RESUMO
Few would dispute that health care should be provided in seamless, well-integrated clinical care environments that bring together the various disciplines needed to provide patient-centered care, to educate trainees, and to conduct research into a particular disease or episode of care. Yet there are relatively few examples of successful or sustained clinical integration, either in the community setting or in academic health centers (AHCs). The authors draw on their experience with several AHCs and other health care settings to address why AHCs have not made better progress in developing integrated centers of clinical care. They characterize two fundamental types of integration that have evolved within the AHC setting: lateral and vertical. Lateral integration tends to occur among similarly situated specialties. It is easier to accomplish and far more common than is vertical integration, which brings together most, if not all, of the professionals and staff necessary to treat or manage many medical conditions and health problems. The vast majority of examples of clinical integration, whether lateral or vertical, fail to integrate essential administrative and financial functions, which has significant consequences for the ability of either laterally or vertically integrated centers to provide seamless, patient-centered care. The authors identify the emergence of several new examples of vertical clinical integration that also integrate administrative and financial functions as models for AHCs to follow and derive lessons and recommendations concerning how AHCs and others can address the cultural, financial, and governance issues that continue to limit the development of vertically integrated, patient-centered care.