Rethinking Health and Health Care: How Clinicians and Practice Groups Can Better Promote Whole Health and Well-Being for People and Communities.

A new National Academies of Sciences, Engineering, and Medicine report, "Achieving Whole Health: A New Approach for Veterans and the Nation," redefines what it means to be healthy and creates a roadmap for health systems, including the Veterans Health Administration and the nation, to scale and spread a whole health approach to care. The report identifies 5 foundational elements for whole health care and sets 6 national, state, and local policy goals for change. This article summarizes the report, emphasizes the importance of preventive medicine, and identifies concrete actions clinicians and practices can take now to deliver whole health care.

The dynamics of integration and integrated care: An exploratory study of physician organizations.

BACKGROUND: Substantial variation exists in how well health care is integrated, even across similarly structured organizations, yet research about what physician organizations (POs) do that enables or inhibits integrated care is limited. PURPOSE: The aim of this study was to explore the dynamics that enable POs to integrate care. METHODOLOGY/APPROACH: We ranked a stratified sample of POs according to patient perceptions of integrated care, as measured in a survey. We interviewed professionals, patients, and family members in 10 higher and 3 lower ranked POs about the process of caring for patients with complex conditions. We derived integration-related themes from the interview data and quantified their prevalence. Using a quasi-statistical approach, we explored relationships among themes and their associations with patient perceptions of integrated care. RESULTS: From 6,104 coded references, we derived a set of themes representing integration perspectives, integration engagement mechanisms, and integration failures. POs experienced frequent integration failures. Higher ranked POs experienced these failures less often because of a combination of functional, interpersonal, and stakeholder engagement mechanisms, which appear to complement one another. Integration perspectives, including both people-oriented and systems-oriented mindsets, appear to play a role in generating these integration dynamics. CONCLUSION: Delivering integrated care depends on a PO's ability to limit integration failures, keeping provider attention focused on patients. Building on the attention-based view, we present a framework suggesting that this ability is a function of both integration perspectives and integration engagement mechanisms. PRACTICE IMPLICATIONS: POs interested in delivering more integrated care should employ a variety of complementary integration engagement mechanisms and facilitate these efforts by nurturing both people-oriented and system-oriented mindsets among PO decision-makers.

Patients' Perceptions of Integrated Care Among Medicare Beneficiaries by Level of Need for Health Services.

Requirements for integrating care across providers, settings, and over time increase with patients' needs. Health care providers' ability to offer care that patients experience as integrated may vary among patients with different levels of need. We explore the variation in patients' perceptions of integrated care among Medicare beneficiaries based on the beneficiary's level of need using ordinary least square regression for each of four high-need groups: beneficiaries (a) with complex chronic conditions, (b) with frailties, (c) below 65 with disability, and (d) with any (of the first three) high needs. We control for beneficiary demographics and other factors affecting integrated care, and we conduct sensitivity analyses controlling for multiple individual chronic conditions. We find significant positive associations with level of need for provider support for self-directed care and medication and home health management. Controlling for multiple individual chronic conditions reduces effect sizes and number of significant relationships.

Higher Medicare Expenditures Are Associated With Better Integrated Care as Perceived by Patients.

BACKGROUND: Integrated care that is continuous, coordinated and patient-centered is vital for Medicare beneficiaries, but its relationship to health care expenditures remains unclear. RESEARCH OBJECTIVE: This study explores-for the first time-the relationship between integrated care, as measured from the patient's perspective, and health care expenditures. METHODS: Subjects include a sample of continuously eligible fee-for-service Medicare beneficiaries (n=8807) in 2015. Analyses draw on 7 previously validated measures of patient-perceived integrated care from the 2015 Medicare Current Beneficiary Survey. These data are combined with 2015 administrative utilization data that measure health care expenditures. Relationships between patient-perceived integrated care and costs are assessed using generalized linear models with comprehensive control measures. RESULTS: Patients who perceive more integrated care have higher expenditures for many, but not all, cost categories examined. Aspects of integrated care pertaining to primary provider and specialist care are associated with higher costs in several areas (particularly inpatient costs associated with specialist knowledge of the patient). Office staff members' knowledge of the patient's medical history is associated with lower home health costs. CONCLUSIONS: Patients who experience their care as more integrated may have higher expenditures on average. Thoughtful policy choices, further research, and innovations that enable patients to perceive integrated care at lower or neutral cost are needed.

Development and Psychometric Analysis of the Revised Patient Perceptions of Integrated Care Survey.

