Are health systems redesigning how health care is delivered?

OBJECTIVE: To explore why and how health systems are engaging in care delivery redesign (CDR)-defined as the variety of tools and organizational change processes health systems use to pursue the Triple Aim. STUDY SETTING: A purposive sample of 24 health systems across 4 states as part of the Agency for Healthcare Research and Quality's Comparative Health System Performance Initiative. STUDY DESIGN: An exploratory qualitative study design to gain an "on the ground" understanding of health systems' motivations for, and approaches to, CDR, with the goals of identifying key dimensions of CDR, and gauging the depth of change that is possible based on the particular approaches to redesign care being adopted by the health systems. DATA COLLECTION: Semi-structured telephone interviews with health system executives and physician organization leaders from 24 health systems (n = 162). PRINCIPAL FINDINGS: We identify and define 13 CDR activities and find that the health systems' efforts are varied in terms of both the combination of activities they are engaging in and the depth of innovation within each activity. Health system executives who report strong internal motivation for their CDR efforts describe more confidence in their approach to CDR than those who report strong external motivation. Health system leaders face uncertainty when implementing CDR due to a limited evidence base and because of the slower than expected pace of payment change. CONCLUSIONS: The ability to validly and reliably measure CDR activities-particularly across varying organizational contexts and markets-is currently limited but is key to better understanding CDR's impact on intended outcomes, which is important for guiding both health system decision making and policy making.

Understanding how health systems facilitate primary care redesign.

OBJECTIVE: To understand how health systems are facilitating primary care redesign (PCR), examine the PCR initiatives taking place within systems, and identify barriers to this work. STUDY SETTING: A purposive sample of 24 health systems in 4 states. STUDY DESIGN: Data were systematically reviewed to identify how system leaders define and implement initiatives to redesign primary care delivery and identify challenges. Researchers applied codes which were based on the theoretical PCR literature and created new codes to capture emerging themes. Investigators analyzed coded data then produced and applied a thematic analysis to examine how health systems facilitate PCR. DATA COLLECTION: Semi-structured telephone interviews with 162 system executives and physician organization leaders from 24 systems. PRINCIPAL FINDINGS: Leaders at all 24 health systems described initiatives to redesign the delivery of primary care, but many were in the early stages. Respondents described the use of centralized health system resources to facilitate PCR initiatives, such as regionalized care coordinators, and integrated electronic health records. Team-based care, population management, and care coordination were the most commonly described initiatives to transform primary care delivery. Respondents most often cited improving efficiency and enhancing clinician job satisfaction, as motivating factors for team-based care. Changes in payment and risk assumption as well as community needs were commonly cited motivators for population health management and care coordination. Return on investment and the slower than anticipated rate in moving from fee-for-service to value-based payment were noted by multiple respondents as challenges health systems face in redesigning primary care. CONCLUSIONS: Given their expanding role in health care and the potential to leverage resources, health systems are promising entities to promote the advancement of PCR. Systems demonstrate interest and engagement in this work but face significant challenges in getting to scale until payment models are in alignment with these efforts.

The importance of understanding and measuring health system structural, functional, and clinical integration.

OBJECTIVE: We explore if there are ways to characterize health systems-not already revealed by secondary data-that could provide new insights into differences in health system performance. We sought to collect rich qualitative data to reveal whether and to what extent health systems vary in important ways across dimensions of structural, functional, and clinical integration. DATA SOURCES: Interviews with 162 c-suite executives of 24 health systems in four states conducted through "virtual" site visits between 2017 and 2019. STUDY DESIGN: Exploratory study using thematic comparative analysis to describe factors that may lead to high performance. DATA COLLECTION: We used maximum variation sampling to achieve diversity in size and performance. We conducted, transcribed, coded, and analyzed in-depth, semi-structured interviews with system executives, covering such topics as market context, health system origin, organizational structure, governance features, and relationship of health system to affiliated hospitals and POs. PRINCIPAL FINDINGS: Health systems vary widely in size and ownership type, complexity of organization and governance arrangements, and ability to take on risk. Structural, functional, and clinical integration vary across systems, with considerable activity around centralizing business functions, aligning financial incentives with physicians, establishing enterprise-wide EHR, and moving toward single signatory contracting. Executives describe clinical integration as more difficult to achieve, but essential. Studies that treat "health system" as a binary variable may be inappropriately aggregating for analysis health systems of very different types, at different degrees of maturity, and at different stages of structural, functional, and clinical integration. As a result, a "signal" indicating performance may be distorted by the "noise." CONCLUSIONS: Developing ways to account for the complex structures of today's health systems can enhance future efforts to study systems as complex organizations, to assess their performance, and to better understand the effects of payment innovation, care redesign, and other reforms.

Dissemination of quality improvement innovations by multisector health care alliances.

PURPOSE: Multisector health care alliances (alliances) are increasingly viewed as playing an important role in improving the health and health care of local populations, in part by disseminating innovative practices, yet alliances face a number of challenges to disseminating these practices beyond a limited set of initial participants. The purpose of this paper is to examine how alliances attempt to disseminate innovative practices and the facilitating and inhibiting factors that alliances confront when trying to do so. DESIGN/METHODOLOGY/APPROACH: The authors adopted multiple holistic case study design of eight alliances with a maximum variation case selection strategy to reflect a range of structural and geographic characteristics. Semi-structured interviews with staff, leaders and board members were used. FINDINGS: The findings show that dissemination is a multidirectional process that is closely if not inextricably intertwined with capacity- and context-related factors (of the alliance, partnering organizations and target organizations). Thus, standardized approaches to dissemination are likely the exception and not the rule, and highlight the value of existing frameworks as a starting point for conceptualizing the important aspects of dissemination, but they are incomplete in their description of the "on-the-ground" dissemination processes that occur in the context of collaborative organizational forms such as alliances. ORIGINALITY/VALUE: Despite a rapidly expanding evidence base to guide clinical and managerial decision making, this knowledge often fails to make its way into routine practice. Consequently, the search for effective strategies to reduce this gap has accelerated in the past decade. This study sheds light on those strategies and the challenges to implementing them.