Care integration within and outside health system boundaries

Objective: Examine care integration—efforts to unify disparate parts of health care organizations to generate synergy across activities occurring within and between them—to understand whether and at which organizational level health systems impact care quality and staff experience. Data Sources: Surveys administered to one practice manager (56/59) and up to 26 staff (828/1360) in 59 practice sites within 24 physician organizations within 17 health systems in four states (2017-2019). Study Design: We developed manager and staff surveys to collect data on organizational, social, and clinical process integration, at four organizational levels: practice site, physician organization, health system, and outside health systems. We analyzed data using descriptive statistics and regression. Principal Findings: Managers and staff perceived opportunity for improvement across most types of care integration and organizational levels. Managers/staff perceived little variation in care integration across health systems. They perceived better care integration within practice sites than within physician organizations, health systems, and outside health systems—up to 38 percentage points (pp) lower (P <.001) outside health systems compared to within practice sites. Of nine clinical process integration measures, one standard deviation (SD) (7.2-pp) increase in use of evidence-based care related to 6.4-pp and 8.9-pp increases in perceived quality of care by practice sites and health systems, respectively, and a 4.5-pp increase in staff job satisfaction; one SD (9.7-pp) increase in integration of social services and community resources related to a 7.0-pp increase in perceived quality of care by health systems; one SD (6.9-pp) increase in patient engagement related to a 6.4-pp increase in job satisfaction and a 4.6-pp decrease in burnout; and one SD (10.6-pp) increase in integration of diabetic eye examinations related to a 5.5-pp increase in job satisfaction (all P <.05). Conclusions: Measures of clinical process integration related to higher staff ratings of quality and experience. Action is needed to improve care integration within and outside health systems

The association between care integration and care quality

Objective: The study aims to analyze the relationship between care integration and care quality, and to examine if the relationship varies by patient risk. Data Sources and Study Setting: The key independent variables used validated measures derived from a provider survey of functional (i.e., administrative and clinical systems) and social (i.e., patient integration, professional cooperation, professional coordination) integration. Survey responses represented data from a stratified sample of 59 practice sites from 17 health systems. Dependent variables included three quality measures constructed from patient-level Medicare data: colorectal cancer screening among patients at risk, patient-level 30-day readmission, and a practice-level Healthcare Effectiveness Data and Information Set (HEDIS) composite measure of publicly reported, individual measures of ambulatory clinical quality performance. Data Collection/Extraction Method: We obtained quality- and beneficiary-level covariate data for the 41,966 Medicare beneficiaries served by the 59 practices in our survey sample. Study Design: We estimated hierarchical linear models to examine the association between care integration and care quality and the moderating effect of patients' clinical risk score. We graphically visualized the moderating effects at ±1 standard deviation of our z-standardized independent and moderating variables and performed simple slope tests. Principal Findings: Our analyses uncovered a strong positive relationship between social integration, specifically patient integration, and the quality of care a patient receives (e.g., a 1-point increase in a practice's patient integration was associated with 0.31-point higher HEDIS composite score, p &lt; 0.01). Further, we documented positive and significant associations between aspects of social and functional integration on quality of care based on patient risk. Conclusions: The findings suggest social integration matters for improving the quality of care and that the relationship of integration to quality is not uniform for all patients. Policymakers and practitioners considering structural integrations of health systems should direct attention beyond structure to consider the potential for social integration to impact outcomes and how that might be achieved.</p