Implementing High-Quality Primary Care Rebuilding the Foundation of Health Care (2021) / Chapter Skim
Currently Skimming:
5 Integrated Primary Care Delivery
5 Integrated Primary Care Delivery
Pages 141-180
The Chapter Skim interface presents what we've algorithmically identified as the most significant single chunk of text within every page in the chapter.
Select key terms on the right to highlight them within pages of the chapter.
From page 141... ...
. Examples include integrating primary care with behavioral health, pharmacy, and oral health services and with public health and services to address social determinants of health (SDOH)
|
From page 142... ...
: • Structural integration: physical, operational, financial, or legal ties • Functional integration: formal, written policies and protocols for activities that coordinate and support accountability and decision making • Normative integration: a common culture and a specific culture of integration • Interpersonal integration: collaboration or teamwork • Process (or clinical) integration: organizational actions or activi ties intended to integrate care services into a single process across people, functions, activities, and operating units over time The committee focuses its recommendations on implementing the structures and processes that support normative, interpersonal, process, and clinical integration to advance whole-person integrated care.
|
From page 143... ...
FIGURE 5-1 Comprehensive Theory of Integration. SOURCE: Singer et al., 2020.
|
From page 144... ...
. The Nuka integrated primary care team supports structural, normative, and process integration; its core includes a primary care clinician, certified medical assistant, registered nurse case manager, and case management support.
|
From page 145... ...
Clinic operational facilitators of high- alignment, community systems and process quality primary care partnerships, and business model (including technology • Digital health address all six facilitators and data systems) • Payment 2.
|
From page 146... ...
. The end result is that the primary care team integrates over multiple levels with the wide range of expertise and resources needed to provide whole-person primary care that includes prevention, chronic disease management, acute care, behavioral health, oral care, vision care, and culturally relevant traditional healing.
|
From page 147... ...
. Both the SCF Nuka and Intermountain integrated delivery systems have strong structural and functional integration foundations that support their clinical and operational leadership, governance accountability, and investment in promoting cultures of whole-person integrated care while managing overall health care costs continuously over time.
|
From page 148... ...
. In the first 2 years, the Blueprint used demonstration funds to hire additional staff for practices and CHTs, including behavioral health specialists, case managers, wellness nurses, social workers, dieticians, pharmacists, and health coaches.
|
From page 149... ...
Seen as an effective model of integrated delivery, the program provides all Medicare and Medicaid covered services, including primary care services and health plan management, dentistry, prescription drugs and medication management, nursing care, rehabilitation services, personal and in-home care, specialty services, nutritional counseling, social work counseling, transportation services, and
|
From page 150... ...
Behavioral Health Integration The evidence for primary care integration is strongest for a behavioral health–primary care model (Asarnow et al., 2015b; Coventry et al., 2015; McGinty and Daumit, 2020; Miller et al., 2014)
|
From page 151... ...
. A meta-analysis of randomized controlled trials of integrated primary care–behavioral health models for children and adolescents demonstrated better outcomes for the integrated care model compared with usual care.
|
From page 152... ...
, rather than isolated medication management, as may be more typical of adult behavioral health integrated care. Integrating behavioral health and primary care has been shown to have value for the care of older adults as well.
|
From page 153... ...
. Primary care–oral health integration is in an early stage of development.
|
From page 154... ...
Many models of integrated care systems have focused on addressing SDOH, care coordination, and behavioral health needs with a goal of reducing high-cost care for adults with chronic disease (Herrera et al., 2019; NASEM, 2019a)
|
From page 155... ...
. To test another model, researchers conducted a trial of a 2-year, longitudinal, home-based, care management intervention for low-income older adults in communitybased health centers using a nurse practitioner and social worker as part of an interprofessional team with the primary care clinician.
|
From page 156... ...
. Integrated models for primary care pediatrics that incorporate social needs, particularly for preventive care visits, use strategies such as group care, and employ CHWs, navigators, and health coaches to ensure that the behavioral health and psychosocial needs of families are met (Freeman and Coker, 2018)
|
From page 157... ...
, many independent physician practices across the country have closed or are the verge of closing. Primary care capabilities to respond to the immediate and long-term health consequences of the pandemic, including economic, mental and social health complications, requires a high level of integration between public health agencies and primary care practices.
|
From page 158... ...
