: Horizontal vs. Vertical
 Clinical integration is established on a
horizontal and vertical plane:
1. Horizontal integration is, among the various
services offered for the same period of care
(e.g. follow-up in the community and job
market integration),
2. Vertical integration is among the various
levels associated with this process (e.g.
between hospitalization and post-hospital
follow-up).”

8. Vertical integration
 “Attempts to bring under one organizational
roof all of the different health care activities
that are necessary for the production of
improved patient health.
 “In health care, involves affiliation under one
management umbrella of organizations that
provide different levels of care. Goals include
increasing efficiency, enhancing coordination of
care along the continuum, and providing ‘one-
stop-shopping’ for managed care purchasers
and payers.”

9. Horizontal integration
 “In health care, involves affiliation under one
management umbrella of organizations that
provide a similar level of care. Usually involves
consolidation of resources among the
organizations with the goals of increasing
efficiency and taking advantage of economies
of scale.”

10. Integration: Structural vs. Functional
 An Effective patient-centred integration
requires two components:
1. Structural integration
2. Functional integration

11. Structural integration
 Bringing together staff and resources in one
single organization under a single unified
hierarchical structure.
 “Requires ownership of the range of health care
services necessary for maintenance or
improvements in patients’ health.”

12. Structural clinical integration
 “Reflects the degree of clinical integration
achieved by hospitals from a structural
perspective. Four dimensions of structural
integration:
1. integration across sites of care
2. integration across divisions of care
3. integration of physicians
4. integration of the information technology

13. Functional integration
 “The extent to which key support functions and
activities such as finance, human resources,
strategic planning, information management,
marketing, and quality assurance/improvement
are coordinated across units.”

14. Virtual integration
 Health care organizations exist within a
network of organizations working towards a
common goal of providing health care to a
given population through contractual
relationships but without common ownership.”

15. The Kaiser-Permanente Medical Care Program
 The organizational model typified in the Kaiser
Permanente HMO has come to be known as
vertical integration.
 Most Kaiser Permanente regional units own
their hospitals and clinics, hire the nurses and
other personnel staffing these facilities, and
contract with a single large group practice (the
Permanente Medical Group) to exclusively
serve patients covered by the Kaiser health
plan.

16. The Kaiser-Permanente Medical Care Program

17. The Kaiser-Permanente Medical Care Program
 The Kaiser form of HMO differs from traditional
fee-for-service models in how it pays
physicians (salary) and hospitals (global
budget). It also differs in how health services
are organized. Most obvious is the prepaid
group practice structure that contrasts with the
traditional United States style of solo,
independent private practice.
 In addition, Kaiser has typically regionalized
tertiary care services at a select number of
specialized centers. Most regions have also
integrated nonphysicians such as nurse
practitioners and physician assistants into the
primary care team.

18. The Kaiser-Permanente Medical Care Program
 Unlike a public district health authority in the
United Kingdom, an HMO such as Kaiser
Permanente is not responsible for the entire
population of a region, but these private,
vertically integrated systems in the United
States do assume responsibility for organizing
and delivering services to a population of plan
enrollees. The prepaid nature of enrollment in
the Kaiser plan permits Kaiser to orient its care
more toward a population health model.

19. "Virtual Integration": Independent Practice
Associations
 IPA-model HMOs were far easier to organize
than prepaid group practices; a county or state
medical society, a hospital, or an insurance
company could simply recruit the office-based
fee-for-service physicians practicing in the
community into an IPA, and thereby create the
basis for an HMO.
 The physicians could continue to see their non-
IPA patients as well.

20. "Virtual Integration": Independent Practice
Associations