Patient benefits from participating in an integrated delivery system: impact on coordination of care.

BACKGROUND: Although the presumption in health services literature has been that integrated delivery systems (IDSs) should improve the coordination of care, the benefits have not yet been well established through empirical research. PURPOSES: This study assesses whether receiving care from providers who belong to the same IDS improves patient-perceived coordination of care; concurrently, we develop a new approach for assessing the performance of IDS. METHODOLOGY/APPROACH: A study was conducted of 222 patients who received primary unilateral total knee arthroplasty at a large IDS' acute care hospital. To isolate the effects of provider membership, we enrolled patients who received surgery from the same surgical department in the same acute care hospital in the IDS. We used baseline and 6-week postoperation patient surveys to assess the impact of the participation of the patients' providers in the IDS on patient-perceived coordination of care. FINDINGS: We found no consistent effects of IDS membership on patient-perceived coordination of care. Patients with in-network rehabilitation care experienced fewer problems than patients with out-of-network rehabilitation care did, while patients with in-network home care experienced more problems than patients with out-of-network home care did. Membership of a patient's primary care physician had no observed effects. PRACTICE IMPLICATIONS: Health care managers and administrators need to undertake a realistic examination of the care-coordinating mechanisms that exist in their IDS. This study has shown that the integration of financial, contractual, and administrative processes is not enough to improve care from the patient's perspective; to improve care, it is advised that an IDS take a patient-centered approach in its design and implementation. We discuss potential reasons for uneven integration of IDS, particularly with respect to the lack of coordinating mechanisms, and argue for the usefulness of the approach developed here for assessing IDS performance over time.

Coordination between formal providers and informal caregivers.

BACKGROUND: The increased "outsourcing" of care-related tasks to patients and their informal caregivers is part of a broader trend in service industries toward engaging customers as "coproducers" of service outcomes. As both quasi-patients and quasi-providers, caregivers may play a critical role in successful coproduction, but they require coordination with care providers to play this role effectively. When tasks are highly interdependent, uncertain, and time constrained, as they often are in health care, relational forms of coordination are expected to be most effective. PURPOSES: This study explores the effects of coordination between formal providers and informal caregivers on caregiver preparation to provide care at home and the effect of caregiver preparation on patient outcomes. Gittell's theory of relational coordination posits that effective coordination occurs through frequent, high-quality communication that is supported by relationships of shared goals, shared knowledge, and mutual respect. We extend the relational coordination model, previously used to examine coordination between formal providers, to encompass coordination of care between formal providers and informal caregivers. METHODOLOGY: We surveyed patients before and 12 weeks after knee replacement surgery to assess outcomes. At 6 weeks postsurgery, we surveyed their caregivers regarding coordination with providers and preparation to provide care. FINDINGS: We found that relational coordination between formal providers and caregivers improves caregiver preparation to provide care, which, in turn, is positively associated with patients' freedom from pain, functional status, and mental health. IMPLICATIONS: Providers should be encouraged to attend to the interpersonal aspects of their interactions with caregivers to promote relational coordination, which may ultimately benefit the patient's health. It is not enough, however, to urge providers to build shared goals, shared knowledge, and mutual respect with patients and caregivers. Dedicated resources and support are needed, given the context of constrained resources and brief encounters in which providers deliver care.

Beyond our walls: impact of patient and provider coordination across the continuum on outcomes for surgical patients.

OBJECTIVES: To investigate patients' experience with coordination of their postsurgical care across multiple settings and the effects on key outcomes. DATA SOURCES: Primary data collected over 18 months from 222 unilateral knee-replacement patients at Brigham and Women's Hospital in Boston, MA. STUDY DESIGN: Patients were surveyed about the coordination of their postdischarge care during the 6-week period postdischarge when they received care from rehabilitation facilities and/or home care agencies and follow-up care from the surgeon. DATA COLLECTION: Patients were surveyed before surgery and at 6 and 12 weeks postsurgery. PRINCIPAL FINDINGS: Patient reports highlight problems with coordination across settings and between providers and themselves. These problems, measured at 6 weeks, were associated with greater joint pain, lower functioning, and lower patient satisfaction at 6 weeks after surgery. At 12 weeks after surgery, coordination problems were associated with greater joint pain, but were not associated with functional status. CONCLUSION: Coordination across settings affects patients' clinical outcomes and satisfaction with their care. Although accountable for transfer to the next care setting, providers are neither accountable for nor supported to coordinate across the continuum. Addressing this system problem requires both introducing coordinating mechanisms and also supporting their use through changes in providers' incentives, resources, and time.