This document discusses integrated care and provides evidence in support of more integrated models of care delivery. It makes three key points: 1) Current healthcare systems often fail to provide integrated care for patients with chronic conditions who require care from both primary physicians and hospitals. Effective coordination of this care can result in better outcomes and lower costs. 2) Integrated delivery systems (IDS) that provide coordinated, team-based care show promise in improving quality of care and health outcomes, especially for patients with chronic conditions. The Veterans Health Administration and Kaiser Permanente are cited as examples of high performing IDS models. 3) Evidence suggests that use of elements of the Chronic Care Model, such as patient registries, self

1. INTEGRATED CARE: POLICY AND EVIDENCE
Stephen M. Shortell, Ph.D.
Blue Cross of California Distinguished Professor of
Health Policy and Management
Dean, School of Public Health
University of California-Berkeley
HSRN/SDO Conference
Birmingham, England
June 3 and 4, 2009

2. “One of the biggest failings of modern healthcare
systems is that they so seldom provide integrated
medical care. In emergencies, patients head for
the local hospitals; for minor illnesses they
consult their family doctor. But for chronic
conditions such as diabetes and cardiovascular
diseases, which are becoming increasingly
prevalent, they require care and advice both in
their primary physician and from the hospital.
Effective coordination of this care results in better
and cheaper treatment, yet too often it does not
happen.
– The Health of Nations, Economist, July 17, 2004:13

3. Global Challenge of Chronic Disease
• 60 Percent of All Deaths Worldwide
• 80 Percent Occur in Low and Middle Income Countries
• Double the Number of Deaths Occurring from
Infectious Diseases
• Huge Negative Economic Impact – 10 years
• China – $558 Billion
• India – $237 Billion
• UK – $33 Billion

4. Integrated Delivery System
(IDS) Definition
A network of organizations which provides or
arranges to provide a coordinated continuum
of services to a defined population and is
clinically and fiscally accountable for the
costs, outcomes and (working with others) the
health status of the population served.

5. Key Features of An Integrated Delivery
System (IDS)
• Shared Values and Goals
• Alignment of Incentives
• Physician Leadership
• A Culture of Teamwork

6. Key Features of An Integrated Delivery
System (IDS) (cont’d)
• Comprehensive Longitudinal Electronic Medical /
Health Records
• Shared Practice Guidelines
• Patient-Centered
• Integration Across Settings
• Matching Resources and Services to Population
Needs
• Linkages to Public Health and Social Services
Source: Adapted from A. Enthoven “Integrated Delivery Systems“, March 25, 2008.

7. Some Models to Consider
• Chronic Care Model
• Disease Management
• “Medical Home”

8. Chronic Care Model
Community
Resources Organizational
and Linkages Leadership and
Practices
Health Care
Team
Redesign
Informed Prepared
Activated Productive Interactions Proactive
Patient Team
Adapted from: E.H. Wagner, B.T. Austin, and M.R. Von Korff, “Organizing Care for
Patients with Chronic Illness,” The Milbank Quarterly, 74 (4), 511-544, 1996.

9. The National Health Service and Social Care
Long-Term Conditions Model
Infrastructure Delivery System Better Outcomes
Community Case Management
Resources
Supporting Empowered and
Informed Patients
Creating
Disease
Decision Support
Management
Tools and Clinical
Information System Prepared and
(NPfIT) Pro-active Health and
Supported
Self-Care Social Care Teams
Health and Social
Care System
Environment Promoting
Better Health
Source: Department of Health 2005a.

10. Summary of Evidence
• Use More Evidence-Based Care Management Processes,
Preventive Services and Health Promotion Programs
(Casalino et al., 2003, Mehrota et al., 2006; Gillies et al.,
2006)
• Use More Elements of the Chronic Care Model (Shortell et
al., 2005, 2009)
• More Likely to Use Electronic Medical Records (EMRs)
(Robinson et al., 2009)

11. Summary of Evidence (Cont’d)
• The U.S. Veterans Administration (VA) Provides Higher Quality of
Care to Its Patients than a Matched Group of Non-VA Medicare
Patients (Asch et al., 2004; Peterson et al, 2004; Kerr, 2004)
• The U.S. Kaiser Permanente System Demonstrated Higher Quality
than NHS with Similar Cost Per Beneficiary (Feachem et al., 2002;
Han et al., 2003)
• Mixed or Limited Evidence on Costs (Fulop, 2009)
• Internationally Little Evidence of Impact on Outcomes of Care
(Fulop, 2009)