This article describes the development and psychometric testing of the Patient Perceptions of Integrated Care (PPIC 2.1) survey, which we administered to 12,364 Medicare beneficiaries who received treatment from 150 randomly selected physician organizations, receiving 3,067 responses (26%). Psychometric analyses, performed using two methods to adjust for respondent inherent optimism (as a measure of response tendency), supported a 6-factor, 22-item model with excellent fit. These factors were (1) Staff Knowledge about the Patient's Medical History, (2) Provider Support for the Patient's Self-Directed Care, (3) Test Result Communication, (4) Provider Knowledge of the Patient, (5) Provider Support for Medication Adherence and Home Health Management, and (6) Specialist Knowledge about the Patient's Medical History. Per Spearman-Brown prophesy calculations, reliability would exceed 0.7 for all factors at 33 or more responses per organization. The PPIC 2.1 survey can distinguish six dimensions of integrated patient care with high physician organization-level reliability at reasonable sample sizes.

A Comprehensive Theory of Integration.

Efforts to transform health care delivery to improve care have increasingly focused on care integration. However, variation in how integration is defined has complicated efforts to design, synthesize, and compare studies of integration in health care. Evaluations of integration initiatives would be enhanced by describing them according to clear definitions of integration and specifying which empirical relationships they seek to test-whether among types of integration or between integration and outcomes of care. Drawing on previous work, we present a comprehensive theoretical model of relationships between types of integration and propose how to measure them.

Incorporating Theory into Practice: Reconceptualizing Exemplary Care Coordination Initiatives from the US Veterans Health Delivery System.

This perspective paper seeks to lay out an efficient approach for health care providers, researchers, and other stakeholders involved in interventions aimed at improving care coordination to partner in locating and using applicable care coordination theory. The objective is to learn from relevant theory-based literature about fit between intervention options and coordination needs, thereby bringing insights from theory to enhance intervention design, implementation, and troubleshooting. To take this idea from an abstract notion to tangible application, our workgroup on models and measures from the Veterans Health Administration (VA) State of the Art (SOTA) conference on care coordination first summarizes our distillation of care coordination theoretical frameworks (models) into three common conceptual domains-context of an intervention, locus in which an intervention is applied, and specific design features of the intervention. Then we apply these three conceptual domains to four cases of care coordination interventions ("use cases") chosen to represent various scopes and stages of interventions to improve care coordination for veterans. Taken together, these examples make theory more accessible and practical by demonstrating how it can be applied to specific cases. Drawing from theory offers one method to anticipate which intervention options match a particular coordination situation.

Organizational Coordination and Patient Experiences of Specialty Care Integration.

BACKGROUND: Delivering care to patients with complex healthcare needs benefits from coordination among healthcare providers. Greater levels of care coordination have been associated with more favorable patient experiences, cost management, and lower utilization of services. Organizational approaches consider how systems, practices, and relationships influence coordination and associated outcomes. OBJECTIVE: Examine measures of organizational coordination and their association with patient experiences of care coordination involving specialists. DESIGN: Cross-sectional surveys of patients and primary care providers (PCPs). PARTICIPANTS: Final sample included 3183 patients matched to 233 PCPs from the Veterans Health Administration. All patients had a diagnosis of type 2 diabetes mellitus and one of four other conditions: hypertension; congestive heart failure; depression/anxiety; or severe mental illness/posttraumatic stress disorder. MAIN MEASURES: Patients completed a survey assessing perceptions of coordinated care. We examined ratings on three domains: specialist knowledge management; knowledge integration across settings and time; and knowledge fragmentation across settings and time. We created care coordination measures involving the PCP and three specialty provider types. PCPs provided ratings on relational coordination for specialists, feedback coordination, and team coordination. We aligned patient's specialty services used with corresponding PCP ratings of that specialty. KEY RESULTS: Patient ratings were significantly lower on specialist knowledge management and knowledge integration when either PCPs did not use feedback coordination (b = - .20; b = - .17, respectively) or rated feedback coordination lower (b = - .08 for both). Teamwork was significantly related to specialist knowledge management (b = .06), knowledge integration (b = .04); and knowledge fragmentation (b = - .04). Relational coordination was related to coordination between the primary care provider and (i) diabetes specialist (b = .09) and (ii) mental health provider (b = .12). CONCLUSIONS: Practices to improve provider coordination within and across primary care and specialty care services may improve patient experiences of care coordination. Improvements in these areas may improve care efficiency and effectiveness.

Health Care Coordination Theoretical Frameworks: a Systematic Scoping Review to Increase Their Understanding and Use in Practice.

