4 Success Factors for Clinically Integrated Networks

Two leaders of early-mover clinically integrated networks discuss how they started, grew, and fine-tuned their organizations.

Creating a clinically integrated network is like beginning a long journey, the length and destination of which is uncertain.

Improving care and reducing costs are the goals, but getting multiple organizations and dozens or hundreds of caregivers to pull together in the same direction depends on openness to evidence-based care protocols and technological (data) capability.

What also helps: A generous dollop of experience in motivating clinicians, especially physicians, to buy into the vision that improved patient care and lower costs are inextricably linked.

Joe Vasile, MD, and Mark Shields, MD, have more experience building CINs than most. Shields, the former senior medical director for Chicago's Advocate Physician Partners, remembers defining the term in the late 2000s as the parent organization geared up efforts to build what has become a 5,000-physician network. Shields left Advocate in 2012 and is now an adviser for Navigant Healthcare.

Vasile, CEO of the Greater Rochester (NY) Independent Physicians Alliance (GRIPA), was instrumental in creating a CIN with 1,300 physicians—half owned by the physician members and half by Rochester Regional Health.

Both physicians say building a CIN that improves quality and cuts costs requires diligence to at least four success factors.

1. Specific (and Limited) Metrics

The physician leaders involved in helping Shields set up APP's structure came to agreement over measurements of quality, cost of care, overtime, and efficiency. Put simply, the organization's ability to move those metrics would not only prove to purchasers that the organization was having an impact, but would prove the same to the organization's physician members, some of whom were skeptical at first.

Those in the early stages of setting up a CIN should focus on a few metrics, such as readmissions, length of stay and a few others, that will drive near immediate quality and savings results.

"At the earliest stage at Advocate, we had about 25 metrics," Shields says. "After a decade, there are 140 going across all specialties."

He says the goal is not to drown physicians in measurement and rankings, but instead to get them to focus on changing processes that affect a few metrics negatively. Vasile credits "actionable user reports" that help physicians and other caregivers address individual problem areas.

"That's when we began not to talk about integrity of the data and instead about how we're actually going to move the scores," he says.

2. Teamwork and Culture

Shields calls clinician culture the critical component to success, defining it as the ability to work together across specialties in conjunction with the hospital to drive quality and patient safety.

"You're working with them to help paint the picture of a rapidly changing environment and the implications for physicians," he says. "That's a big communication issue because it's difficult for them to step back and think two to five years ahead."

Vasile remembers a lot of dinner meetings with physicians explaining the goals and objectives of the CIN. Measuring their buy-in was critical. The best way to do that at GRIPA, he says, is through its clinician portal, which monitors whether physicians are logging in to access the tools. At this point, compliance is close to 100%. Vasile also says an "outspoken" medical director visits their offices and seeks feedback on compliance or lack thereof.

At the primary care level, GRIPA makes quality scores transparent among physicians, and identifiable by name.

"When you have that engagement, physicians are eager to hold themselves accountable," says Vasile.

Shields remembers monitoring clinicians' use of registries and other elements in the portal as a key early indicator of participation.

Every quarter there was a report card on the specific metrics of the specialties and early interventions were arranged with "folks that were lagging," he says.

Another positive influence on culture can come from including as many physicians as possible in governance from the board to the committee level, says Shields.

"My timetable, which I thought was aggressive, happened much quicker than I expected because the physicians started to ask why we were waiting," he says.

3. Compliance with Data and Labor-saving Tools

Compliance with the use of data and technology tools helps clinicians keep a close eye not only on the high-risk patients who represent so much cost in healthcare, but also helps monitor the so-called rising risk population, where earlier intervention can prevent future costs.

Tools in GRIPA's health information exchange, Vasile says, make early interventions easier to identify and effect. "We pick up many who have pulmonary disease, diabetes, and hypertension," he says. Care management is centralized, but each physician has his or her own care manager.

Shields agrees that embedding care managers in the practice facilitates conversation and action between patient or family member and the practice.

4. Selecting and Narrowing the Post-acute Network

Getting the post-acute network right is particularly important for the Medicare population, says Shields.

Selecting which entities you want to work with based on data can be difficult, but performance data, as well as data on length of stay and readmissions, is available from Medicare.

"Health systems are often surprised that [skilled nursing facilities] are interested in partnership, but they shouldn't be because they are a key source of referrals," says Shields. "You can be fairly selective on who will be your preferred partners."

GRIPA, for instance, is tightening compliance and hard-wiring proper care transitions as a way to continuously evaluate its preferred network. The CIN will soon narrow its list of 60 skilled nursing facilities to about 25.

"This drive to integrate physicians to drive quality and cost effectiveness is not going away," says Shields. "There may be some tweaking of insurance products, but whether commercial, Medicare, or Medicaid, they're all driven to increase quality and cost effectiveness, and this process will accelerate."

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