Cross-sector data integration for enhanced community and population health interventions within primary care is a key area of opportunity, particularly to expand the reach of a traditional primary care setting. Primary care practice data can help public health professionals conduct surveillance and community assessments, while access to public health data for primary care team members can allow them to observe information on community needs beyond the "micro" practice level and conduct proactive risk identification (IOM, 2012)
|
From page 159... ...
Specialist and Hospitalist Integration Key to high-functioning primary care teams is a readily available system for referral of patients from primary care to specialist care when needed. From 1999 to 2009, referrals in the United States from primary care to specialty care more than doubled from 41 million to 105 million (Barnett et al., 2012)
|
From page 160... ...
While patients should be referred for specialist care in complex situations, the referral process should not mean that the primary care service is abdicating their role in the management of the patient's condition. Shared responsibility is necessary to have a fully integrated care model.
|
From page 161... ...
Digital Health Integration Digital technology with data system integration is a key facilitator of integrated care delivery and foundational to achieving accessible highquality primary care. As noted in Chapter 1, no other aspect of patient care delivery has changed as much since the 1996 Institute of Medicine (IOM)
|
From page 162... ...
The delivery model incorporated team-based care with non-clinicians, behavioral health integration, care coordination, and a focus on population health. When compared with FFS Medicaid, this program demonstrated a lower rate of cost growth without reducing quality measures or outcomes of care (Kelleher et al., 2015)
|
From page 163... ...
Implementing these structural elements can begin with asking the basic question of what range of services to include in an integrated model of care (e.g., behavioral health, social services, oral health care, pharmacy services, complex care coordination) to meet the needs of the population and then developing an understanding of the interprofessional team needed to provide, coordinate, and engage individuals and families in this care (e.g., care coordinators, CHWs, therapists)
|
From page 164... ...
These practices will likely rely more on external community partnerships for a more virtual integration of behavioral health, social needs, oral health, and public health. Small practices without the space, personnel, or resources to support the team necessary for integrated care can also band together to benefit from economies of scale (Mostashari, 2016)
|
From page 165... ...
. A systematic review, however, found little research on the effectiveness of clinical leadership on integrated primary care practice and outcomes for individuals (Nieuwboer et al., 2019)
|
From page 166... ...
represents a structural facilitator for implementing integrated primary care delivery, but it is not sufficient to achieve sustained implementation of integrated care. From the Theory of Integration discussed earlier, these health centers would possess the organizational features of structural integration and then need ongoing measurement and monitoring to further implement the functional, normative, interpersonal, and process elements of integration to achieve integrated primary care.
|
From page 167... ...
Thus, new payment models, including value-based payment, must account for and incentivize these additional outcomes. In addition to policies and payment structures not explicitly supporting integrated primary care delivery, care transformation and value-based payment initiatives can have downsides.
|
From page 168... ...
Aligned structures, policies, and leadership are not sufficient for sustainable integrated care; each delivery system must create clear systematic implementation processes, including clinical and operational workflows that allow teams to work together to meet the individual and complex medical, social, and behavioral health needs of individuals and families. These processes will often include digital or eHealth innovations and a clear system for data collection, measurement, and "self-study" continuous improvement, which will produce innovations equitably matched to improve health at the community or population level.
|
From page 169... ...
2019. Behavioral health integration with primary care: Implementation experience and impacts from the State Innovation Model Round 1 states.
|
From page 170... ...
The Journal of Ambulatory Care Management 42(4)
|
From page 171... ...
2015. Integrated primary care for patients with mental and physical multimorbidity: Cluster randomised controlled trial of collaborative care for pa tients with depression comorbid with diabetes or cardiovascular disease.
|
From page 172... ...
2016. Evolving models of behavioral health integration: Evidence update 2010– 2015.
|
From page 173... ...
2019. Implementing social determinants of health screening at community health centers: Clinician and staff perspectives.
|
From page 174... ...
2015. Case studies of 8 federally qualified health centers: Strategies to integrate oral health with primary care.
|
From page 175... ...
2014. Proximity of providers: Colocating behavioral health and primary care and the prospects for an integrated workforce.
|
From page 176... ...
2019. Clinical leadership and integrated primary care: A systematic literature review.
|
From page 177... ...
2019. Evolving models of integrated behavioral health and primary care.
|
From page 178... ...
2013. Integrated behavioral health in primary care: Evaluating the evidence, identifying the essentials.
|
From page 179... ...
2018. Integrated behavioral health care in pediatric primary care: A quality improvement project.
|
Key Terms
This material may be derived from roughly machine-read images, and so is provided only to facilitate research.
More
information on Chapter Skim is available.