12. Kaiser-Permanente Reduces Cardiac
Deaths by 73 Percent
• Linkage of Teams with Electronic Health Record and Advanced
Clinical Care Registry
• Integrated Nursing and Pharmacy Teams Worked Collaboratively
with Patients and Their Doctors
• Involved Proactive Patient Outreach, Education, Lifestyle
Adjustments, and Effective Medication Management
• “Technology itself cannot solve the health care crisis. Our
Colorado region achieved results by aligning people and
technology in the most efficient care delivery system...an
integrated approach to deliver the right care at the right time”
– George Halvorson, President and CEO

13. UC Berkeley Study
Use of Care Management Processes by Type of Chronic Condition
Type of CMPs Diabetes Asthma CHF Depression Each of 4
(n = 523)+ (n = 522) (n = 526) (n = 497) Chronic Illness
It Treats
(n = 491)
Patient list or registry 70.2% 62.4% 58.5% 40.8% 39.1%
Provide patient educators 73.9% 53.8% 53.6% 35.4% 30.5%
Physician feedback on quality 66.1% 56.1% 50.8% 32.8% 30.9%
Nurse care managers 54.7% 42.7% 47.5% 25.1% 23.8%
Patient reminders 51.4% 35.2% 35.0% 19.7% 19.1%
Point-of-care reminders 51.2% 36.4% 33.1% 22.9% 19.5%
No. (%) using all 6 CMPs 21.6% 10.5% 10.1% 4.4% -
No. (%) using all 24 CMPs - - - - 3.7%
Mean CMP Use (out of 6) 3.7 2.9 2.8 1.8 -
Mean CMP Use (out of 24) - - - - 11.1
Source: D. Rittenhouse et al., “Improving Chronic Illness Care: Findings From National
Study of Care Management Processes in Large Physician Practices,” 2009, Under Review.

14. National Study of Large Physician Organization and
Management of Chronic Illness – Key Findings
• Only ½ of Recommended Care Management
Processes Are Used
• Disease Registries
• Patient Educators
• Performance Feedback to Physicians
• Highest for Diabetes; Lowest for Depression
• Factors Associated with Greater Use
• Patient-Centered Management Behaviors
• Participation in Quality Improvement Programs
• Hospital / Health System Ownership
• External Evaluation on Quality
• Very Large Groups
Source: National Study of Physician Organizations II, UC-Berkeley, 2009

15. Patient Centered Management Behaviors
1) Organization does a good job of assessing patient
needs and expectations
2) Staff promptly resolve patient complaints
3) Complaints are studied to identify patterns and prevent
problems from recurring
4) Organization uses data from patients to improve care
5) Organization uses data on patient expectation or
satisfaction when developing new services
Adapted from: Malcolm Baldridge National Quality Award, U.S. Department of Commerce,
Washington DC

16. Does Disease Management Really Work
0.35
0.3
0.25
0.2 Disease Control
0.15
0.1
Morbidity
0.05 Patient Knowledge
0 All-cause Mortality
Quality: Outcomes of Care
Source: Scott Weingarten,M.D. “What’s Working and What’s Not in Disease
Management: Lessons Learned Nationally and Internationally.” Annual
Supplement on Disease Management and Quality Improvement. May 6, 2002.

17. Does Disease Management Really Work
1.2 Provider
1 Adherence
0.8 To Guidelines
0.6
0.4
0.2
0
Quality: Processes of Care
Source: Scott Weingarten,M.D. “What’s Working and What’s Not in Disease
Management: Lessons Learned Nationally and Internationally.” Annual
Supplement on Disease Management and Quality Improvement. May 6, 2002.

18. Medical Home
Four Cornerstones
• Primary Care
Comprehensive First Contact Care Across the Lifespan
• Patient-Centered Care
Meeting the Needs and Preferences of Actively Engaged Patients
• New-Model Practice
Evidence-based: Population-based Registries, Performance
Measurement and Improvement, Point of Care Decision Support,
Electronic Health Records; Redesigned Work Processes
• Payment Reform
Pay for Care Coordination; Episode of Care Based Payment
Source: DR Rittenhouse and SM Shortell, “The Patient-Centered Medical Home: Will It
Stand the Test of Health Reform?”, JAMA, May 20, 2009, 301(19);2038-2040.