BACKGROUND: Care coordination is crucial to avoid potential risks of care fragmentation in people with complex care needs. While there are many empirical and conceptual approaches to measuring and improving care coordination, use of theory is limited by its complexity and the wide variability of available frameworks. We systematically identified and categorized existing care coordination theoretical frameworks in new ways to make the theory-to-practice link more accessible. METHODS: To identify relevant frameworks, we searched MEDLINE®, Cochrane, CINAHL, PsycINFO, and SocINDEX from 2010 to May 2018, and various other nonbibliographic sources. We summarized framework characteristics and organized them using categories from the Sustainable intEgrated chronic care modeLs for multi-morbidity: delivery, FInancing, and performancE (SELFIE) framework. Based on expert input, we then categorized available frameworks on consideration of whether they addressed contextual factors, what locus they addressed, and their design elements. We used predefined criteria for study selection and data abstraction. RESULTS: Among 4389 citations, we identified 37 widely diverse frameworks, including 16 recent frameworks unidentified by previous reviews. Few led to development of measures (39%) or initiatives (6%). We identified 5 that are most relevant to primary care. The 2018 framework by Weaver et al., describing relationships between a wide range of primary care-specific domains, may be the most useful to those investigating the effectiveness of primary care coordination approaches. We also identified 3 frameworks focused on locus and design features of implementation that could prove especially useful to those responsible for implementing care coordination. DISCUSSION: This review identified the most comprehensive frameworks and their main emphases for several general practice-relevant applications. Greater application of these frameworks in the design and evaluation of coordination approaches may increase their consistent implementation and measurement. Future research should emphasize implementation-focused frameworks that better identify factors and mechanisms through which an initiative achieves impact.

Development and Testing of the Provider and Staff Perceptions of Integrated Care (PSPIC) Survey.

This article discusses development and testing of the Provider and Staff Perceptions of Integrated Care Survey, a 21-item questionnaire, informed by Singer and colleagues' seven-construct framework. Questionnaires were sent to 2,936 providers and staff at 100 federally qualified health centers and other safety net clinics in 10 Midwestern U.S. states; 332 were ineligible, leaving 2,604 potential participants. Following 4 mailings, 781 (30%) responded from 97 health centers. Item analyses, exploratory factor analysis, and confirmatory factor analysis were undertaken. Exploratory factor analysis suggests four latent factors: Teams and Care Continuity, Patient Centeredness, Coordination with External Providers, and Coordination with Community Resources. Confirmatory factor analysis confirmed these factor groupings. For the total sample, Cronbach's alpha exceeded 0.7 for each latent factor. Descriptive responses to each of the 21 Provider and Staff Perceptions of Integrated Care questions appear to have potential in identifying areas that providers and staff recognize as care integration strengths, and areas that may warrant improvement.

Cross-Cultural Validation of the Patient Perception of Integrated Care Survey.

OBJECTIVE: To test the cross-cultural validity of the U.S. Patient Perception of Integrated Care (PPIC) Survey in a Dutch sample using a standardized procedure. DATA SOURCES: Primary data collected from patients of five primary care centers in the south of the Netherlands, through survey research from 2014 to 2015. STUDY DESIGN: Cross-sectional data collected from patients who saw multiple health care providers during 6 months preceding data collection. DATA COLLECTION: The PPIC survey includes 59 questions that measure patient perceived care integration across providers, settings, and time. Data analysis followed a standardized procedure guiding data preparation, psychometric analysis, and included invariance testing with the U.S. dataset. PRINCIPAL FINDINGS: Latent scale structures of the Dutch and U.S. survey were highly comparable. Factor "Integration with specialist" had lower reliability scores and noninvariance. For the remaining factors, internal consistency and invariance estimates were strong. CONCLUSIONS: The standardized cross-cultural validation procedure produced strong support for comparable psychometric characteristics of the Dutch and U.S. surveys. Future research should examine the usability of the proposed procedure for contexts with greater cultural differences.

Medical Group Structural Integration May Not Ensure That Care Is Integrated, From The Patient's Perspective.

Structural integration is increasing among medical groups, but whether these changes yield care that is more integrated remains unclear. We explored the relationships between structural integration characteristics of 144 medical groups and perceptions of integrated care among their patients. Patients' perceptions were measured by a validated national survey of 3,067 Medicare beneficiaries with multiple chronic conditions across six domains that reflect knowledge and support of, and communication with, the patient. Medical groups' structural characteristics were taken from the National Study of Physician Organizations and included practice size, specialty mix, technological capabilities, and care management processes. Patients' survey responses were most favorable for the domain of test result communication and least favorable for the domain of provider support for medication and home health management. Medical groups' characteristics were not consistently associated with patients' perceptions of integrated care. However, compared to patients of primary care groups, patients of multispecialty groups had strong favorable perceptions of medical group staff knowledge of patients' medical histories. Opportunities exist to improve patient care, but structural integration of medical groups might not be sufficient for delivering care that patients perceive as integrated.

patient perceptions of integrated care and their relationship to utilization of emergency, inpatient and outpatient services.

