Integrated Care: What state of change is your organization in?

With the Center for Medicare and Medicaid Services’ (CMS) first data snapshot focusing on the prevalence of depression and the need for integrated care, the call for population health goals becomes increasingly clear. The pressure is on for system changes to work not only collaboratively to identify goals for patient-centered care but also to create dialogue and communication pathways to exchange data and ensure treatment engagement, adherence and retention across clinical services that traditionally have not engaged with each other [see the New York Medicaid Redesign Team recommendations]. 

There is new emphasis on outcome metrics, data reporting and equitable access to quality care that reduces service disparity and population health risks. As organizations shift to address system changes that leverage growth and expertise in this changing landscape of integrated care, several key steps are needed to assess readiness and identify implementation needs. Organizations must identify growth capacity by looking at their community health needs and determine whether transitions to different models of care would increase the agency’s capacity to address community health needs and support sustainable reimbursements for an altered clinical practice model. An organizational readiness assessment is also crucial (MCTAC executive summary to NYS). An analysis of licensing options, attestation requirements, certification demands, staff knowledge acquisition requirements, and facility expansion needs are required to inform organizational growth plans with defined target goals and an implementation map to support change. Each organization must also consider the levels of system interventions needed, the role and knowledge contributions of its treatment team to the treatment process and identified outcomes when negotiating rates, defining service applications across population groups and identifying the cost of altered models of care (see article, Behavioral health integration: an essential element of population-based healthcare redesign). Organizations need to map growth plans with realistic benchmarks and due dates, and identify key staff to develop training aligned with organizational knowledge needs. In addition, organizations should identify staff strengths while offering opportunities for knowledge acquisition. They should identify population based programming needs and build collaborative partnerships that will be complementary in addressing the identified community and population-based needs while building a foundation of organizational expertise. It is important for the organization to secure data exchange solutions, both quantitative and qualitative in nature, that support changes in its agency’s clinical and business practices, and develop administrative and clinical supports with an intelligent design to better meet its population’s health goals. 

The key is to innovate, educate and be ready for adaptation and change, again and again. This “change wheel” is a moving course of actions. While growth is exciting and sustainability is an ever pressing need for organizations to identify, the end goal is even more important: Bettering population health outcome one person at a time.