Integrating in Health Care: 6 Tools for Working Across Boundaries


Today’s health care providers face the formidable challenge of delivering better, more affordable and more convenient care in the face of spiraling care costs and an epidemic of chronic disease. But the most innovative among them are making encouraging progress by “integrating”—which in this context means working across traditional boundaries between patients and clinicians, health care specialties, care sites and sectors.

The impulse to do so is shrewd, according to our innovation research in sectors from computer manufacturing to education. We’ve found that when a product isn’t yet good enough to address the needs of a particular customer segment, a company must control the entire product design and production process in order to improve it. This is necessary because in a “not-good-enough” product, unpredictable and complex interdependencies exist between components, so each component’s design depends on that of all the others.

Given this, managers responsible for the individual components must collaborate—or integrate—in order to align components’ design and assembly toward optimal performance. IBM employed an integrated strategy to improve performance of its early mainframe computers, and this enabled the firm to dominate the early computer industry when mainframes weren’t yet meeting customers’ needs.

In health care delivery, such integration is analogous to, but something more than, coordinated care. It means assembling and aligning resources and processes to deliver the right care, in the right place, at the right time. This type of integration is a core aspiration of innovative providers leading hot-spotting and aging-in-place programs, capitated primary care practices, initiatives addressing health-related social needs, and other care models that depart from America’s traditional, episodic, acute-care model. How are they tackling it? They’re leveraging very specific tools to facilitate work across boundaries. Here are six of the most common we uncovered in our research:

  1. “Alternative” payment models. Providers operating under the U.S.’s predominant fee-for-service model can only get reimbursed for services pre-approved by insurers; and these have traditionally excluded activities necessary for delivering integrated care, like speaking to other physicians about a shared patient’s treatment. Alternative models, however, such as those paying providers for bundles and/or outcomes of services provided, offer providers flexibility in how they care for patients, and thus more freedom to integrate.
  2. Staffing and organization structure. In traditional health care settings, the majority of clinical care and associated documentation is physician-led. This fact has contributed to high rates of physician burnout, while limiting the contribution of other health care experts and patient advocates. Innovative models we study often integrate experts in behavioral health and health-related social needs with their clinical care teams. Some also include health coaches, patient navigators, and other patient advocates.
  3. Technology. Technology is an obvious tool for enabling more integrated care, but much industry discourse on how best to leverage it focuses narrowly on interoperability of Electronic Health Records (EHRs). By contrast, integrated care delivery models we’ve studied go beyond EHRs, developing technology to drive workflows and standardize recurring care tasks where appropriate. This enables providers to devote more bandwidth to integration activities requiring a more unique approach, like engaging with patients to understand living circumstances affecting their health, or help them better manage chronic conditions.
  4. Protected time for collaboration and data synthesis. Integration in health care is a process, and it’s never finished. Some innovators we’ve studied therefore create protected blocks of time for integration activities, whether it’s daily “huddles” enabling care teams to align on next steps for their sickest patients; weekly “quiet hours” for team members to analyze data across various sources to get an “integrated” picture of their patients’ status; or a fixed number of appointments held open every day so that providers can respond in real-time to patients’ unexpected needs, whether for medical intervention or conversations that deepen their relationship.
  5. Partnerships. Delivering better, more affordable and more convenient care requires a shift away from hospitals, whose high overhead drives care costs up, and into communities. In many cases, it also means addressing non-medical determinants of health. Since it’s difficult (if not impossible) for a single organization to acquire the scale and expertise required to achieve those objectives, innovative providers are partnering with organizations across communities and sectors to do so. For example, Cedars-Sinai Medical Center recently partnered with barbershops across Los Angeles to pilot a program helping African-American men control their blood pressure.
  6. Culture. None of the above tools can change the fact that working across boundaries is often challenging and uncomfortable. It requires empathy, creativity, open-mindedness and unwavering determination to improve all patients’ lives. The highly integrated organizations we’ve studied, including Kaiser Permanente, Oak Street Health and Iora Health, appear to have strong cultures characterized by such attributes, and seek to hire people who can embrace them.

While each of these integration tools is powerful in its own right, it’s crucial to understand that none is a silver bullet for delivering better, more affordable and more convenient healthcare. Providers need to leverage all of them in some shape or form, in order to achieve optimal performance against this objective. Rushika Fernandopulle, CEO and Co-Founder of Iora Health, told us how he reinforces this point. “I’m gonna take some of your internal organs today,” he says with a mischievous grin. “Which one is the most important, and I’ll make sure to leave that?”