BACKGROUND: Patients with multiple chronic conditions have garnered particular attention from policymakers and health service researchers because these patients utilize more services and contribute disproportionally to rising health care expenses. The growing prevalence of patients with multiple chronic conditions has increased the importance of achieving better health care integration for this patient population. Patients may be well positioned to assess integration of their care, but the relationship between patients' perceptions of care integration and use of health services has not been studied. We sought to understand how patient-perceived integrated care relates to utilization of health services. METHODS: We fielded the Patient Perceptions of Integrated Care survey among a random sample of 3000 (<65 years) patients with multiple chronic conditions belonging to the Massachusetts General Hospital Physician Organization; 1503 responses were collected (50% response rate). We assessed relationships between provider performance on 11 domains of patient-reported integrated care and rates of emergency department (ED) visits, hospital admissions, and outpatient visits. RESULTS: Better performance on two of the surveyed dimensions of integrated care (information flow to other providers in your doctor's office and responsiveness independent of visits, p<0.05) was significantly associated with lower ED visit rates. Better performance on three dimensions of integrated care (information flow to your specialist, p<0.05, post-visit information flow to the patient, p<0.001, and continuous familiarity with patient over time, p<0.05) was associated with lower outpatient visit rates. No dimensions of integration were associated with hospital admission rates. CONCLUSIONS: In a single health system, patient perceptions of integrated care were associated with ED and outpatient utilization but not inpatient utilization. With further development, patient reports of integration could be useful guides to improving health system efficiency.

Validation of a Parent-Reported Experience Measure of Integrated Care.

OBJECTIVES: The objectives of this study were to design and validate a survey measuring the parents' and caregivers' experiences of integration of their child's care across providers. METHODS: After review of the literature on care coordination and integration, we solicited input regarding care experiences from focus groups of families with children with chronic conditions. These data informed a 95-item pilot survey that included elements from a care integration measure designed for adult care experiences. The survey was then administered to parents of children who had had at least 1 primary care appointment and 2 specialty care appointments in the previous 12 months. Psychometric analyses were used to establish scales through exploratory factor analysis, internal consistency using Cronbach's α, test-retest reliability using Spearman's rank correlation coefficient, and known-group validity according to χ2 tests. All research activities were institutional review board approved. RESULTS: The pilot survey was completed as either a Web or mail survey by 255 participants. After excluding nonrating or screening questions and items not applicable to a large percentage of participants, 26 experience items were included in the exploratory factor analysis. The final survey contained 19 experience items in 5 scales: access, communication, family impact, care goal creation, and team functioning. Psychometric analyses supported these 5 scales. CONCLUSIONS: This project developed and validated a survey with 19 experience items, plus additional demographic and health needs and usage items. The Pediatric Integrated Care Survey can be used in quality improvement efforts to measure family-reported experience of pediatric care integration.

Development and preliminary validation of the Patient Perceptions of Integrated Care survey.

Valid measures of the integration of patient care could provide rapid and accurate feedback on the successfulness of current efforts to improve health care delivery systems. This article describes the development and pilot testing of a new survey, based on a novel conceptual model, which measures the integration of patient care as experienced by patients. We administered the survey to 1,289 patients with multiple chronic conditions from one health system and received responses from 527 patients (43%). Psychometric analysis of responses supported a six-dimension model of integration with satisfactory internal consistency, discriminant validity, and goodness of fit. The Patient Perceptions of Integrated Care survey can be used to measure the integration of care received by chronically ill patients for two main purposes: as a research tool to compare interventions intended to improve the integration of care and as a quality improvement tool intended to guide the refinement of delivery system innovations.

Defining and measuring integrated patient care: promoting the next frontier in health care delivery.

Integration of care is emerging as a central challenge of health care delivery, particularly for patients with multiple, complex chronic conditions. The authors argue that the concept of "integrated patient care" would benefit from further clarification regarding (a) the object of integration and (b) its essential components, particularly when constructing measures.To address these issues, the authors propose a definition of integrated patient care that distinguishes it from integrated delivery organizations, acknowledging that integrated organizational structures and processes may fail to produce integrated patient care. The definition emphasizes patients' central role as active participants in managing their own health by including patient centeredness as a key element of integrated patient care. Measures based on the proposed definition will enable empirical assessment of the potential relationships between the integration of organizations, the integration of patient care, and patient outcomes, providing valuable guidance to health systems reformers.