21. Chronic Care Management in the UK
• Use of Community Matrons
• A Lot of Different Initiatives
• Risk Stratification
• Peer Support and Patient Self-Management are
Not Routine Part of Care
• No Financial Incentives for Participation in
Chronic Care Initiatives
• Relatively Little Evaluation to Date
• New Integrated Care Pilots

22. Critical Success Factors for Chronic
Disease Programs in England
Whole systems approaches Training to support staff in new roles,
including project management training
Shared boundaries and vision between
health and social care Increasing staff competencies
Empowering people to take responsibility, Organizational stability
including service to users
High-quality information management and
Providing car based on levels of need (risk technology
stratification)
Involvement of al key stakeholders, including
Not running (competing) services in parallel professional representative bodies
Changing professional attitudes and Creating the right incentives
behaviors via organizational culture change
Adequate investment in services
Overcoming resistance to clinical and
managerial change Adequate time frames in which to test
services
Strong clinical leadership
Focusing on realistic targets
Not assuming that initiatives will reduce costs

23. Barriers to the Creation of a Strong
Culture
• Diverse services or products that must be provided
• Complex external environment
• Outcomes difficult to measure
• High degree of diverse professionals who work in health
care organizations. Professional identities and concerns
are often more important than organizational goals and
objectives
• A high degree of specialization – opportunity for a lot of
subcultures to develop
• Rapid growth. Move so quickly that the organization
doesn’t have a chance to reflect on what’s been created.

24. Culture Outcome Options in
Forming Partnerships
Co-Existence
Assimilation

25. Transformation
(Development of A New Culture)
Old New
Rejection
(Separate and Hostile Cultures

26. Some Practical Lessons
• Be clear about what you are trying to achieve
• Start with the work that directly impacts the patient and work “backward”
to design the organizational forms that will best promote this
• “Cultivate the soil”
• Trust among partners
• Local leadership
• Culture of quality improvement
• Effective communication
• Information technology
• Work on the cultural differences between partners
• Align the incentives – including front line staff
• Don’t assume economies of slope or scale – may take time
• Be patient
Adapted from: R. Ruson and C. Ham, “Integrated Care: Lessons from Evidence and Experience”, The
Nuffield Trust, Summary Report, November, 2008

27. Policy Options for Integrating Health and Social Care
• Partnerships between primary care trusts (PCTs) and local authorities
• Important to recognize variations in context and relationships among
stakeholders from one area to another
• User focused. What are we trying to achieve?
• Leadership of PCT board members and senior managers is key
• Integrated governance plus health and social care teams aligned with GP
practices
• Need to involve acute care hospitals
• Clearly articulate the ends to be achieved but be flexible on the means
• The Care Quality Commission can spread positive examples and best
practices to others
C. Ham, “Only Connect: Policy Options for Integrating Health and Social Care”, The Nuffield Trust, Briefing
Paper, April, 2009

28. Making
change possible CARE SYSTEM
• Outcomes:
Supportive Organizations High • Safe
payment and that facilitate performing • Effective
regulatory the work of patient- • Efficient
environment patient- centered teams • Personalized
centered teams
• Timely
• Equitable
REDESIGN IMPERATIVES: SIX CHALLENGES
• Redesigned care processes
• Effective use of information technologies
• Knowledge and skills management
• Development of effective teams
• Coordination of care across patient conditions, services,
and settings over time.
• Use of performance and outcome measurement for
continuous quality improvement and accountability
Source: Institute of Medicine, Crossing the Quality Chasm, p. 127, 2001.

29. Key Recommendation
Think Wholistically –
Four Interrelated Dimensions

30. Components Needed to Achieve System-Wide
Clinical Integration
Strategic x Cultural x Technical x Structural = Results
0 1 1 1 = No Significant Impact
on Anything Really
Important
1 0 1 1 = Small, Temporary
Effects; No Lasting
Impact
1 1 0 1 = Frustration and False
Starts
1 1 1 0 = Inability to Capture
the Learning and
Spread it Throughout
the Organization
Bottom Line  Need all four components integrated and aligned with each
other for lasting system-wide impact

31. Thank You!
What we all strive for
“Healthier Lives In A Safe World”