Rebecca Fogg is a senior research fellow at the Clayton Christensen Institute, where she studies business model innovation in health care delivery, including new approaches to population health management and person-centered care.

4 replies »

  1. When beginning to think about all of this, it makes one think that maybe a lion’s share of our nation’s ‘ unstable HEALTH ‘ and its healthcare problems are ultimately driven by the rapid decline in our nation’s social capital, community by community, after WWII. This decline was especially troublesome from 1950-70.

    Interestingly, our nation’s maternal mortality ratio began to worsen in 1987-88. [ Think about it. ] Since then, it still continues to worsen in all states during the last 15 years, except for Alabama, California, and Colorado. The state by state, maternal mortality ratio (MMR) incidence during 5-10 year, prolonged duration intervals can each be rank-ordered and divided into 6 clusters of about 6-10 states with very similar MMR incidence. The 9 states with the lowest maternal mortality incidence for 1987-96 represented an average of ” 3.44 ” maternal deaths per 100,000 living births annually. For for the 7 best states in 2001-2006, it was ” 3.56 “. And for the 5 best sates in 2005-2014, it was ” 7.22 “. The corresponding data for the 3 successive, Cluster analysis of states with the worst maternal mortality incidence was ” 11.14 ” (9 states), ” 18.65 ” (10 states), and ” 27.58 ” (6 states).

  2. Also, some if us feel that the health care sector has had enough creative destruction and innovation—much of which was thrust upon it by outside non-clinical thinkers—and that burn-out and failed efforts to achieve the golden goals of cost, quality and accessibility—are partly owing to the ragged everlasting desultory efforts to please the policy makers. Eg we can’t have interoperability (every provider can be presented with all the relevant data) while ripping the family doc away from his hospital
    visits and replacing him with hospitalists. This was oxymoronic policy devised by fiscal forces outside clinical medicine.

  3. Good, Rebecca.
    Don’t forget that good social relationships are the very best thing one can aim for to improve health. Happily, one can do some of this without necessarily tapping the care system. .

    See Dr Emma Seppala and The Center for Compassion and Altruistic Research and Education at Stanford. ccare.stanford.edu

    Also J S House in Science Vol 241 29 July 1988. Social Relationships and Health

  4. Now 25 years ago, a book written by Peter Drucker was published, entitled “Post-industrialist Society.” His thesis focused on the industrial transition that was occurring from ‘making things’ to ‘thinking about things’ as a basis for producing financial capital. His opinion for post-industrialist businesses was based on the profits generated by ‘making things.’ Instead of investing in the supply lines and processing machines as a basis of economic growth, he applied the same logic to information processing for corporate economic growth. Simply stated, a business must ‘invest’ in the professional assets of its ‘thinking about it’ assets.

    Some might look askance at the concept of professional development, but that is exactly what Peter Drucker meant. Stephen Covey et al wrote a book about it that appeared in ” 1994.” Its title: “First Thing First.” So, my possibly uneducated assessment is that not one physician or hospital CEO has had the opportunity to participate for 5 or more years in a supportive professional development program! Shame on us all !!!

    Secondly, the term “social determinants” has become associated with extreme poverty and capable of mitigation with a financial investment. Well, it would be difficult to name one national investment, besides Early Childhood Education (aka Head Start), that has successfully reversed the loss of social mobility for certain children within a Zip Code characterized by a high prevalence of poverty. Social Mobility in this scenario refers to the likelihood that a person who grows-up in the lowest socio-economic grouping eventually lives in the 3rd socio-economic grouping during their 40s or 50s.

    Robert D. Putnam, PhD is probably the best student of our nation’s profound loss of social mobility. The most important strategy to reverse the loss of social mobility is a locally unique commitment to improve their own community’s level of Social Capital, community by community. A quotation from Eleanor Roosevelt says it all: “It’s better for every body when it gets better for everybody.”

    It is likely that the list of improvements cited with your Post will continue to be largely ineffectual given the lack of recognition for the prime cause of our nation’s “worsening” incidence of mass shootings and maternal mortality. Parenthetically, the return on investment (ROI) for early childhood education has been determined to be 7:1 . This compares to a ROI of 3-4:1 for flooding mitigation projects.